Perspectives in Nutrition 7th Edition

SEVENTH EDITION
PERSPECTIVES IN
NUTRITION
Gordon M. Wardlaw
Ph.D. , R.D .
Formerly Adjunct Associate I'l'ofessor, Dcpnrtment of Hm11at1 Nutririon
TI1e Obio SttllC University
Jeffrey S. Hampl
Ph.D ., R.D.
Associate Professor. Department of N11t1·itio11
Arizoun State Universi~y
!B Higher Education
Boston Burr Ridge, IL Dubuque. IA New York San Francisco St. Louis
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R Higher Education
PERSPECTWES IN NUTRITION, SEVENTH EDITION
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Library of Congress Cataloging-in-Publication Data
Wardian, Gordon 1\1

Pcrspecm·c,, 111 nutririon / l;nrdon 1\I. Wardlaw, Jc!lrc) S. H.1mpl -7ch ed.
p. cm.
Includes bibliogr.1phK.1I rctCrcncc~ .ind index.
ISBN 978- 0 07 282750 ·7- ISBN 0-07-282750-5 (hard copy : .1lk. papa)
1. Numuon I. H.1111pl, Jeffrey S. U. Tille.
QPl-ll .W3H 2007

612.3-dd2 2006009096
CIP
\\ww.mhhe.com
•
r1e contents
PART ONE NUTRITION BASICS 1
1 What Nourishes You? l
2 The Basis of a Healthy Diet 37
3 Human Digestion and Absorption 79
4 Metabolism 111
PART TWO THE ENERGY-YIELDING NUTRIENTS AND ALCOHOL 149

5 Carbohydrates 149
6 lipids 191
7 Proteins 235
8 Alcohol 271
PART THREE THE VITAMINS AND MINERALS 295

9 The Fat-Soluble Vitamins 295
10 The Water-Soluble Vitamins 335
1 1 Water and the Major Minerals 38 l
12 Trace Minerals 425
P. RT FOUR ENERGY BALANCE AND IMBALANCE 465

13 Energy Balance and Weight Control 465
14 Nutrition for Fitness and Sports 515
15 Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder,
and Other Conditions 553
PART FIVE NUTRITION APPLICATIONS IN THE LIFE CYCLE 581

16 Pregnancy and Breastfeeding 58 l
1 7 Nutrition from Infancy through Adolescence 6 15
18 Nutrition during Adulthood 657
PART SIX PUTIING NUTRITION KNOWLEDGE INTO PRACTICE 689

19 Safety of Food and Water 689
20 Undernutrition Throughout the World 729
m
contents
About the Authors xvii
Preface to the Instructor xix
Preface to the Student xxiv
Textbook Tour xxvi
Supplement Tour xxix
PART ONE NUTRITION BASICS 1

1 What Nourishes You? Current State of the North American Diet 14
As$. ing the .._urrf.)nl Norn Ame(con Diet 14
Chapter Outline l
What Influences Our Food Choices? 14
Case Scenario l
Improving Our Diets 15
Chapter Objectives 2
Health Objectives for the United Stoles for the Yeor 2010 Include
Refresh Your Memory 2
Numerous Nutrition Ob1echves 17
Nutrition and Your Health 2
Using Scientific Research to Determine Nutrient Needs 18
Whal Actually ls Nutrition? 2
Asking Questions and Generating Hypotheses 20
Nutrients Come from Food 2
Laboratory Animal Experiments 21
Why Study Nutrition? 3
Human Experiments 21
Interest in the Field of Nutrition Has a Long History 5
Classes and Sources of Nutrients 7 Expert Opinion Using Research to Answer a Question-Does
Carbohydrates 8 Calcium Really Help with Weight Loss? Dr. Robert
Lipids 8 DiSilvestro, Ph.D. 22
Proteins 10 Peer Review of Experimental Results 24
Vitamins 10 Follov-·Up Studies 25
Minerals 11 How to Use This Knowledge to Evaluate Nutrition Claims
Waler and Advice 26
Nutrient Composition of Diets and the Human Body 1 l Case Scenario Follow-Up 28
Energy Sources and Uses 12 Nutrition Focus Genetics ond Nutrition 29
Summary 33
Study Questions 33
Annotated References 33
Toke Action E)(omme Your Eating Hob11s More Closely 35
Toke Action Creole Your Family Tree for Heolth-Reloted
Concerns 36
2 The Basis of a Healthy Diet 37

Chapter Outline 37
Case Scenario 37
v
vi Contents
Chapter Objectives 38 Goslroinlestinol Hormones- A Key lo Orchestrating Digestion 90

A Food Philosophy That Works 38 Gastrointestinal Control Valves: Sphincters 90
Vo11et-. M·~r s Eating Many Different Foods 39 Goslroint• .lino! Musculorily: Mixing and Propulsion 91
Balance Means Not Overconsuming Any Single Type of Food 39 Nutrition Focus When the Digestive Processes Go Awry 93
t'v'.oderotion Refers N\ostly to Portion Size 40 Case Scenario Follow-Up 96
Nutrient Density Focuses on Nutrient Content 40 The Physiology of Absorption 99
Energ) Density Especlolly Influences Energy Intake d l Ab .rpt •to C ;!I 1()()
Expert Opinion n e Importance of Energy Density in the Diet Types of Absorption 100
Barbaro J Ro/ts Pl D 43 Portal and lymphoric Circulolion in Absorption l 0 l
States of Nutritional Health 45 Ent •roh!"p 1tic 11culot1on l 0 1
Desirable Nutr:i1un 45 Absorption Is Completed in the Large Intestine 103
Undernutrilion d5 Storage Capabilities of the Body 104
Overnulrition 46 Expert Opinion P1ob1ol1cs and Humon Health
How Con Your Nutritional State Be Measured? 46 Steve /-lertzle( Ph D R.D. 106
Analyzing Background Foclors 46 Summary 108
Evoluoling the ABCDEs 47 Study Questions l 08
Recognizing lhe Limitations ol Nutritional Assessment d7 Annotated References l 09
Concern about the State of Your Nutritional Health Is
Take Action Ate You Taking Core of Your Digestive Tract? I I 0
Important 48
Setting Nutrient Needs-Dietary Reference Intakes (DRls) 49 Toke Action lnvest1gote Over-the-Counler Medications for Treating
Est1IT'ated Avr-roqe P qu rel"'1enls (EARsl 49 Comrror GI Tract Problems I I 0
Recommended Dietary Allowances (RDAsl 50
Adequate Intakes (Als) 51
Estimated Energy Requirements (EERsl 51 4 Metabolism 111
Tolerable Upper Intake Levels !Upper Levels, or Ulsl 51 Chapter Outline 11 l
Appropriate U. of the DR: 52
Case Scenario 111
Daily Values (DVs): The Standards Used for Food Labeling 53
Reference Doilr intakes (RDlsl 54
Doily Reference Values IDRVsl 54
Metabolism : Chemical Reactions in the Body \ \ '2
Using the Doily Valui ~ 54
Anabolic. and Cotobol1c Reactions 11 3
Recommendations for Food Choice 56
Sroges of Energy Production 1 13
MyPyram1d-A Menu-Planning Tool 56
Energy for lhe Cell 113
Dietary Guidelines-Another Tool for Menu Planning 62
Adenosine Triphosphale !ATP) as on Energy Source 114
Case Scenario Follow-Up 69
Oxidolion-Reduclion Reoclions: Key Processes in Energy
Nutrition Focus Using Food Labels in Diel Planning 70 MPtobollsm 116
Summary 74 The Role of Enzymes and Vitamins in Oxidotion·Reduction
Study Questions 74 Reachons 1 17
Annotated References 75 ATP Production 117
Take Action Does Your Diel Meet MyPyromid Carbohydrate Metabolism 119
Recammenda11ons? 76 Glycolysis 1 19
Take Action Are You Pulling the Dietary Guidelines into Trons1tion Reaction 122
Practice? 7 7 C1111c Acid Cycle 122
-~ i:., tr ' Tr .msoorl Choin 123
Take Action Aoplymg the Nutntion Focts label to Your Doily Food
Choices 78 Expert Opinion Does a Metabolic Advonrage Exist for !he Hi9h-
Pr. • 1n 011.JI? Andrea C. Buchholz Ph.D., R.D., ond
Dole A Schoeller, Ph.D. 127
3 Human Digestion and Absorption 79 Aerobic Respiration 128
Chapter Outline 79 Glycogen Melobolism l 29
Case Scenario 79 Anoerobic Respiration 129
Refresh Your Memory 80 Anaerobic Glycolysis 129
Chapter Objectives 80 Aerobic and Anaerobic Respiralion 130
The Cell ls the Basis of Human Physiology 80 Lipolysis: Fat Breakdown 130
Organization of the Human Body 81 tv\ok1ng ATP from Felty Acids l 31
The Physiology of Digestion 82 Co1bohydrote: Aids Fat Metabolism 132
The Flow of D1gesl1 on 84 Ke1vgenf!S1s 1 Producing Ketone Bodies from Fatty Acids 132
A Closer Look ot Enzymes in Digestion 89 Lipogenesis: Building Fatty Acids 133
www.mhhe.com/wardlawpers7 vii
Protein Metabolism 134 Fasting and Feasting 141

Producing Glucose from Amino Acids and Other Compounds 134 Fosling 141
Gluconeogenesis from Typical Folly Acids Is Nol Possible 135 Feasling 14 1
Disposing of Excess Amino G roups From Amino Acid Cose Scenario Follow-Up 142
Metobolism 136 Nutrition Focus Inborn Errors of Metabolism 143
What Happens Where: A Review 137 Summary 145
Regulating Metabolism 138 Study Questions 145
The liver l 39 Annotated References 146
Enzymes 139 Toke Action Pu/ Your Knowledge of Metabolism info Practice 148
Hormones 140
ATP Concenlrolions 140
Take Action Reinforce Your Knowledge of Metabolism 148
Vitamins and Minerals 140
PART TWO THE ENERGY-YIELDING NUTRIENTS

AND ALCOHOL 149
5 Carbohydrates 149 Functions of Fiber 162
Carbohydrate Needs 164
Chapter Outline 149
The Carbohydrate Continuum 164
Cose Scenario 149
How Much Fiber Do We Need? 164
Chapter Objectives l 50 Expert Opinion Fiber-Finally o Nutrient
Carbohydrates-An Introduction 150 Joanne L. Slavin, Ph.D., R.D. 165
Structures and Functions of Simple Carbohydrates 151 Health Concerns Related to Carbohydrate Intake 168
Monosacchorides: G lucose, Fructose, and Galoclose 151 Problems wilh High-Fiber Diets 168
Disocchorides: Maltose, Sucrose, and Lactose 152 Problems wilh High-Sugar Diets 169
Oligosocchorides: Roffinose and Slachyose 154 Sugars and Refined Starches and !he Metabolic Syndrome 173
Structures and Functions of the More Complex Problems wilh Lactose Intake, Especially for Some People l 73
Carbohydrates 154 Case Scenario Follow-Up 174
Digestible Polysaccharides: Storch ond Glycogen 155 Nutrition Focus When Blood Glucose Regulation Foils 175
Indigestible Polysaccharides. Fibers 156 Carbohydrates in Foods 181
Carbohydrate Digestion and Absorption 158 Nutrllive Sweeleners 18 l
Digestion 158 Alternative Sweeteners 183
Absorption 160 Summary 186
Functions of Glucose and Other Sugars in the Body 161 Study Questions 186
Yielding Energy 16 1 Annotated References 187
Sporing Proteins from Use as an Energy Source I 6 1 Toke Action Eslimate Your Fiber Intake 189
Preventing Ketosis 162
Take Action Con You Choose the Sandwich with the Most
Fiber? 190
6 Lipids 191
Chapter Outline 191
Case Scenario 191
Lipids: Common Properties and Main Types 192
Folly Acids: The Simplest Form of lipids 193
Essenlial Folly Acids 194
Effecis of o Deficiency of Essenlial FoHy Acids 199
Triglycerides 199
Roles of Triglycerides in the Body 200
Providing Energy for the Body 200
Storing Energy for Loter Use 200
viii Contents
lnsolotmg and Protecting the Body 201 Maintaining Fluid Balance 250
Transporting Fot·Soluble Vitamins 201 Contributing lo Acid-Bose Balance 250
Phospholipids 201 Forming Hormones and Enzymes 251
Sterols 203 Contributing lo Immune Function 251
Fat Digestion and Absorption 204 Forming Glucose 25 l
Digestion 204 Providing Energy 251
Absorption 206 Contributing lo Satiety 251
Fats Carried in the Bloodstream 207 Protein Needs 252
Carrying Dietary Fats Utilizes Chylomicrons 207 Does Eating a High-Protein Diet Harm You? 255
Transporting lipids Mostly Mode by the Body Uses Very-Low-Density Protein in Foods 255
L1poproteins 207 The Value of Plant Protein 255
Nutrition Focus Lipoproleins and Cordiovosculor Disease 212 Expert Opinion A New Appreciation for !he Nut in Nutrition
Another Dimension of Fat: Properties in Food 217 Penny M Kris-Etherton, Ph.D., R.D. 256
Fat in food Provides Some Satiety and Flavor 217 A Closer look at Soy Protein 259
Expert Opinion Atherosclerosis: An Update Evaluation of Protein Quality 259
Bernhard Hennig, Ph.D, R.D. 2 18 Nutrition Focus Vegetarian Diets 26 I
Hydrogenation of fotty Acids 1n Food Production Increases Trans Case Scenario Follow-Up 263
Fatty Acid Content 220 Protein-Energy Malnutrition 264
Fat Rancidity Limits Sheff Life of Foods 222 Kwash1orkor 264
Emulsifiers Improve Many Food Products 222 Marasmus 265
Recommendations for Fat Intake 223 rwoshiorkor and Morosmus Malnutrition in the Hospital 266
Fats in Food 225 Summary 266
Fat Replacement Strategies Are Available 227 Study Questions 267
Fat Is Hidden in Some Foods 229 Annotated References 267
Wise Use of ReducecHat Foods Is Important 229 Take Action Protein and the Vegetarian 269
Case Scenario Follow-Up 230
Summary 230
Take Action /lketing Protein Needs When Dieting to lose Weight 270
Study Questions 231
8 Alcohol 271
Take Action Are You Eating o Diet That Includes Many Saturated
Fat and Trans Folly Acid Sources? 233 Chapter Outline 271
Case Scenario 271
Take Action Applying the Nutrition Facts Lobel lo Your Daily Food
Choices 234
Alcohol- An Introduction 272
7 Proteins 235 How Alcoholic Beverages Are Produced 273
Chapter Outline 235 Alcohol Metabolism 274
Case Scenario 235 Alcohol Dehydrogenase Palhway 276
Refresh Your Memory 236 Microsomal Ethanol Oxidizing System (MEOS) 277
Chapter Objectives 236 Catalasr Palhway 277
Proteins-Vital to Life 236 Benefits of Moderate Alcohol Use 278
Amino Acids 237 Health Problems from Alcohol Abuse 278
Amino Acid Form and Function 237 A 0 :.er look at Cirrhosis 281
Tronsominotion and Deommotion 238 Why Does Alcohol Abuse Typically Lead to Cirrhosis? 281
Essential and Nonessenhal Amino Acids in Perspective 238 Expert Opinion Alcohol and Nutrition
Proteins-Amino Acids Bonded Together 240 Charles H Hoisted. M.D 282
Protein Synthesis 24 I Guidance Regarding Alcohol Use 282
Protein Organization 244 Alcohol Dependency and Abuse 284
Denaturation of Proteins 244 Geneltc Influences 284
Protein Digestion and Absorption 245 The Effect of Gender 284
Digestion 245 Ethnicity and Alcohol Abuse 284
Absorption 247 Other Condil1ons 285
Functions of Proteins 248 How Is Alcoholism Diagnosed? 285
Producing Vital Body Structures 248 Do You Have o Problem with Alcohol? 286
Protein Turnover -Adopting to Changing Condition 248 Treatment of Alcoholism 286
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Nutrition Focus Binge Drinking 287 Annotated References 291

Case Scenario Follow-Up 290 Ta ke Action Could You or Someone You Know Have a Problem
Summary 290 with Alcoholism? 293
Study Questions 291 Take Action Investigate the Energy Cost of Alcohol Use 294
PART THREE THE VITAMINS AND MINERALS 295

9 The Fat-Soluble Vitamins 295 Vitamin D in Foods 3 12
Vitamin D Needs 31 3
Chapter Outline 295
Vitamin [}Deficiency Diseases313
Case Scenario 295
Refresh Your Memory 296 Expert Opinion Miracle Vitamin D: Importance for Bone Health
Chapter Objectives 296 and Prevention of Common Cancers, Autoimmune Diseases,
Vitamins: Vital Dietary Components 296 and Other Disorders Michael F. Halick, Ph.D., M.D. 3 T4
Historical Perspective on the Vitamins 297 Pharmocologic Use of Vitamin D Analogs 315
Storage of Vitamins in the Body 298 Upper Level for Vitamin D 316
Vi tamin Toxicily 298 Vitamin E 31 6
Molobsorplion of Vi tamins 298 Natural and Synthetic Vitamin E 316
The Fat-Soluble Vitamins 299 Absorption, Transport, Storage, and Excretion of Vitamin E 317
Absorption of the Fat-Soluble Vitamins 299 Functions al Vitamin E 317
Distribution of the Fat-Soluble Vitamins 300 Vitamin E in Foods 320
Vitamin A 300 Vitamin E Needs 320
Absorption, Transport, Storage, and Excretion of Vitamin A 301 Vitamin E-Deficiency Diseases 321
Cellular Relinoid·Binding Proteins 30 l Upper Level for Vitamin E 321
Retinoid Receptors in the Nucleus 302 Vitamin K 322
Functions al Vitamin A 302 Absorption, Transport, Storage, and Excretion of Vitamin K 322
Vitamin A Analogs for Acne 304 Functions of Vitamin K 322
Possible Carotenoid Functions 304 Dietary Sources of Vitamin K 323
Vitamin A in Foods 305 Vitamin K Needs 323
Vitamin A Needs 306 Vitamin K-Deficiency Diseases 324
Vitamin A-Deficiency Diseases 306 Nutrient Supplements: Who Needs Them
Nutrition Focus
Upper Level for Vitamin A 307 and Why? 326
Vitamin D 309 Ca se Scenario Follow-Up 330
Vitamin D3 Formation in the Skin 3 10 Summary 330
Absorption of Vitamin D2 from Food 310 Study Questions 331
Metabolism, Transport, Storage, and Excretion of Vitamin D 310 Annotated References 331
Functions of Vitamin D 310 Take Action Preservation of Vitamins in Foods 333
Toke A ction A Closer Look ot Supplement Use 334
1 0 The Water-Soluble Vitamins 335

Chapter Outline 335
Ca se Scenario 335
G eneral Properties of the Water-Soluble Vitamins 336
B-Vitami n and Vitamin C Status of North Americans 337
Enrichment and Fortification of Foods with B-Vitamins 337
Thiamin 338
Absorption, Transport, Storage, and Excretion of Thiomin 338
Functions of Thiamin 338
Thiomin in Foods 340
Thiomin Needs 340
Thiomin·Deficiency Diseases 340
x Contents
RiboRavin 341 Vitamin C 365

Absorption Transport, Storage, and Excretion of Riboflavin 34 1 Absorption. Transport, Storage, and Excrehon of
Functions of Riboflavin 34 1 Vitamin C 365
Riboflavin in Foods 342 Functions of Vitamin C 365
Riboflavin Needs 34 2 Vitamin C in Foods 367
Riboflovin-Def1c1ency Diseases 343 Vitamin C Needs 367
Niacin 343 Vitamin C-Deliciency Diseases 368
Absorption, Transport, Storage, and Excretion of Niacin 343 Vitamin C Intake above the RDA 368
Functions of Niacin 343 Upper Level for Vitamin C 368
Niacin in Foods 344
Expert Opinion Vitamin C Antioxidant and ProOxidont Functions
Niacin Needs 346
ond the Keystone of Tight Control Mork Levine, M. D , and
Niacin-Def1ciency Diseases 346
Sebastian} Padayolty. M.R.C.P., Ph.D. 372
Pharmacologic Use of Niacin and Upper Level for Niacin 346
Panfothenic Acid 347 Nutrition Focus Vitamin-like Compounds 374
Summary 376
Absorption, Transport, Storage, and Excretion of Pantothenic Acid 347
Study Q uestions 376
Functions of Pontolhenic Acid 348
Pantothenic Acid in Foods 348
Pantothenic Acid Needs 34 8 Take Action Spolling Fraudulent Claims on the Internet 379
Pantothenic Acid Deficiency Diseases 349 Take Action Spolting Fraudulent Claims in Popular Books for Sole
Biotin 349 al Health·Food Stores and Bookstores 380
Absorption Transport, Storage, and Excretion of Biotin 349
Functions of Biotin 349
Sources of Biotin: Food and Microbial Synthesis 350 I I Wate r a nd the Major Minerals 381
Biotin Needs 350
Biotin-Deficiency Diseases 350 Chapter Outline 381
Vitamin B-6 351 Case Scenario 381
Absorption, Transport, Storage, and Excretion of Vitamin B-6 351 Refresh Your Memory 382
Functions of Vitamin B-6 351 Chapter Objectives 382
Vitamin B-6 in Foods 352 Water 382
Vitamin B-6 Needs 353 Water in the Body-Intracellular and Extracellular Fluid 383
Vitamin B-6-Deficiency Diseases 353 Functions of Water 386
Phormocolog1c Use of Vitamin B-6 and Upper Level for Water in Foods 387
Vitamin B-6 353 Water Needs 387
Folate 354 Water·Deficiency Diseases 387
Absorption, Transport, Storage, and Excretion of Folale 355 Wolei Toxicity 391
Funchons of Folate 355 Minerals 392
Folote in Foods 356 Absorption, Tronspo1t, and Excretion of Minerals 392
Folate Needs and Dietary rolote Equivalents 356 runctions of Minerals 393
Folote-Deficiency Disease 356 Food Sources of Minerals 394
Case Scenario Follow-Up 359 North Americans al Risk for Mineral Deficiencies 394
Upper level for Folate 359 Toxicity of Minerals 394
Vitamin B-12 359 Sodium (No) 395
Absorption Transport, Storage. and Excretion of Vitamin B-1 2 360 Absorption. Transport, Storage, and Excretion of Sodium 395
Functions of Vitamin B-12 362 Functions of Sodium 395
Vitamin B-12 in Foods 362 Sodium 1n Foods 395
Vitamin B-12 Needs 362 Sodium Needs 396
Vitamin B-12-0eficiency Diseases 362 Sodium·Deficiency Diseases 396
Choline 363 Upper Lev~! for Sodium 396
Absorption, Transport, Storage. and Excretion of Choline 364 Potassium (K) 397
Functions of Choline 364 Absorption Transport, Storage, and Excretion of Potassium 397
Choline in Foods 364 runctions of Potassium 397
Choline Needs 364 Potassium in Foods 397
Choline-Deficiency Diseases 364 Potassium Needs 397
Upper Level for Choline 364 Potossium·Deficiency Diseases 398
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Chloride (Cl) 398 Iron in Foods 432

Absorption T-:insp t, Storage, and Excretion cf Chloride 398 Iron Needs 432
Functions ol Chloride 398 lron-Oelic1ency Diseases .:132
Chloride in Foods 399 Uppr •vel ' Iron .d 34
Chlo1ide Needs 399 Expert Opinion I on Overload: Too Much of a Good Thing
Chloride-Delic1ency Diseases 399 801bora A B owman, Ph.D. and Giuseppina Imperatore, M.D.,
Upper L~ve lo• Chloride 399 PhD 436
Nutrition Focus lv1inerols and Hypertension 400 Zinc (Zn) 435
Expert Opinion A Close Look at the DASH Diet Absorption -ronsport, Storage, and Excretion of Zinc 435
Marlene Most PhD., RD.. F.A.D.A. 403 Functions of Zinc 436
Calcium (Ca) 404 zinc 1n Foods 437
Absorption Transport , Storage, and Excretion of Calcium 404 Zinc Needs 437
Functions of Calcium 406 Zinc-Deficiency Diseases 438
Calcium in Foods 4 10 Upper Level for Zinc 438
Calcium Needs 4 l 1 Copper (Cu) 439
Colcium·Deficiency Diseases 4 l 1 Absorption Transport, Storage, and Excrelion of Copper 439
Upper Level lor Calcium 4 14 Functions of Copper 439
Cose Scenario Follow-Up 415 Copper in Foods 440
Phosphorus (Pl 415 Copper Needs 440
Absorption ~ronsporl Storage, and Excretion of Phosphorus 4 15 Copper-Deficiency Diseases 440
Funaions of Phosphorus 4 15 Up~1 L1 ·vel fc.r C pper 440
Phosphoius in Foods 416 Selenium (Se) 441
Phosphorus Needs 4 16 Ab! ti n 1i or .port, Sloroge, and Excretion of Selenium 44 1
Phosphorus·Deliciency Diseases 4 16 functions of Selenium 4.d 1
Uppe. le 01 Ph.:> .pl •rvs 4 16 Selenium 1n Foods 44 1
Magnesium (Mg) 416 Sele111um Needs 44 1
Absorplr ~ 01" p I ~t:>roge and Excretion of Magnesium 416 Seleniu~Def1ciency Diseases 442
Functions ol Magnesium 4 17 Jpp I rJI ~lenium 443
M.ognesium in Foods 417 Cose Scenario Follow-Up 443
M.ognes1um Needs 4 17 Iodide (I) 443
Magnesium-Deficiency Diseases 417 Absorption Tronsport, Storage, and Excretion of Iodide 443
Upper level lor Magnesium 4 I 8 Functions of Iodide 444
Sulfur (S) 418 Iodide in Foods 444
Summary 420 Iodide Need~ 444
Study Questions 420 Iodide-Deficiency Diseases 444
Annotated References 420 Upper level for Iodide 445
Fluoride (Fl 446
Toke Action How High Is Your Sodium Intake? 423
Absorption Transport, Storage, and Excretion of Fluoride 446
Toke Action Working for Denser Bones 423 Functions ol Fluoride 446
Fluoride 1n Foods 447
Fluo11de Needs 447
12 Trace Minerals 425 Jpp vt>l 1 r t luonde 447
Chapter Outline 425 Chromium (Cr) 447
Case Scenario 425 Ab.orpllon Tor part Storage and Excretion of
Refresh Your Memory 426 Chromium 447
Chapter Objectives 426 Functions ol Chromium 448
Trace Minerals-An Introduction 426 Chromium in Foods 448
Research on Trace Minerals 427 Chrom·um Needs 448
Difficulties in Studying Tro ., Minerals 427 Chro 1um·Deficiency Diseases 448
Trace Mineral Needs 427 Manganese (Mn) 448
Sources nf Troce Minerals 428 Molybdenum (Mo) 449
Iron (Fe) 428 Ultratroce Minerals 449
Absorption Transport, Storoge, and Excretion of Iron 428 Boron IB) 449
Functions of Iron 431 Nickt>l INI) 452
xii Contents
Silicon {Si) 452

Nutrition Focus Nutrition and Cancer 454
Arsenic (Asl 4 5 2
\tonod'ull" (V 453 Toke Action Analyze Iron and Zinc Intake in a Sample Vegan
Summary 461
D1e1 464
Study Questions 461 Toke Action Check Out Your Municipal Water Supply 464
PART FOUR ENERGY BALANCE AND IMBALANCE 465

1 3 Energy Balance and Weight Control 465 Energy Imbalance 482
Chapter Outline 465 Estimating Body Fol Content and Diagnosing Obesity 482
Case Scenario 465 Using Body Moss Index lo Define Obesity 4 84
Refresh Your Memory 466 Using Body f-ol Distribution lo Further Evaluate Obesity 486
Chapter Objectives 466 Why Some People Are Obese-N ature Versus
Energy Balance 466 Nurture 487
Positive ond Negohv~ Energy Balance 467 How Doe> Nature Conlribute to Obesity? 488
Energy Intake 467 Does the Body Hove o Set Point for Weight? 488
Energy Output 46Q Does Nurture Hove o Role? 4 89
Boso1 "' <>fobo 15• 4t-9 "'atu " Jr :l Nurtur.:. -ogelher 489
Determination of Energy Use by the Body 472 Treatment of Overweight and Obesity 490
Direct ond r .:lir• t Ca1or1mdry 472 What to L, '~ for 1r o <;o,md We1ghHoss Pion 490
Estimote5 al Er 1Y N d 472 Wishful Shrinku19-Why Con'I Quick Weight Loss Be t\Aostly
Why Am I Hungry? 473 fot? 492
H 1pothalamus I ey Sotit>ty Regulator 475 Werght Cycling Is All Too Common 492
Satiety Regulation at Other Body Siles 476 Wf 3ht l 1r Perspective 493
Control of Feeding through Body Composition 476 Control of Energy Intake: The Main Key to Weight Loss and
Hormones That Affect Satiety 476 Weight Maintenance 493
Nutrients in the Blood Thot Affect Satiety 477 Regular ~hysicol Activity: A Second Key to Weight Loss and
Does Appelite Regulate Whal We Ear? 477 Especrally Important for Loter Weight M aintenance 494
Hunge1 and Appetite 1n Per ,peclive 477 Behavior Modification: A Third Strategy for W eight
Estimation of a Healthy Weight 478 Loss 495
Using Body Moss Index IBMJl 10 Set Healthy Weight 478 Relapse Prevention Is Important 498
Soc.101 Support Aids Behoviorol Change 498
Expert Opinion Sorting Out Sotiely and Weight Regulation.
Hormones and D1elory Mocronulrienfs Nutrition Focus Popular Diets-Why All the Commotion? 499
Pe/et). Hovel, D. V.M .. Ph.D. 479 Cose Scenario Follow-Up 502
Pulling Healthy Weight into Perspective 481 Professional Help for Weight Loss 502
Medications for Weight Loss 502
Tr~otmenr of S. vcre Obesity 503
Treatment of Underweight 505
Summary 506
Study Questions 507
Toke Action A C •s0 Looi at Your Weight Status 509
Toke Action An Action Pion to Change or Maintain Weight
Stolu 509
I 4 Nutrition for Fitness and Sports 51 5

Chapter Outline 515
Cose Scenario 515
The Close Relationship between Nutrition and Fitness 516
www.mhhe.com/wardlawpers7 xiii
Designing a Fitness Program 518 15 Eating Disorders: Anorexia Nervosa,

Phase l · Getting Storied Means Getting Going 518
Bulimia Nervosa, Binge-Eating Disorder,
Phase 2: Achieving and Maintaining Even Greoler Physical
Fitness 518 and Other Conditions 553
Energy Sources for Muscle Use 521 Chapter Outline 553
Adenosine Triphosphote IATP)-lmmediotely Usable Energy 521 Case Scenario 553
Phosphocreotine: The lnifiol Resupply of Muscle ATP 521 Refresh Your Memory 554
Glucose: Major Fuel for Shorl·Term, Hlgh·lnlensity and Medium-Term Chapter Objectives 554
Exercise 522 From Ordered to Disordered Eating Habits 554
Fat: The Main Fuel for Prolonged low-Intensity Exercise 526 Food: More Thon Just a Source of Nutrients 555
Prolein A Minor Fuel Source, Primarily for Endurance Exercise 527 Overview of Anorexia Nervosa and Bulimia Nervoso 555
The Body's Response to Physical Activity 528 Is There a Genetic Connection to Eating Disorders? 559
Specialized Functions of Skeletal Muscle Fiber Types 528 Anorexia Nervosa 559
Adaptation of Muscles and Body Physiology lo Exercise 528 Nutrition Focus The Personal Side of Eating Disorders 560
Power Food: Dietary Advice for Athletes 529 Profile of the Typical Person with Anorexia Nervosa 562
Energy Needs 529 Early Warning Signs 562
Carbohydrate Needs 530 Physical Effects of Anorexia Nervoso 563
Fol Needs 533 Treatment of Anorexia Nervosa 565
Prolein Needs 534 Case Scenario Follow-Up 567
Vi!amin and Mineral Needs 534 Bulimia Nervosa 568
Expert Opinion Does Increased Physical Aclivily Necessitate Typical Behavior in Bulimia Nervosa 568
Anlioxidonf Supplements? Priscilla M. Clarkson, Ph.D. 536 Heallh Problems Stemming from Bulimia Nervoso 570
A Focus on Fluid Needs 537 Treatment of Bulimia Nervosa 570
Fluid Replacement Strategies 539 Eating Disorders Not Otherwise Specified (EDNOSJ 571
Use of Sports Drinks 539 Binge-Ealing Disorder 572
Specialized Dietary Advice for before, during, and after Other Examples of Disordered Eating 573
Endurance Exercise 540 Expert Opinion The Female AthleJe Triad
Replenishing Fuel during Endurance Exercise 541 Jackie Berning, Ph.D., R.D. 574
Carbohydrate Intake during Recovery from Prolonged Exercise 542 Prevention of Eating Disorders 574
Case Scenario Follow-Up 543 Organizations to Help You Understand More about Eating
Nutrition FocusEvaluating Ergogenic Aids to Enhance Athletic Disorders 576
Performance 544 Summary 577
Summary 546 Study Questions 577
Study Questions 546 Annotated References 578
Annotated References 546 Toke Action Assessing Risk of Developing on Eating Disorder 579
Take Action Meeting the Protein Needs of on Athlete-A Cose Toke Action Helping Prevent Eating Disorders 580
Study 548
How Physically Fit Are You? 550
Take Action
PART FIVE NUTRITION APPLICATIONS IN THE LIFE CYCLE 581

1 6 Pregnancy and Breastfeeding 581 Refresh Your Memory 582
Chapter Outline 581 Chapter Objectives 582
Case Scenario 581 Planning for Pregnancy 582
Prenatal Growth and Development 583
Early Growth: The First Trimester Is a Very Critical Time 584
Expert Opinion Folic Acid Intervention: Public Health Outcomes
lynn 8. Boiley. Ph.D. 586
Second Trimester 587
Third Trimester 588
Definition of a Successful Pregnancy 589
Increased Nutrient Needs to Support Pregnancy 590
Increased Energy Needs 590
xiv Contents
Adequate Weight Goin 590 Development ol Feeding Skills in Older Infants 626
Increased Protein and Carbohydrate Needs 592 lntroduct in ,f 'X.liJ fo...ds al About 6 tv\onrhs of Age 628
Increased Vitamin Needs 592 Case Scenario Follow-Up 631
Increased Mineral Needs 592 H'lalth Pr· 1bl~ •ms Retot~ to Infant Nutriliol" 632
Is there on lnsl1nctive Drive During Pregnancy to Consume Nv::ma Preschool Children: Nutrition Concerns 634
Nurienl ? 593
Nutrition Focus Food Allergies ond lntoleronces 635
Food Plan for Pregnant Women 593 Helping ') Cl iild Choose Nutritious Foods 637
Use of P•enotol Vitamin and Mineral Supplements 595 Childhood Feeding Problems 638
Pregnant Vegetarians 595 Use of Multiv1lomin ond Mineral Supplements 641
Effect of Nutritional Status on the Success of Pregnancy 595 Other Nulrilionol Problems in Preschool Children 642
Prenatal Care and Counseling 596 Modifico11ons of Childhood Diets lo Reduce Future Disease Risk 643
Cose Scenario Follow-Up 597 School-Age Children: N utrition Concerns 644
Physiological Changes of Concern d uring Pregnancy 597 Breakfast Fol Intake and Snacks 644
Heartburn, Constipation and Hemorrhoids 597 Type 2 Diabetes 646
N utrition Focus Effects of Other Factors on Pregnoncy Overweight and Obesity 646
Outcome 598 Expert Opinion Are Sowy Marketers Contributing to the Obesity
Edema 601 Ep1dem1c.. in Children?
Morning Sickness 601 Coro/ Byrd-Bredbenner. Ph D. R D F.A D.A 648
Anemia 602 The Teenage Years: Nutrition Concerns 650
Gestational Diabetes 602 Nu rilionol Problems ond Concerns of Teens 650
Pregnonc 1-lnduced H 1pertension 602 A Closer Look al the Diets of Teenage Girls 651
Breastfeeding 603 Helping Teens Eot More Nutritious Foods 65 l
Ability to B1eoslfeed 603 Working with the Teenage Mind-Set 652
Production of Human Milk 604 -<>enog 1nochn9 Practices 652
Let-Down Reflex 605 Summary 653
Nutritional Guo! 1ties of Human Milk 606 Study Questions 653
Food Pion for Women Who Breastfeed 606 Annotated References 654
Breastfeeding Today 608
Take Action Gt:tt1n9 Young Bill to Eot 655
Environmental Contaminants in Human Milk 610
The BreostfeAding of Preterm Infants 6 10 Take Action Evoluoling o Teen lunch 656
Summary 611
Study Questions 6 11 1 8 Nutrition during Adulthood 657
Annotated References 61 2
Chapter Outline 657
Take Action Torgeting Nutrients Necessary For Pregnont Case Scenario 657
Women 613 Refresh Your M emory 658
Take Action Pulling Your Knowledge obout Nutrition ond Chapter Ob jectives 658
Pregnancy to Work 6 I4 Nutrition and Adulthood: A n Introduction 658
Compression of Morbidity 659
A Diet for the Adult Years 660
1 7 Nutrition from Infancy Through A Closer Look at Middle and Older Adulthood 661
Adolescence 6 15 Life ~pon 66
Chapter Outline 615 Lile Expectancy 66 1
Case Scenario 6 15 The Graying of North America 662
Refresh Your Memory 616 -t e "' !fin r on ....I Aging 662
Chapter Objectives 6 16 Nutritional Implications of Aging 663
Nutrition and Child Health: An Introduction 616 Decrw ;ed Appetite and Food Intake 663
Infant Growth and Physiological Development 617 Decline 1r1 Dental Health 666
The Growing Infant 6 l 7 Reduced Thirst Sensation 666
Effect of Undernutrition on Growth 618 Foll in Gastrointestinal Traci Function 666
Assessment of Infant Growth and Development 618 Changes in Liver, Gallbladder and Pancreallc Funclion 666
Brain Growth 620 Decline in Kidney Function 667
Adipose Tissue Growth 620 Reduced Immune Function 667
Failure lo Thrive 620 Reduced Lung Function 667
Infant Nutritional Ne ds 62 l Reduced Hearing and Vision 667
Formula Feeding fo1 Infants 625 DecreosP. in Leon Tissue 668
www.mhhe.com/wardlawpers7 XV
Increases in Fat Stores 669 Community Nutrition Services for Older Adults 682
Reduced Cardiovascular Health 669 Expert Opinion Nutrition and Healthy Aging
Decline in Bone Health 669 Katherine Tucker, Ph D 680
Other Factors That lnffuence Nutrient Needs in Aging 670 Case Scenario Follow-Up 684
Depression in Older Adults 670 Summary 685
Alcoholism in Older Adults 671 Study Questions 685
Alzheimer's Disease 672 Annotated References 685
Nutrition FocusComplementary and Alternative Medicine Toke Action Am I Aging Healthfully? 687
Practices 673 Toke Action Helping Older Adults Eat Better 688
Nutrient Needs and Dietary Planning in Middle and Older
Adulthood 679
PART SIX PUTTING NUTRITION KNOWLEDGE INTO

PRACTICE 689
Approval for a New Food Addilive 712
19 Safety of Food and Water 689 Common Food Additives 71 3
Chapter Outline 689 Risks of Food Additives 717
Case Scenario 689 Substances That Occur Naturally in Foods and Can Cause
Refresh Your Memory 690 Illness 717
Chapter Objectives 690 Environmental Contaminants in Food 718
Safety of Food and Water: Setting the Stage 690 Lead 718
What Are the Effects of Foodborne Illness? 691 Dioxin 719
Why Is Foodborne Illness So Common? 691 f'.lo.ercury 719
Food Preservation: Post, Present, and Future 694 Urethane in Some Alcoholic Beverages 719
Foodborne Illness: When Undesirable Microorganisms Alter Polychlorinoted Biphenyls IPCBsJ 720
Foods 695 Cadmium 720
General Rules for Preventing Foodborne Illness 695 Protection lrom Ev1ronmental Toxins in Foods 720
Expert Opinion Food Safety Why Should You Core? Our Water Supply: Safety Issues 720
Lydia Medeiros Ph.D, RD 701 Bottled Wa ter 721
A Closer Look at the Primary Microorganisms That Couse Monitor ing the Safety of Your Water 721
Foodborne Illness 703 Options Regarding Your Water Source 722
Case Scenario Follow-Up 710 Nutrition Focus Pesticides in Food 723
Food Additives 711 Summary 725
Uses of food Addilives 711 Study Questions 726
Intentional versus Incidental Food Addi tives 71 l Annotated References 726
The GRAS list 711
Toke Action Con You Spot the Improper Food Safety
Synthetic Compounds 712
Practices? 728
Tests of Food Additives for Safety 71 2
Take Action Toke o Closer Look at Food Additives 728
20 Undernutrition Throughout the World 729

Chapter Outline 729
Cose Scenario 729
World Hunger: A Continuing Plague 730
World Hunger Today 731
Critical L1le Stages When Undernutrition Is Devastating 734
General Effecls of Semislarvotion 736
Cose Scenario Follow-Up 737
xvi Contents
Undernutrition in the United States 737 Appendixes A-1

Helping lhe Hungry in the Uniled Slotes 737
Socioeconomic Foclors Reloted to Undernulrifion 7 40 A Chemistry: A Tool for Understanding Nutrition A -1
Possible Solutions to Poverty ond Hunger in lhe United Stoles 7 41 B Detailed Depictions of Glycolysis, Citric Acid Cycle, Electron
Undernutrition in the Developing World 7 42 Transport Chain, Classes of Eicosanoids, and Homocysteine
Metabolism A -26
Food/Populohon Reho 74 2
War and Polil1col/Civil Unrest 7 44 C Human Physiology: A Tool for Understanding
Nutrition A -31
Rapid Depletion of Nolurol Resources 7 44
Inadequate Sheller and Sonilolion 7 45 D Dietary Advice for Canadians A-56
High External Debt 7 47 E The Exchange System: A Helpful Menu-Planning Tool A -65
The Impact of AIDS Worldwide 7 47 F Exchange System Lists A-70
Reducing Undernutrition 1n the Developing World 7 49 G Dietary Intake and Energy Expenditure Assessment A-78
H Fatty Acids, Including Omega-3 Fatty Acids, in Foods A -89
Expert Opinion Alleviating Food Insecurity and Hunger I The 1983 Metropolitan Life Insurance Company Height-
Hugo Melgar.Quinonez, M.D, Ph.D., and Weight Table and Determination of Frame Size A-91
Ano Claudio Zubieto, Ph.D 752 J Nutrition Calculations A-94
Nutrition Focus The Role of Biolechnology in Expanding K Sources of Nutrition Information A-97
Worldwide Food Availability 754 L English-Metric Conversions, and Metric and Household
Some Concluding Thoughts 751 Units A-101
Summary 756 M Estimated Average Requirements for Nutrients A-103
Study Questions 757 N Food Composition Table A-106
Take Action Fighting World Undernutrition on o Personal
level 758 Glossary G -1
Toke Action joining the Batlle against Undernutrition 758 Credits C-1
Index 1-1
a out t e out ors
Gordon M. Wardlaw, Ph.D., R.D., most recently taught introductory nutr1uon
courses to students in the Department of Human Nutrition at The Ohio State
University. He has recently retired from teaching, but remains active in the field.
Dr. Wardlaw is the author of many articles that have appeared in prominent nutrition,
biology, physiology, and biochemistry journals and was the 1985 recipient of the
American Dietetic Association's Mary P. Huddleson Award. Dr. Wardlaw is a member
of the American Dietetic Association, member of rhe American Society I-Or Nutritional
Sciences and is certified as a Specialist in Human Nutrition by d1e American Board of
Nutrition.
Jeffrey S. Hampl, Ph.D., R.D., teaches coursework in public health nutrition in

the Department of Nutrition at Arizona State University. Prior to his university
appointment, Dr. Hamp! worked as a nutritionist with rhe Special Supplemental
Nutrition Program for Women, Inf.ants, and Children (WIC) and as an outpatient
dietitian in a major medical center. Dr. Hampl's research, which has been funded by
rhe U.S. Department of Agriculture and the State of Arizona, focuses on the nutri-
tional status of resource-constrained children and their families, and he has published
articles in leading nutrition and medical journals. The winner of the 2002 Dannon
Award for Excellence in Communiry Nutrition, Dr. Hampl is a member of the
American Dietetic Association, the American Public Health Ac;sociation, and the
American Society for Nutritional Sciences. He is also a spokesperson for the American
Dietetic Association and was d1e lead author for the Association's position paper on
disease prevention and health promotion.
xvii
TO THE INSTRUCTOR
Because you teach nutrition, you w1doubtedJy find it a fasci - dents can apply tl1e knowledge they gain to improve their
nating and challenging subject. You probably also find that health . Throughout the chapters, we strive for the same objec-
reaching nua-ition is a challenge in and of icself. Claims and tive as many of om colleagues, to educate students to become
counterclaims abound regarding the need for certain dietary judicious consumers of both food and nutrition information.
components. For example, one group of researchers promotes We seek to help students son through the wealtl1 of nutrition
a reduction in salt intake for the general population as a means information and misinformation available to them. This text is
of preventing hypertension. Other researcherl> assert that designed to help them better understand and evaluate the
despite excess salt intakes, most North Americans maintain nutrition information tl1e~· encounter on cereal box labels, arti-
normal blood pressure values. This appan.:nt dichocomy only cles in popu lar magazines, nutrition- and diet-related websites,
adds to the challenge of teaching in a rapidly changing field. guiddines issued by government agencies, and more.
As textbook authors, we understand the importance of pro- Once students have achieved a solid working knowledge of
'~ding accmate, balanced, and up-to-dare coverage of nutrition nutrition, our goal is to assist tl1em in assessing their personal
topics, particularly those that are controversial. To provide stu- nutrition needs ratl1er tl1an strictly adJ1ering to every guideline
dents with a sound introduction to the study of nutrition, we issued for an entire population. After all, a population by defi-
draw on as many reliable sources as possible. This se\'enth edi- nition includes a scope of varying genetic and cultural back-
tion of Penpcctivcs i11 N1ttrition reflects new material from the grounds along \.Vith varying responses to diet.
recently published Dietary Reference intakes by the Food and A~ a final note, we know that students often come to this
Nutrition Board, articles in major nutrition and medical jow·- course witl1 many preconceptions and questions about nutrition
nals and leading nut1irion and health newsletters, and chapters "hot topics." To address students' concerns, we have included
in Modern Nutrition in Health and Disease, edited by Maurice coverage of topics that touch their lives: earing disorders, nutri-
Shils and his colleagues. We constantly scour the literature with tional supplements, phytochemicals, vegetarianism, diets for ath-
the goal of pro,·iding clear and balanced perspectives on recent letes, popular (fad) diets, and complementary and alternative
research so that you and your students can better trnderstand medical practices. (Sec the Chapter Highlights section of this
and participate in the debates of current mrn·ition issues. preface for examples.) RegardJess of the topic, the overall empha-
sis remains the same-the importance of understanding one's
food choices and diet practices to best meet personal needs.
Personalized Approach to Nutrition
A prominent theme in nutrition today is individuality. Intended Aud ience
Nutrition advice is not a one-size-fits-all proposition. For
example, not all people find that saturated fat in their diet rais- We have developed this book with nut1irion and science majors
es their blood cholesterol values above recommended stan- in mind. The chemistry, biochemistry, and physiology present-
dards. Individuals respond differently, often idiosyncratically, to ed in tl1e text assume that students have bad at least some col-
certain nutrients. The goal of understanding how nutrients lege-level science. Because this course often attracts students
af}ect people as individuals is a key objective of this text. from a fairly broad range of majors, we have been careful to
Moreover, e,·en at this introductory level, we do not assume include examples and explanations that are relevant to nutri-
that all nutrition students are alike. We incorporate opportuni- tion, health education, human ecology, human performance,
ties, sucl1 as the Take Action activities, for srudents to learn nmsing, and other health-related majors. For students who
more about their own health and nutrition. Tn this way, stu- \visb to learn more or need assistance witl1 tl1e science involved
xix
xx Pre Face
in metabolism and body systems, additional information can be Chapter 1 W hat Nourishes You?
found in Appendix A, Chemjsrry: A Tool for Understanding
Ne\\' figu re 1-1 on rwo views of macronutrients and new
Nutrition :md Appendix C, Human Physiology: A Tool for
Figme 1-2 on the proporcion of nutrients in d1e human
U nderstanding Ntmicion.
body more clearly convey these important concepts.
Previous table on the benefits and risks of diet habits has been
Key Revisions to the Seventh Edition converted into figure 1-5.
New Figure 1-6 on the scientific method now uses as an
Creating a textbook is a dynamic process. Rather than simply example the efficacy of d1e Atkins diet.
updacing fucts and numbers with each new edition, we seek to New Expert Opinion by Dr. Robert DiSilvestro discusses the
be responsi,·e to changing instructor and student needs. We use of research methods ro answer the question of whedier
challenge oul'selves to take a fresh look at each new cdjtion to calcium intake influences weight regulation.
find ways to refine and improve the book and make it a better New Figu re 1-8 shows rui herbal supplement label ro illustrate
teachlng rool all around. ~!any of the new featu res in the sev- the FDA disclaimer on such products.
enth edition are a direct result of feedback we have received
from instructors. Their advice on the level and presentation of Chapter 2 The Basis of a Healthy Diet
science has been invaluable. We have also learned a great deal New Expert Opinion by Dr. Barbara Roils discusses energy
from the students in the comses we reach. Their feedback can density.
be seen in improved illustrations and clearer discussions of dif- Figure 2-1 o n nutrient density has been revised to include
ficult concepts. equal volume compru·isons.
Chapter content on the MyPyramid and d1c 2005 Dietary
Gu idelines for Americans was totally rewritten ro reflect
Up-to-Date Nutrient Guidelines
d1c latest government advice. MyPyramid is introduced
A major component of this revision involves the continual and aJJ its components arc discussed, including discre-
updating of darn and discussions related to d1e latest Diet~1ry tionary calories.
Refercn"c Intakes. Chapter content has also been rewrim:n The 2005 Dietary Guidelines for AJnericans have been sum-
throughout to reflect advice provided by MyPyramid and the marized into three major points in the chapter content.
2005 Dietary GuidcliJics for Americans. The foll list of41 guidelines is detailed in new Figure 2-8.
New Figure 2-9 rcprcs<.:ms a summary of the key information
Improved Science Coverage contained on a Nutrition Facts panel. This figure is part of
the new Nua·icion Focus feature on food labeling .
Throughout the book ,u·e many dynamic new illustrations that
"·ill help students grasp important scientific concepts with Chapter 3 Human Digestion a nd Absorption
greater clarity. Chapters 3 and 4 contain many new digestion Figure 3-4 has been redrawn to be a more realistic and thor-
and metabolism diagrams. Complex subjects sucl1 as glycolysis ough reprcscncacion of the oral cavity and salivary glands.
and the citric acid cycle have been reinterpreted with color and Figure 3-5, process of swallowing; Figure 3-7, anatomy of the
nw1iber sequencing ro belp srudenrs comprehend the steps stomach; Figure 3-11, peristalsis; and Figmc 3-13, smaU
i1wolvcd iJi diese processes. intcstiJ1e, have all been redrawn for realism and clarity.
New Figure 3-10 illustrates die location of sphincters in die
Content Reorganization GI tract.
New Figure 3-15 shows blood circulation in the body.
Take Action activities are no longer specifically cicd to a
New photo shows close-up of villi.
detailed diet analysis early in d1e course. Not having students
New Figure 3- 18 tracks flu.id intake and fluid loss in d1c body.
create a detailed diet analysis in Chapter 2 allows you to assign
Nutrilion Focus box now includes discussion and photos of
a diet analysis project at any time in the course.
gallstones, ulcers, and refl ux disease daniagc:.
The Nutrition Perspective boxes at die end of the chapters
ha,·e been moved into the main chapter discussion. T hey have Chapter 4 Metabolism
been shortened and renamed NuO"ition Focus to indicate d1e
change. Some older essays have been replaced or relocated (see New chapter opening scenario presents a familiar situation
Contents for details). diat college students can more easily identify with.
First half of tbe chapter has been rewritten with the hdp of
Dr. Eugene J. Fenster. His input simplified and clarified
Chapter Highlights the challenging nature of this content.
£\·cry figure in th is chapter is eid1er new or completely
The following is a list of some of the key changes, updates, and redrawn in order ro help studenrs better understand
enhancements tbar h..wc been incorporated into the seventh metabolism. (More detailed views of metabolic parbways
edition chapters. can still be found in Appendix B. )
www.mhhe.com/wardlawpers7 xxi
New figmes more clearly show anabolism and catabolism Chapter 8 Alcohol
(Figure 4 -1 ); the stages of metabolism (Figme 4 -2 ); end Improved Figure 8-1 more clearly demonstrates blood alco-
result of citric acid cycle metabolism (Figure 4-8); anaero- hol concenn·ations.
bic metabolism (Figme 4-12); ( lipolysis (Figure 4-13); Redesigned Figure 8-3 summarizes the effects of alcohol
beta-oxidation of faa:y acids (Figure 4-14 ); ketosis abuse on the body.
(Figure 4 -15 ); metabolism during feasting (Figure 4-21 ); Phoro of a liver affected by cirrhosis has been added.
and metabolism d1u;ng fasting (Figme 4-22). Recommendations for alcohol intake from the 2005 Dietary
New Expert Opinion by Dr. Andrea Buchholtz and Dr. Dale Guidelines for Americans are listed in a margin note.
Schoeller explores the concept of metabolic advantage for Brief mention of the new medication acamprosate ( Campral)
certain dietary patterns. has been added.
Chapter 5 Carbohydrates Chapter 9 The Fat-Soluble Vitamins
New Expert Opinion on the health effects of fiber written by Figure 9-3 has been revised to better show the metabolism of
Dr. Joanne Slavin. vitamin A.
The latest diabetes medications and polycystic ovary syn· New Figure 9-5 demonstrates the effecrs of macular degener-
drome are discussed in the Nutrition Focus foarure on ation on vision.
blood glucose regulation. Figure 9-6 now provides a clearer representation of vitamin D
Tagat0se ii. mentioned as a new alternative sweetener and is metabolism.
added to Figure 5-13, which shows the chemical strucrures New Expert Opinion by Dr. Michael Halick on the impor·
of alternati,·e sweeteners. tance of vitamin D has been added.
Recommendations for carbohydrate intake from the 2005 New Figure 9 -12 summarizes the various antioxidant systems
Dietary Guidelines for Americans are highliglm::d in a mar- and compounds in the body.
gin note. Figure 9-13 on vitamin K metabolism hns been simpli fied.
New Figure 9- l4 explores a logical approach to supplement
Chapter 6 Lipids use.
Figure 6-3 on the fatty acid content of various foods has been
redrawn in an easier-to-understand format. The S•lmc is Chapter 10 The Water-Soluble Vitamins
n·ue for Figure 6-8 on emulsiJiers. Homocysteine discussion has been simplified throughout die
New Figure 6-6 on the classes of eicosanoids has been chapter. (Appcndix B now contains the complete homocys-
added. teinc pathway. )
Figure 6-10, fat absorption, and Figure 6-12, lipopron.:iJ1 Improved Figure 10-7 now shows a more realistic case of
interactions, have been redrawn to include numbered spina bifida.
sequences to assist students in navigating the steps in each Food sources of choline are featured in a margin table.
process. New Expert Opinion by Dr. Mark Levine and Dr. Sebastian
Ne" Table 6-3 summarizes the roles of the various lipopro- Padayatty delves inro the functions of vitamin C.
teins in the body. New Figure l 0-11 summarizes the roles of vitamins in the
New Expert Opinion by Dr. Bernhard Hennig explores the body based on specific cell functions.
etiology of atherosclerosis.
Recommendations for fat intake from the 2005 Dietary Chapter 11 Water and the Major Minerals
Guidelines for Americans are featured in a margin note. Improved Figure 11-1 provides a better visual comparison of
New Table 6-5 shows the trans fat content of common foods. water compartments in the body.
The osmosis discussion has been simplified and is accompa-
Chapter 7 Proteins nied br impro\'ed Figure 11-2.
The discussion of protein turnover was mo\•ed ro a more rele- New Figure 11-3 walks snidenrs through the steps involved
vant position in the middle of the chapter. in sodium flux across the cell membrane.
Improved Figure 7-2 more clearly provide~ an overview of Water content of various foods is featured in a new margin
protein synthesis. table.
Recent findings of the ability of protein to lead tO a state of Figure 11-4 has been updated to reflect the new DRls for
satiety arc mentioned. water.
The discussion of soy has been rewritten to reflect the gener- The hormonal regulation of blood presstu·e has been split into
ally negative results of recent imen·ention trials regarding two figures to make the content easier to grasp (now
soy and bone health, Figure 11 -5 and Figure 11-6).
cholesterol-lowering ability, and treatment of menopausal DRls for sodium, potassium, and chloride throughout chap-
symptoms. ter discussions have been updated.
The discussion of the evaluation of protein quality has been New Expert Opinion by Dr. Marlene Most prO\ides insights
simplified. into the DASH diet.
xxii Preface
Ne\v Figme 11 -9 shows tht! vario us sites of influence o n calci- Chapter 16 Pregnancy and Breastfeeding
um balance in the body.
In Figure 16-1, a close-up of placental circulatio n has been
Latesr methods for d iagnosing osteoporosis and latest medica- added .
tions used to treat the disease are discussed. New Nutrition Pocus featur e looks at the many factors that
New Figure 11-5 shows how bone density d iffers d uri ng a influence pregnancy outcome.
person's lifetime and why p reventing severe bo ne loss is New Expert Opinio n by Dr. Lynne Bailey explains d1e
important.
impor tance of meeting fo late needs before and during
pregnancy.
Chapter 12 Trace Minerals
Food plan for pregnant and lactating women has been re\1sed
Figme 12-1 on iron metabolism has been improved. to reflect the advice proYided in MyPyramid.
New Table 12-2 on the fuctors that affect zinc a bsorption has New margin note shows the stark difference in nutrient com-
been added. posir.ion between cow's milk and human milk.
Redi-awn Figure 12-5 better guides students thrnugb seleni-
um metabolism. Chapter 17 Nutrition from Infancy through
New photo shows mottling of teeth from excess flu oride
Adolescence
exposme.
New Figure 12-7 summarizes d1e roles of tninerals in the Food plans for children .rnd teenagers have been revised to
body based o n specific cell fi.rncrions. reflect the advice provided in My.Pyram id.
The! Nutrition Focus feature that looks at cancer has been New MyPyramid for Kids has been added (fig. 17-6).
moved to this chapter (previo usly in Chapter 10). New Experr Opinion by Dr. Carol Byrd-Bred benner discusses
social trends that are contributing to the epidemic of obe-
Chapter 13 Energy Balance and Imbalance sity in c hi ldren today.
New statistics on the growing problem of O\'erweighr in soci-
ety arc added as a margin note. Chapter 18 Nutrition during Adulthood
Clearer discussion of basal metabolism has been provided. lntrodm:to r y t cx r material has been u pdated to reflect the
Latest estimates for e ne rgy nee&; fro m My Pyramid ar e listed. 2005 Dietary Guidelines fo r Americans.
New Expert Opinion by Dr. Pete r Havel discusses ho rmo nes New Expert Opinion by Dr. Kathe rine Tucker cxplon:s the
and other factors that affect satiety. importance of mt.:eting adult nutrient needs.
Figure 13-18 has been redrawn and expanded to include the New Table 18-3 provides strength training recommendations
ne\\' Lap- Band procedure. for o lder adulrs.
Chapter 14 Nutrition for Fitness and Sports Chapter 19 Food and Water Safety
New Figure 14-1 high lights the benefirs of physical activity. Figure J9 -2 has been updated to reflect the latest recommen-
New Figure 14 -5 illustrates glycolysis. dations o n safe food-holding temperatw·es.
New Figure 14-6 o n metabolism during exercise has been Statistics o n mad cow d isease in North America have been
redrawn and greatly simplified. updated .
New Table 14-3 lisrs fuel use by muscles based on V02 anax New discussio n o n the safety of o ur water supply, a growing
Nevv Expert Opinion by Dr. Priscilla Clarkson addresses tl1e concern in Nord1 America (an.d worldwide), has been
need for antioxidant supplementation b)' athletes. included .
New Table 14-8 shows the nuo·ient content of various energy Listor alternative sweeteners now incl udes tagarose.
bars. Short discussion on cadmium in foods has been added.
Table 1-±-10 has been sho rtened to include onJy the major
ergogenic aids commo nly used roday. Chapter 20 Undernutrition throughout the World
>Jew Take Action box has a tool to assess physical fitness. Updated content includes the pledge by industrialized
nations to forgi ,·e the foreign debt of some developing
Chapter l 5 Eating Disorders: Anorexia Nervosa,
countries and the devastating impact of the o ngoing war
Bulimia Nervosa, Binge-Eating Disorders, and in Darfur.
Other Conditions New Expert Opinio n by Dr. H ugo Melgar-Quinonez and
Ne\v Nutrition Focus feature contains essays o n the personal D r. Ana C laudia Zubieta discusses the effects of food inse-
side of ano rexia nervosa and bulimia nervosa. curity worldwide.
Figure 15-1 summarizes rhe physical effects of ano rexia ner- Statistics regarding the worldwide AIDS epidemic have been
vosa and bu limia nervosa. updated.
The list of medications used in the treatment ofvarious eating New Figure 20-5 summarizes the general approaches to solv-
disorders has been updated. ing tl1e problem of undernurrition \\'Orldwide.
www.mhhe.com/wardlawpers7 :xxiii
Special Acknowledgments Catherine Jen, Wayne State University

Connie Jones, Northmestern State University of Louisiana
We would Like to thank Tom Hudgens for his help with this Younghee Kim, BoJJ1ling Green State Uni11ersity
revision. OUl· editor, Lynne Meyers, supported and assisted us Allen W. Knehans, University of Oklahoma Health Sciences
through every step of the revision and facilitated decisions that Center
arose as we planned and produced the seventh edition. Jodi Mindy Kurzer, University of Minnesota
Rhomberg and Peggy Selle diligcncly monitored the copyedit- Elizabeth Konz, Lexington Community College
ing and production tasks. All these individuals contributed key Robert D. Lee, Central Michigan University
expertise to the project. Linda J. Lolkus, Indiana University Purdite Universi'ty-
Fort Worth
Mary Mead, Univenity ofCalifoniia Berkeley
Thank You to Reviewers Juliet Mevi-Shiflett, Diablo Valle)' College
Gaile Moe, Seattle Pacific University
and Contributors Mohey Mowafy, Northern Michigan University
Kathy Mtmoz, Humboldt Sta,te University
With each edition, our goal remains the san1e: to produce the Judy Myhand, Louisiana State University
mosr accurate, up-to-date, and useful textbook possible. These Jill Patterson, Penn State University
ambitious goals would not be achieved without the meticulous, Roman Paulak, East Carolina University
professional assistance of colleagues who have assisted us in so Debra Pearce, Northern Kentucky University
many ways. Their advice and suggestions have greatly helped Erwina Peterson, Yakima Valley Community College
refine the content of this edition. We owe our sincere thanks to Nirmala V. Prabhu, Edison College
the following individuals: William R.. Proulx, State University of New Yodt College at
Becky Alejandre, American River College Oneonta
Nancy Amy, University of California-Berkeley Elizabeth Quintana, West Virginia U11iversi'ty
Janet B. Anderson, Uta/~ State University Rebecca Roach, Universit')' of Illinois at Urbana-Campaign
Kim Archer, University of Kansas Christian K. Roberts, University of California- Los Angeles
James Bailey, University of Tcnncsee-Kno.,.,,-Pille Brent J. Shriver, Te."Cas Tech University
Diane Beaudry, Shoreline Co~mmi.nity College Joanne Slavin, University ~fMinnesota- St. PaiJ.l
Jacqueline Berning, Unive1·sity of Colorado at Colorntlo Springs Carole A Sloan, Henry Ford Communiry College
Donna Beshgetoor, San Diego State University Mollie Smjth, California State Uni11e1·.rity-Fresno
Jacqueline Buell, The Ohio State Uni11ersity Bernice G. Spurlock, Hinds Comm1mity College
Carol Byrd-BredbetUler, Rittgers Uni11ersity Anthony Stancan1piano, Olllahoma City Gommimity College
Nancy L. C:molty, University of Gear.girt Lydia Steimnan, University of Texas at Austin
Lakshmi N. Cbilukrui, Uni11crsity of California-San Diego Leeann S. Sticker, Northwestern State Uni11ersity of Louisiana
Tina Crook, University of Central A~·kansns Jon Story, Pii.rdue University
Ruth C. Davies, Edison College Robin Sytsma, Solano Comm1mity College
Christine DuPraw, San Diego Mesa College Elsie Takeguchi, Sacramento City College
Eugene J. Fenster, Longview Community College Delores Truesdell, Florida State University
Cindy W. Fitch, West Vir,ginia University Jean Widdison, Salt Lake City Comm11:nity CoJ/ege
Betty J. Forbes, West Vi1;ginia University Jurist Willis, Miami-Dade Commtmity College
Erin Francfort, Idaho State Uni1Jcrsity
Leonard E. Gerber, University of Rhode Island
A Request to Professors Who Use This Book
JiJJ Golden, Orange Coast College
Nanci Grayson, University of Colorado As you might imagine, it is difficult to stay abreast of the vast
Guy E. Groblewski, University of Wisconsin-Madison range of n utrition science, following all the various controver-
Donna V. Handley, Uninrsity of Rhode island sies and new devdopments. We try our best but realize that
Roschelle Heuberger, Central Michigan University sometimes we miss an element that deserves attention. If you
Beckee Hobson, College of the Sequoias find contem that you question or believe warrants further con-
Kevin Huggins, Auburn University sideration, feel free to conract us.
/
xxiii
xxiv Preface
We extend our best wishes for success to you and your Jeffrey Hamp! Ph.D., R.D.
students. Department of Nutrition
Arizona State University
Gordon Wardlaw Ph.D., R.D. 7001 E. Willfams Field Road
P.O. Box 290 Mesa, Arizona 85212
Mendocino, CA 95460 E-mail: jeff.hampl@asu .edu
E-mail: gordonmarkwardlaw@gmail.com
TO THE STUDENT
Cholesterol, sports drinks, food labeling, bulimia nervosa, alter- Pedagogy
native sweeteners, vegetarianism, Salmonella foodborne illness,
and genetically engineered foods-we suspect you have heard The seventh edition of Perspectives in Nutrition incorporates
some important tools to help you learn the nutrition concepts
about these topics. Which topics are important enough tO be a
in this text. Following is a guide to those tools:
consideration in your life or in the life of someone you know?
Americans pride themselves on their individuality. Nutri - 1. Each chapter begins with a Refresh Your Memory box
tional advice should be given accordingly. For example, not all reminding you of previous chapter content (or coursework)
of us have high blood cholesterol and other significant risk fac- that will be helpful to know for understanding the currenr
tors for developing premature cardiovascular disease. The need chapter. Also at the beginning of each chapter is a case sce-
to tailor dietary advice to each person's individual nanire is the nario that allows you to apply knowledge gained from the
basic approach of this book. First, you are given a brief intro- d1apter in a real-life setting. A follow-up to each case sce-
duction to the study of nutrition; second, you are told how to nario is provided in the chapter at the point at which the spe-
be a knowledgeable consumer. With so much information cific content needed to answer the case scenario is covered.
available-both accurate and inaccurate-you should know 2. C hapter O bjectives help you focus your attention on key
how to make informed decisions about your nutritional well- ideas in the chapter.
being. Third, you are encouraged to learn the basic principles 3. Throughout each chapter are boldfaced key terms, which
of nutrition and how to apply the concepts in this book that are defined in the margin. All boldfaced terms appear with
pertain specifically to you. their definitions and prommciations in the glossary at the
The text discusses some of the most interesting and impor- end of the text.
tant elements of nutrition and food consumption to help you 4. Also throughout each chapter are margin n otes, which
understand both how your body works and how your food further explain ideas or provide references to other chap-
choices affect your health. ters. Some margin notes, as well as the text itself contain
URLs to nutrition-related websites.
5. The numerous tables throughout the text present major
I Features points.
6. The Concept C hecks, which follow the major sections
Planning a New Way of Eating withi11 each chapter, summarize key points. If you are hav-
Early in the text, we present many of the basic guidelines for ing trouble understanding the material in the Concept
planning a healthy diet, including a description of the USDA Check, you should reread the preceding section.
MyPyramid in Chapter 2. Later, in Chapter 13, we review steps 7. Critical Thinking questions ask you to apply information
involved in setting nutritional goals and designing a diet plan as you learn it. This fosters understanding of the material.
to attain those goals. 8. Nutrition Focus essays within each chapter develop cur-
rent topics in nutrition in greater detail.
9. Each chapter ends with a s ummary, which conveys the
Understanding the World Around You main ideas in the chapter, and study ques tion s-both
In a coJJege environment, it is often difficult to envision how provide a review of chapter matetial.
real the problem of world hunger is. Chapter 20 examines the 10. Annotated References are provided to back up material
tragedy of undernutrition and the conditions that create it. The presented in the chapter. If you are preparing a research
chapter allows you to explore possible solutions that offer hope paper for your class or would just like more information
for the future of this world. on specific topics, consult these sources.
www.mhhe.com/ wardlawpers7 xxv
11. Also at the end of each chapter are Take Action boxes, A Request to Students Who Use
which relate the chapter's major concepts to your daily
life. For example, you may be asked to look more careful- This Book
ly at your own diet, examine your fumily history, or apply
information }'Ou've learned to friends or family. We rry our best but realize that sometimes we miss a side of an
12. A variety of supplements to this text, including dietary argument that deserves attention or do not make something
analysis software, are available to you. These instructional perfectly clear. If you find content that you question or believe
aids are designed to help you learn the major concepts warrants more detail or a clearer explanation, feel free tO con-
developed in the text and prepare for class examinations. tact us.
13. The ARIS website ''" mhl u.:0111 ·,, .m.11.rnpt.1°'- con -
tains an onlinc learning center with quizzes, £lash cards, Gordon M. Wardlaw Ph.D., R.D.
other activities, and web Links designed to further help you P.O. Box 290
learn about nutrition. This website is organized according Mendocino, CA 95460
to each chapter in the book. E-mail: gordorunarkwardJaw@gmail.com
JefTrcy S. Hamp! Ph.D., R.D.

Department of Nutrition
Arizona State University
7001 E. Williams Field Road
Mesa, Ari:GOna 85212
E-mail: jefT.hampl@asu.edu
iextbook Tour Perspectives in Nutrition, Seventh Edition ·
Thoughtfully Crafted New illustrations

The presenracion of sciencific concep~ has been enhanced br
d~rnanuc new illustrations. Realisric renderings and careful color·
coding and numbering of processes assisc srudents in grasping
difficult concepts.
Blood formation
(and clotting')
Energy Vitamin 8-6 Homocysteine

metabolism Vitamin 8-12 metabolism
Folote
Thiomin Vitamin K' Vitamin 8·6
RiboRovin Folote
Niacin Vitamin 8· 12
Pontolhenic ocid Choline (not a true
Biotin vitamin, however)
Vitamin B- 12 RiboRavin (indirect)
Vitomin E
Vitamin A Vitamin C (likely)
Vitomin D Corotenoids
Vitomin K lipoic ocid (not a true
Vitamin C vitamin, however)
RiboRovin (indirect)
Vitamin A Vitamin 8·6

Vitamin D VitominC
Folate
N!ilhlt!'ll! dolrn1 we..

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Textbook Tour
Moclenmon
Moclerotton "~by""'
nctTOWlng cl each load group
from bolkxn lo lop The widiw
bo... >lends for load. ~ r.nle
or no solid lats or odded sugo<•
These "-Id be selected moro
ohen. The noncwer lop oreo
sl<w>ds for load. cool<lining moro
odded wgors and <0Gd fob. The
mot• oclivo you ore. !ho more ol
tl>Ma foods can fit into your die!
Dynan1ic
Photographs
Over 100 ne\\ photogr,1phs
of people in real life
siruaaons help enliven and
bring rdc\'anc.:c ro the text.
- . . ...... - Oils __..._. . . Mdi'h&
xxvll
Expe1-t Opinion
Vitam in C: Antioxidant and Pro-Ox
and the Keystone of Tight Control
Mork Levine, M. D., and Sebastion J. Podoyotty, M.R.C.P, Ph.D.
ll ot1tom•n C (ctCOrt>tc ocid. os.c;.orboae) on ~nJ ~n humonl, en ~ to 100Jo5d hl'Nl t~
latly beL..,odf Should "'lomm C be atwned r.- "'J
-n
"
ah.Iii q1,;tltions, irl' ~ i:r...n tc:me essential be
C pl>y.iology, boology, ood ~.iry. Current Topics of Note
The l.uc~t nutrition issues reported m rhc media .ire
expl.uncd in clear, scientific terms. Scudcnrs learn how ro
read beyond the headlines ro m,1ke sound nuuicion
judgme111s.
A Personalized Approach to Nutrition

!"he authors prO\·idc ample opportunities for srudenrs co .tpply
nuttiuon concepts and guidelines to their own Lives. Real lik
examples and individuali/cd .1crivitics make the matcri.11 rekvam
.ind help srudents learn ro asses~ the ''alid.ity of nurricion d,1irns.
I t E tf11i1
Latest Dietary Guidelines

Throughout the text, content has been updated ro reflect
MyPyram1d, 2005 Dietary Guidelines for Americans, and the
latest Dietary Reference I ntakes.
MyPyra mid.gov
STEPS TO A HEALTHIER YOU
Bors
1.1\or £nergY
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die dtapter folder, select an image, and \choc.olo\e A7 \0
So\011<.e Sor .
you're read\ to import the ml.lgc into the Soli~loch00
applicauon of your choice. It\ that ~lonc:e \ (I] Glutothione
\choc.olo\e c.n~p l Various peroxide• peroxidosu Voriou• alcohol,
simple! Sou\cler SOI \choCO
t
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free radical•
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Illustrations, Photos, and Tables

Full-color digital fib of the art and tables in Perspecrtvi:s 111
Nutrition arc logic.1lly organized and allow you ro e,1s1ly
PowerPoint Lecture Outlines customize your cla~~room materials.
.-\ complete PowerPoim lecrun: outhnc \\'tth illustration~
from rhe rexrbook b aYailablc for every chapter. Use the
outline as is or modif)• ir to match your specific cOlITTe needs.
.... Carbohydrate
4 kcal per gram
Protein
Carbohydrates 4 kco1 per grom
Energy - Alcohol
• Composed of C. R 0 sources 7 kcol
for body per gram
• ProYide a major source of fuel for the body functions
• Basic unit is glucose

• Simple and Complex CHO
• E nergy yielding (.+ kcal gm) Fat
9 kcal
per grom
Supplement Tour
Animations
Animations found on the Digital Content Manager
CD-RO.Mallow m u to harne~s the visual impacr of
processes in motion. You can import the animations
into prescataliom or onlinc cour~e materi,1ls.
Text-Edit Art
Hydrolysis Is accomplislw!d beause wtlen the suc:l'OM! molecule binds to the KtM!
Site of' the enzyme. the enzyme"s COOf'l'JrallOn is dwlsed SO thU the Olt)'gefl bndge H.l\'c you ever \\ishcd you could customize
between the tw0 monoucchandes IS eJq>OSed to ~r mol«ules 111 the solvent.
illu~trarion~to meet your course needs? \Vid1 Tcxt-
Edit Art, you can change the size, color, and labels.
You c:m C\'Cn resize o r delete portio ns of figu res.
Red blood cell

/
Norm~I conc:.,,1ntlon con<tntrai.d sol.alon
l• I A diluw so ~tlo n wlOI •

low kin corKtn" at on
,.,..h In sw.llng l bU C~
• trows! •nd sUbs...,ont
rup1Ure tpu11' of r9d In d!4I
jgw(tr loft f>Ott ol tho eel~
1b1 A norm•I conctntnllo<I I•
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OUHldo the toll ~al IO
th• Inside lhO co1q results
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blood Coll. W>• MOVff
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wtch •high Ion
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butlhoA ls no noc- solltlon (b/.o ~ =owsi.
"'ov•rMnt.
xxx
Supplement Tour
NBC News Nutrition

Video Clips NBC News
EnHven your lccnircs wirh the nutrition
topics that arc on your studems' minds.
McGraw-Hill i~ pleased co announce
that we haYc li..:cnscd a senes of videos
!Tom NBC News. These brief dips on
Nutrition Video Clips
imponant nutrition issue~ arc pcrfccr
for introducing lecture copies or class Select a Clip
discussions. A~k your local
representative about this valuable
•• Trans Fa Free FD.Id!
Pyramid Scheme
2:111
1:59
presentation CD. You and your students
cru1 ;tlso access Lhc videos on rhe
•• VitamlnE
Low Carbohydrate Diets
1:49
2:03
textbook website. • The War on Obesity 2:15
•• High Fiber Diets and Colon Cancer

Mercury, Flsh and Pregnancy
1:50
4:00
•• Cholesterol Lowering Drugs

Fighting Childhood Obesity
2:07
4:55
•• Osteoporosis 1:09
Guidelines lot Brustfeeding Mothets 4:29
EXIT
xxxi
I
Supplement Tour 1I
I
ARIS
ARIS (Assc~mcnt, Rc\'lcw, and Instruction System) is an exciting, new electronic homework and course management system from McGraw-
Hill. ARIS helps vou and your sLUdenrs utilize all the resources found on lhc l'erspccti1>e.r i11 N11tritio11 website. Beuer yet, ARIS allow\ you m
imporr your own content, creare assignmt:nrs, and post announcemen~. ARIS aho indu<l~ an automatic grading function for quizzing and
testing materials. Moreover, this dynamic McGraw-Hill rool is easil} loaded into cour~c management system such as WebCT or Blackboard.
Contact vour local McGraw Hill representative for information on how you can take a<l\'antage of the power of ARIS.
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xxxH
WHAT NOURISHES YOU?
CHAPTER ONE
CHAPTER OUTLINE CASE SCENARIO:

...J
~
Nutrition and Your Heolth While Brenda was driving to campus lost week, she heord a radio odverfisement for 0
What Actually Is Nutrilion? • Nutrients Come
From Food • Why Slvdy Nutrition? o supplement containing a plant substance that hos recently been imported from z
Interest in the Field of Nutrition Hos o Long Chino. It supposedly gives people more energy in general, and helps people cope '"z
History with the stress of doily life. This advertisement caught Brenda's oltenfion because she c--i
Classes and Sources of Nutrients
Carbohydrates • lipids • Proteins • hos been feeling run.cfown lately. She is toking a full course load and hos been
'°
--i
Vitamins • Minerals • Water working 30 hours a week at a local restaurant to try to make ends meet. Brenda 0
Nutrient Composition of Diets and the Human doesn't hove a lot of extra money to spore. Still, she likes to try new things, and this z
Body o:J
recent breakthrough from Chino sounded almost too good to be true. Aher search- )>
Energy Sources and Uses (/)
ing for more information on the Internet, she discovered that the recommended dose (")
Current State of the North American Diet
(/)
Assessing the Current North American Diet • would cost $60 per month. Because Brenda is looking for some help with her low
What Influences Our Food Choices? •
energy level, she decides to order a one-month supply. Does this extra expense
Improving Our Diets • Health Ob;ectives for the
United Stoles for the Year 20 I 0 Include make sense lo you?
Numerous Nutrition Obiectives
Using Scientific Research to Determine Nutrient
Needs
Asking Questions and Generating Hypotheses
• Laboratory Animal Experiments • Human
Experiments
Expert Opinion: Using Research to Answer a
Question-Does Calcium Really Help with
Weight Loss?
Peer Review of Experimental Results • Follow-up

Studies
How to Use This Knowledge to Evaluate
Nutrition Claims and Advice
Cose Scenario Follow-Up
Nutrition Focus: Genetics and Nutrition
Toke Action
1
D o you need to take a balanced multivitamin and mineral supplement? Are you eating too much
saturated fat, Irons fat, and cholesterol? Is much of what you eat unsafe? Are some foods actually
iunk foods? Should you become a vegetarian? If you hove asked yourself any of these questions or if you
are confused about what you should eat, you ore not alone. This chapter will help you sort out some of
these issues os you ore introduced to the science of nutrition.
As you begin this study of nutrition, keep this in mind: re-
CHAPTER OBJECTIVES CHAPTER 1 IS DESIGNED
search over the lost 40 years has shown that o healthy diet-no-
TO ALLOW YOU TO:
tably one rich in fruits and vegetables-coupled with regular
1. Define the terms nutrition, carbohydrates, proteins, lipids (fats},
prolonged, vigorous exercise and strength-building exercise can
a/coho/, vitamins, minerals, waler, kilocolories (kcal}, and Fiber.
both prevent and treat many age-related diseoses. 3 Overall, the
2. Use the caloric values of energy-yielding nutrients to determine
nutritional lifestyles of many North Americans are out of balance the total energy content {kcal) in a food or diet.
with their physiology.5 And since we live longer than our ances- 3. list the major characteristics of the North American diet and the
tors did, preventing the age-related diseases that develop later food habits that often need to be improved.
in life is a more important focus today than in the post. 4. Describe the various factors that affect our doily" food choices.
By optimizing dietary choices we can strive to bring the goal 5. List various attributes of a healthful lifestyle that are consistenl
with the Healthy People 2010 goals.
of a long, healthy life within reoch.15 This is the primary theme
6. Identify diet and lifestyle factors that contribute to the
not just in thi s first chapter but throughout the entire book. 10 leading causes of death in North America.
7. Understand the basis of the scientific method as if is used in
developing hypotheses and theories in the field of nutrition.
REFRESH YOUR MEMORY AS YOU BEGIN YOUR STUDY 8. Identify reliable sources of nutrition information.
OF NUTRITION IN CHAPTER 1, YOU MAY WANT TO 9. Understand the role of genetic background in the development
REVIEW: of nutrition-related diseases.
Basic concepts in chemistry in Appendix A. "l
The metric system in Appendix L
•
~=-=-..,- -
Nutrition and Your Health

old terms in the book ore defined in a glos-
B sary, which follows Chapter 20. Many bold
terms ore also defined in the chapter margin
In your life time, you wiJJ eat abo ut 70,000 meals and 60 tons o f food. T his opening
chapter will take a close look at the general classes of nutrients supplied by this food,
the role research plays in sorting out which food co mponents are essential for the
when first presented. mainte nance of health , and the powerful effect of genetic backg round in determining
overall health.
What Actually Is Nutrition?

nutrition The science of food; the nutrients and The American Medical Associatio n has defined nutrition as "The scie nce of food, the
the substances therein; their action, interaction, nutrients and the substan ces therein, their actio n, interaction, and bala nce in relation
and balance in relation to health and disease; to health and disease, and the process by which the o rganism ingests, digescs, absorbs,
and the process by which the organism {i.e., transports, utilizes, and excretes food substances."
body) ingests, digests, absorbs, transports,
utilizes, and excretes food substances.
Nutrients Come from Food
What is d1e difference between food and nutrients? Food provides bo th th<.: cm:rg)
and the nutrients needed to build and main tain all body ce lls. Many of rhcse subsranccs
ar e essen tial nutrients if the body can 'r make them (or make eno ug h oFthem ) to meet
needs (Note that su n exposure o n the skin produces vitamin D , but some of us still
need a dietar y soun:e [see Chapter 91 ). 10
2
www.mhhe.com/ wardlawpers7 3
Fur a substance to be considered essential, thn:c chan.lcteristics are needed:

1. Its omission from the diet must lead to a decline in hum,u1 biological ftmt:tion,
such as function of the nervous system.
2. If the omitted nutrient is restored to the diet before permanent damage occurs,
those aspects of human biological function hampered by its absence should regain
normal function.
3. A specific biological function of the nutrient must be identified.
Why Study Nutrition?

Nutrition is one key to developing and maintaining a state of health that is optimal for hysical activity reflects any movement of
you. A poor diet coupled with a sede1muy lifestyle contribute to many causes of death the body caused by muscular contraction
in North America (Table l-l ).1 i These habits <ue known to be risk factors for life- that results in the expenditure of energy. The
threarening chro nic diseases and deaths: cardiovascular (heart) disease, stroke, hy- term exercise in contrast is generally reserved
pertension , diabetes, and some forms of cancer. (Note that Table 1-2 defines these for physical activity that is done with the intent to
and other key terms used in nutiir:ion.) Nor consuming enough essential nutrients in provide a health benefit, such as improved mus·
younger )'Cars also makes us more likely to suffer health consequences in later yea.rs, de tone or stamina.
such as bone fractures from the disease osteoporosis. Iron-deticienC)' anemia is an-
other possibility of a nutrient deficiency, especially in women and chi ldren. At the same
time, taking too much of a nutrient supplement-such as vitamin A, \'itamin B-6, cal-
cium, or copper-can be harmful tu organs such as bones, kidneys, and nerves.
Another dietary problem, drinking too much alcohol, is associated with cirrhosis of
the liver, some forms of cancer, accidents, and suicides.
All of rhese consequences of modern li,·ing are partly an "affliction of affluence."
Nott!, however, that tl1ese diseases are often preventable. Age fast or age slowly: it is
partly your choice. U.S. government scientists calculate that a poor diet and a lack of
sufficient physical activity contribute to up to 350,000 fatal case!> of cardiovascular
disease, cancer, and diabetes each year. 17 Thus, the combination of poor diet and coo
little physical activity is indirectly the second leading cause of death. In addition, obe-
sity is considered the second leading cause of preventable death (smoking is the first ). 18
Table 1·1 I Ten Leading Causes of Death in the United States

Ronk Couse of Death Percent of Total Deaths
All causes 100
Diseases of the heart (primarily coronary heart disease)*H 29
2 Cancer*t * 22
3 Cerebrovascular diseases (stroke)*f It 7
4 Chronic obstructive pulmonary diseases and
allied conditions (lung diseases)t 5
5 Accidents and adverse effectst 4
Motor vehicle accidents (2)
All other accidents and adverse effects (2)
6 Diabetes* 3
7 Influenza and pneumonia 3
8 Alzheimer's disease* 2
9 Kidney disease*t 2
10 Blood.borne infections
From Cenlers lor Oiseose Conlrol and Prevention, Notional Vital Stalislics Report, accessed Ociober 9, 2002. Conodion statistics
ore quite similar.
•causes of deoth in which diet ploys o port The major health problems in North America
tCouses of deoth in which excessive alcohol consumption ploys o port ore largely caused by a poor diet, excessive
icouses of death in which lobocco use ploys o port energy intake, and not enough physical
#Diseases of the heart and cerebrovosculor diseose ore included in the more global term cordiovosculor d1seosft. activity.
4 Chapter 1 What Nourishes You?
Table 1 ·2 I Glossary Terms to Aid Your Introductio n to N utrition

anemia Generally refers to o decreased oxygen-carrying capacity of the blood. This con be caused by many factors, such as iron deficiency or
blood loss.
body moss index (BMI) Weight (in kilograms) divided by height (in meters) squared. A volue of 25 or greater indica tes a higher risk for weight-related
health disorders if one is also overfol. See Tobie 13-3 in Chapter 13 to determine your body moss index.
cancer A condition characterized by uncontrolled growth of abnormal cells.
carbohydrate A compound containing carbon, hydrogen, ond oxygen otoms; most are known as sugars, starches, and fibers. Supplies 4 kcal/gram.
cardiovascular (heart) disease A general term thol refers to any disease of the heart and circulatory system. This disease is characterized by the
deposition of fatty material in lhe blood vessels (hardening of the arteries), which in lurn con lead lo orgon domoge and death; also termed coronary
heort disease (CHD), because the vessels of the heart ore the primary sites of the disease.
cholesterol A waxy lipid found in oil body cells; ii has a structure con taining multiple chemical rings (steroid structure). Cholesterol is found only in foods
that contain animal products.
chronic Long-standing, developing over time. When referring to disease, this lerm indicates that the disease process, once developed, is slow and tends to
remain; a good example is cardiova scular disease.
cirrhosis A loss of functioning liver cells, which ore replaced by nonfunctioning connective tissue. Any substance that poisons liver cells con lead to
cirrhosis. The most common cause is chronic, excessive alcohol intake.
diabetes A disease characterized by high blood glucose, resulting from either insufficient or no release of lhe hormone insulin by lhe pancreas or general
inability of insulin to act on certain body cells, such as muscle cells. The two major forms are type 1 diabetes (requires doily insulin therapy) and
type 2 diabetes (may or may not require insulin therapy).
essential fatty acids Fatty acids that must be supplied by the diet to moinloin health. Currently only linoleic acid and alpho-linolenic acid ore
classified as essential ftty acids.
essential nutrient In nutritional terms, a substance that, when left out of a diet, leads to signs of poor health. The body either can't produce this
nutrient or can't produce enough of it to meet its needs. Then, if added back to a diet before permanent damage occurs, the affected aspects of
health ore restored.
fat A general term that describes substances that dissolve in organic solvents such as benzene and elher. Fats are mostly composed of carbon and
hydrogen, with relatively small amounts of oxygen and other elemenls.
hypertension A condition in which blood pressure remains persistently elevated. Obesity, inactivity, alcohol intake, and excess soll intake all con
contribute to lhe problem.
kilocalorie (kcal) The heat energy needed to raise the temperature of 1000 g (1 liter) of water 1° Celsius. Also written as Calorie, with a capitol C.
lipid A compound containing much carbon and hydrogen, little oxygen, and sometimes other atoms. Lipids dissolve in ether or benzene, but not in
water, and include fats, oils, and cholesterol.
minerals Elements used in the body to promote chemical reactions and lo form body structures.
nutrients Chemical substances in food that contribute to health, many of which are essential parts of a diet. Nutrients nourish us by providing energy,
materials far building body parts, and factors to regula te necessary chemical processes in the body.
obesity A condition characteri zed by excess body fat. Typically defined in clinical settings as a body mass index (BMI) of 30 or above, but
this cutoff is no! always appropriate.
osteoporosis Decreased bone mass where no obvious disease con be found. This bone loss is related to the effects of aging, genetic background, poor
diet, and hormonal changes occurring in postmenopausal women.
protein Food and body components mode of amino acids; proteins contain carbon, hydrogen, oxygen, nitrogen, and sometimes other atoms, in a
specific configuration. Proteins contain the form of nitrogen most easily used by the human body. Supplies 4 kcal/g.
risk fodor A term used frequently when discussing diseases and the factors contributing to !heir development. A risk factor is on aspect of our lives-such
as heredity, lifestyle choices (i.e., smoking). or nulritional habits- that may make us more likely lo develop a disease.
stroke The loss of body function that results from a blood clot or other change in arteries in the brain that affects blood flow. This in turn causes the death
of brain tissue. Also called a cerebrovoscufor occident.
vitamins Compounds needed in very small amounts in the diet to help regulate and support chemical reactions in the body.
water The universal solvent; chemically, H20. The body is composed of about 60% waler. Wa ter (fluid) needs are about 9 cups (8 fl oz. each) for
women and 13 cups for men per day; needs are greater if one exercises heavily (see Chapter 14) .
www.mhhe.com/ wordlawpers7 S
Put together, obesity and smoking spell even more u·ouble for your health. And, as you
\\•ill learn in Chapter 13, surgery to help treat obesfry costs abom $12,000 to $40,000.
As always, treating health problems is much more costly than preventing tl1em.
As you gain understanding about your nuo·itional habits and increase your knowl-
edge about nutrition, you have the opportunity to dramatically reduce your risk for \
,
many common health problems. 15 For additional help, the U.S. government provides
two websites that can link you co many sites providing health and nuu·ition informa-
tion (www.hcalthfinder.gm and '"''' ·nutrition.gm). Three other helpfu l websites are
'' \\.\\ .catriglu.urg, "''' \\. n,mg;u or.rnfrs.cciu, and "'"'' ·'' cbmd.cnm .
Interest in the Field of Nutrition

Has a Long History
The science of nua:ition e,·olved primarily from the discipline/> of physiology, chem -
istry, and medicine. 4 Our interest in the relationship between food and the mainte-
nance of healtl1 has a long history, begi nning some 2400 years ago in Greece, during
the time of Hippocrates. The Bible even contains references to the importance of cer-
tain foods, such as beans.
The science of nutrition began in the 1600s in Europe. A Btitish physici.111, Sydenh:un,
in 1674 showed that iron filings in wine can be used to treat anemia. In the 1740s, a
British naval smgeon, Lind, found that tl1e consumption of citrus fruits-lemons and
limes-cures the disease scurvy in sailors. Between ] 770 and 1794, Lavoisier and Increasing vegetable intake, such as o doily
Laplace in France discovered that certain carbon-containi11g compounds are tl1c source salad, is one strategy to combat development
of energy for body fimctions. In 1816 German scientist Magcndic showed rhat dogs frd of many chronic diseases.
onl}' c:u·bohydrate and fur lost much body protein and died within a few weeks.
By 1830, ir was known that foods contain three major constintcnts: proteins, car-
bohydrates, and fats. By 1850, at least six minerals-calcium, phosphorous, sodium,
potassium, chloride, and iron-had been established as essential to the diets of higher
animals. Nutrition as a scientific discipline emerged as scientists realized that compo-
nents in foods, some of which are presenr in very small a111om1rs, contribute to health.
During the 1880s, a Japanese physician, Takaki, showed that a common disease of
sailors, called beriberi, can be treated with evaporated milk and meat. Later research n the fifth century sc, Hippocrates said "let
in the Dutch East Indies by borb Eijkman and Grijns showed rhat the same disease is food be your medicine and medicine be your
associated with the use of refined rice, whereas use of the whole.: rice grain prevented food."
the problem. By 1901, it was assw11ed that refined rice lacks an essential mmient (later
called \varer-soluble Band then eventually found to be the vitamin thiamin), which was
present in the whole-grain form.
In tlie 1890s, Rubner in Germany and Atwater in the United Statt:s established the
scurvy The deficiency disease that results ofter
energy (kcal) content ofa gram of carbohydrate, fat, and protein (4, 9, 4, respt:ctivcly).
o few weeks to months of consuming o diet that
This research also quantified human energy ompur, shO\\~ng that, on average, we ex- locks vitamin C; pinpoint hemorrhages on the
pend about 2000 to 3000 kcal/day. skin ore an early sign.
In 1906, the amino acid tryptophan was shown ro be essential for mice by Willcock
and Hopkins in Britain. By 1913, Osborne and Mendel in the United States had beriberi The thiomin defi ciency disorder
shown that food proteins are quite different in terms of their amino acid content. choracterized by muscle weakness, loss of
The year 1912 was a banner year-the term vitaminc was coined by Polish scientist appetite, nerve degeneration, and sometimes
edema.
Funk at dus time to describe certain compounds present in very small amolll1ts in
foods that promote healili. Vita came from d1e Latin for "life," and nminc came from amino acid The building block for proteins
ilie term for nitrogen bonded to carbon ( technicalJy, called an amine). (The c was containing a central carbon atom with a
dropped from vitaminc to form 11itamin in the 1920s, when it was shown that some nitrogen otom and other atoms attached.
vitamins do not contain nia·ogen.) Recommended Dietary Allowances (RDAs)
By 1915, mttrition experts knew that six minerals, four amino acids, and tl1ree Recommended intakes of nutrients that ore
vitamins-A, B (later shown to be a group of vitamins), and the anti-scurvy factor (later sufficient to meet the needs of almost all
shown to be ascorbic acid, which we also calJ vitamin C )-wcre essential nutrients. individuals (97%) of similar age and gender.
From the 1920s to coda)', nutrition research has been a key part of tl1e intense scien- These ore established by the food and Nutrition
tific inquiry that characterized the twentieth century. Recommended Dietary Boord of the National Academy of Sciences.
Allowances (RDAs) for nunienrs were first published in the United States in 1943 in
response to growing recognition of the poor nutritional heald1 of many Americans. All \i-
tamins we know of today had been characterized by 1949. The researdi on vitamins such
as diiamin, vitamin K, vitamin C, <md vitamin B-12 even led to Nobel prizes for Eijkman,
Dam, Szent-Gyorgyi, and the group of researchers Minot, Murphy, and Whippk:. By
1950, some 35 nua-ients had been shown to be necessary to maintain human health.
Today we know that the minimum diet for humans must conr.'lin about 45 essential nu-
trients in ordl.!r to mai11tain health (Table l -3 ).
In 1968, Dudrick in the United States was able to support the nutrient needs of
dogs using onJy inmwenous feedings of purified nutrients. Soon after, it was !tho" n
that this is also possible for humans. Thus, we had evidence d1ar meeting rhe needs for
nutricms known to be essential at that time sufficed to maintain heaJth.
Over the past 40 years, interest in nutrition has grown, especially among hcaltb-
conscious consumers. U.S. government policymakers stepped up their interest in nutri-
tion after me 1969 White House conference on food, nun·ition, ai1d health, and as "ell
increased supporr of federal feeding programs. Following th is, more ai1d more research,
much of whjch was flmded by the U.S. federal government, supported the role of nu-
trition in die maintenance of heaJth as well as showed a link between poor nutrition
(both inadequate and excessive nutrient intakes) and VMious healm probkms. To dare,
Table 1 ·3 I Essential Nutrients in the Human Diet and Their Classes*

Many foods ore rich sources of nutrients that Energy-Yielding Nutrients
we recognize today as essential for health.
Protein
Carbohydrate Fat (Lipids)t (Amino Acids)
glucose A six-carbon carbohydrate found in Glucose; (or a carbohydrate that Linoleic acid (omega-6) Hi~lidine
blood as well as in table sugar bound to yields glucose) a-Linolenic acid (omego-3) lsoleucine
fructose; also known as dextrose, it is one of Leucine
the simple sugars. Lysine
Methionine
Phenylalanine
Threonine
Tryptophan
Valine
Non-Energy-Yielding Nutrients
Vitamins Minerals
Some
Questionable
Water-Soluble Fat-Soluble Major Trace Minerals Water
Thiamin A Calcium Chromium Arsenic Water
Riboflavin D§ Chloride Copper Boron
Niacin E Magnesium Fluoride II Nickel
Pontothenic acid K Phosphorus Iodide Silicon
Biotin Potassium Iron Vanadium
B-6 Sodium Manganese
B-12 Sulfur Molybdenum
Folofe Selenium
c Zinc
he vitamin-like compound choline plays es-
"This 1oble Includes nurrlenls 1ha1 the current Dietary Reference Intakes and related publications list for humons. Some disagreement
sential roles in the body but is not listed
exisls over the questionable minerals and certain other minerals not listed. Fiber could be added lo the lisl ol essential substances
under the vitamin category at this lime. Rough but II is nal a nulrient (see Chapter 51. Alcohol is o source of enetgy bul is not on essential nulrienf
estimates of human needs for this compound re- tThe lipids listed ore needed only In small amounts, about 5% of total energy needs (see Chapter 61.
cently have been set (see the inside cover of the ?To supply fuel for the brain end other cells os well os prevent ketosis and 1he muscle loss that would occur ii prolein were used lo
text). Note, however, that body synthesis suffices synlhesize carbohydrate (see Chapter 5)
during many stages of life (see Chapter 10 for iSunshine on the skin olso allows the body to make vitamin D for itself (see ChopJer 91.
details). Primarily for dental health (see Chapter 121
we have made much progress in the field of nutrition, but more work nl!eds to be done, itomins and minerals ore needed in such
and nutrition problems still plague peoples in all parts of the world (see Chapter 20 ).5 small amounts in the diet thot they ore
called micronutrients. In contrast, because
carbohydrates, proteins, lipids, and water ore
Classes and Sources of Nutrients needed in much larger amounts, they ore called
macronutrients.
To begin the study of nmrition, let's start with <ll1 overview of the \'arious dasscs of
nutrients. You are probably already famil iar with the terms carbohydr ates, lipids ( fats
and oils), pro t eins, vitamins, and minerals (figure 1- L). These.:, plus water, make up
the six classes of nun·ients found in food (review Table 1-3).
Nun·icnts can rhen be assigned to rhrec functional categories: (1 ) those that prima-
rily pro'"idc us with energy (typically expressed in kilocalories [kcal] ); (2 ) those that
arc important for growth and development (and later maintenance); and (3 ) those that micronutrient A nutri ent needed in milligram
act to keep body functions running smoothly. Some O\'c.:rbp exists among these group- or microgram quantities in a diet.
ings. The energy-yielding mmients make up a major portion of most foods. 10
macronulrient A nutrient needed in gram
Prom o t e Growth Regulate quantities in the diet.
P rovid e E nergy and D evelopment Body Processes
Most carbohydrates Proteins Proteins
Proteins Lipids Some lipids
Most lipids ( fats and oils) Some vitamins Some vitamins
Some minerals Some minerals
Water Water
Let's now look more closely at these six classes of nutrients.
I
Protein
I'
Starch Hemoglobin
Storoge form of corbohydrote in foods
Glymol {
The black, wh ite, and red circles repre-

Eoch green hexogon represents the sent carbon, hydrogen, and oxygen atoms, This protein, found in o red blood cell, is
corbon groups in one glucose molecule. respectively, in the triglyceride molecule. a structure formed of linked amino acids.
figure 1 · 1 I Two views of corbohydrotes, lipids, and proteins-chemical and dietary perspectives.
Carbohydrates
element A substance that cannot be separated Carbohydrares are composed mainly of the elem ents cnrbo n, hydrogen, and 0>.ygen.
into simpler substances by chemical processes. Carbo hydrates provide a major source oft'l1el for the bo dy, o n average 4 kcal per gram
Common elements in nutrition include carbon, (kcaljg).8 Small carbo hydrare structures arc called sugars o r simple sugars. Table sugar
oxygen, hydrogen, nitrogen, calcium, (sucrose) is an example. l t is made up of the sugars g lucose and fructose. Some simple
phosphorus, and iron. sugars, such as glucose, can chemically bond to form larg<.: storage carb<>h )rdrates,
starch A carbohydrate made of multiple units of (allcd polysacd1aridcs or complex carbohydrates ( review Figure 1-1). An example or
glucose attached together in a form the body this type of carbohydrate is Lhe starch in potatoes.
con digest; also known as complex
carbohydrates.
C~H
20H 0 c H20 H
H HO
H OH
T he chemistry review in Appendix A de-

scribes the shortcut notation used to draw
these sugar structures. Essentially, any corner
H
Glucose
OH OH
Fructose
H
represents a carbon (unless otherwise noted), ' 7 T- - - --.-- ·•• - T - · --,~ ~ . .. . -~~ - - - - : -,,
and, up to four hydrogens ore presenr on each · · :1 . ,, ·~ . c~rb~h_id!ates :. . ,. · . · : ,.:,
~a .. . ··I _ .~• -. _ ';.._ • '"!.. .;j
carbon to yield four bonds per carbon.
Aside from e njoying their tasre, we need sugars and other car bohydrates in our diers
primarily to help sarist)' the energy need s of o ur body ceUs. G lucose, which the body
can prod uce from most carbohydrates, is a major source of e nergy in most (ells. When
not eno ug h carbohydrate is eaten to supply suffi cient g lucos<.:, the body is forced to
make g lucose from p rotein s.
Digestio n of some d ietar y starch begins in the mo uth. The digestive p rocess con-
tinues in the small intestine tu1til starches br<.:ak down into sing le sugar molecules (sud1
as g lucose), which are absorbed imo the bloodstream using cells that line the smaJl in-
testine (see Chapter 3 for mo re on d igestio n and absorptio n ). However, the bonds be-
tween the sugar molecules in certain comp lex caxbohydrates caJ)J1ot be broken dO\\'n
by human digestive processes. T hese carbohyd rates arc part o f what is called fiber.
Such fiber passes through the small intesti ne undigested to p rovide bulk for tcces
°
fo rmed in the large intestine (colo n ). 1 Chapter 5 fucuscs o n carbo hydrates.
fiber Substances in plant foods that ore not
Lipids
broken down by digestive processes of the
stomach or small intestine. These add bulk lo Lipids (e.g., fats, oils, and cho lesterol) ar<.: composed mostly of the clemc.:nts carbon
feces. Fiber naturally found in foods is called and hyd rogen; they contain fewer oxygen atom s tl1an carbohydrates d o . B<.:c:rnse oftbis
dietary fiber. difference in composition, lipids yield more energy per gram than carbo h ydrates-on
glycerol A three carbon alcohol used to form average, 9 kcal/g. (Sec C hapter 4 for mo re de tails concerning the reason for the high-
triglycerides. e ncrgy yidd of lipids.) Lipids arc insoluble in water but can d issolve in certain organ.ic
solvents (e.g., ether and benzene ).
fatty acid Ma jor part of most lipids; composed T he basic sn-ucnirc of most lipids is the three-carbon glycer o l mo lecule with a fart}
of a chain of carbons Ranked by hydrogen with a cid attached to each o f· tl1e thr<.:e carbons (review Figure 1-1). T his fo rm lipid is gen or
an acid group erally called a triglyceride . T1ig lycerid es arc a key energy som ce for the body and Ull
0 major form of fat in foods. They are also the.: majo r form fo r energy sto rage in tl1e body. 1l
II In this book, Lhc more fam iliar te rm fnts o r fats and oi/swilJ gem.:rally be used r;uher
(-C-OH) at one end and a methyl group than lipids or trig(vccritfes. Fats arc lipids that are solid at room temper.uure and o ih.
(-CH 3J ot the other. arc Lipids tl1at are liquid at room temperature.
triglyceride The major form of lipid in the body Most lipid i; can be separated into two basic types- sa turated and u nsaturnted-
and in food. It is composed of three fatty acids based o n tl1e chemical structure of cl1eir dominant fatty acids. T his diH\:rcm:c dcrcr
bonded to glycerol, on alcohol. mines whethe r a lipid is solid o r liquid at room temperature. Satw-ated fatty acid'>
contain no carbon-carbon do uble bonds, while unsatur.u ed fatty acids contain o ne O "
more in what is called a cisconfiguration. Plant oils rend to contain many Lrnsaturated
fa tty acids, which makes them liquid ;1t room temperature. Animal fa ts are ofte n rich
in saturated fatty acids, which makes the m solid at room temperature. Almost all Foods
contain a variety of sarurated and unsaturated fatty acids.
Lipids
.- ... . ......, ........ ..,. . ·. __-----::, ": -,- ~.~--:" - .
~ - · Saturated F~tty Acid. (Ste~ric Acid)
- • • - -•• __ ,_._ _ _ _ _ _ I - -
H H H H H H H H H H H H H H H H H 0 H 0
I I I I I 1 I I I I I 1 I I I I I II I II
H-c-c-c-c-c-c-c-c-c-c-c-c- c - c - c - c - c - c - o- H H - C - O - C - fatty acid
I I I I I I I I I I I I I I I I I
H H H H H H H H H H H H H H H H H
H-
I
C- 0 -
11
C- fatty acid
-- - -- -.--.....-- -- - -~---- -· - f •
H-
I
C- O-
11C - fattyacid
, Polyunsaturated 'Fatty Acid (Linoleic Acid)
- -- --- ~ - .. - - - .. ... - . .-
-- ' - . . I
H H H H H H H H H H H H H 0 9
Glycerol
I I I I I I I I I I I I I II
H-c-c-c-c-c - c=c- c - c = c - c - c - c-c-c-c-c-c-o - H
uch attention hos been given to

Two specific polyunsaturat ed fa tty acids- linokic acid a nd alpha- linolenic acid-
are essential nurrients. These must come from our diets. T hese t \\'O fa tty acids thar rhe
M eating less saturated fat in the post few
years. This is because saturated fat bears o
body can't produce, called essential fatty acids, perfo rm several important firnctions great deal of the responsibility for raising blood
in the body: they help regulate blood pressure and play a role in the synthesis and re- cholesterol. High blood cholesterol leads to
pair of \'ital cell par ts. H owever, we need only a fcvv tablespoons of a common veg- clogged arteries and so con eventually lead to
etable oil (such as rhe canola or soybean oil fo und in supermarkets) each day to supply cardiovascular disease.
the essential forty acids.8 Adding fish in :i dice at le:ist twice a week adds to thi::. bene-
fit derived from the inclusion of vegetable oil. T he unigt1e unsan1rated fatty acids in
fish complement d1c heald1y aspects of vegct:iblc oil. This will be explained in grc.:atcr cis configuration A form seen in compounds
detail in Chapter 6, which foc uses on lipids. with double bonds, such as fatty acids, in
Some foods also contain trans fatty acids, in which the unsarurnred fut srn1cwre which the hydrogens on both ends of the
has been altered from the more typicaJ cis form during food processing. These a re double bond lie on the some side of the plane
commo nly called trews fats and arc found prirna1i ly in deep-fried foods (e.g., do ugh- of thal bond.
nuts and fre nch fries), snack foods (c_g., cookies a nd crackers), .md solid fats (e.g., stick
polyunsaturated fatty acid A fatty acid
marg;lli nc and shortening). Large amounts o f trnm fats in die d iet pose certain health
containing two or more carbon-carbon double
risks, so as with saturated fat, intake should be minimized (see C hapter 6 for details).s bonds.
All food labels now have to list trans fat content (see Chapter 2 fo r more details con-
cerning food labels). trans fatty acids A form of on unsaturated fatty
acid, usually o monosaturoted one when found
in food , in which the hydrogens on both
carbons forming lhot double bond lie on
H opposite sides of that bond (trans
configuration). Stick margarine, shortenings,
-C=C- I and deep-fat fried foods in general are rich
j I -C = C-
sources.
H H 1
H trans configuration Compound in which the
' . hydrogens lie opposite each other across a
cis i:onfigurcition carbon-carbon double bond.
any health-food stores market protein Proteins

powders and shakes for bodybuilders
Like carbohydrates and fats, proteins are composed of the elements carbon, oxygen,
and other athletes. However, the North
and hyd rogen. But unlike the other energy-yielding nutrien ts, all proteins also contain
American diet contains nearly two times the re-
nitrogen. Proteins arc the maii1 strnctural material in the body (review Figu re 1-1 ). For
quired amount of protein. Thus, these products
example, proteins constinitt: a major part of bone and muscle; they arc aJso im porranc
are unnecessary.
components in blood, cell membranes, enzymes, and immune fuctors.8 Fu rthermore,
proteins can also provide energy for the body-on average, 4 kcal/g. Typically, the
enzyme A compound that speeds the rate of a body uses liulc protein for t he purpose of meeting daily energy needs. Proteins arc
chemical process but is not altered by the formed by the bonding together of amino acids. Twenty common amino acids arc
process. Almost all enzymes are proteins {some fou nd in food; nine of these are essential nutrients for adults, and one additional amino
are mode of nucleic acids) . acid is essential for infants. Chapter 7 focuses o n proteins.
Amino Acids
NH2
CH -S-CH -CH - CH 0
2 2 2
< "
C- OH
Alanine Valine Methionine
Vitamins
Vitamins exhi bit a wide variety of chemical structures and can contain the elements car-
bon, hydrogen, nitrogen, oxygen, p hospho rus, sulfur, and others. The main function
chemical reaction An interaction between two of vitamins is to enable many chemical reactions to occm in the body. Some of these
chemicals that changes both participants. reactions help release the energy trapped in carbohydrates, lipids, and proteins.
Remember, however, that vit<m1ins themselves provide no usable energy for the body. 10
OH OH
T he J 3 vitamins are d ivided into rwo groups: four that dissolve in fat and so arc fat
soluble vitamins (vitamins A, D, E, and K) and nine that dissolve in water and so arc
water soluble vitamins (vitamin C and the B vitamins, such as thiamin). T he two
groups of vitan1ins often act q uite differently. For example, cooking destroys water-
soluble ,·itamins much more readily than it does fat-solub le vitamins. 'Water-soluble vi-
tamins are also excreted from the body much more readily than are fat-solub le \'ita-
ruins. Thus, the fat-soluble viramins, especially Yitamin A, are much more like!)' to
accumulate in excessive amounts in the body, which then can cause roxicity. The vita-
mins a.re the focus of Chapters 9 and 10.
Minerals
The nun-ients discussed so fur are all organic compounds, whereas minemls are struc- organic Any substance that contains carbon
turally very simple, inorganic substances, wh id1 exist as groups of one or more of the atoms bonded to hydrogen atoms in the
same atoms. These terms, 01;gm1ic and inownuic, have nothing to do with agricu lture but chemical structure.
are based on sin1ple chemisn-y concepts (see Chapter 2 for a different use of the term on inorganic Any substance lacking carbon atoms
food labels). Inorganic substances fo r the most part do not contain carbon atoms. bonded to hydrogen atoms in the chemical
i\IIinerals typically functio n as such in the body (Na+, K+ ), or as parts of simple min- structure.
eral combinations, such as bone mineral [Ca10(P0 4 ) 6 OH2 ]. Because of their simple
electrolytes Compounds tha t separate into ions
strucrure, minerals a.re not destroyed during cooking. (However, they can still be lost
in water and, in turn, are able to conduct an
if they leak into the water used for cooking and then cliscarded if that water is not con-
electrical current. These include sodium,
sumed. ) Alt.hough minerals themselves yield no t:nergy as such for the body, they arc chloride, and potassium.
a-itical players in ner\'ous system fonctioning, other cellu lar processes, water balance,
and structural (e.g., skeletal ) systems.10
The amounts of the 16 or more cssenti.11 minerals that. arc required in the diet for
good health vary enormously. Thus, they arc clivided into rwo groups: major 1ninerals
and u·ace minerals, based on clietary needs. If dail)' needs ~u·e less than 100 mg, rhe
mineral is put in the nace mineral class. The actual dietary reguiremenr for some trace
minerals has yet tO be determined. Minerals that conduct electricity when dissolved in
\\'atcr arc also called electrolytes; these include soditu11 , potassium, and chloride.
Minerals arc the focus of Chapters 11 and 12.
Water
Warer is tht.: sixth class of nutrients. Altbougb sometimes m·erlooked as a nutrient,
water is the macronutriem needed in the largest quantity. Water (chemically, H 20) has
nw11erous \'ital fonctions in the body. Ir acts as a solven t and lubric,111t, as a medium solvent A liquid substance that other
for tr,msporting nutrients and waste, and as a medium fo r remperau1re regu lation and substances dissolve in.
chemical processes. For these reasons, and because the human body is approximately
metabolism Chemical processes in the body
60% water, we require about 3 liters (L)-cquivalent to 3000 g or 12 cups-of a com - that provide energy in useful forms and sustain
bination of water and/or beverages containing water every day. vital activities.
Water is not only avai lable from the obvious sources, but it is also the major com-
ponent in some foods, such as many fruits and vegetables (e.g., lettuce, grapes, and
melons ). The body even makes some water as a by-product of m etabolism. 10 i.Vater is
examined in detail in Chapter 11.
Nutrient Composition of Diets

and the Human Body
The quantities of the various nutricnrs th:it people consume vary widely, and the nu-
nienr <'!mounts present in different foods also ,·ary a great deal. Tht.: toral daily intake
of protein , far, and carbohydrate amounts to about 500 g (about l lb). ln contrast, the
rypical daily mineral intake totals about 20 g (about -l teaspoons), and the daily vita-
min intake totals less than 300 mg ( I/15th ofa teaspoon). Although each day we re-
quire a gram or so of some minerals, such as calcium and phosphorus, we need only a
few milligrams or less of other minerals. For example, we need about 10 mg of zinc
per day, which is just a few specks of the miner,11.
Figure 1-2 contrasts the relative proportions of all the major classes of nutricn ts in Alcoholic beverages ore rich in energy, but
a lean man and a lean woman with the proportions of both a cooked steak and french alcohol is not an essential nutrient.
12 Chapte r 1 What Nourishes You?
0% <1% <1%
II Carbohydrate
16% 13% • Protein
27%
37% !J f at
Al% 54% 62% •Minerals 11.
\'"
11
O Water
/ i 7%
4% 5%
1% 1%
French fries Steak Healthy man Healthy woman
Figure 1 ·2 I The proportions of nutrients in

the human body compared to those found in
typical foods-animal or vegetable. Note that fries. Note how the mmiem composition of the htu11an body diffors from the: nutri -
the amount of vitamins found in the body is tional profiks of the foods we car. T his is because growth, development, and later
negligible, and so is not shown. maintenance of rhe human body an: directed by the genetic material (DNA) inside the
cell nucleus. This genetic bluepril1t determines how each cell uses the essential nutri-
c:ms to perform body fu ncrions. 13 These nutrients can come from a variety of sources.
Cells are nol concerned whether avai lable amino acids come from animal or plant
sources. The carbohydrate glucose can come from sugars or starches. In sum, whaL you
deoxyribonucleic acid (DNA) The site of cat provides cells with basic matcriab w fu nction according to tJ1e directions supplied
hereditary information in cells; DNA directs the by tJ1e genes housed in the cell.
synthesis of cell proteins.
genes The hereditary material on

chromosomes that mokes up DNA. Genes Energy Sources and Uses
provide the blueprints for the production of cell
proteins.
Humans obt~tin Ll1c energy needed to perform body functions and do work from car-
alcohol Ethyl alcohol or ethanol (CH 3CH 20H). bohydrates, fats, and proteins. Foods generally provide more than one cnergy source.
H OH Plant oils arc one exception; these are 100% fut. Alcohol is also a source of energy for
I I some of us, supplying about 7 kcaljg. It is not considered an essential nutrient, howe\'cr,
H-C-C-H because it has no required function. Still, alcoholic beveragcs-generalJy also rich in carbo-
I I hydrate, such as bcer--contribute energy to the diet of people who drink such beverages.
H H Tht: body transforms the energy trapped in carbohydrate, protein, and far (and al-
compound A group of different types of atoms cohol) into ocher forms of energy in order to: 1O
bonded together in definite proportion (see also
• Build new compounds
molecule). Not oil chemical compounds exist as
molecules. Some compounds are mode up of
• Perform muscu lar movements
ions attracted to each other, such as
• Promote nerve transmissions
Na+cL-(toble salt). • Maintain ion balance wid1in cells
ion An atom with on unequal number of Chapter 4 describes how that energy is released from chemical bonds and then used b)
electrons and protons. Negative ions hove body cells to support the processes just described.
more electrons than protons; positive ions hove You have likely noticed on food labels that the energy in food is often expressed in
more protons than electrons. terms of cal0ties. (Chapter 13 has a diagram of the instrument that can be used to
measure calories in foods [bomb calorimeter].) Techrucally, a calorie is the amount of
heat energy it rakes to raise the temperature of 1 g of warer 1 degree C elsius ( 1°C).
Because a calorie is such a tiny measw·e of heat, food energy is more accurately ex-
pressed in terms of the kilocalorie (kcal), which equals 1000 calories. (If the "c" in
calories is capitalized, th is also significi. kilocalories. ) A kcal is the omoum of beat
energy it takes to raise the tcmperanire oflOOO g (1 L) of water l °C. The term kilo-
'Percent Dally Values (DV) are based on a 2,000 I NGREDIENTS: WHOLE

Nutrition Facts calorie diet. Your daily values may be higher or WHEAT . WATER, ENRICHED
Serving Size 1 slice (36Q) Servings Per Container 19 lower depending on your calorie needs: WHEAT FLOUR [FLOUR.
QalO<ies: 2,000 2,500 MALTED BARLEY, NIACIN,
Amount Per Serving Total Flit less than 65g 80g REDUCED IRON, THIAMINE
Sal Fat Less lhan 20g 25g
Calories 80 Calories from Fat 10 Cholesterol less than 300mg 300mg
MONONITRATE (VITAMIN B1)
AND RIBOFLAVIN (VITAMIN
% Dally Value• % Dally Value• Sodium Less than 2.400mg 2,400mg
Total Carbohydrate 375g
82)), CORN SYRUP, PAR-
3009
Total Fat 1g 2% Total Carbohydrate 15g 5% Oletruy Flbel 25g 30g TIALL Y HYDROGENATED
conoNSEED OIL, SALT,
Saturated Fat Og 0% Dietary Fiber 2g 8%
Trans Fat less than 1g .. .. Intake of trans
YEAST.
lat should be as low as possible.
Cholesterol Omg 0% Sugars less than 1g
Sodium 200mg 8 % Protein ~
Vitamin AO% Vitamin CO% Ca1cium0% Iron 4%
HONEY WHEAT BREAD
Figure 1 - 3 I Use the nutrient values on the Nutrition Facts label lo calculate the energy content of o food. Based on carbohydrate, fol,
and protein content, a serving of this food (Honey Wheat Bread) con loins 81 kcal ([ 15 X 4] + [ l x 9] + (3 X 4] = 81 ). The label lists
80, suggesting that the calorie value was rounded down.
ca/m·ic and irs abbreviation kcal are used throughout this boo k. fn everyday usage, the n many scientific journals, the kilojoule (kJJ,
word calorie (without a capital "c") is also used loosely to mean kilocnlorie. Any values rather than the kilocolorie, is used to express
given on food labels in calories are acmaUy in ki localories (Figure 1-3 ). A suggested in- the energy content of food . A moss of l gram
take of 2000 calories per day o n a food label is really 2000 kcal. moving at o velocity of 1 meter/sec possesses
As you have seen, carbohydrates, proteins, lipids, and alcohol provide the body with the energy of I joule (J); I OOOJ = I kJ. Since
differing amounts of energy. Use the 4-9-4 rough estimates for carbohydrate, fat, and heat and work ore just two forms of energy,
protein introduced over the last few pages co determine energy content of a food. measurements expressed in terms of kilocolories
Consider a typical del u~xe hamburger sandwich: (o heal measure) ore interchangeable with
measurements expressed in terms of kilojoules
Carbohydrate 39 grams X 4 = 156 kcal
{o work measure): 1 kcal = 4.18 kJ.
Fat 32 grams X 9 = 288 kcal
Protein 30 grams X 4 == 120 kcal
Total 564 kcal
Note also that the 4-9-4 estimates have been adjusted for ( 1) digestibility and digestibility The proportion of food substances
(2 ) substances not available for energy use. Such substances include waxes and some eaten that con be broken down into individual
fibrous parts of plants. The energy estimates are then rounded to whole numbers. 8 nutrients in the intestinal tract for absorption
You can also use the 4-9-4 estimates to determine what portion of total energy in- into the body.
take is contributed by the various energy-yielding nutrients. AssLune that one day you
consume 290 g of carbohydrates, 60 g of fat, and 70 g of protein. This consumption
yields a total of 1980 kcal ((290 X 4] + [60 X 9] + [70 X 4) = 1980). The per-
centage of your total energy i11take derived from each n utrient can then be determ ined:
% of energy intake as carbohydrate= (290 X 4 ) + 1980 = 0.59 X 100 = 59%
% of energy intake as fat = (60 x 9) + 1980 = 0.27 X 100 = 27% Carbohydrate
% of energy intake as protein= (70 X 4) + 1980 = 0.14 X 100 = 14% 4 kcol per gram
Check your calculations by adding rhe percentages together. Do they total 100? Protein
4 kcal per gram
Concept I Check
Nurrjtion is the study of food and nutrients-their digestion, absorption, and metabolism Energy . . Alcohol
and their effect on health and disease. Food contains vitaJ nutrients that are essential for sources 7 kcal
for body per gram
good health: carbohydrates, lipids {fats and oils), proteins, \'itamins, minerals, and water. functions
Nutrients have three general functions in the body: ( l) to prO\~de materials for building
and maintaining the body; (2) to act as regulators for key metabolic reactions; and (3) to
participate in metabolic reactions that provide the energy necessary ro sustain life. A com-
mon unit of measurement for this energy is the kilocalorie (kcal). On average, carbohy·
drates and protein proYide 4 kcaljg of energy to the body, while lipids proride 9 kcal/g. Fat
Although not considered a nutrient, alcohol provides about 7 kcal/ g. Thc: other classes of 9 kcal
nutrients do not supply energy bur ~u·e essemiaJ for proper body functioning. per gram
I Current State of the North American Diet

he Food and Nutrition Boord also recom· Humans derive energy mostly from carbohydrates, fars, and proreins. ff we ignore al·
T mends limiting saturated fat, trans fat, and
cholesterol intake when putting their diet guide-
cohol, Non:h Americ:l.ll adults conslUTie on average 16% of their energy inrake as pro-
teins, 50% as carbohydrates, and 33% as fats. These perccnrages are estimates and vary
lines into place. slightly from year to year and to some extent from person to person. This pattern falls
within the 10% to 35%, 45% to 65%, and 20% tO 35% distribution of energy intake from
protein, carbohydrate, and fat, respectively, advocated by the Food and Nutrition
Board of the National Academy of Sciences.8 These recommendations apply to bod1
the United States and Canada (see Chapter 2). These percentages for each macronu·
trient make up what is termed the Acceptable Macronutrient Distribution Range
(AMDR). Note that recommendations for different disn·ibutions of energy intake
Acceptable Macronutrient Distribution Range among protein, carbohydrate, and fat come and go io the popular press. Thjs will be
(AMOR) Range of intake for a specific
reviewed in Chapters 5, 6, and 7.
mocronulrient that is associated with o reduced
risk of chronic diseases while providing for
Animal sources supply about two-thirds of protein intake for most Nord1 Ame1icans;
recommended intakes of essential nutrients. plant sources supply only about om:-tl1ird. In many other parts of t he world, it is just
AMDR ore set for carbohydrate, protein, and the opposite: plant proteins- fi-om rice, beans, corn, and other \'egetabks-dominare
fat !various forms); each is intended to provide protein intake. About half the carbohydrate in North Amaican diets comes from sim-
guidance in dietary planning. ple sugars; the other half comes from starches (such as in pastas, breads, and potatoes).
About 60% of d ietary far comes from animal sources and 40% from plant sources
Assessing the Current North American Diet

Information about the North American diet comes from large sw-veys designed to rind
out what and when people eat. The U.S. government uses the National Health and
Nutrition Examination Survey (NHANES) ad ministered by rhe U.S. Department of
Health and Human Ser\'ices. In Canada, th is information is gathered by Health
Canada in conjw1ction with Agriculnire and Agrifood Canada. Results from these sur-
veys and other srudies show thar we eat a wide va riety of foods. Many people an; met:t-
ing their nutrient needs; some are not. Chapter 2 will look ar d1is situation in more
detail. For now, note that studies show that some of us should choose more foods rhar
arc rich in iron, calcium, magnesium, potassium, ,·itamin A, various B \'itamins, ' 'ita-
min C (especially smokers), vitamin D, vitamin E, zinc, and fiber. 3 Daily intake of a
balanced mulrivitami.n and mineral supplement to help meet these nutrient needs is
also a strategy, but does not make up for a poor diet in all respects, such as for calcium,
potassium, and fiber intake (see Chapter 9 for more on supplement use).
RoL1tinely, experts recommend thar we pay more attention to balancing energy in-
take with need. An excess intake of energy is usually t ied to an overindulgence in sugar,
fa t , and alcoholic beverages.7 African Americans and Hispanics in particular may need
salt Generally refers to a compound of sodium t0 pay special attention to the amount of saJt and alcohol in their diets. This is because
and chloride in a 40:60 ratio. they have a greater chance of developing hypertension than do other ctluiic groups in
North America, and these substances are rwo of rhe many factors li nked to dcvatcd
- I ri.1 ..Li......
blood pressure. Actually, a careful look at salt and akohol int<lke-along wirh saturated
fat, trans fat, cholesterol , and total energy intake-is a useful and recommended task
for aJJ adulrs.5
Believing that supplements provide the nutrition Many North Americans would benefit from a more helpfu l balance of foods in their
her body needs, Janice regularly tokes numer- diets-greater moderation in the inrakc of some foods is needed, su ch as sug.1rcd soft
ous supplements while paying relatively liHle of· drinks and fried foods, while increasi11g rhc variety of other foods, such as fruits and
fen/ion lo doily food choices. How would you vegetables. 19 Few adults currendy meet the "5 A Day" minimum rccornmendarion for
explain to her that this practice may lead lo total servings of vegetables (2: 3) and fruits (2:2).
health problems?
For suggested answers to the Critical Thinking
What Influences Our Food Choices?
questions in this and every chapter, see the web-
site for this book www.mhhe.com/wardlawpers7. We eat ptirnarily for nourishment-we have to cat to survive. But food means far more
to us than d1at. Food symbolizes much of what we think about ourselves. Throughout
www.mhhe.com/wardlawpers7 15
om lives, we spend L3 to l 5 years eating. Impor tant re;1sons for the specific foods we
choose are: 2 3
• Fla11or, texture, and appearance. These are the most importnnt factors determining
our food choices. Creating more flavorfu l foods rhar arc both healthy and profit:iblc cientists suspect we are ba rn with a taste for
is :i major focus of the food industry ( referred to as "bener !Or you" products). sweets and over time acquire a taste for fat.
• Ea1·ty influences. These expose us to various people, places, and situations and go on
to influence our lifelong food choices. Many aspects of ethnic diet patterns (dis-
cussed more ful ly in Chapter 2) begin as we a re introduced tO foods as child ren.
• Routines rrnrf habits. Most of us eat from a con.: group of foods: about 100 basic
items account for 75% of an individual's total food intake. OvcraJJ, food habits and
food availability and convenience strongly inAuence choices.
• Nutrition, or 1vlwt we thinlz ofas ('healthy foods. ''North Americans who tend to make
health-related food choices are often well-educated, middle-class professionals.
T hese same people are generally health oriented, have active litcsrylcs, and focus on
weight control.
• Ad11e1·tising. The food industry in the U nited States alone spends well over $34 bil-
lion <rnnually on advertising. Some of th is advertising is helpful, such as when it pro-
motes the importance of calcium and fiber intake. However, the food indul>try also
advertises highly sweetened cereals, cookies, cakes, and pastries because such prod-
ucts can reap the greatest profits.
• Restaurants. Today, about half of all food dollars in North America is spent on
meals outs\de of home. This food is often very high in energy, served in overly gen- ccording lo Dr. Andrew Weil, the primary
erous portions, and of poorer nutritional quality compared to foods made at home. danger from food is overindulgence.
However, over the past 10 yea.rs, restaurants have placed healthier items on their
menus.
• Social changes. Many of us today bave increasingly busy lives. This create!> the need
for convenience . Supermarkets now supply already-prepared meals, microwave cn-
trees, and \'arious quick-pn:p frozen products.
• Economics. Food cost is importanr but plays only a moderate role in food choices
for many of us, because North Americans spend only abom l 0% of ali:er-rax income
on food (this percentage will be greater for low-income people). However, as in-
come increases, so do meals eaten away from home.
Daily food intake is a complicated mix of innate (c.g" genetic) and social intluenccs. 21
These factors are depicted in Figure L-4. Chapters 13 and 15 will look at issues of food
choice with spc6tic reference to weight control and eating disorders. What inllucnccs
your food intake on a daily basis? How are you the same as or different fro m the typi-
cal North Ame1ican?
Improving Our Diets

More efforts by the general public are needed to lower satu rated fat, tm11s fat, sugar, and
cholesterol intakes and to improve variety in our diets, but our cultural diversity, varied
cuisines, and generally higb nutritional status should be points or pride for Nor th
Americans. Today we can choose from a tremendous variety of food products, the result
of multifaceted cultural currents and innov:ition by food manufacturers.
Du1ing the past hundred years, North America has led the world in creating new food
°
product!>. 2 From toaster pastries to microwave popcorn, the va1iery of food products in
a t:ypical supermarket is nearly limitkSl>. Today we arc caring more break.fast cereal~, pizza,
pasta entrees, stir-fried meats and vegetables served on rice, saladi,, vitamin- and mim:ral-
A market research firm surveyed the eating
fortified juices, tacos, burritos, and fuj itas than ever before. Sales of whole milk are down,
habits of people in 2000 North American
whereas in the same time period saks of fat-free and 1% low-fut milk have increased. households. The top meal choice was pizza,
Consumption of frozen vegetables, rather rhan canned vegetables, is also on the rise. Still, followed by horn sandwich, hot dog, peanut
sofi: drinks are more popular than milk, although not as beneficial to the diet.6 butter and jelly sandwich, steak, macaroni and
One recent trend by food manufacturers has been to promote meal replacement cheese, turkey sandwich, cheese sandwich,
bars (also called "energy" bars). These bars typically contain about L80-250 kcal, with hamburger on a bun, and spaghetti.
Figure 1 ·4 I Food behavior is inOuenced by

many sources, some of which ore shown.
Which ore important in your life?
a protein:carbohyd1~uc:fal ratio typical of common diets. However, some bars rcpt.ice

much of the c.1rbohvdralc with protein. All of the bars arc fortified with virnmim and
m inerals in .1111011 nrs r.rnging from about 25 LO I 00% or typical human needs. Some
people find thaL Lhcsc bars provide a convenicm way to consu me a meal (or sn;Kk) on
the run while ;ilso tbcusing on cermin nutricllls they may underconsumc, such .1s the
,·itamin foLuc or the mineral calcium. Critics suggest Lhese produces arc rcall~· Jml Lhe
nut1itional equi\ ,tlent of :l low-faL yogurt and piece of fruit.
North Amcric,rns currently arc living longer, and many enjoy better general heald1.
Man) also ha\'c more monev and more di,·ersc food ;ind litesryle choices co consider.
The nutritional consequences or these trends arc not folly known. Death!> from car-
di<l\'ascular disca-.c, for example, h:l\'c dropped dramatically since the late 1960s, partl)
because of bcncr mcdit:.11 t:arc and diets. Still, if affiucncc leads to sedentary lilcsryks
and high intakes or \aturatcd far, tmns fat, cholesterol, sodium, sug.lr, and .lkohol.
hea lth problems c.rn rcs ulL.:; For example, obesity is'' growing p roblem in our popu
lation. 18 Because or better technology and grc:llcr choices, WC can have a much bctlCI'
diet roday than C\ ct bdcm~-if \\'C know what d1oices w make.
The goal or thi'> book is LO help you find the best path to good nlllrition. Nutrition
l'xperts often s.1\ thaL thl'rc arc no "junk" or bad foods. 1 Obviously, though, man~
foods and be\'Cragcs ah1ilable in supermarkcL•,, such as pastries and sug;1r rkh '><>ft
Regular physical activity complements a healthy
drinks, pro,,idc tcwer nutrients in comparison "ith encrm content and, chw., con -
diet; practice both each day. Whether it's all at tribute to lc~s nutriLi<>U'> food habits. 14 One's nn:rall diet is the proper focu., in .1 nu-
once or in segments throughout the day, ideally tritional evaluation. ( luptcr 2 will cmphasi;lc Lhis poinl and show you ho\\ ro b.ll.incc
incorporate 30 to 60 minutes or more of such your dice. A., you rccx.unine your nutritiona l goals, remember that your health 1s
activity into your doily routine. la rgdy your responsibility (Figure 1-5 ).
Breast cancer
Alcohol (i)
Obesity (i)
i7"::::::----J1---=::::,,.. Mouth, esophagus cancer
Alcohol (T)
IMJi~--,/'r\--t---- Hypertension -------lr-----i~-=---.,.ii
Salt (i)
Alcohol {i)
Fruits and vegetables ( ~)
Cardiov ascular disease

Saturated fat ('i)
Cholesterol (i)
Fiber(.!.)
Obesity (1)
Liver disease
Alcohol (i)
Diabetes
Obesity (i)
Stomach cancer
Cured smoked Prostate cancer
foods (i) Saturated fat (i)
Tomatoes and
Colon cancer tomato-based
Dietary fat (i) foods (J.)
Fiber {.J,)
Fruits and vegetables (J.)
Calcium (J.)
Red and processed meat (i)
Osteoporosis _ _ _ __,
Calcium (J.)
Figure 1 ·5 I Some possible health problems associated w ilh poor dietary habits. An upward arrow (i) indicates excessive intake whi le a downward
arrow (.J..) indicates low intake or deficiency. In addition to those habits listed in th e figure, no illicit drug use, odequate sleep (7- 8 hours), adequate water
and related fiuid intake, and a reduction in stress (praclice better time managemenl, relax, meditate, listen to music, have a massage, a nd stay physically
aclive) provide a more complete approach to good nutrition and health. Add to this approach maintaining close relalionships with others and a positive
outlook on life. Finally, consultation w ith health~are professionals on a regular basis is important. Early diagnosis is especially useful for controlling the
damaging effects of many diseases. Prevention of disease is on imporlant investment of one's time, including during the college years.
Health Obiectives for the United States for the Year 2010
Include Numerous Nutrition Obiectives
Health promotion and disease prevention have bet:n public health strategies in the
United Srares and Canada since the late 1970s. One part of this strategy is Healthy
People 2010, a report issued in 2000 by t he U.S. Department of H caIth and Hu man
Ser\'ices' Public Health Service. 12 T his report consists of health promotion and disease
prevention objectives for the year 2010 and assigns each of the objectives to appropri -
ate U.S. federal agencies ro address. Many nutrition -related objectives arc part of the
overall plan (Table 1-4 ).
The main objectives of Healthy Pc()plc 2010 arc to promote healthful litestyles and to
reduce preventable death and disability. Minority groups in particular are the focus of
Healthy Pc()p[e 2010 program~, because overall healrh status currenrly lags in these pop-
ulation groups, especially with respect to hypertension, type 2 diabetes, and obesity. A healthy d iet benefits people of a ll ages.
18 Chapter 1 What N ourishes You?
Table 1 •4 I A Sample of Nutrition·Related Objectives from Healthy People 2010

Current
Target Estimate
Increase the proportion of adults who are at a healthy weight
(defined as a body moss index between 18.5 and 25). 60% 35%
Reduce the proportion of adults who ore obese
(body moss index of 30 or more). 15% 23%
Reduce the proportion of children and adolescents who are
overweight or obese. 5% 10%
Increase the proportion of persons age 2 years and older who
consume ot least two doily servings of fruit. 75% 28%
consume at least three doily servings of vegetables, with at
least one-third being dork green or deep yellow vegetables. 50% 3%
Probobly the worsr food-reloted trend in North consume at least six doily servings of groin products, with al
America is Jorge servings of foods, especially least three being whole groins (e.g., whole wheat bread ond
in restaurants. Consumers might see these as a oatmeal). 50% 7%
bargain, but few need the extra energy Increase the proportion of persons age 2 years and older who
supplied by the increased serving sizes. One consume less than 10% of energy intake from saturated fat. 75% 36%
response could be to shore the oversized
portion with someone else.
consume 6 g or less of salt (2300 mg or less of sodium) daily. 65% 5%
meet dietary recommenda tions for calcium (see inside cover
of this book) . 75% 46%
Reduce iron deficiency among young children and females of
childbearing age. 6% 10%
Note: Related ob1ectives include those addressing osteoporosis, various lorms of cancer, diabetes prevention and treatment, food al-
lergies, cardiovascular disease [coronary heart disease and stroke), low bir1h weight, nutrition during pregnancy, breastfeeding, ea~
ing disorders, physical activity, and alcohol use {see later chapters).
Concept I Check
North Amencans generally h:wc a variety of food availablt: to us. However, some of u~
could improve our diets by focusing on rich food sources of iron, calcium, vitamin A, vari-
ous B vitamins, vitamin C, vitamin D, vitamin E, potassium, magnesium, zinc, and fiber. In
addjtion, many of us shoLJd reduce ow· consumption of energy, sugar, saturated fut, trnns
Today soft drinks ore more popular than milk far, cholesrcrol, salt, and alcoholic beverages. These recommendations are consistent with
although not as beneficial to the diet. Soft an overall goal to attain and mainrain good health. Our specific food choices depend on
drinks account for about 10% of the energy taste, tcxn1re, and appearance of foods; habits and routines; health knowledge and con-
intake of teenagers in North America and in
cerns; advertising; and various social trends such as increased use of restaurants.
turn contribute to generally poor calcium
intakes seen in this age group.
Using Scientific Research to Determine

Nutrient Needs
How do we know what we kno\\' about nutrition? How has this knowledge been
gained? In a word, research. Like otl1er sciences, the research t hat sets the foundation
for nuuition has de\ doped through the use of the scientific method, a testing proce·
du re designed co detect and e liminate error. The first step is the observation of a nat-
hypotheses Tentative explanations by scientists ural phenomenon. Scicntists tl1en suggest possible explanations, calkd hypotheses,
to explain a phenomenon. about its cause. Distinguishing a true causc-and·effect relationship from mere coinci-
dence can be difficult. For instance, early in the past cemury, many patients in mental
hospitals sufforcd from the disease pellagra, which suggested a possible relationship
pellagra A disease characterized by
between mental illnes!> and this disease. In rime, ir became clear char chis suppo~ed inflammation of the skin, diarrhea, and
connection was simply coincidental; the real culprit was the poor diet common in men · eventual mental incapacity; results from an
raJ institutions at that time (sec Chapter 10 for details). insufficient amount of the vitamin niacin in
To rest hypotheses and eliminate coincidenral explanations, scientists perform con· the diet
trolkd scientific experimen ts. The data garhered from these experiments 111'1) either
support or refi.tre each hypothesis. If the results of many experiments :.upporr a h~ · experiments Tests mode to examine the validity
of o hypothesis.
pothesis, the hypothesis becomes generally accepted by sciemists ;rnd c.111 be calkd a
theor y {such .is the theory of graviry). \'cry often, the results from one experiment theory An explanation for a phenomenon that
suggest a new set of questions to be answered (Figure 1-6 ). hos numerous lines of evidence to support it
Observations Made and

Questions Asked
Physicians in the mid· l 950s note thot 1n
short-term experiments, people fed o
low·colorie, high-fol diet lose weight
more quickly ti-ion people fed o
low-calorie, high·corbohydrote diet.
Hypothesis Generated
Do low·colorie, h1gh·fot diets (e.g .. Atkins
diet) lead lo more weight loss over time
than low·calorie, high-carbohydrate diets2
The
Scientific
Method
Research Experiments Conducted
A study published in 2003 describes
whc;it happens when 63 people ore
assigned for o year to either o
low-calorie, high·fot diet or o
Follow-up Experiments Conducted low·colorie, high·corbohydrote diet.
to Confirm or Extend the Findings
A study published in 2005 describes what
happens when 160 people ore assigned
lo one of four diets for one year. Two
of the diels ore o low·colorie, high·fot diet
and o low·colorie, high·corbohydrote diet.
Again, weig_ht loss in these two groups
does not differ significonlly at the end of
"
Finding• Evaluated by
the study (Journal of the American Medical lnve1tigator1
Association 293· 43, 2005). Weight loss does not differ significon~y
between the two groups al the end
of the study.
Findings Evaluated by Other

Scientists and Published
Upon peer review, the research findings
appear valid and ore published in The
New England Journal of Medicine.
(348 2082, 2003).
Figure 1 · 6 I Implementing the scientific method using low-calorie, high-fat diets as on example.
Scientists consistently follow these steps in conducting scientific research It is important not lo embrace
a nutrition or other scientific concept until it has been thoroughly tested using the scientific method.
Incidentally, in the fina l study few people on the low-calorie, high.fat diet were able to follow the
guideline of <50 g of carbohydrates per day.
The scientific method requires a skeptical attitude. Scientists must not accept pro·
posed hypotheses and theories until they are supported by considerable evidence, and
they must reject those that faj1 to pass critical analysis. Likewise, students should adopr
a healthy skepLicism and be critical of many current ideas about nutrjtion. 2 Dr. Robert
DiSilvestro discusses this concept further in the Expert Opinion, p. 22.
ulcer Erosion of the tissue lining, usually in the A recent example of r.his need for skepticism involves stomach uJcers. Nor so many
stomach (gastric ulcer) or the upper small years ago, "everyone knew" that stomach ulcers were caused mostly by a strcssfi.il
intestine {duodenal ulcer). These ore generally lifestyle and a poor diet. Then, in 1983, an Australian physician, MarshaU, reported i11
referred to os peptic ulcers. a respected medical journal that ulcers are usually caused by a common microorgarusm
called Hclicobn.ctcr pylm·i. Furthermore, he Stated that a Cllre is possible using antibi-
otics. At first, other ph)1Sicians were skeptical about this finding and continued to pre·
scribe medications sucb as antacids mat reduce stomach acid. But as more studies were
published and patients were cured of ulcers using antibiotics, the medical profession
eventually accepted tl1c findings. (He was even given the Nohel Prize for Medicine in
2005 for this discovery.) Today, uk:cr~ are managed for the most part by medications
that destroy the pathogen. We can expect that scientific discoveries will always be sub-
ject to challenge and change.
As you will see, sound scientific research requires that:
1. Questions are asked.

2. Hypotl1eses are generated to explai n the phenomena.
3. Research is conducted (experiments).
4. locorrect explanations arc rejected.
5. The most likely explanation is used as the basis for a model.
6. Research resu lts are subjected to review by other scientists and pubUshed in a sci-
entific journal.
7. The results ;1re confirmed by more experiments and studies.
Asking Questions and Generating Hypotheses

Histo1ical evencs have provided clues to important relationships in nut1ition science. In the
fifteenth and sixteenth centtuies, for example, many European sailors on the long voyages
to the Americas developed the disease scurvy. The sailors ate very few fruits and vegetables,
and eventually a Btitish naval surgeon, Lind, ruscovered that lime juice prevented or cured
scurvy. After this, sailors were given a ration of lime juice, earning them the nickname
" limeys." This simple practice ensured a healthy workforce for the British navy and helped
Research using laboratory animals contribu tes it dominate tl1e seas worldwide. About 200 ye<U'S later, scientists identified \ritamin C, the
to our nutrition knowledge. nurrient present in tl1e lime juice and other fruits and vegetables that prevents scurvy.
In a related approach ro using historical obscrvatioo, scientists establish nutritional
hypotl1eses by studying the dietary and disease patterns among various populations in
today's world. If one group tends w develop a certain disease but another group docs
not, scientists can speculate about the role diet plays in this difference. The study of
epidemiology The distribution and diseases in populations is cal led epidemiology and ultimately forms the basis for many
determinants of disease in human populations. laboratory studies.
Ai1 example of the use of epidemiology occmred in the 1920s, in die United
States, when Goldberger noticed that residents in mental institutions-but not their
infectious disease Any disease caused by caretakers-suffered from pellagra. He reasoned that if pellagra were an infectious
invasion of the body by microorganisms, such disease, botl1 groups wou ld suffer from it. Since they did not, he concluded that pel-
as bacteria, fungi, or viruses. lagra is caused by a dietary deficiency.
Historical and epidemiological findings can suggest hypotl1eses about the role of
diet in various health problems. Proving the role of particular dietary components,
however, reqllires controlled experiments. For instance, once the high incidence of pel-
lagra in mental institutions du1i ng the 1920s was linked to poor diet, various foods
were given to patients who had die disease. These experiments showed iliat yeast and
high-protein foods could cure these patients iftl1e disease was nor in its final stage, in-
dicating that pellagra results from a deficiency of some nutrient present in mese foods.
Eventually, th.is nurrient was found to be d1e B vitamin called niacin.
www.mhhe.com/wa rdlawpers7 21
Laboratory Animal Experiments

When scientists canno t test their hypotheses by expeLirnents wirh humans, they often
use laborato ry animals. M uch of what we know about human nutritional needs and
functio ns has been generated from labo rato ry animal experiments. Still, human exper-
iments are tl1e m ost convincing to scientists. In t:he 1930s, scieotists showed that a
pellagra-like disease seen in dogs, called blacktongue, is cured by nicotinic acid. Only
when nicotinic acid actually cm ed pellagra in humans were scientists convinced that
nicotinic acid (later classified as tl1e vitamin niacin) was tl1e critical dietary factor.
Still, the use of humans in certai n types of experiments is considered unethical.
Althou g h some people argue that labo raror y animal experiments are also unethical,
most people believe that the careful , humane use of animals is an acceptable alterna-
tive to using h uman su bjects. For example, most people would d1ink it is reasonable
to feed rats a low-copper diet to srudy the importance of this mineral in the forma-
tion of blood vessels. Almost universally, ho\.vevcr, people would o bject to a similar
study in infants.
The use of laboratory animal experiments to study the ro le of n utrition in certain
human diseases depends o n the availability of an animal m odel- a d isease in such an - animal model S1udy of disease in laboratory
imals that closely mimics a particular h uman disease. However, most h uman ch ronic animals that duplicoles human disease. This
diseases do not occu r in laboratory an imals. IFno animal model is available and human con be used to understand more a bout human
experiments are ruled o ut, scientific knowledge often cannot advance beyond wh at can disease.
be learned fro m epide mio logical studies. case-control study Studies in which individuals
who hove the condition in gueslion, such as
Human Experiments lung cancer, ore compared with individuals
who do not hove the condition.
Various experimental approaches are u sed to rest research h)rpotl1eses in hLtmans, in-
double-blind study An experiment in which
cluding case-control and dou ble-blind swdics.
neither the participants nor the researchers ore
aware of each participant's assignment (test or
Case-Control Study placebo) or the outcome of the study unlil it is
In a case -control study, scie ntists compare individuals who have tl1e cond ition in completed. An independent lhird party holds
question, such as lung cancer, with indi\'iduals who do not have d1e condition . the code and the data until the study hos been
Comparisons arc made o nly between groups that arc matched for other major ch arac- completed.
teristics {e.g., age, race, and gender) not bei ng stuclied. You can tl1ink or such a study control group Participants in on experiment
as a "mini" epidemiological study. T his type of study may idc n ri~1 facro rs other than who ore not given the treatment being tested.
die disease in question, such as frui t and vegetable intake, t hat d iffer between d1e two
groups, thus providing researchers with clues about the cause, progression, and pre-
vention of the d isease. However, wit ho ur a controlled experiment, researchers canno t
definitely claim cause and effecr.16
Double-Blind Study
An important approach for more definit ive testing of hypod1escs is the double-blind
stud y, in which a group o f participants-the experime nt:il group- fo llows a specific efore researchers conduct any research
protocol (e.g., consu ming a certain food o r nutti ent), and participants in a correspo nd- process using humans (or laboratory ani-
in g control group conform to their no rmal habits. People arc random!}' assigned to mals), they must first obtain approval from the
each group, such as by the flip of a coin. Scientists d1en observe the experimental Human Use (or Animal Use) Committee at their
group over ti me to see if there is any effect that is no t found in die control g ro u p. university or company. The committee determines
Sometimes inclivid uaJs ar c used as their own control: fi rst they are observed for a pe- if the experimenlol protocol is valid and assesses
riod of time, and then they are treated and d1eir responses noted. the risks and benefits of the potential therapy to
Two features of a double-blind study help reduce the introduction of bias (preju- the subject and, when appropriate, society al
dice), which can easily affect the outcome of an experiment. First, neid1er the par tici- large. In human studies, the committee insists
pants nor d1e researchers know which individuals arc in the experimental g rou p and that o document depicting the risks and benefits
which are in the control group. Second, d1e expected effects of the experime ntal proof the study be developed, which the partici-
tocol are not disclosed to the participants o r resear chers until after the entire srudy is panls must receive and sign. The process is
completed. This approach reduces the possibi lity that researchers may see tl1e change called informed consent, meaning the participant
they want to see in the participants to prove a certain "pet" hypothesis, even tho ugh knows what he or she is expected to do in the
such a change did not actually occur. T his approach also red uces the chance that the research study and the associated risks.
Expert Opinion I•
Usin~ Research to Answer a Question-Does Calcium
Realry Help with Weight Loss?
Robert DiSilvestro, Ph.D.
Obesity continues to be a major problem in many countries. The public In this short study, the higher calcium intake via dairy hod no effect on
would like a magic bullet that con safely produce major weight loss without two measures relevant lo the other mechanism by which calcium may affect
the need for changes in diet or exercise habits. If the public can't hove thot, body fat use. Still, o longer time of increased calcium intake may be needed
the next best olternotive is something that con give o modest boost to the for such effects. This idea is supported by o longer study. In this study, which
weighr loss effects of o proper diet ond exercise. One such "something" was o diet survey study, a measure of body fat use was proportional to co~
could be calcium. cium intake. However, it is not known if the calcium directly caused the ef-
Is this idea really true? We don't actually know. It could be true for some fect or if calcium intake is really just on indicator of some other behavior.
circumstances and not for others. There ore also studies that don't support
the story. In addition, there is more than one way to interpret those studies
Diet Surveys Support, But Don't Prove,
thot do seem to support o calcium- body weight connection.
a Calcium-Body Weight Connection
A number of studies hove analyzed the diet patterns of different groups of
How Could Calcium Help with Weight Control?
people. Some of these studies find that intake of calcium and/or dairy prod-
You may think that calcium is just involved in bone health. Calcium is in· ucts show some relationship to body weight. Still, when diet surveys ore com·
valved in bone health, but ii may also help with weight control in at least two pored to some health porometer, it is hard to distinguish o direct relationship
ways: from o purely coincidental one. For example, o high calcium intake moy
cause the lower body weight, or o high calcium intake may just be indico-
• Calcium binds to some of ingested fat, which stops absorption of that fat.
• As calcium intake goes up, production of a hormone mode from vitamin D
goes down; this hormone favors body fat production over breakdown.
Each of these mechanisms is reasonable based on how the body works

and based on some research in isolated cells and experimental animals.
However, the practical issue is how much these mechanisms Auctuote with
typical variations in human calcium intake. In other words, calcium intake
may not furn these mechanisms up or down much except al extremely low or
extremely high calcium intakes. In addition, the effects of calcium intake moy
occur only when some other circumstances ore also true (i .e., ot certain lev·
els of fat ond protein intake, certain levels of exercise, etc.). If the other cir-
cumstances needed to bring about o calcium effect ore rore, then most
people would not obtain a body weight benefit from o high calcium intake.
There is one human study supporting the idea thot calcium con hove
some effect on dietary for absorption. In this short-term study, people were
fed diets for one week in which calcium intake was manipulated mainly via
dairy products. The high calcium intake reduced dietary fat absorption, as
shown by higher fat excretion in the feces. However, the amount of energy
lost this way was not enormous. It is also not known if the number would be
lower, higher, or the same with different types of diets. The net energy loss
in this study could be important if maintained for a long lime, but it still might Whether calcium intake contributes to weight control is
account for only about 9 lb loss (oboul 4 kg) per year. a hotly-contested research question.
. - - - ~ -- - - - . ·-- - -~ -- . - -=. -- - I :
live of health consciousness. Moreover, not all diet survey studies show a re- live than calcium supplements. One criticism of lhese studies is that the low
lationship between calcium intake and body weight. This find ing is not sur- calcium group as well as the calcium supplement group lost less weight than
prising, because body weight is affected by numerous factors. would be expected from the energy restriction alone. Furthermore, the dairy
It has been suggested that some of the studies that do not show a calcium- group last just the amount of weight expected from dietary energy restriction
weight connection may not have examined a wide enough range of calcium alone. Did the dairy group simply have the best compliance to the weight
intakes. On the other hand, ii is not clear whether the range of calcium in- loss diet? It remains to be seen if the subsequent studies, which ore only pre-
takes in the studies with the negative results are much different from the sented now as meeting reports, reinforce this concern.
range in the studies with positive results. There are three intervention studies that do not see a statistically signifi-
cant weight loss effect of increased calcium intake, though one saw a small
trend in !hat direction. One of these studies increased calcium intake via sup-
Retrospective Analysis of Calcium Intervention plements, another used dairy products, and a study from our laboratory had
Studies Is Interesting but Not Conclusive some people take supplements or consume l %low-fat milk. Our study, which
A number of studies have been done in which calcium was given for a rea- is only published al present as a meeting report summary, included super-
son other than to study body weight. In some of these studies, body weight vised exercise as part of the weight loss regimen.
was measured just for general information purposes. When this data was re- One difference between the three studies that did not show an effect and
analyzed, in some cases increased calcium intake looked like ii might impact the two studies from one laboratory that did is the calcium content of the low
body weight. However, because these studies didn't control for factors such calcium diet. The two studies that report an effect of calcium each used 400
as energy intake and because the results were not totally consistent, these to 500 mg of dietary calcium per day in the low calcium group. In contrast,
studies cannot be fully conclusive. the studies showing no effect had lhe low calcium intake set al 700 to
800 mg per day. Perhaps calcium intake and/or body calcium functional
status must be changed drastically lo have an effect on weight loss. Also, be-
Experimental Animal Studies Are Useful But cause both studies with 400 lo 500 mg background calcium intake come
Are Not the Last Word from one research group, there could be something else about the study de-
sign that distinguishes these studies from those of other groups.
Work in experimental animals supports the idea that calcium intake can of-
fecl processes involved in body weight gain and in body fat accumulation .
Even so, these results do not guarantee !hat typical calcium intake variations So, What's the Real Story?
in people-who have many other factors affecting their body weight-will
Based on data so for, calcium and/or dairy intake will not produce large
significantly impact body weight control. Also, in an unpublished study from
amounts of weight losses all by itself. Also, variations in calcium intake will
our laboratory, in mice fed excess energy and fat, doubling calcium intake
not affect body weight in every circumstance. What is not known is whether
did not limit excess weight gain. However, calcium intake may impact body
calcium can affect body weight in some circumstances, and what, if any,
weight in mice with different ranges of calcium intakes or with differen t back-
these circumstances ore. If calcium intakes need to change from very low
ground diets.
(i.e., 400 mg/day) lo very high to see an effect, not many people will be
helped. Although it is common for people lo consume less than the recom-
Calcium Intervention-Weight Loss Studies mended amounts of calcium, very few people consume only 400 mg of cal-
Give Mixed Results cium per day. At the moment, the best advice is to follow the traditional
approaches to weight loss or maintenance but to meet calcium needs in case
If calcium intake con have a distinct effect on body weight in most types of
calcium intake does help.
people, this effect should show up in calcium-weight loss intervention trials.
In these !rials, distinct amounts of calcium ore given to people as supple-
ments or dairy products, and attention is paid to other aspects of diet (i.e., Dr. DiSilvestro is Professor of Human Nutrition ot The Ohio State
energy intake). One research group has generated two papers on such stud- University, Columbus, Ohio. He received o Ph.D. in biochemistry
ies. In each case, a high calcium intake produced a greater weight and/or from Purdue University and is well known for his work in copper and
fat loss than did a low calcium diet, with dairy products being more effec- zinc metabolism. He has recently begun to study calcium as well.
persons participating begin to feel better simply because they arc involved in a research
study or are receiving a new treatment, a phenomenon called the placebo ej'fect.
placebo A Fake medicine used to disguise the Derived from the L1.tin word placebo, meaning "I shall please," the placebo dlccr
roles of participants in on experiment; if fake cannot be explained by pharmacological or otber direct physical action. It may instead
surgery is performed, it is called o sham be Linked ro a simple reduction in stress and anxiety. Overall, it is cri tical to make al-
operation. lowances for the placebo effect in rcsearch studies.
1n a double-blind experiment, the control group often receives a sugar pill (or other
placebo treatment) to camouflage who is in which group and thereby ro eliminate the
bias introduced by th<.: placebo effect. During the course of the expcrimcnr, neither rhe
researchers nor the participants know who is getting the real treatment and who is get-
ting a placebo. Sometimes only a single-blind prot0col is possible, in which the par-
ticipants (and possibly somt: of the researchers) are kept in the dark. Either way, no"
it is up to the experimental treatment- not just the practice of both groups taking .1
pill- co show an effec.1., if one is possible.
A recent ex<tmple illustraLes the need to test hypotheses based on epidemiological
wo other common types of studies ore mi- observations in double-blind studies. L6 Epidemio.logists using primarilr case-control
T grant and cohort. Migrant studies look ot
changes in health in people who move from one
studies found that smokers who regularly consumed fruits a nd vegetables had a lower
risk for Jung cancer than did smokers who ate few fruits and vegetables. Some scien-
country to another. Cohort studies start with a tists proposed that beta-carotene, a pigment present in many fruits and vcgcr::ibk~,
healthy population ond follow them, looking for could reduce the damage that tobacco smoke cn.:ates in the lungs. This hypothesis
the development of disease. helped fuel sales of supplements of beta-carotene.
However, in double-blind studies involving beavy smokers, the risk of lung cancer
was fou11d to be /1ig/Jcr for those who took beta-carotene supplements than for those
who did nor (note that this is 110t true for the small amount of beta-carotene found
naturally in foods). Some investigators criticized this research, argu ing thal the be~
carotene was given too kite in rhe smokers' lives robe of much use, bur even these crir-
ics did oot suspect that the supplement would increase cancer risk. Soon alter these
results were reported, the U.S. federal agency supporting rwo other large ongoing
studies thar employed beta-carotene supplements called a hair ro rhe research, scaring
that these supplements are ineffective in preventing both lung cancer and c:irdiovascu-
lar disease .
Overall, health and nutrition advice provided by grandparents, parents, fiicnds, and
other well-meaning i.n<lividuals can't be verified unless it is put ro the ultimate scil:n-
tific rest-blinckd studics. 16 Until that is done, we can't be sun: that the substance or
procedure in question is truly effective. VVhen people say, "I get fewer colt.ls now that
I rake vitnmin C," they overlook the fact that many cold symptoms disappear quickly
with no treatment; the npparent curative effect of vitamin C or any other remedy is
often coincidenta l rather than causal to the narural healing process.
All consumers need to become more sophisticated about science, irs accepted stan-
dards of evidence, and its current limitations. Failure to do so leads many tO a frantic
pursujt of fraudulen t remedies. To ignore science is to risk learning about d1c dangers
of various health practices prinwily ti-om being harmed by them. Medical science docs
not ignore novel approaches to disease prevention and cttre. Anecdort:S and personal
exp<.:riences can be important dues leading to fruitful experimcnrarion , but die)' are
not credible e' i<lence.2
Peer Review of Experimental Results

Once an experiment is complete, scientists summarize rhc findings and seek to publish
the results in scientific journals. Generally, before such results are published in scien-
tific journals, they a.re critically reviewed by other scientists fami liar with the subject.
Careful research contributes to nutrition The objecrivc of this peer review is ro ensure d1at only high-quality research findings
knowledge, more so than does personal are published. This is an impor tanr step because most scientific research in this coun-
experience. try is funded by chc federal government, nonprofit foundarions, drug companies, ,111d
www.mhhe.com/wardlaw pe rs7 25
In
For thousands of years, early humans con-

Clinical
r----::Cose-control sumed o diet rich in vegetable products and
practice studies low m animal products. These diets were gen-
observations erally lower in Fat and higher in dietary fiber
than modern diets. Do the differences in human
diets throughout history necessarily tell us
Epidemiological Human which diet 1s better-that of early humans or of
observations intervention
modern humans? If not, what is a more reliable
trials
woy lo pursue this question of potential diet su-
periority?
Figure 1 ·7 I Doto from o variety of sources can come together to support o research hypothesis. For
example, epidemiological studies show that type 2 diabetes is characteristically found in obese
populations, when compared with leaner populations. Physicians notice in clinical practice tha t type 2
diabetes is much more likely in their obese patients than in their leaner patients. Cose-control studies
show that obese patients ore much more likely lo hove type 2 diabetes than the leaner comparison
group that is matched for other characteristics. laboratory animal studies show that overfeeding that
eventually leads lo obesity often leads to the development of type 2 diabetes. Finally, human
intervention trials show that weight loss con correct type 2 diabetes in many people. laboratory
researchers also show that the enlarged fat cells associated with obesity ore much less responsive lo the
hormonal signals involved in blood glucose regulation (see Chapter 5). All these lines of doto come
together with biological plausibility from various laboratory studies to support the research hypothesis
that obesity con lead to type 2 diabetes.
other priv<ltC industries. All Lhcsc fo nd ing sources can have sa·ong expectations aboul
the rcsean.:h ouccomes. ln theory, the scientists cond ucting these research studies will
be fai r in cv~1 l u;:iring chcir n:sults and will not be influenced by rhe funding agency. Peer
review help:. e nsure th.u the resc:archers arc .1s objective as possible. T his the n helps en -
sure thaL results published in peer-reviewed journals, such as rhe A11irricn11 ]1111r11nl peer-reviewed journal A journal that publishes
of Cli11irnl NT1triti1111, Tbc Nc111 E11[1fn11rf ]oTtmnl <!( Merfici11r, and the f111tmnl <d' t/Jc research only ofter two or three scientists who
Amc1·icnn /) frtaic As.wcintio11, arc much mo re reliable than chose: found in popu lar were not por1 of lhe sludy agree the study was
magazines o r promoted on television talk sho ws. Unfortu naLely, hyped -Lip press re well conducted and the results ore fairly
leases from reputable journ.1ls .rnd major universities arc the m.1in sources for chc in - represented. Thus, the research hos been
approved by peers of the research team.
formation presented in Lhe popul.w media, and claims are ~ddom scrut inizcd by
journalists thc:mscl\'es for accurac) and scientific rn.lidity.
Follow-Up Studies
£\en if an accc:ptabk protocol has been followed and the results of ,1 swdy h,l\c been
accepted b\ the scicnti tic communin, one experiment is ncYer enough LO prm c a p.1r-
ticu1ar hypothe-.1s or proYide a basis for nutritional rccommcmfations. Rather, rhe re
suits obtained in one labor.Hon must be confirmed by expcrimt:nts conducted in other
laboratories and pmsihly under '.1rying circumstances. Onlv rhcn can '''e rc.1lly trust
and use the results. The more lines of e\idencc .wailablc to support an idc:a, the more
likely it ts to be true ( figu re 1-7). It is impor tant to avoid rushing to accept nc:w ide,1s
as fact or incorpor,lring them into your health habits until they .m: pron:d by several
Lines or evidence .2
26 Chapter 1 Whal Nourishes You?
How to Use This Knowledge to Evaluate Nutrition

C laims and Advice
Based on what has been covered so fa r, the following suggestions should help you
make healthful ~tnd logical nutrition decisions:l6
1. Apply the basic principles of nutrition as outlined in this chapter (along with those
listed in My Pyramid, the 2005 Dietary Gujdclincs for Americans, and related re·
sources in Chapter 2) to any nut:Jition claim, including ones on websites. Do you
note any inconsistencies? Do reliable references support the claims? Beware of the
following:
• Testimonials about personal experience
• Disreputable rublicarion sou rces
• Dramatic results ( rarely trne)
• Lack of evidence from supporting snidies made by other scientists
2. Examine the background and scientific credentials of the individual, organizations,
or publication making the nutritional claim. Usually, a reputable author is one
whose educational background or present affiliation is with a nationally recognized
university or medical center that offers programs or courses in the field oF nutri-
tion, medicine, or a closely aJlied specialty.
3. Be wary if the answer is "Yes" to any of the folJowing questions about a heald1-
related nutrition claim:
• Are only advantages discussed and possible disadvantages ignored?
• Arc claim~ made about "curing" disease? Do they sound too good ro be o·uc?
• Is extreme bias against the medical community or traditional medical treatments
evident? Physicians as a group strive to cure diseases in their patients, using what
proven techniques are available. Tht}' do not ignore reliable cures.
• Is the claim touted as a new or secret scientific breakthrough?
megadose Intake of o nutrient for beyond 4. Note the size and duration of any study cited in support of a nt1tricion claim. The
estimates of needs or what would be found in a larger it is and the longer it went on, the more dependable its findings. Also con·
balanced diet; 2 to l 0 times human needs is a sider the type of study: epidemiology versus case-control versus double-blind .
starting point for such a dosage. Keep in mind that "contributes to," "is Linked ro," or " is associated with" docs
not mean "causes."
5. Beware of press conferences and other hype regarding the latest findings. Much of
this will nor survive more detaiJed scientific evaluation.
6 . When you meet with a nutrition professional, you should expect that he or she will
do the following:
• Ask questions about your medical hiscory, lifestyle, and cLtrrent eating habits.
• Formulate a diet plan tailored to your needs, as opposed to simply tearing a
form from a tablet tl1at could apply to almost anyone.
• Schedule fol low-up visits to u·ack your progress, answer any questions, and help
keep you morjvated.
• Involve family members in the diet plan, when appropriate.
• Consult directly with your physician and rcadiJy refer you back to your physi-
cian for those health problems a nut:Jition professional is not trained to treat.
7. Be skeptical of"practitioncrs who prescribe megadoses ofvir:imin and mineral sup-
plements for c\·eryone.
8. Examine product labels carefully. Be skeptical of any product promotion not
clearly stated on the label. A product U. not likely to do somctl1ing d1at is not
specifically claimed on its label or package insert (legally part of the label ).
This cautious approach to nuttition-related advice and products is even more im
Toking numerous nutrient supplements con lead
portant today because of sweeping changes in U.S. lnw passed in 1994. The Dictar}
to health problems. Chapter 9 will explore the Supplement Health and Education Act (DSHEA) of 1994 classified vitamins, miner-
appropriate and safe use of nutrient als, amino acids, and herbal remedies as "foods," effectively restraining die U.S. Food
supplements in detail. and Drug Administration (FDA) from regulating d1em as heavily as food additives and
www.mhhe.co m/wardlawpers7 27
Figure 1 ·B I FDA disclaimer on a

Supplement Facts supplement label. Keep in mind that although
FDA requires the highlighted statemenl, ii does
Serving Size 1 Soltgel
Each Soltgel Contains % DV
not mean the supplement hos been tested or
Ginseng Extract (Panax ginseng) (root) 100 mg
endorsed by FDA.
(Standardized to 4% Glnsenosides)
·oaily Value (DV) not established.
INGREDIENTS: Gelatin, Soybean Oil, Panax Ginseng Extract.

Vegetable Oil, Lecithin, Palm Oil, Glycerin, Sorbitol, Yellow
Beeswax, Hydrogenated Coconut Oil, Titanium Dioxide, Yellow
5, Blue 1, Red 40. Green 3, Chlorophyll.
DIST. BY NUTRA ASSOC., INC.
4411 WHITE POINT RD .. SPRING CITY, IL 12345
Suggested use: Adulls- 1 to 2 capsules daily
taken with a full glass of water, or as a tea. add
one to two capsules lo a cup of hot water
When you need to perform your best, take ginseng.
This statement has not been evaluated by the Food
and Drug Administration . This product is not intended
lo diagnose, treat. cure, or prevent disease .
drugs. According to this act, rather than the m:mufacnirer having ro prove a dietary he American Dietelic Association has a toll·
supplement is safo, FDA muse prove it is unsafe before preventing its sale. In contrast, free holline, (800) 366-1655, thal provides
the safety of food additives and drugs must be demonstrated to FDA's satisfuction be- dietitian referrals through the Nationwide
fore they are marketed. Nutrition Nelwork and nutrition messages in
Currently, a dietary supplement (or herbal product) e<rn be marketed in the United English and Spanish. You con also find out more
States without FDA approval if ( 1) di ere is a history or its use or other evidence that about nutrition on their website www.eotright.
it is expected to be reasonably safe when used under rh1.: conditions recom mended or org. In Conodo, use www.dietitians.ca.
suggesn.:d in its labeling, and (2) the product is labeled as a dietary supplement. (FDA
can act if the product mrns out to be dang1.:roL1s, as with the recent ban on thc sup-
plement ephedra after numerous deaths.) The labels on such products are allowed to
claim a benefit related to a classic nutrient-deficiency disease, describe how a nurrient
affects human body structure or function (called structure/ function cl.tims; see the
section on nuuition labeli ng in Chapter 2 for details), and claim that general well- registered dietitian (R.D.) A person who hos
being results from consumption of the ingredients. Examples could be "maintains completed a baccalaureate degree program
approved by the America n Dietetic Association,
bone health,, or "improves blood circulation." Howe\'er, die labels of products bear-
performed at least 900 hours of supervised
ing such claims also must prominently display a disclaimer regarding FDA support in professional practice, and passed a registration
boldface type (Figure 1-8). Despite this warning, when consumers find these products examination.
on the shelves of supermarkets, heald1-food stores, and pharmacies, they may mistak-
enly assume FDA has carefully evaluated the products. (The effectiveness and safoty of
many herbaJ and related products is discussed in Chapter 18. )
The fact remains d1:tt many of us arc willing to try tuitested nutrition products and
believe iu d1eir miraculous effects. Popular products claim to increase muscle gro\\'th,
enhance sexuality, boost energy, reduce body fur, increase strength, supply missing nu-
trienrs, increase longevity, and even improve brain function. Clearly, many nutritional
produces commonly found in stores are not sn·ictly regulated in terms of effectiveness.
The actual amount of product in the package and potency are also often in question.
ln general, narional brands arc more reliable "'id1 respect to these questions. Finally,
few haw been thoroughly C\'aluatcd by reputable scientists. So if you embark on a self-
cure by means of such products, you will probably waste money and possibly risk ill
health. A better approach is to consult a physician o r register ed ctietitian first. 2 You
can find a registered dietitian in North America by visiting "" \\ .1:..llrigh t mg. or """
. di1:titiJn~.-..1 , consulting tl1e Yellow Pages in the telephone directo ry, contacting the
locaJ dietetics association, or calling the dietary department of a local hospital. Make
sure die pason has die credentials "R.D." after his or her name ("R.D.N." is also used
in Canada). This indicates the person has completed rigorous classroom and clinical Registered dieticians ore a reliable source of
training in nutrition and participates in continuing education. Appendix K also lists nutrition advice.
ecen~y, moior nutrition organizations put many reputable sources of nutrition advice for your use. Finally, the following wcb!>itc~
together l 0 red Rags that they consider can help you C\'aluate ongoing nutrition and health claims:
signals for poor nutrition advice:
\\"\\ "\\ .•K~h . 1 >r~
1. Recommendations that promise o quick fix
\\"\\"\\.quack\' :uch.com
2. Dire warnings of dangers from o single
"" '' .nc.1h I.org
product or regimen
dictary-suppkmc:n ts .in Ii 1.nih .gc >\
3. Claims that sound too good to be true
4. Simplistic conclusions drown from o
"""'" Ill l gm
complex study These sites are maintained by groups or indi,·iduals commined to pro\'id.ing re.t'>oned
5. Recommendations based on o single study and authoritati\'e nutririon and health ad,icc to consumers. Another information source:
6. Dramatic statements that are refuted by is the American Dicteric Associauon at """" c: nright.org.. Also, d1c website for this book
reputable scientific organizations pro\'ides information on the latest discoveries (\\ "" mh.hc:.com/ '' .lrdl.rn pu' ).
7. lists of "good" and •bod" foods Nutrition is a rapi<lly Olh ancing fielJ and there arc always new findings .
8. Recommendations mode to help sell a
product
9. Recommendations based on studies
published without peer review Brenda should be cau tious about toking any supplement, especially one advertised as
l 0. Recommendations from studies that ignore o "recent breakthrough." As you hove read, dietary supplements ore not closely regu·
lated by FDA, o general statement such as "increases energy" would be considered o
differences among individuals or groups
structure/function claim and such product labeling does not require prior approval by FDA.
Furthermore, FDA will not hove evaluated either the safety or effectiveness of such o product.
Even harmful dietary supplements ore difficult for FDA to recall. There is also o chance that the
supplement could contain little or none of the advertised ingredient. Unfortunately, Brenda will
find all this out the hard way and will be out $60. Her hard-earned money would be better
spent on a nutritious diet and o medical checkup at the student health center. All consumers
need to be cautious about nutrition information, especially regarding dietary supplements mar-
keted as cure-oils and breakthroughs-let the buyer beware!
Concept I Check
The scientific mclhod is the procedure for teMing the validil) of possible exphuutions or J
phenomenon, called hypotheses. Experiments are conducted to either suppon or refute a
specific hypothesis. Once we have much expcrimcnral information that support!> a specilic
hypothesis, it then can be called a theory. Ideally, experiments are conducted i11 a blinded
fashion, where the ~ubjects and researchers (preferably both) do not find out the results or
an experiment unril after the experiment is completed. This reduces bias in the results and
minimizes the placebo effect. All of us need to be skeptical of ne" ideas in the nutrilion
field. We should wail until many lines of experimental evidence support a concept before
adopting anr suggmcd dietary practice.
Genetics and Nutrition
The growth, den:lopmenr, and maincenance of years in ad\ ance of\\ hat illnesses \\ill likelr eventu-
cells and ultimately of the entire organU.m are di- ally de\·elop in a person. 10 The hope is then to re-
rected b~ genes presenc in the celb. The genes con- place genes that cncour,1gc diseases, such as cancer
tain the codes due control the e\pression of and Alzheimer's, with those char do not. Such in-
indi\·idual traits, such as height, eye color, and sus- formation as well may provide opportunities for
ceptibili~ co many diseases. An indi\·idual's genetic physicians in the future to diagnose disease more
risk for a given disease is an important factor, al- accurately and to prescribe indi\•idual medical ther-
though often not 1he only 1:1ctor, in determining apies, instead of creating .11! patients \\'irh the same
whether he or she develops that disease.13 disease using essentially the same rhcrnpy. l tis likely
Interest in the human genetic code and its re- that many medications may be more appropriate in
lationship to specific dise.1scs Im exploded in re- certain people given their genetic rraits.
cent years. The U.S. gO\ernment through the An exciting application ofchc Human Genome
Human Genome Project and a private company Project is DNA microarrays, also called gene chips.
ha\'e each sequenced the more rhm 35,000 genes About 100,000 pieces of DNA can be loaded onto
present on human chromosomes. These efforts a dlip the size of a fingernail. Blood can be
ha\'e not actu.Uly ~equenced rhe genes of just one processed and then pl.Ked on the chip and rapidly
person, but h,l\'e compiled a composite genome rested for altered genes. Genetic material bmding
based on the DNA conrributed by a te\\ indi\·idu- to certain areas on the chip can signal a healthy
als. Each gene esscntialh· represents a recipe, not- form of a specific gene or alrernarel~ .1 form that is
ing the ingredients (specifically, amino acids) and associated with disease. Current!\', about 75 labora-
hm\ those ingredients should be put together. The tories in the United States arc using this technol-
human genome rhen would be the cookbook. ogy ro im·esag.ue disease nsk. 9
Ir is like!)' that soon it will be relatively easy co
scrc:en a person's DNA for genes that increase the
risk for disease. Currently, a woman can pay about Nutritional Diseases Genes ore present on DNA-o double
$2700 to be rested for a mutation in the BRCAl with a Genetic Link helix. The cell nucleus contains most of
and BRCA2 genes; these mutations grc.1rh' increase the DNA in the body.
the risk for brealtt cancer (sec .1 later section in this Most chronic diseases in which nmrition plays a
Nutrition Forns). To dace, scientists have de\'cl- role <trc also influenced by gcneucs. The risks of dc-
opcd about 600 genetic tests. Many .lre for very \·cloping cardiovascular disease, hypl'rtension, obe-
rare diseases and forrunate ly often arc much less ex- sity, diabetes, cancer, and osteoporosis .ire
pensive than the rest for rhe BRCA genes. These influenced by intcractfons between genetic and nu-
genetic tests arc cspccinlly valuable for fumilies tritional fuctors. Srud ies of fumilies, including those
plagued b) certain illnesses, bur more routine rest- \\~th rwins and adoptccs, prcl\·ide strong support mutation A change in the chemistry
ing of nO\\ -health) people to predict future risks of for the effect of generics in these disorders. [n fact, of o gene thot is perpetuated in
cancer or other diseases is pobed to gro\\' rapidly. family hiscory is considered co be one of the im- subsequent divisions of the cell in
This field is brand nc\\ and is about to mushroom portant risk fucrors in the dcvclopmcm of many which it occurred; o change in the
into a significant part of medical practice, as almost nutrition-related disea~cs.22 sequence of the DNA.
eYery medical condition has .i genetic component.
,\1osr, however, arc not single gene disorders but
instead arise from alcerauons in a number of genes.
Cardiovascular Disease
Each year new !mks between specific genes and About one in C\'Cry 500 people.: m North Amenca
diseases arc reported. Decoding of the human has a dcfccti\'e gene chat great!) dcl,ws cholesterol
genome could ultimate!} allow for tailoring of dices remornl from the bloodstream. As )'OU will learn in
with rcspccr to indi\•idual nutrient needs or the in- Chapter 6, this and orhcr genetic eficcts lead to an
di\'idual's response co certain diet patterns. In ad- increased risk of developing cardiovascular disease
dition, it is thought that this greater a\•ailabilir.y of at a young age. Diet changes can help these people,
genetic information could ultimate!)' transform the but medications and possibly surgery may be
practice of medicine, allowing for the prediction needed co address these problems.
(co11tin11ed)
29
Hypertension Cancer
An estimated l 0 to 15% ot' Lhe North American A few types of cancer (e.g., some forms of colon ,
population is 'Cl'}' sensitive tO salt intake. When prostate, and breast cancer) have a strong genetic
these salt-sensitive individuals consume too much link, and genetics may play a role in others. StiU,
salt, their blood pressw·e climbs above the desirable obesity alone increases the risk of se,•eral forms of
range. The fact that more of rhesc people arc cancer. And one-third of all cancers result from
African American than White suggcsr.s a genetic smoking. Again, genetics is often not enough; en-
component. At prcscm, d1e onl)' way LO determine vironment also contributes to the risk profile (see
whether individuals with hypertension arc salt scn- Chapter l2 fur more details).
siti,•e is to place them on a salt-restricted diet and
sec if their blood pressure falls. Note also that many
Osteoporosis
cases ofh)tpertension are unrelated to salt sensiti,•ity
bone mass Total mineral substance and are caused b>' other racLors (sec Chapter 11 ). Bone mass and resttlring bone strength is similar in
\such as calcium or phosphorus) in o twins as well as in mothers and their daughters. The
cross section of bone, generally exact relative importance of genetic versus dietary
expressed as grams per centimeter of Obesity
factors is unknown, bur a number of gene~ have been
length. Most obese North Americans lm·c at least one par- shown to cont1i bute to a person's overall 1isk oflo"
c:nt who is also obese. Findings from many human bone mass. Jn any case, children and adobccnrs
studies suggest that a ''ariery of genes (likely 250 or need to consume sufficient calcium to build strong,
more) are involved in the regul,uion of body dense bones, thus reducii1g the risk of osteoporo~i~ in
weight (sec Chapter 13 for more derails). Little is later life. Adults should continue that practice. The
known, however, about the spe.:ific nature of Lhese porous bones that arc a result of osteoporosis greatly
genes in humans or how the acrnal changes in body u1Crcase the risk of fracrw·es, cspccially in the w1ist,
metabolism (such as lower energy use in general or spine, and hip. As discussed in Chapter 11, the risk of
fat use uJ particular) .in.: produced. osteoporosis in women can be greatly redm:cd b~ a
Still, although some ind1\'iduals may be geneti- combination of medical and nuttitional means if ther-
11 ~'-' I 1 -
cally predisposed to store body fat, whether they apy is started at least by midlife.
Wesley no/ices that at family gatherings actually do so depend~ on how much excess energy
his parents, uncles, aunts, and older d1ey ultimately consume. A common concept in
siblings typically drink excessive nutrition is that 1111tr111·c (how people live and the Your Genetic Profile
amounts of alcohol. His father has been environmental factors that influcncc them) allows
arrested for driving while intoxicated, as 1111t1trc (each person's genetic potential) to be ex- From this discussion, you can see rhat a family his-
hos one of his aunts. Two of his uncles pressed. Although nor everyone "·ith a genetic ten- tory ofcertau1 diseases raises your risk of de\'doping
died before the age of 60 from alcohol dency toward obesity develops this condition, he or those diseases. By recognizing your potential for de-
abuse. As Wesley approaches the age she does h,we a higher llferimc risk rhan individuals velopu1g a particular disease, you can avoid behaY-
of legal drinking, he wonders if he is without a genetic predisposition ro obesity. ior that contributes to it. For example, women with
destined to foll into the pattern of alcohol a family history of breast cancer l>hould a\·oid be-
abuse. Who/ advice would you give lo wming obese, should minimize alcohol use, .1nd
Diabetes
Wesley concerning his future use of should obtain mammograms regularly. Jn general
alcohol? Both of the rwo common types of diabetes-type 1 the greater number of your relatives who had a ge-
and type 2-ha,·e genetic links, as revealed b~· fam - netically Lransmitted disease and the closer they are
ily and twu1 srudies. Only sensitive and expensive related ro you, the greater your risk. One way to as
testing can determine who is at risk. The form of sess yow· risk is to put rogctl1er a family rree of ill
diabetes invol\'ed in about 90% of all cases, rype 2 nesscs and deatl1s by compiling a tell' key facts or
diabetes, also has a strong link to obesity. A genetic your primary relatives: siblings, parents, aunts anc
tendency for type 2 diabetes is expressed once a per- uncles, and grandparents.
son becomes obese but often not before, again il- Figure 1-9 shows an exan1ple of a family tret
lustrating that nurrure affects nature (sec Chapter 5 (also called a genogram). High-risk conditions in
for more details). elude rwo or more first-degree rclarives in a famil)
30
Maternal Figure 1 ·9 I Example of o family tree
Maternal grandmother for Eugene, designated as "Self" al the
Paternal Paternal grandfother . 1901 lrunk of the tree. The gender of each
grandfather grandmother . 1895 d. 1984 fa mily member is identified by color
b. 1885 b. 1890 d. 1972 ~smoked cigarettes (blue squares for moles, orange circles
d. 1980 d. 1941 Alcoholism Obese for females). Doles of birth (b) a nd deofh
mn OOJi.1.a;.1,@a mn 1:mmr.r:m1 (d) ore listed below each fami ly member.
Uncle Father Uncle Aunt Mother lnfanf' If deceased, the cause of death is
b. 1923 b. 1917 b. 1910 b. 1922 b. 1927 b. l 9'.l7 highlighted using white text against a
d. 1972 d. 1985 d. 1989 d. 1988 d. 1937 block background. In addition to causes
Alcoholism Back Diabetes Asthma m:J!ftM'.111.I of death, medical conditions the family
Rheumatoid surgery Smoked l:!l~·l~l'J.111'='1 members experienced ore noled
arthritis Hypertension cigarettes beneath each name. Create your own
Prostate cancer 1:mr.n1111 fam ily tree of frequent diseases using lhe
.. Figure in the second Take Aclion section
as a guide. Then show your family tree
Female • Male Brother Sisler Sister to your physician lo get o more complete
b. 1J52 b. 1955 b. 1963 picture of whol lhe information means
Self Alco~olism
Daughter for your health.
b. Born b. 1990
d. Died
Couse of death
with a specific disease (fast-dt:gree relatives include into the hearts of people with poor heart circulation. heck out the website
one's parents, siblings, and offspring). Anorher This gene therapy has led to improvement in heaJtl1. www.hhs.gov/fomilyhistory for
sign of risk or inherited disease is development of In addition, a number of infants worldwide were more information of using a family tree in
r11e disease in a first-degree relative before age 50 treated for a severe immune delicic:ncy disease with heohh·reloted evaluations.
to 60 years. 22 In the family in Figure 1-9, prostate genetic therapy by putting new genes in ilieir white
cancer killed the man's farJ1cr. Knowing iliis, the blood cells. Many arc alive and well today. Scientists
son should be tested regularly for prosratc cancer. hope that one day gene therapy application:. such as
Hi:. sisters should consider frequent mammogram~ ilicse can be used to treat many diseases, especially in-
and other preventive practices because their mother lmired dist:ases. Still, much more research is needed
died of breast cancer. Because heart attack and for tlrnt to happen on a routine basis.
stroke are also common in the fami ly, all ilie chil-
dren should adopt a lifestyle rJ1ar minimizes the risk
of developing these conditions, such as a moderate Genetic Testing
animal fut and sodium intake. Colon cancer is also
evident in du: fam ily, so careful screening through- Tn recent year~. scientists have developed ways of
out life i~ important. testing a person\ genes for the likelihood of devel-
oping catain diseases. For cases such as
Huntington's disease, a degenerative brain disor-
Gene Therapy der, a positive gene rest guarantees the evenrual de- virus The smallest known lype of
infectious ogenl, many of which cause
velopment of the disease. However, with diseases
disease in humans. They do not
Scientists are cmrcntly developing therapies to cor- such as cancer, a positive gene rest simply indicates metabolize, grow, or move by
rect some generic disorders. Typically, ilic gene ofin- a greater risk for developing r11c disease. ln addi- themselves. They reproduce by the aid
teresr is inserted inro a virus, and tl1en this 1'irus is cion to chc diseases mentioned, risk factors for birth of a living cellular host. Viruses ore
injected into the target tissue. For example, a gene defects, certain forms of muscLdar dystrophy, and a essentially a piece of genetic molerio\
that stimulates blood 11esscl gro11th has been inserted host of other diseases can be detected through ge- surrounded by a coot of protein.
into a 1~rus, and rJ1is combination has been injected netic resting.
(co11tin11erf)
31
Today in the United States, newborns arc rou- crease disease risk may face job and insurance dis-
phenylketonuria IPKU) A disease ti nely tested for phenylketonuria, an inherited crimination. Testing positive could also lead to un ·
caused by o defect in the ability of the metabolic disease that leads to mental retardation necessary radical treatment. As well, a sceminglv
liver to metabolize the amino acid and other problems if appropriate treatment is nor hopeless diagnosis could result in depression or
phenylalanine into the amino acid given. Infants found to have this disorder an: put withdrawal fi-om life when a cure is out of reach. 11
tyrosine. Toxic by-products of on a special diet, which reduces development of the Some experts recommend that anyone consid·
phenylalanine con then build up in the disease (sec Chapter 4 for details). ering genetic tesLing should first undergo gem.:tic
body and lead to mental retardation.
Because genetic background docs influence dis- counseling. Genetic counselors arc trained to ana-
ease risk, certain dietary advice is more beneficial for lyze family history and evaluate risk of dcvdoping
some people than for others. For example, people or passing along an inherited disease. The)' can also
prone to osteoporosis, as mentioned earlier, need to help determine whether testing is wonh the cime
be more aware of calcium intake. Overall, the ben- and trouble, since genetic rests arc primarily for
efits or genetic testing include the opportunity for people whose family history puts Lhem at especially
more individualized nutrition and health ad\•ice, high risk of having a gcneLic detect. Genetic coun-
more informed decisions by couples attempting to selors can be fou nd by contacting a local hospitJI or
have children (i.e., alternatives such as adoption or nearby uni, ersity-affiliated hospital or medical
1
therapeutic abortion), im:reascd surveillance for che school.

disease, and the ability to plan ,1ppropiiately for the In chc fi nal analysis, would you r:ithcr kncl\\ if
future. 11 However, it is nor possible, given the limit you were at risk for a specific disease that a genetic
on resources presently allocated to medical care in test c0tJd point out? If so, ask your physician about
North America, to identif~: all people ar genetic risk the possibility and wisdom of testing you for the ge·
for the major chronic discilSes and other healtl1 netically linked diseases in your family tree. Also, be
problems. In addition, in many cases genetic sus- aware that, tl1roughour this book, discw;sions will
ceptibility docs not necessarily guaranrce develop- point out how you can personalize m1trition ,1thice
ment of the disease. And, in almost all cases, there based on your genetic background. In this way, you
is no way to cu re a specific gene alterarion-only can identify :rnd avoid d1c "controllable" risk faccor.;
the health problems tl1at result can be treated. tl1at would contribute co d1e development or genet-
Thus, the wisdom of genetic testing is an open ically linked diseases present in your family.
Genetic analysis for disease
question. Perhaps preventive measmes and careful The following web links will help you gather
susceptibility will be more common in scrutiny for the specific generically linked diseases more info rmation about generic conditions and
the futu re as the genes that increase risk using one's family tree would suffice. testing:
for various diseases are isolated and Researchers also an: concerned that people
www.gencticalliance.org Alliance of Gcnccic-
decoded. who arc found to have genetic alrcrarions that in-
Support Groups.
www.kumc.edu/gec/support lnformauon on!
genetic conditions and rare conditions.
c;tnccrnet.nci. nih.gO\ /p_gcnetics.hLml Genetics
information from the National Cancer lnslirure,
ww\\ .nhgri.nih.gov National Human Genome
Research Instirute (at the NTH) home page
Describes latest research findings, discusses eth1
ical issues, and provides a talking glossar~1•
WW\\'.faseb.org/gcnetics Compilation of majo
genetics societies throughuur rhe world
Information on genetics meetings, society poliq
statements, and so on.
vcctor.cshl.org Cold Spring Harbor Llbs DNtl.
Leaming Center home page; includes anima
tion of genetic techniques.
ww\\,ncgr.org National Center liir Genomi<
Resources home page.
32
-- ~ u
Summary
1. Nutrition is Lhe sruJy of the food subscarn:es Yit.11 for health and 6. Result~ from large nutnt1on surveys in the United Stares .rnd
the study of how the body uses these subsrnnces w promote and Canad:i suggest that some of us need to conceno-ate on consuming
~upporr gro\\'th, m.Untenan..:e, and reprodlli:tion of celli.. Research foods th:it supph• more of certain vitamins and minerals and fiber.
in the field h:u. been especially vigorous from die past cenrury LO Regular use of a balanced multivitamin and mineral supplement is
die present. another strategy LO make up for some dietary shortcomings.
2. Nutrie1m in foods fall into six chsse:.: ( 1) ca rbohydrate~. (2) lipids 7. The flavor, cexwre, and appearance of foods primarily influence
(mostly fats and oils), ( 3) proteins, ( -t) ''itamins, (5) minerals, an<l our food choice~. Several other factors also hel p deternunc food
(6 ) water. The first three, along wid1 alcohol, prmide energy for habirs and choices: ow· upbringing, ,·arious social and culrur.tl fac-
the bod~· w use. tors, die image we wa m w project ro others, eonvenit:nce, eco·
3. The body transforms the energy contained in ..:arbobydr:ite, pro- nomics, emotional srnte, and concerns abou r health.
tein, and far into other forms of energy, which allo\\' L11e body w 8. The scienrilic method is rhe procedure for testing the validity of
function. Fat prm·idcs, on :ll'eragc, 9 kcal/g, whereas protein and possible explanatio ns of a phenomenon, called hypotheses.
..:arbohydrate each provitks, on a' crage, 4 kcal/g. \'it<tmins. min- Experiment~ .tre conducted ro eirher support or refute a ~pecific
erals, and warc.:r do not supply energy ro t ht body but arc ei.scn· hypothesi~. Once we ha\'e much experimental information char
tial for proper body function. supports a ~pee.ilk hypothesis, it tl1en can be called a theor y. All of
4. A basic plan for health promotion and disease pre\cmion im:ludes us need to be skeptical of new ideas in rhe nutririon field, 1\'atring
eating a v.1ricd diet, performing regu lar physical :1Cti,·ity, not umil nuny lines of experimental e1•idenee support a concept be-
smoking, nor .ibusing nurricnt supplemenLS (if used), consuming fore adopti ng any suggested d ietary practice.
adct1uate fluid, getting adequate sleep, limiting alcohol imakc (if 9. Genetic backgrou nd influences the risk for many heaJth-relattd
consumed ), and limiting or ..:oping with srress. diseases. Examining one's fami ly tree provide!> dues for an indi·
5. The: primary fo..:u~ of m1tricion pl.111ning ~hou ld be on food, not ,·idual LO such risks. Pre\entive me:i.sures are then import:tnl w im·
on dierary supplements. The foct1~ on foods to supply nmricnt plcment, C!>pccially \\'ith respect to diet.
needs avoids the possibility of se\'l.:rc: nurriem imbal.111cc'>.
Study Questions
l. Name one chronic disease associated \\'ith poor nutrition habits. 8. Lbt one food habir you should work on ro improve your health.
Now lii.t a ti:\\' corresponding risk factor!>. Indicate wh) and list three actions ro take.
2. Explain the concept of energy as it relate~ w foods. What a.re the 9. What nutrition-related disease i!t common in your r:tn1ily? What
fuel (energy) '"1lues used for a gram of carbohydrate, fat, protein, step or steps could you take ar this point to minimiz1: yoLLr risk?
and alcohol? I 0. List one nutrition daim you have heard recently that sounds too
3. Idenrif)· three \\".1ys that \l'atcr is used in the body. good ro be rrue. \Vhar do you suspect is the motive of tl1e person
-!-. Wendy's Big .Bacon Classic contains 44 g carbohydrate, 36 g fot, providing the advice?
and 37 g protein. Calculate the pt:rcentage of ent:rgy derived
from far.
5. Describe rwo types of fat and cxpl.iin "hy tl1e difference:. are im- BOOST YOUR STUDY
port:tnt in cenm of overall health.
6. According to national nutrition surveys, which nutrients tend to Check out the Perspectives in Nutrition: Online Learning
be underconsumed by many adulr North Americans? Why is this Center www.mhhe.com/wordlawpers7 for quizzes, flash
the case: cords, activities, and web links designed to further help you learn
7. List fou r health objectives for die United States fo r the )'Car 2010. about what nourishes you.
How would you rate yourself in e.Kh area? Why?
An notated References
l. \D:\ Reports: Position of the Amcric.rn TlJ<' n111r.,.;ca11 Dmtric AJ.S11rinti111111nw 1h111 s/Jo11/d rll/p/Jnsi:;,· ndl'quac.v of the total dic111rrr
Dic[ct.ic Associarion: Toral dicr npproa.:h w there arc 11ngood 11r bndfaod.<, 011/vgood or bnd time, tbc imponnnce ofolmzi11i11g nun·ie11t.rf,.om
communicating food am! O\ltrition informa- di.-ts 111· cn1i11l1 sryli:s No single feud 111· rypc 11ff11od fimds, n11d p11rrim1 umtrol, ro11pl~d with 11•c(11ht
rion. fotmurl of t/Je Arm'TIClfll Diaetic nsSOCllf • ms1m:sguod bealr/J. pm ns 110 smg/c.fiJtJd or typt' crmtml nud rcg11/m· pl~11flcnf ncti1•ir.i\
tiou 102: 100, 2002. '!!Jnod iJ 11ffcs.rnril1• dctl'i111mtnl 1t1 hen/th. Adults
2. AD.'\ Rcporrs: Posirion of the American 11mou11r.< ofcm·bol~vd1·nte.jiu, muf p1·orci11 inn 171c nrriclt- l'fJlfrll's mnny q11cst.i1ms rlmt ,-{)011/tf
D ietetic A>>Oci.Hion: Food J.nd nutrition misin· dicr. tbis s/J11uld bt -15 111 65'%, 20 111 35%, nud /1c nskcd bcjim· n11y bcnlth·rdnud clnim 1s 11(·
fornurion. ftmmnl of tbc A111crim11 Dictrtic 10 to 35%, rcspcct1 l'c~v. rcprrd n11d fllll i11m pmctin·.
Associntim1 l 02:260, 2002. 9. t::ril'nd SH, Stoughron RB: The m.igic of mi 17. MokdaJ AH and other~: Actu.tl .:.m~c~ of dl'Jth
Jlucb ji111d n11d 1111tritim1 misi11flw111rrtim1 per· croarrnys. Sc1rntiflc A111101·icn11, p. 44, February in th e United Stares, 2000. frmrnnl t!( r!Jt•
l'fldcs N1wrb A111crirnu .rqcfrt_.1•. ludiridunls 2002. A111cricn11 ,\ft-dim/ rlssocintio1129 I: 1238. 20!H.
sh1111ld rnn:jit!~v consider tbt rmi11111g oft/Jn.re DNA 111icr11m·m_1~-nls11 cnlll'ff..!fCllc cbips-nff .\11wk111g is rb,· let1d111g en use of /Wcl'mtnblt-
ll'b11 gil'<' me/; nr/Jtirc, nm( be nssm-cd tbnt r-.:._f/is·
/ikt-Z1· to SIJlllJ re1•0/urir111i::.c 111crlim/ mrr. dcnrh i11 rbr U11irtd Srnru, with ol1tsi1y n rl11s<'
tc1-uf. dfrtitinu.r nn- n rdinbk .<011rc.-.
Indil'idunls 1J1ill /"' nblc t11 /Jm•t t/1cir 11w11,t1r· Sfftmd. A c11111bim11iu11 11fn pn11r dfrt rwd 111nc·
3. ADA Rcporrs: Po~irion of the American 11aic bnckl1ro1111if nun~VZ<·d; r/Jis will lidp fll~vsi· riJ•t lifmylc 11Ceo111w.fin· nbo11t 11111--rlm·d of nil
Dietetic ,'\:.sociar1on and Dietiti:ms of Ca1uda: rinm ding110.it' diseases 1111d 111i/111· /m1ltb nd1•icc. d,·ntbs i11 t/J1· Unit<'d Srntr.r.
>Jucrition Jnd women'~ health. jflllmn/ of tbt TJ;c procrsJ cif min..IJ D N rl wicrom"rn_v.r 1s de· 18. Obhan~ky SJ .md other>: f\ potenriJI dcdinc 1n
A111crw111 Dietetic Assonnrio11 10-!:984, 2004. Hribcrl i11 detnil. life cxpcc t.mq· in thl' United St.He' in t.hc 2J ,t
Co111p1'<·bmsive /oak nt hcnltb is.rues rclntcd t1111u- I 0. Gropper S~ and orhcri.: Ad\'J.nced nmrition .md cenmry. 'l71c Nm• E11gln11rl /1111mnl of .\Jtdicmi·
tritio11 r/Jnt women nftcu frm:. Wide~)' ndJ>ocnrcd h11 ma.11 metaholi,m. 4th ed. Iklmotu, CA· 352: 1138, 2005.
nrt' dim ricb in ji·uits, Prg<"rnbla, mid 11'/Jolr· Thomson Wadsworth , 2005.
flmin breads nnd camls. ll'itb sm111: lowfnt dnh:\' "171r.!fl'llll'itt11prob/0111if111•1n1>c£f/bt 1111d 11b.:siry 111
E.wdlcm s11111-cr.fi11' r/1•' foust ji11di11.,1J.< i111111rri· 1111r soricf)• is likl'(1· w lend llJ more 11Nrnll prmin·
1111d lcm1 menr d1oius. bidirid11nl 1111trimrs
LikcZ1•to be 1mdcrcow11111cd include rnlci11111, ircm, tion scimcc. f li rt' 1!c11t/J.( 1111 nlnm1i11_1J tmmn1is1bn1 1b1:,
rirnmin D, 1•icn111i11 £, muf fo/nr,-_ I 1. Gutrm.1cher AF, Collin• FC: Rt.':llizing die 11•ida-prmd i11crcnsc i11 body we[qbt multi r.-.r11/t 111
promise of gcnomks in biomedical research. n li.f~ t·xpcrtn11cy ojji:wiT ymnjiw t11rlny's c/Jildmt
4. Carpenter. KJ, H.1 rper At: En>lution ofknowl·
jr111r11nl 11f tb1· A 111t"ricn11 i\ frdirnl Assoontio11 c11111pnffd ti/ t/;cir pn.rcnrs. llcl'e1'1iiJ.1J this n·md 11}
edge of the: essemial 11utri.:nrs. Jn Shi lls ME and ..1J1·.:n1a· 111•t-r11•.:i._q/Jt n11d obt·sit.1· tlms is rmrinl.
mhcrs {cc.ls. ;: .\f1Jdcn1 1111nfrio11 i11 hcnlrh n11d 294: 1399, 2005.
disease. I Orh t:d. Philadelphia, PA: Lippi neon: 111is nrtir/1• rel'icws the pnt"1Jtin/ _f{ll' 11si11g r/J,· 19. Pacrat:iku l ~ :111d others: E1sr-tood com.ump
Willi.1m\ & Wilkin~. 2006. gmaic Prt!fih' 11f11 ptrs1111 wlmt prnPidi11..11 tion among U.S . .idulr~ .rnd children: Dict.1r1·
btnlth·rdnrcd 1itf1•icc. Grnrt1c t.:sti11._n J11ill likc~\' anc.J nutrient inr.1ke profik. /1111rnnl of tut
A sbort bfrt111:v o_(11ut1·iril!11 is f11'111•id,·d i11 tbr
/Jnpr n bi.!1i111pn<t1111 btnlt/J cm·<" int/Jc ji1111rc. A11w·irnu Dietetic .Associn1im1 Io:~: 1332. 2003.
c1111tcxtt1f the rh:fl11itio11 of r111 csse11rinl 1111!1'it11r.
:i. Cordain L .rnd others: Origins and e\·olmion of 12. Hcnlrb.1• l't·oplc 1010 W!!ets hc,1ltlw diec and n011lm· iutnkr 11Jjirsr faorl c1111h·1/mtcs n !or of
the Western diet : H ealth implic.1tion~ for rhc healthy weight a' .:ritiral goals. }1111r1111/ of tbr
jirr n11d ,·11c1~fJY Ill n rlicr. Such ji111ds rn11 nlm
Awcricrw l)icwic A.t<1Jcinti1111 100:300, 2000. crmPd 11111 111111·e /Jcnltl1ful_fil(ldS inn tifrt.
2 Jst centuri-- A111c1·1cn11 /011mnl of C!i11icnl
l\'11n·irio11 8 1:341, 2005. Ri:n11lm-Jirsr-ji11Jd r11m11111a·s 11'011/d {1r 11•1Jr '''
M1111y 11f 1br 1111tnti1111.1Jon./s i11d11df1f in jiicus 011 lou•o-:firt ifflJJS 1111d,11rcn1~1· limit 11r
Ju r.:cmr lm11m11 history tbt' 11pern/I rtirr /ms in· Hcaldw People 20 LO nre e1211111cmrr.d. 71Po i11'11id mgnn·d soft drillh n11d frrnd1 fi·it's.
c/11dcd n _m·mt 1111111b.:r 1!(fiiod; ricb in r,;_fhud kcy._t/llfll.< nrc to 1"rd11u 11b1·sir_v n11d i11ncti1•ity
m.1Jnrs, 1·cfi11cd flours. snlr, 1111d fntty meats. 171is 20. SloJ n Ar.: Whar, when, .rnd where Amcric.ms
i11 t/Jc A111cncm1 pop11/nt11111.
e;ir. Food Talm11/1t1JY 57(8):48, 2003
dJn11gi: IJns rcsult«d i1111 dalini: in diet q11nlit_1•
L3. Jackson K: Pinnccring the frontier of murigc· The Nrwr/J rl111aicn11 rlier is 1111drr._1]11111.1J am·
jiw 111n111• of 11s 111 rbc 111oda11 world.
nomics. Todny's Dutiru111 p. ~4. November
6. Corron PA and others: Dietary sou rces of nurri· stn11t cbn11p1·; this i11c/11dt'S iun·od11cri1m 1f 111'11'
2004.
wt~ among U.S .•tdulcs, 1994 to 1996. /1111mnl
food producrs ns 11•ell ns 11cw types 1{n-stnum1m.
A11 rxc1t111._t/ rlc1•d11p111rnt in 1111tritia11 J11i!I b' 171is nrric/,· dacribcs rbr /0 h-ndi1111trends111 rt'-
11f tbc II 111n-im11 Dtctftic llssocin.r io11 l 04:921,
t/;c n/Jility M 11se n pcrso11 'sJ7enctir profile ro pm· ll" rrl to tbesc nu d or/Jcr cb1111gi·s.
2004.
11idr 1111wr p1-cc1sr 1111tri1w11 ..1J11idn11r<' l~i· dicti· 21. Tl10Jin S and at.her•: Gen~tic .111d em·ironmcn-
'f71c ffrr /mdi11p t11o;g_1· so111·cu Jin· A111e1'im11
t11111s n11d ot/J<-r d111ie1nm. 11ns nl'ticfr discusses tal influences on ~ating behavior: The $\\cd1~h
nd11/ts 11n- (iu 11rdrr): ymsr br.:nd, beef;
r/Ji.r po.rsibili1.v. Young Male Twins Study. 11111.-rirnu Joumnf 1~r
mkes/c11okies/q11ick brwr/s/ d1mg/11111rs, soft
drh1ks/S11dn, n11rl mill·. The soft dri11ks/sodn n11d 14. hmk food or junk\ choices? 7i!{ts U11iiorrsif)• Clinicnl N1111·irio11 81 :564. 2005.
cnkc etc. mtt'gorics n/so bni·c been w0Pi11g up i11 Hen/th c;~ N11h·itio11 Lcrtci; p. 3, &ptembcr 2003. Gmctics plnys n di.rti11ct nik i11 tb1· de11d11p111mr
tlic m•do- co111pnrcd to tlJ<" 1980s. Clrnr~i· 111ni1_)' Some Jll'eer 1ir hig/J:f'n r ji111ds cfllt be snj'dy i11 ror· 11f cnti11g hnbits, mch ns m111ti1111n/ cntili..n 111· ,.,..
ndults 111·cd ro i111pr11p,; r/Jt'ir di.:rm·y c/Joica. prwnurl into nu ut/Jrrn•is<' hcnlt/;_v rlict. T71is srrninrd cn1i11g. Gwcrics mny /u li11l·.:d /II t/Jt'
7. Drc:\\·110wski, A, Levine AS: Sugar and far- bcnltby dirt should /11· 1frb i11 .fruit.<. J1c,11ct11blu, 11111on11t •lfl'nrillw /111r111011cs f111d 11tlicr pliysio·
From genes w culture. /011mnl of N11t1'irio11 n11d whn/t:fJl'lli11 breads nnd cei·mlr mid sbo11/d !u._qirnl fnmws r/1111 mn i11j111mcr wtilJ_IJ hnbirs.
133:829.$, 2003. cm1mi11 some loll'jirt n11d fnt:f1w dnii:1• c/111ius 22. W.tttcndorf DJ, Hadky l)\Y: F.1milv hiMory·
Added Sll._fJnrs n11d fntl" nrm1111t.fin-..1Jrente1· tba11 n11d lcnn pr11td11 .ro111-ri:.r. A pcl'Sllll '.r tom./ dietn1:1• T he rhrec·gencration pedigree. A1111-r1cn11
SO•' of<'m'IZT)' itttnl.•r i11 t/J.: typical Norrb i11tn/u· is ll'hnt drrt-r1m11rs rlH q11nlil)• 11/11 dfrr. Fnmily P/~1·sirin11 72:+41, 2005.
American rlia. 111.:ir 01•.-rcmu11111p1ion is befog 15. Lubin F and other..: Litc.•st·yle and ethnicity play Hcpit~Pi11p f11111 i~I' /Jcnlt/J /Ji.<tm:v is n 1'fl!t111blr
blamed fiw n wirlt• mngc 1ifcbro11ir 1iismses, J rok i11 .111·.:ausc morr.i lity. Joumnl of //Jiii, in nm·ssill~IJ n ptrstm 's f11t111·,· IJmlrb 1·isks .-ls
fi·o111 cnrdil!Mswlnr discnst to o/Jui~r 1111rl din· Nutririmr 133.1 180, 2003. di.rrus.rrd in rbc nnirk, s/Jnriug mc/J i11jiw111n 111111
bctrs. Fnt n11d JJt._f/fll' S(flll ro npptnl to c111oriom Dicmr_v lmbit:r rlmt rcdun· nll·cnmr 11101·tnlity ll'il/J 1111c's pb,1<riri1111 rn11 br Pr1:v iwp11rtn111.
and nn· r/Jc do111m1wr 11bjccr farfl111d e1·npi11gs. indudc fornmw 1111 !Jot/1 bi_11hjibt-r fi111ds 1111d 23. \Vetter AC and other~: HO\\ and "hy do indi·
Wr need m comidrr rl1is n.r Tl'< cba11.rc foods ricb tb1IS<' lrlll' i11 snt11mud jfrr n11d cboifstrrol. dduals make food .md physical acttvtry chotcc'>?
in fnr n111f su_11n1: P11!ithic lifc.•1J'l'· brr/lits i11c/11dc rc/111/nr phy.<im/ N11tritio11 Rel'iews 59(3):Sl1- S20, 200 l
8. Food and N urririon Board: Dir:tn1:1• rcfarc11ce in- nctii•it,1• n11d 111•01di11g S1111Jking nnd 11bcsity. Hmltb l111birs nrr 11~fl11mc.-d by n 11111nba 1ffnt·
tnkes for cun;_l]y, cm·/Jo/~1·dnrre,jiba;.firt,fntty ncids, 16. Making ~cnsc of mcdi.:al new~. Co11.m111er tors: bdit'p, 1•nl11es. liji: i:xprrfrnc.->, s11ci11rr111111111ir
cb1J!estcrnl, protein, n11d n111i11n ncids. Washington Rl'p11ns 1111 Hrn/1/J, p. 8, 1\lay 2005. sttltus, cd11rnrio11i1/ armi11111t·11r. iuro-pcr.<111111/ I'<>
DC: The N;1rional Academy Pres.'>, 2002 . Cn11n1T11crs 11.-rd ro lie IPnlJ 11fbmltli dni111.r lntiousbips, /(ft' stn.1Jr, nud s11.-inl mks. Enrb dai·
11JtS report prm•1da tbe lntnt g11id1111cc for mntfc it1rhc11cu•.r medin. ns m11ch nf rbis i11fr11'· siou mndt· n:._f/nrifil7l1 benlt/1 prncr1a-s dcpmd.< 1111
11111crn1111t1·it'11t i111nka. ll'ir/J rc._111ll"ii to th<' 111rr.tio11 is .r11sprct jh1111 n wmrijir Jtn11dp11i11t. input fr11111 rb.·sc n11d ot/Ja-fnrmrs.
www.mhhe.com / wardlawpers7 35
Take I Action
I. Examine Your Eating Habits More Closely.

Choose one day of the week that is typical of your eating pattern. List all foods and drinks you consume for 24 hours. In addition,
write down the approximate amounts of food you ate in units, such as cups, ounces, teaspoons, and tablespoons. Check Figure 2-7 in
Chapter 2 for examples of appropriate serving units for different types of foods, such as meat and vegetables.
Aker you record the amount of each food and drink consumed, indicate why you chose to consume the item. Use these suggested
abbreviations to indicate why you picked that food or drink.
FlVR Flavor/texture ADV Advertisement PEER Peers

CONV Convenience WTCL Weight con trol NUTR Nutritive value
EMO Emotions/comfort HUNG Hunger $ Cost
AVA Availability FAM Family/cultural HLTH Health
There con be more than one reason for choosing a particular food or drink.
Application
Now ask yourself what your most frequent reason is for eating or drinking. To what degree is health or nutritive value a reason for your
food choices? Should you make these reasons higher priorities?
I
"] • 111- .1-'
I • •
" . ... •
• • .r-
t l -
l 08' ' '
• •- - - .
., .... ~~-..-
. . f' .. .... ... .
·_L•,.
-
'
-. -.Jr
~ • .a I a, .M:;,,
I '· J:
t ... , . f " .. • i:a.
....:1·-··-.
.J ...1 ...
• •
Take I Action J
II. Create Your Family Tree for Health-Related Concerns

Adopt this diagram to your own family tree. Under each heading, list year born, year died (if applicable), maior diseases that devel-
oped during the person's lifetime, and cause of death (if applicable). Figure 1-9 provides one such example.
Note that you ore likely to be al risk for any diseases listed. Creating o pion for preventing such diseases when possible, especially
those that developed in your family members before age 50 to 60 years, is advised. Speak with your physician about any concerns
arising from this exercise.
Your Your Your Your

great· great· great· great-
grandfather grandfather grandfather grandfather
Your Your
po tern al maternol
grandfother grandfather
Father's Father's Your Mother's

brother brother fa ther brother
Y ur
cousins cousins
Key
Brother Brother
D = Male
0 = Female
. ... I
• . ... ,.. ...-..
4 • •
~ . • 'ff'
LI> t
t -
• I
THE BASIS OF A HEALTHY DIET

~
~
A Food Philosophy That Works Andy is like many other college students. He grew up on a quick bowl of cereal and 0
Voriely Means Eating Many Different Foods •
Bo/once Means Not Overconsuming Any Single milk for breakfast and a hamburger, French fries, and cola for lunch, either in the z
Type of Food • Moderation Refers Mostly to school cafeteria or at a local fast-food restaurant. At dinner, he generally avoided "'
z
Portion Size • Nutrient Densily Focuses on c
Nutrient Content • Energy Densily Especially eating any salad or vegetables, ond by 9 o'clock he was deep into bogs of chips -I
Influences Energy Intake ;:::o
and cookies. Andy has taken these habits lo college. He prefers coffee for breakfast
=i
Expert Opinion: The Importance of Energy
Density in the Diet
and possibly a chocolate bar. Lunch is still mainly a hamburger, French fries, and 0
Stales of Nutritional Health
cola, but pizza and tacos now alternate more frequently than when he was in high z
tp
Desirable Nutrition • Undernutrition • school. One thing Andy really likes about the restaurants surrounding campus is )>
Overnutrition (/'l
that, for just about half a dollar mare, he can supersize his meal. This helps him ()
How Can Your Nutritional Stole Be Measured? (/'l
Analyzing Background Factors • Evaluating the stretch his food dollar; searching out value meals for lunch and dinner now hos be-
ABCDEs • Recognizing the Limitations of come port of a typical day.
Nutritional Assessment
Can you provide some dietary advice for Andy? Start with his positive habits
Concern about the State of Your Nutritional
Health Is Important and then provide some constructive criticism based on what you now know.
Setting Nutrient Needs-Dietary Reference
Intakes (DRls)
Estimated Average Requirements (EARs} •
Recommended Dietory Allowances (RDAs} •
Adequate Intakes (Ats} • Estimated Energy
Requirements (EERs} • Tolerable Upper Intake
Levels {Upper levels, or Uls) • Appropriate
Uses of the DRls
Daily Values (DVs): The Standards Used for
Food labeling
Reference Doily Intakes (RDls} • Doily Reference
Values (DRVs} • Using the Doily Values
Recommendations for Food Choice
MyPyromid-A Menu-Planning Tool • Dietary
Guidelines-Another Tool for Menu Planning
Case Scenario Follow-Up
Nutrition Focus: Using Food labels in Diet
Planning
Take Action
37
H ow many times hove you heard wild claims about how healthful certain foods ore for you? As
consumers focus more and more on diet and disease, food manufacturers are asserting that
their products hove all sorts of health benefits. Supermarket shelves hove begun lo look like on
1800s medicine show. "Toke fish oil capsules to ovoid a heart attack." "Eat more olive oil and oat
bran lo lower blood cholesterol." Hearing these claims, you
would think that food manufacturers hove solutions lo all our
health problems. 8 CHAPTER OBJECTIVES CHAPTER2 IS DESIGNED
Advertising aside, nutrient intakes out of balance with our TO ALLOW YOU TO:
needs- such as excess energy, saturated fat, cholesterol, Irons 1. Develop a healthy eating pion based on the concepts of variety,
balance, moderation, nutrient density, and energy density.
fat, salt, alcohol, and sugar- are linked lo many leading causes
2. Outline the ABCDEs of nutrition assessment: anthropometric,
of death in North America, including obesity, hypertension, car·
biochemical, clinical, dietary, and economic.
diovosculor disease, cancer, liver disease, and type 2 diabetes.
3. Describe what the Recommended Dietary Allowances (RDAs)
Physical inactivity is also too common. In Chapter 2, you will ex· represent and how these relate to the other standards included
plore the components of o healthy diet-a diet that will minimize in the new Dietary Reference Intakes.
your risks of developing nutrition-related diseases. The goal is to 4. learn the food groupings used in the MyPyromid food guide.
provide you with o firm understanding of basic dief· 5. Review the 2005 Dietary Guidelines for Americans and the
4 diseases these guidelines ore desigried to prevent or minimize.
planning concepts before you study the nutrients in detoil.
6. Describe what o nutrition label currently consists ol and which
health claims and label descriptors ore allowed on a food
package.
REFRESH YOUR MEMORY AS YOU BEGIN YOUR
STUDY O F DIET PLANN IN G IN CHAPTER 2, YOU MAY
WANT TO REVIEW:
The terrns in the morgin in Chapter 1 ond Tobie 1-2.
The impoct of the Dietary Supplement Heolih ond Education Act IDSHEA) on certain lobel cloims in Chapter 1.
The Impact of genetic background on the rfsk of developing certoin chronic diseases in Chapter 1.
..• ..
A Food Philosophy That Works

You may be surprised to learn that minimizing your Lisk of developing common nutrition·
related diseases can be accomplished by doing what you've heard many ti.n1es before:
consmne a vwriety offoods balanced by a moderate intake ~f each food. A variety of foods
is best because no one food meets all your nutrient needs. Meat prmridcs protein and
iron but little calcium and no vita.min C. Eggs also provide protein but little cakium be·
cause tl1e calcium is mostly in the shell. Cow's milk contains calcitm1, but very little iron.
ome people would like to live mostly on And none of tl1ese foods contain fiber. Thus you need a variety of foods in your diet be-
S french fries. What is the nutrient content of
french fries? Check the food composition table in
cause the required nutrients are scattered among many foods. 2
Health professionals have recommended the same basic diet and health plan for the
Appendix N for the vitamin C content of french past 40 years: control how much you eat, focus on the major food groups, and stay
fries. How many servings would you need to eat physically active. Whole-grain breads and cereals, fruits, and vegetables have always
to meet vitamin C needs (75 to 95 mg/day)? been among the foods emphasized for our diet for these past 40 years. 10
(Answer: 4 to 5 servings) It is disappointing, however, that according to a recent survey conducted by the
American Dietetic Association, two of five people in the United States believe that fol ·
lowing a healthfol diet means completely giving up foods they enjoy. To the contrary,
a healthfot diet requires only some simple planning and doesn't have to mean depriva-
tion and misery. Besides, eliminating favorite foods typically doesn't work for "dieters"
in the long run. The best plan consists of learning the basics of a healthful di.et-,1
38
www.mhhe.com/ wardlaw pers7 39
rnriery and b.11.mce of tc>C><.h from .ill food groups and modcrare consumprion of all
Voriety--<:hoose different types of foods within
foods. 10 Lee's no\\ fine rune this .id,·icc b,· focusing on varie~\ b.'llance, moder.nion,
each food group.
nutrient densi~, .111d cner~ dcnsi[).
Balance-choose foods from all six food
Variety Means Eating Many Different Foods groups.
\'arie~ in your diet means choosing a number of diftt:rcnt foods" ithin .my gi,·en foot! Moderotion--<:ontrol portion size so that
group, rather than eating che "same old thing" day after lhy. \'ariccy m.1kes me.11., more balance and variety ore possible in your diet.
interesting and helps ensure chat a diet contains sufficient nutrients. I-or e\.1111ple,
carrots- a rich source of a pigment that fonns 'itamin A in our bodies lll.1) be your
fa\'oritc \eg,erablc; however, if you choose carrots e,·ery da) as your onlv vegetable
source, \"OU m.l) miss out on che ,·iramin folate. Other \'cgetables, such ,,., bron:oli .111d
asparagu::., an: rich snun:es or chis nutrient. This concept is true of all classes of fomb:
fruits, n:gctablcs, gr.iins, .llld so on. Different foods within each class v.1ry somcwh.11
in the nutrients they contain, bur they generally provide similar rypes nf nu tricms.
A benefit or variety in the diet, especially within the fr uit anti vegetable groups, is the
inclusion or., rich Stlpply of \\'hat scientists call phytoch em icals. These pl,llll rnmpo phytochemicol A chemical found in plants.
nenrs .1n: nor considered essential nuLrienrs in the diet. Still, many or these substances Some phytochemicals may contribute lo a
provide significant he.\lth beneflrs. 1 Considerable research attention is focused on var reduced risk of cancer or cardiovascular
ious phytochemic,1ls in reducing che risk for certain diseases (e.g., cancer). You can't disease in people who consume them regularly.
jusr buy a bottle of phyt0chcmic.1ls-they .ire generally .wail.lblc only within whole
foods. Curn:nt multi\ it.1111in and mineral supplements conr,1in IC" or none of thc\e
beneficiaJ plant chcmic.1ls.
~umcrou~ population studies sho'' reduced cancer risk among people who regularly ome research suggests that increasing vari·
com.umc fruits .md vcgec.1blcs. Th.is is true for cancer of the gastrointcsnnnl (Gl ) tr•Kt, ety in a diet con lead lo overeating. Thus, as
breast, lung, and bladder. Researchers surmise that some ph~ rochcmicab present in the you include a wide variety of foods in your diet,
fruits and 'egetablcs block the cancer process. 13 The cancer process .md the spccilic poy attention to total energy intake as well.
roles of some phymcl1emicals in this regard arc described in the Nutrition 1-ocus in
Chapta 12. For ntl\\, reali..:e chat cancer de,·clops over man) years ,i,1 a mulri~rep
process. If a phywchcmkal blocks any one of the steps in this proccs::., it reduce!. the
chances that cancer will ultimately appear in the body. Some phytochemicals han: .1bo
been linkcd ro a reduced risk of cardio\'Jscular disease. Could it be rhat because hum.in:.
e,·oh-ed on a wide variety of plant-based foods, the body developed with a need for 1hc~e
phytochcmicals, along with che various nutrients present, ro m.11ntain optimal health?
It ''ill likely Lake many ye::irs for scientists to unr~wcl the importa.nt effect~ ol" the
myri.1d of ph~rtochcmic.1ls in foods, and it is unlikely that alJ will ever be available or er
fccrivc in ~upplcmem form. For this reason, lead ing nutrition and medic:il experts sug-
gest that a diet rich in fi·uits, vegetables, and whole-grain breads and ccre;1 ls is the moM
reliable way to obLain d1e potenria.l benefits of ph)'tochemicals. 6 Table 2 - l lbts some
phytochemirnls t1micr study, with their common food sources. Table 2-2 prm ides a
number Of Sllggestiom for including more phytochcmicalS in YOlU" diet, ,\S dOCS the
website ' "'" "'· d.l\ 1 and "'1,_i. \ 11~1 1111 .._o •
Balance Means Not Overconsuming Any Single Type of Food

One w.n to babnce your diet JS \ 'OU consume a 'arietv of foods is to sckct foods from
the six ~1ajor food g~oups every da~·: 1 5 •
• Graim
• \ 'cgctablcs
• Fruits
• MiJk
• ~\eat & Beans
• Oils Focus on nutrient-rich foods as you strive to
meet your nutrient needs. The more colorful
A dinner con:.isting of a bean buniro, lettuce and romaro salad with oil .111d vineg;11· your plate, the greater lhe content of nutrients
dressing, a glass of milk, and an apple covers all groups. and phytochemicols.
40 Chapter 2 The Basis of a Healthy Diet
Table 2· 1 I Some Phytochem icol Compounds under Study6

Phytochemicol Food Sources
Allyl sulfides/orgonosulfurs Garlic, onions, leeks
Soponins Garlic, onions, licorice, legumes
Carotenoids (e.g., lycopene) Orange, red, yellow fruits and vegetables (egg yolks ore a source
as well)
Monoterpenes Oranges, lemons, grapefruit
Capsoicin Chili peppers
Lignons Flaxseed, berries, whole groins
lndoles Cruciferous vegetables (broccoli, cabbage, kale)
Fruits, vegetables, beans, and whole-groin
breads and cereals ore typically rich in lsothiocyanates Cruciferous vegetables, especially broccoli
phytochemicals. Phytosterols Soybeans, other legumes, cucumbers, other fruits and vegetables
Flavonoids Citrus fruit, onions, apples, grapes, red wine, tea, chocolate, tomatoes
lsoflavones Soybeans, other legumes
Cotechins Teo
Ellogic acid Strawberries, raspberries, grapes, apples, bananas, nuts
Anthocyonosides Red, blue, and purple plants (eggplant, blueberries)
Fructooligosoccharides Onions, bananas, oranges (small amounts)
Resverotrol Gropes, peanuts, red wine
Some reloled compounds under study ore found in animal products, such as sphingotipids (meal and dairy producls} and conju-
gated linoleic ocid \meal ond cheese! These compounds ore not phytochemicols per se because they ore nol from plant sources,
bul they hove been shown lo hove health benefits.
cods rich in phytochemicols ore now part of Moderation Refers Mostly to Portion Size
a family of foods referred to as functional
Although moderating portion size is a good practice, eating moderately requires planning
foods .6 A functional food is a food that pro·
ymu· entire day's diet so that you don't overconsume nutrient sources. For example, if you
vides health benefits beyond those supplied by
the traditional nutrients it contains. Since a
eat something relatively high in far, salt, and energy, such as a bacon cheeseburger, you
should cat foods that arc less concentrated sources of the same mmients, such as fruits and
tomato contains the phytochemicol lycopene, it
salad greens at other meals that same day. This aids in balancing your diet. If you pretcr
con be called a functional food. You may hear
whole milk to low-fat or fat-free milk, reduce the fat elsewhere in your meals. Try low-fat
this term more from the food industry in the
salad dressings, or use jam rather than butter or margarine on toast. Overall, strive t0 sun-
future.
ply moderate serving sizes of some foods rather than eliminate these foods altogether.
Many nutrition experts agree that there are no exclusively "good" or "bad" foods.
Even so, many North Americans have diets that lack the foundations of a healthy food
plan-variety, balance, and moderation .3 •16 ConsumiJJg diets that a.re overloaded with
foods high in futty meats, fried foods, sugared soft drinks, and refined srarches can re-
su lt in substamiaJ risk for nutrition-related chro nic diseases.
Nutrient Density Focuses on Nutrient Content

Nutrient density has gained acceptance in recent years as an assessment of the nutri-
tional quality of :111 individual food. To determine the nutiient density of a food, simply
compare its vitamin or mineral content with the amount of energy it provides. A food is
said to be nurrienr dense if it provides a large amount of a nutrient tor a rdarively small
amount of energy (compared \\~th other food sources). The higher a food's nutrient den-
nutrient density The ratio derived by dividing a
sity, the better it is as a nutrient sow·ce. Comparing the nutrient density of different foods
food's contribution to nutrient needs by its
contribution to energy needs. When its is an easy way to estimate their relative nutritional q uality. Generally, nuuient density is
contribution to nutrient needs exceeds its determined with respect to individual nuo·ients. For exampk, many fruits and vcgetabks
energy contribution, the food is considered to have a high content of vitamin C compared with their modest e nergy contc:nt, that i~,
hove a favorable nutrient density. tbey are nutrient-dense foods for vitamiI1 C. Moreover, as Figure 2- 1 1.hows, fat-free milk
is much more nutrient dense than is a sugared soft drink for many m1ti·ients.
Table 2·2 I Tips for Boosting the Phytochemical Content of a Diet

• Include vegetables in main ond side dishes. Add these to rice, omelets, potato solod, ond
postos. Try broccoli or cauliflower florets, mushrooms, pees, carrots, corn, or peppers.
• Look for quick-fixing groin side dishes in the supermarket. Pilafs, couscous, rice mixes, and
tabbouleh ore just o few that you'll find.
• Choose fruit-filled cookies, such os lig bars, instead of sugar-rich cookies. Use fresh or conned
fruit as o topping for puddings, hot or cold cereal, pancakes, and frozen desserts.
• Put raisins, gropes, apple chunks, pineapple, grated carrots, zucchini, or cucumber into
coleslaw, chicken salad, or tuna solod.
• Be creative at the salad bor: Try fresh spinach, leof lettuce, red cabbage, zucchini, yellow
squash, cauliflower, peas, mushrooms, or red or yellow peppers.
• Pock fresh or dried fruit for snacks away from home instead of grabbing a candy bar or going hungry.
• Add slices of cucumber, zucchini, spinach, or carrot slivers lo the lettuce and tomato on your
sandwiches. Choosing whole.groin cereals is on excellent
• Try one or two vegetarian meals per week: beans ond rice or pasta; Chinese vegetable stir fry; way to increase the nutrient content of a diet.
or spaghetti and tomato souce. Ideally, the cereal should have al least 3 g of
fiber per serving.
• When doily protein intake more than meets recommended amounts, reduce the meal, fish, or
poultry in recipes by one-third to one-half ond odd more vegetables ond legumes such os soy.
• Keep o bowl of fresh vegetables in the refrigerator for snacks.
• Choose fruit or vegetable juices instead of soft drinks, preferably 100% juice varieties.
• Substitute teo for coffee or soft drinks on a regular basis.
• Hove o bowl of fruit on hand.

• Switch from crispheod lettuce to leof lettuce, such as romaine.
• Use salsa as o dip for chips in place of creamy dips. A1Jdy, described in this chapter's Cose
Scenario, would benefit from more variety in
• Choose whole.groin breakfast cereals, breads, and crackers.
his diet. What are some practical tips he con
• Add flavor to your plate with ginger, rosemary, basil, thyme, garlic, onions, parsley, and chives use to increase his fruit and vegetable intake?
in place of salt.
As noted previously, menu planning focuses mainly on the total diet- not on these-
lection of one critical food as key to an adequate diet. Nonetheless, nutrient-dense
foods-such as fat-free and low-fat milk, lean meats, legume1. (beans), oranges, carrots,
broccoli, whole-wheat bread, and whole-grain breakfast cereals-do help balance less
nutrit:nt-dense foods-such as cookies and potato chips-which many people like to
ear. The latter are often called empty-calorie foods because they tend to be high in
sugar and/or fat but few other nutrients.
Eating nutrient-dense foods is especially important for people who tend nor to eat
a lot of food. This includes some older people and those following weight-loss diets.
Energy Density Especially Influences Energy Intake

energy density A comparison of the energy
Energy density is a concept that has captured the attention of nutrition scientists in re- content of a food with the weight of lhe food.
cent years.9 Energy density of a food .is determined by c:omparing the energy content An energy-dense food is high in energy content
\\~th the weight of food. A food that is rich in energy but weighs relatively little is con- but weighs very little (e.g., many fried foods),
sidered energy dense. Examples include nuts, cookies, fried foods in general, and fut-free whereas a food low in energy density, such as
processed snacks such as pretzels. Foods with low energy density include fruits, vegetables, an orange, weighs a lot but is low in energy
and any food that incorporates lots of water during cookiJ1g, such as oatmeal (Table 2-3). content.
Dr. Barbara RoUs discusses energy density in detail in the Expert Opinion, p. 43.
42 Chapter 2 The Basis o f a Healthy Diet
Figure 2· 1 I Comparison of the nutrient

density of a sugary soft drink with that of fat- Percent Contribution to Adolescent Female RDAs
free (i.e., skim) milk. Choosing a glass of fot-
free milk makes a significantly greater
contribution to nutrient intake than does a 40% 30% 20% 10% 0% 0% 10% 20% 30% 40%
sugary soft drink. An easy way to determine I I I I I I I I
nutrient density from this chart is to compare Ener~y
i_____.. (kco)
the lengths of the bars indicating vitamin or
mineral contribution with the bar that represents
energy content. for the soft drink, no nutrient Protein
surpasses energy content. Fat-free milk, in
contrast, has longer nutrient bars for protein, Vitamin A
vitamin A, the vi tamins thiomin and riboflavin,
and the mineral calcium. Including many
Vitamin C
nutrient-dense foods in your diet is a good way
to meet nutrient needs.
Thiomin
RiboAovin
Niacin
Calcium
Iron
Sugared soft drink, 8 fl. oz. Fat-free milk, 8 A. oz.

(l cup) (l cup)
Table 2·3 I Energy Density of Common Foods (Listed in Relative Order)
Very Low Low Energy Medium Energy High Energy

Energy Density Density Density Density
(less than 0.6 kcal/g) (0.6 to 1.5 kcol/g) (1.5 ta 4 kcal/g) [greater than 4 kcal/g)
Lettuce Whole milk Eggs Graham crackers
Tomatoes Oatmeal Ham Fat-free sandwich cookies
Strawberries Cottage cheese Pumpkin pie Chocolate
Broccoli Beans Whole-wheat bread Chocolate chip cookies
Salsa Bananas Bagels Tortilla chips
Grapefruit Broiled fish White bread Bacon
Fat-free milk Fat-free yogurl Raisins Potato chips
Carrots Ready-to-eat Cream cheese Peanuts
breakfast cereals
with l % low-Fat milk
Vegetable soup Plain baked potato Coke with frosting Peanut butter
Cooked rice Pretzels Mayonnaise
Spaghetti noodles Rice cakes Butter or margarine
Vegetable oils
Doto adopted from Rolls B, Barnell RA: Va/umetrics. New York: HarperCallins, 2000 .
www.mhhe.com/ wardlawpe rs7 43
: Expert Opinion
The Importance of Energy Density in the Diet
Barbara J. Rolls, Ph.D.
With the surge in the incidence of overweight and obesity, effective dietary voted body weight. My colleagues and I have shown in several studies that
strategies for weight management are needed. On the surface the issue is the effects of energy density and portion size combine to increase food in-
clear-cut: simply reduce energy intake below energy expenditure. There is take, confirming that large portions of energy.dense foods ore particularly
much debate and controversy, however, over the optimal way this goal should problematic for weight management. On the other hand, large portions of
be achieved. Although it is unlikely that a single dietary strategy will ever fit foods low in energy density, such as soups and salads consumed at the start
everyone's preferences, health professionals have a responsibility to commu- of a meal, ore associated with enhanced satiety and a reduction in energy
nicate to the public which strategies are considered both safe and effective. intake at the meal. Other dietary factors that hove been shown to enhance
satiety are increases in fiber and protein.
Designing Diets That Reduce

Hunger and Enhance Satiety Why Focusing on Macronutrient
Composition Is Not As Helpful
The biggest problem in weight management is adherence to the diet, no mol-
ter what its composition. Because of this problem, the Focus has shifted away Both the scientific community and proponents of popular diets for weight loss
from the macranutrient composition of the diet (e.g., fa t vs. carbohydrate) hove emphasized the importance of the proportions of the mocronutrients in
toward dietary factors that affect hunger and satiety (the feeling of fullness diets for weight loss. In the 1980s and 1990s the focus was on reducing the
and satisfaction after eating). Since weight loss is achieved through energy amount of fat in the diet. Remember the proliferation d fat-Free or reduced-
restriction, adherence is more likely if hunger is con trolled and dieters feel fa t products? This emphasis on fat reduction was reflected in an evidence-
satisfied based report published by the Notional Institutes of Health in 1998 that
Short-term studies show that the energy density (kcal/g) of the diet affects
both the amount consumed and how satisfied people feel. Foods low in en-
ergy density provide bigger portions for a given number of calories. Water
is the dietary component that has the biggest impact on the energy density
of foods. Water adds weight but no calories and therefore decreases the en-
ergy density. Increasing the water con tent of recipes (for example, by the ad-
dition of vegetables) is associated with reduced energy intake and enhanced
satiety. Whereas waler decreases energy density, fat increases it because fat
has 9 kcal/g, or more than twice that of carbohydrates and protein (both
have 4 kcal/g). People overeat high-fat foods not only because they taste
good but also because fa t packs so many calories into a relatively small
amount of food.
A surprising finding in recent years, both in controlled lab studies and in
studies of free-living individuals, has been the demonstration that people tend
to eat a consistent weight or volume of food over a day or two. Furthermore,
they are relatively insensitive to calories while they are eating. A number of
lab-based studies show that when offered unlimited amounts of similar dishes
with different energy densities, people consume a consistent weight of food.
Thus, when the food offerings contain fewer calories per gram, people con-
sume less energy but still report feeling just as fu ll and satisfied. If people eat
foods high in energy density, they have to restrict portions to avoid excessive
energy intake.
In our current "obesigenic" food environment in which we are surrounded
by tasty, inexpensive, energy.dense foods in huge portions, it is difficult to Salads are low in energy density if we limit additional
avoid overeating. Indeed, a number of studies find that eating out, porticu· calories from salad dressing, and especially minimize
larly at fast-food restouronls, is associoted wi th increased intake and ele- bacon bits, cheese, and croutons.
(continued)
assessed the data from 48 randomized, controlled trials of weight-loss diets. vegetables, fruits, whole groins, legumes, lean protein, and low-fat dairy
The report found that on lower-fat diets (20 to 30% of calories) people lost products. Furthermore, despite the emphasis on weight loss, the key lo weight
weight, and this weight loss was associated with o reduction in energy in· management is actually prevention of weight gain; this goal will also require
take. The emphasis on fat reduction in the 1998 report was related to the innovative strategies to reduce the energy density of the diet.
fact that most of the clinical trials meeting the criteria for inclusion focused In summary, optimal diets for weight management should
on the fat content of the diet. Since then, the emphasis hos shifted lo re-
• Provide adequate amounts of foods and nutrients from a variety of food
stricting carbohydrates and increasing protein intake. A number of clinical
groups
trials have shown that low-carbohydrate, high-protein diets are associated
• Fit with consumer's preferences, be affordable, and be readily available
with significant weight loss over 6 lo 12 months. As with low-fat diets, en·
• Emphasize quality rather than quantity
ergy intake on low-carbohydrate diets was reduced; this reduction was
• Help control hunger and promote satiety through reductions in the energy
probably due to the restriction of food choices. The verdict is not yet in on
density of the diet
how these alterations in the proportions of mocronutrienls affect health or
whether adherence to such restrictive programs is possible in the long term. Dr. Barbara Rolls is Guthrie Chair of Nutrition in the Department
It remains lo be proven whether variations in the mocronulrienl composi- of Nutritional Sciences at The Pennsylvania State University,
tion of the diet con significantly affect the role of weight loss when energy University Park, Pennsylvania. She obtained a B.A. in biology
intake is held constant. There ore small differences in the metabolic effects of from The University of Pennsylvania and a Ph.D. in physiology
the mocronulrients, but welkontrolled metabolic studies hove found thol from The University of Cambridge, England. She is past president
these differences hove only a small impact on weight loss. of both the Society For the Study of Human Ingestive Behavior and
the North American Association For the Study of Obesity. She is on
the editorial boards of leading iournals and is the coauthor of four
Use Energy Density
books, including Th irst and The Volumetrics Weight-Control Plan:
As a Guide to Food Choices
Feel Full on Fewer Calories. Her research interests include the con-
Using energy density os a guide to food choices not only enhances satiety but trols of food and Fluid intake, especially as they relate to obesity,
also leads consumers to foods that health professionals routinely encourage: eating disorders, and aging.
Overall, foods with lots of water and fiber provide a low-energy-density contribu-
O ne more dietary strategy to consider is in-
creased meal frequency. Eating smaller,
more frequent meals and snacks provides bene-
tion to a meal and help a person feel full, whereas foods with high energy density must
be eaten in greater amounts in order to contribute to fullness.9 This is one more rea-
fits lo the body-such as lower blood glucose, son to support a diet rich in fruits, vegetables, and whole-grain breads and cereals, a
cholesterol, and triglycerides-since body me- pattern that also is typical of many ethnic diets throughout the world. Still, favorite
tabolism is not as overwhelmed as ii is with foods, even if they are high in energy density, can have a place in your diecary pattern,
large meals. In addition, fasting for much of a but you \Yill have to plan for them. 7 For example, chocolate is a very energy-dense
day may lead to overeating once eating re· food, but a small portion at the end of a meal can supply a satisfying finale. In addi-
sumes. As long as overall energy intake remains tion, foods with high energy density can help people with poor appetites, such as some
appropriate, spreading food throughout the day o lder people, ro maintain or gain weight.
is a healthy practice. One idea is to pock a The following sections of Chapter 2 describe varioLtS states of nutritional health and
lunch and consume it throughout the day rather provide tools and nutrient guidelines for planning healthy diets to support overall
than all al once at noontime. health.
Concept I Check
Basic diet-pl:rnning concepts include consuming a va1iet:y of foods, balancing a diet by con-
suming foods from each or the six food groups, and moderating portion size with each
food choice so that the diet is not excessive in energy. Choosing nutricnr-densc foods,
such as fat-fi-cc milk, fruits, \·egetables, and whole-grain breads ,md cereals, help~ create a
diet with many nutrients but not excessive 111 energy content. i\lany of these foo<h arc .1lso
rich sources of phytochemicals, supplying an e\·cn greater health benefit to the dice.
Consuming foods oflow energy density, such as fruits and \'Cgerables, ma~ also help in
weight control in that these toods prO\·idc satiety after a meal because of their large weight
bur relatively link energy content.
States of Nutritional Health

The body's nu rrition.11 health is determined by the sum of its nutritio na l status with nutritional status The nutritional health of o
respect to each needed nutrient. We recognize three general categories: desirable n u person as determined by anthropometric
tri cion, undernutr itio n, and overnutrition . The conuno n term malnut r itio n can measurements (height, weight, circumferences,
refer to e ithe r ovcrnut ritio n o r undcrnu tri tio n. Neither state is cond ucivc to good and so on), biochemical measurements of
health. nutrients or their by-products in blood and
urine, o clinical {physical) examination, o
dietary analysis, and economic evaluation.
Desirable Nutrition
undernutrition Foiling health that results from a
The nutritional status for a particular nutrient is optimal when body tissues h.ive long-standing dietary intake that does not meet
enough of the nutrient to support normal metabolic functions as well as ~urpl us stores nutritional needs.
to be used in times of increased need. 5 A desirable nutritional state can be ,Khieved b\
overnutrition A stole in which nutritional intake
obtaining essential nutricrm from a \'ariety of foods. greatly exceeds the body's needs.
malnutrition Foiling health that results from

Undernutrition long-standing dietary practices that do not meet
nutritional needs.
Undcrnurririon occurs when nutrient intake does not meet nua-ient need'>. Any sur
pluses arc then put to use and health begins co decline. J\llany mmicnrs arc in high de-
mand because of' rhc constant cycle of cell loss and larer regeneration in rhe body, such
as in the g.1srroinrestin.1I tract. For thh reason, certain nutrient stores arc c:-.h.1u1>tcd
rapidly, including many of the B \'itamins. Therefore, a regular intake is nccdcd. 5 In
addition, some women in North America do not consumc sufficient iron m meet
month ly losses and e\'cnnially deplete their iron stores. Reduced biochemical functions
and ultimately cl inical evidence of an iron deficie ncy can develop (Table 2 -4 ).
Table 2·4 I Categories of Nutritional Status with Respect to Iron *
General Condition Condition with Respect to Iron

Overnutrition: nutrients consumed in Results in toxic damage to liver cells; may
excess of body needs (degree of toxicity contribute to cardiovascular disease
varies for each nutrient)
Desirable nutrition: nutrients consumed to Adequate liver stores of iron, adequate blood
support body functions and stores of values for iron-related compounds
nutrients for times of increased need
Undernulrition: nutrient intake does not Many changes in body functions associated with o
meet nutrient needs; biochemical changes decline in iron status (e.g., iron-containing proteins
then toke place and pigments in the blood drop below acceptable
amounts [e.g., 12 ng/ml) and oxygen supply to
body tissues is reduced); eventual pole complexion;
fatigue upon exertion; "spooning" of the nails in o
severe deficiency; poor body temperature
regulation
' Thi$ general scheme con apply lo all nutrients. Iron was chosen because you are likely lo be famiLar with this nutrient Note that
ng refers 10 nanogrom$, or l0 9 grams.
Reduced Biochemical Function s

Once nutrienr stores are depleted, a continuing nutrjtional deficit drains body tissues fur-
ther. The body can onl)' compensate to a cerrain point.5 When tissue concentrations of an
biochemical lesion An indicalion of reduced essential nutrient fa.II sufficiently low, a biochemical lesion resu lts and the body's meta-
biochemical function (e.g., low concentrations bolic processes eventually slow down or even stop. Diminished enzyme fimction often is
of nutrient by-products or enzyme activities in the cause of the slowdown in biochemical function. This type of oua:ient deficiency is
the blood or urine) resulting from a nutritional termed subclinical because there are no overt signs or symptoms. At the subclinical stage
deficiency. for poor iron status, concentrations of bernoglobi.n (a red blood ceU protein) in the blood
subclinical Disease or disorder that is present are lower than considered healthy; d1e synthesis of hemoglobin requires iron.
but not severe enough to produce signs and
symptoms that can be detected or diagnosed. Clinical Signs and Symptoms
clinical lesion A sign seen on physical If a biochemical deficit becomes severe, clinical signs and symptoms eventually develop
examination or a symptom perceived by the and become ounvard.ly apparent. 5 It is then possible to note clinical lesions in the
patient resulting from a nutritional deficiency. body, perhaps in the skin, hail", nails, tongue, or eyes. In the case of an iron deficiency,
the complex.ion may become ver)' pale in Caucasians, and fatigue can quickly develop
during even moderate activity.
sign is a feature visible on examination,
A such as Aaky skin. A symptom is a change
in body function that is not necessarily apparent
Overnutrition
Prolonged consumption of more nutrients than the body needs can lead to overnutri-
to an examiner. An example is stomach pain. tion. In the short run, for instance a week or two, ovemutrition may cause only a fow
symptoms, such as stomach distress from excess fiber or iron intake. But if an excess
intake continues, some nutrients may increase to toxic amounts, which can lead to se-
rious djsease. 5 For example, too much vitamin A can have negative effects, particularly
in children, pregmrnt women, and older adults.
The most common type of overnutrition in industrialized nations-excess intake of
energy-yielding nuttients-often leads to obesity. In the Jo ng run, obesity can then
lead to other serious diseases, such as type 2 diabetes and certain forms of cancer. Use
the website shJpc.:up.org to learn more about ilie importance of avoiding this form of
overnutrition.
For most vitamins and minerals, the gap between desirable intake and overnutrition
is wide. Even if people take a l)'pical balanced multivitamin and mineral supplement
daily, they probablr won't receive a harmful amotmt of any nm:rient. Howe\•er, tl1c gap
benveen optimal intake and overnutrition is very narrow for vitamin A, calcium, iron,
copper, and other minerals. Thus, if you take nutrient supplements, keep a close eye on
youT total vitamin and rruneral intake botl1 from food and from supplements to avoid
toxicity. Men in genera.I and older women should be especially cautious of supplements
containing iron (see Chapter 9 for former ad\'ice on use of nutrient supplements).
I How Can Your Nutritional State Be Measured?

To find out how nutritionally fit ')'Oti ue, a nutritional assessment-eithCT whole or in
pan-needs to be performed (Table 2-5 ). Generally, this is performed by a physician,
often with the rud of a registered ruetitian.
Analyzing Background Factors

Since family history plays an important role in determining nutritio nal and health sta-
ms, it must be carefully recorded and critically analyzed as part of a nutritional asscss-
menr. Other related background parameters include: (1) a merucal history, especially
for any ilisease states or treatments that could in1pede nutrient absorptive processes or
ultimate use; (2 ) a list of medications taken; ( 3) a social history; ( 4) information ab our
the person's level of education since poorly educated people have a greater risk for
poor healtl1; and ( 5) economjc stams to determine the abifay of tl1e person to pur-
chase, transport, and cook food. 5
www.mhhe.com/wa rdlawpe rs7 47
Table 2-5 I Conducting an Evaluation of Nutritional Health anthropometric assessment Pertaining to the
measurement of body weight ond the lengths,
Parameters Example
circumferences, and thicknesses of ports of the
Background Medicol history (e.g., current diseases, post surgeries, current weight, weight body.
history, and current medications)
biochemical assessment An assessment
Social history (marital status, cooking facilities)
focusing on biochemical functions (e.g.,
Family history
concentrations of nutrient by-products or
Education attainment
enzyme activities in the blood or urine) related
Economic status
to a nutrient1s function.
Nutritional Anthropometric assessment: height, weight, skinfold thickness, orm muscle
circumference, ond other porometers clinical assessment An assessment that focuses
Biochemicol (laboratory) assessment of blood and urine: enzyme activities, on a person's physical evidence of diet-related
concentrotions of nutrients or their by-products diseases, for example, general appearance of
Clinical assessment (physical examination): general appearance of skin, eyes, and skin, eyes, and tongue; evidence of rapid hair
tongue; rapid hair loss; sense of touch; ability to walk loss; sense of touch; and ability to cough and
Dietary assessment: usual intake or record of previous days' meals walk.
dietary assessment An assessment that focuses
on the typical food choices of the person,
relying mostly on the recounting of one's usual
intake or a record of one's previous days'
Evaluating the ABCDEs intake.
In addicion to backgrou nd factors, four nutritional parameters complete the picwre of economic assessment An assessment that
nutritional status. Anth ropometric assessment measurements of height, weight (and focuses on the ability of the person lo purchase,
\\·eight changes), skin folds, and body circumferences provide an outline of the current transport, and cook food. The person's weekly
state of nutrition. !\lcasures of body composition are easy to obrain and are generally budget for food purchases is also a key factor
reliable. However, an in-depth examination of nuu·itional health is impossible without to consider.
the more expensive process of biochemical assessments. This involves the measure- heart attack Rapid fall in heart function caused
ment of the concentrations of nutrients and nutrienr by-products in the blood, urine, by reduced blood flow through the heart's
and foces and of specific blood enzyme activities.5 blood vessels. Often port of the heort dies in
For example, in Chnpter 10 you will learn that the Stanis of the ,·itamin thiamin in the process. It is technically called a
the body is measured in part by determining the activi[y of an enzyme calkd rranskc- myocardial infarction.
rolase used in the bre;tkdown of glucose. Ir is possible to isolate thar enzyme from cells,
such as red blood cells, and determine if ir can proc<.:ss its starring products quickly
enough. To test for this, cells a.re broken open and thiamin is added to the preparation
to sec if this speeds the rate of the transketolasL: enzym<.: br more than 25%. If so, we
say that the red blood cells lack sufficient tbiamin for the enzyme to function .u max-
imal capacity.
Dming a clinica.I assessment, the health professional searches for any ph~ 1 sical evi-
dence or diet-related diseases (e.g., high blood pressure). Possible problem areas are
assessed when the health professional takes a dose look at the person's di er (dietary
assessment), including a record of ar least the previous few days' inrake. Finally, rhc
econ omic assessm ent (from the background ana l ~1sis ) , which impacts the person's
ability to purchase and prepare foods needed to maintain ht:alth, provides further de-
tail to the picture. Now the true nutritional state of a person emerges. 5 Taken togethc.;r,
these tl\'c parameters form the A.BCDEs of nutritional assessmc.;m: amhropomet1ic,
biochemical, clinical, d ier.1ry, and economic (figure 2-2).
Recognizing the Limitations of Nutritional Assessment

or
A long time may elapse bl.'.rwccn the initial development poor 11L1Lritiona l health and
the firsr clinical evidence of a problem. Recall that a diet high in saturated (typ!i..:ally
solid ) fat often increases blood cholesterol, but without producing any clinical evi-
dence for years. However, when the blood vessels become sufficientl~1 blocked by cho- The first evidence that one's diet is out of
lesterol and other materials, chest pain during physit.:al actiYity or a heart attack may balance with one's physiology could be a heart
occur. Much of the current nutrition research is designed to develop better methods attack. About 25% of oil heart attack victims do
for early detection of nuu·ition-related problcrns such as heart attack risk. not survive the event.
Figure 2·2 I (a) Anthropometric,

(b) Biochemicol, (c) Clinical, and (d) Dietary Another example of a serious health condicion with delayed symptoms is low bone
information helps determine a person's density resulting from a calcium deficiency-a particularly relevant issue for adolescent
nutritional status. (e) Economic status odds females. Many young women consume well below the needed amount of calcium but
further information, rounding out the ABCDEs
often suffer no ill effects in their younger years. However, the bone structures of these
of nutritional assessment.
women with low calcium intakes do not reach full potential during tbe years of grov.rth,
which makes ostcoporol.is more likely later in Jife.
Furthermore, clinical symptoms of mmitional deficiencies-diarrhea, an irregular
walk, and facial sores- are not very specific. These may have difterent causes. Because
it can take a long timt: for signs and symptoms to develop and since these also c:in be
quite \'ague, it is often difficu lt w establish a link between an individual's current diet
and nutritional state.5
Concern about the State of Your Nutritional

Health Is Important
Figure 1-5 in Chapter 1 portrayed the close relationship between nutrition and health.
The good news is that people who focus on maintaining nutritional health are apt to
enjoy a long, vigorous lite. For example, a recent study found that women who obser\'e
www.mhhe .com/ wardlawpe rs7 49
a healthy lifestyle experienced an 80% reduction in risk for heart attacks compared ro practical example using the ABCDEs for
women without such healthy practices. 18 Here is a list of what these healthy women did: evaluating nutritional state con be illus-
• Consumed a healthy diet that
trated in a person who chronically abuses oleo·
hol. Upon evaluation, the physician notes:
• Was varied
• Was rich in fiber (a) Low weight-for-height, recent 1O·lb weight
• Tnduded some fish loss, muscle wasting in the upper body
• Was low in animal fat and tn:ms fat (b) Low amounts of the vitamins thiamin and fo·
• Avoided becoming overweigh t late in the blood
• Regularly drank a small amount of alcohol (c) Psychological confusion, facial sores, and
• Exercised for at least 30 minutes dai ly uncoordinated movement
• Did not smoke (d) Dietary intake of little more than alcohol·
fortified wine and hamburgers for the lost
week
Concept I Check (e) Currently residing in a homeless shelter;
$35.00 in his wallet; unemployed
A desirable nutritional state results when the body has enough nutrients to function fully
and cont:llns srorcs to use in times of increased needs. When nutrient intake fails to meer Evaluation: This person needs professional olten·
body needs, undernutrition develops. Symptoms of such an inadequate nutriem intake can lion, including nutrient repletion.
rake months or years to develop. Q,·erloading the body with nuaients, leading to overnu-
tiition, is another potential problem to avoid. Nutritional state can be assessed b) using an-
thropometric, biochemical, clinical, dicrar}', and economic asse~sments (ABCDfa).
•
., '·1 n,·,.,Hrig
Tom loves lo eat hamburgers, fries, and lots of
Setting Nutrient Needs- pizza with double amounts of cheese. He
Dietary Reference Intakes (DR ls) rarely eats any vegetables and fruits but, in·
stead, snacks on cookies and ice cream. He in·
Using the tools of nutrition research disc ussed in C hapter 1 and those of nutrition assists that he has no problems with his health, is
sessment just discussed in this chapter, it is possible to determine the amount of each nu- rarely ill, and doesn't see how his diet could
trient needed by the human body. People have pursued this question for centuries. cause him any health risks. How would you ex·
Before World War II, when many men were rejected from military service because of the plain to Tom that despite his current good
effects of poor nutrition on their health, the need for official dietary recommendations health, his diet could predispose him lo future
was recognized. In 1941, a group of 25 scientists formed the first Food ond N utrition health problems?
Board. They established dietary st.'lJ1d:irds for evaluating the nutritional intakes of large
populations and for planning ag1iculturaJ production, first p ublished u1 1943.20
The rrame\\'ork of the latest recommendations from the Food and Nutrition Board
are called D ietary R eferen ce Intakes (DRls) and have been released in stages
Dietary Reference Intakes (DRls) The term used
throughout the last 10 ye<lrs. 2
to encompass the latest nutrient
Under the umbrella of the DRis, fi ve sets of standards have been establ ished: Esti- recommendations mode by the Food and
mated Average Requirements (EARs), Recommended Dietary Allowances (RDAs), Nutrition Boord of the Notional Academy of
Adequate Intakes (Als), Estimated Energy Requirements ( EEi~ ) , and Tolerable Sciences. These include RDAs.
Upper Intake Levels ( Upper Levels, or ULs) (see the inside cover of this textbook).20
All refer to intake averaged over a number of days, not a sin gle day. Following is a more Estimated Average Requirement (EARs) An
amount of nutrient intake that is estimated lo
detailed discussion of each of these standards.
meet the needs of 50% of the individuals in a
specific age and gender group.
Estimated Average Requirements (EARs)
Estima ted Average Req uiremen ts (EARs) are the nutrient intake that is estimated to
EARs
meet the needs of 50% of the indiYiduals in a certain age and gender group (Figure 2 -3).
To set an Estimated Average Requirement, the Food and Nutr·ition Board must be
able ro agree on a specific measurable functional mark.er to use for establishing nutri-
ent adequacy. Such markers are typically the activity of an enZ}'me in the body or the
DR ls
ability of a cell to maintain physiological hcalth. 20 (The specific markers used for vari-
ous nuu-ients will be discussed in C hapters 9 d1rough 12. ) If no measurable functional
marker is available, no Estimated Average Requirement can be set, such as for the min-
eral calcium. The Estimated Average Req u irement also includes an adjustment for the
amount of each nutrient that passes th rough the digestive a·acr unabsorbed. At the
Uls
1.0
EAR
l.O ~
.."'
UL
""Ill
..."'
~
-0
<
0.5 0.5 0
.:it.
ii"'
- - - - Increasing Level of Intake---+-

- e • A nutrient intake value that is estimated to meet the requirement
of half the healthy individuals in o life stage and gender group. When set For o nutrient, on intake below the
Estimated Average Requirement is likely inadequate for on individual.
Recommended Dietary Allow ance (RDA): The dietary intake level that is sufficient to meet the nutrient
requirement of nearly all (97% to 98%) heolihy individuals in o particular life stage and gender group. W hen
set For o nutrient, aim for this intake.
Adequate Intake (Al): A recommended intake value based on observed or experimentally determined
approximations or estimates of nutrient intake by o group (or groupsl of healthy people that is assumed to
be adequate - used w hen an RDA cannot be determined. W hen set for a nutrient, aim for thi s intake.
Tolerable Upper Intake Level (Uppe Lev-JI or UL): The highest level of nutrient intake that is likely to
pose no risk o f adverse health effects for almost all individuals in the general population. As intake increases
above the Upper Level, the risk of adverse effects increases.
Figure 2-3 I Dietary Reference Intakes (DRl s) . This figure shows that 50% of North Americans would have an inadequate intake by consuming the Estimated
Average Requirement (EAR), whereas 50% would have their needs met. Only about 2 to 3% of this group of people would have an inadequate intake if each
were to meet the Recommended Dietary Allowance (RDA); 97 lo 98% would hove their needs met. At intakes between the RDA and the Tolerable Upper Intake
Level (Upper Level or UL), the risk of either on inadequate diet or adverse effects from the nutrient in question is close lo 0. The Upper level is then the highest
level of nutrient intake that is likely to pose no risks of adverse health effects to almost all individuals in the general population. At intakes above the Upper Level,
the margin of safety to protect against adverse effects is reduced. The Adequate Intake (Al), set for some nutrients instead of on RDA, lies somewhere between
the Estimated Average Requirement and the Upper level. In determining the Adequate Intake for a nutrient, it is expected that the amount exceeds the RDA for
that nutrient, if an RDA were known. Thus, the Adequate Intake should cover the needs of more than 97 to 98% of individuals. The actual degree lo which the
Adequate Intake exceeds the RDA is likely to differ among the various nutrients and population groups. The Food and Nutrition Boord stoles that there is no
established benefit for healthy individuals if they consume nutrient intakes above the RDA or Adequate Intake.
Estimated Average Reguircment, the needs of tbe other 50% of the population would
not be met for the nu a:ient. Thus, the Escimated Average Reguirement can o nly be
used ro evaluate the adequacy of diets of a group of people, nor individuals.20 Specific
Estimated Average Requirements are listed in Appendix M.
Recommended Dietary Allowances (RDAs)

Recommended Dietary Allowances R econunended D ietary Allowances (RDAs) represent intake of a nutrient that is suffi-
(RDAs) Recommended intakes of nutrients tha t cient to meet rhe needs of nearly all individuals (97 to 98%) in an age and gender group
are sufficient lo meet the needs of almost all (see the inside cover). RDAs are based on a multiple of the Estimated Average
individuals (97 lo 98%) of similar age and Requirements (genera.IJ)' the RDA = EAR. X 1.2 ). Because of this relationship, an RDA
gender. can be set for a nutticnr only if the Food and Nutrition Board has enough informarion to
determine an Estimated Average Requirement. Additional consideration in setting an
RDA also c~tn be given to a nutrient's ability to prc\'ent chronic disease rad1er than just
prevem defici ency. 20
Setting O ne RDA: Vitamin C

The amount ofvitami.n C needed each day to prevent SCLLl"\')1 is about 10 mg. H owe,·cr,
as you "~ II learn in Chapter 10, vitamin C has other functions as well, some of which arc
involved in the \\'Orkings of the immw1e system (see Appendix C for details on the
immune system). Based on this relationship, the concentration of '~tamin C in one com-
ponent of the immune system-notably, white blood cells (specifically neutroph ils)-
can be used as a marker for vitamin C adequacy in an individual. The Food and
Nua-ition Board concluded that near-maximal saturation of white blood cells with vi-
tamin C is, in fact, the best marker for optimal vitami11 C starus. It takes, on average,
a daily intake of about 75 mg for men and about 60 mg for women for near-saturation
of white blood cells. These average amow1ts then become the Estimated Average
Requirement for young adult men and women .
The Estimated Average Requirement for vitamin C is multiplied by 1.2 to yield the
RDA; in this case, the RDA becomes 90 mg/ day for men and 75 mg/day for women.
Other age groups have slightly different recommendations; smokers should add
35 mg/ day to the RDA for their age and gender (see Chapter 10 for details).
Putting the RDA for Vitamin C to Use

If you total the amowit of vitamin C you eat in 1 week and divide by 7, you will have
yam average daily vitamin C consumption. If that value is close to the RDA, you are
most likely consuming enough vitamin C. EYen if you eat less tlian the RDA, you will
not likely suffer iU effects; your needs are most likely less than tl1e RDA, which is set
to include almost all individuals, some of whom probably need more vitamin C tl1an
you do. As a general rule, however, tl1e further you stray below the RDA on a regular
basis-particularly as you approach tl1e Estimated Avt:rage Requiremt:nt-the greater
row- risk of a nutritional deficiency.20 Symptoms of a vitamin C deficiency may be sub-
tle and develop slowly. Ir takes a long time to detect problems such as a weakened im-
mune system and even poor wound healing. If }'OU suspect tliat your diet is not
nutritious enough, don't wait for warning signs ro develop. Start eating a diet that
meers the RDAs set for \~tam in C (and all the other nutrients listed for your age and
gender), rather than risk the development of health problems from poor nutrition.
Adequate Intakes (Als)

Nuu-ienrs for which thc:re is not enough information to establish an Estimated Average
Requirement are assigned Adequate Intakes (Als) (see the inside cover). Adequate Adequate Intakes {Als) Recommendations for
Intakes are based on estimates of the average nutrienr inrnke tl1at appears to maintain a nutrient intoke when not enough information is
defined mmitional state (e.g., bone health ) in a certain population. 20 Adequate Intakes available to establish on RDA. Als ore based
have been set fo r essential fatty acids, fiber, some B - \~tamins, the vitamin-like com- on observed or experimentally determined
pou11d choline, vitamin D, and some minerals such as cakimn and fluoride. In addition, estimates of the average nutrient intake that
appears lo maintain o defined nutritional state
Adequate Intakes are set for infants wider 1 year of age because experimentally study-
{e.g., bone health) in a specific population.
ing the effects of nua·ienr deficiencies in infants would be unethical.
Used when no RDA con be set.
Estimated Energy Requirements {EERs) An

Estimated Energy Requirements (EERs)
estimate of the amount of energy intake that
RDAs and Adequate Intakes for nutrients are set high enough to meet the needs of al- will balance energy needs of on overage
most all healthy individuals. In contrast, a different standard is used to express energy person wi thin specific gender, age, and other
needs, called Estimated Energy Requirements (EERs).4 These refer to the average considerations.
needs for various age groups and genders (see the inside cover). Unlike for most vitanlins Tolerable Upper Intake Levels (Uls) Maximum
and minerals, excess energy consumed (above energy needs) is not excreted. Thus, to pro- chronic doily intake of a nutrient that is unlikely
mote weight maintenance, a more conservative standard is used for energy needs than for to cause adverse health effects in almost oil
nutrient needs. Overall, an Estimated Energy Requirement is only a rough estimate, be- people in a population, This number applies to
cause energy needs depend on energy use, and in some cases the need for growth or a chronic doily use.
hlllmrn milk production. For most adults, the ability to obtain and maintain a bcaltl1y
weight is tl1e best yardstick of energy balance--energy intake matching energy output.
Tolerab\e Upper tntake Levels (Upper Levels, or ULs)

The To lerable U pper Intake L evels (ULs) is the maximum level of daily intake of a
nutrient that is unlikely to cause adverse health effects in almost aJl people (97 to 98%)
in a population (see d1e inside covcr).20 The number applies to chronic daily use and is
set to protect even very susceptible people in the healthy general population. For vita ·
min C the amount is 2000 mg/day. Inrakes greater than this amount can cause di::u--
rhea and inflammation of the stomach lining.
The Upper Level is not a goal for nutrient intake but, rad1er, is a ceiling bdow which
nutrienr intake should remain . Still, for many of us there is a margin of safety above the
UL before any adverse effects are likely to occur. Not eno ugh information is available
t0 set an Upper Level for all nutrients, but this does not mean that toxicity from these
nutrients is impossible_ Furthermore, there is no clear-cut evidence diat intakes abo,·e
the RDA o r Adeq uare Lltake con.fer any additional heald1 benefits for most of us.
The Upper Level for most nutrients is based on the combined intake of food, water,
supplements, and fortified foods. Four exceptions are die vitamin niacin and the min-
erals magnesium, zinc, and nkkel , for which die Upper Level for eacl1 refers 011ly to
nonfood sources, such as medicines and supple ments. This is because toxicity due to
dietary intake of niacin, magnesium, zinc, or nickel is unlikely. 2
Energy needs in adulthood are based on an
energy intake required to maintain weight.
Appropriate Uses of the DRls
The DRis are intended mainly for diet planning (Table 2-6). Specifically, a diet plan
should aim to meet any RDAs set. If no RDA has been determined for a nutrient, use the
Adequate fotake as a guide. Finally, d1e Upper Level for a nutrient should not be exceeded
(Figw-e 2-4). 2 •20 Keep in mind also mat none of diese dietary standards are necessarily ap·
prop1iate ammmts for individuals who are already tmdernourished or for diose with dis-
eases d1at require higher intakes. This concept will be covered in Chapters 9 dirough 12.
Concept I Check
T he Dietary Reference Intakes apply to both

the United States and Canada because sci-
entists from both countries worked together lo
Dietary Reference fotakes are set for specific nutrients in order to guide food intake.
These standards include Recommended Dietary Allowances (RDAs), Adequate Intakes
(Ais), and Tolerable Upper Intake Levels (Upper Levels, or Uu). Recommended Dietary
establish them. Allowances represent the nutrient needs for healthy individuals. RDAs •u·e established for
specific age and gender categories. No one knows his or her own nutritional requirements;
the best general rule is that the further you stray from nutrient standards ser for your age
and gender, especially below the Estimated Average Req uirement (EAR), the greater your
chance of having a m1tritional deficiency or toxicity. Adequate Intakes are set wl1en there is
not enough information to set a more precise RDA. An Estimated Energy RequiremenL
(EER) has also been set for various ages and genders. Intakes above Upper LeYels generally
should not be consLUned on a long-term basis unless a physician prescribes the amount and
monitors the person carefully, because toxic effects are possible.
Table 2 - 6 I Putting the DRls for Nutrient Needs to Use

RDA Recommended Dietary Allowance. Use lo evaluate your current intake for a specific
nutrient. The further you stray above or below this value, the greater your chances of
developing nutritional problems.
Al Adequate Intake. Use to evaluate your current intake of nutrients, but realize that an Al
designation implies that further research is required before scientists con establish a more
definitive number.
EER Estimated Energy Requirement. Use to estimate your energy needs according to your
height, weight, gender, age, and physical activity pattern.
UL Upper Level. Use to evaluate the highest amount of doily nutrient intake thol is unlikely
to cause you adverse health effects in the long run. This number applies to chronic use
and is set to protect even very susceptible people in the healthy general population. As
your intake increases above the Upper Level, the potential for adverse effects generally
increases.
Deficient state Recommended Dietary Allowance Upper Level (UL) met or

(RDA), Adequate Intake (Al), and exceeded
Estimated Energy Requirement (EER)
foll in this range.
-
~==---~-'------------:-----=-=====:!.
Increasing Nutrient Intake
Figure 2·4 J Think of the nutrient standards that ore port of DRls as snapshots along a line. As
nutrient intake increases, the Recommended Dietary Allowance (RDA) for the nutrient, if set, is eventually
met and a deficient state is no longer present. An individual's needs most likely will be met because
ecol! from Chapter l that the Food and
RDAs ore set high lo include almost all people. Related to the RDA concept of meeting on individual's
Nutrition Boord hos also established
needs ore the standards of Adequate Intake (Al) and the Estimated Energy Requirement (EER). These con
Adequate Mocronulrient Distribution Ranges
be used lo estimate on individual's needs for some nutrients and energy, respectively. Still, keep in mind
that these standards do not share the same degree of accuracy as the RDA. For example, EER may hove (AMDRs) for intake of carbohydrate, protein, fat,
lo be adjusted upward if the individual is very physically active. Finally, as nutrient intake increases and certain other nutrients. These recommendo·
above the Upper Level (UL), poor nutritional health is again likely. However, this poor health is due now lions complement those mode as port of the DRls
lo the toxic effects of a nutrient rather than to those of a deficiency. (e.g., RDAs). 20
Daily Values {DVs) : The Standards Used

I for Food Labeling
The DRls and accompanying nutrient standards are not used in food labeling because
they are age and gender specific. We can't have differem: packages for men and women
or for teens and adults. The US Food and Drug Adminimacion (FDA) has developed
a set of genetic standards, called Daily VaJ ues, that are used to express the nutrient Doily Values Standard nutrient·intoke values
contenr of foods for the Nutrition Facts panel on food labels . The content of a partic- developed by FDA and used as a reference for
ular nurrient is listed on labels as a percentage of the Dail~, Value. These percentages expressing nutrient content on nutrition labels.
serve as a benchmark for evaluating the nutrient content of foods. They do not, how- The Doily Values include two types of
standards-RDls and DRVs.
ever, represent a set of tailor-made recommendations for an adult. You will see why
once the method for setting Daily Values is described. Reference Daily Intakes (RDls) Nutrienl·intoke
The Daily Values are based on two sets of dietary standards. The first, R eference standards set by FDA based on the 1968 RDAs
Daily Intakes (RDis), are for ''itamins and minerals. The second, Daily Referen ce for various vitamins and minerals. RDls hove
Val ues (DRVs), are standards for protein and various dietary components that have been set for fou r categories of people: infants,
no RDA or other established nutrient standard (e.g., total fat). These two terms- toddlers, people over 4 years of age, and
Reference Daily Intakes and Daily Reference Values-do not appear on labels. To make pregnant or lactating women. Generally the
highest RDA value out of oil ca tegories is used
reading labels less confusing for consumers, the term Dail;• Vafae is used to represent
as the RDI. The RDls constitute port of the Doily
the combination of these rwo sets of dietary standards, since the differences between
Values used in food labeling.
Reference Daily Intakes and Daily Reference Values for typical consumers are inconse-
quential. For health professionals and n utrition experts, though, it is important to un- Daily Reference Values (DRVs) Nutrienl·intoke
derstand how nutrition label information (Reference Daily Intakes vs. Daily Reference standards established for protein,
Values) is actually deri\'ed: carbohydrate, and some dietary components
lacking on RDA or a related nutrient standard,
such as total fat intake. The DRVs for sodium
and potassium ore constant; th ose for the other
Daily Values, used on food labels, are a
nutrients increase as energy intake increases.
combination of RDI and DRV standards. The DRVs constitute port of the Daily Values
r,.--------"'~~--------·'
used in food labeling.
RD ls: For food labels, standards set DRVs: For food labels, standards set for
for nutrients that have RDAs or other many nutrients that do not have RDAs or
established nutrient standards other established nutrient standards
Reference Daily Intakes (RDls)

Reference Daily Intakes (RDis) make up the majority of the Daily Values (DVs).
The Reference Daily Intakes have been set by FDA using a compilation of the nutri-
e nt standards published in 1968. Essentiall~r, Reference Daily Intakes use the highest
RDA values of any age category set in 1968. For example, consider iron: In 1968,
the RDA for adult men \\'as 10 mg/day and that for adult women and adolescents
was 18 mg/day. The iron Reference Daily Intake for adults is the higher value:
18 mg/day. Table 2-7 lists the Reference Daily Intakes used for various age groups.
anode also hos a set of Doily Values for use The Reference Daily Intake values currently in use, which are based on the 1968
on food labels (see Appendix DJ. RDAs, are generally slightly higher than cwTent RDAs and related nutrient srandards.
FDA plans to eventually re\'ise the Reference Dail~' Intakes to reflect the latest nurri·
em standards.
Daily Reference Values (DRVs)

The Daily Values for some food constituents are based on Daily Reference Values
(DR.Vs) rather than RDis. Daily Reference Values cover certain dietary components
tl1at have no RDA or related nutrient standard at dlis time, such as saturated fatty acids
and cholesterol. (Protein is tl1e exception, because it has a DRV and :ilso an RDA. )
Overall, the Daily Reference Values for energy-yielding nutrients are based on 30% of
utrition educators often instruct patients lo total energy intake from fat, 60% from carbohydrnte, and 10% from protein.
N look only at the total amount of a nutrient
(shown on the left side of the Nutrition Facts Using the Daily Values
panel) rather than the %Daily Value when
watching a specific nutrient. This is because the Note that some of tl1c Daily Values, such as those for saturated fat, total fat, and fiber,
%Doily Value is not correct unless that person are related to total energy intake. B)' accounting for this, you can evaluate your diet even
consumes 2000 kcal/ day. For example, if a per- if your energy imake is more or less tba.n tl1c standard energy intake, 2000 kcal, used on
son is to limit his or her saturated fat intake to the food label. For example, if you consume only 1600 kcal per day, the total percentage
20 g per day, the % Doily Value does not proof Daily Value for each of tl1ese nurrienrs sh ould add up to no more than 80% because
vide adequate information to assess grams of 1600 + 2000 = 0.8, or 80%. Lf you ear 2800 kcal, your total percentage of Daily Value
saturated fat consumed in a day. for each nua-ient in all the foods you eat in one day can add up to 140%, because 2800 +
2000 = 1.4, or 140%. Howe\•er, the% Daily Valm:s for some dietary constituenrs, such
as cholesterol and sodium, are noc adjusted for differences in energy intake.
In the same way, you can calculate the amount of a certain nutrient you have left i.n
a day by using the% Daily Value. For example, if you consume 2000 kcal per day, ymu-
total fat intake for the day shouJd be 65 g or Jess. If you consume 10 g of fat at break-
fast, you have 55 g, or 85%, of your DaiJy Value left for tl1e rest of the day.
T he Nutrition Facts panel on the label of a food product lists various components
of the food as a percentage of their Da.ilr Values (for details, see this chapter's
Nutrition Focus, titled Using Food Labels in Diet Planning). Use this information on
food labels to learn more about your food choices. Unformnarely most adults do not
do this. To practice using this information, suppose that one serving of a macaroni and
cheese product contains 15% of tl1e Daily Value for iron. Since the Daily Value for iron
is 18 mg, this product contains about 3 mg ofiron per serving (18 X 0.15 = 2.7 mg).
Concept I Check
Daily Values are current!)' used as a benchmark for representing the nutrient content of
foods on nutrition labels. Nutrient conrenr is expressed as a percentage of the Dail)' Value
for a nutri1:nt, which in turn is based on a Reference Daily Imake (RDI) or Daily Reference
Use the Nutrition Facts label to learn more Value (ORV). The Reference Daily Intakes for vitamins and minerals constitute the major·
about the nutrient content of the foods you eat. ity of Daily Values afld are based on the 1968 RDA standards. The DaiJy Reference Values
Nutrient content is expressed as a percent of have been set for some nutrients that don't have an RDA or Adequate lntake, such as far
Daily Value. Canadian food lows and related and cholesterol. To decrease confusion, the Daily Value is the only rerm that appears on
food labels hove a slightly different format food labels.
(review Appendix D).
Table 2-7 I Comparison of Do ily Values w ith 1he Latest RDAs and Other Nutrient Standards 1
RDA or Other Current Dietary Standard

Current Daily Values for Males Females
Dietary Constituent Unit of Measure People over 4 Years of Age 19Years Old 19 Years Old
Total Fot2 g <65-<1 07
Saturated fatty acids2 g < 20-<36
Protein2 g 50-80 56 46
Cholesterol3 mg <300
Corbohydrote2 g 300-480 130 130
Fiber g 25- 37 38 25
Vitamin A µ.g Retinol activily equivalents 1000 900 700
Vitamin D International units 400 200 200
Vitamin E International units 30 22-33 22- 33
Vitamin K µg 80 120 90
Vitamin C mg 60 90 75
Folate µg 400 400 400
Thiamin mg 1.5 1.20 1.10
Riboflavin mg 1.7 1.30 1.10
Niacin mg 20 16 14
Vitamin B-6 mg 2 1.30 l .30
Vitamin B-12 µg 6 2.40 2.40
Biotin mg 0.3 0.03 0.03
Pantothenic acid mg 10 5 5
Calcium mg 1000 1000 1000
Phosphorus mg 1000 700 700
Iodide µg 150 150 150
Iron mg 18 8 18
Magnesium mg 400 400 310
Copper mg 2 0.9 0.9
Zinc mg 15 11 8
Sodium 4 mg < 2400 1500 1500
4 3500 4700 4700
Potassium mg
Chloride4 mg 3400 2300 2300
Manganese mg 2 2.3 1.8
Selenium µg 70 55 55
Chromium µg 120 35 25
Molybdenum µg 75 45 45
Abbreviolions: g = gram; mg = milligram; µg = microgram
I Doily Values ore generally set at the highest nulrienl recommendation in a specific age and gender category Many Doily Values exceed current nutrient standards . This is in port because aspects of lhe
Daily Values were originally developed in the early 1970s using estimates of nutrient needs published in 1968. The Daily Values hove yet to be updated lo reRect the current stole of knowledge. Note
also that the Doily Values for some nutrients je.g., total fol, soluroted fatty acids, protein, carbohydrate, and liberl increase os energy intake increases above 2000 kcal/day.
2fhe lowest Doily Values ore based on a 2000 kcal diet. All based on a caloric distribution of 30% from fol (and one-third of this totol lrom saturated fatl, 60% from corbohydrofe, and 10% from pro-
tein as energy intake ranges from 2000 kcal/day lo 3200 kcal/day.
3Bosed on re<:ommendcnions ol lederol ogencies
~The considerably higher Doily Values for sodium and chloride ore there lo allow for more diet Oexibility, but fhe extra amounts ore not needed to mointoin health.
SS
56 Chapter 2 The Basis of o Heollhy Diet
Recommendations for Food Choice

The following sections will describe various guidelines for pltuuling healthy diets.
MyPyramid-A Menu-Planning Tool

Since rhi.:: early twentieth cenn1ry, researchers have worked to clarif)• tb<.: science of nu-
oition into practical terms, so that people with no special training, could cstimare
whether their nutritional needs were being met. A seven food-group plan, based on
foods trndiriona.lly eaten by people in North America, was one of rhe first formats de-
signed by USDA. Daily food choices had to include items from each group. This plan
had been simplified by the mid-1950s to a four food-group plan: a milk group, a meat
group, a !Tuit and ,·egerablc group, and a bread and cereal group. ln 1992 this plan
was illustrated using a pyramid shape.
In April 2005 USDA unveiled their latest food guide plan, MyPyrnmid. Entitled
MyPyra mid.gov "Steps to a Healthier You," MyPyramid provides a more indi\'idualizcd approach to
STEPSTO A HEALTHIER YOU improving diet and lifcstyk than did prcviou5 food gu.ides. Overall, l\ilyPyramid trans-
lates the latest nutrition advice into l 2 separate pyramids based on energy needs ( 1000
ro 3200 kcaljday ). 15 Its goal is to provide advice t hat wil l help consumers livi.:: longer,
bctrcr, ;rnd healthier lives. (MyPyramid replaces the Food Guide Pyramid introduced
in 1992.)
The MyPyramid symbol represents the ri.::commended proportion of foods from
each food group that creates a healthy diet. Physical activity is a new clement in the
pyramid. To benefit from the individualized ad,rice that is the hallmark ol the plan,
however, consumer!> need m utilize the website, _\ I) P\ ramid.g1,, . 14
MyPyramid, pictured in Figure 2- 5, is designed to illustrate:
• Pc1·sounlizntion, demonsw1ted at Lhc My Pyramid website, ,\1~ P) 1-.1111id.gm.
• Gmd.11nl i111provc111e11t, encouraged by the title "Steps to a Healthier You."
• Physical n.cti11i~v, represented by the steps ;tnd the person clim bing Lhem.
ppendix D contains the Canadian Food • Vn.riet)•, symbolized by the six color b,uids representing the five food groups and
A Guide to Healthy Eating. o ils. Foods from all groups ;1re net:ded each day for good health. Orange is used for
grains, green for vegetables, red for fruits, yellow for oils, blue for milk ,rnd milk
products, and purple for meat & beans.
• Prop01·ti011rility, i.ndica[ed by the different widths of the food group bands. The
wid[hs suggest how much food a pcrs<>n should choose from e,tch group. The bands
arc wider for grains, ,·cgaabks, and fruits because these groups should form the
bu lk of one's dieL. The narrowest band is for o ils, incticating these should be eaten
sparingly. All the \\'idths are just a general gujde, however, and nor exacr propor-
t ions. Check ~l~l\ r.unid .gm for d1e amount that is right for you.
• lvlodcnition, represented b)' the narrowing of each food group from bottom tO top.
The wider base represenrs fonds wirh lirtle or no soUd fats, addt:d sugars or caloril.'.
sweeteners, and salt. These should be selected more often to get Lhe most nutrition
from energy consumed.
An innovative aspect of MyPyramid is the interacti\'e technolot,•y found on
M~ l'w.rnud gm . Here is a list o( the programs:
!vfvPym111iri P/11.11 provides a quick estimate of what and ho\\ much food J. person
should eat from the different food groups based on age, gender, and activity level.
MyPym111irf Trnckc1· provides more derailed information on diet qu:ility and physi-
cal activity i.tarus b)' comparing a day's worth of foods ea.ten to the guidance
provided b) MyPyramid. Ir allows the user to sdect from 8000 foods and
600 .1ctivitics. Nutrition and physical :.Ktivity messages are based on the need ro
maintain currem weighc or ro lme weighr.
www.mhhe.com /wardlawcont# 57
Proportionality
Proportionality is shown by the different
widths of the food group bonds. The
_ widths suggest how much food a person
should choose from each group.
The widths ore just a general guide, not
Mode ration exact proportions. Check the website
Moderation is represented by the for how much is right for you.
narrowing of each food group
from bottom to top. The wider
base stands for foods with little
or no solid fats or added sugars.
These should be selected more Variety
often. The narrower top area Variety is symbolized by the 6 color
stands for foods containing more bands representing the 5 food groups
added sugars and solid fats. The of the Pyramid and oils. This illustrates
more active you ore, the more of that foods from all groups ore needed
these foods can fit into your diet. each day for good health.
'
'
''
Personalization
.MyPyramid.gov
,,•' ~radual Improve ment
Personalization is shown by the
person on the steps, the slogan,
and the website. Find the kinds
_, STEPS TO A HEA~I~!-~B..YQ~--- ~~o~~~~~r~:;;:~:;h;ni~d~~~gu:tby
con benefit from toking small steps to
and amounts of food to eat each improve their diet and lifestyle each day.
day at MyPyramid.gov.
Grains Fruits Oils Miik Meat & Beans
Figure 2-5 I The anatomy of MyPyromid. USDA's new MyPyromid symbolizes a personalized approach to healthy eating and physical activity. The symbol
has been designed to be simple. fl has been developed to remind consumers to make healthy food choices and to be active every day.
Inside ll1yPymmid provides in-depth information for every food group, including rec-
onunt:nded daily amow1ts in commonly used measures, like cups and oum.:es, with
examples and everyday tips. The section also includes recommendations for choosing
healthy oils, discretionary calories, and physical actiYity (refer to Table 2-8 on discretionary calories The amount of energy
page 58 for a listing of discretionary caJories. Basically this term refers to the en - theoretically allowed in o diet ofter the person
ergy intake allowed from food choices rich in added sugars or solid fat. For most has met overall nutrition need. This generally
of us, very tc'" discretionaqr caJories .H·e ~wai lablc in dai ly diet planning). small amount of energy gives individuals the
flexibility to consume some foods and
Stnn Toriny prm~des tips and resources that include downloadable suggestions on beverages that may contain alcohol (e.g., beer
a.II the food groups and phrsical activity and a worksheet to trKk one's diet. and wine), added sugars (e.g, soft drinks,
candy, and desserts), or added fats that are
port of moderate- or high.fat foods (e.g., many
Putting MyPyramid into Action
snack foods).
To put MyPyramid into action, you first need w estimate your cnl'rgy needs (die web-
site helps you with die calculation ). Figure 2-6 pro,·ides a rough guide.
Once you have determined the energy allowance that is appropriate for you, you can
use Table 2-9 to discover bow your energy needs correspond m the recommended
number of servings from each food group.
58 Chapter 2 The Basis of a Healthy Diel
Table 2·8 I Discretionary Calories Counting Servings

Allowed in o Diet i\lyPyramid prcwidc!> sen mg sizes of foods for che '.1rious food groups in household uniu..
Energy Intake Discretionary Calories • Graim: 1 slice or lm:.1d, 1 cup of ready-to C•ll breakfast cereal, or 1/2 i.:up i.:onkc.:d
!kcal) (kcal) rice, pasta, or cooked i.:creal cou nts as a one ounce equivalent.
1000 165* • Vegctnblcs: 1 cup or
raw or cooked vegcLablcs or vegetable juice or 2 cups or
t"l\\
leafy greens counts as I cup.
1200 171 * • Fruits: 1 mp off ruil or 100% fruit juice or I/ 2 cup of dried fruit counL!. .1s l nip.
1400 171 * • Jfillt: l cup of milk or \'Ogurc, 1 1/2 outKes of narural cheese, or 2 ou1Kc:s ol
processed cheese coums ~ one cup.
1600 132
• Jfcat o.- Bm11s: l ounce of meat, poulcr). or fish, 1 egg, 1 tablespoon of pe.mut
1800 195 burrer, 1/4 cup i.:ooke<l dr) beans, or 1/ 2 ounce of nut!> or seeds count'> -''> a one
2000 267 ounce cqui\ .1lcnt.
2200 290 • Oils: A teaspoon or
any oil from plants or ti~h Lhat is liquid at room tc:mpcr.1turi:
counts as a :;en mg, as do :.Ltch serving:. orfoods rich in oils (e.g., mayonnaise ,\11d
2400 362 soft mar g;1rinc ).
2600 410
2800 426 Planning Menus with M yPyra mid
3000 512 Remember the tollo'' ing points when using ~ h Pyr.1mid to plan your d.uh menu':
3200 648 ] . The guide docs not apph to inf.mes or children under 2 year11 of age.
2. No one food is absolutch essential to good nutrition. Each food is ni.:h in \Ome
The overoll intent 1s ro not exceed !his discretionary colo<ie
allowance-the combination of foods and beverages with al nutrients but ddkiem in •ll least one essential nutrient (Table 2-10 ).
cohol. added sugars, or added lots 3. No one food group prm ides all cssenri.11 nutrients in adequate amoums. J-.ad1
'The amount of discretionary calories is higher for 1000 lo food group m.1kcs Jn important, distini.:ti\e contribution to mtLrirional im.1ke.
1400 kcal diets than for a 1600 kcal diet because these diets 4. Varicry is l he key LO success of the guide .111d is fi r:.L g,uar::u1teed by d1oosing food\
with less energy ore intended for children 2 to 8 years of age.
Adults typically need at least 1600 kcal. from all the group!>. Funhennorc, one should consume a \'ariety of lc>ods "ithin
each group. (When dioo1,ing produce~ in the mi lk group. be especi.11ly L.1rdul to
look at S<ltllt"ucd fat comcnt to minimize that intake. )
5. The foods "irhin a group ma)' \'arr widch with rc!>pcct to nutrienr~ Jnd ern:rg\
conccnr. For c:x.implc, the energy content of 3 oz of baked pocato " 98 kcal,
where.1s rluc of 3 o.r of potato chips is 470 kcll. Compare an orange: and •111 .1ppk
\\ii:h ri:spci.:r 10 vit.1mi11 C using the food wmposition table in Appendix N.
oy dose attention to the stated serving size Energy Intake Range (kcal)
for each choice when following MyPyramid. Sede ntary means a lifestyle that includes
This aids in controlling total energy intake. See Children Sedentary ~ Active only the light physical activity associated
Figure 2·7 for a convenient guide to estimating with typical day-to-day life.
2-3 years 1000 ~ 1400
common household measures. Note that serving Active means a lifestyle that includes
sizes listed for one serving in a MyPyramid Females physical activity equivalent to walking
group or on a food label ore often less than is more than 3 miles per day ot
typically served in restaurants today. 4-8 years 1200 ~ 1800 3 to 4 miles per hour in addition to
9-13 1600 ~ 2200 the light physical activity associated
14-18 1800 ~ 2400 with typical doy-to·doy life
19-30 2000 ~ 2400
31-50 1800 _.... 2200
51+ 1600 _.... 2200
Moles
4-8 years 1400 ~ 2000
9-13 1800 ~ 2600
14-18 2200 ~ 3200
19-30 2400 _.. 3000
31-50 2200 ~ 3000
Figure 2-6 I Estimates of energy 51 + 2000 ~ 2800
needs provided by MyPyromid.
Table 2·9 I MyPyramid Recommendations for Daily Amounts of Foods to Consume from the Six Food Groups Based on
Energy Needs
Energy Intake 1000 1200 1400 1600 1800 2000 2200 2400 2600 2800 3000 3200
Fruits 1c 1c 1.5 c 1.5 c 1.5 c 2c 2c 2c 2c 2.5 c 2.5 c 2.5 c
Vegetables 1•2 1c 1.5 c 1.5 c 2c 2.5 c 2.5 c 3c 3c 3.5 c 3.5 c 4c 4c
Grains3 3 oz-eq 4 oz-eq 5 oz-eq 5 oz-eq 6 oz-eq 6 oz-eq 7 oz-eq 8 oz-eq 9 oz-eq 10 oz-eq 10 oz-eq 10 oz-eq
Meat & Beons2 2 oz-eq 3 oz-eq 4 oz-eq 5 oz-eq 5 oz-eq 5.5 oz-eq 6 oz-eq 6.5 oz-eq 6.5 oz-eq 7 oz-eq 7 oz-eq 7 oz-eq
Milk4 2c 2c 2c 3c 3c 3c 3c 3c 3c 3c 3c 3c
OilsS 3 tsp 4 tsp 4 tsp 5 tsp 5 tsp 6 tsp 6 tsp 7 tsp 8 tsp 8 tsp 10 tsp 11 tsp
Discretionary
calorie allowance6 165 171 171 132 195 267 290 362 410 426 512 648
Abbreviations: c ~ cup or cups; oz-eq = ounces or equivalent; tsp " teaspoon
1Vegetables ore divided into five subgroups !dork green vegetables, orange vegetables, legumes, starchy vegetables, and other vegetables). Over o week's lime o variety of vegetables should be eaten,
especially green and orange vegetables.
20ry beans and peas con be counted either as vegetables (dry beans and peas subgroup) or in the meat & beans group. Generally, individuals who regularly eat meat, poultry, and fish would count
dry beans and peas in the vegetable group. Individuals who seldom eat meal, poultry, or fish (vegetarians) would consume more dry beans and peas and count some of them in the meat & beans group
until enough servings from that group ore chosen for the day.
3AJ least half of these servings should be wholl!ijroin varieties.
4 Most of these servings should be fot-free or low fol.
Slimll solid fots such as butter, stick margarine, shortening, ond meat fat as well as foods that contain these.
60iscrelionory calories refers to food choices 11ch in added sugars or solid fat.
Table 2·10 I Nutrient Contributions of Groups in the MyPyramid Food Guide Plan
Food Category Major Nutrient Contributions Food Category Major Nutrient Contributions
Milk Calcium Fruits (can't) Magnesium
Phosphorus Potassium
Carbohydrate Fiber
Protein Vegetables Carbohydrate
Riboflavin Vitamin A
Vitamin D Vitamin C
Magnesium Folate
Zinc Magnesium
Meat & Beans Protein Potassium
Thiomin Fiber
Riboflavin
Grains Carbohydrate
Niacin Thia min
Vitamin B-6 Riboflavin3
Folate 1 Niacin
Vitamin B- J 22
Folate4
Phosphorus Magnesium 5
Magnesium' lron 3•4
Iron Zinc4
Zinc Fiber5
Fruits Carbohydrate Oils Fat
Vitamin A Essential fatty acids
Vitamin C Vitamin E
Folate
1Primarily in plan I protein sources
2Qnly in animal foods
31f enriched
4 Whole groins and some enr1d1ed/ forlified products
swhole groins
Portion Sizes
-- 2 tbsp measure 2 tbsp salad dressing,

peanut butter, margarine, etc.
- to 2/3 cup
1/2
measure
Medium/small fruit
- 1 stondard bagel Bogel or English muffin
,
-· -
- 1/2 to 3/4 cup Baked potato; ground or chopped foods;
1/2 cup generally equals 2 ounces.
or - 1 cup Lorge apple or orange;

1 cup of ready·to·eat breakfast cereal
Fig ure 2·7 I A golf boll, tennis boll, small yo-yo, computer mouse, baseball, and fist make convenient guides to judge
MyPyromid serving sizes. Additional handy guides include:
thumb = 1 oz of cheese palm of hand = 3 oz
4 stocked dice = 1 oz cheese 1 ice cream scoop = 1/2 cup
thumb tip to first joint = 1 tsp hondful = 1 or 2 oz of a
small (individual-size) matchbox = 1 oz meat snack food
bar of soap or deck of Ping-Pong boll = 2 tbsp
cords = 3 oz meat
Q,·erall, MyPyrn.mid incorporat es the foLtndations of a hcalthr diet: variety, balance,

and modern.tion. The nutritional adequacy of diets phumed using this tool, howeYer,
depends on selection of a variety of foods (Table 2-ll ). L5 In addition, to ensure
enough vitamin E, vitamin B-6, magnesium , and zinc-nutrients sometimes low in
diets based on this plan-consider the following advice:
1. Choose primarily low-fat and far-free items from the milk group. By reducing en-
ergy intake in this way, you can select more items from other food groups. ff milk
causes intestinal gas and bloating, emphasize yogurt and cheese. (See Chapter 5 for
details on the problem oflactose maldigestion and lactose intolerance).
Table 2· 11 I Putting MyPyromid into Practice
Meal Food Group

Breakfast
l small orange Fruits
3/4 cup low-Fat Granola Grains
with 1 cup fat-free milk Milk
l /2 toasted, small raisin bagel Groins
with 1 tsp soft trans fat-free margarine Oils
Optional: coffee or tea
Lunch Typical restaurant portions contain numerous
servings from the individual groups in
Turkey sandwich Groins MyPyromid.
2 slices whole-wheal bread Meal & Beans
2 oz turkey
l small apple Fruits
1 oatmeal-raisin cookie (small) Discretionary calories
Optional: diet soft drink or iced lea
3 P.M. Study Break
6 whole-wheal crackers Groins
1 tbsp peanut butter Meat & Beans
l cup Fat-free milk Milk
hat about physical activity? Walking,
Dinner W gardening, briskly pushing a baby
stroller, climbing the stairs, ploying soccer, or
Tossed salad
1 cup romaine lettuce Vegetables dancing the night away are all good examples
1/2 cup sliced tomatoes Vegetables of being physically active. For health benefits,
l 1/2 tbsp Italian dressing Oils physical activity should be moderate or vigorous
1/2 carrot, grated Vegetables and add up to at least 30 minutes on most or all
3 oz broiled salmon Meat & Beans days of the week. For weight loss or preventing
1/2 cup rice Groins weight gain, about 60 minutes a day may be
1/2 cup green beans Vegetables needed. (The some goal applies to children and
with 1 tsp soft Irons fat-free margarine Oils teenagers in general.} For maintaining prior
Optional: coffee or tea
weight loss, at least 60 to 90 minutes a day may
Late-Night Snack be required.
1 cup "light" fruit yogurt Milk
Nutrient Breakdown
1800 kcal
Carbohydrate 56% of kcal
Protein 18% of kcal
Fat 26% of kcal
This menu meets nutrient needs for oll vitamins and minerals for on overage adult.
62 Chapter 2 The Basis of a Heollhy Diel
2. Include plant foods that are good sources of protein, such as beans and nuts, at
least several times a week because many are rich in vitamins (such as vitamin E),
minerals (such as magnesium), and fiber.
3. For vegetables and fruits, try tO include a dark green vegetable for vitamin A and
a vitamin C-rich fruit, such as an orange, every day. Don't focus primarily on po-
tatoes (e.g., french fries ) for your ''egetable choices. Surveys show that fewer than
5% of adults eat a full serving of a dark green vegetable on any given day. Increased
consumption of these foods is important be.cause they contribute vitamins, miner-
als, fiber, and pbytochemicals.
4 . Choose whole-grain varieties of breads, cereals, rice, and pasta because they con-
tribute vitamin E and fiber. A plate about two- thirds covered by grains, fruits, and
vegetables and one-third or less covered by protein-rich foods promotes this diet
advice. A daily serving of a whole-grain, ready-to-eat breakfast cereal is an excel-
lent choice because the ''itamins (such as vitamin B-6 ) and minerals (such as zinc)
typically added to it, along with fiber, help fill in the potential nutrient gaps just
listed.
5. Include some plant oils on a daily basis, such as those in salad dressing, and cal fish
at least twice a week. This supplies you with health-promoting furry ai.:ids.
Rating Your Current Diet

Regularly comparing your daily food intake with MyPyramid recommendations for
you r age, gender, and degree of physical activi ty is a relatively simple way to cvaluan:
you r overall diet. Strive to meet the recommendations. 15 (The diets of most adults fail
Tomatoes ore a rich source of nutrients and in this evaluation, especially with respect to servings of milk and miJk products, veg-
phytochemicols. etables, fruits, and whole-grain breads and cereals. 16 ) If meeting the recommendations is
not possible, identify the nutrients that are low in your diet based on the nutrients fOLmd
in each food group (review Table 2-10). For example, if you do not consume enough
servings from the milk. group, your calcium intake is most likely too low. You need to
then find foods you enjoy that supply calciLm1, such as calcium-fortified orange juice.
Customizing MyPyramid to accommodate youx own food habits may seem a daunting
task now, but it is not difficult once you gain some additional nutrition kno'<vledge.
Getting Going
Start putting MyPyramid into practice and use the MyTracker feature to follow your
progress. Implementing even small diet and exercise changes can have positive results.
Better health will likely follow as you strive to meet your nutrient needs and balance
your physical activity and energy intake. In addition, follow the guidance from the
2005 Dietary Guidelines for Americans (discussed in the next section) regarding alco-
hol and sodium intake and safe food preparation.
Concept I Check
MyPyramid translates the general needs for carbohydrate, protein, fat, vitamins, and miner-
als into the recommended number of daily servings from each of five major food groups. Ir
is a convenient and valuable cool for planning daily menus.
Dietary Guidelines- Another Tool for Menu Planning

MyPyramid was designed to help meet nutritional needs for carbohydrate, protein, far.
vitamins, and minerals. However, most of the major chronic "k.iUer" diseases in North
America, such as cardiovascular disease, cancer, m1d alcoholism, are not primarily asso-
ciated with deficiencies of tJ1csc nutrients. DeticienC)' diseases such as beriberi (thiamin
deficiency), scu rvy (\'itamin C deficiency), and pellagra ( niacin deficiency) arc no
A salad with leafy green vegetables conlributes longer common in North America. For many North Americans, the primary dierar~·
many nutrients to a diet. culprit is overconsumption of one or more of the following: total energy intake,
www.mhhe.com/wardlaw p ers7 63
sarur,ucd fac, cholesterol, trnm fat, alcohol, and sodium (salt) ( Underconsumption or ppendix D contains nutrient guidelines for
calcium, iron, f(>Lue and other B-Yitamins, vitamin C, ,·irnmin D, \'itamin E, pmassium, Canadians.
magnesium, and fiber i'> also a problem for so me peopk. )
In response to concerns n:garding these killer disease patterns, '>ince 1980 the
VSDA and L1 .S. Departmcm of Health an<l Human Scn·ice<; ( DHHS ) ha\'e publi<.hed
Dietary Guidelines fo r Americans ( Dietary Guidelines for -;hort ) to aid diet plan - Dietary Guidelines for Americans General
ning. C o mpared lO p.1st reports, the latest Dfrtni:v Guidclillt'S f or A mcricnm ( 2005 ) goals for nutrient intakes and diet composition
place~ stronger emph.1si'i o n mo nito ring one's energy intake and incn:.1.,ing phnical .1 c set by the USDA and the U.S. Deportment of
ti\ ity. 11 This is because more or us .m: becoming o verweight each year. Health and Human Services.
The report identities 41 kc\ recommendations, o f which 23 m: for the general pub-
lic and 18 arc for speci.11 popul.uiom. They are grouped inro ninc general copic11:
• Adequate nurrict1l i11l•lke '' ith in caloric needs
• \Veight managcmenr
• Physical •Kti\'i ry
• Specific food groups to encourage
• Fats
• Carbohy<lrarcs
• Sodium and potassium
• Ako holil: ben:rage'>
• F ood s.llC~
figure 2 -8 lists the key rccommend.11.ions "ithia each general topic. T he .Khicc pro-
\ided refers to people.: 2 years and older and wiU w1doubcedl) coincide with wh.u you
ha,·c .1 lread) heard o r read:, -
• Consume a 'arieC) of nutrient-dense foods and beverages wirhin and amo ng the
basic food groups o f (\1) Pyramid while choosing food s that limit the 111lakc sat- or
urated and trnm fats , cholesterol, .1ddcd sugars, salt, .111d alcohol ( i r used ). Food~ to
cmpha'>ize arc \Cget.1blcs, fruits, legumes (beans), who le g raim, and fat free o r lcm -
fat milk or equi,·alcm milk products .
• ;\1.\intain bod) weight in .1 healthy range br balancing ener~ imakc from foOlb .1nd
bC\'Cragcs \\ ith th,u npcnded. For the latter, engage in ,l[ le.1st 30 minutes or
modcrate-inrcnsiry p hysical activi ~', above usu al activity, at "ork or home o n most
days of the \Yeck.
ADEQUATE NUTRIENTS WITHIN ENERGY NEEDS
• Consume a variety of nutrient-dense foods and beverages wi thin and among the basic food groups while
choosing foods that limit the intake of saturated and trans fats, cholesterol, added sugars, salt, and alcohol.
• Meet recommended intakes within energy needs by adopting o balanced eating pattern, such os MyPyromid.
Key Recommendations for Specific Population Groups
• People over age 50. Consume vitamin B· 12 in its crystalline form (i.e., fortified foods or supplements).
• Women of childbearing age who may become pregnant. Eat foods high in iron from animal products
and/or consume iron-rich plant foods or iron-fortified foods with on enhancer of iron absorption, such
as vitamin C-rich foods.
• Women of childbearing oge who may become pregnant and those in the first few months of pregnancy
Consume adequate amount of the synthetic form of the B vitamin folote (i.e., folic acid) doily (from fortified
foods or supplements) in addition lo food forms of folole found in o varied diet
Older adults, people with dork skin, and people exposed to insufficient ultraviolet bond radiation (i.e., sunlight}.
Consume extra vitomin D from vitamin D-fortified foods and/or supplements.
Figure 2·8 I Key recommendations within each general topic from th e latest Dietary Guidelines for Ameri cans. continued
WEIGHT MANAGEMENT
• To mointoin body weight in o heolthy ronge, bolonce energy intoke from foods ond beveroges with
energy expended.
• To prevent grodual weight gain over time, make small decreases in energy intake from food and
beverages and increase physical activity.

• Those who need fo lose weight. Aim for a slow, steady weight loss by decreosing energy intake while
maintaining on adequate nutrient intake and increasing physical activity.
• Overweight children. Reduce the rote of body weight gain while allowing for growth and development.
Consult a health-core provider before placing a child on a weight-reduction diet.
• Pregnant women. Ensure appropriate weight gain as specified by a health-core provider.
• Breoslfeeding women. Moderate weight reduction is safe and does not compromise weight gain of the
nursing infant.
• Overweight adults and overweight children with chronic diseases and/or on medication. Consult o
heahh·core provider oboutweight·loss strategies prior to starting o weight·reduc.tion program lo ensure
appropriate management of allier health conditions.
• Engage in regular physical activity and reduce sedentary activities to promote health, psychological well-being,
and a healthy body weight.
• To reduce the risk of chronic disease in adulthood: Engage in at least 30 minutes of moderate-intensity physical
activity, above usual activity, at work or home on most days of the week.
• For most people, greater health benefits con be obtained by engaging in physical activity of more vigorous
intensity or longer duration.
• To help manage body weight and prevent gradual, unhealthy body weight gain in adulthood: Engage in
approximately 60 minutes of moderate· to vigorous·infensity activity on most days of the week while not
exceeding energy needs.
• To sustain weight loss in adulthood: Participate in at least 60 to 90 minutes of daily moderale·intensity
physical activity while not exceeding energy needs. Some people (men over 40 years of oge and women over
50 years of age) may need to consult with a heolth·core provider before participating in this level of activity.
• Achieve physical fitness by including cordiovosculor conditioning, stretching exercises for Aexibility,
and resistance exercises or calisthenics for muscle strength and endurance.

Children and adolescents. Engage in ot least 60 minutes of physical activity on most, pref.erobly all,
days of the week.
• Pregnant women. In absence of medical complications, incorporate 30 minutes or more of
moderate-intensity physical activity on most, if not all, days of the week. Avoid activities with o high risk of
falling or abdominal troumo.
• Breastfeeding women. Be aware that neither acute nor regular exercise odversely affects the mother's
ability to successfully breastfeed
• Older adults. Participate in regular physical activity to reduce functional declines associated with aging and
to achieve the other benefits of physical activity identified for all adults.
Figure 2 · 8 I Key recommendations with in ea ch generol topic from the latest Dietary G uidelines fo r Americans. (continued)
FOOD GROUPS TO ENCOURAGE
• Consume o sufficient amount of fruits and vegetables wh ile staying within energy needs. Two cups of fruit
and 2 1/ 2 cups of vegetables per doy ore recommended for a reference 2000 kca l intake, with higher or
lower amounts depenCling on one's energy needs.
• Choose o variety of fruits and vegeta bles each day. In particular, select from a ll five vegetable subgroups
(dork green vegetables, ora nge vegetables, legumes, starchy vegetables, ond other vegetables) several
times o week.
• Consume 3 or more ounce-equivalents of whole-groin products per day, with the rest of the recommended
grains coming from enriched or whole-gro in products. In general, at least ha lf the groins should come from
whole groins.
• Consume 3 cups per day of fat-free or low-fat milk or equivalent milk products.

• Children and adolescents. Consume whole-groin products often; al least half the groins should be
whole groins. Children 2 to 8 years should consume 2 cups per day of fat-free or low·fat milk or
equivalent milk products. Children 9 years of oge ond older should consume 3 cups per day of fat-free
or low·fat milk or equivalent milk products.
FATS
• Consume less than 10 percent of energy intake from saturated fatty acids and less than 300 mg
per day of cholesterol, and keep irons fatty acid consumption as low as possible.
• Keep total fat intake between 20 to 35% of energy intake, with most fats coming from sources of
polyunsaturated and monounsoturoted fatty acids, such as fish, nuts, ond vegetable oils.
• When selecting and ereporing meat, poultry, dry beans, and milk or milk products, make choices that
ore lean, low-•at, or faHree.
• limit intake of fats a nd oils high in satura ted and/or Irons fatty acids, and choose products low in such
fats a nd oils.

• Children and adolescents. Keep total fat intake between 30 to 35% of energy intake for children 2 to 3 years
of age and between 25 to 35% of energy intake for children and adolescents 4 to 18 years of age, with
most fats coming from sources of polyunsaturated and monounsaturated fatty acids, such as fish, nuts, and
vegetable oils.
~~~~. --:-,~J~~~ ~~~.....,- .. - ~~.--.c~ -~---. ~

~1:-..:-.·.-·' '_:''" __ "'.·=~- - ·• ~· ~~- .. ~·J.. .... ~··-~- -.-_-:·..._~~ _li".·1_J~_:___•_:__ --=-._, .•:·.;._ .• ·i' -~-.·_Y ~-- ,_-: :- -- ":·,~-
• Choose fiber-rich fruits, vegetables, and whole grains often.
• Choose and prepare foods and beveroge.s with little added sugars or caloric sweeteners, such as a mounts
suggested by MyPyramid.
• Reduce the incidence of dental caries by practicing good oral hygiene and consuming sugar· and
starch-containing foods and beverages less frequently.
__
,
Figure 2 - 8 I Key recommendations within each general topic fro m lhe latest Dieta ry G uideli nes for Americans. (continued}
-, •. . " - - - ..... _ _ . , . . . , . . . _ . - - . • 1.
. ~., . ' . : ~ . I
• Consume less tha n 2300 mg of sodium per doy (approximately 1 tsp of salt).
• Choose and prepare foods wi th little salt. At the some time, consume. potassium-rich foods, such as
fruits and vegetables.

• Individuals with hypertension, blacks, and middle·oged and older adults. Aim to consume no
more than 1500 mg of sodium per day, and meet the potassium recommendation
(4700 mg per day] with food.
• Those who choose to drink alcoholic beverages should do so sensibly and in moderation-defined
as the consumption of up to one drink per day for women and up to two drinks per day for men,
(12 oz of o regular beer, 5 oz of wine or l 1/2 oz of 80 proof distilled spirits count as
o drink for purposes of explaining moderation.)
• Alcoholic beverages should not be consumed by some individuals, including those who cannot restrict
their alcohol intake, women of childbearing age who may become pregnant, pregnant and lactating
women, children and adolescents, individuals toking medications that con interact with alcohol, and
those with specific medical conditions.
• Alcoholic beverages should be avoided by individuals engaging in activities that require attention, skill,
or coordination, such as driving or opera ting machinery.
To ovoid microbial foodbome illness:

• Cleon honds, food contocl surfaces, and fruits and vegetables. Meat and poultry should not be woshed
or rinsed to ovoid spreading bacteria lo other foods.
• Separate row, cooked, and reody·to·eat foods while shopping, preparing, and storing foods.
• Cook foods lo o safe temperature lo kill microorganisms.
Chill (refrigerate) perishable food promptly ond defrost foods properly
• Avoid raw (unpasteurized) milk or any products mode from unpasteurized milk, row or partially
~~ked eggs or foods containing row eggs, or row or undercooked meol and poultry, unpasteurized
1u1ces, and raw sprouts.
lnfonts and young children, pregnonl women, older adults, and /hose who are immunocompromised.
Do not eat or drink raw (unpasteurized) milk or any products mode from unpasteurized milk, row or
partially cooked eggs or foods containing row eggs, row or undercooked meat and poultry, raw or
undercooked fish or shellfish, unpasteurized juices, and raw sprouts.
• Pregnant women, older adults, and those who are immunocompromised. Only eot certain deli meats and
fronkfurters that hove been reheated to steaming hot.
Figure 2·8 I Key recommendations within each general topic from lhe latest Dietary Guidelines for Americans. (continued)
www.mhhe.com/wardlaw pers7 67
• Praccice safe food handling "vhen preparing food. This includes clean ing hands, brochure designed for the public based on
food conract surfu.ccs, and fruits and vegetables before preparation, and cooking the 2005 Dietary Guidelines for
foods to a safe temperature to kill microorganisms. Americans is entitled "Finding Your Way to a
Healthier You." It communicates the ma jor
A basic prcrnisc of the Dietary Guidelines is that nutrient needs should be met pri -
themes of the 2005 Dietary Guidelines for
rnaiily through consuming foods. 17 Foods provide an array of mmients and other
Americans but uses simpler messages. The 2005
compounds that may have beneficial cffocts on health. In certain cases, fortified foods
Dietary Guidelines for Americans (and the con·
and dietary supplements may be usefltl sources of one or more nutrients t.hat otherwise
sumer brochure) ore available at
might be consumed in less than recommended amounrs. These practices are especially
www.healthierus.gov/ dietaryguidelines.
important for people \,\'hose typical food choices lead to a diet that cannot meet one
or more nutrient recommendations, such as for vitamin E or calcium. However, di-
etary supplements an: not a substitute for a healthful dice.
Practical Use of the Dietary Guidelines

The Dietary Guidelines are designed to meet nutrient needs while reducing the risk of
obesity, h)rpcrrension, cardiovascular disease, type 2 diabetes, alcoholism, and food -
borne illness.
The Dietary Guidelines are nor difficult to implement (Table 2-12 ). 15 Despite pop-
ular misconceptions, this O\'erall diet approach is not especially expensive. Fruits, veg-
etables, and low-fat and fat -free mi lk are no more expensive than the chips, cookies,
and sugared soft drinks they should in part replace.
Note also that diet recommendations for adults have been issut:d by other scientific
groups, such as the American Heart Association, Office of the U.S. Surgeon General,
National Academy of Sciences, American Cancer Society, Canadian Minisn·ics of
dvice from the American Dietetic
Health (see Appendix D), and World Health Organization. All are consistent witb the
Association suggests five basic principles
spirit of the Dietary Guidelines. These groups encourage people to modi~, their eat-
with regard to diet and health.
ing behavior in ways that ;u·e both healthfttl and pleasurable.
• Be realistic, making small changes over time.
The Dietary Guidel ines and You • Be adventurous, trying new foods regularly.
When using the Dietary Guidelines, you should consider yow· own state of health. • Be Rexible, balancing some sweet and fatty
Make specific changes and sec whether they are effective. Note that results are some- foods with physical activity.
times disappointing, e\·en \\'hen you arc following a diet change very closely. Some • Be sensible, including favorite foods in smaller
people can cat a lot of saturated fat and still keep blood cholesterol under control. portions.
Other people, unforumatel)', ha\'e high blood cholesterol even if they eat a diet low • Finally, be active, including physical activity in
in saturated fat. Differences in genetic background are a ke}' cause, as you learned in doily life.
Chapter l. Your diet should be planned with this individuality in mind, taking into
account your cmrent health status and fami ly history for specific diseases. However,
tailoring a muque nunirion program for every North American citizen is currently
unrealistic. MyPyramid and the Dietary GLtidelines provide typical adnlts with simple
advice that can be accively practiced by anyone willing to take a step toward good
hcah:h. 11 · L5
There is no "optimal" dier. Instead, there are numerous healthful diets. Visit the
website of the International Food lnformat.ion Council (ilic.org.). This site is a great
resource for cmrent nutrition information.
Concept I Check
Dietarr Guidelines for Americans have been set by a variety of private and government or-
ganizations. These guidelines are designed to reduce the risk of developing obesity, hyper-
tension, type 2 diabetes, cardiovascular disease, alcoholism, and foodborne illness. To do
so, they recommend eating a variety of foods, which is fostered by foUo\\'ing MyPyramid.
T hey also recommend performing regular physical activity, aiming for a healthy weight, and
moderating total fat, saturated fat, trm1s fat, salt, sugar, and alcohol intake, while focusing
more on fruits , vegetables, and whole-gr;iin products in daily menu planning. Safr food
preparation and storage arc also highlighted.
' I 'fhirlr•ng Table 2· 12 I Recommended Diet Changes Based on the Dietary Guidelines
Shannon has grown up eating the typical If You Usually Eat This, Try This lnstead Benefit
American diet. Having recently read and White bread Whole-wheat bread • Higher nutrient density, due
heard many media reports about the relation- to less processing
ship between nutrition and health, she is begin- • More fiber
ning lo look critically at her die/ and is Sugory breakfost cereal Low-sugar, high-fiber cereal • Higher nutrient density
considering making changes. However, she with fresh fru it • More fiber
doesn't know where ro begin. What advice • More phytochemicals
would you give her?
Cheeseburger with french fries Hamburger and baked beans • Less soturoted fat and
frans fat
• Less cholesterol
• More fiber
• More phytochemicols
Potato salad Three-bean salad • More fiber
• More phytochemicols
Doughnuts Bron muffin or bagel with light • More fiber
cream cheese • Less fat
Regular soft drinks Diet soft drinks • Less energy
Boiled vegetables Steamed or souteed vegetables • Higher nutrient density, due
to reduced loss of woter-
soluble vitamins
he Exchange System is a final menu·
Conned vegetables Fresh or frozen vegetables • Higher nutrient density, due
planning tool. This tool organizes foods
to reduced loss of heal·
bosed on energy, protein, carbohydrote, and fat
sensitive vitamins
content. The result is a manageable framework • lower in sodium
for designing diets, especially for treatment of
diabetes. For more information on the Exchange Fried meals Broiled meals • less saturated fat
System see Appendixes E and F. Folly meats, such as ribs Leon meats, such as ground • less saturated fat
or bacon round, chicken, or fish
Whole milk Low-fat or fat-free milk • less saturated fat
• less energy
• More calcium
Ice cream Sherbet or frozen yogurt • Less saturated fat
• Less energy
Mayonnaise or sour cream Oil and vinegar dressings or • Less soturoted fat
salad dressing light creamy dressings • Less cholesterol
• Less energy
Cookies Popcorn (air popped with • less energy and trans fat
minimal margarine or butter)
Heavily salted foods Foods flavored primarily wilh • Lower in sodium
herbs, spices, lemon juice
Chips Pretzels • Less fat
www.mhhe .com/ wardlawpers7 69
Nutrition recommendations ore often mode on

a population-wide bosis. However, in some
cases, it would be more appropriate if these
were mode on an individual basis once a
person's particular health status is known.
The most positive ospecl of Andy's diet is thot it contoins odequote protein, zinc,
ond iron becouse it is rich in onimol protein. On the downside, his diet is low in
colcium, some B vitomins (such as folote). and vitomin C. This is because ii is low
in doiry products, fruits, and vegetables. It is also low in many of the phytochemicol (plonl-
bosed) substances discussed al the beginning of Chapter 2. In addition, his fiber intake is low
because fast-food restaurants primarily use refined groin products rather thon whole-groin prod-
ucts. And since most super-sized options apply lo foods rich in fa t (french fries) ond sugar (soft
drinks), his diet is likely excessive in those two components.
He could alternate between tacos and bean burritos to gain the benefits of plant proteins in
his diet. He could choose a low-fat granola bar instead of the candy bar for breakfast, or he
could toke the time to eat a bowl of whole-groin breakfast cereal with low-fat or fat-free milk to
increase fiber and calcium intake. He could also order milk at least holf the time of his restau-
rant visits and substitute diet soft drinks for the regular vari ety. This would help moderate his
sugar intake. Overall, Andy could improve his intake of fruits, vegetables, and dairy products if
he focused more on variety in food choice and balance among the food groups.
Using Food Labels 1n Diet Planning
Toda), nearl) all foods sold in the supermarket amounts based on 2500 kcal an: listed as "di tor
muse be labeled with the product name, name and t0tal fat, s.iruratcd fat, carbohydrate, .ind orher
address of d1c manufacnircr, ,unount of product in components.
the package, and ingredients listed in de,ccnding
order by wcighr. This tood and bc\CJ-agc labeling i'
monitored in North America b) gm crnmcnt .1gen -
ecall from Chapter 1 that the nutri· cics 5uch as the US Food and Drug Adminimation
Exceptions to Food Labeling
lion label uses the term calorie to ex· (FDA) in the United States. T he listing of ccnain
press energy content in some coses roods such as ri·csh fruits and vegetables, fi~h.
food constituents is also required- specifically, on a
but kilocolorie (kcal) values ore actually meats, and poulLry currently arc nnc required w
Nutrition Facts panel ( rigurc 2 9 ). Use this in for
listed. h.wc NutriLion Facts labels. However, many gro
macion to learn more about what you ca1.
ccrs and some meat packers have volunc.1rily chosen
The following components must be listed: renal
lO prO\·idc their cust0mers with information abom
calories (kcal), calorics from fat, tmal fat, saturated
these produces. Nutrition Facts l abel~ on meat
fat, mws far, cholesterol, sodium, total c.11·bohy
products will likclr be required in the commg
drate, fiber, sugars, protein, ,·icamm A, 'ita.min C,
years. The next rime you are at the gmccn \tore,
c.1lcium, and iron. In .1ddition co these required
.isk where you might find information on the lrC\h
components, manufacturer~ can choo5e ro list
produc~ that do not ha\·e a Nutrition Faces p.rncl.
pol\'Unsaruratcd and monounsaturared fat, potas-
You will likely find a poster or pamphlet near the
sium, and others. Listing these componc1m i~ ,.,_
produce; ofi:en, these pamphlecs contain recipe~
quired, howe,·cr, if a claim is made about the health
th.it u~e your favorite fruit, vegetable, or cut of
benefits of the specific nutrient l see the section en-
meat. The\· may C\'en assist you in your endca\or w
ridcd Health Claims on 1-ood Labels ) or if the food
impm,·c your diet.
is fortified with that nutrient.
Becau5e protein deficiency b nm a public
Recall that the percentage or the DJify
health concern in the United Stares, declarauon ot
Value is usually given for each nutricm per
the % Dail~· Value for protein is not mancl.itor~ on
serving. le is important to under!>tand that
foods for people O\'Cr 4 years or age. If d1c % Daily
these percenrages are ba~ed on J 2000 kcal
Value is given on a label, FDA requires that the
diet. T hen::fore, they are not as applicable to
product be anal)•zed for protein quality. Bccau~e
people who require considerably mon.: or less
this procedure is expensive and time-consuming.
than 2000 kcal per day with respect to far and
manr companies opt not ro list a % Daily Value for
carbohydrate intake.
protein rather than undergo the expense. Howcn:r.
utrient and herbal supplement labels Serving sizes on the N utrition Facts panel
labels on food for infancs and children under
hove o different layout that includes must be consistent among similar foods. T his
4 years of age must include the % Daily \'alue for
o "Supplement Facts" heading. Chapters 1 m~.ms that all brands of ice cream, for cx.1111 -
protein, as must the labels on any food c.irrymg "
and 9 show examples of these labels. ple, must use the same serl'ing size on their
claim about protein content (sec Chapter 17).
label. However, these serving sizes may differ
from those of MyPyramid since those of food
labels are based on typical sen ing sizes. In
addition, food claims made on package<, mu<,c Health Claims on Food Labels
follow legal definitions (Table 2- 13 ). For
example, if a product claim~ to be "fo\\ As a marketing tool directed to\\'ard d1e he.ilth
sodium," it must ha\'e 140 mg of sodium or conscious con~umer, food manufaccurer~ bkc cc
less per ser\'ing. assert chat their products han: all 50rts of healcl
Many manufacturers lil>t the Daily Values set benefits. After rc\'iewing hundreds of comment~
for dietary componencs such as fat, chobcerol, and on the proposed rule allowing health claims, FD:\
onodo hos established o set of health carbohydrate on the Nutrition F.icts panel. Thi~ which ha5 kgal oversight m·er most food product~
claims for their nutrition labels (see can be useful as a reference point. A~ noted, the) has decided ro permit some health claims \\·ich cer
Appendix D). arc based on 2000 kcal; if the label is large enough, tain restrictions.
70
- - ! I
Serving size is listed in
household units (and
grams). Poy careful
attention to serving
size to know how many
--- --- --- servings you ore
--- --- eating: e.g., If you eat
double the serving size,
you must double the %
Daily Values and
Serving Size 1 Pouch (61 g)
1
Serving Per Container 6 calories.
Amount P11t S4inlng

Calorles 250 Calories fromFaDO
The % Doily Values
'Y. llallrYlllue shows how a food fits
11% into an overall
13% 2000-kcol doily d iet.
'----
Nutrient claims such
as "Good source," and There is no % Doily
health claims. such os Values for sugar.
Reduce the risk of limi ting intake is the
osteoporosis.· must best advice.
follow legal definitions
expensive testing
65g required to determine
20g
300mo
2A00mg
I protein quality.
300g
25g
Only vitamin A,
Calort11 p11t 9...:
vitamin C, calcium, and
Fat 9 • Carbohydrate 4 • Protein 4
• 1ntnke should boas tow ns possible.
iron ore required to be
A Quick Guide The package must include listed on the label. _ j
to Nutrie nt Sources the nome and address of INGREDIENTS: ENRICHED MACARONI PRODUCT
lhe Food manufacturer. IDURUM WHEAT R.OUR, Gl YCERYL MONO·
STEARATE , SALT , NIACIN. FERROUS Sl1FATE,
% Doily Value THIAMIN MOllONlTRATE (VITAMIN 81).
RIBOR.AVlll IVITAMIN 82( , FOUC ACID), CHEESE
20% or more = High source SAUCE MIX (WHEY, PARTIAl.l YHYDROGENATED
l 0%- 19% = Good source SOYBEAN Oil , MAL TOOEXTRIN , WHEY PROTEIN
CONCENTRATE, CORN SYRlf> SOUOS, SAl.T,
0%-5% = Low source Ingredients ore listed in
MILKFAT , SUGAR , SODIUM, NATURAi. R.AVOR ,
descending order by CITRIC ACID. MONOSOOIUM GLUTAMATE,
weight. MOOIAEO FOOD STARCH, LACTIC ACID, VEUOW S
Figure 2 · 0 I The Nutrition Feels panel on a current Food label. This nutrition informolion is required on virtually all processed food products. The '}o Doily
Value listed on lhe label is lhe percenloge of the generally accepted amount of o nutrient needed doily that is presenl in 1 serving ol lhe product. You con use
the ~o Doily Values lo compare your diet with currenl nutrition recommendations for certain diet components. let's consider fiber. Assume lhot you consume
2000 kcal per day, which is the energy inloke for which the % Doily Values listed on labels hove been colculoled. If th e totol '}o Doily Value for dietary fiber in
oll lhe foods you eat in one doy odds up to l 00%, your diet meets the recommendations for fiber Food labels olso contain the name ond address of the food
monufoclurers This allows consumers to contact the manufacturer if they desire.
71
-- - - - -
Table 2· 13 I Definitions for Comparative and Absolute Nutrient Claims on Food Labels
Sugar low-fol, as it exceeds 3 g per serving. Reduced half lhe fot of reference food (if the food de-
• Sugar free: less thon 0.5 g per serving fat is the term used instead. rives 50% or more of its kcal from fol, the re-
• No added sugar; without added sugar; • Law satura ted fat: 1 g or less per serving duction must be 50% of the fat) and, second,
no sugar added: and not more than 15% of kcol from sa turated that lhe sodium content of a low-calorie, low-for
• No sugars were added during processing or fatty acids food has been reduced by 50%. In addition,
pocking, including ingredients tho! contain • Reduced or less fat: at least 25% less per "light in sodium" may be used for foods in
sugars (for exomple, fruit juices, opplesouce, serving than reference food which the sodium content hos been reduced by
or jom). • Reduced or less saturated fat: at least of least 50%. The term light may still be used lo
• Processing does not increase the sugar con- 25% less per serving thon reference food describe such properties as texture and color, as
lent above the amount naturally presenl in lhe long as the label explains the intenl-for exam-
Cholesterol
ingredients. (A functionally insignificant in- ple, "light brown sugar" and "light and fluffy."
• Cholesterol free: less than 2 mg of choles-
crease in sugars is acceptable for processes • Diet: A food may be lobeled with terms such
terol and 2 g or less of saturated fat per
used for purposes other than increasing sugar as die/, dietetic, artificially sweetened, or sweet-
serving
content.)
• Low cholesterol: 20 mg or less cholesterol
ened with nonnulritive sweetener only if the
• The food that ii resembles ond for which it claim is not Folse or misleading. The food con
and 2 g or less of saturated fat per serving
substitutes normally conlains added sugars.
and, if the serving Is 30 g or less or 2 tbsp or
also be labeled /ow calorie or reduced calorie.
• JI the food doesn't meet the requirements for less, per 50 g of lhe food
• Good source: Good source means that o
o low- or reduced-calorie food, the product serving of the food contains 10 to 19% of the
• Reduced or less cholesterol: at least 25%
bears a statement that the food is not low Doily Value for a porlicular nutrient. If 5% or
less cholesterol and 2 g or less of saturated Fot
calorie or calorie reduced and directs con- less it is o low source.
per serving lhon reference food
sumers' attention lo the N utrition Facts panel • High: High means that a serving of the food
for further information on sugars ond calorie Sodium contains 20% or more of the
content. • Sodium free: less thon 5 mg per serving Daily Value for o particular
• Reduced sugar: al least 25% less sugar per • Very low sodium: 35 mg or less per serving nutrient.
serving thon reference food and, ii the serving is 30 g or less or • Organic: Federal stan-
2 tbsp or less, per 50 g of the food dards for organic foods
Calories
• Law sodium: 140 mg or less per serving allow claims when much
• Calorie free: fewer thon 5 kcal per serving
and, if the serving is 30 g or less or 2 tbsp or of the ingredients do not
• Low calorie: 40 kcal or less per serving and, ii
less, per 50 g of the food use chemical fertilizers or
the serving is 30 g or less or
• Light in sodium: at least 50% less per serv- pesticides, genetic engineering, sewage sludge,
2 tbsp or less, per 50 g of the food
ing than reference food antibiotics, or irradiation in their production A1
• Reduced or fewer calories: at least 25%
• Reduced or less sodium: at least 25% less least 95% of ingredients (by weight) must meet
fewer kcol per serving than reference food
per serving than reference food these guidelines to be labeled "organic" on the
Fiber
Other Terms front of the package. If the front label instead
• High fiber: 5 g or more per serving. (Foods says "mode with organic ingredients," only
• Fortified or enriched: Vi tamins ond/or min-
making high-fiber claims must meet the definition 70% of the ingredients must be organic. For
erals hove been added to the producl in
for low fol, or the level of total fa t must appear livestock, the animals need to be allowed to
amounts in excess of of least 10% of that nor-
next to the high-fiber claim.) graze outdoors and as well be fed organic
mally present in the usual product. Enriched
• Good source of fiber: 2.5 to 4.9 g per feed. They also cannot be exposed to large
generally refers lo replacing nutrients lost in
serving amounts of antibiotics or growth hormones.
processing, whereas fortified refers to adding nu-
• More or added fiber: at least 2.5 g more per • Natural: The food must be free of food
trients not originally present in the specific food.
serving than reference food colors, synthetic flavors, or any other syn thetic
• Healthy: An individual food thot is low fat
and low saturated fol and hos no more than substance.
Fat
• Fa t free: less than 0.5 g of fat per serving 360 to 480 mg of sodium or 60 mg of choles- The follow ing terms apply only to mea t
• Saturated fat free: less than 0.5 g per terol per serving can be labeled " healthy" if it and poultry products regulated by USDA.
serving, and the level of /rans fotty acids does not provides at least 10%of the Doily Value for vi- • Ex tra lean: less than 5 g of fat, 2 g of satu-
exceed 0.5 g per serving tamin A, vitamin C, protein, calcium, iron, or rated Fat, and 95 mg of cholesterol per serving
• Law fat: 3 g or less per serving and, if the fi ber. (or 100 g of on individual food)
serving is 30 g or less or 2 tbsp or less, per 50 g • Light or lite: The descriptor light or lite con • Lean: less than 10 g of fat, 4.5 g of saturated
of the food. 2% milk can no longer be labeled mean two things: first, !hot a nutritionally al- fat, ond 95 mg of cholesterol per serving (or
tered product contains one-third fewer kcal or 100 g of on individual food)
Many definitions ore ltom FDA's Diclionory of Terms, os established in conjunction with the 1990 Nutrition Education ond Labeling Act (NELAJ.
72
Currently, FDA limits the use of health mes- lar disease (sec ChapLer 6 for more detaill> on
sages to specific instances in which there is signifi- plane stanols and scerols).
cant scientific agreement that a relationship exists
A "'may" or "'might" qualifier must be w.cd in any
between a nutrient, food, or food constituent and
statement.
the disease. 8 The claims allowed at this time may
ln addition, before :i he:ilLh claim can be made
show a link between the following:
for a food product, iL must meet rwo general re-
• A diet witJ1 enough calcium ,md a reduced risk of quirements. First, cl1e food must be a "good source"
osteoporosis (before any fortification) of fiber, prmein, vitamin A, The nutrition information on the food
• A diet low i_n total fat and a reduced risk of some vitamin C, calcium, or iron. The legal dctini1ion of labels on these three products can be
cancers good source appears in Table 2-13. Second, a single combined lo indicate nutrienl intake for
• A diet low in saturated fut and cholesterol and a serving of the food product c.mnot contain more a peanut butter and jelly sandwich.
reduced risk of cardiovascular disease (typically than 13 g of fut, 4 g of saturated fat, 60 mg of cho-
rdcrred to as heart disease on the label) lesterol, or 480 mg of sodium. Ir :i lood exceeds any
• A diet rich in fibcr~ontaining gr:iin products, one of these requirementl., no health claim can be
fruits, and \'egetablcs and ,1 reduced risk of some made for it despite its other nutritional qualities. For
cancers example, even though whole milk il> high in calcium,
• A dice lo\\ in ~odium and high in potassium and ics bbel can't make the health cl.um :ibouc calcmm
a reduced risk of hn1Crtension and srroke and osteoporosis bec:iuse whole milk contains 5 g of
• A diet rich m fruits and vegetables :ind a reduced sarurated fat per sening.
risk of some cancers In :iddition, the product muse meet criccri:i
• A diet adcqu,ne in the synthetic form of the ,;ra- specific co the health cl:iim being made. For exam-
min tolate (i.e., folic :icid) and a reduced risk of ple, a health claim regarding fot .111d cancer can be
neural tul1C defects (a tvpc of birth defect) made only if the product conLains ~ g or less of fat
• Use of sugarles.\ gum and a reduced risk of rood1 per sening, which is the standard for lo\\ fat foods.
decay, espcci<llly when compared with foods high Overall, claims on food~ foll into one of four
in sugars and stJrches categories:
• A diet rich in fruits, Yegetablcs, and grain prod- psyllium A type of dietary fiber found in
• Health cl:iims- doscly regulated lw rDA
ucts th.n contain fiber and a reduced 1isk of car- the seeds of the plantago plant.
• Preliminary health daims- regul:ned by l-DA
diovascul.ir di~e;1sc. Oms (oatmeal, oat bran, and
but evidence may be scam lcir the claim
o.it !lour) and psyllium :ire two tibcr-1ich ingre-
• Nurrient claims- doscly reg11la1cd by !~DA (re-
dients that can be singled out in reducing the 1isk
view Table 2-13)
of cardiovascular dise,1se, as long as d1c statement
• Structure/function claims -:is discussed in
also say~ the diet should also be low in saturated
Chapter 1, these arc not t::DA approved or ncc-
fat and cholesterol. n December 2002, FDA created three
essariJy valid
• A dice rich in "hole grain toods and other plane new preliminary classes of health
foods as well .l5 low 111 total fat, samrated far, claims. The agency announced that it
and cholesterol and a reduced risk of cardio- would now allow health claims for foods
vascular disease and certain cancers based on incomplete scientific evidence
• A diet lo" in saturated fut and cholesterol as long as the label qualified it with a
that also includes 25 g/<la) of soy prorein disclaimer such as •this evidence is not
and a n:duccd mk of cardim·.\SCular dis- conclusive."8 These preliminary health
ease. The Matemcnt "one ~crving of(name claims haven't shown up on many foods
of food ) prO\id~ _ _ g of SO)' protein" al this time (nuts, such as walnuts, and
must also .1ppear .1.\ p.m of the hcaltl1 claim. fish have been some of the first exam·
• Fatty acids from oils present in fish and a re- pies). These claims also cannot be used
duced risk of c::irdioYascular disease on foods considered unhealthy (review
• Margarine~ comaining pbnr stanols and Tobie 2-13 for the definition of healthy
sterols and a reduced risk. of cardiovascu· Eating fish al leasl !Wice a week conlribules lo overall health. with regard to a food).
73
Summary
1. Variety, balnnce, and moderation are three watchwo rds of diet needs of healthy individuals within specific gender :ind age caC<:-
planning. gories. Adequate Intakes (Ais) are used who.:n not ..:nough informa-
2. Nutrienr density is a usefu l concept. It reflects the nutrient con - tion is available to set an RDA. Estimated Energy Requiremcnts
tent of a food in relation to its energy content. Nuuiem-dense (EERs) providc a benchmark for energy needs. Tolerable Llpper
foods are rebtivcly rich in nutrients in comparison with energy In take Level~ (U pper Levels, or ULs) for nuLrient intake have
conrenr. been seL for somo.: vit:tn1ins and m inerals. All of the many dietary
3. Energy densiry of a food is derermined by comparin g conrenr wirh standards fall under rl1e tem1 Di11tn.ry Reftrwcc !nm.Im ( DR/s).
tbe weight of food. A food that is rich in energy but weighs rela- Daily Values are used as a basis for expressing the nutrient contenc
tively lirrlc, i.uch as nurs, cookies, fiicd food~ in genera.I, and most of food5 on the Nutrition Facts panel and arc based for the most
snack foods (including fin-free brands), is considered energy pan on rhc RDAs published in 1968.
dense. Foods \Yith low energy density include fruits, vegetables, 7. M) Pyramid is designed to translate nua"io.:m recommendations
and any food that incorporates tors of water during cooking, such into a food p lan that exhibits variety, balance, and moderation.
as oarmeal. The best results arc obtained by using low-fat or fat-free d:iiry
4. A person's nutritional stare c:tn be categorized as desirnblc 111ttri- products; incorporating some vegetable proteins inro rhe dkr in
tion, in which the body has adequate scores frir times of increased addition lO animal-protein foods; including citrus ri·uirs and dark
needs; 1111rfonmt1"iti1m, which may be pn:sent with or without clin- green vcgerables; and emphasizing whole-grain bread~ and cereals.
ic.ti i.ymptoms; and m•1!1"111ttritio11, which can lead m vit:tn1in and 8. Dicraq' Guidelines for Americans have been issued to help reduci.:
mineral roxiciLics and varioul> chronic diseases. chronic diseases. The guidelines emphasize eating a variei:y of
5. !::.valuation or nutritional state involves analyzing background fac - foods; performing regular physical activity; maintaining or im-
tors as well as .1mhropomctric, biochemical, clinical, dietary, and proving weight; moderating consumption of fat, tmm fat, choles-
economic ass..:ssments. ft is not always possible to detect nutri- terol, sugar, salt, and alcohol; eating plenry of wholc-g.ra111
tional inadequacies via nutrition assessment because signs and product~, fruits , and vegetables; and sately preparing and ~toring
~ymptoms of deficiencies are often nonspecific and may not appear foods , especially perishable foods.
for many year:.. 9. Food labels are a useful tool to crack your nurricm imakc and le;1m
6. Recommcm.kd D ietary AlfO\\"aJlCCS (RDAs) arc set for many nuai- more abou r the nutrirional ch,1racreristics of the foods you cat.
cntl>. These amounts }~dd enough of each nLttricnl to meet the Any health cla.ims listed must follow criteria set by FDA.
I Study Questions
I. [)cscribc die philosophy underlyi ng the creation of M}'l\ramid. 8. Nutritionists encourage all people to read labels on food packages
What dietary changes would you need t<> make ro meet the pyra- to learn more about what tl1ey eat. \Vhar four nurrienrs could eas-
mid g1.1ideline~ on a regular basis? ily be tracked in your diet if you read the Nutrition Facl:. panels
2. Trace the progression, in terms of physical rcsuJts, of a per~on who regular!~, o n /()od products?
went from .111 uodernmLrished w an overn ourished state. 9. Expl.1in why consumers can have conf:idence in FDA-appmn:d
3. Ho" rnu ld the nutritional status of the person ar each state in hcruth cklims on food packages.
question 2 be evaluated? 10. Relate the importance or variety in a diet, especially with regard LO
4. Describe the int:em of rhe Dietary Gttidelines for Americans. Point fruit and vcgewble choices, to the discovery of v:irious phyto-
out one criticism for its gene ral application to all North Americ.m chcmicals in foods .
adults.
5. .Based on the discussion of rl1e Dierary Guide li ne~ for Americam, BOOST YOUR STUDY
suggest cwo key dictar) changes the Lypical North American adult
shOLtld consider making. Check out the Pe rspectives in Nutrition: Online Learning
6. How do 1U1As and Adequate lnrakes diffor from Daily Values in Center www.mhhe.com/ wardlawpers7 for quizzes, flash
intention and :ipplication? cords, activities, and web links designed lo further help you leorn
7. How would you explain the conct.:ptl> of nmrienr dcn~iry and en- about various tools For diet planning.
ergy density ma fourth -grade class?
Annotated References
1. ADA Rcporrs: Position of the American cal rinrl other compo11c11ts tlmr nfs11 cnmrib11tc to 14. Mitka M: Gm·emmcnt un vei ls a new food pvra-
Dietetic Association: Fu nctional foods. Jo11mnl lmrlt/J. Foods ric/J in specific pl~vtoc/Je111icals m·c mid. ]011mnl uf tbe American Metlicnl Associ-
oft/Jc American Dictrrir Associntio11, l 04:814, oftc11 unm·d f1111ctio11nl ji1ods. 111is a1·tic/c Jim n ation 293:258 1, 2005.
2004. vm·iety ofpl~vrochcmicals 1111dcr m1dy IH well ns Botb the pl'os nnd cons of.A{yPyra1111d an- raised
F1mcrio11nl foods nl'e foods that bm•c bcnltb- c111·1wt rippro11cd hcnlt/J claims for foud labels. by mm·itio11 a11d medical expt1·ts. T/Je biggtft
promoti11g p1'opertics b1:wmtl rlmse proi•ided by 7. Kral T\TE anti others: Combined cflt.-crs of en- criticism is that tbc tool is pnr.ctically 11sclm zm-
11urric11t co11tent alcme. Tbe mnny potenrin/ ben- ergy dcnsicy and portion size on energy int.ike le.is a perso11logs1m to the MyPymmid website ro
efits offimctional foods m·c described fo the arin women . American fournril of Cli11ica l find 1111t the details rcgm·ding the diet plnn.
tirlc. Still, since foo ds 11nt11rnlly co11tni11 N1m'itio11 79:962, 2004.
n11111crous tliffei·mt 1mrricms and pb_vrochemi- 15. Rebuilding the pyramid. T11frs U11h>cl'Siry
Tiu ro111bi11arim1 of inrrcasi11g porrilm size n11d Hcnltb e:r Nutrition Letter, p. 1, June 2005.
cnh, a11 imponantforns i..r to co11sidcr <myfimc- incrensillg c11c1l}y drn.n ty n:mltcd inn g1'eatcr
tional food to be a part oftin or/Jerll'ise health_v fotld iurnke i11 the women i11 t/Jis ft111(v. The re- T1Je latest 111m·irio11 advice fi·o111 My]>ymmid is
diet, especially one rich i11 fruits n11tl vegctnl1les. searclnrs mg_rrest that bot/J fa.cum ma.v be co11- discussed. App~l'illg the recommendariom ro
2. Barr SI and others: Planning diets for individu- t1·ib11ri11g tlJ rbc excess cne1gy intake sec11 i11 some rve1·yday rift is /Jig/Jligbttd.
a ls usi ng the D ietary Reference l nt:1 kcs. adults. 16. Reeves MJ, J'WTcn:y AP: Healchy litcstylc cbarac-
Nutrition Rl-i•ie1vs 61 :352, 2003. 8 . Liebman B: Claims crazy: Which t)11~ can ~·ou cerisrics among adults in cbe Uniccd Smee~, 2000.
171is m·riclr describes approprin.tt' nscs of rhr. believe? N11N·ition Action HcnlthLrttcr 30(5 ): I, Arcbit>es uf ltitmial Medicine 165:854, 2005.
Rccommmded Dietm'_\' A f/011•a11ccs, Adcquntc 2003 (lune) Few adults (about 3%of r'/Josc i11 rhc j'ftri>1:v) al't
lnrnku, am/ Tolerable Upper 111rnke Lc1•tls. Com1mm·s can rcZv 011 rl1c nrwrncy uf tbc Nll'i- fo/lowi11g fl II of rhc four keys to fl bcn lrh_v lifestyle.
Diaa1:v intakes fi·om indiPid11als is best evalu- om hcaltlJ daims approPcd b_v FDA. Structure/ 11Jc keys arc 11011s111oki11g, healt/Jy 11•,-ig/Jt, co11-
nted with t/Jc Recommcwfed DietntJ' Alloll'a11as fimctimi clai111s a11d r/Jef111·rhcomi11g pn:limi- s11111i11g ri c11mbinari1m of a.r least 5 fhtir 1111d
and Atlcq11atc Intakes. Upp•.,. Levels sbottld 11ot 11aiy /Jmlt/J c/nims (i.e., th11sr rbar mmr cnn·y 11 l'CJJ&tn/Jlcs ser1•i1tJJS per day, rmd performing at
br exceeder/ 011 f1 cJm111ic basis. disclaimer c1mrcmillg FDA apprr>vnl) s/Jo11/d be Im.rt 30 mim1tes ufp/Jysicrel nctit•ity S dnys ur
3. De Boer SW and others: Dictar)' inrakc of i'fui ts, 1•i.-111ed rnmio11s~)'. more pc1· week.
,·cgetablcs, .md fut in Olmsccd Cmmry, 1\linn. 9. Liebm.111 B: Bigger means: Smaller \\'aiscs. 17. Revised Dicrar\' Guidelines to help Americ.ms
J\fnyo Cli111c f'rocatlings 78: 16 1, 2003. N11tritio11 Aaio11 Healt/Jlctto; p. I, June 2005. live bencr lives. FDA Co11s11111c1~ p. 18.
Most uf the adults in this dicr survey co11suwcrl T/1c nnirh- ro11tnins 11 rtis.-msiou f/11 rllCllJ)' dc11- t\farch- Apri l 2005.
less 1/J1111 tbr rcco11m1t·11rlcrl amounts offruits sif)• and pmrticn1 applirnri1111.< tfJ a 1fniZv tlicr. 771i.r article summarizes the /nu.rt dicrar..1• _rr11irtc-
and 1•c..11ctnblcs n11d 11101·c fnt rbnn is rccom- Hig/Jli,_rrl1tcd is rbr IPOl'k of n1: Bnrbam Rolls. li11es in simpfc terms. C11lorfi1l grap/Jirs Mc 111 ·
mmdtrl. Effin·rs arc 11ocdcd t11 C1J11Pi11ct nd11/ts t/J<• a 11tl111r uf t/1is dJflptcr 's Expar Opi11iu11. c/nded to m1pbas1~ the mnjo1· points.
in JJt'llt'ml to follmi• n /Jcalr/Jirr dicr. 10. Man:ui. JB: Ne" age fonds for discJse preven- 1S. Stampfcr JM and others: Prim:1ry prc,·ention ot
4 . Food .md Nutriti<in Bo~rd: Dicrni:v rt'fermrc tion. Todny's Diuiti1111, p. 24, J\iay 2003. coronar)' heart disease in women rhrnu~h dice
i11tah-s fin· mcr._qy, ca rbo/Jydmtc, fibc1; fat, ji11ty
Fruirs, l'•'!J•'tablcs, 1wts, nnd w/Jolr grnim nn: and lifi:~tyk . 11JC Nl-i11 E11gla11d Jr111mnl of
acids, c/Jolcstc1·ol, protein, and amino nritfs.
good .rolll'&t'S ·~f'pbyr:ochcmirnls. Dietnryg11idancc Mcdiciuc 343:16, 2000.
W.1~hington D C: N.uion.11 Ac.idem)' Press,
s/Jo11lrl /Je b11s1·d 1111 co11.r11111i11g tbcscji1C1ds, ideally
2002. l%11ic11 wbo rnusuwc n l'lll'icd diet (om· ric/J i11
iu tbefr wbolc state.
111is 1·.-port p1·0l'ides the lttti·st g11ida11ce fur jibCJ; iucl11des s11111e .fish, and is lull' in fried foods
11 . J\ lcadcm« M: Hc.1lthier c.ui11g. FDA Ctmsumn; autl 1wi111nl jnt), n11oid 11Pcrivcigbt, dri11k mini/
macrmmtrimr and euo~rr.1• illmkt·s. Elw;g_v iu- p. 10, J\[Jy-)une 2005.
takr i11 ntfulr/Jootl s/muld lfrncrnl(v watch 1mr1;gy a1111111ms 11fnfcob11/, exc1'cise 011 n tlnif.1• bnsisjlw
1111rp11r so ll't:(rr/Jt 11in.i11tc11n11ce is achieved. 11Jc lnrcsr [)1crm','' Guidd111n jiw A111o'icr111s nbour 30 111i1111tcs, and a11oid smflkm,!J reduce
(2005) nn· 1•c1•ielJ'rd. Tile ariidc /ll'Ul'ides pmc- t/Jcir risk n.f /Jmrt attnck by m1r1· 80% &111nparcd
5. H ammond KA: Diccary and d inical assessmcnr.
tical r1d11ic,• '"put tlmcg11iddi11cs into t1ctio11- ro or/Jcr n•omm.
I n J\ilahan LK, Escott -Stump S (cd~. ): Km11Sr"'s
n rnsk ruo fell' ndulrt m·c tl11i11,n well. 19. Uncle Sam's tlic1 book. Tufts U11iPc1-siry Hen/th
food, 1111tririon, tmd diet tbcrapy. 11th ed.
Philaddphia: \VB Saunders, 200-t 12. Mcersdiacrt CJ\l: One >izc duc5 not fill all- c.~ Nutrition Lcrrn; P- 1, March 2005.
£.,-c,·llt11t cbapur 011 tbt arscssmmt rif 1111tn- Thc }kw food Guidance System. TodnJ•~< 1111pltm&11tntio11 of t/Je In.test Dictm"_V G11iddi11u
tio11nl ftat11s. T/Je folloll'ing rbnpter in this re...-r- Dir1iri1111, p. 42, Augusr, 2005. fo1· Amcricnm is discussed. 71ir authors Sll[J._ITCft
b11ok (Cbaprer 17) b_v T.H. Cnruo11 co111pli111c11ts T7Jis 111·ticlt disrusscs the pl'll.t 1111d mus "f the 11c11• tbar e1w1 .r111all c/mngrs t/Jnr co11jimn to this
r/Je discussion ll'itb a drtailrd look at biorhmti- ;\ ~vPymmid plau prnmorrd by USDA. fr also r1·- pln11 cnn pnividr /Jcalr/J bmcfits.
cal assessment of n11tritiou11/ .rtntus. 1•icws the 11111·io11s tool.r 11.ffnert 1111 tbe 20. Yates AA: Dietary Rt:ferencc lntakt:i.: Rationale
6. Hasler CM: Functional fuods: Benefits, con- 111111m111yp_vmmid.go1• mrbsitt:. and Application~. In Shils J\11.E and mh~r,; (eds.):
cerns, and chaUcngcs-A position paper from 13. Miln er JA: Molecular cargers for bioacri\'c food Jlodem 1111tntio11 i11 health and d1scnst•. I 0th ed.
the Ameri.:an Council on Science and Heahh. compom:nts. ]oumal rif N11tritio11 134:2492$, Philade lphia, Pt\: Lippincocr Williams &
Joumnl of N11rritto11 132:3772, 2002. 2004. \'Vilkins, 2006.
We 11011' k110111 tlmt 011" diet and its comtit11c111s 171c phytoclm11icnls fo1md 111 a /Jca/t/J.v diet pr11- T11c aut/Jcw fm11>itlcs n detailed tliswssion of r/Jc
fi·om b11t/J plant anti a11imal sources p1·11pirfe 111'dc 1111111cnms hcnlrh brncfit<. 111cse affect cell rario11alt- nnd d cvclupmcn t ~f the Dictm'y
mort' t/Jn11 the essential 1111tric11ts J7tch as pr11tci11 mttnb11/ism at a 1•c1·y bnsir i.'i>d, in tum /Jr/ping Rifcreuce bitakcs. lucltulcd is a discussio11 ufht111'
a11d 1•irn111i11s, namc~v a l'nl'ict)' of phyrochemi- ro prt1•cnr dismsts mc/J ns cancc1: ro implcmcm tlJt' vai·i1111s stm1danls.
Take I Action I
I. Does Your Diet Meet MyPyramid Recommendations?
Using your food-intoke record from Chapter 11 place each food item in the appropriate group of the accompanying MyPyromid chart.
That is, for each food item, indicate how many servings it contributes to each group based on the amount you ote (see page 58 for
serving sizes). Note that many of your food choices may contribute to more than one group. For example, toast with soh margarine
contributes to two categories. ( 1) the groins group. and (2) the oils group. Aher entering all the values, odd the number of servings
consumed in each group. Finally, compare your total in each food group with the recommended number of servings shown in Tobie 2-9
or obtained from the wwwMyPyromid.gov website. Enter o minus sign(-) if your total falls below the recommendation or o plus
sign ( +) if it equals or exceeds the recommendation.
Indicate the Number of Servings from MyPyromid That Each Food Yields·
Food or Beverage Amount Eaten Milk Meat & Beans Fruits Vegetables Groins Oils
. : 'f.t
Group totals
Recommended servings
Shortages in
numbers of servings
Take I Action
II . Are Yo u Putting the Dietary Gu idelines into Practice?

As noted in this chapter, the advice provided by the 2005 Dietary Guidelines for Americans can be summarized into three main points
and a number of related activities. Fill out the following inventory to see to what extent you ore following the basic intent of the
Guidelines.
Food Intake
Do you:
Consume a variety of nutrient-dense foods and beverages within and among the basic food groups of MyPryomid?
Choose foods that limit the intake of:
[] [BJ Saturated lot
[] !ill Trans fats
[] !ill Cholesterol
w !ill Added sugars
w [ill Solt
[] [ill Alcohol (if used).
Emphasize ln your food choices:
[YJ [ill Vegetables
[YJ [ill Fruits
[YJ !ill Legumes (beans)
[] ~ Whole groin breads and cereals
[YJ [ill Fat-free or low-fat milk or equivalent milk products
Body Weight
Maintain body weight in a healthy range by balancing energy intake from foods and beverages with energy
expended
Engage in at least 30 minutes of moderate-intensity physical activity, above usual activity, al work or home on most . I
days of the week.
,.
•• •
Cleon hands, food contact surfaces, and fruits and vegetables before preparation
Cook foods to a safe terriperolure to kill mfcroorganisms
Figure 2-8 points to other health practices that ore part of the 2005 Dietary Guidelines for Americans, but this abbreviated list includes
the ma jor points lo consider.
Take I Action I
I
Ill. Applying the Nutrition Facts Label to Your Daily Food Choices
Imagine that you are al the supermarket looking for a quick meal before a busy evening. In the frozen food section, you find lwo
brands of frozen cheese manicotli (see labels o and b) . Which of the two brands would you choose? What information on the
Nutrition Facts label contributed to this decision?
Nutrition Facts Nutrition Facts

Serving Size 1 Package (260g) Serving Size 1 Package (260g)
Servings Per Container 1 Servings Per Container 1
Amount Pill Serving
Calories 390 Calories from Fat 160 Calories from Fat 35
% Oaitw Value• % Oallw Value•
Total Fat 18g 27% Total Fat 4g 6%
Satu rated Fat 9g 45% Saturated Fat 2g 10%
Transfat2g Trans Fat 1g
Cholesterol 45mg 14% Cholesterol 15mg 4%
-
So
-d-
iu_
m _8_8_0_m_g~~~~~-36% Sodium 590mg 24%
Total Carbohydrate 3Bg 13% Total Carbohydrate 28g 9%
Dietary Fiber 4g 15% Dietary Flber 3g 12%
Sugars 12g Sugars 10g
Prote"iii1'7g Protein 19g
Vitamin A 10% • Vitamin C 4% • Vitamin C 10%
Calcium 40% • Iron 8%
•Percent Daily Values are basecl on a 2,000 'Percent Daily Values are based on a 2.000
calorie diet Your dally values may be higher calorie diet. Your dally values may be higher
or lower depending on your calorie needs: or lower depending on your calorie needs:
Calories: 2,000 2.500 ca1011es: 2,000 2.soo
Total Fal less lhan 65g 80g
Total Fal Less 1han 65g 80g Less lhan 20g 25g
Sat Fal Less lhan 20g 25g Salfal
Choles18rol Less lhan 300mg 300mg
Oholeslerol Less than 300mg 300nlll Sodium Less lhan 2,400mg 2,400mg
Sodium Less lhan 2.400mg 2.400mg
Potassium 3,500mg 3,SOOmg
Total Carbohydrate 300g 375Q 300g 375g
Dietary Fiber 25g 30g
Total cartioh)'llrate
Dietary Aber 25g 30g
Calories per uram:
Fal 9 • Cart>ohydrale 4 • Protein 4
•·intake of trans lal should be as low as
Calories per gram:
Fal9 • Carbohydra1e 4 • Plotein 4
··intake ot trans fal should be as low as
..
possible. possible.
{a)
HUMAN DIGESTION
AND ABSORPTION
~
CHAPTER OUTLINE CASE SCENARIO: ~
The Cell Is the Basis of Human Physiology Elise is o 20-yeor-old college sophomore. Over the lost few months, she hos been 0
Organization of the Human Body experiencing regular bouts of heartburn. This usually happens ofter o large lunch or z
The Physiology of Digestion
The Flow of Digestion • A Closer Look of
dinner. Occasionally she hos even bent down ofter dinner to pick up something and '"
z
Enzymes in Digestion • Gostrointestinol had some stomach contents travel bock up her esophagus and into her mouth. This c
-i
Hormones-A Key to Orchestroting Digestion • especially frightened Elise, so she visited the University Health Center.
~
Gostrointestinol Control Valves: Sphincters • =i
Gastrointestinal Muscularity: Mixing and The nurse practitioner at the Center told Elise it was good she come in for a 0
Propulsion checkup. She suspects she hos a disease called gostroesophogeal reflux disease z
Nutrition Focus: When the Digestive Processes co
(GERO). She tells Elise that this can lead to serious problems if not controlled, such )>
Go Awry (/)
Cose Scenario Follow-Up as a rare form of cancer. She provides Elise with a pamphlet describing GERO and ()
(/)
The Physiology of Absorption schedules on appointment with o physician for further evaluation.
Absorptive Cells • Types of Absorption • Porto/ What type of dietary habits likely contribute to Elise's symptoms of GERD? What
and Lymphatic Circulation in Absorption •
Enterohepotic Circulation types of medications hove been especially useful for treating this problem? Overall,
Absorption Is Completed in the Large Intestine how will Elise cope with this health problem, and will it ever go owoy?
Storage Capabilities of the Body
Expert Opinion: Probiotics and Human Health
Toke Action
79
M erely eating food won't nourish you. You must first digest the food-in other words, break ii
down into usable forms of the essential nutrients that can be absorbed into the bloodstream.
Once nutrients are token up by the bloodstream, they con be distributed to and used by body cells. tB
We rarely think about, let alone control, digesting and absorbing foods. Except for a few voluntary
responses-such os deciding what and when to eat, how well to chew food, and when to eliminate the
remains-most digestion and absorption processes control them-
selves. We don't consciously decide when the pancreas will secrete
digestive substances into the small intestine or how quickly food-
CHAPTER OBJECTIVES CHAPTER3 IS DESIGNED
stuffs will be propelled down the intestinal tract. Various hor- TO ALLOW YOU TO:
mones and the nervous system mostly control these functions.5
1. Define tissue, organ, and organ system.
Your only awareness of these involuntary responses may be o
2. List some charocteristics of the 12 organ systems and outline o
hunger pong right before lunch or a "full" feeling after eating that role for each related to nutrition, especially the cardiovascular
last slice of pizza. system, lymphatic system, endocrine system, nervous system,
immune system, and urinary system.
In this chapter you will examine digestion and absorption os
3. Outline the overall processes of digestion and absorption,
well as some related aspects of the human physiology that sui:r including the roles played by the organs of the gastrointestinal
port nutritional health. In the process you will become acquainted tract and the related accessory organs: liver, gallbladder, and
pancreas.
with the basic anatomy (structure) ond physiology (function) of the
4. Become familiar wi th some specific enzymes and hormones that
circulatory and endocrine systems. These and other body systems
act in digestion of the various nutrient groups.
control our nutritional status, and the nutrients derived from food
5. Identify the ma jor nutrition-related gastrointestinal health
contribute to the proper functioning of these systems.7 problems and typical approaches to treatment.
REFRESH YOUR MEMORY AS YOU BEGIN YOUR STUDY

OF HUMAN DIGESTION AND ABSORPTION IN CHAPTER 3, YOU MAY
WANT TO REVIEW:
The basic chemical composition al carbohydrates, proteins, and lipids in Chapter 1.
Cell structure and function in Appendix C
Physiology of the major body systems (aside from the digestive system) in Appendix C.
The Cell Is the Basis of Human Physiology

The body is composed of trillions of cells. Each cell is a self-contained, living entity.
(Review Appendix C if you arc 1mfa1niliar with the parts of a ceU, such as the p lasma
membrane or mitochondria.) Cells of the same type join together, typicaUy using imer-
tissues Collections of cells adapted to perform cellular substances, to form tissu es, such as muscle tissue. One, two, or more tissues
o specific function. combine in a particular way ro form more complex structures, caUed organs. NI
organs cona·ibutc ro nutritional health, and a person's overall nutritional stare deter-
organ A group of tissues designed to perform
a specific function-for example, the heart, mines how well each organ firnctions. At a still higher level of coordjnation, several
which contains muscle tissue, nerve tissue, and organs can cooperate for a common pmpose to form an organ system , such as the
so on. digestive system. Overall, the human body is an organism made up of a coordinated
unit of many highly structured organ systems (Figure 3-1 ). 18
organ system A collection of organs that work Chemical reactions occw· constantly in every living ceU: the production of new sub-
together to perform an overall function.
stances is balanced by the breaking down of o lder ones, as exemplified by the consranr
odenosine lriphosphote !ATP) The main energy formation and degradation of bone. For this turnover of substances to occur, cells
currency for cells. ATP energy is used to require a continuous supply of energy in the form of dietary carbohydrate, protein,
promote ion pumping, enzyme activity, and and/or fut. Almost all cells need oxygen to transform the energy in rhese nutrients to
muscle contraction. a form of energy the body can use-adenosine triphosphate, or ATP (see Chapter ..J.
for more on ATP). Cells also need water; building supplies, especially amino acids and
80
Atom
Stomach
Pancreas
l----...
Stomach
Lorge
Cell J
intestine
Stomach ~
cell
------ Lining of the

stomach
Figure 3-1 I Levels of organization of the human body. Each level is more complex than the previous level. The organ system shown is the gostrointestinol
(GI) tract.
minerals; and chemical regulators, such as the vitamins. AJJ of these substances enable
th e tissues, constituted fro m individual cells, to function properly.
Adequately supplying all nutrients to the body's cells begins with a healthful diet.
To ensu re optimaJ use of nutrients, the body's cel ls, tissues, organs, and o rgan systems
also m use work efficiently.2
O rga nization of the Human Body

epithelial tissue The surface cells that line the
T issue comprises groups of similar cells working together to accomplish a specialized outside of th e body and all passageways
task. Humans arc composed of four primary types of tissue: epithelial, connective, within it.
muscle, and nervous. Epithelial tissue is composed o f cells that cover surfuccs both
outside and inside the body. These cells secrete.: important substances, absorb nutrients, connective tissue Cells and their protein
and excrete waste. Connective tissue supports and pro tects the body, stores far , and products that hold different structures in the
body together. Some structures are mode up of
produces blood cells. Muscle tissue is designed for movement. Nervous tissue found
connective tissue-notably, tendons and
in the brain and spinal cord is designed for communication. T hese follr tissues form
cartilage. Connective tissue also forms port of
various organs and , ultimately, organ systems (review Figure 3-1).18 bone and the nonmuscular structures of arteries
T his chapter focuses on the digestive system. T he nutriea rs we consume in food are and veins.
unavailable until they have been processed by the d igestive system. Using chemical and
mech anical means to alter food, nutrients can be released and absorbed into th e body muscle tissue A type of tissue adopted for
for distribution to body tissues. Table 3-1 summarizes the components and fun ctions contraction.
of the digestive system and various other organ systems as well. nervous tissue Tissue composed of highly
Sometimes organs within a system can serve another system. For example, the pri- branched, elongated cells that transport nerve
mary functio n o f the digestive system is to convert the food we eat into absorbable impulses from one port of the body to another.
nutrients. Ac the same time, the digestive systt:m st:rves the immune system by
82 Chapter 3 Human Digestion and Absorption
Table 3·1 I Organ Systems of the Body
System Major Components Functions Related to Nutrition

Cardiovascular Heart, blood vessels, and blood Transports nutrients, waste products, gases, a nd hormones throughout the body
and plays a role in the immune response and the regulation of body temperature
Lymphatic lymph vessels, lymph nodes, and other Removes foreign substances from the blood and lymph, combats disease,
lymph organs maintains tissue flu id balance, and aids in fat absorption
Nervous Brain, spinal cord, nerves, and A moior regulatory system: detects sensation, controls movements, and controls
sensory receptors physiological and intellectual functions
Endocrine Endocrine glands, such os the pituitary, A major regulatory system: participates in the regulation of metabolism,
thyroid, and adrenal glands reproduction, and many other functions through the production and subsequent
action of hormones
Immune White blood cells, lymph vessels and Provides defense against foreign invaders
nodes, spleen, thymus gland, and
other lymph tissues
Digestive Mouth, esophagus, stomach, intestines, Performs the mechanical and chemical processes of digestion, absorption of
and accessory structures, namely the liver, nutrients, processing of nutrients {especially the liver), and elimination of wastes
gallbladder, and pancreas
Urinary Kidneys, urinary bladder, and the ducts Removes waste products from the circulatory system and regulates blood acid-
that carry urine base balance, overall chemical balance, and water balance
lntegumentory Skin, hair, nails, and sweat glands Protects the other organ systems, regulates temperature, prevenls waler los!'>, and
produces o substance that converts to vitamin D upon sun exposure
Skeletal Bones, associated cartilage, and joints Protects, supports, and allows body movement, produces blood cells, and stores
minerals
Muscular Smooth, cardiac, and skeletal muscle Produces body movement, maintains posture, and produces body heat
Respiratory Lungs and respiratory passages Exchanges gases (oxygen and carbon dioxide) between the blood and the air
and regulates blood acid-base {pH) balance
Reproductive Gonads, accessory structures, and genitals Performs the processes of reproduction and influences sexual functions and
behaviors
The cardiovascular and lymphatic organ systems together make up the circulatory system ond so contribute lo circulatory functions fn the body. The endocrine end nervous organ systems contribute to the
regulatory funclions. The digestive, urinary, integumenlory, ond respirotory organ systems contribute lo the excretory functions, whife the muscular and skeletal argon systems contribute to storage copo-
bilifies in the body.
preventing dangerous pathogcos fro m in vading the body and causing illness. A~ you
srudy nutrition, you will no te Lhc multiple roles played by many organs (Figure 3-2).
Appcmljx C contains mo re details on these and orber body systems.
The overriding theme o f the study o f human nutrition is tO underst:rnd the actions
of nutrients as they affect di fferent cells, tissues, organs, and organ systems. N utrient
intake impacts each o rgan system, and a particular organ sysrem uses nurrienrs in a par-
ticular way. 2
I The Physiology of Digesti on

gastrointestinal (GI) tract Comprises the main
sites in the body used in digestion and T he gastrointestinal (GI) tract is a lo ng tube stretching from the mo uth t0 rhc anus
absorption of nutrients. The tract consists of the (Figure 3-3). T nis tube, also known al> t he alimentary canal, is partitioned fro m the
mouth, esophagus, stomach, small intestine, body in such a way rbat nutrients must pass through its walls to be absorbed into d1e
large intestine, rectum, and anus. bloodsm:am. Just eating a food is not eno ugh- most nutrients muse be digested and
digestion The process by which large ingested all nutrients must be absorbed to be of use to body cells. Certain diseases may hamper
molecules ore mechanically and chemically digestion and/or absorptio n, denying the body use o f nutrients in a meal. 2 A common
broken down lo produce smaller molecules that example is the d iarrhea that accompanies many diseases.
can be absorbed across the wall of the GI tract. The GI a-:1.ct is a complex system that per·form s a variety of physiological fun ctio ns:
movement (motility), secretion , digestion, a bsorptio n, elimination , and nucrienr
(
Foodstuffs - - . . Digestive System --.. Unabsorbed
Water foodstuffs
..__-..;;;"""- Organic waste (e.g., urea)

Minerals
Water
Internal External
environment / environment
Figure 3 · 2 I Exchanges of nutrients occur between our external environment and the internal environment of the circulatory system via the digestive system
(which includes the liver, gallbladder, and pancreas), respira tory system, and urinary system. Overall, the human body is a combination of 12 systems
working together to support cell needs.
Figure 3·3 I Ma jor organs of the

gastrointestinal (GI) tract (1 , 2, 3, 7, 8, and 9)
and accessory organs (4, 5, and 6) used in
digestion and absorption of nutrients.
D Mouth and
salivary gland
GI Tract Flow
Mouth
.J,
Esophagus (10 in longI
J.
Stomach-4-cup (I-liter) capacity. Food remains
about 2 to 3 hours or longer for large meals.
J.
Small intestine-duodenum (10 in long), jejunum
(4 ft long), ileum (5 ft long)-about 10 ft
(3.1 meters) in total length. Food remains about
3 to l 0 hours. ~ Gallbladder
Lorge intestine (colon}-cecum, ascending colon,

transverse colon, descending colon, sigmoid
colon-3 ~ ft (1 .1 meters) in total length. Food
con remain up to 72 hours.
J.
Rectum
.J,
Anus
83
production. ( Nun·ient prodttction refers to the synthesis of vitamins, such as vitamin

K, by bacteria that live in the intestine.) Most of these processes are u11der autonomic
control; t hat is, they arc involu11 tary. Almost all fun ctions involved i11 digestio n aud
hormone A compound with a specific site of absorptio n are con trolled by hormones, hormonelike compounds, and the nervous
synthesis that, when secreted info the system .3
bloodstream, controls the function of cells in its
target organ or organs. Hormones can be
amino acidlike (epinephrine), proteinlike The Flow of Digestion
(insulin), or fotlike (estrogen).
Before we eat a bite of most foods, the work of digestion- the breakdown of foods into
usable fo rms we can absorb-is already partially accomplished. Cooking or other prepa-
rations, such as marinatillg, pounding, aud dicing, generally begin the process. Starch
granules in foods swell as they soak up water during cooking, making them much eas-
ier to digest. Cooking also softens the rough connective tissues in meats and the fibrous
tissue of plants, such as that in broccoli stalks. As a result, the food is easier to chew,
saliva A watery fluid, produced by the salivary swallow, and break down during digestion. As you will see in Chapter 19, cooking also
glands in the mouth, that contains lubricants, makes many foods, such as eggs, meat, fish, and poultry, much safer to ear.
enzymes, and other substances.
Digestio n within the body begins in the mouth , where glands produce saliva
mucus A thick fluid secreted by glands ( Fig ure 3-4).3 Sal iva contains enzymes that break down carbohydrates to simpk
throughout the body. It contains a compound sugars and mucus that lubricates the morsel o f food (Table 3-2). Ch ewing d ivides
that has both a carbohydrate and a protein solid food into smaller, more manageable pieces, which increases the surface area
nature. It acts as both a lubricant and a means exposed to the saliva. The food is now referred to as a bolus. Saliva also conraim
of protection for cells. lysozyme, a set of enzymes that kill bacteria b)' rupturing their ceU membranes .
bolus A mass of food that is swallowed. Finally, saliva bathes the teeth wit h flu oride and other substances that protect
against d ecay (see Chapter 5 for d etails).
lysozyme A set of enzyme substances T he tongue contains taste receptors for sweet, salt, sour, and bitter tasres.1 ll1e salty
produced by a variety of cells; it can destroy taste is due to sodinm ions (Na+) enhanced by chloride ions (Cl- ). The sour taste is due
bacteria by rupturing cell membranes. to the presence of hydrogen ions (H+ ). Bitter and sweet tastes are generated by specific
umami A brothy, meaty, savory flavor in some componen ts in t he food that interact \\~ th membrane receptors on the tongue. A fifth
foods. Monosodium glutamate enhances this taste sensation called umami has been proposed. 10 This taste sensntion is elicited by
flavor when added lo foods. monosodium glutamate, a substance often added to restaurant foods to enhance flavor.
Brothy, meaty, and savory are examples o f LLrnami sensations, such as for mushrooms.
Parotid salivary gland

Porotid duct
(a) (b) Salivary glands
Figure 3 - 4 1(o) The oral cavity is the beginning of the GI tract. Incisor and canine (pointed) teeth are useful in tearing food, such as from a chicken leg.
Molars (flat teeth) are used to grind food into smaller pieces. (b) The salivary glands near lhe oral cavity produce saliva to aid in swallowing and digesting food.
Table 3·2 I Important Secretions and Products of the Digestive Tract

Secretion Sile of Production Purpose
Solivo Mouth Contributes lo starch digestion,

lubrication, swallowing
Mucus Mouth, stomach, small Protects cells, lubricates
intestine, large intestine
Enzymes Mouth, stomach, small Promote digestion of foodstuffs
(amylases, intestine, poncreos into particles small enough for
lipases, absorption
protea ses)
Acid Stomach Promotes digestion of protein
among other functions
Bile liver (stored in gollblodder) Suspends fot in water to aid
(bile acids, fot digestion in the small
cholesterol, and intestine
lecithins)
Bicarbonate Pancreas, small intestine Neutralizes stomach ocid when
it reaches the small intestine
Hormones Stomach, small intestine Stimulate production and/or
(gastrin, secretin, release of ocid, enzymes, bile,
cholecystokinin, ond bicorbonote; help regulate
gastric-inhibitory peristalsis ond overall GI tract
peptide) flow
This sensation of tla\'or is then augmented by input from approximately 6 million

olfactory ceUs in the nose. When we chew a food, chenucals are released that stim-
ulate the nasal passages. Thus, it makes perfect sense t hat when we are sick and our
noses arc stuffed up and congested, eve n our rnosr favo rite foods wi ll not taste as
good as they normally do. Flavor is also ::iftccted by human genetic Yariation in both
taste and olfactory scn5ations. The abili ty to detect bitter substances- such as in
broccoli or cabbage-is one example. This abi lfr:y is importanr since so me bitter sub-
stances are also quite toxic. 10
A variety of diseases and drugs, as well <\S the effects of aging, can alter the sense of
taste. Overall, flavor is a complex combination of taste, olfaction, physical sensations
from cerrain chemicals in foods (such as in chili peppers), and textural sensations.
The mou [h and sromach are connected by the 10-incb-long esophagus. At its
entrance is a valvelike nap of tissue, the epiglottis, that prevents food from being lodged
in the o·achea (windpipc). 5 When food is swallowed it lands on the epiglottis, which then The body digests the foods presented. Despite
covers the larynx (the opening of the trachea). Breathing automatic:tll) stops. These
1 whot you moy hove heard or reod, the order in
which foods ore eaten ploys no role in digestion.
involuntary responses ensw-e that swallowed food travels only down the esophagus, aided
by muscle conn-actions of the esophagus and by gravity (Figure 3-5). ff fond travels down
the trachea, choking may occur (the \ictim "ill not be able to speak or breathe). A series
of rechniques ro treat such a person is called the Heimlich .Maneuver (see w\\w. olfactory Sense of smell.
he11nhd11mnrute.org for details). epiglottis Flop lhot folds down over the trocheo
As food exits tbe esophagus, it enters the stomach. The stomach is essentially a hold- during swallowing.
ing tank with a capacity of about 4 cups ( 1 L). 5 Note that stomach size can vary, and
parietal cell Gastric gland cell !hot secretes
its volume can be expanded to about 16 cups ( 4 L) if needed. In cona-asr, stomach vol-
hydrochloric ocid ond intrinsic factor.
ume can be reduced surgically as a radical treatment for obesity (more on this Ll1 Chap-
ter I 3 ). The sromach continues the digcstiYe process by sea-ering very strong acid chief cell Gastric gland cell thot secretes
(hyd.rochknic acid [HCl]) from the parietal cells as well as enzymes from the chief cells pepsinogen, precursor of pepsin.
~l~~~~~~-41£i~-- Hard
palate
Bolus
Pharynx
Tongue
Epiglottis
Larynx Epiglottis
closes over Esophagus
Esophagus larynx
Bolus
Trochee
(a) Bolus of food is pushed by (b) As bolus moves into pharynx, the (c) Esophageal muscle con tractions push bolus
tongue against hord palate and epiglottis doses over larynx. toward stomach. The epiglotti s then returns to
then moves toward pharynx. it's normal position.
Fi gure 3·5 I The process of swallow ing. Swallowing occurs as the food bolus is forced (o) into the pharynx from the oral cavity, (b) through the pharynx,
and (c) into the esophagus on the way to the stomach. Choking occurs when the bolus becomes lodged in the trachea, blocking a ir to the lungs, instead of
passing into the esophagus.
(Figuxes 3-6 and 3-7). Th is acid and enzymes arc then slowly mixed into the food. T he
chyme A mixture of stomach secretions and resul ting soupy mass orfood and secretio ns is called chyme. The chyme is usually ready
partially digested food. to leave t he stomach within 1 to 4 ho urs after food is eaten . T he more soLid t he ch yme,
the longer it takes to leave the sto mach.
T he hydrochlo ric acid produced by the stomach is ver y important. It destroys the
bio logical activity o [ ingested proteins. Otherwise protein substances such as certain
plant and animal ho rmones in food could go on to affect human fun ctio ns. For the
most part bacteria and viruses in foods are also destroyed. ln adcLition, the acid con-
verts so me inactive stomach enzymes into active fo rms and solubilizes dietar y miner-
A nothe.r term to describe the stomach is
gastrtc. :tls such as calcium so they can be mo re easily absorbed.9
hydrochloric acid (HCI) 0
stomach acid 1
lemon juice 2
+
!. A
Coca-Cola , beer, vinegar 3 Cl c
[H +] c I
tomatoes 4 'iii D
m
....
black coffee 5 (.)
norm al rainwater .5
urine 6
saliva
pure water, tears 7 neutral pH [H+ ]= [OH - ]
human blood
seawater 8
baking soda, stomac h antacids 9 I
Figure 3·6 I Th e pH sca le. The diagonal line J:
indicates the proportionate concentration of Q.
Great Salt Lake 10 Cl
B
hydrogen ions (W ) to hydroxide ions (OW) at milk of magnesia [OHj c A
each pH va lue. Any pH va lue above 7 is basic, household am monia 11
'iii
Ill
s
(1) E
while any pH value below 7 is acidic. As pH ....
(.)
bicarbonate of soda 12
decreases, each lower pH unit hos ten times the .5
amount of hydrogen ions than the previous unit. oven cleaner 13
Therefore, only a small cha nge in pH can have a
drastic affect on a cell, and so on orga n systems. sodium hydroxide (NaOH) 14
Gastric
Chief cells
Stomach
Esophagus
Chief cells
Small Opposing
intestine muscle layer
Gastric Muscularis
glands mucosa
Stomach Cross Section of

Inner Stomach Walls
Figure 3 . 7 I Physiology of the stomach. Surface mucous cells produce mucus for protection from stomach acid and enzymes. Parietal cells produce the
hydrochloric acid (HCIJ and chief cells produce the enzymes. Mucous neck cells, scattered among the cells in the gastric pits, also produce mucus.
You might wonder how the stomach protects itsdf frorn the acid and enzymes it reduction of mucus relies on the presence of
produces. First, the stomach has a thick layer of mucus secreted by surface mucous cells compounds called prostaglandins.
and mucous neck cells in the stomach lining. (Goblet cells perform a similar function Heavy use of aspirin and related NSAID med·
in the intestines.) This mucus helps prevent the stomach from "digesting" itself. The icotions con cause breakdown of the stomach
production of acid and enzymes in the stomach is tied to the release of a specific hor- wall because they inhibit prostaglondin produc-
mom: called gastrin. This release does not occur except when we arc Lhinking about tion. This in tum lessens the barrier between gas-
eating or arc actualiy in th<.: process of eating. Lastly, as the concentration of acid in the tric cells and the highly acidic gastric secretions.5
sromach increases, acid production tapers off, also because of hormonal conu·ol.9
One other important function of the stomach is the production or a substance called
intrinsic factor. This vital material is essential for the absorption of one of the 13 vita- prostoglandin (PG) One of several potent
mins, vitamin B-12 (sec Chapter 10). 3 hormonelike compounds mode of
The sromach empties into the small intestine, which i~ coiled below ir in the polyunsaturated fatty acids that produce
abdomen (Figure 3-8 ). The smaJJ intestine is divided into three sections: the first part, diverse effects in the body.
the duodenum, is about 10 in. long (0.3 m); the middle segment, rbe jejunum, is NSAIDs Nonsleroidol onti-inAammotory drugs;
about 4 ft Long (1.3 m); and the last section, the ileum, is about 5 fi: long (1.6 m).5 includes aspirin, ibuprofen (Advil®), and
The small intestine is considered small because of its narrow diameter ( I in. [2.5 cm l), noproxen (Aleve®l.
not its length. Most digestion is completed in rhe duoden um and upper jejunum, with
the help of enzymes made by intestinal cells and the pancreas. Muscubr contractions intrinsic factor A substance presenl in stomach
in the small intestine constantly mix the food with digestive flu ids, enhancing diges- secretions that enhances vitamin B-12
absorption.
tion. A meal remains in tJ1e small intestine about 3 to 10 hours.
The small intestine empties into the large intestine (also called the colon). This organ feces Substances discharged from the bowel
is about 3~ ft long ( 1.1 rn ) and is separated into five sections: cecum, ascending colon, during defecation, including undigested food
transverse colon, descending colon, and sigmoid colon.5 Little digestion occurs in this residue, dead GI tract cells, mucus, bacteria,
organ (95% of total digestion has already taken place in the small intestine). Food that and other waste material.
reaches the large intestine is mostly iniligestible. This residue remains in the large intes-
tine for about 24 to 72 hours before elimination from the body a~ feces.
Organ Digestive Functions

D Mouth and Chewing begins
sol ivory Moisten food with saliva
glands
Lubrication with mucus
Release of starch-digesting {amylase) enzyme
Initiation of swallowing reAex
ID Esophagus Lubrication with mucus

Move food to stomach by peristaltic waves
EJ Stomach Store, mix, dissolve, and continue digestion of food
Dissolve Food particles with secretions
Kill microorganisms with acid
Release of protein-digesting (pepsin) enzyme
Lubricate and protect stomach surface with mucus
Regulate emptying of dissolved food into small
intestine
llJ Liver Production of bile to aid in fat digestion and

absorption
D Gallbladder Storage, concentration, and later release of bile
into the small intestine
mPancreas Secretion of sodium bicarbonate and carbohydrate·,

fat-, and protein-digesting enzymes
fJ Small intestine Mixing and propulsion of contents
Digestion and absorption of most substances using
enzymes mode by the pancreas and small intestine
[JI Lorge intestine Mixing and propulsion of contents

Absorption of sodium, potassium, and water
Storage and concentration of undigested food
Formation of feces
Ii] Rectum Store Feces and expel via the onus, which is the
opening to the outside of the body
Figure 3·8 I Physiology of the GI tract. Many organs cooperate in a regulated fashion to allow digestion and subsequent absorption of nutrients in foods.
T he terminus of the large intestine is attached ro the rectum , which is connected to

the anus. T hese final sections of the GI tract work with the large intestine to prepare
the feces for elimination through the anus. 5
T he liver, pancreas, and gallbladder work with the GI tract but arc not a ph)'Sical
bile A liver secretion that is stored in the part o f it. They are thus called accessory organs. 18 The liver provides bi le, which aids
gallbladder and released through the common in fa t digestion and absorption by suspending fat in water, creating many tiny fat
bile duct into the duodenum. It is essential for dro plets. Bile is stored in the gallbladder until needed. The bile duct leads fro m the
the digesfion and absorption of fat. gallbladder and connects ~w i th the pancreatic duct, which allows digestive enzymes
and other prod uces from tJ1e pancreas, such as sodium bicarbonate (Na H CO ~), co
be mixed wi th bile before entering the duodenum for djgestio n . This bicarbonate
neut ralizes the acidic chyme as it enters the duo denum . The latter section entitled
GasrrointestinaJ Control Valves: Sphincters discusses the role of bicarbo nate in t he
small intestine in greater detail.
www.mhhe.com/wardlawpe rs7 89
o- The sta rting material,

~
sucrose, consists of
glucose and fructose
L
O ' ""°re
bonded together.
Gl"'~-0
oP Bond
-----......_ r-\:-! \
~ - ~"
Sucrose binds to
the enzyme.
/~~'od"'" glucose and

fructose ore
released, and the
enzyme is free to
act again.
The binding of sucrose to

Active site
the enzyme places stress
on the glucose-fructose
bond, and the bond
breaks.
Enzyme
(sucrose) J
Figure 3 . 9 I A model of enzyme action. Enzymes increase the speed with which chemical reactions occur, but they ore not altered themselves os they do
so. In the reaction illustrated here, the enzyme sucrose is splitting the sugar sucrose into two simpler sugars: glucose and fructose. Only these simpler sugars
are absorbed from the small intestine to enter the bloodstream. Note that sometimes energy input is needed to push the reaction along, but not in this case.
A Closer look at Enzymes in Digestion

Enzymes speed up digestion by catalyzing chemical reactions. This catalysis brings cer- he naming system for enzymes is often quite
tain molecules close together and then creates a favorab le environment for the simple. The first port of the enzyme name
intended reaction. The enzyme lowers the amoLmt of activation energy needed for the usually indicates the target; the ending is then
action to proceed (Figw·e 3-9). (Appendix A provides more detail on enzyme action.) -ose. For example, sucrose is the enzyme that
Enzymes usually act only on a specific substance; for example, enzymes that recognize digests the sugar sucrose.
table sugar (sucrose ) ignore milk sugar (lactose). It is also possible for some of these
enzymes to digest the digestive tract itself. For this reason, nerve and hormonal mech-
anisms in the digestive tract control enzyme release. Enzymes are released as needed,
but generally not at other times.7
Digestion utilizes a chemicaJ process known as hydrolysis, in which water is used hydrolysis A chemical reaction in which o
to split large molecules into smaller o nes. The process evenmally yields basic mole- compound is broken down by the addition of
cules, which can be absorbed through the intestinal wall. waler. One product receives a hydrogen ion
A few digestive enzymes are made by the mouth and sLOmach. Most, however, are (H+), while the other product receives o
synthesized by the pancreas and small intestine (Chapters 5, 6, and 7 will review these hydroxyl ion (OW). Hydrolytic enzymes break
enzymes in detail).9 T he pancreas is capable of responding to changes in nutrient down compounds using water in this manner.
intake with appropriate changes in enzyme production. lncreased protein intake leads
ro increased protein digestive capabi lity. This result is likely Linked to the ability of the
hormone cholecystokinin (CCK) to increase the synthesis of protein-digesting cholecystokinin (CCK) A hormone thol
enzymes by the pancreas. Diets high in fat and low in carbohydrate lead to an increase stimulates enzyme release from the pancreas
in fat-digesting enzymes. and bile release from the gallbladder.
When either the small intestine or the pancreas is diseased, inadequate quantities
of important digestive enzymes may be produced. This scarcity can resL~t in incom-
plete digestion and very limited absorption. 2 In such cases, nutrients in the undigested
food travel into the large intestine rather than being absorbed into the bloodstream.
In the large intestine the w1digested food is metabolized into acids and gases by bac-
teria. 2 The resultant feces appear foamy and greasy because of trapped gases and the
Table 3.3 I Gastrointestinal Tract Hormones

Hormone Stimulus to Secretion Secreted by Action
Gastrin Food in the stomach, especially Pyloric region of the stomach Stimulates parietal cells to produce
proteins, caffeine; spices; alcohol and upper duodenum acid, stimulates chief cells to produce
enzyme that begins digestion of protein
Secretin Acid chyme, partially Duodenum, jejunum Stimulates pancreas to produce
digested protein bicarbonate
Cholecystokinin (CCK) Food, especially fat and proteins Duodenum, jejunum Stimulates contraction of gallbladder,
in duodenum secretes pancreatic digestive enzymes,
inhibits stomach motility
Gastric inhibitory peptide Protein and fat in chyme Small intestine Inhibits stomach motility, stimulates
insulin secretion
presence of undigested fat. Intestinal malabsorption also often causes a distended

abdomen because of intestinal gas. l 1
Gastrointestinal Hormones-A Key to Orchestrating Oigestjon
P eople who have pancreatic disease may

not produce sufficient enzymes for
digestion. In cystic fibrosis, excess production of
Four hormones, part of the endocrine system, primarily regulate the GI tract: gastrin,
secretin, cholecysrokiniu, and gaso·ic inhibitory peptide (Table 3-3 ).6 The term hoi·-
mone comes from the Greek "to stir or excite." To be a true hormone, a regulator)
mucus may block release of enzymes from the compound must have a specific synthesis site from whicb it enters the bloodstream to
pancreas. This results in malabsorption of nutri· reach target cells. Note that hormones arc not available to all cells in the body, but only
ents and associated discomfort. An affected act in those cells with the appropriate receptor protejn. These receptors arc bjghly spc-
person may be prescribed replacement enzymes, cific for a certain hormone and are generally found on the cell membrane. (A few hor-
which ore token right before eating. Usually mones can penetrate the cell membrane and bind to receptors on DNA.)
these ore coated to protect against destruction Many hormonelike compounds, such as vasoactive intestinal peptide, bombcsin,
by acid in the stomach. substance P, and somatostatin, also conrrol important aspects of Gl function. 5 These
compounds diffi.1sc from cells or nerve endings to nearby cells. Many hormondiki:
compounds are fow1d in the intestine and the brain. When a person thinks about eat-
ing or prepares to eat, the whole GI tract begins to prime itself for action.
Hormonclike substances p<u-ticipate in this process. The cells that synthesize these hor-
mones and hormonelikc compounds are scattered throughout the GI tract.
Gastrointestinal Contro1 Valves: Sphincters

sphincter A muscular valve that controls flow of A sphincter is a circular muscle arrangement (as in the anus) that acts as a valve to reg-
foodstuff in the GI tract. ulate passage or flow of material. The intestinal tract includes several sphincters, which
respond to stimuli from nerves, hormones, hormonelike compounds, and pressure that
builds up around them (Figure 3-10).
The flO\\ of food through the esophagus is controlJed by d1e upper and lower
esophageal sphincters. 18 The lower esophageal sphincter (also known as the cm·dinc
sphincter due to its proximity to the heart) prevents backflow (reflux) of stomach con-
tents into the esophagus. It generally opens only in response to muscle contractions in
the esophagus, which propel ingested food down to the stomach.
The lower esophageal sphincter for the most part should remain closed, as the stom-
ach contents are highly acidic. If stomach acid comes in contact with the esophagus, it
heartburn Pain caused by stomach acid can cause a pain known as heartburn.
bocking up into the esophagus and Irritating The pyloric sphincter, located at the junction of the stomach and first part of the
the tissue in that organ. small intestine (duodenum), controls the movement of the stomach contents into the
pyloric sphincter Ring of smooth muscle small intestine. Under hormonal and nervous system cono·ol, the pyloric sphincter allows
between the stomach and the duodenum. only a few milliliters (about a teaspoon) of stomach contents at a time to squirt into the
small intestine. This rate allows bicarbonate ions released from d1e pancreas to eftlciemly
Sphincte r Function
D Lower esophageal
sphincter
Prevent bockAow (reflux) of stomach contents
into the esophagus
EJ Pyloric sphincter Control the Row of stomach contents into the

small intestine
EJ Sphincter of Oddi Control the Aow of bile into the small intestine
lleoceol sphincter Prevent the contents of the large intestine from

reentering the small intestine
D Anal sphincters Prevent defecation until person desires to do so
Figure 3· 1 O I Sphincters of the GI tract. These ringlike muscles control the flow of contents through the GI tract in response to stimuli from nerves,
hormones, hormonelike compounds, and pressure that builds up around th e sphincters.
neutralize the hycL-ogen ions coming from the stomach acid. Thjs ncutraliz.ation is ctiti-
cal to reduce the risk of acid erosion of the srnalJ intestine. Such erosion might produce
an ulcer. The pyloric sphincter also prevents back£Jow of intestinal contents imo the ulcer Erosion of the tissue lining, usually in the
stomach, thereby protecting the stomach lining from bile in the intestinal comcnts. 18 stomach jgastric ulcer) or upper small intestine
The sphincter o f Oddi lies at the end of the common bile duct. ·w hen the hormone (duodenal ulcer). The general condition in
cholecysto kinin (CCK) stimulates the gallbladder to cona·acr during digestion , the either area is often termed a peptic ulcer.
sphincter of Oddi relaxes and allows the output of the gallbladder and much of that sphincter of Oddi Ring of smooth muscle
from the pancreas to flow from the common bile d uct to the duodenum. 18 between the common bile duct and the upper
The ileocecal sphincter is found at the end of the small intestine and opens in part of the small intestine (duodenum). Also
response to the presence of intestinal contents in its vicinity. Otherwise the sphincter called the hepatopancreatic sphincter.
remains closed to prevent the contents of the large intestine from backing up into the
ileocecol sphincter Ring of smooth muscle
small intcstine. 18 In this way bacteria from the large intestine are prevented from
between the ileum of the small intestine and the
invading and colonizing the smaU intestine. The small intestine must have a relatively colon.
low concentration of bactetia because bacteria can compete for mttl'ients and disrupt
absorption, especially for fat.
Ar the far end of the brge intestine are two anal sphincters, one under voluntary
conrrol. 18 Once toilet-rrained, a child can determine wbc n to relax t he sphincter to
allow for d efecation , and when to keep it constricted. defecation expulsion of feces from rectum.
peristalsis A coordinated muscular contraction

Gastrointestinal Muscularity: Mixing and Propulsion that propels food down the GI tract.
Food is propelled down the GI tract by a process called pedstalsis. 9 Watching a snake
swallow irs prey graphically illustrates rhe process. Most of the GI tract bas two layers
of muscles-circular and longitudinal. Peristalsis consists of a coordinated squeezing
Figure 3· 1 1 I Peristalsis and segmenlolion. A Wove of contraction Woll of Gt tract

swallowed bolus is propelled through the GI tract -1- J
by coordinated contraction and relaxation of the
muscles of the GI wall. (a) Peristalsis is a wove of
conlroclion that moves the bolus ahead of the
wove through the GI trod toward the onus.
(bl Segmentation is o bock-and-forth action in the
small intestine that breaks oporl the bolus into
increasingly smaller pieces and mixes them with
digestive juices.
(a) Peristalsis (b) Segmentation
and shortening of these muscles (Figure 3-11 ). This process begins in the e~ophagus
in the fOrm of two "a\ ei. of muscle action closely following each other. ln the stom-
ach, peristaltic wa\'CS create a mixing and grinding action as often as d1ree rime~ per
mass movement A peristaltic wove that
minute during digestion. The stomach wall is composed of three opposing musdc b.v-
simultaneously coordinates contraction over a ers (circular, diagonal, and longitudinal), which in combination enable the stomach to
large area of the large inlesline. Moss conu-act in enough directions to fully mix food with gastric juices (review figure 3-7).5
movements propel material from one portion of The most prominent peristalsis occurs in the small intestine, where contractions
the large intestine to another and from the large occur about every 4 Lo 5 seconds. The large intestine has comparatively sluggish wa\•es
intestine info the rectum. of peristalsis (called haustrations). These lead to occasional m ass movem ents ro help
eliminate the fcce!>.
Concept I Check
The gasrroincestinal <GI) tract includes the mouth, esophagus, stomach, small mtcstine,
large intestine (colon), rectum, and anus. Associated with the Gl tract are the Sllivary
glands, liver, gallbladder, and pancreas. Together these organs perform the digcscion .rnd
absorption needed m cxtrnct nutrients from food and deliver them to the bloodstream.
Hormones, such as gastrin and cholccystokinin (CCK), regulate digestion.
Sphincters throughout the GI tract control the flow of food by blocking the passage
between organs unul the proper time.
In the GI tract, a coordinated muscular act:i\ity called pcriscalsis propels food from the
esophagus ro che anus. Segmentation in the intestines di,ides and mixes the content~, aid-
ing digestion and absorption. Enzymes produced by cells in the mouth, stomach, pancreas,
and small intestine digest the food to forms of nutrients that can be absorbed. The time
from ingestion of food to the CYentual elimination of the feces from the body is usu.di)
about 1 to 3 days.
When the Digestive Processes Go Awr
The finc-runed org..m s\·stem \\c call the digcsrin: The typical symptom of an ulcer i~ pain about
~·stem can den:lop problems. Ki1m\ing Jbout 2 hours aft.er eating. Stomach acid acting on a me.ll
these common problems can help you aYoid or initates d1e ulcer after most of the me,11 has mo\ ed
lessen them. from me sire of the ulcer.
wo other common GI tract disorders,
The primary nsk associated with Jn ulcer is the
lactose molabsorption/intolerance
possibility that it wiJI erode entirely through the
and diverticulosis, ore covered in Chapter 5.
Ulcers stomach or intestinal \\'all. The Gl comems could
Note tho! low-fiber diets are lhe common
then spi ll inm rhc body cavities, causing a major
cause of the latter disorder.
About 25 million North Americans develop ulcers infecLion. In addition, Jn ulcer may erode a blood
during their lifetimes. The principal causes arc an vessel, leading to massiYc blood loss inro the stom·
acid-resistant b~icterial infectio n {HelicobacttT ach or small intcstint:. for these reasons, it is
pylon· f H. pylon/), the he .wy use of aspirin and important not to ignort: the C<1rly warning signs of
related NSAlD medications, .111d disorders that ulcer Jc\'clopment.
cause e:-cessin: Jcid production in thl'. ~romach ln the past, milk and cre.un therapy-the so-
(Figurl'. 3-12). And, .11h:r hl'.ing our of favor for callcd Sippy diet-\\ as U!!cd to hdp l.'.ure ulcers.
some years, stres~ 1s no\\' regarded as .1 predisposing Clinici.rns no\\ kno\\ thJt milk .111d cream arc cwo
faccor for ulcer~. cspeci,111~ if the person is infct:red of c:he worst foods a person with .rn ulcer could eat.
\\ith H. pylori or ha~ ceruin .mxiety disorders. The l.'.alcium in rhcse foods stimul.nc~ Momach .1cid
proton pump inhibitor A medication lhol
fu the stom.1ch lining deteriorates in ulcer secretion and actual!~ inhibits ulcer healing.
inhibits the ability of gastric cells lo
de,·clopmcnt Jnd lo~es its mucus layer protecrion, Today, a combination of .1pproaches is used for secrete hydrogen ions. Examples ore
rhc acid tltrther erode~ the stomach tissue. Acid can ulcer rherapy. 13 People infected \\ith H. pylori arc given esomeprazole (Nexium) and
also erode the tbsuc lining of the first part of the antibiotics as \\'di as stonMch acid-bh:king medica- lonsoprazole (Prevocid). low doses of
SlllJll intestine. Peptic ular 1s the general term for tions called proton pump inhlbitors (e.g., omeprazole this class of medicotions ore also
both these condition~. ~lose ulcers in young people lPriJosec ], esomeprazolc l Nc\ium ], lamoprazole available without prescription (e.g.,
occur in the snull inte~tine; in older people they [Pre\'acid]) and pos5ibl} bismuth to eradicate omeprozole (Prilosec) .
occur prima1il~ in the stomach. H. f~l'lori. (Recall that pr11to11 is another term for the
Genetics
Dietary
factors ,
such as
alcohol
Weakened Figure 3· 1 2 I Development of a

mucosa I peptic ulcer. H. pylori bacteria and
defense NSAIDs (e.g., aspirin) cause ulcers by
impairing mucosa! defense, especially in
the stomach. In the some way, smoking,
genetics, and stress con impair mucosa!
defense, as well as cause on increase in
the release of pepsin and stomach acid.
All these factors con contribute lo ulcers.
(co11ti1111ed)
93
healthy
astric
111 the stomach. Some of these medications are

H2 blockers Medications such os now available over the counter in nonprescrip-
cimetidine (Togomet) that block lhe tion doses for cases of indigestion and hcanburn
increase of stomach acid production (sec next section). Medications that coat Lhe
caused by histamine. ulcer, such as sucra.lfare (Carafate), arc also com-
monly used.
People with ulcers should also refrain from
smoking and minimize the u~c of aspirin and
histamine A breakdown product of the related NSAIDs. These practices reduce the
amino acid histidine that sHmulates acid
mucus secreted by the stomach. A medicacion
secretion by the stomach and hos other
used to treat arthritis pain, called "Co.x-2
effects on the body, such as contraction
of smooth muscles, increased nasal
inhibitor" (celecoxib [CelebrcxJ), is less likely to
secretions, relaxation of blood vessels, cause stomach uJccrs and, so, has been used as a
and constriction of airways. rcplacemenr fo r NSAJDs. Tr docs offer some
Close-up of o stomach ulcer. This needs to be treated
advamages over NSAJDS, but is nor rotally ~ate
or eventual perfora tion of the stomach is possible. for some people, such as tho~e with a hi~rory of
cardiovascular disease or srrnkes. Overall, this
combination of lifcsrylc therapy and medical
trearment has so revolutionized ulcer therapy
that dietary changes arc of minor importance
spirin is port of the class of medica- today. Current diet-therapy approaches recom -
tions called nonsteroidal onti- hydrogen ion that creates acidii:y.) In many cases, mend simply avoiding foods tbar increase ulcer
inflommotory drugs (NSAIDs). Also there is a 90% cure rate for Ii. pylori infections in the symptoms (Table 3-4).
included ore ibuprofen (Motrin or Advil) first week of this rreaLment. Recurrence is unlikely if Nore also that stomach acid is not a problem for
and noproxen (Aleve). the infection is cured, but an incomplete cure almost people not prone to or currently experiencing ulcer~.
certain!)' leads to repeated ulcer formation. Because stomach acid performs important fimctions.
Antacid medications ma}' also be part of antacids, despite their usual presence alongside rhe
ulcer care, as is a class of medicines called H 2 breath mints in a convenience store, should not be
blockers. These include cimetidine (Tagamet), used excessively. Abuse by overingesting antacids
ranitidine (Zantac), and famoridine (Pepcid ), all containing magnesium (and many do) could result
of \\'hich block histamine-related acid secretion iJ1 magnesium toxicity.
Table 3 · 4 I Recommendations to Prevent Ulcers and Heartburn from Occurring or Recurring
Ulcers
1. Stop smoking if you ore now a smoker.

2. Avoid large doses of aspirin, ibuprofen, and other NSAID compounds unless a physician advises other·
wise. For people who must use these medications, FDA hos approved an NSAID combined with a medica-
tion to reduce gastric damage.
3. limit consumption of coffee, tea, and alcohol (especially wine), if this helps.
4. Limit consumption of pepper, chili powder, and other strong spices, if this helps.
5. Eat nutritious meals on a regular schedule; include enough fiber (see Chapter 5 for sources of fiber).
6. Chew foods well .
7. Lose weight if you ore currently overweight.
Heartburn
l. Observe the recommendations for ulcer prevention.
2. Wait about 2 hours ofter a meal before lying down.
3. Don't overeat at mealtime. Smaller meals that ore low in fat ore advised.
4. Try elevating the head of the bed (6-inch blocks) .
94
I
- -
Heartburn
About half of North American adults experience
occasional heartburn. This gnawing pain in the
upper chest is caused by the mo\'emcnr of acid
from the stomach into the esophagus, and so, the
more serious form of this problem is called
gastroesophageal reflux disease (GERD ). 8
gastroesophogeal reflux disease (GERO)
Unlike Lhc sromach, the esophagus produces very
Disease that results from stomach acid
little mucus to protect it, so acid quickly erodes bocking up into the esophagus. The acid
the lining of the esophagus, causing pain. irritates the lining of the esophagus,
Symptoms may also include nausea, gagging, causing pain.
coughing, or hoarseness. GERD is characterized
by such symproms of acid reflux rwo or more
nmes per week. People who lm·e Gl:.RD experi-
ence occasional relaxation of the lower
esophageal sphincter. Typically it should be
relaxed only during swallowing, but in individu -
als with GERD it is relaxed at other times as well.
Certain physical conditions can lead to heart·
burn. for example, both pregnancy and obesity
result in increased production of estrogen and
progesterone. These hormones relax rhe lower
esophage.11 sphincter, making hearcburn more
likely. 15 In the latter case, adipose nssue turns A number of over-the-counter medicolions ore morke1ed
certain circulating hormones inro estrogen; rhus, for heartburn. Attention to diel and lifestyle, however, is
the more .1dipose tissue, the more estrogen is generally a more important measure to take.
produced. The Case Scenario Follow-Up de-
scribes rhe therapy options for GERJ) and related
heartburn.
Constipation and Laxatives
Constipation, which 1s difficult or infrequent e\·ac· constipation A condition characterized
uation of the bowels, is commonly reported by by infrequent bowel movements.
adulrs, especially older .1dults (d1e colon becomes
more sluggish as we age). Slow mo,·ement of fecal
material through the large intestine causes consti-
pation. A~ Auid is increasingly absorbed during the
extended time the !Cces stay in d1e large intestine,
they become dry and hard.
Constipation C<ln rcsL1lt when people rcgul:irly
inhibit their normal bowel reflexes for long peri-
ods. People Ol.l) ignore normal urges when it is
inco1wenicnr w interrupt occupational or social
activities. Muscle spasms of an irritated large inrcs·
tine can also slo" the movement of teces and con-
tribute to constipation . .Medications such as
An endoscopic view of lhe esophagus that shows the antacids as well as calcium and iron supplements
signs of reflux esophagitis. can also cause constipation.
(w11tin11cd)
95
Case Scenario i Follow-Up
Elise's GERD con be treated, but currently ii will be a lifelong condition. Typical
dietary advice includes consuming smaller, more frequent meals that ore low in
.....,...:..E._. fat, not overeating at mealtimes, waiting about 2 hours after meals before lying
down, and elevating the head of the bed about 6 inches (review Table 3-4) . All th ese rec-
ommendations reduce the risk of stomach contents forcing their way bock up the esopha-
gus. Other helpful advice includes stopping smoking if practiced, losing excess weight if
erhaps you have heard that taking overweight, and limiting intake of chili powder, onions, garlic, peppermint, caffeine,
laxatives ofter overeating prevents alcohol, and chocolate. All these factors encourage relaxation of the lower esophageal
deposition of body fat from the excess sphincter and/or irritate the esophagus. If this advice doesn't control Elise's symptoms,
energy intake. This erroneous and dan- her physician may turn to medications. The primary medications used to control GERD
gerous premise has gained popularity inhibit acid production in the stomach (see the Nutrition Focus discussion on ulcer med-
among followers of numerous fad diets. ications such as omeprazole [Prilosec]) . If this and other medical therapy foils to control
You may temporarily feel less full after the problem, surgery to strengthen the lower esophageal sphincter is possible, but gener-
using a laxative because laxatives hasten ally will not cure the problem.4,s,19 Lifetime diet and lifestyle management, and most
emptying of the large intestine and likely medica tions, will still be needed to manage the problem. Such management is
increase Ruid loss. Most laxatives, how- important since long-standing GERD increases the risk of esophageal cancer.
ever, do not speed the passage of food
through the small intestine, where diges-
tion and most nutrient absorption take
place. As a result, you can't count on lax-
Eating foods with plenry of fiber, such as coughin g or sneezing, or straining during bowel
atives lo prevent fat gain from excess whole-grain breads and cereals, along with d rink- movements, particularly with constipation, can lead
energy intake. ing more fluid to avoid dehydration, helps treat to a hemorrhoid. H emorrhoids can develop w1110-
typical cases of mild constipation.14 More serious ticed Lmtil a strained bowel movement precipitates
laxative A medication or other substance cases require laxative therapy as well (see the next symptoms, which may include pain, itching, and
that stimulates evacuation of the paragraph). Fiber stimulates peristalsis by drawing bleeding.
intestinal tract. water into the large intestine and helping form a Itching, caused by moisture in the anal canal,
bulky, soft fecal output. Eating dried fruits also can swelling, or other irritation, is perhaps the most
help stimulate the bowel. Tn addi tio n, people with common symptom. Pain, if present, is usually
constipation may need to develop more regular aching and steady. Bleeding may result from a
bowel habits; allowing the same time each day for hemorrhoid and may appear in the toilet as a bright
rf1.1n~i ni:i· a bowel movement can help train the large intestine red streak ill the feces. T he sensation of a mass in
to respond routinely. Finally, relaxation facilitates the anal canal after a bowel movement is sympto-
.loci is considering going on a new diet regular bowel movements, as docs regular physical matic of an internal hemorrhoid d1at protrudes
that emphasizes eating only fruits before activity. through the anus.
noon, meat at lunchtime, and starch and Laxatives can lessen more serious cases o f Anyone can develop a hemorrhoid, and about
vegetables at dinner. In addition, the diet constipation .14 T hese wor k by irritating the half of adul ts over age 50 do. Pressure from pro·
recommends "cleansing" the intestines intestinal n erve jw1Ctions to stimulate the longed sitting or exertion is o ften enough to bring
with laxatives and enemas every other peristaltic muscles, o r by drawing water (by o n symptoms, although diet, lifcsrylc, and possibly
week. Whal reasons would you give Joci means of b ulk-forming fiber) into the intes- herediry play a role. For example, a low-fiber diet
to steer clear of this regimen? What are tine to enlarge fecal o utput. The larger o utput can lead to hemorrhoids as a result of constipation
some possible harmful effects that could and straining during bowel movements. 20 If you
stretch es the peristaltic muscles, making them
result? re bound and d1en constrict. Regular use o f think you have a hemorrhoid , you should consult
laxatives, h owever, sho uld be tmder the super- your physician. Rectal bleeding, although usually
vision of a ph ysician . Overall, for most people caused by hemorrhoids, may also indicate other
the bulk-forming fiber laxatives are die safest problems, such as cancer.
to use. A physician may suggest a variety of sdf-carc
measures for hemorrhoids. Pajn can be lessened by
applying warm, soft compresses or sitting in a tub
Hemorrhoid s
of warm water for 15 to 20 minutes_ Dietary rec-
hemorrhoid A pronounced swelling in a H emorrho ids, also called piles, arc swollen veins of ommendations arc the same as those for treating
large vein, particularly veins found in the the rectum and a.n us. T he blood vessels in this area mild constipation, emphasizing the need to con·
anal region. are subject to intense pressme, especially during sume adequate fiber and fl uid . Over-the-counter
bowel movements. Added stress to the vessels from remedies, such as Preparation H, can <USO offer
pregnancy, obesiry, pro longed sitting, violent relief of symptoms.
96
Irritable Bowel Syndrome other serious digestive problems. The website
ww\1 .ibsgroup orh provides tunher information.
Many adults (25 miJlion or more in the UniLed
Stares) ha\'e irritable bowel syndrome, a combin.i-
tion of cramps, gassiness, bloating, and irregular Diarrhea
bowel function (diarrhea, constipation, or alternat-
Diarrhea, a GI tract disease that generall>• lasts only
ing episodes of both ). Jr is more common in young
a fe,1 days, is defined as increased fluidity, fre-
women than in young men. The disease leads to
quency, or amount of bowel movements compared
about 3.5 million physician visits each year in the
to a person's usual pattern. Most cases of diarrhea
United States.
result from infcctions in the intestines, with bacte-
Symptoms associaLed with irritable bowel syn-
ria and viruses the usual offending agents. They
drome include 'isible abdominal distension, pain
produce substances that cause the intestinal cells to
relief after a bowel mo\"cmcnt, increased stool fre-
secrete Aui<l rather than absorb llu1d. Anot11er form
quency with pain onset, looser stools with pain
of diarrhea can be caused by consumption of sub-
onset, mucus in the feces, and a teeling of incom-
stances that arc not readily absorbed, such as the
plete elimination even after a bowel movemcnt. 12
sugar alcohol sorbitol found in sugarless gum (see sorbitol An alcohol derivative of glucose.
The cause is thought tO be altered intestinal
Chapter 5).2 When consumed in large amounts
peristalsis coupled wirh a decreased pain threshold
such unabsorbed substances draw excess water into
for abdominal distension. In the laner case a minor
the intestine, leading to diarrhea. Treatment of
amount of abdominal bloating causes pain that the
diarrhea generally requires drinking locs offluid (to
average person would not sense. It is also notC\\'Or-
compensate for flu id losses); reduced intake of t11e
thy that up to 50% of sufferers report a hiswry of
poorly absorbed substance also is important if
verbal or sexual abuse.
that is a cause. Prompt treatmem- within 24 to
Therapy is individualized and can include a
48 hours- is especially important for infants and
trial of nigh-fiber foods and yogurt as well as
older people, because they are more susceptible to
elimination diets that focus on a\·oiding dairy
the effects of dehydration associated with diarrhea
produces and gas-formmg foods, such as legumes
(see Chapte~ 17 and 18 ). Diarrhea that lasts more
and certain \'egetables (cabbage, beans, and broc-
than 7 days in adults should be
coli ) and fruits (grapes, raisins, cherries, and can -
investigated by a physician because
taloupe). The person should have onl}' moderate
ir can be a symptom of more serious
caftcine intake or eliminate caffeine-containing
intestinal disease, especially if there
foods and beverages altogether. Low-rat and more
is also blood in the feces.
frequent, small meals may help the person since
large meals can trigger contractions of the large
intestine. Other strategics include a reduction in
stress, psychological counseling, antidepressanrs, Gallstones
and other medications, such as diphenoxylatc
tLomotil ), alosctron (Lotroncx), and tegaserod Gallstones arc a major cause of ill-
(Zelnorm). 12 ness and surgery, affecting 10 to
Referral to a registered dietitian can be benefi- 20% of U.S. adults. The stones
cial, because many patients experience imprO\emcm themselves are pieces of solid mate-
with the elimination of specific problem foods, such rial that de,clop in the gallbladder
as gas-forming foods. A good patient/physician when subManccs in the bi lc-
relationship is also important for d1e treatment of primaril}' cholesterol (80% of gallswncs) and bile Gallbladder and gallstones seen oher
irritable bowel syndrome. Although irritable bowel pigments (20%)-form crystal-like particles. Gall- surgical removal from the body. Size
syndrome can be uncomfortable and upsetting, it is stones varr in size and may be as small as a grain of and composition of the stones vory from
essenciall) harmless~ it carries no risk for cancer or sand or as large as a golf ball. one case lo another.
(contimmi)
97
Gallstones are caused by a combination of fac- Sometimes gallstones may make their way out
tors, with excess weight being the primary modifi- of the gallbladder and into the bik ducts. This
able factor, especially in women 20 ro 60 years of blockage of flow can lead to fever, intermittent pain
age.17 Excess bodr weight tends to reduce the in the right upper abdomen, nausea with some
jaundice Yellowish staining of skin, ai110Lmt of bile salrs in bile, resulting in relatively vomiting, and jaundice. A blockage ma)' also inrer-
scleroe of the eyes, and the other tissues more cholesterol in bile. Excess body weight also tere with the flow of digestive enzymes !Tom die
by bile pigments that build up tends to reduce the ability of the gallbladder to pancreas into the small intestine, leading to illflam·
in the blood. empty properly. High blood insulin, which can mation of the pancn:as.
develop from excess body weight, can also increase Surgical removal of the gallbladder is die
the cholesterol content of bile. Other risk fuctors most common method for treating gallstones
include genetic background (e.g. , Native (500,000 surgeries per year in the United States).
Americans), advanced age (> 60 years for both Nonsurgical u-eatmcnts, used only in special situ-
women and men), reduced activity of the gallblad- ations, involve oral therapy with medications that
der (the gallbladder contracts less than normal), dissolve gallstones. This u-catmcnt works best for
altered bile composition (too much cholesterol, small cholesterol gallstones.
bilirubin Bile pigment that is derived roo much bilirubin, or not enough bile salts}, ai1d Prevention of gallstones includes maintaining a
from hemoglobin during destruction of diet (e.g., low-fiber diets). Excess estrogen from heald1y weight and avoiding overweight, especially
red blood cells; it is excreted by the liver pregnancy, hormone replacement therapy, or birth for women. ,'\voiding rapid weight loss (> 3 lb per
into the gallbladder. control pills can lead to gallstones (from increased week), limiting in rake ofanimal protein and focusing
cholesterol levels in bile and decreased gallbladder more on plant protein take, and following a h.igh-
movement). Gallstones also tend to develop in fiber diet can help as weU. Regular physical activity is
people who have diabetes (due to high blood also important. ln addition, moderate cafleine and
insulin and triglycerides) liver cirrhosis, gallbladder alcohol intake confers some protection. 17
infections, and various other diseases. In addition,
gallstones may develop during rapid weight loss or
prolonged fasting; as the liver metabolizes more A Recap
body fut for energy needs, it secretes more choles-
terol into the bile. Overall, typical medical disorders of the Gl tract
Most people with gallstones do not have symp- arise from differences in anacomical features and
toms; stones arc usually detected during an examj- lifestyle babies among individuals. Because of the
nation for another illness. Srmptoms can include importance of various nutrition and lifestyle
intermittent pain in the right upper abdomen, pain habits-such as adequate fiber and fluid intake,
between the shoulder blades or the right shoulder, regular physical activity, not smoking, or not
nausea, or gas and bloating. Attacks may last from abusing NSAID medications-nutrition and
20 co 30 minutes or as long as several hours. Once lifestyle thcrap)' is often effective in treating GI
a true attack occurs, subsequent attacks arc much u·act disorders.
more likely.
98
I The Physiology of Absorption absorption The process by which nutrient

molecules ore absorbed by the GI tract and
Mo'>t nurrienr absorption occurs in Lhc small intestine; rhc stomach and large i111es· enter the bloodstream.
tine parricipate co a minor nrrnt. The small intestine can ultimately ab\orb about 95% short-chain fatty acids Fatty ocids thot contain
of the frmd cnerg~ 1t recei\ e\ in the form of protein, carbohydrate, fat, .md .1lcohol. ln fewer than 6 carbon atoms.
general, only w.ucr, a portion of .ikohol int.ikc, and a ft:,, forms of fats ,ire absorbed
to a significanr c\tcnt b) the stomach. Some minerals, "ater, and short -chain fatty
acids (produced hy bacccri.11 action) arc .ibsorbed in the large intcstinc. 3
The euent .rnd cfticicnc) of .1bsorption in the small intestine arc linked to its incred-
ibk surface area. The \\all of che small inrestim: is folded, and \\'ithin the folds ,ire lin-
gerlikc projections called \illi (Figure 3-13). The "fingers" trap nutrients between each
Figure 3-1 3 I Organization of the small

intestine. The small intestine hos several structural
levels. Because of the folds in the intestinal wall, the
villi "fingers" that project into the intestine, and the
brush border on each absorptive cell that makes up
the villi, the surface area for absorption is up to
600 times that of a simple tube A close-up view of the intestinal villi
poncreos
x~,,_~~--=,........--Epithelium
_.f.:).;..__'-----Submvcoso
,............_Circular muscle
---.- --Longitudinal muscle Blood

capillary
- ----Seroso n 1-- - '--network
·Wll<r-;-,,..r:..,..--lntestinal
glond
other to enhance absorptio n. Each villus " fin ger" is made up of nw11erous absorptive
absorptive cells A class of cells, also called
enlerocyles, that cover the surface of the villi
cells (enterOC)'tes). Each of these cells has a brush border, made up of microvilli and
jfingerlike projections in the small intestine) and covered with glycocalyx. Intestinal enzymes are often found on the glycocalyx. All
participate in nutrient absorption. these folds, fingers, and indentations in the small intestine increase its surface area
600 times beyond that of a simple tu be.5
glycocalyx Projections of proteins on the
microvilli; they contain enzymes to digest
protein and carbohydrate. Absorptive Cells
The absorptive cells of the small intestine lie side by side with mucus-forn1ing goblet
cells as well as endocrine cells that produce hormones and hormonclike substances. All
mucosa Mucous membrane consisting of cells these cells form a principal part of the intestinal mucosa. The absorptive cells are p ro-
and supporting connective tissue. In the duced in o pen-ended pits (called C1)tpts) buried deep in the mucosa of the small intes-
digestive tract there is also a layer of smooth tine. They then migrate from the crypts to the tips of the villi. As the cells migrate,
muscle supporting the mucosa. Mucosa lines they mature, and their absorptive efficiency increases. By the time they reach the tips
cavities that open to the outside of the body, of the villi, however, they have been partiaUy degraded by digestive enzymes and arc
such as the stomach and intestine, and
ready to be slo ughed off. Newly fo rmed absorptive cells constantly migrate from the
generally contains glands that secrete mucus.
crypts to replace dying ones; tl1is replacement takes approximately 2 to 5 days.7 Since
cell production requires a variety of nutrients, groups of cells undergoing const~ult
replacement have a correspondingly enhanced need for nutrients. For this reason, tl1c
small intestine rapidly deteriorates during a nutrient deficiency o r in scmistarvation
even though many of the old cells can be broken down and their compo nents reused .
If a disease causes tl1e villi to lie down, the surface area of tl1e small intestine decreases
Concer treatments often involve the use of and mabbsorption results. T his happens in celiac disease (also called g lutc11-i11dnud
medications (chemotherapy} lo prevenl rapid cnteropath:y). T his disease is caused by an allergic response to a protein called g httcu,
cell produclion and growth. Cancer cells are fow1d in wheat, rye, barley, and buckwheat. T o prevent attacks, any foods derived from
the Intended target. Diarrhea is a common these grains must be avoided .1
side effect of chemotherapy. Why would this
h'!Ppen? Types of Absorption
T he wall of the small intestine absorbs nutrients through various means and proccsst:s
that are illustrated in Figure 3- 14: 18
passive diffusion Absorption that requires • Passive diffusion: When the nutrit:nt concentration is higher in the caviry (lumen)
permeability of the substance through the wall of the small intestine than in the absorptive cells, the difference in nutrient con et~n
of the small intestine and a concentration tration drives d1e nutrient into d1e absorptive cells by diffusion. Passive diffusion
gradient higher in the intestinal contents than in aUows for the absorption of fats, water, and some minerals.
the absorptive cell.
lumen The inside of a tube, such as the inside

cavity of the GI tract.
Figure 3-14 I Nutrient absorption relies on

four major absorptive processes. Passive
diffusion (color green) is simple diffusion of
nutrients across the absorptive cell membranes.
Facilitated diffusion (color blue} uses a carrier
protein to move nutrients down a concentration
gradient. Active absorption (color red) involves a
carrier protein as well as energy to move 0
nutrients (against a concentration gradient} into
absorptive cells. Phogocytosis and pinocytosis Interior of
(color orange) ore Forms of active transport in absorptive cell
which the absorptive cell (yellow} membrane
engulfs a nutrient to bring it into the cell.
• Facilitated diffusion: A difference in concena-arion is not enough ro d rive •lbsorp-

facilitated diffusion Absorption in which o
rion of some nutrients into the absorptin: ct:lls by diffusion alone. Sometimes car- carrier shuttles substances into the absorptive
rier proteins or other processes are required for absorption. Fructose is one exam - cell but no energy is expended. A
ple of a compou nd that m akes use of faci litated diffusion. concentration gradient higher in the intestinal
• Active absorption: In addition to the need for a carrier prorei11, some nutrients also contents than in the absorptive cell drives the
require cnerg)' input to move from the lumen of the smaU intestine into the absorp- absorption.
tive cells. Th.is mechanism makes it possible for cells to cake up mmicms even when
active absorption Absorption using a carrier
they are conswued in low conceno-arions. Some sugars, such as glucose, :ire actively
and expending ATP energy. In this way the
absorbed, as axe amino acids. absorptive cell con absorb nutrients, such as
• Phagocytosis and pinocytosis: In a Fu rthe r means of active abso rption , absorptive glucose, against o concentration gradient.
cells literally engulf compounds (phagocytosis) or liquids (pinocytosis ). In tht:se
processes a cell membrane forms an indentation of irsdf so that when particles or endocytosis (phagocytosis/pinocytosis) Forms
Ouids 1110\'C into the indentation, the cell membrane su rrounds and engultS them. of active absorption in which the absorptive cell
forms on indentation in its membrane, and
This process is especi;tlly used when a breastfeeding infant absorbs immune sub-
particles (phagocytosis) or Auids (pinocylosis)
stances from human milk.
entering the indentation ore then engulfed by
the cell.
Portal and Lymphatic Circulation in Absorption
The villi in the intestint: are di-ained by rn o different sets of vessels, portal and lymphatic
(Figure 3-15 ). The nutrii:nts fo llow one of thi:se systems for absorption based on solu-
bility in either ( 1) water or (2) organic soh-ents, such as chloroform and benzene. The::
ourrienrs tl1at are soluble in water (proteins, carbohydrates, short- ru1d medium-chain medium-chain fatty acids A fatly acid thol
fatty acids, B vitamins, and vitamin C) are absorbed in to the blood. Blood leaves the contains 6 lo 10 carbons. Short-chain folly
heart \'ia the aneries, travels to the small intestine, and eventually ends up a t the capil- acids contain fewer than 6 carbons.
bry beds inside the villi (review Figmc 3-15 ).3 The blood exits the capillary beds and portal vein A large vein leaving from the
collects in a large portaJ vein, which leads djrectly to the liver. Tbjs direct path enables intestine and stomach that connects to the liver.
the liver to process absorbed mmients before tl1ey enter tbt: genera.I circulation. Blood
flow used for portal absorption accounts for 30% of the heart's total output. lymphatic system A system of vessels that con
The lymph atic system also drains the vill i. T he lymphatic vessels carry particles that accept fluid surrounding cells and large
particles, such as products of fat absorption.
are either fat soluble ( long-chain fatty acids and the far-so luble vitamins A, D, E, and
This lymph Auid eventually passes into the
K) or too large to pass through the capillaries into the bloodstream (large proreins that
bloodstream via the lymphatic system.
escape from the bloodstream and chylomicrons that fo rm after the absorption of fat) .3
Substances ar e squeezed through the spongelike vessels of che lympharic system by mus- chylomicron Lipoprotein mode of dietary fa ts
cular activity (see Figure C-5 in Appendix C). The lymphatic vessels from the intestine that ore surrounded by o shell of cholesterol,
drnin into the thoracic d uct, which stretche!.. from the abdomen co the neck. This duct phospholipids, ond protein. Chylomicrons ore
is connected to tl1e bloodsu·eam via a large vein near tl1e neck, tl1e left: subclavian vein. 5 formed in the absorptive cells (enterocytes) in
the smoll intestine after fat absorption and
travel through the lymphatic system to the
Enterohepatic Circulation bloodstream.
During meals, bile ci rculates through the liver to the ga llbladder, tlu·ougb c:be small enterohepotic circulation A continual recycling
inn.:stinc into the portal vein, and then returns to the liver. This recycling is called of compounds between the small intestine and
enterohepatic circulation (Figure 3-16). Approximately 98% of die bi le is recycled; the liver; bile acids ore one example of a
only 1 to 2% is removed from the body by elimination in the fcces .3 (Sec Chapter 6 for recycled compound.
a practical application of the knowledge of this process, employed by a class of blood
cholesterol-lowering medications ai1d certain brands of margarine and salad dressings.)
ft. '-<"
Concept I Check The medical history of a young girl who is
The smaJI intestine is the major site tor absorption. Numerous folds and fmgcrlike projec- greatly underweight shows that she had three-
tions increase the surface area to 600 times that of a simple rnbc. This pro\'idcs a large area quarlers of her small intestine removed after
for nurrient absorption. Absorptive cells haw a life span of 2 to 5 days, so the lining of the she was in;ured in a car accident. Explain how
small intestine is constantly being renewed . These cells perform passive diffusion, promoted this accounts for her underweight condition,
by a concentration gradient; facilitated diffusion, promoted by a concentration t,rradienc even though her medical char/ shows that she
plus a carrier; and active absorption, which uses energy in addition to :t carril.!r to work eats well.
agaimt a concentration gradient. AbsorptiYe cells also engulf compounds and liqu ids via
Right side of the heort occepts

oxygen-depleted venous blood
thot hos already circulated to
body cells
Leh side of the heart receives

oxygen-rich blood from the
lungs.
Fl Blood is pumped out of right
side of the heart to lungs.
D Oxygenated blood from the leh

EJ Gas exchange tokes place in the
side of the heart is destined for
body cells.
lungs. Blood picks up oxygen ond
releases carbon dioxide.
Blood reaching the small intestine

supplies oxygen ond nutrients to
cell; olso picks up nutrients from
digestion of food.
Nutrient-rich venous blood leaves

the small intestine ond travels via
a portal vein to liver.
Near the small intestine, lymph

vessels pick up fats. Lymph is
eventually returned to the blood.
When blood reaches the kidney,

waste products, excess nutrients,
ond water ore removed. The
removed substances ore excreted
via urine. Filtered blood returns
bock into circulation.
Copillories
Figure 3~15 I Blood circulation through the body. This figure shows the paths that blood takes from the heart to the lungs (1-3), back to the heart (4), and
through the rest of the body (5-9). The reddish-orange color indicates blood that is richer in oxygen; blue is for blood carrying more carbon dioxide. Keep in
mind that arteries and veins go to all ports of the body. Pay particular attention to sites 7 and 8. These sites are key parts of the process of nutrient absorption.
cndocytosis (phagocyrosis/pinocrrosis). The products of absorpcion, if water soluble, pass

into the portal \•ein thar dr:i.in~ the intestine and enter tbc li\'er. The products of fut diges-
tion mostlv enter the lymphatic system and then !.he bloodstream. Some participants in
digestion, such as bile, arc reabsorbed after use in the small intestine and returned to tl1e
liver, to be sent back again to the small intestine during another round of digcscion. Thi~
circula[ion is called entm1/Jcpntic cimt!ntitm.
Figure 3 · 16 I Enterohepolic circulation. To

E Gallbladder view this circulation, start at the liver. It secretes
substances, such os bile acids, that collect in
the gallbladder. The gallbladder empties these
0 liver substances into the small intestine. There, some
of the substances ore then absorbed by the
small intestine ond returned to the liver through
a portal vein. In this way some substances,
such os bile acids, con be recycled by the liver
for reuse.
Absorption Is Completed in the La rge Intestine

The small intestine is responsible for about 90% of the water absorbed from the GI
tract (Figure 3-17). This absorption reduces the lO liters (L) the GL tract receives
(3 L of dietary fluid pins 7 L of GI tract secretions) to abour 1.5 L. The remnants of
digestion d1at enter the large intestine are the remaining water, some minerals, and
undigested food fibers and starches. Only a minor amount (5%) of carbohydrate, pro-
tein, and fat escapes absorption in the smaU intestine. 3
The large intestine absorbs prin1arily sodium and potassium, along with some water,
leaving very little water w1absorbed (Figure 3-18 ). This absorption occW's mostly in the
first half of the large intestine. Short-chain fatty acids made from botl1 the bacterial
fermentation of some plant fibers and undigested starches are also absorbed in the large fermentation The metabolism, without the use
intestine, along with some vitamins synthesized by bacteria, such as vitamin Kand biotin. of oxygen, of carbohydra tes to alcohols, acids,
Dr. Steve Hertzler discusses the latest findings on the effects of this bacterial action in me and carbon dioxide.
Expert Opinion on probiotics.7· 16 By the time the contents of the large intestine pass
through the first rwo-thirds of its lengtl1, a semisolid mass is formed. This mass remains
in the large intestine until peristaltic waves and mass mo\'ements push it into the rectum
for elimination through the anus (Table 3-5). 5
Table 3·5 I A Summary of Digestion Functions, Organ by Organ

Organ Functions
Mouth Chewing of food
Some digestion of starch
Esophagus Possogewoy
Stomach Food storage; acidity kills bocterio
Some digestion of protein
Small intestine Final digestion of ell energy-yielding nutrients
Absorption of nutrients
Lorge intestine Absorption of water and some minerals; storage of nondigestible remains
Anus Elimination of waste os feces
liver Production of bile
Goll bladder Storage and release of bile
Pancreas Production and release of enzymes and bicarbonate into the small intestine
Organ Prima ry Nutrients Absorbed

D Stomach Alcohol
(20% of total)
Water (minor amount)
EJ Small Intestine Calcium, magnesium, iron, and other minerals
Glucose
Amino ocids
Fats
Vitamins
Water (70% lo 90% of total)
Alcohol (80% of total)
Bile acids
EJ Lorge Intestine Sodium
Potassium
Some fatty acids
Gases
Water (10% to 30% of total)
Figure 3· 1 7 I Major sites of absorption along the GI tract. Note that some absorption of vitamin K and biotin tokes place in th e large intestine. All nutrients
except most of those that ore fat soluble travel through the portal vein to the liver ofter their absorption.
The presence of feces u1 the rectum powerfully stimulates defecation. This process
i1wolvcs muscular reflexes in the sigmoid colon and rectum as well as relaxation of the
two anal sphincters (one internal and one external; only the external sphincter is under
voluntary control). The feces primarily consist of indigestible plant fibers, tough con-
nective tissue from animal foods, and bacteria from the large uitescine. 7
Storage Capabilities of the Body

The human body must mamtain reserves of nutrients. Otherwise, we would need ro
N utrient intake also directly inAuences nutri·
ent absorption. For example, vitamin C in
a meal increases iron absorption in the some
eat continuously. Storage capacity varies for each nutrient. Most fat is stored at sites
designed specifically for this-adipose tissue. Short-term storage of carbohydrate
meal because it changes iron into o more occurs m muscle and liver, and the blood maintains a small reserve of glucose and
absorbable stole. amino acids. Many vitamins and minerals are stored in the liver, while other nutrient
stores ru·e found at other sites in tl1e body. 18
When people do not meet their nutrient needs, some nutrients arc obtained by
breaking down a tissue that contains high concentrations of the nutrient. Calcium is
taken from bone and protein is taken from muscle. These nutrient losses in cases of
long-term deficient.)' harm these tissues.
Many people believe that if too much of a nutrient is obtained-for example, from
a vitamin or mineral supplement-only what is needed is stored and the rest is excreted
www.mhhe.com/wardlawpers7 1 OS
Fluid Ingestion
(3 l)
--+ Figure 3· 1 8 I Fluid volumes in the GI trocl.
The body primarily relies on the small intestine lo
Solivory gland secretions absorb the fluid that enters the GI tract from
(ll) ingestion and various secreti ons.
Gastric
secretions
(2 l)
Pancreatic
secretions
(1.2 l)
90% of Auid
absorbed in the
Small intestine small intestine
secretions
(2 L)
9% of Auid
absorbed in the
large intestine
Ingestion or
secretion
~
1% of Auid in
Absorption
feces
by the body. This is true for many vitamins and minerals. However, large dosages of
vitamin A can cause harmfol side effects because it is not readily cxcrcred. This is one
reason why obtaining your nutrients primarily (or exclusively) from a balanced diet,
rather than relying on supplements, is the safesr means m acquire the building blocks
you need to maintain good health.
This review of human anatomy and physjolOb'Y !Tom a digestion and absorption per-
spective sets the stage for a more detailed tmdcrstandfog of tbe nutrients. Chapters 5,
6, and 7 will build on this information .
Concept I Check
Some water and mineral absorption occurs in lhc.: large intestine. The remaining contents
fom1 the teccs, which consist primarily of indigestible planr fibers, tough connective tis-
sue from animal foods, and bacteria. Nutrients arc consranrly present in the blood for
immediate use and arc stored to a greater or lesser extent in body tissues for later use
when sufficient amounts from food imakc an: unavailable. However, when the body suf-
fers a nutrient deficiency caused by an inadequate diet, it breaks down vital tissues for
their nutrients, which can lead to ill health. Additionally, too much of any nutrient can The skeletal system provides o reserve of calcium for
be detrimental. It's best to focus primarily (or exclusively) on obrnining all essential day-to-day needs when dietary intake is inadequate.
nutrients from a balanced diet. Long-term use of lhis reserve, however, reduces bone
strength.
Expert Opinion i
Probiotics and Human Health

Steve Hertzler, Ph.D., R.D.
The Bacteria Down Below trointestinol tract. Thi s approach required meticulous laboratory testing of
many bacterial strains using in vitro (i.e., test tube) systems that can only
How much do you weigh? Hove you ever slopped to think that a full 1.25 kg
roug hly approximate actual condi tions inside the body.
(almost 3 lb) of your body weight is mode up of microorganisms? There
ore about 100 trillion microbial cells in the body, on amount that is 10
times larger than the number of human cells. The vast majority of these Probiotics a nd the Gastrointestinal Tract
cells exist in the gastrointestinal tract, mainly in the colon. On a doily
Despite the challenges associated w ith probiotic survival, the evidence for
basis, these microbes perform many metabolic func tions, some of them
the health benefits of certain probiotics continues to accumulate, espe-
beneficial to our health and some that ore potentially damaging . Striking
cially for conditions of the gastrointestinal tract. For example, the use of
on appropriate balance between a healthy and unhealthy intestinal
probiotics to reduce the colonization of the stomach by Helicobacter
microfloro is becoming increasingly recognized as on important con-
pylori, the main causative agent of stomach ulcers, is one promising
tributor to overall health. Probiotics ore one such strategy for maintaining
approach. Several Lactobacillus strains hove been shown to be inhibitory
this balance. (A related term is prebiotics. These compounds stimulate the
toward the growth of H. pylori, both in a test tube and in experimental
growth of bacteria in the colon [e.g., fructooligosocchorides]) .
animals (mice). However, studies in humans hove shown only limiled or
The soles of probiolics in the United Stoles hove increased by 19% annu-
no success of probiotics, and probiotics hove never been as effective as
ally for the last two years, with estimated soles of $764 million for 2005
medical treatments for eradication of this organism. Some studies suggest
(includes yogurts and cultured drinks). Are probiolics worth this kind of
that it may toke up to 18 weeks of probiolic administration for beneficial
investment?
effects to be observed.
It appears that probiotics ore particularly important for helping to main-
tain the integrity of the intestinal wall, which serves as a barrier to incom-
Probiotics: A Definition
ing disease-causing microorganisms and toxins. This benefit is likely the
Probiotics, a phrase that originated in Greek as "for life," ore defined by the result of the interaction between probiolic bacteria and immune cells found
World Health Organization as " live microorganisms which, when adminis- in the wall of the intestine. Such on interaction con reduce inflammation,
tered in adequate amounts, confer a health benefit on the host." Thus, the a key factor in diseases such as Crohn's disease and ulcerative colitis.
probiotic approach involves the feeding of live bacterial cells, mainly lactic There ore exciting new findings that o type of E. coli (the Nissie 1917
acid-producing bacteria (e.g., the Laclobacil/us or Bifidobaclerium genera), strain) given daily for 1 year was just as effective as a standard medica-
in foods or as dietary supplements. Numerous studies hove shown that lac- tion (mesolozine) in maintaining the remission of ulcerative colitis. The spe-
tic acid produced by these organisms tends lo inhibit the growth of less ocid- cific type of E. coli used in this study is safe and hod no greater side effects
tolerant organisms such as Escherichia coli and the genus Clostridium that than mesolazine treatment. Further, o new study suggests that probiotics,
ore generally regarded as harmful. the Bifidobacterium infontis 35624 strain in particular, may be effective in
reducing the symptoms of irritable bowel syndrome by limiting a tendency
toward inflammation.
Challenges for Probiotics in the Body Finally, some of the strongest evidence for probiol ics relates to the
Key requirements for the successful use of probiolics are the survival of the prevention and treatment of several types of diarrhea, including trav-
probiolic organism as it makes its way through the gastrointestinal tract and eler's diarrhea, relapsing Clostridium difficile-induced enteritis and diar-
the subsequent colonization of the organism in the gut. The hurdles that pro- rhea, rotovirus diarrhea in infants, ontibiolic-ossocioled diarrhea, and
biotic bacteria face include destruction by stomach or bile acids and com- diarrhea associated with lube Feedings in hospitalized patients. A meto-
petition with other bacteria in the colon. One method for overcoming this onalysis (summary of several studies grouped together) of 9 studies
problem is the selection of probiotic bacteria that are highly resistant to stom- showed a 61 lo 66% reduction in the risk of antibiotic-associated diar-
ach and bile acids and that also possess the ability lo colonize the gos- rhea when probiotics were given concurrently. Probiotic organisms used
www.mhhe.com/wa rdlaw pe rs7 107
Probiotics and Allergy

Because of the involvement of probiotics in immune responses, there hos
recently been great interest in whether probiotics may lessen the chances
of allergies to foods or other substances. The exposure of infants to the
probiotic Loctobacillus GG a t the time near birth reduces by 50% the
number of coses of otopic eczema (skin rash due to allergy) at the age
of 2 years. Further, a recent study suggests that this benefit is maintained
up to the age of 4. It is unclear yet whether probiotics hove on effect on
respiratory allergic diseases that develop later in life. However, in this
recent study, the excretion of lower levels of nitric oxide in the breath of
children exposed to probiotics suggests that the placebo group may
hove hod more underdiognosed or subclinicol respiratory allergic
diseases.
Probiotics: The Advantages

and Disadvantages
The research literature on probiotics hos expanded greatly in recent years
and covers many more conditions than hove been mentioned in this fea-
ture. Probiotics may be involved in the prevention of various infections
(e.g., yeast infections). may help lo lower blood cholesterol and blood
pressure, and may be involved to some degree in cancer prevention . In
addition, probiotics ore relatively inexpensive (a month' s supply of
Yogurt is a convenient source of probiotic bacteria for your diel. These Loctobocillus GG, sold under the brand name Culturelle, costs only about
bacteria conlribute to GI tract health. $20) . So, what ore the potential downsides of probiotics? First, many of
the probiotic bacterial strains used in research are not available to the gen·
erol public. Second, because probiolics ore typically classified as dietary
supplements in the United Stoles, they are not subject to strict reg ulation by
FDA for product quality, effi cacy, and safety in the same way that phar-
maceuticals ore. Thus, "the buyer beware" attitude still applies to most
for the prevention and trea tment o f diarrhea include Lactobacillus rham-
probiotic supplements on the morkel. Clearly, ihe future for probiotics is
nosus GG, Saccharomyces boulardii, Enterococcus Faecium SF68,
Bifidobacterium bifidum, and Streptococcus ihermophilus. In addition to bright, but much work needs to be done to ensure that consumers con pur-
the prevention of diarrhea caused by pa thogenic microgonisms, diar- chase reliable and effective products.
rhea caused by lactose intolerance con be reduced as well. Previous
studies hove clearly shown that fermented dairy foods such as yogurt,
which contain live cultures, con improve lactose digestion in the small Dr. Hertzler is currenlly Assistant Professor of Human Nutrition al The
intestine. My laboratory hos demonstrated that kefir, o type of fermented Ohio State University. He earned his Ph.D. in human nulrifion from
milk that is like a drinkable yogurt, improves lactose digestion similarly The University of Minnesota in 1995 and studies carbohydrate
to yogurl. metabolism, glycemic index, lactose intolerance, and probiotics.
I ----- -- - - - - -. ------_-_ - -
Summary
l. The basic structural unit of the human body is the cdl. Cellular far digestion is S}'nthesized by the liver, stored in rhe gall bladder,
scrucmrc varie!. accoriling ro the type of job rhe cell must perform. and re leased in digestion.
2. Cells join together to make up tissues; tissues unite ro form 8. The major absorptive sites an: fingerlike projections in the small
organs; and organs work together as an organ system. incestine called Pilli. The absorptive cells that cover rhe \•illi arc
3. The gascroinrcstLnal (GI) tract con.~ists of the mouth, esophagus, replaced every 2 to 5 days. Thus the inceslinal Lining continua.Hy
stomach, small inrestine, large imestinc (colon), rectwn, and anus. renews irsclf. Absorptive cells can perform passive diffusion, facil -
Most absorption of 1mtriems occurs in the small intestine. itated diffusion, and acrive absorption, a.s well as endocyrosis
4. The salivary glands, Liver, gallbladder, and 1xuKrcas participate in (phagoq•tosis/pinocyrosis), a specific type of active absorption.
digestion and absorption. Products from the last three organs 9. Water-soJuble compounds in the absorptive cells, such as glucose
emcr the smalJ intestine where enzymes and bile play important and amino acids, enter the portal vein drnt dra.Lns the intestine and
roles in digesting protein, fut, and carbohydrates. travel to the liver. Pat-soluble compOLtnds enter die lymphatic sys-
5. The GI tract cont.1ins valves (sph incters) d1at control the flow of tem, which evenrually connects co the bloodstream. Some sub-
food. Muscular conn-actions, called peristalsis, propel the food srances used in digestion, sucb as bile, are absorbed by the small
down the Gl tract. Segmentation contractions mechanically break intestine, sent back to the liver through the portal vein, and
down and mix the intestinal contents. Nerves, hormones, a.nd hor· released into d1e small intestine again to act in furd1er digestion oF
monelike compounds control the activity of the sphincters and food. This rccyding is called enterohepatic circulation.
peristaltic and segmencation processes. LO. Final water and mineral absorption, as well as absorption of prod-
6. The mouth chews food to break it into smaller parts, increasing its ucts from bacterial metabolism of some plant fibers, occurs in the
surface area, which enhances enzyme activity. Some starch diges- large intestine. 01lCe the feces enter the rectum, the imperus for
tion occurs in the mouth. Protein digestion begins in the stomach. elimination is strong.
Carbohydrate and protein digestion arc finished in the sma.ll intes- I l. Limited stores of nutrie nts are prcsenr in rhe blood for immediate
tine, where fat digestion begins in earnest and is completed. Some use and stored ro a greater or lesser extent in body tissues for later
plant fibers are digested by the bacteria present in the l ~u·ge intes- use when sufficient food is unavailable. When the body suffers .i
tine; widigcsted phu1r fibers exit the body in the feces. n11triclll deficiency it breaks d own vital tissues for their nutrients,
7. Digestive cnzvmcs are secreted by the mouth, stomach, pancreas, which can lead to ill hcald1. Additionally, roo much of any nutri-
and cells forming the wall of tbe smaJJ Lntestinc. Bile needed for ent can be detrimental.
Study Questions
1. ldentif)1 at le<tSt one cona'ibution to overall nutrition sratus pro- 9. How is blood routed through the digestive system? Which nutri·
vided by each of the 12 organ systems of the body. enrs encer die bloodstream di rccdy? Which nutrients arc first
2. Conrrast passive diffusion and active absorption. Indicate die role absorbed Lllto the lymph?
of ATP, if a.ny. 10. The body l1as the ability to recyde some substances. How is chis
3. Outline rhe possible resu.lcs on digestion and absorption of a dis- true for d1c digestive tract?
eased pancreas.
4. Describe why the small intestine is better suited than the other GI
tract organs to carq• out the absorptive process.
5. Ldentit)• the C\\'O organs rhat empty their contents imo the small
BOOST YOUR STUDY
inrestine. How do d1e digestive substances made b)' t hese organs
contribute to the digestion of food? Check out the Perspectives in Nutrition: Online Learning
6. Where is hydrochloric acid (HCI) secreted, and how is its produc· Center www.mhhe.com/ wardlawpers7 for quizzes, flash
tion regulated? What are irs roles in digestion? cords, activities, and web links designed to further help you learn
7. Describe the actions of the digestive hormones. about issues surrounding human digestion and absorption.
8. Describe the actions of the digestive enzymes and explain how
they function in digestion.
Again~t the grain: Who needs to a\'Oid whe.it? 7. Gropper SS and others: Ad\';'lnced nutriLion and cn11m: Erndicntim111f rhis 111z1n11i1111 is i111por·
C011mm1•r lfr/111rts 1111 1-li:nlt/J, p. 10, July 200S. human 111ct.1bolism. 4th ed. Belmont, CA: tnnt fol' ulcer /Jcnli11_n n11d rcducin..IJ the l'isk 1f
Altbo11g/J n btg/J-jibcr dfrr fends ro 1mm_v /Jrnlth ·n1om~on Wadsw(lrth, 2005. ulcer reocmrrwcc. Gc11crnlZv n t11•11·11•c«k fttTiod
benefits, wi11g 1Pbcnt products t11 ncbin•.: mch n CJmptt'I' 2 ofrbis rcxrbook pr11J1idcs n demiltd of nmiliiorics nud ncid mpprrs.rio11 i.r e111pftlyed.
llllfll is /Jnn11f11/ for people 111it/J cclinr disrnse. Ir dtscrip1irm of the d(ncstfrr procrssc.r 11f llJ1• h11111n11 Follow-up resting wit/J n1111lysis uf b1mtb or.fi:cal
i.s cspccinlZ1• 1111ponn11t tbnt people w/u1 cxpcri· body. !:>t11dcms sccki11g more dmiils nb1111T 1figt'S· snmpU:s is rcrnmmmdcd for proplr: wlJ11 dfJ 11ot
mer jl11sbi11.!J, zrrbing, biJ>cs, 1111111iti11g, or tio11 nm{ nbs111prio11 will find this rhnpw· /Jdpful. respond to tbl'l'nP.v.
lnm1/Ji11_r1 difjiculrics ll'it/Jin nvo IJOtm ofc11ri11g 8. Hcidclb:iugh IJ and mhcrs: Management of H. Muller-Lisser SA :md other., J\lyths and mis·
111/J.:nr be tesrcd .for tbc disense. 171e article dis· gastrocsophagc.11 reflux disease. A 111rrirn11 concc:piion& :iliom wn~rip:nion. Amencn11
rnssa 111rrh11d1 uf dingnosis nnd trcntmwr for Fnmily P/J_vsicum 68:13 1l,2003. }011rnnl 11f Gnstrocntm1!ogy l 00:232, 2005.
reline disensc. Jr ts i111por11mr to n·mt n:tmring bttll'rb111·11 bw·en,·i11..1J fibe1· i111nkr n11d nt>o1di1t11 dd~l'drn·
2. Baum C .rnd other~: Gasrrointcsrinal disease:. ln bernust' it cn11 lrnd m n fiwm 11f'<sopbngcnl cmtcct: tio11 oftm /Jc!ps i11 mild cns1·s oj'comtipfltio11.
Bowman BA, Russell RM (eds. ): Prcsc11tk11m1•f· Rcd11ci11g tb.- size 11f111cnls n11d dc11flli1tl) th1: hmd Move dijJiwlr cases require fl cnr~fitl pl~1•sici1111
t'dflt' i11 1111n-irio11. 8th ed. Washingt0n, DC: 1ift/1.: b1:d arc two lifestyle c1111sidcmrio11s. Acid· &Jlfll11ntio11 nnd Iil1c(r t/Jc use of lnxnth•l'S n11d
lSLI Press, 2001. /Jh1cki11..11111cdirntim1s an- 11c1·y bclpful; typa n11d 11sr otbcr mcdicntitms. Ofrm the lnttcr fl1'C 11cr_v
Difruptim1 i11 1111)' 1111mbcr of the step.< in the ofs11cb wcdicario11s nre S11111111m-i=ed int/Jc nrtidc. /Jdpfttl n11d nre l'cvicwt•d i11 tbt 11 rtic!c.
digcsri11c pmcrss rn11 lend to 111nlnbsorpti1m nnd 9. Kk:in S and others: The JlimcntJrl' tract in 15. Nilsson i\l a11d others: Obc~it)' .md estrogen as
i11 tm·11 to p1·11teiu, e11c1~1J.l', n11d micro1111trie111 nmririon: In Shils 1'vIE and others ( cd~. l: Hcnltb risk factors for gasi:roesophagc:tl reflux symptoms.
d~ficirncics. just ns r/11· GI tmct is esswtinl for n11d dismsc. l 0th ed. Philadelphia, PA: Jo11m11/ (/f rbe A111cricf111 Mcdirnl Ass11cinri1111
1111tri1·111 11tilizn1io11, illlJC.rtcd 1111tric11ts nlso Lippincott. \\lil li.1ms & Wi lkins, 2006. 290:66, 2003.
pln.1•au nelil'<' role i11 111nintniu111ggnm·oin· Obesity is n mnjm· risk fncrm·fiir !Jflstrni11Wti·
n1is c/Jnptc1· is II ffJ>irtt• of t/Je (;j rrntt Sl1'11r·
resrilJnl /Jcnhb 1111d fi111ai1111. 11n/ 1·cjl11:.: discnsc. Prod11crio11 of cst1'0,l)c•1 by
rzll'e. blood mppZ1·. 111:nous SJ'.<tem co1urol. <._;I
3 . Bender DA, Mayes PA: Nurricion, digestion and trnct b111·1111111cs, 1111n·it·11t nbs01·pti1111, i11tcsti1111/ adipose rismc is onr likdy l't'nso11 jlw thr rein·
absorption . In Murray RK :ind ocher<; (eds.): 111icroo1~1Jn11is111s, nnd i11111m111• system. 1711·
tiombip. ll~(iJ/Jt loss reperses the co11ru tf r/Jr dis·
Hni·pcr~< illustmted bwclmmstr.v. 26th ed. New cnse n11d so fr very bmcjicini to these pcrsom.
t't'Sflonse oft/Jc Gl trnct to food is fllso cs:pln in ed.
York: Lange Medical Books/McGr;rn -Hi ll , 16. Sanders ME: l'robioClcs: Considerations for
2003. 10. Le Coutre J: T:isre: the metabolic scn~e. Fuud
human hdth. N11h·iri1111 Re1•icws6 I(3 ):9 l, 200:-l.
'frclmulngy 57(8):34, 2003.
Mo.<1 fnorf..<tujfs i11.natcd nn- illitin.l~r 111111p1iif· Pl'llbiotic mirrom;gn11isms 11u1y piny n11 i111p11r·
17Jr primm·y tn.rtf sc11sflti01u nrt' Sll'tcl, snit, s11111;
nb/c r11 lm111nns: rbc_y mn11111 be nbsorbcd by th" rn11t rn!c in bdpi11g t/Jt {1111~,, pl'llttrt itsdffh1111
nnd /Jitfl'I: U111nmi ro1mds 11111 tbt Ii.rt. Rcs1:nrr/J
di._J]t'.<tii1,. system 1111ril b1'11km do11111 i11to Jlllflll&r i11fcrrio11, cspccinlZl' rhn r w/Jic/1 fl rises 11/or1!1 tbt·
into tbr use of rbis k110111/ed.1Jc ofrnsrc pc1wprim1
molccult:s. 171is chflptr1· prOJ11des n elem· sup·IJ_v· i11tcri11r smfnres 11fthe gnsrl'IJil11csti11nl trncr. Ju
tn i111pr111•1· 1/Je rnstc o.fsome' ji11Jds is 1111g11ili_JJ.
step dae1·iptii111 11f thi; digcsti1111 nnd subscq11wt Nortb A11w·icn f1111d.r m1·1~·11tZ)• co11rai11i11f1 pro·
nbsm·prion. 11. Li<:bm:in B: Who you gomi:i .:am Ga:.hu~rcrs.
biotia nl'e ,·.w/usit1d)• dnir_v prod11crs, mr/J ns
N11triti1111 Action Henlrblcrm; p. 1, May 2003.
-!. Dc\'aulr KR: c.;astrocsoplugcal rcllux: i\lcdkal ,r11..1)111·1, .rome Jim11s 11f 111ill.', s11111r Ji1r111s 1if r11ttngt
TJ;fr article focuses on nu i11tcn•u11• ll'itb D1: cheese, 1111d 11 fell' otbcr pl'ad11ctJ.
and surg.ical oprions. A111ericn11 Family Ph_vsicin11
68:1271, 2003. .llichad Lc1•itt, n noted expcn mi intc.rri11nl gn.r.
17. Schardr D: Not c\'crybody must get stones. •V11·
C1111sc.< 1111d trent111c11tf(JI· u11cm11f11rtnbk cnscs
Mtdicnri1111.r .rttcb ns prorn11 p11111p i11/Jibit01:; nr.- tri1io11 Actio11 Hcnfl/JletrL·1; p. 8. November 2004.
nrc rr1•icn•cd, mch ns th1· possil11f link ro laccosi·
bdpjitl i11 rrmti11.1J g11strocs11plmgml reflux dis· E.wcs.s body ll'cight is r/Jr pri111111'_1' modijinbfr ri.1k
111111rfi._11<'slirm, sorbitol i11tnkt·. fllld c1msu111p1i1111
msc. 171e sm;,nicfll n·cntmc11rs nrc much 11111rc jhcrorfo1· de1>elopi11g gnllbllldde1· sto1w. l.oll'·
of bi:m1s n11d 11nriom 11(1/'etnblc.r. Some people 1rrc
risky, n 11d so 11.rc 11111st be cn1·i:f11IZ1• cmuidi'/'cd. fiber diets nr<' nls11 implicated.
!J11t/Jtrcd 11111rc l~v this gas prod 11ctio11 tbn 11 others;
5. G:mong \VF: Rn•frtt• of wcdirnl physiolog_v. 25th so1111· pc11plc «xpcricm:eftw or 110 sy111{1tm11sfhm1 18. Seeley RR and orhcrs: A11ntomy n11d plJ.i•siology.
ed. New York: Lmge J\lcdical Books/McGraw· dn i~v ..nn.r pnid11crio11. 7th ed. Boston: McGraw-Hill, 2006.
Hill, 2001. 12. ~ lc rt7 HR: lrritJblc bowel disc:1sc. F/Jc Nt'll' 171is rc.>:t pnn•idcs C111nprc/JmsiJ>c C//VCl'flfll' elf the
171i.r rc.\·t is fl/I excel/mt raourcc for !cnmi11.1J E11gln11d ]111mrnl of1\frdiciut' 349:2136, 2003. nnnt11111y nnd pbysiology of tl1cgnm·oi11tcsrhml
11101·t nbo/lf di._l)rstio11 n111{ nbsv1·ptio11. Spuiftc 171e most c11m111011 sy111p1nm.< of in'itnblc botl'cl tmct ns 111cl! ns ot/gr rdntcd b(}(('I .rystmu.
c/Jnptt·rs l'<ftr m thclrmcml process of digmirm sy11drm11e i11c/11dt' n cb1111g« 111 th<' nppi:nm11cc or 19. Smil'h L: Updated ACG guidelines for diagno·
nud nl1sorptio11 nr wdl ns n:g11lntio11 ofgnm·oi11· jh·q11m0· ~f'st1111ls, n11d nbdl)111i11nl pni11 rbr11 is sis and treatment of GERD. A111C1·icn11 Fn111i~,.
rcsti1111! ji111ctim1. rdicJ>fd by dcfi'cntio11. Affatcd pC11plc s/Jo11ld Phyricin11 71 :2376, 2005.
6 . Granncr DK: Hormones of the paurn.·a, and cspcrinlly suk mrdicnl bdp if w.:igbt loss, GI 17;e nrtictr 011rti11cs t/Jc din,1)1101ir n11d rr.:nt111w1
g:isrroimcstm:tl tract. In 1\lurray RK :r.nd oi:hcrs rmct blading, fi't>t1·, or frequent 11[1Jbrti111c of GERD. T/Jc n11t'1on s1i.t1_1wsr tlmt simple diet
{cd~. ): Hntpcr's biuc/Jcmim'_v. 25th ed. Sr:imford, J~·111ptn111s fire presc11t. 111 some cn.ra mcrmsing mid lifcstylr cbn11..1Jcs, mch ns ni•nidhtl) /J1gb-fnr
CT: Appkton & Lang:c, 2000. film· in milt· is bdpf11/. R1:g11lnr .vogurt c011rn111p· menls 1111d nor ~1·i11g du11•11 1111111cdirru~1· nftxr n
171elfnstroi11rcsri11al rrncr secretes mn11y hor· tio11 wny 11/s11 be bclpf11f brcnusr ir rnu iucrensc men/, cnn help treat t/Jc dfrcflSt' ill m1111y mst'I.
111011.:s, p~rlmps 1111m· rlm11 n11y 11t/Je1' 01:1fn11 sy.r· t/Jc c1mco1tmrirm of bmcficinl rypcs 1~(bnctain 20. The low·d0\111 on hemorrhoids. UC lkrkdey
rem. Gnst1·oi11t.:stinfll hon11011cs n.ssist iu. nfl tbi· tbat rcsidr in the lm;gr. i11tcsti11e. !Ve/bms I.ct/Cl: p. 4, Ju ly, 2004.
ji111ctiom oft/JC GI trnct, inrluding the pro· 13. 1\lcun.:r LN, Bower DJ: Management of Hcmo1'>'buiris nrt com1111111/y cxp~rimced l~l' 111n11y
pdlill..fl 11ffouds111ff's 111 siw of1figcstiu11. proJ>id· 1-Jdimbnrtor py!i1ri infection. Amt'l'icnu Fnmily ndttlrs. lvftnmn:s to rrducr mcl1 nsk rmd fl.r 1J>c//
i11g tlu proper &11P1r1111111rnt fol' digesri11c Pb.'~irin11 65:1327. 2002. n·cnt tbc problem m·r discws.-d, mc/J ns nu nde·
p1·uc.:ssa, n11d 111u1•illg digcstil'e products nrross Hdicobnrrnr pylori is tlu cnme t!f111os1 peptic qunrc fluid n11rffibrr i11rn/1c. Formufltc(v /Jcmor·
tbc i11tcsti11nl m11cosn. ulm· di!i:nst fl 11d is nl.ro n risk j'rut111'f11r .rrnm'ir r/Joids rnrcZv lmd ro srrio111 bm!th problems.
Take I Action ] ,
I. A re You Taking Care of Your Digestive Tract?

All of us need to think about the health al our digestive tracts. There ore symptoms we need to notice as well as habits we need to
practice in order to protect our GI tracts. The following assessment is designed to help you examine habits and symptoms associated
with the health of your digestive tract. The Nutrition Focus in the chapter explained why lhese habits ore important lo examine. Put o Y
in the blank to the left of the question to indicate yes and on N lo indicate no.
1. Are you currently experiencing greater than normal stress and tension?
2. Do you hove o fam ily history of digestive tract problems (e.g., ulcers, hemorrhoids, diverticulosis, constipation, lactose
intolerance)?
3. Do you experience pain in your stomach region about 2 hours ofter you eat?
4. Do you smoke cigarettes?
5. Do you toke aspirin frequently?
6. Do you hove heartburn at least once per week?
7 . Do you commonly lie down ofter eating a large meal?
8. Do you drink alcoholic beverages more lhan two or three limes per day?
9. Do you experience abdominal pain, bloating, and gas about 30 minutes to 2 hours ofter consuming milk products?
l 0. Do you often hove to strain while having o bowel movement?
11. Do you consume less than 9 cups (women) lo 13 cups (men) of a combination of waler and other fluids per day?
12. Do you perform physical activity (e.g., jog, swim, walk briskly, row, stair climb) less than 30 minutes on fewer than
5 days of the week?
13. Do you eat a diet relatively low in fiber (recall that significant fiber is found in whole frui ls, vegetables, legumes, nuts and
seeds, whole-grain breads, and whole-grain cereals)?
14. Do you frequently hove diarrhea?
15. Do you frequently use laxatives or antacids?
Interpretation
Add up the number of yes answers you gave and record the total in the blank lo the right. _ _
If your score is from 8 to 15, your habits and symptoms put you at risk for experiencing future digestive lrocl problems. Toke portic·
ulor note of the habits to which you answered yes. Consider trying to cooperate more with your digestive tract.
II. Investigate Over-the-Count-er Medicatiqns for .Treating Copi'm on

GI Tract Problems
Visit your local pharmacy and check out the medications on sole for treating indigestion, heartburn, constipation, diarrhea, and hemor-
rhoids. Select one category and compare four brands for
,, .... ..
2
1. Price/usual dal ly dose
Active ingredients
..
3 Warning to users ••
4. Advice as to when lo see a physician
Write a critique of your discoveries about these.Products, and summarize what you would say about Jhe..safeJy and efficacy of Jhese
products.
METABOLISM
~
Metabolism: Chemical Reactions in the Body
Anabolic and Catabolic Reactions • Stages of
Ano loves lo eat, and she typically eats large quantities of food ot pizza parties and
family gatherings. However, she doesn't want lo develop a weight problem. Both
=
0
z
Energy Production • Energy for the Cell •
Adenosine Triphosphate (ATP} as on Energy her mother and father ore overweight, and they both have type 2 diabetes. One of "'
Source • Oxidation-Reduction Reactions: Key Ana's friends tells her Iha! she con avoid both overweight and type 2 diabetes while
Processes in Energy Metabolism • The Role of
Enzymes and Vitamins in Oxidation-Reduction eating as much as she wonts as long as she ovoids carbohydrates ond eats a lot of
Reactions high-fat foods. Another friend tells Ano that this is not true. Instead, she should focus
ATP Production
Carbohydrate Metabolism • Glycolysis • on high-protein foods. Then o third friend tells Ana that she can eat as much os she
Transition Reaction • Citric Acid Cycle • The wonts os long as most of each meal is made up of carbohydrates that come from
Electron Transport Chain • Aerobic Respiration
• Glycogen Metabolism • Anaerobic fruits, vegetables, and starches such as posla.
Respiration • Anaerobic Glycalysis • Aerobic All of Ana's friends think they know how each of these energy-yielding nutrients
and Anaerobic Respiration
(fats, proteins, ond carbohydrates) behaves in the body, how each of these nutrients
Expert Opinion: Does a Metabolic Advantage
Exist for the High-Protein Diet? contributes lo the amount of energy she consumes, ond what becomes of that food
Lipolysis: Fat Breakdown energy. The friend who tells Ano lo ovoid carbohydrates lhinks that carbohydrates
Making ATP from Folly Acids • Carbohydrate are more likely lo be converted into body fat compared lo the fol present in food.
Aids Fat Metabolism • Kelogenesis Is
Producing Ketone Bodies from Folly Acids The friend who tells Ana lo focus on eating protein thinks that the body "burns"
Lipogenesis: Building fatty Acids all the energy from protein, and so proteins in the diet cannot contribute lo body fat.
Protein Metabolism By the end of this chapter you will know which of Ana's friends is correct.
Producing Glucose from Amino Acids and
Other Compounds • Gluconeogenesis from
Typical Folly Acids Is Not Possible • Disposing
of Excess Amino Groups from Amino Acid
Metabolism
Whal Happens Where: A Review
Regulating Metabolism
The Liver • Enzymes • Hormones • ATP
Concentrations • Vitamins and Minerals
Fasting and Feasting
Fasting • Feasting
Nutrition Focus: Inborn Errors of Metabolism
Take Action
111
M etabolism refers to the entire network of chemical processes involved in maintaining life. It en-
compasses all the sequences of chemical reactions that occur in the body. These biochemical
reactions enable us to release and use energy from foods, syn-
thesize one substance from another, and prepare waste products
for excretion.2 Although it may seem that on overwhelming num- TO ALLOW YOU TO:
ber of reactions toke place within your body, oil of them con be
1. Define the terms energy metabolism, anabolism, catabolrsm,
categorized as one of two classes. One class puts different mol- aerobic metabolism, and anaerobic metabolism.
ecules together, while the other class tokes molecules apart. 2. Describe aerobic and anaerobic metabolism of glucose with
Reactions that put molecules together require energy. The source reference to lactate production.
of this energy is the energy released when other molecules ore 3. Describe why odenosine triphosphote (ATP) is considered the
energy source of the cell.
broken apart.
4. Outline how the energy potential of glucose, fatty odds, amino
Studying metabolism con help you comprehend o variety of acids, and alcohol is e)(trocted-using metabolic pathways
nutrition concepts. Understanding metabolism clarifies how car- such as glycolysis, the citric acid cycle, and the electron
transport chain-and eventually deposited into ATP.
bohydrates, proteins, fats, and alcohol ore interrelated. You will
see, for example, how the carbons in proteins become the car-
5. Describe the roles vitamins and minerals ploy in energy
metabolism.
bons of glucose, and why the carbons of most fatty acids cannot
6. Explain the origin of C02 and H20 generated by energy
become the carbons of glucose. metabolism.
Studying metabolic pathways in the cell also sets the stage 7. Describe the central role of ocetyl-CoA in cell metabolism
for examining the roles of vitamins and minerals. Many vitamins 8. State the source of ketone bodies and their role in energy
and minerals contribute to the enzyme activity that supports metabolism.
metabolic reactions in the cell. 8 Overoll, the functions of both 9. Describe the fate of energy from mocronulrients during the fed
stole.
mocronutrients and micronutrients will be easier to understand if
10. Describe the fate of energy-yielding substances in the body
you ore familiar with the basic metabolic processes in the cell.
during the fasting state.
11. Briefiy e)(ploin how metabolism is regulated.

STUDY OF METABOLISM IN CHAPTER 4, YOU MAY
WANT TO REVIEW:
Various components of the mocronutrient classes-carbohydrates, proteins, and lipids-in Chapter 1
Basic chemistry concepts in Appendii< A.
The components of the cell and hmclions of various organelles in Appendix C.
Enzyme function and regulation in Chapter 3.
Hormone function in Chapter 3
M etobolism = anabolism + catabolism Metabolism: Chemical Reactions in the Body

As noted in the chapter overview, metabolism refers to d1e entire network of chemi-
caJ processes involved in maintaining life. It encompasses all the sequences of chemical
intennediote A chemical compound formed in reactions that occur in the body. These chemical reactions enable ceJJs to release and
one of many steps in o metabolic pathway. use energy from foods, convert one substance into another, and prepare waste prod-
ucts for excretion. 2
A progression of metabolic chemical reactions from beginning to end is called a
pathway. Compounds formed as the pathway proceeds :ire called intermediates.
V irtually every step in any pathway depends
on an enzyme to initiate the specific chemi-
cal reaction.
112
Anabolic and Catabolic Reactions Proteins

Glycogen
Anabolic pathways build compounds (Figure 4-1 ). Energy must be expended for an- Carbohydrate Triglycerides
Protein and other
abolic processes to take place. For example, to make sucrose {table sugar) plants com- lipids
Fat
bine together the simple sugars glucose and fr uctose.
ANABOLISM
glucose + fructose --=::::::;::: . sucrose
ADP + P; ) A
N
~ )
H 20
A
B
In addition, the ch emical reactions that synd1esize -C- C- bonds (fatty acid synthesis), 0
0 l
II ATP I
-C-N-bonds (protein synthesis), -C-N- bonds (urea synthesis), and -C-O- '-._..--" s
M
bonds2 (triglyceride synmesis) require anabolic energy input (sec Appendix A for de-
tails). The chemical elements and compounds used to for m the new substan ces often Amino acids
are called biiilding blocks. Sugars
Conversely, catabolic pathways break dO\vn compounds into small units. T he su- Fatty acids
Glycerol
crose molecule discussed in the anabolism example will be broken down into glucose
and fructose in the GI tract during digestion. Figure 4 · 1 I Anabolism and Cotobolism.
CATABOLISM Anabolism relies on cotobolism to provide the
glucose + fructose needed energy input from ATP.
sucrose
H?2
Later, d1e complete catabolism of this glucose and fr uctose rcsuJts in the release of car-
bon dioxide (C0 2) and water (H 2 0). Energy is released in me process: some is
trapped for cell use and the rest is lost as heat. Recall fro m Chapter l that cells use this
energy fo r fo ur specific purposes: building compounds, contracting muscles, conduct-
ing nerve impulses, and pumping ions (e .g., across cell men1brancs). 2
Stages of Energy Production

T he production of energy for cell use occurs in three stages. 2 In the first stage, large cids commonly lose o hydrogen ion at the
food molecules, e.g., proteins, are broken down during digestion and absorption into pH found in human cells (pH 7.4). When
smaller units, in this case anlino acids. In the second stage, most of d1ese and other that ion is lost, the name of the acid is changed
smaJJer compounds are further degraded to the two-carbon intermediate com- by dropping the reference lo acid and adding
on ofe ending. Thus, acetic acid become ocefofe.
pow1d acetic acid ( CH3 %-oH), the acid found in vinegar. In the third stage, acetic
acid (termed acetate or an acecyi group when a hydrogen ion is missing) is degraded
to carbon dioxide and water (Figure 4-2). Some of the energy released in this catabolic
process drives the synthesis of adenosine triphosphate (ATP). ATP is energy in a adenosine triphosphate [ATP) The main energy
fo rm that cells use (Figure 4-3a) . Chapter 3 introduced the first stage, digestion and currency for cells. ATP energy is used to
absorptio n. This chapter examines the last two stages. promote ion pumping, enzyme activity, and
muscular contraction.
Energy for the Cell

T he energy that human cells use comes from chemical bonds found bcnveen the atoms
in carbohydrate, fat, pro tein, and aJcoho l. T his energy is o riginaJly placed there d uring
photosynthesis, wben plants use solar energy to make glucose and other organic photosynthesis The process by which plants
(carbon -containi ng) compounds. The ch emical reactions in photosynmcsis form com- use energy from the sun to produce energy-
pounds d1at contain more energy than carbon dioxide and water, the building blocks yielding compounds, such as glucose.
used. Virrually all organisms use the sun-either directly, or indirectly as we do-as
their source of energy (Figme 4-3b ).2
T he by-products of eventual human energy metabolism are carbon dioxide, water,
and heat. OveraJl, chemical energy from ingested food that passes through body cells
is even tuaJly and irretrievably dissipated to the environment as hear.
114 Chapter 4 Metabolism
Catabolism
Stage D
Breakdown of
complex molecules
to their component
building blocks Amino acids Single sugars Fatty acids,
glycerol
Stage ID
Conversion of building
blocks to acetyl-CoA
(or other simple
intermediates)
Stage B
Metabolism of
acetyl·CoA to C02 Citric acid
and formation of ATP cycle
(and Electron
transport chain)
Figure 4 · 2 I Three stages of catabolism (steps 1-31.

respiration The use of oxygen; in the human
organism, the inhalation of oxygen and the
exhalation of carbon dioxide; in cells, the
oxidation (electron removal) of food molecules,
to obtain energy. Thus, in human respiratio n , the starting materials are energy-yielding compounds
such as glucose, which, through an elaborate multistep process, are converted to end
products such as carbon dioxide and water (e.g., C6H 120 6 + 6 0 2 ~ ~ 6 C02 + 6
H.,O). This process results in the [r:mstcr of energy from food to cells, which in turn
o.JJ~ws energy-requiring pathways in cells ro function.3
Many chemicaJ reactions in the body could not occm without the add ition of out-
side energy supplied by food. Outside energy permits compounds, such as some forms
of ami no acids, to be transformed into products such as glucose. And although amino
acids and glucose molecuJes themselves contain the energy needed for synthesis of still
other compounds, rhese and other energy-yielding molecules provide neither the right
amount of energy for a chemical reaction nor a form of energy that ceUs can use di-
rectly. For example, a glucose molecu le contains over 100 times more energy than re-
quired ro facilirarc an individuaJ chemical reaction in a cell. Thus, a cdJ must have a
means of breaking down energy-yielding molecules to release and then convert rhe
chemical energy trapped i.n them into smaller, usable energy forms.2
Adenosine Triphosphate (ATP) as an Energy Source

To release tbe energy in ATP, cells spli t it into adenosine diphosphate (ADP) plus Pi,
a free (inorganic) phosphate group (Figure 4-4). ADP can also be split into adenosinc
monophosphate (A.MP) plus Pi to yield energy, in a reaction muscles are capable of
per forming during intense exercise when ATP is in short supply (ADP + ADP~ ATP
+ AMP). Only energy in ATP and its derivatives can be used directly by the cell.10
Every cell contains catabolic pathways tlrnt release energy to allow ADP to combine
Sunflowers capture solar energy and transfer it with Pi to form ATP. An enzyme later can break the ATP bond to release energy
into chemical energy in the form of protein, needed for anabolic reactions. ATP itself is ,·ery stable. Ir actuaJly rakes an enzyme to
carbohydrate, ond fat in the sunflower seeds. w1lock the energy that is stored in the molecule. lo
Respiration:
ATP
Energy use:
•
• Carbohydrate • Build compounds
• Fat • Move muscles
• Protein • Perform nerve conduction
• (Alcohol) • Pump ions
ADP + P;
EJ
(a ) (b )
Figure 4.3 1Solar energy input and human energy output. (a) ATP synthesis and use. Energy from foods is used to synthesize ATP. The ATP then provides
energy for the cell. (b) The corn plant uses solar energy to synthesize glucose From carbon dioxide and water (step I). We cook and eat the corn (step 2),
transferring much of the energy in the glucose from the corn to ATP energy for our cells lo use (step 3). Eventually, this energy leaves our bodies as heat
(step 4). Some energy may be stored as fat if we overeat, and a small amount is lost in urine and feces.
Energy output to Figure 4 . 4 I ATP stores and yields energy.

perform cell functions ATP is the high-energy slate; ADP is the lower·
energy state. (a) When ATP is broken down to
ATP
t ADP ) + p
ADP plus P;, energy is released for cell use.
When energy is trapped by ADP plus P1, ATP
con be formed. (b) ATP represents a storage
(a )
'
Energy input to allow
for energy storage
form of energy for cell use because it contains
high energy bonds. P; is the abbreviation for on
inorganic phosphate group.
(b)
Adenosine
(adenine + ribase)
Structure of ATP
P,
v
High-energy
bands
During metabolism, a cell is constantly breaking down ATP in one site wh ile re-
building it in another. An exhausted muscle cell has a very high cuncenrrarion of ADP
and a \'cry low concentration of ATP. When this happen~ , muscle cell activity, such as
muscle contraction, m.iy slO\Y down o r cease altogether. A lo" ATP concentration then
stimulates metabolic processes thar produce ATP. Only b} resynthesizing needed ATP
can the muscle cell ready itself for future action. 10
Adenine
High-energy
:id,
0I
phj~phote
0 0
-o-P-0-
II I
P-O-P-O
I
o-
I
o-
I
o-
OH OH
Ribose
The energy used to perform physical activity is

in the form of ATP. Chemical structure of adenosine triphosphote (ATP).
Oxidation·Reduction Reactions: Key Processes

in Energy Metabolism
O xidation-reduction reactions form a vital link between the energy-yielding nurricntl>
and the fo rmation of ATP.
A substance is oxidized when it loses one or more electrons.
A substance is reduced when it gains one or more electrons.
Eleca·on flow governs oxidation-reduction processes. If one substance loses elt:ctrons
(is oxidized), another substance must g;.1in electrons (is reduced). The two proce~scs
go rogcther; one cannot occur withour the other. 8
Consider the oxidation-reduction reaction involving iron:
Fe2+ H Fe3 + + e-
Hcrc, Fe2 + has lost an electron (has been oxidized ) (Fe2+ ~ fe3+ + e- ). AJrernarcly,
N ow that you ore familiar with oxidation
and reduction reactions, you con examine
the term antioxidant. This term is typically
Fe3 + can gain an electron (be reduced ) (Fe3+ + e- ~ Fe2 +). This oxidation and re-
duction of iron occurs during the transport of o.Kygen to body cells.
used to describe a compound that con donate 0Kidation-reduction reactions involving carbon-contain ing compounds are some-
electrons to oxidized compounds, putting them what more difncult to visualize. A simple rule has been developed ro determine
into a more reduced (stable) state. Oxidized oxidation-reduction reactions in these compounds. 1f the compound gains oxygen ur
compounds lend to be highly reactive; they seek loses hyd1·ogcn, it has been oxidized. 1f ir loses oxygen or gains hydrogen, the com-
electrons from other compounds to stabilize their pound has been reduced. T he following process LUustrarcs this definiLion.
chemical configuration. Dietary antioxidants
such as vitamin Edonate electrons to these 0
highly reactive compounds, in turn, putting these ~
oxidized compounds into a less reactive state oxidation
CR 3 -CH 3 CH 3 - CB 2-0H
(see Chapter 9 for details). ethane
4
eth anol
reduction
(
0
2H
0 0 OH 0
II II \......
oxidation I II
CH3-C-c-o- CH3-C-c-o-
pyruvate reduction
I
H
( lactate
28
116
This method of determining oxidation and reduction-determining oxygen and hy-

drogen exchange-is used extensively i.n nutritfon. for example, in rhe reaction illus-
c:rated, pyruvate (made from glucose) is reduced to form lactate by gaining two
hydrogens. Thi.s happens during intense exercise (see Chapter 14). Lactate is oxidized
back to pyruvate by losing two hydrogens.
Scientists generally use the terms oxiti.&itio11 and reduction as verbs or adjectives.
'Vben the terms arc used as verbs, pyruvate is said to be 1·erfoced to lactate, and lactate
is said to be oxidized to pyrurnte. ·when the terms arc used as adjecti,•es, lactate is said
to be the reduced form of pyruvate, whiJc pyruvatc is the oxidized form of lactate.
The Role of Enzymes and Vitamins in Oxidation-Reduction

Reactions
Oxidation-reduction reactions in the body are controlled by enzymes. One important
class of these enzymes, designated dchydrngenascs, removes hydrogens from energy-
yielding nutrients or their breakdown products. These hydrogens are eventual ly do-
nated to the final acceptor, oxygen, ro form water. In the process, large amounts of
energy are transferred to ADP plus Pim make ATP. 2
Two B vitamins, niacin and ribofla,·in, assist dehydrogenase enzymes and, in nun,
play a role in mrnsferring tbe hydrogens from glucose to oxygen in the mcrabolic path-
ways of the cell.ll Niacin functions as the coenzym e named nicotinamide ad enin e coenzyme A compound tha t combines with on
d.inu cleotide (NAD). This oxidized form can accept one hydrogen ion and two elec- inactive protein, called on opoenzyme, to form
trons to become NAD H + H +. (The extra hydrogen ion remains free in the cell. ) In a catalytically active protein, called a
other words, the oxidized form of niacin, NAD+, is reduced ro form NADH +fl+. holoenzyme. In this manner, coenzymes aid in
Note that NAD+ indicates ir has one less electron than in its complete configuration. enzyme function.
By accepting two electrons and one hydrogen ion, NAD + becomes NADH + H + , nicotinamide adenine dinucleotide (NAO) A
with no net charge on the coenzymc. compound that readily accepts a nd donates
Riboflavin plays a similar role. In its oxidized form, the coenzyme form is kDown as electrons and hydrogen ions; formed from the
:flavin adenine dinucleotide (EAD). When it is reduced (gains two hydrogens, equiv- vitamin niacin.
alenr to two hydrogen ions and two electrons), it is known as FADH 2. ffavin adenine dinucleotide (FAD) A compound
The reduction of oxygen (0) to form water (H20) is the ultimate driving force for that readily accepts and donates electrons and
Life, because it is vital to the way cells synthesize ATP. Thus, oxidation-reduction reac- hydrogen ions; formed from the vitamin
tions arc a key to lite. riboflavin.
Concept I Check
Metabolism encompasses all the sequences of chemical reactions in the body. Anabolic
prol:esses build compounds using energy input, whereas catabolic processes break down
compounds into small units, yielding energy. Adenosine triphosphate (ATP) is the form of
energy used by a cdl. The synthesis of ATP from ADP a11d Pi involves the r:ransfer of en-
ergy from foodstuffs. This process uses oxidation-reduction reactions, in which electrons
(along with h)rdrogen ions) are transferred from energy-ridding macronutrients eventually
to m.')'gen. This reaction forms water and releases much energy, which can be used to pro-
duce ATP.
ATP Production
This section will look at how cells convert the energy found in food to energy stored
in the high-energy phosphate bonds of ATP. It will begin by examining how cells pro-
duce ATP from carbohydrates. Once you understand this process, you will turn your
attention to how ATP is produced using the energy stored in fats and proteins. Along
A s each of the subsequent pathways is de·
scribed, o good way lo understand them is
to diagram each step as you go. Afterward,
the way you w1U see bow these energy-yielding processes arc interconnected. (Cells can compare your figures with those provided
also produce ATP using the energy stored in alcohol; that process is discussed in throughout the chapter. In addition, more de·
Chapter 8.) tailed pathways con be found in Appendix B.
1 18 Chapter 4 M etabolism
aerobic Requiring oxygen. ff oxygen is present, cellular respiration may be aerobic. In che absence of oxygen,
anaerobic respiration will occur. Aerobic respiration is far more efficient than anaero-
anaerobic Not requiring oxygen.
bic respiration at producing ATP. As an example, starting with a single molecule of glu-
cose, aerobic respiration will result in the net gain of 30 to 32 ATP. In contrast,
anaerobic respiration is limited to a net gain of 2 ATP per glucose.
The four stages of aerobic respiration can be explained using glucose as an example
(Figure 4-5 ):2 •11
1. Gl)'colysis. This pathway breaks glucose down into pyruvare. This breakdown of
glucose also resulrs in the production of NADH + H +. As well, energy released
during glycolysis generates a net production of two molecules of ATP. Glycolysis
cytosol The water-based phase of the occurs in the cytosol of cells.
cytoplasm; excludes organelles such as 2. Transition rc titm. Tn this pathway, pyruvate is furth er oxidized to form an aceryl
mitochondrio. 0II
mitochondria The main sites of energy group CH3- C- O, which is t11en bonded tO coenzyme A (CoA) to form aceryl-
production in a cell. They also contain the CoA. The transition reaction produces NADH + tt+ and releases carbon dioxide
pathway for oxidizing fat for fuel, among other (C0 2 ) as a waste product. The transition reaction takes place within mitochondria
metabolic pathways. of cells. Note that it is in i:hese cellular structures mar the reactions of aerobic res-
piration occur.
3. Citric acid cycle. ln this pad1way, d1e acetyl-CoA produced by the transition reac-
tion enrers into the citric acid cycle, wim d1e end result being the production of
NADH + H +, FADH2 , ATP, and C02 . The C02 is then released as a waste prod-
uct. Like the transition reaction, t11e citric acid cycle takes place within mit01.:hon-
dria of cells.
4. Electrrm trawport chain. The NADH + H + and FADH 2 produced by stages l
through 3 of respiration enter this pamway. In t11e electron transport chain,
NADH + H+ is oxidized to NAD+, and PADH 2 is oxidized to FAD. Ar the end
of the electron transport chain, oxygen is combined wit11 hydrogen ions (H +) and
electrons to form water. lt is in the electron transport chain that the majority of
the ATP is produced; keep in mind d1at it is an aerobic process. The electron trans-
port chain takes place within mitochondria of cells.
E
Glycolysis
Glucose ~ 2 Pyrvvole
26 or
2ADP ~ 2ADP ' ) 28_ADP )
26or
: ATP ) 2 ATP 28ATP
Figure 4 . 5 I The four phases of energy metabolism. Glycolysis in the cytoplasm produces pyruvote (step l ), which enters mitochondria if oxygen
is available. The transition reaction (step 2) and the citric acid cycle that follow occur inside the mitochondria (step 3). Also, inside mitochandrio, the electron
lransport chain receives the electrons that were removed from glucose breakdown products (step 4). The result of glucose breakdown is 30 to 32 ATP,
depending on the particular cell.
www.mhhe.com/wardlaw pers7 1 19
Carbohydrate Metabolism
Because glucose is the main carbohydrate involved in cell metabolism, this section will
track its step-by-step metabolism as an example of carbohydrate metabolism. The
metabolic pathways that comprise the complete oxidation of one glucose molecule can
be summarized in a single, simplified equation:
oxidation l
C 6H 120 6 + 602 ~ 6C02 + 6H 2 0 + energy
glucose oxygen carbon water
LReduction
dioxide t
In this equation the conversion of C 6H 12 0 6 to C0 2 represents an oxidation process,
whereas the conversion of 0 2 to H 2 0 represents a reduction process.
Some of the energy that is released in this reaction is used to produce ATP, but
much of the energy is simply released as heat. However, this heat should not be con-
sidered wasted energy. It is used to maintain the body temperature needed to support
each cell's metabolic reactions. 2
Glycolysis
Gtycot,rsis literaJly means "breaking down glucose." The glycolysis pathway has a dual glycolysis The metabolic pathway that converts
role: It degrades carbohydrates such as glucose to generate energy, and it provides glucose into 2 molecules of pyruvate acid, with
building blocks for synthesizing needed cell compounds, such as glycerol for triglyc- the net gain of 2 ATP and 2 NADH + 2W.
eride synthesis.1 1 glycogen A carbohydrate made of multiple
Before glycolysis can begin, a cell must obtain glucose. Only a few types of cells, units of glucose with a highly branched
such as liver and kidney cells, can produce their own glucose from certain amino acids, structure; sometimes known os animal starch. It
and only liver and muscle cells store glucose ro a rnajor extent. This glL1cose is stored is the storage form of glucose in humans ond is
as glycogen. Liver and muscle cells break down the glycogen to glucose (or a closely synthesized (and stored) in the liver and
related form). Other body cells must obtain glucose from the bloodstream, so the muscles.
bod)' needs to maintain a fairly constant concentration of blood glucose to survive (see
Chapter 5 for details). The product of glycolysis is two units of a tlu-ee-carbon com-
pound called pyntvnte (Figmes 4-6 and 4-7).
To begin glycolysis, a phosphate group from ATP is added to glucose, which makes the
glucose more reactive (step 1). Another phosphate group from ATP is added to the newly
formed glucose-phosphate compound (step 2), which then splits into two 3-carbon-
phosphate compounds (step 3). These a.re converted through a se1ics of steps into two
molecules of the 3-carbon compollnd pyruvate (step 4). Thus, in glycolysis a cell starts
witl1 a 6-carbon glucose molecule and produces two molecules of the 3-carbon compound
pyruvare. In the process, four hydrogens (containing a. total of four e lectrons) are removed
(step 5), and four ATP are generated (seeps 6 and 7). The electrons and hydrogen ions are
picked up by a canier-in this case, NAD+. Recall that each NAD+ (oxidized form) ac-
cepts two electrons and one hydrogen ion, yielding NADH + H+ (reduced form). 3
The end result of glycolysis includes the synthesis of2 NADH + 2H+. There is also Glucose
a net gain of two ATP. This arises because it takes two ATP to "prime" glucose for fur- 0
tber metabolism (steps 1 and 2), but fow- ATP ~ue then produced from each glucose
II
molecule (steps 6 and 7), yielding a net gain of two ATP. These two ATP represent only c-o-
about 5% of the total ATP that can be produced by the complete oxidation of one glu-
1
cose molecule. Most of the energy still resides in the pymvate molecules and the NADH C=O
+ H+ produced. (The Latter must enter the electron o·ansport cl1ain to yield ATP.) I
Glucose is not d1e only carbohydrate that can produce ATP by glycolysis. Other CH3
simple carbohydrate forms, such as fructose, also can be converted to intermecliate
Pyruvate
compOLmds found in tbe glycolysis pathway. These compounds then follow the re-
maining steps in tbe pathway.
Figure 4·6 I Glycolysis simplified. The

process begins with one glucose (C 6H120 6) Glucose
(step 1) and ends with two pyruvotes (C3H,p3) (6·carbon
(step 4). Some ATP is both used (steps 1 and 2) molecule)
and produced by the process (steps 6 and 7) .
The four electrons and two of the hydrogen ions
released are captured by 2 NAD · (step 5). The
other two hydrogen ions float free in the
cytosol. Pyruvote then con undergo further
[[I c ATP
ADP
/
metabolism in the citric acid cycle.
Two ATP used
'----~--(----'~ b:· ~~;']

ADP
3·corbon molecule
new tool for understanding how we as in·

dividuols differ in the metabolic response
to nutrients may lie in the ability lo track the oc· 2NAD..
tuol metabolic intermediates made to form this
response, such as how we respond to exposure
from different fatty acids. This opprooch, called
C ~
2 NADH +2
metabolomics, should be more accurate than

merely looking for differences in DNA between 2X
individuals to predict dietary responses.
, 2ADP
Reference no. 7 reviews this new tool of
research. C 2ATP
m
t
2X These ATP make
up for those used
to begin glycolysis.
c 2ADP
2ATP
B
2X 1...._Py_ru_va_t_e __.T These 1

TP represent
the net production
of glycolysis.
www.mhhe.com/ wardlawpe rs 7 121
Energy-investment []] Adding phosphorus to glucose

steps Glucose
using ATP produces on activated
molecule.
[ill
c ATP
ADP
E Reorrongement, followed by o
,,,
11
second addition of phosphorus

ATP Yield using ATP, produces fructose 1,
6-biphosphote.
- 2 ATP )
E
c
The 6·corbon molecule is split into
ATP two 3-carbon·phosphate
E molecules.
ADP
....
EJ Oxidation, followed by the
addition of phosphorus produces
E 2 NADH + 2W molecules and
two 3·corbon·phosphote·
2X
phosphate molecules.
Energy-harvesting 2Xc NAD+J

steps 2P)
rlJ 2X NADH + (!
~ Removal of 2 phosphate groups
by 2 ADP molecules produces
I
2X 2 ATP molecules and two r
3-corbon·phosphote molecules. J
2 ADP
+2 ATP ( 2ATP
Removal of water produces two
3-corbon-phosphote molecules.
2X
~ HP Removal of 2 phor.phate groups

by 2 ADP molecules produces
2 ATP molecules.
2X
+2 ATP
c 2ADP
2ATP
D ~ fyruvate is the end product of
t~e glycolysis pathway.
Generally the pyruvote enters the
2ATP
(Net Goin ATP)
[!lJl 2xl Pyruvate 1 mitochondria for further
breokdown.
Figure 4 - 71 Glycalysis, step by step. This metabolic pathway begins with glucose and ends with pyruvate. Net gain of two ATP molecules can be
calculated by subtracting those used during the energy-investment steps from those produced during the energy-harvesting steps. Text in boxes to the for right
explains the reactions. See Figure B-1 in Appendix B for a more detailed view of glycolysis.
The two pyruvate molecules formed at the end of glycolysis still contain much
stored energy. PyruYate passes from the cytosol into mitochondria, where the u-ansi-
tion reaction converrs pyruvate into a form that can enter the citric acid cycJc.3
Transition Reaction
C oA is short for coenzyme A. The A stands

for ocetylotion because CoA provides the
two carbon ocetyl group to start the citric acid
In order to enter the ciuic acid cycle, pyruvate must be converted to an acetyl group
in a process called a transition reaction. The pyruvate is then arrached to coenzyme A
(CoA), forming acetyl-CoA. This overal l reaction is ixreversible, which has imporrant
cycle. metabolic consequences, as you \\'ill see. The conversion of pyruvate to acetyl-CoA re-
quires the B vitamins thiamin , riboflavin, nfacin, and pantothenic acid. For this reason,
carbohydrate metabolism depends on the presence of these viramins.s
The transition reaction oxidizes pyruvate and reduces NAD+. It can be sunu1rnrized as:
pyruvate + CoA + NAD + ~ acetyl -CoA + C02 + NADH + H+
Note that each glucose yields 2 pyruvate for the transition reaction. As with the
NADH + H+ produced by glycolysis, the NADH + H + produced by the transition
reaction will eventually enter the e lectron transport chain.
Concept I Check
To begin gl)•colysis, two phosphate groups from two ATP molecules arc added to glucose
to make the glucose more reactive. This doubly phosphorylated glucose continues through
glycol)'sis in the form of various intermediates (steps 1-3). Eventually one of the intermedi-
ates is split into two molecules of a 3-carbon compound. Each of these 3-carbon com-
pounds goes through a series of chemical reactions (steps 4-7) to become the 3-carbon
pyruvate. Thus, in glycolysis, glucose with 6 carbons, 12 hydrogens, and 6 oxygens
(C 6H 120 6) is converted to two molecules of pyruvatc, each composed of 3 carbons, 4 hy-
drogens, and 3 oxygens (C 3H 4 0 3) . In the process, 4 hydrogens (containing 4 protons and
4 electrons) are removed, allowing NAD+ to be reduced to form NADH + H '". Each
NAD+ has accepted 2 electrons and 1 proton, producing NADH (the cxrra H + is an un-
bound proton). Also produced in this phase of glycolysis is four ATP. However, since two
ATP arc needed to "prime" glucose (steps l and 2), rbere is a net gain of only rwo ATP
per glucose. Next, each p)'ruvate typically enters the O'ansition reaction and is oxidized to
a 2-carbon acetyl group carried by coenzyme A, and 2 NAD+ are reduced to form
2 NAD H + 2 H +. C0 2 is a waste product of the reaction.
Citric Acid Cycle

The acetyl-CoA molecules produced by the transition reaction enter d1e cirric acid
Metabolism is port of everyday life, and such cycle. The cin·ic acid q rcle is a series of chemical reactions used by cells to convert the
activity increases when we increase physical carbons of an acetyl group to carbon dioxide while at the same time harvesting energy
activity. in order to produce ATP (Figure 4 -8).10 Each complete turn of the citric acid cycle
produces NADH + H + and FADH2 , which, like the NADH + H+ gcnernted by gly-
colysis and the transition reaction, will enter the electron transport chain. The details
of the ciu·ic acid q rcle can be found in Figure 4-9.
ther names for the citric acid cycle ore the
O tricorboxylic acid cycle (TCA cycle) and
the Krebs cycle, named ofter Sir Hons Krebs, the
How the Citric Acid Cycle Works
To begin the ciu-ic acid cycle, acetyl-CoA combines with a 4-carbon componnd, ox -
scientist who first described it.
aloacetate, to form the 6-carbon compound citrate (Fignre 4-9, step 1) . In the
process, the correspo11ding CoA molecule is released and can be reused. During one
complete turn of the citric acid cycle, the 6-carbon citrate molecule is metabolized
back to a 4-carbon oxaloacetate molecule (steps 2-8) and 2 -carbon dioxide molecules
TP from the citric acid cycle goes on to are released (steps 3 and 5 ) . The cycle is now ready to begin again with oxaloacetate
form ATP. and another acetyl-CoA.
Ove rview of the Citric Acid Cycle
2-corbon·CoA molecule
(Acetyl-CoA)
4-corbon molecule
(Starting material)
16-corbon molecule
· -
1 4-carbon molecule
(starting material)
(]] The citric ocid cycle begins when EJ Then, the resulting 6-carbon EJ Finally, the resulting 4-ca rbon
molecule is further oxidized (i.e.,
o 2-carbon frogment is molecule is oxidized (i.e'l
transferred from acetyl-CoA to a hydrogen is removed to torm hydrogens ore removed to Form
4-carbon molecule (the starting NADH+ H+I, ond a corbon is FADH2 and NADH+W ). This
material). removed to form C02. regenerates the 4-carbon sta rting
Next, the 5-carbon molecule is material, completing the cycle.
oxidized in the same manner,
and another corbon forms
C02 • In the process the cycle
generates GTP, which con yield
ATP.
Figure 4·8 I How the citric acid cycle works.
Each complete turn of the citric acid cycle yields potential ATP in the form of 0 0
guanosine triphosphate (GTP) (step 6) as well as NADH + H + (steps 2, 4 , and 8 ) and
FADH 2 (step 7 ). \Vhcn reviewing this overall reaction, focus on the input of an acetyl
II
c-c-o-
I
group thar was produced by the oxidation of pyruvate and on the output of GTP, 0
NADH + H +, FADH2 , and C0 2 . 1 II
CH2 - c-o-
From the C itric Acid Cycle to the Electron Tran sport Chai n Oxaloacetate
ln aerobic respiration, a cell starts with a 6-carbon gl ucose and eventually produces 0
6 C0 2 , 10 NADH + H +, 2 FADH 2 , and 4 ATP. 1t rakes two turns or Lhc citric acid II
cycle to process one glucose, because the glucose was split into rwo 3-carbon frag- CH 2 -c-o-
ments as a result of glycolysis.
All the carbons in glucose are released in the form of carbon dioxide. The carbon
dioxide evencually leaves the body by way of the lungs. In the process, ATP is synthe- HO-C-c-o-
I 11
sized directly by both glycolysis and the citric acid cycle, and NADH + H + and 0
FADH, arc produced. 1 II
The -final pathway or aerobic respiration is d1e electron transport chain. Most of the CH2-C-O
_..\TP produced during <lerobic respiration is produced by d1e electron transport chain. Citrate
The NADH + H + and FADH2 produced pmfously by other reactions are used to supply
rhe energy needed for ATP synthesis in the eleca·on rransport chain. In this \\'ay, much
more ofd1e energy released from glucose metabolism is transferred to ATP (Figure 4-10).2
The Electron Transport Chain oxidative phosphorylotion The process by

~lost cells perform the electron transport chain. This metabolic process, called which energy derived from the oxidation of
oxidative phospho r ylation , requires the minerals iron and copper. Iron is a compo- NADH + W and FADH 2 is transferred to ADP
nent of cytochromes in the electron transport chain, and copper is a component of
+ P; to form ATP.
an enzyme present. cytochrome Electron-transfer compound thot
Dllli.ng d1e first steps of the electron transpor t chain, bod1 NADH + H + and FADH2 participates in the electron transport chain.
are oxidized (i.e., d1cir hydrngcns arc removed; review Figw·e 4-9). T he details of these steps
123
ntermediotes of the citric acid cycle, such as

Transition Reaction oxaloocetote, con leave the cycle and go on
Pyruvote is first metabolized in o
transition reaction to ocetyl-CoA. to form other compounds, such os glucose. Thus,
It is ocetyl·CoA that octuolly enters the citric acid cycle should be viewed os o traffic
the citric acid cycle. In the process, circle rather than as o closed circle.
NADH + H+ is produced and
C02 is lost.
The citric acid cycle begins

when on ocetyl group carried
by CoA combines with o C4
oxoloocetote molecule to form
e
citrate.
Twice over, substrates ore
oxidized, NAD* is reduced
to NADH + HT and C02 is
released.
Alpho·ketogluterote
Acetyl-CoA )
Citric acid
cycle
+ H'
ATP eventually is mode os

Oxoloocetote is re-formed Succinote energy is released from
during the final step of the the breakdown of on
cycle. intermediate in the cycle.
ATP
FAD '--
Once again on intermediate in

the cycle is oxidized, and NAD"
is reduced to NADH + W.
Again on intermediate in the
cycle is oxidized, but this time
FAD is reduced to FADH2.
Figure 4 . 9 I The transition reaction and the citric acid cycle. The net result of one turn of this cycle of reactions (steps 1-8) is lhe oxidation of on ocetyl
group to two molecules of C0 2 and the formation of three molecules of NADH + H+ and one molecule of FADH 2. One GTP molecule also results, which
eventually forms ATP. The citric acid cycle turns twice per glucose molecule. Note that oxygen does not participate in any of the steps in the citric acid cycle. It
instead porticipotes in the electron transport chain (described on page 123). See Figure B-2 in Appendix B for o more detailed view of the citric acid cycle.
www.mhhe.com/wa rdlaw pers7 125
Figure 4 · 1 0 I Simplified depiction of

High-energy Low-energy electron transfer in energy metabolism. High-
molecule,
such as glucose ---·-·~
molecule, such as
~02 oodH 20
energy compounds, such as glucose, give up
-trADH +H
electrons and hydrogen ions to NAD+ and
FAD. The NADH +Wand FADH 2 that ore
e- formed transfer these electrons and hydrogen
ions, using specialized electron carriers, to
FADH2 oxygen to form water (H 20). The energy
J
yielded by the entire process is used to
o~+
generate ATP from ADP and P; .
FAD <H' -
ADP +
.~
P1 - ATP
~~
m HP
in the pathway ;u-e illusn-ated in Pigme 4-11 , steps 1 and 2. Pairs of electrons are then sep- electron transport chain A series of reactions
arated by coenzyme Q (CoQ) (step 3). Thus, ald1ough NADH + H + and FADH2 mms- using oxygen to convert NADH + W and
fer their hydrogens to d1e electron transport chain, the hydrogen ions (H +), having been FADH2 molecules to free NAD• and FAD
separated from their electrons (H ~ H + + c-), arc nor carried down the chain with the molecules with the donation of electrons end
electrons. After the pairs of electrons have been scpru-ated, each is passed along a group of hydrogen ions to oxygen, yielding water
and ATP.
iron-containing cytochromes. At each transfer from one cytochrome to the next, some en-
ergy is given off. A portion is eventually used to generate KfP from ADP and Pi, but much
is sim ply released as heat. At the end of the chain of cytochromcs, OA-ygen, hydrogen ions,
and dccn·oos are wlired to form warer: l/2Gi + 2H+ + 2e---+ H 2 0 (step 4 ).3
The key thing ro remember here is that the net result of the electron transport chain
is the production of ATP and water (steps 4 and 5).
Just How Many ATP Are Produced?

Once the NADH + H + and FADH7 have transferred their hydrogens to the dectron
u-anspon chain, they arc again in the -form of NAD+ and FAD and arc ready to shurtle
more hydrogens to the electron transport chain. In Figure 4-11, step 1, NADH + H +
donates its chemical energy to an FAD-relared compound called fla,·in mononucleotide
(FMN). In contrast, FADH2 donates its chemical energy at a latter point in the electron N ote that a product called Coenzyme 0· 10
is sold as o nutrient supplement in health
food stores (the number 10 signifies that it is the
transport chain ( Figure 4-11, step 2). T his different placement of FAD and NAD + in
tl1e electron transport chain results in a diffi:rence in ATP production. E.Kh NADH + form found in humans). However, when the mito·
H + in a mitochondrion releases enough energy to form the equivalent of2 .5 ATP, while chondrio need coenzyme 0, they make it. Thus,
each FADH2 releases enough energy to furm tl1e equivalent of 1.5 ATP. 2 to maintain overall health, people do not need
Of all die ATP yielded by the complete oxidation of glucose, almost 90% arc syn- to toke in coenzyme Q in their diet or in the
tl1csized in the electron u-ansport chain. form of o supplement. (Such use may be helpful,
however, in people with heart failure; see
So This Is Why Oxygen Is Important Chapter 18.)
Because oxygen is essential to the processes of the clecu·on transport chain, d1e elec-
tron transporr chain is part of aerobic metabolism. NAD H + H + and FADH., pro-
duced during the cinic acid cycle can be regrneratcd into NAD+ and FAD on ly by the
eventual transfer of tl1ei.r electrons and hydrogen ions to oxygen, as occurs in the dcc-
rron transport chain. T he citric acid cycle has no abilirv to oxidize NADH + H + and
FADH 2 back to NAD+ and FAD. Tl~s is ultimately ,;,hy o>..-ygen is essential to many
life forms; a final acceptor of the electrons and hydrogen ions generated from the
breakdown of energy-yielding nutrients is needed. Wid1our oxygen, most of o ur cells
are unable to extract enough energy from energy-yielding nutrients to sustain li fo. 2
Figure 4· 11 I Organization of the
electron transport chain. As electrons Electron Transport System
move from one molecular complex to lhe olher,
hydrogen ions (H+) are pumped from the
mitochondrial matrix into the ;ntermembrane Cytochrome b,c 1
H+ complex
space (steps 1-4). (Nole thal each
mitochondrion has on inner and outer Cytochrome c
membrane.) As hydrogen ions flow down a oxidose
complex
concentration gradient from lhe intermembrone
space into lhe mitochondrial matrix, ATP is
synlhesized by the enzyme ATP synthase
(step 5). ATP leaves the mitochondrial matrix
by way of a channel protein. See Figure B-3
in Appendix B for a more detailed view of the
electron transport chain.
number of defects hove been described re- D

lated to the metabolic processes that take
place in mitochondria. A variety of medical Mitochondrial
interventions can be used to treat the muscle Matrix
weakness and muscle destruction typically
arising from lhese disorders; the use of speci fic
nutrients and related metabolic intermediates in
H
treatment is reviewed in reference no. 9.
H'
lntermembrane
H+ Space
ATP synthase
protein complex
Summary: The Electron Transport C hain Resu lts

in the Production of ATP a nd Water
The electron transport chain involves the passage of electrons along a series of clecuon
carriers. As electrons are passed along fro m one earlier to the next, small amo unts of
energy are released. Some o Fthis e nergy is ultimately used to generate ATP. NADH +
H + and FADH 2 supply bo th hydroge n ions and electrons to the electron transport
chain. Ar the end of r:he electron transport chain, h~1droge n ions, electrons, and oxy-
gen combine ro fo rm water.
Concept I Check
1n the citric acid cycle, a 2-carbon acetyl group in the form of acctyl-CoA combines with a
4-carbon oxaloacetate molecule to form the 6-carbon citrate molecule. Through various
While, looking al electron microscopy slides of chemical reactions, the cycle releases two carbon dioxide molecules and evenntaily yields
muscle cells, you observe various organelles. another oxaloacetate, the starring material. This new oxaloacetate can combine with
However, the large number of mitochondria another accryl-CoA molecule to begin the process again. The NADH + H + and FADH 2
you see is remarkable. Your instructor asks you produced by glycolysis, the transition reaction, and the citric acid cycle donate their elec-
lo explain this observation to your classmates. rrons and hydrogen ions to the electron transport chain, yielding water and ATP and in the
How would you do so? process regenerating NAD+ and FAD.
126
, Expert Opinion
Does a Metabolic Advantage Exist
for the High-Protein Diet?
Andrea C. Buchholz, Ph.D., R.D., and Dale A. Schoeller, Ph.D.
High·protein/low-<:orbohydrote weight-loss diets hove become very popular. suit in o 12-week weight loss that is 2.5 kg greater, and in o 24-week weight
Despite initial skepticism by many investigators, results from a number of loss that is 4.0 kg greater, than the weight loss on high-carbohydrate/
studies hove shown that these diets do initially yield greater weight losses low-fat diets. Assuming that this weight loss hos the typical composition of
than do high-carbohydrate/low-fat diets. On overage, high-protein diets re- 80% fat moss ond 20% fat.free mass:
2.5 kg X 80% fat moss X 1000 g/kg X 9.5 kcol/g fat 0 19,000 kcal
2.5 kg X 20% fat-free moss x 1000 g/kg X 1. 1 kcol/g fat-free mossb 550 kcal
Total kcal represented by 2.5 kg weight loss = 19,550 kcal

4.0 kg x 80% fat moss x 1000 g/kg x 9.5 kcol/g fat 30,400 kcal
4.0 kg X 20% fat-free moss X 1000 g/kg X 1.1 kcol/g fat-free moss 880 kcal
Total kcal represented by 4.0 kg weight loss = 31 ,280 kcal
"9.5 kcol/g is the gross energy densily of fol moss. II ls higher than the 9 kcol/g melobolizoble energy for dietary fol because
there is no odjuslmenl for incomplete absorplion.
b t .1
kcal/g is the energy densily ol fol·free moss. II is colculoled From the gross energy value of protein adjusted for urinary
energy losses due lo incomplete melobotism and the percentage of fa~Free moss thol Is protein.
Thus, the difference in weight loss ofter 12 to 24 weeks of treatment re- mocronutrients. This increase in energy use in sedentary individuals is esti·
flects a 19,550 to 31 ,280 kcal difference in energy balance, respectively, mated to be 41 kcal/day on o 1500 kcal/day energy intake. This amount
or roughly 200 kcal/day. This finding hos caused several investigators to ask represents only 20% of the 200 kcol/doy difference in energy balance be-
whether a high-protein weight-loss diet provides a metabolic advantage to tween the two diets. Thus, if there is o metabolic advantage associated with
the body. a high-protein diet, ii is only a small one.
Weight loss occurs because of negative energy balance, when energy If the difference in total energy expenditure does not adequately explain
expenditure exceeds energy intake. Given that protein, fat, and corbohy· the 200 kcol/doy energy imbalance between o high-protein/low·
drole ore all used for energy metabolism but that the yield of ATP produced carbohydrate diet and a high-carbohydrate/low-fol diet, then there must be a
con vary slightly depending on the route of metabolism, it is reasonable to difference in energy intake. One important consideration in studies compor·
consider that diets differing in macronutrient distribution may influence total ing weight-loss treatments is the accuracy of participants' energy intake data.
energy expenditure. If o particular diet were lo increase total energy expen· Ideally, weight-loss studies ore conducted in free-living participants. While this
diture relative to another, then for the some energy intake, energy balance situation is desirable because it provides results under real-life conditions, it
would be more negative for that diet and weight loss would likely be greater. also means that participants ore ultimately responsible for their dietary re-
Is it possible that individuals on a high-protein diet "burn" more energy than ports. Because of the well-known tendency of people to underreport their di-
those on a high-corbohydrote/low-fot diet? etary intake, actual intake may be 10 to 50% greater than what is reported
In controlled studies in which participants consume the same amount of in diet records. Even if meals ore provided to participants, noncompliance
energy ond in which protein intake is held constant and fat is substituted for con occur ond dietary intakes ore likely to be higher than prescribed. Thus,
carbohydrate diet, neither total energy expenditure nor resting metabolism researchers' knowledge of actual dietary intakes of free-living participants in
of those participants on o high-carbohydrate differ from those on o high-fat weight-loss studies-regardless of mocronutri ent distribution-ore numeri·
diet. However, increasing protein intake from 15% to 30 to 35% of total en· colly uncertain.
ergy intake does increase resting metabolism and the degree to which the Even if participants accurately reported their dietary intakes, there would
body must increase energy expenditure to digest, absorb, and process the still remain the potential for errors in the calculation of metobolizoble energy
(continued)
I I
I
sumed food and the chemical energy lost in feces (due to incomplete ab-
sorption) and urine (due to incomplete cotabolism). The metobolizoble en·
ergy values commonly used today ore the general factors of 4 kcal/g for
carbohydrate, 9 kcol/g for fat, and 4 kcol/g for protein described by
Atwater in the early 1900s. However, Atwater clearly demonstrated that
these factors were average values: although they can be used to calculate
the metobolizable energy of o whole diet, they are in error lo some degree
for most single food items. This problem is due to differences in the bioovail-
ability and chemical structure of individual mocronulrients. These general
factors have been found to overestimate measured metabolizable energy by
1 to 18%, particularly for high-fiber foods. This overestimation might explain
some of the difference in weight loss observed on two diets differing in
macronutrient distribution even if the diets ore prescribed under controlled
conditions. That is, while calculated energy intakes may be similar between
two groups of participants following diets differing in macronutrient distribu-
tion, actual energy intakes may be lower in one group relative lo the other,
and thus weight loss would likely be greater. Experimental data, however,
ore lacking.
Greater negative energy balance, and thus weight loss, hos been ob-
served in individuals consuming a high-protein/low-carbohydrate diet than
those consuming a high-carbohydrate/low-fat weight-loss diet. Experimental
evidence shows that the small metabolic advantage of the high-protein diet
Carbohydrate, protein, fat, and alcohol all contribute does not adequately explain this energy imbalance. The energy imbalance
chemical energy to the body. must therefore be due to differences in energy intake. However, the cause is
difficult lo determine because of widespread underreporting of energy in-
takes and because of possible errors in calculated versus metabolizable en-
ergy intakes. Further research on the effects of a high-protein diet on energy
intake. In considering this issue, it is worthwhile to brieAy review thermody-
intake is needed.
namics. The first low of thermodynamics states that energy con neither be
created nor destroyed, but only transformed. Thus, the human body is con-
stantly transforming energy-in this case, potential energy stored in C-C and Dr. Buchholz is Assistant Professor of Foods and Nutrition at the
C-H bonds-by oxidizing food to produce heat while using some of that en· University of Guelph. She earned a Ph.D. in nutritional sciences from
ergy by shuttling ii to ATP for use in muscle contraction, ion pumping, and the University of Toronto. Dr. Schoeller is Professor of Nutritional
chemical synthesis. The human body, however, is not a perfect engine and Science at the University of Wisconsin-Madison . He earned o Ph.D.
cannot utilize all the potential energy available in food. This is the concept in chemistry from Indiana University. Both have research interests in
of metobolizable energy, or the difference between the gross energy of con· energy metabolism and body composition.
Aerobic Respiration
As a result of the pathways of aero bic respiration , some of the energy in food is con-
verted to a form of energy that cells can use rather than just being converted immedi-
ately to heat, as would have happened if you had ignited the food with a match. The
AT P yield from the complete aerobic breakdown of one glucose is 30 to 32 ATP. These
ATP account for about 40% of the energy found in o ne molecule of glucose. The re-
maining energy (60%) escapes as heat via all the reactions that take place in which ATP,
GTP, NADH + H + and FADH2 arc not made.2 T he same 40:60 ratio applies to the
energy metabolism of fatty acids and amino acids. That ratio is fairly efficien t given
that, for comparison, an automobile engine captures only about 10% o f the chemical
energy in gasoline. The human body is about foLU· times more efficient than an auto-
mobile in extracting energy from carbon-based compounds. In the Expert Opinion, Dr.
Andrea Buchholz and Dr. Dale Schoeller discuss whether diet composition influences
th.is efficiency, as is claimed by some weight-loss diets (e.g" low carbohydrate diets).
Glycogen Metabolism
Glycogen synthesis involves adding glucose molecules to an existing glycogen mole-
cule. Glycogen provides liver and muscle cells with a short-term storage form of glu-
cose. Later, when glucose is needed, glycogen breakdown yields glucose as a glucose-
phospbate compowid, which eventually enters into glycolysis. However, there is a dif-
ference in the way the body uses the glycogen stored in liver cells and the glycogen
stored in muscle cells. The glucose-phosphate compound formed when the liver breaks
down glycogen can eventually be released as glucose into the bloodstream. Therefore,
this glucose is available to all the cells of the body. In contrast, the glucose-phosphate
compound formed when muscle cells break down glycogen is available for use only by
that muscle.
Anaerobic Respiration
Some cells lack mitochondria and so are not capable of aerobic respiration. Other cells
W hen respiring onoerobicolly, some mi-
croorganisms such os yeast produce
ethanol, o type of alcohol, instead of lactate
are capable of turning to anaerobic respiration when oxygen is lacking. When per- from glucose. Other microorganisms produce
formed, this anaerobic respiration is not nearly as efficient as aerobic respiration, be- various forms of short·choin fatty acids. All this
cause it converts only about 5% of the energy in a molecule of glucose ro energy stored anaerobic metabolism is referred to os
in the high-energy phosphate bonds of ATP. 2 fermentation.
Anaerobic Glycolysis
The anaerobic glycolysis pathway encompasses glycolysis and the conversion of pyru-
vate to lactate ( Figure 4 -12).
Anaerobic Glycolysis in Red Blood Cells

For cells, such as red blood ceUs, that lack mitod1ondria, anaerobic glycolysis is the
only available method for making ATP. Such cells lack the oxygen -requiring (aerobic)
pathway needed for using NADH + H + for ATP synthesis, and they also lack the abil-
iry to use this process to recycle NADH + H+ back to NAD+. Therefore, when red
-~
blood cells convert glucose to pyrnvate, NADH + H + builds up in the cell. Eventually,
the NAD+ concentration fu.Us too low to permit glycolysis to continue, because most
of the NAD+ present is in the form NADH + H+.3
The pathway that regenerates NAD+ anaerobically involves a reaction that com-
bines pyruvate with NADH + H+ to form lactate (review Figure 4-12). Tn the process,
NADH + H + turns into NAD+. The reaction that produces lactate to regenerate
NAD+ can be summarized as: 4-.J
,.~
7
pyruvate + NADH + H + ~lactate+ NAD+
The lacr:ue produced by the red blood cel l is then released into the bloodstream,
- . --. .
picked up primarily by the liver, and synthesized back into pyruvate, glllcose, or some Quick bursts of activity rely on the production
other intermediate in aerobic respiration. of lactate to help meet the ATP energy demand.
Anaerobic Glycolysis in Muscle Cells

Like red blood cells, muscles that are being exercised also produce lactate when they run
out of NAD+. By regenerating NAD+, the production of lactate allows anaerobic gly-
colysis to continue. Muscle cells can then makc the ATP required for muscle contraction
even if little O>.')'gen is present. However, as you will find out in Chapter 14, it wiJI be-
come more difficult to contract those muscles as the lactate concentration builds up.
Figure 4· 12 I Anaerobic glycolysis with

lactate as the end product. This process "frees" Glucose
NAD+ and it returns lo the 9lycolysis pathway
to pick up more hydrogen ions and electrons. 2ATP
2ADP
)
2X Glyceroldehyde 3-phosphate
- - - 2 NAD+
.__...
- - -... 2 NADH + W
2X l, 3-bisphosphoglycerate
2ADP
2ATP
2X
Aerobic and Anaerobic Respiration

Cells need ro release energy ston:d in food fuels and then trap as much or this energy
as possible in the form of ATP. The body cannot afford to lose all energy immediately
as heat, even Lhough some hear is necessary fo r maintenance of body temperature.
G lycolysis (aerobic and anaerobic), the transition reaction, the citric acid cycle, and the
electron transport chain accomplish many tasks in the body. Most important, however,
is that they enable ceUs to capture some of the chemical energy in food in the form of
ATP, which then acts as cellular fi.te l.2
I Lipolysis: Fat Breakdown

Lipolysis is part of a process of splitting- breaking down-triglycerides into free fauy
lipolysis The breakdown of triglycerides to
acids and glycerol. The further breakdown of the fatty acids for energy production is
glycerol and fatty acids.
called fatty f1,cid o:citiation, because the dona[ion of electrons from fatty acids to oxy-
peroxisome Cell organelle that uses oxygen to gen is rhe net reaction in the energy-yidding process. Th is process takes place in the
remove hydrogens from compounds. This mitochondria and peroxisomes of the cell, but only mfrochondria can use the energy
produces hydrogen peroxide (H 20 2), which released to form ATP.
breaks down into 0 2 and H20. Fatty acids are liberated from rriglyceridc storage in adipose cells by an enzyme
carnitine A compound used lo shuttle fatty called bonnone-se11sitivelipasc. The activity of this enzyme is increased by the hormones
acids from the cytosol of the cell into glucagon, growth hormone, epinephrine, and others, and is decrcasl.'d by the hormone
mitochondria. insulin. The forty acids a.re taken up from the bloodstream by cells and arc shuttled from
the cell cytosol into the mjwchondria using a cru-ricr caJlcd carnitinc (Figure 4 - 13 ).5
Lipolysis Figure 4· 1 3 I lipolysis. Because of the

action of hormone-sensitive lipase, fatty acids
are released from triglycerides in adipose cells
Adipose cells
and enter the bloodstream. (Hormones such as
i epinephrine increase the activity of this
enzyme.) The fatty acids ore taken up from the
l
Triglycerides
~
bloodstream by various cells and shuttled into
Hormone· the inner portion of the cell mitochondria. This
sensitive shuttling utilizes carnitine. The fatty acid then
lipase undergoes beta-oxidation to yield acetate
Q~ ~odd, JT
molecules, half as many as the number of
carbons in the fatty acid.
J Bloodstream
Cytosol
Making ATP from Fatty Acids n healthy people, cells produce the cornitine
needed for synthesis, and cornitine supple·
Almost all fatty acids in nature are composed of an even number of carbons, ranging ments provide no benefit. In patients hospitalized
from 2 to 26. The first step in transferring the energy in such a farty acid to ATP (fatty with acute illnesses, however, cornitine synthesis
acid oxidation) is to cleave the carbons, two at a time, and convert the (\VO-carbon frag· may be inadequate for their needs. These pa·
ments to acetyl-CoA. The process of converting a free fany acid to mu ltiple acctyl-CoA tients may need to hove cornitine added to their
molecules is called b eta-oxidation, because the second carbon on a fatty acid (count- intravenous total parenteral nutrition
solutions.
ing after the acid Li-OH1 end) is called the /;etrr carbon. 2 This is where the reaction
begins. During beta-oxidation, NADH + H + and FADH2 are produced. So as with
glucose, a fatty acid is eventually degraded into the 2-carbon compound acetate, in the beta-oxidation The breakdown of o fatty acid
form of acetyl-CoA. Some of the chemical energy contained in the starting compound into numerous acetyl-CoA molecules.
is transferred to NADH + H + and FADH 2 (Figure 4-14).
The acetyl-CoA enters the citric acid cycle, and two carbon dioxides are released,
just as with the acetyl-CoA produced from glucose. Thus, the breakdown product of
both glucose and fatty acids, acetyl-CoA, uses a common pathway-the citric acid
cycle. One big difference, however, is that a 16-carbon fatty acid yields 104 ATP,
whereas the 6-carbon glucose yields only 30 to 32 ATP. That results in a ratio of about
7 ATP per carbon for fatty acids versus about 5 ATP per carbon for glucose. This dif-
ference results from the greater number of C-H bonds per carbon in a fatty acid com-
pared ro glucose. It is the oxidation of these chemical bonds that provides most of the
energy to drive ATP synthesis. Note that many of the carbons in glucose are also
bonded to hydroxyl groups (-OH) ratber than only to hydrogen atoms, as is primarily
the case with fatty acids. Thus, as a whole, the carbons of glucose exist in a more oxi-
dized state. This is why fats yield more kcals/g than carbohydrates (9 versus 4)-fats
are less oxidized (more reduced) than carbohydrates. 2
I H- -- ~:_:~-i~-
Figure 4· 14 I Beta-oxidation of fatty acids.
H H H 0
In beta-oxidation, each 2-corbon fragment
I
---c-c-
I I II
---C-C-OH
(acetyl group) yields electrons and hydrogen
ions to form NADH + W and FADH 2 as the
H,c 1
H
I
H H
I fragments ore split off the parent fatty acid. The
2-carbon acetyl molecule then typically enters
the citric acid cycle (as ocetyl-CoA).
NADH + H NADH + H.i> NADH + {!-!'
No matter how man)' carbons a fatty acid contains, it is usually broken down into
0 0 acetyl-CoA. Occasionally, a fatty acid has an odd number of carbons, so the cell forms
II II many acetyl-CoA, plus one 3-carbon compound (propionyl-CoA). This enters the cit-
CH3-C-c - o- ric acid cycle directly, bypassing acctyl-CoA. It can then go on ro )'ield NADH + H +,
FADH2 , and carbon ilioxidc, and even other products such as glucose.
co,l
Py ruvate
Carbohydrate Aids Fat Metabolism

In addition to its role in energy production, the citric acid cycle provides compounds
0 0
that leave the cycle and enter biosynthetic pathways. T his means that even though
II II
c-c-o- most oxaloacerate is reused in the cycle, a min imum amount of synthesis must still be
0
main tained because this removal from the citric acid cycle for biosymhetic reactions
l II could slow citric acid cycle activity. One potential source of this additional oxaJoacerate
is pyruvate. Thus, as fatty acids create acetyl-CoA, carbohydrates such as glucose are
needed to .keep the concentration of pyruvate high enough to resupply oxaloacet.1tc to
O xaloacetate
the citric acid cycle. Overall, rhc enrire pathway for fatty acid oxidation works better
when carbohydr;ue is .lYai lable.
Ketogenesis is Producing Ketone Bodies from Fatty Acids

ketone bodies Incomplete breakdown products Ketone bodies <Ue products ofincomplete fatty acid oxidation. l 3 Hormonal imbalances-
of fot, containing three or four carbons. Most chieOy, Lnadcquate insulin production to balance glucagon action in the body-allow
contain a chemical group called a ketone, for the development of some rnetaboljc cond itions that lead to signillcant production
hence the name. An example is acetoocetic of ketone bodies called lwtosis (Figme 4-15 ).
acid.
1. Fatty acids stored in adipose cells are rapidly released into the bloodstream. A fall
ketosis The condition of having a high in blood insulin is rhe ker reason, because insulin inhibits lipolysis and, instead, fa-
concentration of ketone bodies and related vors fat storage. The bulk of tl1e increase i11 fatty acids in the blood is taken up by
breakdown products in the bloodstream and
the li ,·er.
tissues.
2 . Fatty acid oxidation co acetyl-CoA predominates over fatty acid synthesis in the
liver becanse t11e presence of a high amount of free fatty acids i nhibit~ tl1e first step
in fatty acid synthesis.
3. As the liver takes up the fatty acids and degrades them to acetyl-CoA, the ca-
pacity of the citric acid cycle to process the resulting acetyl-CoA m olecules de-
creases. This is mostly because the metabolism of fatty acids to acetyl-CoA yields
many ATP, and high amounts of ATP slow citric acid C)'cle activity in li\•er cells.
Essentially, there is no need ro use the citric acid cycle-the main role of which
is to transfer energy from fuels for use in ATP synthesis-when the cells have
plenty of ATP already. Other possible contributors include lack of enough ox -
aloacetate or coenzyme A to allow for all tbc fatty acids to be oxidized in the cit-
ric acid cycle.
Ketosis
Fote of many Ketone bodies, such as acetoocetic acid

fatty odds 0 0
Low corbohr,drote Fatty acids released Numerous fatty

II ll
CH3 - C - CH2 -C-OH
intake, insufficient in large quantities acids Rood into
insulin production by odipose cells the liver
limited
ability
Figure 4 · 1 5 I Key steps in ketosis. Any condition that limils insulin availability lo cells results in some ketone body producti on.
These metabolic changes encourage the liver cells to first form acetyl-CoA and
then unite two acetyl-CoA molecules to form a 4 -carbon compound. This com-
pound is further metabolized and eventually secreted into the bloodstream as the ke-
tone bodies acetoacetic acid and two related compounds, beta-hydroxybutyric acid
and acetone.
Most ketone bodies are subsequently converted back into acetyl-CoA in other body
cells, which use the ketone bodies for fuel. The acetyl-CoA is tl1en pushed tl1rougb the
cinic acid cycle. One of the ketone bodies formed (acetone) leaves the bod}' via the
lungs, giving the breath of a person in ketosis a characteristic, fruity smell.
Ketosis in Semistarvation or Fasting

When a person is in a state of semistarvation or fasting, carbohydrate avallability falls,
and so insulin production falls. This fall in blood insuJin then causes fatty acids to flood
into the bloodstream and eventually form ketone bodies, as just described. The heart,
muscles, and some parts oftbe kidneys then use ketone bodies for fuel. After a tew days
of ketosis, the brain also begins to metabolize ketone bodies for energy.
This adaptive response is important to semistarvation or fasting. As more body cells
begin to use ketone bodies for fuel, the need for glucose as a body fuel diminishes. This
tl1en redm:es tl1e need for the liver and kidneys to produce glucose from amino acids The use,of a very-low-carbohydrate diet to in-
(and as well rrom the glycerol released from lipolysis), sparing much body protein from duce ketosis for weight loss is covered in
being used as a fuel source. The mai ntenance of body protein mass is a key to survival Chapter 13. Why is careful physician monitor-
in semistarvation or fasting. Death is seen when about half of the body protein is de- ing needed if this type of diet is Followed?
pleted, usually coming after about 50 ro 70 days of toral f:isting. in prolonged fasting,
about half the energy needs are met by the use of ketone bodies; only 5% ofcncrmr use
comes from glucose that was made from amino acids.20
Ketosis in Diabetes
In type 1 diabetes, little to no insulin is produced. This lack of insu lin does nor allow
for normal carbohydrate and fat metabolism. Without sufficient insu lin and the related
inability to readlly utilize C<lrbohyd.rate, excess production of ketone bodies occurs. 18
If the concentration of ketone bodies rises too high in the blood, the excess spills into
tl1e urine, pulling the electrolytes sodium and potassium with it. Eventually, severe ion
imbalances occur in me body. T he blood also becomes more acidic because two of the
three forms of kct0ne bodies contain acid groups. The resulting condition, known as
diabetic lwtoacidosis (DKA), can induce coma or death if not u·eatcd immediately, such
as with insulin, electrolytes, and fluids (see Chapter 5 for more derails). Kctoacidosis
usually occurs only in ketosis caused by uncontrolled type 1 diabetes; in fasting, blood
concenu-ations of ketone bodies usually do not rise high enough to cause the problem.
I Lipogenesis: Building Fatty Acids

Lipogen esis is the formatio n of lipid. T he majority of rbc patl1ways used arc found in lipogenesis The building of fatty acids using
the cyrosol of liver cells. Ingested protein or carbohydrate that the body docs not use derivatives of acetyl.CoA.
immediately can be converted into triglycerides and srored as such. Some of the pro-
tein can reside in amino acid pools in the body, but the amoLmt is not significant. Most
carbohydrate is stored as glycogen, but the total amount rarely exceeds 350 g in the
encire body. Thus, when a lot of amino acids and/or glucose are left over in the body
after a large meal containing protein and/or carbohydrate, some of rhe carbons can be
used to synthesize fatty acids. (It is typically of minor importance in humans, how-
ever.)17 This process requires ATP and the B-vitamins biotin, niacin, and pantothenic
acid. Because ATP is used, lipogenesis is an energy-losing proposition for a liver cell.
In Jjpogcnesis, me liver begins with carbons from glucose and the carbons from
amino acids that arc metabolized to acetyl-CoA. Cells in the liver bond the acetate
malonyl·CoA Building block in fatty acid parts of aceryl-CoA molecules (actually in the form of malonyl-CoA) together in a se·
0 0 rics of sreps to form a 16-carbon saturated fatty acid, palm.itic acid. Insulin increases
II II activir)' of a ke)' enzyme used in the pathway (fatty acid synthase). This 16-carbon fatty
synthesis: HO-C-CH 2- C- Coenzyme A acid can later be lengthened to an 18- or 20-carbon chain either in the cytosol or mi-
very·low·density lipoprotein (VLDL) The tochondria.2 llltimately, the fatty acids are joined to a form of glycerol (produced dur-
lipoprolein created in the liver that carries both ing glycolysis from gl~1ceraldehydc 3-phosphate) to yield a t:riglyceridc. Tbe t:rigl)1ccridc
the cholesterol and the lipids token up from the is later re leased to the general circulation as a very-low-density lipoprot ein, or
bloodstream by the liver and those that are VLDL (see Chapter 6). CeJJs that take up fat may use it for ATP production, or it may
newly synthesized by the liver. be stored in cells (mostly adipose cells), alo ng with otl1er fats that originate Ii-om di-
etary intake.
Concept I Check
Fatl) acids are degraded into mm1erous acctyl ·CoA molecules. These molecules participate
in the citric acid q 1cle and electron transport chain to yield carbon dioxide, water, and ATP.
To synthesize fat, a cell binds numerous acct<ltC molecules together to form ;i fatry acid.
Three nmr acids can then be joined to glycerol to }'icld a triglyceride. If •lCCtyl-CoA oxida-
ticm in lin:r cells is limited, such as in cases of long-term fasting, the acctyl-CoA resulting
from fatty acid oxidation tends w force the production of ketone: bodic5. Thr.:sc ketone
bodies enter the bloodstream and arc: eventually metabolized to carbon dioxide and water
(after being converted back co acetyl-CoA) by \'arious cells. In lipogencsis, carbons origi-
nally donated by acctyl-CoA arc used ro form farry acids.
Protein Metabolism
Protein metabolism begins after proteins are degraded into amino acids. To use an
amino acid for fuel, cells musr first split off the amino group (-NH?) (see Chapter 7 ).
These pathways often require vitamin B-6 to function. Removal of the amino group
carbon skeleton What remains of on omino produces carbon skeletons, which mostl)' enter the citric acid cycle. Some carbon
ocid alter the amino group hos been removed. skeletons also yield acetyl-Cof\ or pyruvaLc (Figure 4-16 ). 3
Amino acid metabolism mostly takes place in tl1e liver. Only branched-chain amino
acids- leucine, i&oleucine, and V<lline-are metabolized primarily at other sites-in tlus
case, the muscles.8 Branched-chain amino acids are added to some liquid meal re-
placement supplements gi\'en to hospitaJized patients. Some fluid replacement formu-
las marketed to athletes also contain branched-chain amino acids (sec Chapter 14).
It is important ro norc that some carbon skeletons enter the citric acid cycle as
acetyl-CoA, whereas others form intermediates of tl1e citric acid cycle or glycolysis.
Any part of the carbon skeleton that can bypass acetyl-CoA and enter the citric acid
he steps in protein synthesis are covered in cycle directly, or form pyru\'ate, can evenniaJJy become part of glucose via gluconeo-
Chapter 7. genesis. Such is rrue for the amino acids alanine, methionine, arginine, histidine, as-
partic acid, and others ( rcviC\\ Figure 4-15 ). 2
Producing Glucose from Amino Acids and Other Compounds

Tbc entire pathway to produce g lucose from compOLmds such as certain amino acids-
gluconeogenesis The production of new g luconeogenesis-is present only in liver cells and in certain kidney cells. A t)rpical
glucose by metabolic pathways in the cell. starting material for th.is process is oxaloacetate, wluch is derived primarily from tl1e
Amino acids derived from protein usually carbo n skeletons ofsome amino acids, mostly the amino acid alanine. Pyrn\'ate can also
provide the carbons for this glucose. be converted to oxaloacetatc ( review Figure 4-16 ).
The 4 -carbon oxaloacetate loses one carbon dioxide and converts to a 3 -c.u·bon
compound phosphoenolpyruvate, which d1en re,·erses tl1e path back through glycoly-
sis to glucose. It takes rwo of this 3-carbon compound to produce the 6-carbon glu-
cose. Some steps in gluconeogenesis are simply a n.:vcrsaJ or variation of the glycolysis
<
NH3
pathway. This entire process requires ATP as well as cocnzyme forms of the B-vitamins
biotin, ribollavin, niacin, and B-6. 3 CH3-CH ~
To learn more about gluconeogencsis, exam ine Figure 4-16, which traces the p:uh-
C-OH
way in converting glutamic acid, an amino acid, to glucose. Glutamic acid first loses its
Alanine
amino group to form its c:ubon skeleton. This enters tbe ciL1ic acid cycle directly and
is converted by stages to oxaloacetate. Oxaloacetutc loses one carbon as carbon diox-
ide, and the 3-carbon phosphoenolpyruvate produced then moves through glycolysis C02 lNH3
to form glucose. EvencuaJJy, two gluramic acid molecules arc needed to form one glu-
cose molecule.
0
II
1
0
II
0
II
Gluconeogenesis from Typical Fatty Acids Is Not Possible
- o - c - C - CH2-C-O
Why can't a typirnl fatty acid be turned into glucose? A fatty acid with an even num-
Oxaloacetate
ber of carbons- the typical form in the body-breaks down into many acetyl-CoA
molecules. The step between p)'ruvate and acetyl-CoA is irreversible; •Ketyl-CoA can
never re-form into pyrurnte once the carbon dioxide molecule is lost. The only option
Figure 4-16 I Gluconeogenesis. Carbon

skeletons of amino acids that become pyruvote
(such as alanine, glycine, cysteine, serine, and
2X threonine) !step l) or enter directly into the
citric acid cycle (such amino acids include
osporogine, arginine, ospartic acid, histidine,
Phosphoenolpyruvote glufomic acid, glutamine, isoleucine,
(PEP) methionine, praline, voline, and phenylalanine)
(step 3) or are called glucogenic amino acids
because these carbons con become the
carbons of glucose. Any parts of carbon
Glucogenic
amino acids, skeletons that become ocetyl.CoA ore called
such os alanine ketogenic because these carbons cannot
become parts of glucose molecules (step 2).
These include leucine and lysine, and parts of
isoleucine, phenylalanine, tryptophon, and
tyrosine. The deciding factor is whether port or
all of the carbon skeleton of the amino acid
Acetyl-CoA EJ yields o "new" oxoloocetate molecule during
metabolism, two of which ore needed lo form
glucose (step 4).
Citric acid Glucogenic

0
cycle amino acids,
such as
glutomic acid [@
()
Glucogen\c
amino acids,
such as voline
then for acctyl-CoA, besides forming fatty acids or kctones, is to combine with
oxaloacctate in the citric acid cycle. However, two carbons of acctyl·CoA are added to
oxaloacctate at the beginning of the citric acid cycle, and two carbons are subsequent!~·
lost as carbon dioxide when citrate converts back to the starting material, oxaloacerate.
So at tl1e end of one cycle no carbons arc left to UJr.n into glucose. Thus it is impossi·
ble to convert typical fatty acids into glucose.3
The only part of a triglyceride that can become glucose is tl1e glycerol portion.
Propionyl-CoA formed from tl1e metabolism of odd·chain fatty acids can do tlie same.
Glycerol enters into the glycolysis pathway, and propionyl-CoA can directly enter tlie
citric acid cycle at succinyl-CoA. Propionyl-CoA can then flow tl1rough the citric acid
cycle to oxaloacetate and then tl1rough the process of gluconeogenesis to convert to
glucose. G lycerol can follow tl1e gluconcogenesis patl1way from glyceraldehyde 3-
phosphatc to glucose. Glucose yield from tliese compounds is insignificant, however,
because tlic body produces li ttle propionyl-CoA and only about 10% of the molecular
weight of a triglyceride is glyccrol. 2
Recall from the earlier discussion on ketosis tliat if there is an insufficient amount
of carbohydrate in tl1e body to meet ongoing needs, tl1e liver and kidneys arc forced
to synthesize glucose from body protein to support tl1e energy needs of the brain and
red blood ct:lls. Liver and kidney cells primarily begin witl1 carbon skeletons from
amino acids that are able to directly enter the citric acid cycle or form pyruvate. These
compounds are converted to oxaloacetate, tlien to a 3·carbon intermediate com-
patmd, phosphoenolpyruvate, and fina.Uy to glucose. lnitia.Uy when a person fasts, the
Liver performs about 90% of total body gluconeogenesis. This falls to about 60% in pro·
longed fasting.
Disposing of Excess Amino Groups from Amino Acid

Metabolism
The catabolism of amino acids yields amino groups (-NH2 ), which tl1en form ammo-
nia (NH 3 ) . The ammonia needs to be excreted because its buildup is toxic to cells. The
Liver prepares the amino groups for excretion in the urine using tl1e urea cycle. During
the urea cycle, two nitrogen groups-one ammonia group and one amino group-
react through a series of steps with carbon dioxide molecules to form urea
0
II ,
(H,NCNH,) and water. Evcnru.tlly, urea is excreted in the urine (Figure 4 -17):' In
live~ diseai.e~ ammonia can build up to toxic concentrations in tl1c blood, whereas in
kidney disease the toxic agent is urt:a. The form of nitrogen in the blood- ammonia
or urea-is :i di:ignostic tool for detecting liver or kidney d isease.
Concept I Check
Individual amino acids lose an amino group and become carbon skeletons. Many carbon
skeletons can be further metabolized so that they cmer either the citric acid cycle or the
glycolysis pathway. The carbons can thcn proce1.:d throL1gh gluconeogenesis to form new
glucose. If the carbon skeleton forms acetyl-CoA, glucose production is not possibk from
that part of the amino acid. The amino groups go on to form parr of urea, which is ex-
creted rrom the bod)' in urine.
Amino ocids
Figure 4· 1 7 I Disposal of excess amino
groups. The nitrogen groups, one os
ammonia and rhe other os on amino group,
form port of urea, which is excreted in
0
II
Ammonia + Amino group + C02 urine (H 2NCNH 2). The nitrogen groups
(NH3) (- NH2) originally come from amino acids that went
through tronsominotion reactions ond ultimately
deominotion to yield the free nitrogen groups.
Kidney
Out of body
What Happens Where: A Review

Glycolysis rakes place in the cyrosol of a cell. The end product of glycolysis, pyruvace,
enrers the mitochondria, where it is ti.u-ther degraded in the cin·ic acid cycle. The
NADH + H + made in the cytosol d ming glycolysis must be shuttled into the mito-
chondria if the electron transport chain is to be used to convert NADH + H + back to
NAD+ and simultaneously produce ATP. The type of shuttle determines how many
ATP each NADH + H + yields. Generally, 2.5 ATP arc formed. One type of shuttle
system results in the loss of one potential ATP, so only 1.5 ATP result. 2
Fatty acid oxidation also occurs in tl1e mitochondria. The product of bcra-
oxjdation, acetyl-CoA, is metabolized by the citric acid cycle in the miLOchondria.
Fatty acids arc synrhcsized primarily in the cytosol. 2
Gluconcogcnesis begins in the mitochondria with the production or oxaloacetate.
OxaJoacetate cventuaJly returns tO the cyrosol, where new glucose is produced. The
same is true for the mea cycle; some sragei. occur in the cytosol and some in the
mitochondria ( Figure 4-18 ).2
Figure 4· 18 I A bird'Hiye view of cell

metabolism. Note that acetyl-CoA forms a
crossroads for many pathways and that the Triglycerides
citric acid cycle con also be used to help build
compounds, such as certain amino acids.
Anabolic and cotobolic processes may appear
to shore the some pathways, but generally this
is true for only o few steps. Separate enzymes Glycerol Fatty acids
control anabolic and cotobolic flow in o
pathway. This allows the cell significant control
over metabolism, since o specific set of
enzymes con be activated to promote either
anabolism or cotobolism. If the chemical
reactions in anabolism and cotobolism were -~
..
catalyzed by the some set of enzymes, the c
Q)
direction of flow of compounds through these 8:

:..::;
pathways would be dictated exclusively by the
concentration of the starting materials rather
Lipolysis and fatty acid oxidation
than by the cell's changing needs for energy or Phosphoenolpyruvote
synthesis of needed compounds.
Proteins
Amino acids
Since the electron tr.111sport chain yields mo!>t or the ATP for the cell, die mito·
chondria are the cell's major energy-producing organelles. Cells that need to m:ike :i
lot of ATP, such ~1s muscle cells, have thousands of mitochondria, whereas celb that
need vt:ry little ATP, such :is adipose cells, have fewer mitochondria.
Energy metabolism can take 111:111y forms in the body. By stringing together the gly-
colysis p.1thwa>' and the citric :icid cycle, cells c:in convert carbohydratt:s into fatty
acids, convert carbohydr:itcs into c:irbon skeletons for synthesis of certain amino acids,
and use the energy in carbohydrates to fo rm ATP (review Figure 4 -18 ). These path-
ways can also turn carbon skeleto ns of some amino acids into carbon skeletons oth- or
ers. Furthermore, they can convert carbon skeletons from some :rn1 ino acids ro glucose
or have them drivt: ATP synthesis. Finally, farry :icids can provide energy for ATP '>yn-
thesis or produce ketone bodies. The glycerol part of the triglyceride can eith1.:r be
converted into glucose and be used for fuel, or can contribure to ATP synthesis via par-
ticiparion in glycolvsis, citric acid cycle, and electron transport chain metabolism
(Table 4-1 ).
Regulating Metabolism
Among the organs, the li\'t:r plays the major role in n:gulating metabolism: it responds
ro hormones and makes use of vitamins. Addition:tl means of regulating metabolism
involve enzymes, ATP com:entralions, and minerals. 3 ~ ~
Table 4·1 I Summary of Energy-Yielding Nutrient Metabolism

Contributes Yields fot Energy Cost
to Energy Yields Amino Acids for Adipose of Conversion to
Nutrient in Diet Needs? Yields Glucose? for Body Proteins? Tissue Stores? Adipose Tissue Stores
Carbohydrate Yes Yes Yes, can provide carbons Yes, but not High
(glucose} for the carbon skeletons of readily
certain amino acids
lipid Yes Generally not; the glycerol Indirectly by adding carbons to Yes Minimal
(triglycerides) present provides a minimal oxaloacetate that then can form
amount a carbon skeleton for certain
amino acids from a citric acid
cycle intermediate
Protein Yes, but generally Yes, excess amino acids can Yes, but not readily Yes High
(amino acids) not much be converted to glucose
The Liver
The liver is the location of many nutrient inrercon\'ersions (Figure 4 -19). f\1lost nuu-i-
ents must pass first through the li"er after absorption into the body. Whac leaves the
U\'Cr is often different from \\"hat entered. Key metabol ic hmctions or
the liver include
conversions between ,·arious forms of simple sugars, fat and cholestero l synthesis, pro-
duction of ketone bodies, am ino ~Kid metabo lism, urea production, and alcohol me-
tabolism. Nutrient storage is an ,1dditional liver function.8
Enzymes 1• " ~ - . TL.IHt.j{ln

1
.,
Enzymes are the key regulators of metabol ic pathways; both rheir presence and their
rate of acti\'iry arc critical ru chemic,1! reactions in rhc body. Enzyme S)'nthesis and rares If you hod unlimited resources to design o drug
of ac.:ti,·iry .m: controlled by cells and by the products of the reactions in which the en- that inhibits lipogenesis, which aspect of cellu-
zymes participate. For example, a high-protein dicl leads to increased synthesis of cn- lar respiration would you look to affect? What
zymcs associated with amino acid catabolisrn and gluconcogcnesis. With.in hours of a unintended metabolic consequences might re-
shirr to a low-protein diet, the synthesis of' rnzymcs associated wirh amino acid me- sult From using such a drug? Reviewing Figure
tabolism will slow. 3 4-18 might help you answer this question.
Urea Figure 4· 19 I Liver metabolism. Most

nutrients must poss first through the liver after
absorption into the body. What leaves the liver
Blood proteins is often different from what entered. VLDL
stands for very-low-densily lipoprotein. This
Amino lipoprotein carries fat from the liver to other
acids Aminoocids body cells (see Chapter 6 for details).
I Glycerol,
glucose,
VLDL
golactose
[Giucose
Fructose Lactate
Hormones
Hormones, including insulin, scr\'e as regulators of metabolic processes. Lo\\ It:' cl~ of
insulin in the blood promote gl uconcogenesis, protein breakdown, and lipolysis.
Increased blood insulin promotes the synthesis of glycogen, far , and protein.
ATP Concentrations
ATP concentration in a cell plays a role in the regulation of metabolism. High ATP
concentrations decrease energy-yielding reactions such as glycolysis and promote ,111a-
bolic reactions, such as Upogencsis, that use ATP. High ADP concentrations, on the
other hand, stimulate energy-yielding parhways. l2
Vitamins and Minerals

Many vitamins and minerals participate in metabolic pathways (Figure 4 -20 ). Mosr no-
table are the B-vitamins thiamin, riboflavin, niacin, pantothenic acid, biotin, vitamin B-6,
fobte, and ' citamin B-12 as well as the minerals iron and copper. Because so m:rny
metabolic pathways depend on mmient input, health problems can develop from
nutrient deficiencies. 8 The roles that \'itamins and minerals play in metabolism ''ill be
discussed in greater detail in Chapters 9, 10, 11, and 12.
Concept I Check
Glycolysis takes place in the qrrosol of the cell; the transition n:action, cin-ic acid c~·de, and
electron rransporr chain occur in micochond1ia. Fatt~· acid oxidation occurs in mitochondna;
ratty acids are symhcsized mostly in the cytosol. Both urea formation and gluconcogenesis mke
place in both mitochondria and the qrrosol. Hormone balance, enzyme activity, and the need
for ATP all influence the rare at which these metabolic pathways operate. Because many mcca-
bolic pathwayl. converge al acetyl-CoA, it is ccnm1l to energy metabolism.
Carbohydrates r-
IJ __ Lipids Proteins
(glycogen in particular)
Niacin Vitamin B-6

Vitamin B- 12
Vitamin B-6 Fatty acids and gycerol Niocin Folote
Vitamin C
Niacin RiboAovin
Vitamin K
Biotin Thiamin
Pantothenic Niacin
Monasoccharides ocid Amino acids
Pontothenic acid
Biolin
Thiamin Thiamin Vitam in B-6
-- I
Vitamin B-12
Niacin Vi tamin B·6 Biotin Folote
Pontothenic .__ _ _ _ _ _• Acetyl·CoA Folote Vitamin B-12
acid (pantothen_ic_ a
_ c_id
_l_ -1""'. ,__ _ _ _ _ _ _ Vitamin B-l 2
Biotin
RiboRovin
Thiamin Folate Vitamin B-6
Magnesium
RiboAavin Vitamin B-12
Niacin Iron
Capper
----
Figure 4·20 I Many vitamins and minerals participate in the metabolic polhwoys.
Fasting and Feasting
This chapter ends with a brief discussion of the conscguenccs of fasting and feasting.
Some of the material in this section will repeat whar you ha\'e already learned, and
some will sen ·e as a prc,•iew for subsequent chapters.
Fasting
When individuals fast, their metabolic rate slows, reducing their need for energy. The
decrease in metabolic rate is due to decreased food intake and organ breakdown (pro-
tein breakdown). With die resultant fall in insulin production, fasting encourages
gluconcogenesis, protein breakdown, and far breakdown with subsequent production
of ketone bodies (F igure 4 -21 ).5,l3 Loss of body protein, as it is broken down for en-
ergy, is rapid until the nervous system adapts to using ketone bodies for energy. For
the first few days of a fast, protein supplies about 90% of needed glucose, with the re-
maining 10% coming from glycerol. (ln prolonged fasting , about half the body's en-
ergy needs are met by ketone bodies; only 5% of energy use comes from glucose that
was made from w1ino acids. )
Sodium and potassium depletion can also result as die two elements are drawn i.nto
tbe urine along "~th kerone bodies. Fina11~1, increased blood urea levels result because
of the breakdown of protein.
The maintenance of body protein mass is .1 key ro survi\'al in semistarvation or fast-
ing. Dead1 is seen when ;1bout half the body protein is depicted, usually coming after
about 50 to 70 days of total fasting.
Feasting
The most obvious result of foasting is the accumul;1tion of body fat. ln addition, feast-
ing, wirh rhe resultant increase in insu lin production by che pancreas, encourages the
burning of glucose for energy needs as well as the synthesis of glycogen and, to a lesser Feasting especially encourages the synthesis of
exccnc, prorci.n and fat (Figure 4-22 ).5.17 glycogen and storage of fat.
Excess Carbohydrate
Any carbohydrate consumed in excess will first be used to ensure that glycogen scores
are maximized. Once glycogen stores ha\'c been filkd, die consumption of carbohy-
drate \\i.ll stimulate carbohydrate catabolism. This then k ssen5 the need for any fut
Fasting Figure 4·21 I Fasting (solid line) initially

encourages use of glucose, fatty acids, and
Energy need] amino acids for energy needs. Prolonged
fasting (dashed line), which ends up depleting
I I
glycogen stores, leads to increased production
Ketone I I Ureo of glucose from both glycerol and certain
bodies •• \. J Glucose
]• f carbon skeletons of amino acids. This supplies
NH3_}
glucose to glucose-dependent cells, such as red
blood cells. Ketone body production also
increases.
Glucose Fatty odds Glycerol Aminoocids
1 l
Corbohydrole
(from glycogen)
Fol
(from adipose stores)
1
Protein
(from body cells)
Figure 4·22 I Feasting (solid line) Feasting

encourages glycogen and triglyceride synthesis
and storage and allows amino acids to
participate in the synthesis of body proteins.
Glycogen J L Triglycerides J
Minimal synthesis (dashed line) of fatty acids
using glucose or carbon skeletons of amino
Glycerol phosphate Body proteins
acids occurs unless intake is quite excessive in
comparison to overall energy needs.
catabolism. There are two caveats to this statement. First, recall that carbohydrate con-
sumption stimulates insulin secretion, and increased amounts of insulin in the blood
have an affect on rat
metabolism . Second, if excess energy is consumed, carboh)rdratl!
can be synthesized into fat and so contribute to body fat stores. However, again this
pathway is nor very active u1 hLUnans. 17 l n addition, it is energetically expenl>ive w con-
vert carbohydrate to body fat ( review Table 4-1 ).
Excess Protein
Contrary to \\ ha1 you may have heard, rncreased protein/amino acid consumption
asling encourages does not promote muscle development. Any protein rnnsumed in excess wil l fir!>t
stimulate increased protein catabolism and then will contribute to far synthesis and the
Glycogen breakdown
accumufation of body for. 8 However, the e nergy cost of converting protein into bod~·
Fat breakdown
fat is higher than ir is for rhe conversion of dietary far to body far (review Table 4-1 ).
Gluconeogenesis
Synthesis of ketone bodies
Excess Fat
easting encourages Unlike rhe consumption or excess carbohydrare and protein, consumption of fur does
Glycogen synthesis not promote fat carabolism. Most of the fat in a meal goes immediately into storage in
Protein synthesis adipose cells.8 Furthermore, compared t0 the conversion of carbohydrate and prorcin,
Fat synthesis rebth·cly little energ~· is required to convert dietary fat into body fut. Therefore, high-
Urea synthesis far diets promote ::iccumulation of bndy fat (review Table 4-1 ).
As you have learned in this chapter, one of Ana's friends got ii wrong and the
other two did not quite gel it right. W hile ii requires a large amount of energy
lo convert either carbohydrate or protein into body fat, ii takes very little energy lo con-
vert dietary fol into body fat. In addition, a gram of lot contains more energy than a
gram of either carbohydrate or protein, so if Ana eats equal amounts of carbohydrate (or
protein) and fol, she will obtain more energy from the lot than from the carbohydrate (or
protein). Still, Ana says she likes to eats a lot, but this does not mean that she is allowed
as much carbohydrate or protein as she wants. Excess consumption of any energy-
yielding nutrients-carbohydrate, protein, or fat-wil l ultimately lead to the accumulation
of body fat.
Inborn Errors of Metabolism
Your knowledge of metabolism Im a \'Cry practical of the substance char must he cat.1bolizcd, such ~
application: some people h;wc inborn errors of me· phenylalanme. Other e\<tmpb of thcr.ipies in spe-
tabolbm. Tiu~ means elm the person lacks a !ope· cific case-. include ph.1m1.Kologic;1I doses of 1ita·
cific enzyme ro perform normal metabolic mins, such as 1ir.1min B 12, .\lld repl.\ccment of
functions . The metabolic path\\'a)' in which this en- the blocked produce, such .1s chc amino acid tyro·
zyme is supposed to participate nm1 no longer sine in PKU (see the nex r ~cc ti on tix detai b).9
functiom properly. Typically this will cause altcrna-
ci\'e metabolic prouuCl!> to be formed, some or Phenylketonuria
\\'hich arc toxic 10 the body.
The majoriry of easel. ol PKU <>Lc111· bcGtusc the en -
Ho\\' dm:s a pcrson develop .111 inborn error of
zyme phenylalanine hydroxyhi\e docs not !'unction
metabolism? The person inherits ddecri1•e gene
efficiently in the li\'cr. Because of thb, phenylala-
codjng for a specific c111yme from both parents.
nine builds up in the blood ol 1hc person with
Both parent~ arc like!\ LO he carriers in that the~
PKU. If not correcccd early (\\ithm 30 days of
ha1·e one hcJltlw gene Jnd one dctccti\'c gene for
birth ), rhi~ buildup of phcnv1.1l.\llinc lead\ to pro-
the cnzrmc 111 their chromosomes. Each parem
duction of toxic phcrwlalanme h\' product~, such as
then donates the dcti:rnn: form of the gene to the
phenylpyru\'ic acid, 11 h1ch chen cJn lc.1d to m ·crc
otEpring, c.lllsmg the olhpring w ha11: two dclcc-
mental rctardation. 6
tin: copic~ of the gene, Jnd therefore lictk or no
PKU occur~ in about one per I 0,000 births.
actinry of the cnz) me tlut the gene normally
,\lost carriers can he dccccrcd w11h a \1111pk blood
would produce. Chapter 7 will cm·er in detail ho\\'
test. People of Irish descent arc espco.111} alkcccd.
a gene is used to produce proteins such as enzym~.
Toda~. most infants an: di.1gnmcd \\ 1th111 a lc11 days
For nm1, rc.1lize th.it if .1 person has a ddcctin:
of life and arc starred on .1 phcnvlal:minc restricted
gene, he or she 11 ill produce a dcfi:cti\'c protein
dicc. 1+ This dice utili1cs a lo\\ ·phcnyl.1lanine infant
based on rhe insrruccion' contained in that <ldi:c-
formula, which is 1·cry expt.•mi1e. During infanq,
t11·c gene. There is also the possibility that one or
nutritional needs can change on .1 week!) b.1sis, so
both p.m:nts 111.1r •lCtti.\ll~ h.\\'e the disease thcm-
these infunts :ire monitored rnntinually rhrough
sch·es and not simplv be c.micrs. Generally, ho\\'-
blood phenylal:minc resting.
ercr, these indi\'idu.1ls arc rounsclcd Jgainst having
Phenylalanine, protcrn, and energy intakes
children, or .ll the vcr) lc.\Sl shou ld sec a generic
must be c.tn:full)• moniwred. 1 rhc .1mino Jcid An infant who does not develop
counselor w ,\ssess 1he rbk of passing th1: inborn properly may have an inborn error or
phenyl.llaninc is .m csscmi.11 11u1ricnt, which means
error of metabolism on t0 their offspring. metabolism. A physician needs to
that Cl'cn someone wi 1h PKU h.is to obtain phcnyl-
Some char.1Crcristics of inborn errors ofmw1b- investigate this possibility.
.1l:tni.ne from his or her dic1; htmC\cr, 1he ,1moum of
olism include the follo\\'ing: 19
phcnyhi.J~mine consumed needs to be monitored 6
• The\ .lppe.1r ~oon after birth. Such a disorder i~ cardi.tlly co pm ent toxic .1mmmts from building up.
suspected 11 hen otherwise physically \\'ell children Starting in infancy, spcci.11 fi>rmul.1s .1rc .11 ail·
de1 clop los' of appcrne, 1omiring, dclwdrarion, Jbk to pro1·ide nutrients for indirn.iuals 11·ith PkT.
physic.ii wc.1knc~s. or de1·clopmcnral delays ~oon Because infants h,l\'c h1gh-procein needs, sans~·mg
J.ltcr binh. I-or some of these condinons, infants protein rcqu1remenrs-w1thou1 Jl'o hal'lng high
.ire ~crecned for che potential to lm·e J specific in· intake~ of phcnylal.111111c-is 1mpms1bk '' ithout
born error of mcr.1boli,m, ~uch as phcnylke- rhcsc special!\' prepared formulas Some of chesc
conuria (PK.LI ). (Rei 1c11 the discussion of PkLJ in formulas pro\'idc no phcnylal,111111c; others prm·ide
Chapter I.) J small amount. for infants, formul.b .ire designed
• The~ .1rc \'Cr~ ~pcc1tic, imoh'ing only one or a fc11 to prm idc about 90%or protein needs .md 80%of
enzymes. These c111\'mes usual!~ participate in energy needs. Human milk or rcgul.1r mfant for ·
catabolic p.llll\\ .ws (in \\ltich compounds arc de- mula then c.111 be used ro ntJke up rhc dillcrcncc.1 9
graded), ~uch ~for the .1mino acid phcnyl.i.Janinc. L.1tcr in life, food~ un he 11!\cd to m.1kc up
• No cure is pmsible, bur tvpic.1lly the~· can be con- the difference, e~pcciJlly food~ low in phenylJla·
rrollcd. This control might include reducing intake nine. Fruits and \'Cgcrablc~ .1rc n.11urally low in
143
~uffkicnt phenylalanine hrdroxylJse .icrivicy \'er~ serious b:icrerial intcxriom, men
NormJI: phcnyl.1l.111inc ryrosinc tal retardation, and cat.1racts m the
eye. An inf.tnt with galacro~cmi:l typi
reduced phenylalanine hydroxylase Jcci,·iry phem lpyrll\ ic acid callr dc,·clops \'onliting .ilTcr .1 1;;,,
PKU: phcnyl.1hrn111c ----------------~ phcmll.Ktic .icid days of consuming infant formul.1 or
{
other rcl.ncd product!> breast milk. BO(h cont.iin much gabc-
tose as part of the milk sugar lactose.
This child will be switched to a soy
formula. ln addition, all dairy prod
ucts and other lactosc-contai ni ng
products (butter, milk solids), organ rne.m, and
phenylJlaninc, :rnd breads .md cereal\ ha\'e .1 mod- some fruits and vegetables must be avoided. Srrict
erate Jmount. Dairy producrs, eggs, rm:.m, nuts, l.1bcl n:ading is also important for controlling rhc
and cheeses arc \'Cry high in phcm J.il.inim: .md so tfocasc bcc:lusc lactose can be found in a \'.lriCt) ot
arc not JIJowed on the dice. Diet sofi: drinks and products. Note that even in \\CIJ-conrrollcd ca~cs,
other fCmds and bc\'cragcs comaming the altcrna slight mental retardation (such as ~pccch dclJ\ s)
tin: sweetener aspartamc are .ilso not Jllowed he .111d catar.lct:s are seen. GaJacwscmia ocrnrs 111 I in
cause these conrain phcnyh1l.1111ne (sec Chapter 5 65,000 births. 15
for details). Older children :ind adulrs can use .1 for-
mula that is \'Cry lo\\ in phenylalanine, which .1'
lows the person ro consume more foods hut still
limits intake of phcnylalaninc. Overall, the nl.ljont)'
G lycogen Storage Disease
of the person'!. nutrient intake throughout life ''ill Glycogen storage disease is a b'TOUp of disease~ that
come from a special formula. Nore that thb for result from the inability to metabolize glycogen to
mula has a \'cry disagreeable smell and t•lste. glucose in the liver. There are a number of possible
The diet is ideal!) followed for life. Physiciam enzyme defects along the pathway from glvcogcn
used LO recommend chat it was appropriJte to en<l to glucose. The most common forms cause poor
the diet after age 6 because brain development ".1s physical growth, lo\\' blood glucose, and li\'cr en
complete. Later it was found , however, that diet largemcnt, and occur in 1 in 60,000 births. Low
discontinuation led to decreased intelligence and blood glucose rcsuJrs because liver glycogen break·
Children with PKU must be careful not lo behavior problems such as aggressiveness, hypcrac down is typically used to maintain blood glucose
consume diet soh drinks con taining
tivity, and inattention . 19 between meals (see Chapter 5 for derails). People
asportome, which conloins
If a woman with PKU has abandoned the diet, wit h glycogen storage disease typically have ro con
phenylalanine.
she needs ro return to the diet at leaM 6 months be- sume frequent meals in order to regulate blood
fore becoming pregnant. 4 Otherwise the fetus glucose. They also consume raw cornstarch be-
even though it docs not lm·e PKU- will be n1ec11 meals; this is slowly digested and so helps
exposed ro a high blood phenrlalamne Jnd related maintain steady blood glucose. Careful monitoring
toxic produces from the mother. This could result of blood glucose is \'cry important in these people
in mi!.carriage, or d1c infanr could be born with a in order to know when blood glucmc 1s too lo\\
low birth \\eight or heart defects. and needs co be treated. 19
galactosemio A rore genetic disease
choroclerized by the buildup of lhe
single sugar goloctose in the
A number of other \"Cf} rare inborn errors of
bloodstream, resulting from the inobilily Galactosemia metabolU.m involve \'3rious amino acids, fatl) acid~,
of the liver to metabolize ii. If present at and the sugars fructose and sucrose. Typicall\, in
birth and left untreoled, this disease con In galactoscmia, rwo principal specific enzyme de large hospitals and in state health dcp.lrrme1m,
cause severe mental retordalion and fects lead to a reduction in the galacwsc metabolism physicians, nurses, and registered dietitian~ c1n
cataracts in the infant to glucose (J third form is very rare). GalJctose then help .1ffocted persons and their fami lies with the~c
builds up in rhe bloodsrream, which can kad to ,111d other inborn errors of metabolism. 19
144
Summary
1. Planes caprun: solar energy by way of photosynrhcsis. VirtuaJJy all 9 . During low carbohydrate intakes and uncontrolled diabercs, more
energy available to foci the human body ultimately comes from acccyl CoA is produced in the liver rhan can be 1nerabolizcd to
the sun ,\S solar energy. carbon dioxide and warer. This excess aceryl-CoA is synthesized
2. ATP is rhe major form of energy used for cellular mc.:tabolism. As inro kct0ne bodie~, which flood into the bloodstream and arc me-
ATP breaks down to ADP plus P;, energy is rclc.:ascd from Lhc bro- mbolized by orhcr tissues, such as nervous rissue.
ken bond. In humans, mer;lbolic path\\'ays make it possible to cx- 10. When amino acids arc broken down, they lose their amino groups
rracr energy from C- H bonds in food and transform it imo ATP; and become carbon skeletons. These can be metabolized to other
in the process, some energy is lost as hear. compounds that cmcr the citric acid cycle, eventually yielding en-
3. In glycolysis, glucose is degraded into rwo pyruvarc molecules, ergy for ATP synd1csis. Some carbon skeletons can be formed into
yielding NADH + H + (a form of potential energy) and ATP. oxaloacctatc, an intermcdiare found in me citric acid crcle, which
Pyruvate c;111 proceed d1rough aerobic pathways to form carbon in turn can be used to form glucose. Converting the carbon skele-
dioxide and warcr. Pyruvatc also can react with NADH + H "" in rom of amino acids ro glucose i~ part of a process known as
an anaerobic pathway tO form lactate. Both pathways allow gl uconeogenesis.
NADH + H + to eventually be re-formed into NAD \ which ls l l. Acct:yl-CoA molecules, and thus fatty acids in general, cannot par-
needed for glycolysis to continue. ricipate in gluconeogenesis.
4 . Prior w entry into die citric acid C)'Clc, pyruvare is formed into 12. Glycolysis takes place in the cyrosol of a cell, whereas the transi-
aceryl-CoA in what is called a transition reaction. One NADH + tion reaction, the citric acid cycle, and the eleco·on transport chain
H + is produced and one carbon dioxide mokcuk is released. rake place in the mirochondria. Farry acid oxidation takes place in
5. Aceryl-CoA undergoes many metabolic conver~ion~ in the cioic the mitochondria, and fatty acids for d1e most part are synthesized
acid cycle, eventually yielding two more carbon dioxide molecules. in the cytosol. The synthesis of urea and the pathway for gluco-
In this way, tht: citric acid cycle accepts rwo carbons from acecyl- ncogenesis both rake place partly in me cytosol and partly in the
CoA and yields two carbons as carbon dioxide. In the process, mitochondria. Urea is made in the liver, while glucose is made in
NADH + H+, FADH 2 , and a form of energy thar can yield ATP the liver and kidneys.
directly (GTP) arc formed. L3. Aceryl-CoA is pivotal in cell metabolism because carbohrdrares,
6. NADH + H + and FAD HJ enter the clcco·on transport chain to proteins, amLno acids, fatty acids, and alcohol all can yield acer:yl-
yield numerous ATP moleC°uJes. Water forms as oxygen combi_ocs CoA during their metabolism. The coordination of various meta-
\\~th the electrons and hydrogen ions (released from NADH + bolic pathways for food fuels allows the carbons of glucose to
H + and FADH2 ) in the electron transport chain. become the carbons of fatty acids and the carbons of some amino
7. In furry acid oxidarion, 2-carbon fragments arc cleaved from a fatty acids to become the carbons of glucose.
acid at a time, producing multiple acetyl-CoA molecules. These 14. Tbe vitamins rhiamin, niacin, riboflavin, biotin, pantothenic acid,
enter the citric acid cycle and electron transport chain, and as did and vitamin B-6 and the minerals magnesium, iron, and copper
the aceryl-CoA that arose from carbohydrate breakdown, yield play important roles in the metabolic pathways.
carbon dioxide, NADH + H -r, FADH 2 and ATP. Likewise, these 15. The bod)' responds to fasting by reducing its metabolic rate.
NADH + H + and FADHJ enter the elect.ron tra11sporc chain to During a fast the body breaks down both amino acids and fats for
yield numerous ATP molecules and water. energy. The loss of protein can ultimately cause death. A conse-
8. In fat synthesis (lipogencsis), aceryl groups in effecr are combined quence of the breakdown oflipids is the formation of ketone bod-
to yield a furry acid, primarily the 16-carbcm palmiric acid. These ies, which can provide energy to certain body cells, and ketosis.
fatty acids can then react with a form of glycerol to produce a 16. Feasting resulrs in the accumulation of body fat. The use of pro-
triglyceride. tein as an energy source will increase urea synthesis.
Study Questions
1. Many vitamins and minerals are used in energy metabolism.
taoxidation, etc. )? Why is it considered important in the body's
Identify d1rcc vitamins and/or minerals and describe their roles in
chemical processes?
ATP synthesis.
5. What is lactate, and how and where is it formed in d1e cell? Which
2. for what purposes do cells use ATP energy?
tissues produce the most lactate? Why?
3. Explain how the ATP concentration is mainrained in a cell. What
6. Trace the steps in gluconeogenesis from body protein to the for-
is the key stimulus to ATP production?
mation of glucose.
4. \Vhat is the "common denominator" compound of the many
7. How are far and carbohydrate metabolism related? Use rhc term
pathways of energy metabolism (citric acid cycle, glycolysis, be-
/utosis.
146 Chapte r 4 Metabolism
8. Li~t rhc metabolic processes discussed throughout rhis chaprer

and their loc.1rion in the cell. BOOST YOUR STUDY
9. Des\:i·ibc thc reason most fatty acids do not lurn inro glucose in Check out the Pe rspectives in Nutrition: Online Learning
the body. Center www.mhhe.com/wardlawpers7 for quizzes, flosh
10. Explain how physicians can use certain aspect~ of protein metabo- cords, activities, and web links designed to Further help you learn
lism co diagnose kidney or liver disease.
oboul metabolism.
l. Acos1a PB and od11:r~: N1micm intake~ and G1111tl'olfi11._'1 blood pbc11.1•lrtlnnir11· co11cwrmti1111s II Mayes PA, Bender DA: 0\'crvic\\ of mc1abo·
physicJI !,'TO\\'th of children with phcnylkc- in p/Jc11ylkl'IOWl1'in fr cmci11/ for 11/lnwiittf for Iism. In Mmray RK and other" (eds.): Hnrpcr's
tonuria undergoing nutrition therapy. /n111'llnl 11on11nl brrtm n11d c11g11itii>c drvdopmcut. Ei•m bi11dm11frtry. 26th ed. New York: Applcl<ln &
11/the AmtTirnu Dictt'fic llrs1Jcifllio11 103: 1167, mild i11fl'1'nsts nbm•c 11111wrtf mlllfl"S iu blood Lrngc i\lcdical Books/ i\kGraw I-Ji ll, 2003.
2003. plm1,vlrtln11i11t· prm•rd lmm~f11/ iu rim st11d,v. 111 t/Jc brertkdoum 11/c111'/10/rytirnrr, p1'JJCi"ius, n11d
lt is 11rr_y i111p11rtn11r for pr11plt niit/J PF..'U to 7. Gcrnun JB .tnd other~: Mcr.ibolomics in prac1icc: fnr for e1mw• 11rcd.s, nfl thr Jmllm>rt.\•s lmd r11 rb.-
111cl'f protein 11ecds 111nh1mt exceeding Wrlll.V Emerging knowledge to guide ti1rurc dkreoc Jd- prod11ctio11 of ncctyl-CiiA.
needs. fa:ct•t•diug pr11tci11 1ucds so111c111brtt might \'icc tow-anl inlLi\'idu.tlizcd health. jm1rnnf rif the 12. Mayes PA, Bo1l1<1m Kivi: lfa1cncrgctic.~: The
provide Cl'l'JJ num· bmrfit in terms ofgrn111tb. J111w·icn11 Dittttir Ass11cirtri1m I05:J.l.25, 2005. role of ATP. In 1\.lurray RK and others reds.):
Vs<' of the mrdicnfji111d dcsiplClf f01· tbis disease A 1/l'lr rout 111 r/Jr 1111dc1·strt111fi11g ofb1111• ,,,,. as Hrtrpe1•'s bi11c/Je1111st1)'. 261h ed. NC\\ York·
II the eomustmu fol' 111ttti11g protL'i11 1111d 011rr· i11dil'id11rtls diffi·1· m t/Jc merrtbolic ri:spm1sc ro Appkron & L111gc Mcdk.11 Book.../1\klira"
nil n11tntw11 11t'fds. 1111tl'imts 111ny /fr i11 t/11• rtbility t11 tmrk t/11· 11r· Hill, 2003.
2. Berg )l\I and others: Riodm11i.m')'· 5th ed. Ne\\ turtl munbolic i/11,·rmcdirtus mrtdc ltl form t/Jis
ATP is rt /Ji._q/J·mn:!J.v r111111w1111d !1ccn 11.rr 1Jf 1t.<
York: WH Frcem:tn, 2002. l'l'.<Jlonsc, mc/J ns boll' we rt"Spund to c.\11ost1rr
cbrn1icnl.rrr11cr11rr. Tl1cgrc:nt 111111111/ff of1·11ti:_q.1•
Ewellmt tcxtl11111k ronring tbr latat findings in frnm dijftffnt fatty acids. 111is nppronr/J i.r
rdcnmf 011 brm/1dm1111 of ATP to ADI' rt11d f'1 is
mctrtbolism. Details n:grmfi11.rr rhr cimccpts dis- wiled 1J1/'t11bo/0111irs mul sbould be 11111rc rtrc11-
been use oftbc n:licf oft/Ji: rcp11fsiu11 brn1w11
cwscd in r/Jis c/Jrtprel' nrr m>nilnb/c. 171c1·c rm: l'flh" r/Jrt11 lllt'l'<'ZI' /011ki11gfor diffrrmrcs in DNA
pbosphnte lr1·1111ps. ATP nrrs 11.1 r./Jr "m•'':!JY rnr·
rt-!s11 rfctnilcd figul't's s/Jowing rile 1'flri1111s 111etrt· bm1>cC11 i11diPirf11rtls ro pndict dii:tnry l't'.<pomcs.
rmc:i•" of t/Jt rel/, tm11sjiTri11...1J nw:11.v jh1111 mb·
bolic p1rr/Jn•a.1•s. 171c t1rtidr ITPiews t/Jis /It'll' tciof ofrc.<cft1·cb.
sm11cr.< 1!f/Jfr1/Ja &1WlJY potrnti11/ to thost' of
3. Champc PC and Others: Bioclm11istry. 3rd ed. 8. Gropper SS and od1ers: Adwrnccd 1111triti1m lurl't'I' e11n;g.v potmtinl.
Philadelphia, PA: Lippincot Williams & n11d lm111n11 m1·trtboli.m1. -!d1 ed. Bclmom CA:
13. l\ l.wcs PA, Bod1am Kt\L: th1d.11ion of farn
Wilkens, 2005. Thomson/Wadsworth, 2005.
acids: Kcrogenc~i~. 111 J\lurra} RK .111d other>
T71iJ rrxtb11ok pror>idcs c11/orf11/ rtrid bigb~1· rt 11110- TlJis rc...:tl1ot1k is t':>:ctllmt fiw m•inri11g tbt i11tt'- (eds.): Hrtrpn"s billrlmnfrtry. 26th ed. Ne''
mud fi_rr11rcs tlmt illusrrnu rbi: 11111·ions bioc/Jcm· gmriti11 of 1111rrimrs imo tbc 1•rt1·i1ms mctnbofic York: Appleton & Lange i\lcdical Bmik.~/
icnl prtthn>rtys i11 n er/I. 111c rcxr drsc1·iprio11s rt1'1' pMb1Pnys. 111c nuthttl'J nlso prm•id,- n IJrlpjitl l't'- i\lcGraw Hill, 2003.
also cnry to follow, mnkin.tf t/Jis 11 1•0~1· bclpf11/ l'ii:w of cell metnbolum rts n bnd•drop to 1111dcr-
book fo1· lcnn1i11g mol'c nbour metabolism. stft11di11g the rnrillus mtrnbolir pnrbwn.i·.r jiumd l(aosis doc.< not occur 1111/c.rs r/Jcr,· is rt JI i!tCl't'rtsc·
iu tbr all. in tbc le1•e/ of ci1ntlnti11,,q /iw frtf'T)' ncids hr th<'
4. Committee on Genctks: Maternal pheoylke-
bl110dstrcnm. 771l'Sc fra .frttry rtrids m·1· rhr pn·-
tonuria. Pcdirttl'irs J 07:427, 2001. 9. J\farriagc B and others: Nutiitional cofucror
wrsors uf l1rto11t bodies 11111d,· by t/Jc lr110:
Plm1ylkrto1111rin d11ri11g prcg11n11cy fr big/JZ1• u·catmcm in mitochondrial ilisordcrs. //Jlm1rtl 1if
the Anu:rirnn Dicu-rir Ass11rirttio11 I 03:1029, 14. N,1ciooaJ [nsLituce~ of J-h:.1lrh Coll\ensu~
toxic ro t/J1· growi11.'f fi:rw rt nd 111rty 1-cs1tf1 in
growtb rctrtnfnt1011 rtnrf sig11ificrt11r bfrrb dt·- 2003. Dc,·clopmcnr Prind: Nation31 lmtirurc~ of
Hcalrh Conscn~~ Development Conrcn:ncc
fects. T71e besr 011tco111os ofpnw11rt11q ocm1· 11•/Jm A 1111111bcr ofdefcm bm•r hem dcscri/!t'd rdntcd to
Srarcmenr: Phenylkeronuria: screening. .1nJ
strict co11m1/ of mrtrt·mrtl plm1ylrtfn11hu is t/JI' 111cmbolir pr11ccss.-s tbrtt rnk,· plnu m mirorlJ1m·
n.cbirred before eo11ccprio11 n11d r/Jc11 co11tinued man:igcmcnr, Ocrober 16- 18. 2000.
drin. A 1'nricf)• 11f111rdical intt'/'l'C11tio11s cau be
r/Jro11gbo11t tbc prcg11n11ry. Pcdirtrrics l 08:972, 200 I.
used to trcnt rbe musdc 11•ertlmcss n11d 11111sck dc-
5. Foster DW: The: rok of the carnitim: system in stmctio11 typim/~1•fo1111d in tlm1· disardcr'.<; rbf us1· Gmcric te.m'n..qfor pbwyfh-rimnl'ln /ins bcc11 111
human metJbolism. Amrnl.c of tbe New Yori• ofspuijir 1111/ricnts rtnd relntcd 111ctnbc1fic inter· pince fm· n/1110.<1 -JO yen rs rt 11d h11.r lit'f11 l'<'I'.\' mr-
Acndcm)' of Scien cu l 033: 1, 2004. mcdintc.r 111 rrcnt111c11r is 1Y1•1cn•rd 111 tl11s co11r1~\·t. Ct'.<sjitl ill pni•c:nrin...q J•-l'el'I' 1111·ut11/ 1wrtl'dntin11
lO. Ma)'cs P~ Bender DA: Thl' ci tric acid cycle:
in tbn11sn11d.< of d1ilrlrm nud nrfult.c. .\frtnbolir
In rlu fed smrc. i11 mws ofglueose 111embolim1,
routrnl of pbrn.1•lk.-t111111nn is 11rri·ssm:1· rtCl'Oif r/Jt
t/Jc lir>er prim111·i~v srons n11.1• nPnilnblcg/11cosc ns The carabnlism of .icttyl-CoA. In J\lurray RK
l~fi· spn11 of.11teb i11diPid11rtf.c.
g~1·coge11. In contrnsr, in t/Jrfnsrcd stntc tbc li1>cr and others (eds. ): Hni11a's biocbcmim:v. 26th
produces 11111r!J.rrl11rose. 771is nnirh' 1·cpicw.r t/Jc ed. Nm York: Appleton & Lange J'vlcdical 15. Ridd KR and others: An updau:d re\ icw of 1he
l'Dfr oj'tbc cnr11iti11c J)'Jrt'lll (n.11d ot/Jc1· biologicnl Books/l\kGr:m· Hill, 2003. long-rcrm ncurologic.11 cllccrs or ga1Jc1osenm.
systa11s) i11 this sll'itch i11 01•1·t·n.I/ mctn.bo/is111. 111c citric rtri1f 9·clr is rt series of1'Cllctiuus i11 rbe Ptdintric Nt•11rulag1• 33(3): 153, 2005.
6. Gassio Lt and others: Cognitive fi.mction~ in 111it11d1011drirt rbnt bri11gs rt/11111/: rJ1e rnrnbolimr Limiting galncrt1sc i11rn.ilc i11,,qnlnctosw1irt is
dassic phcnylkctonuna and mild hyperph.:nyl- uf11ccryl-C11A, libcrnri11,,1J bydnt11rn inns. Up1111 criticnl far kssmi11..11tbc11rnr11l11...qicnf rt11d ntb,·r
:ilanacmia: Experience in paediatric population. 11.vidrttion. tbrsc /Jydrogm imu lmd ro r/Jc 1·dcrtst' lll;[Jrt11.rysrm1 da/i11r rbnt rn.kc,; plnr1· ill rim dis·
Dcvelopmmtnl .lfrdici11r n111i Child Nrnr11/og,v uf 11111;t ofrbc n1•niltrblr tllOlf.\' u/rism1·f'11t'ls rt11d 1wdci: Sri/I, .111111t dalint ll'ill bt Sl'm, pnl'tirn-
47:443, 2005. .-i•rm11rt! m/1t1irr ns ATT~ lrtr(v in tbt llCl'l'OllS S)'SfCllJ.
16 S.\Udubra> JJ\1 .md othcrv Cli11i~al appm.1ch to Prnd11r11u11 offntt.1· ncids 11s111_q cnrb1ms fi·um Srump S (eds.): Krn11u 's food, 1111rnt11m. n11d
111hc1i1cd metabolic d i\cu·dcrs m nco11atcs: An 11rhcr 111no·o11111rirn1s sur./J ns_r1lllr11.fe, termed de du:t tbrmp_v. 11 rh ed. Phil.1dclphia: \~I\
()\ cn·ic\\. 'mminrs ill Vrnnnrolugy 7( I ):3, 1101'11 lipt1gc111:.ns. is .<cm nfre1· 111rn/s. Still, rrs '>.1undcr,, 2004
2002 fo1111d 111 t/Jis 1mtl1', ii 11gaumlf.1 of 111i1101 1111- E.xct:!lmt dmptrr 011 Ilic" mrdicnf 1111tritio11 tl1'r-
771L"rr 111"' nl1111w JOO 111b11m t'no1-s of man/Jo· portn11rr 11•1tl1 rr_11nrd 111 tht mcrmrc i11 b/11nd npy fi>r i11bom n-rors of 11ut11bolim1. 111<' c/Jnpta
li.tm rhnt cn11 .rt11rr i11 i11fn11ry; nbom 211 Ill'<" tl"tf1(\'(t'l'td<'.< SUI/ 11ftcr n IJ/t(I/. pi·m•idc.r 1111icb rlctnil 011 t/Jr mle 11j'n11trim111 i11
nmmnl1/t ro 11·rnt111t11r. 1)•pirnl(t t/Jr 111(n11t iJ .mrli dis1wdcrs.
b11ru nftrr n 11tw111nl prr1111n1ut n11d dtlil'rr)· bur 18. Trachrcnbarg Dr.: Dia bet i( keroacido~i~.
20. \'Jlllr.illu: TB, i\ut<:rt TH Ketone~: ,\ktabo
sm111 dat"rtomw pl~1·sicnllyf111· 1111 nppnrmr r,;n· A111rr1m11 Fnmilv l'/Jpuin11 71 1659, 2005
lism 's uglv duckling. Xmrit1011 Rtvuws
s1111 n11d docs 11111 mpond 111 r_vpicnl mctl1rnl tber· 771t l't·tos1s thn1 r1111 dt1•dop 111 p11111·Z1• rrmrcd 61 :327. 2003
np1. l'rnmn11.11srniptOlllJ111·t sci::.11res, 1·1•idr11cr ~vpc 1 dinbrru iJ p111m11nlZ1' l'<TV lmm1ftt! fll !11is nnulc co11t11im n dt'lnilcd d1swssi1m of l·e·
11fl11·rrfni/1,,.,·, rnrious /J(11r1 duorders, 1111d /Jrnltli 111111rims11ads to be trmrrd 1111111.-dintdv. tone pn1d11aic111 n11d poss1b/r mcdiml npplun·
hvpl(_tTZvcm11n 17Je 11rt1clr rnwn•s nu/J trefllmfllt, i11c/11d111..rr tmm. Of pnrrtrnlnr wtcr,;st is t/Jr l11smrscnl
17 Timlin i\IT, !'.irks EJ: Temporal pmcrn ofdc prm•isio11 rlf i11s11/111 n11d i11n·nl'011111s fluids. nccomir 11f r/Jc stttrl.Y of l.wn11cs i11 /111m1111
no\o lipogcm:~i~ in Lhc po~rprandial \t.m: in 11urnbolim1
hcJlthy men. A111cricn11 /1111n111/ of Clmicn/ 19 Trahm\ C,\I· 1\leJicJI nutrition thcr.11w for
X11tritio11 81 :35, 2005. metJl:mlic di\ordcr~. In .\l,1h.m LK, bcon-
Take I Action
I. Put Your Knowledge of Metabolism into Practice

A Friend is very overweight and describes to you his method of weight loss. He fasted compleiely for 1 week ond !hen initiated o slricl
diet of 400 to 600 kcal/day under a physician's supervision. The food energy comes from a liquid formula, which he drinks for break·
fast. He skips lunch and eats a small dinner of 3 ounces of protein, 1/2 cup of vegetables, 1 cup of fruit, and two starch items (a smoll
potato, a piece of bread, etc.}. He has lost approximately 25 lb in 12 weeks.
Based on your knowledge of energy metabolism, answer the following questions he poses:
1. During the fasting stage, what were the likely sources of energy for the body's cells? W hat metabolic processes occurred to pro-
vide glucose for red blood cells? brain? kidneys?
2. During the restrictive phase, how did the metabolic processes in the body most likely change from the fasting state?
II. Reinforce Your Knowledge of Metabolism

By this stage in your education, you hove likely had a number of exposures to the topic of cell metabolism. Review your textbooks or
notes from previous courses that discussed metabolism and see how the following topics were presented from the standpoint of that dis·
cipline. Far example, coverage of glycolysis might have o different emphasis in a biology class than in a nutrition class.
ATP
Glycolysis
Citric acid cycle
Electron transport chain
Hormones that regulate aspects of metabolism
Insulin
Glucagon
Enzyme activity
A general knowledge of metabolism will benefit you throughout a career in the sciences, whether in the health sciences or the biologi·
cal sciences. Understanding metabolism especially will help you see how new developments in your field relate to cell function .
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CARBOHYDRATES
CHAPTER FIVE

Carbohydrates-An Introduction Myeshio is a 19-year-old African American female who recently read about the
Structures and Functions of Simple health benefits of calcium. She decided to increase her intake of dairy products,
Carbohydrates
Monosocchorides: Glucose, Fructose, and and lo start, she drank l cup of l % milk at lunch. Not long aherword, she experi· -i
Goloctose • Disocchorides: Maltose, Sucrose, enced blooling, cramping, and gassiness. She suspected that the source of this pain I
and lactose • Oligosocchorides: Roffinose and m
Stochyose wos the milk she consumed, especially because her parents and her sister hod com- m
Structures and Functions of the More Complex plained of the some problem. She wanted to determine if the milk was, in fact, the
z
m
Carbohydrates
Digestible Polysaccharides: Storch and
cause of her gastrointestinal discomfort. So the next day she substituted a cup of yo- '°(;)
;<
Glycogen • Indigestible Polysaccharides: Fibers gurt for the glass of milk at lunch. Subsequently, she did not have any pain. Whal -<
Carbohydrate Digestion and Absorption has Myeshia discovered? Whal component of milk is likely causing the problem? m
Digestion • Absorption 6
Functions of Glucose and Other Sugars in the z
(;)
Body
Yielding Energy • Sporing Proteins from Use as z
on Energy Source • Preventing Ketosis c
-i
Functions of Fiber
Carbohydrate Needs '°
m
The Carbohydrate Continuum • How Much z
-i
Fiber Do We Need? (./)
Expert Opinion. Fiber-Finally a Nutrient )>

Health Concerns Related to Carbohydrate Intake
z
0
Problems with High·Fiber Diets • Problems with )>
High.Sugar Diets • Sugars and Refined
Starches and the Metabolic Syndrome •
Problems with lactose Intake, Especially for
n
0
Some People I
....
Nutrition Focus: When Blood Glucose
Regulation Foils
Carbohydrates in Foods
Nutritive Sweeteners • Alternative Sweeteners
Take Action
149
W hat did you eat to obtain the energy you ore using right now? Chapters 5, 6, and 7 will ex-
amine this question by focusing on the main nutrients the human body uses for fuel. These
energy-yielding nutrients ore mainly carbohydrates (on average, 4 kcol/g) and fa ts and oils (on average,
9 kcol/g) . Little of the other common fuel-protein (on overage,
4 kcal/g)-is used for that purpose by the body.
It is likely that you have recently eaten some fruits, vegeto- CHAPTER OBJECTIVES CHAPTER5 IS DESIGNED
bles, dairy products, cereal, breads, and pesto. All these foods TO ALLOW YOU TO:
supply carbohydrates. Unfortunately, the benefits of these foods 1. Identify the basic structures and food sources of the ma;or
are often misunderstood. 1 As a result people think carbohydrate- carbohydrates: monosaccharides, disaccharides,
polysaccharides (e.g., starches and fiber).
rich foods are fattening-they are not. Pound for pound, carbcr
2. list the functions of corbohydrafe in the body and the problems
hydrates are much less fattening than fats and oils. Furthermore, that result from not eating enough corbohydrate.
high-carbohydrate foods- especially fiber-rich foods such os 3. Ourline Iha beneficial effects of fiber on the body.
fruits, vegetables, whole-grain breads and cereals, and 4. State the RDA for carbohydrate and various guidelines lor
legumes- have been promoted by many experts for lhe impor- carbohydrate intake.
tant health benefits these foods supply.32 Some people think sug- 5. Recognize food sources of carbohydrate.
ars necessorily cause hyperactivity-not so, according lo 6. List some alternative sweeteners that can be used to reduce
sugar Intake.
well-designed scientific investigations. Almost all carbohydrate-
rich foods, except pure sugars, provide essential nutrients and 7. Describe lhe regulalion of blood glucose and the nutrients Jhat
con become blood glucose.
should generally constitute 45 to 65% of our daily energy in·
8. Identify lhe consequences of lactose maldigestion/iatolerance
take.11 Let's take o closer look at carbohydrates, including why and diabetes, and list dietary measures to take to reduce the
the current trend toward carbohydrate bashing is misguided. risk for developing, as well as managing, these health
problems.

OF CARBOHYDRATES IN CHAPTER 5, YOU MAY WANT TO REVIEW:
The health claims on food labels for various carbohydrates in Chapter 2.
The anatomy and physiology ol digestion and absorption in Chopler 3.
The processes of glycolysis, gluconeogenesis, and ketosis in Chopler 4
Carbohydrates-An Introduction
Carbohydrates are a primary fue l source for some cells, such as rhose in rhe ner\'ous
system and red blood cells. 14 Muscle cells also rely on a dependable supply of c.u·bu-
hydrate to fuel intense physical activity. Yielding on average 4 kcal/g, carbohydrares
are a readily available fuel for all cells in the form of blood glucose :rnd srorcd in the
liYer and muscles as glycogen. Carbohydrate stored in the liver can be used to main-
tain blood glucose aYailabiJity in times when the diet does nor supply enough. Srill,
regular i.ntake of carbohydrate is i.mportanr, because (jver glycogen stores arc exhausted
in about 18 hours if no carbohydrate is consumed. After that point, the body is forced
Fruits such as peaches are an excellent source to produce its own carbohydrate from the amino acids in body and food protein~ this
of carbohydrate. evenniaUy leads to health problems. 14
vVe have sensors on our tongues that recognize sweet carbohydrarcs. Re!.e::1rchcr1.
surmise th::it rhis sweetness indicated a safe energy source to earl~· humans, and so c:.i.r-
bohydrare became an important energy source. The returning Crusaders brought
sugar from the Holy Land to Europe. Columbus inrroduced sugarcane to the
Americas. The French later grew sugar beers as a source of sugar. 1-t
150
Primarily choosing the healthiest carbohydrate sources, whik moderating intake of

those that arc less healthful, contributes to a healthy diet.32 It is difficult to eat so lit-
tle carbohydrate tbat body needs are not met, but it is easy to overconsume tl1e car-
bohydrates mat can contribute to health problems. This chapter explores this concept
further as it looks at carbohydrates in detail.
Structures and Functions of Simple Carbohydrates

Most forms of carbohydrates are composed of carbon, hydrogen, and oxygen in the sugar A simple carbohydra te with the
ratio of l :2: l, respectively. The general formula is ( CH20 )12, where n represents the chemical composition (CH 20)n. Most sugars
nw11ber of rimes tl1e ratio is repeated. The chemical formula for glucose is C 6 H 120 6 , form ringed structures when in solution.
or ( CH2 0)6 .20 The simpler forms of carbohydrates are called sugars and often take Generally refers to monosoccharides and
di saccharides.
me form of single or double sugars, called m o nosaccharides and disaccharides, re-
spectively. The more complex forms of carbohydrates are polysaccharides, L-ypically ei- monosaccharide A class of simple sugars, such
ther sta rch es or fibers . as glucose, which is not broken down further
A), discussed in Chapta 4, plants use carbon dioxide, water, and energy ( from me during digestion.
sun ) to produce the carbohydrates we eat. Recall from tl1at chapter tl1is complex
disaccharides A class of sugars formed by the
process is called photosynthesis (Figure 5- l ). chemical bonding of two monosoccharides.
C02 + H 20 ~ ( CH 20 )11 +02 polysaccharides Carbohydrates containing
many glucose units, from 10 to 1000 or more.
Monosaccharides: Glucose, Fructose, and Galactose starch A carbohydrate made of multiple units
The common monosaccharides ( mono meaning "one" and sncclmridc meaning of glucose attached together in a form the body
can digest; also known as complex
"sug:ir" ) arc glucose, fructose, and galactosc. G lucose is the most common monosac-
corbohydrate.
cb:iride in the body, bur we c:it very little orit as such. Other names for glucose arc
dextrose or blood s11gm: In Figure 5-2, the chemical structure of glucose is shown in fiber Substances in plant foods that ore not
both its linear and ring l·o rms. Glucose exists in the body in the ring form. Because it broken down by the digestive processes that
is a six-carbon monosaccharide, glucose is cal led a h exose (he.'<: meaning "six ," for six take place in the stomach or small intestine_
carbons; osc is the ~tandard word ending for carbohydrates ).2 0 Fibers naturally found in foods are called
Fruct ose is also a hexose. Un like glucose, it can form either a five- or six-member dietary fiber.
ring (rc,·icw Figure 5-2 ). Fructose, also called lcvulosc, is found in hexose A general term describing a
• Fruit carbohydrate containing six carbons.
• Honey (about half fructose, half glucose) fructose A monosaccharide with six carbons
• High-fructose corn syrup, which is used in the production of soft drinks, frozen that forms a five-membered or six-membered
desserts, and confections. The presence of fr uctose in these products makes it a ring with oxygen in the ring; found in fruits
common sugar in our diets. In most North American diets, fructose accounts for ond honey.
about 8 to l 0% of total energy intake.
lactic acid A three-carbon acid, also called
Fructose, after abso1-pLion by tl1c small intestine and transport to the liver, is almost lactate, that is formed during anaerobic cell
,1U metabolized to glucose or to intem1ediates in tl1c glycolysis patlrn·:iy. Some fructose metabolism; a partial breakdown product of
is then converted to glycogen, lactic acid, or fat, depending on tl1e amou nt consumed. glucose.
Sun 6 carbon diox ide Figure 5· l I A summary of photosynthesis.

(C02) Plants use carbon dioxide, wa ter, and energy
to produce carbohydrates such as glucose.
Glucose is then stored in the leaf but con also
Energy undergo further metabolism lo form starch and
fiber in the plant.
152 Chapter 5 Carbohydrates
Figure 5·2 I Forms of the six-carbon

H H H
monosocchorides-fructose, glucose, and
goloctose- shown in the linear form and in the I
H-C-OH
I
C=O
I
C=O
ring form where each corner represents a
carbon atom unless otherwise indicated. I
C=O
I
H-C-OH H-C-OH
I
(Appendix A reviews this shortcut notation.)
This ring structure is the predominant form I
HO-C-H
I
HO-C- H
I
HO-C-H
when in solution. Only the D-isomer forms of
these monosacchorides ore metabolized by the I I I
body. (Appendix A also reviews the concepts of H-C-OH H-C-OH HO-C-H
isomers.) I
H-C-OH
I
H -C-OH
I
H-C-OH
I
H-C-OH
I
H-C-OH
I
H-C-OH
I
H
I
H H
I
CHPH CH20H
~H20H
0
H OH
OH H
H H OH H OH
OH H
Synthesis of lactic acid and fat is stimulated by fructose intakes that are two or more
times typical intakes. 14
Galactose is the third major monosaccharide of nua·irional importance.
goloctose A six-carbon monosocchoride; on
Comparison of the structure of this simple sugar with that of glucose shows that the
isomer of glucose.
two structures are almost identical, except that the hydrogen (-H) and the hydroxyl
group (-OH) on carbon-4 arc reversed (review Figure 5-2). Galactose is not usually
found free in nature in large quantities but, rather, combines with glucose to form a
disaccharide called lactose (fow1d in miJk and other dairy producrs). Once absorbed
into the bod)r, galactose is converted into glucose in the Jjver, whjch can be used to
provide immediate energy or is stored as glycogen. 20
sorbitol An alcohol derivative of glucose that Another monosaccharidc found in nature is ribose, a five-carbon sugar (or penrose;
yields about 3 kcol/g but is slowly absorbed
penta means "five"). This is present in a cell's genetic material. Very little ribosc is pres-
from the small intestine. It is used in some
ent in our diet; we produce this sugar from other foods we eat. 20
sugarless gums and dietetic foods.
Finally, a few sugar alcohols are present in foods and will be discussed later in this
condensation reaction Chemical reaction in chapter, in the section on nutritive sweeteners in foods. Currently, the major sugar al-
which a bond between two molecules is formed cohol used in rhc manufacture of foods and beverages is sorbitol. 35
by the elimination of a small molecule, such as Once you are familiar with the chemical forms of the sugars, it js much easier to un-
water. derstand bow they are interrelated, combined, digested, metaboliz!!d, and synrbcsizcd.
maltose Glucose bonded lo glucose.
sucrose Fructose bonded lo glucose; Jobie Disacchgrides: Maltose, Sucrose, and Lactose
sugar.
Carbohydrates containing rwo sugar units are called disaccharides (di means "two").
lactose A sugar composed of glucose linked to These are formed when two monosaccharides combine and a water molecule is splir
another sugar called galactose. off in what is called a con densation reaction . The three most conunon disaccharidcs
found in namre arc maltose, sucrose, and lactose. All contain glucose (Figure 5-3).20
www.mh he.com/wardlawpers7 153
(a )
CHiOH CH:PH
CHiOH O
H
+
~
H20 0
H OH OH H H OH OH H
- • • _ ~ • - I I - .. • --.c--.~ :'llll'T -f r~ ' - I '
(b ) I·:. .Giu~~se : · . ·: · 1 Ffuctose 1 ~~ 1 ;-'· ' ' ; • • Sucrose
l -~-'-", _ _:!_-____ ..;.·-.. -·-. ,.::;;,.·~~--- ---.i'-1.-- i.'·-~·1-' -- - ·•. . _ -----· .
+ 0
H OH H OH H OH H OH
(c)
Figure 5 · 3 I Joining of two monosocchorides to form a disocchoride. (a) Maltose is made up of two glucose molecules and is formed in germinating grains.
(b) Sucrose, or common table sugar, is made up of glucose and fructose. (c) Lactose, or milk sugar, is made up of glucose and galactose. Note that lactose
contains a different type of bond (beta, or ~) from that of maltose and sucrose (alpha, or a), a property that makes lactose difficult to digest for individuals
who produce less of the enzyme lactose.
One <:arbon on each participating mo nosaccha1i<.le is chemically bonded together by

oxygen. Two forms of this C-0-C bond exist in nature, called alpha (a) bonds and alpha (~) bond A type of chemical bond that
beta ( 13 ) bonds, and m·c depicted slightly different!}'· As shown in Figure 5-3, maltose con be digested by human intestinal enzymes;
and sucrose contain tl1e alpha form, whereas lactose contains the beta form. Many car- drown OS (lQJ(.
bohydrates contain long chains of glucose with the individual molecules bonded to-
beta (~) bond A type of chemical bond that
gether by eid1cr alph:t or bet:l bonds. Using what is calkd a hycfrolysis reaction, cannot be broken by human intestinal enzymes
humans can digest these carbohydrates, but only if rhe glucose mokcuks arc linked by during digestion when ii is part of a long chain
alpha bonds. 14 This topic will be covered later in this chapter, when fiber is dist:usscd. of glucose molecules (e.g., cellulose); drown as
Malrosc consisr.s of two glucose molecules joined by an alpha bond. When seeds crgc.
sprout, they produce enzymes tl1at break. down tl1e polysaccharides (starch) to sugars
hydrolysis reaction A chemical reaction in
such .is malcosc and glucose. These sugars pro\'idt: tl1e energy for the plant to grow. In
which a bond between two molecules is broken
a process called malting,, the sprouting proces!. is stopped by heat. This is the first step
by the inclusion of a water molecule. The water
in tl1c production of alcoholi1.: be\'eragcs such as bt:er. In the absence of oxygen yeast donates o hydrogen to one reactant and a
converts most of the carbohydrates ro ethanol (alcohol) and carbon dioxide in a hydroxyl (-OHJ group to the other reactant.
process called fermentation (discussed in Chapter 4 ). There.: will be more about the
production of alcohol products in Ch:1pter 8. Few other food products and beverages
common misconception is that honey con· contain maltose. Io fact, most maltose rhat we ultimately digest in the small intestine
fains vitamins and minerals. You can prove is produced during the digestion of starch (see a later section on carbohydrate diges-
to yourself that honey is no more nutritious than tion in thii. chapter).
sucrose by consulting Appendix N. Only the Sucrose, common table sugar, is composed of glucose and fructose.: linkcd via an
sweetener molasses, a by-product of sucrose alpha bond. 20 Large :unotmts of sucrose are found naturally only in planrs, such as sug-
production, contains any appreciable amount of arcane, sugar beets, and maple tree sap. The sucrose from these sources may be puri-
minerals. However, our consumption of molasses fied to va rious degrees. Brown, white, and powdered sugars are common forms of
is very low. sucrose sold in grocery stores. I
Lactose, the primary sugar in mill;: and milk products, consists of glucose joincd ro
galactose by a beta bond. As discussed in ,1 later section of this chapter, many people
are unable tO digest large amounts of lactose because they don't produce enough of
S imple forms
Monosaccharides
Glucose, fructose, galactose
d1e enzyme lacrase that is capable of breaking its beta bond. This can cause intestinal
gas, bloating, cramping, and discomfort as the unabsorbed lactose is metabolized inro
acids and gases by bacteria in the large imcstinc. 28
Di saccharides
You arc likely to cncounrer many diflcrent words referring ro mo nosaccluridcs .rnd
Sucrose, lactose, maltose
disaccharides or products containing d1ese simple sugars. Note that all the terms listed
Ofigosaccharides in Table 5 -4 later in the chapter are names !'or sugars either naturally present in f{)od
Raffinose, stachyose products or added during their manufacture. These mooosaccharides and dis;iccbaridcs
Polysaccharides are often referred to as simple s1tgm·s bccause they contain only one or two sug-Jr w1irs
Starches (omylose and omylopectin), and, therefore, have a simple chem ical structure. Food labels lump all these sugar!>
glycogen under one category, li sting diem as "sugars." 1
omplex forms
Most fibers Concept I Check
Monosaccharidcs are single sugars. From a nutritional standpoint, the impormnc monosac-
dnrides are glucose, fructose, and galactosc. Disaccharides are double sugars. The major di-
saccharides in the diet are sucrose (glucose bonded to fructose), maltose (glucn~e bonded to
glucose), and lactose (glucose bonded LO galacrose). The disacchaiidcs have either .1lpha or
beta bonds. Our bodies arc unable to break down most of the beta bonds. Once absorbed
imo the body, most carbohydrates arc ultimatdy u·ansformcd into glucose by the liver.
raffinose An indigestible oligosoccharide

made of three monosacchorides (golactose-
glucose-fructose). Oligosaccharides: Raffinose and Stachyose
stachyose An indigestible oligosaccharide From a nutritional standpoint, oligosaccharides contain 3 to abom l 0 single sugar
made of four monosacchorides (galactose units ( oligo means "scant"). (Chemists and biochemists, however, lump disacch.u-ides
galactose-g Iucose-fructose). in r11e o ligosaccharide category as wclJ.)2 0 Two oligosaccharides of nutritional impor-
tance arc raffLilose and stacbyose, which are found in legumes, such as kidney beans.
These oligosaccharidcs are constructed of typical monosacch:u·ides bur an.: bonded to-
ged1er in such a way that digestive enzymes cannot break them apart. Thus, when we
consume legumes, raffinose and stachyosc remain Lmdigested on reaching die large in-
testine. There, bacteria metabolize diem, producing gas and od1er by-productl>. 14
Many people have no trouble digesting legumes, but others experience unpleasant
side effects from intestinal gas. An enzyme preparation called Beano, which prevenrs
these side effects, can help such people if raken right before a meal. Once conswned,
the enzyme preparation works in the digestive tract to break down many of the indi-
gestible o ligosaccharides in legumes (and other vegetables). Beano is made from mold,
so persons sensitive to molds may react allergically and should avoid it or use with cau-
tion. For more information or free samples, contact the manufacturer (800-257-8650).
Structures and Functions of the More Complex

Carbohydrates
Beano con be used to reduce intestinal gas
produced by bacterial metabolism of The polysaccharides, often referred to as complex carbohydrn.tcs, include some diat an:
oligosaccharides in the large intestine. digestible (e.g., starch) and some that arc largely indigestible, such as fibcr. 1+
Digestible Polysaccharides: Starch and Glycogen

Polysaccharides contain many monosaccharide uuirs, up to 1000 or more. Most poly-
saccharides of nuaitional importance are synthesized from glucose, such as when Yeg-
etabks rmn glucose into starch during manuation. This makes peas and corn sweetest
" 'hen they are young. Starch, the major digestible polysaccharide in our diet, is the
storage form of energy in plants. There <lre rwo rypes of plant starch-amylose and amylose A straight-chain type of starch
amylopectin-both of which are a source of energy tor plants and the animals that composed of glucose units.
eat plancs. 20 amylopectin A branched-chain type of starch
Both amylose and amylopectin contain many glucose units linked by alpha (di.- composed of glucose units.
gestible) bonds. The primary difference between rhe two types of starch is that amylose
is a straight-chain polymer, whereas amylopectin is highly branched (Figure 5-4) .
Cooking increases the digestibility of these starches by maki11g them more soluble in
water and thus more available for attack by cligestive enzymes. Amylase and amylopectin
are fouHd in potatoes, beans, breads, pasta, rice, and other starchy products, typically in
a ratio of about 1:4. Amylopcctin raises blood glucose much more readily than amylase,
since its numerous br~uiches provide many opportunities for digestive enzyme activity.
The enzymes act only at the ends of the glucose chains. The more mm1erot1s the
branches of a starch, the more sites (ends) are available for enzyme action (see the dis-
cussion of glyccmic index and glycemic load in a later section of this chapter).20
The branches in amylopcctin also allow it to form a very stable starch gel, enabling
it to retain water and resist water seepage. Food manufacturers commonly use starches
rich in amylopcctin in sauces and gra\'ies for frozen foods because they remain stable
O\·er a wide temperature range. Food manufacturers may also use processes to bond
the starch molecules to one another, further increasing food stability. The resulting
Glucose
~---0
- . or·.-- · - --- --'l ~ - I • -

Amylopectin I. -· '•: ·" 1 • .Glycogen ·
:ft.._ •A• I _ 'I .. ~ ;· 1-'I • _,,;_, • •
Figure 5-4 I Some common starches. We consume essentially no glycogen. All glycogen found in the body is mode by our cells, primarily in the liver
and muscles.
product, called modified food starch, is used in baby foods, salad dressings, and in-
stant puddings.
Glycogen, the storage fo rm of carbohydrate in humans and other animals, is a glu-
cose polyme r with alpha bonds and numerous branches. The amount of carbohydrate
in a diet greatly influences tl1e amount of glycogen stored. The structure of glycogen
is si1nilar to tliat of amylopectin, bur the branching patterns are more complicated (re-
view Figure 5-4). As with amylopectin, glycogen, because it is so highly branched, is
quickly broke n down by enzymes in body cells in ·which it is stored. 20
The live r and muscles are the major storage sites for glycogen . .Because only about
120 kcal of glucose are available as such in body fluids, muscle and liver storage si res
for carbohydrate energy-amounting to about 1800 kcal-are extremely imporrant. 1{
As noted in tl1is chapter's introduction, the 400 kcal of glycogen made by rhe liver can
be turned into blood glucose, while tlle 1400 kcal of glycogen made by muscle cdls
cannot. Still, glycogen in muscle cells supplies glucose for muscle use, especially dur-
ing high-intensity and e ndurance exercise. (See Chapter 14 for a detailed discussion of
carbohydrate use during physical activity. )
lncligestibfe Polysaccharides: Fibers

As some vegetables age, their sugars are
converted to starches. Folklore surrotrnding fiber or " roughage" has been a part of Americ<m cu ltu re since
the 1800s. In the 1820s and 1830s, a minister named Sylvester Grah a m traveled up
and down the East Coast extolling the virtues of fiber. He left us a legacy-the graham
cracke r. H owever, today's graham cracker bears little resemblance to the whole-grain
product he promoted. T he next wave of fiber fre11zy crested i.n tl1e mid-1870s witl1
dietary fiber Fiber found in food. Dr. Jolu1 H arvey Kellogg and his brotl1er Wil liam o fbreakfust cereal fame. Dr. Kellogg
functional fiber Any fiber added to foods thal beca1m: the first person to earn a million dollars from " health foods." One of his p.1-
has shown to provide health benefits. tients was Charles W. Post, who followed tlie Kelloggs' lead and started the Post
Toasted Cornflakes Company. In 1901 alone, Post netted $1 million fro m his Grapc-
cellulose A straight-chain polysaccharide of N uts cereal and oilier products. As you will see, present-day scientific evidence sup-
glucose molecules that is undigestible because
ports this early promotion of fiber as part of a healthy diet.
of the presence of beta bonds; port of insoluble
The term fiber refers ro rhe dietary fiber that is found naturally in foods as well as
fiber.
ro otbe r fo rms of fiber tllat may be added to fo ods. This second category is called
hemicellulose A mostly insoluble fiber functional fiber; any of these fibers must show beneficial effects in humans to be in-
containing goloctose, glucose, and other cluded in tliis latter category. Total fiber (or just tlie term fiber) is the n the com bina-
monosacchorides bonded together. tion of dietary fiber and functional fiber in the food product. 11 Currently tbe N utrition
pectin A soluble fiber containing chains of Facts label includes only tl1e category dietary fiber; tbe label has yet to be updated to
various monosoccharides; characteristically reflect the latest definition of fiber by tl1c Food and N utritio n Board.
found between plant cell walls. In terms of their chemical composition, 6 be rs are composed primarily of tl1e non-
starch polysaccharides cellulose, hemicelluloses, pectins, gums, and mucilages. The
gums A soluble fiber containing chains of
only no ncarbohyd rate components of dietary fibers are lignins, which include co mplex
galoctose and other monosacchorides;
alcohol derivatives (Table 5-1 ). Almost all forms o f fiber come from p lants, a nd as a
characteristically found in exudotes from plonl
stems.
gro up, none are digested in me human stomach or small intestine.H
Cellulose is a straight-chain glucose polymer similar to amylose; however, unUkc
mucilages A soluble fiber consisting of chains am ylose, which contains alpha bonds, the glucose units in cellulose are linked by bcca
of golactose and other monosocchorides; bonds. As noted earlier, glucose molecules joined by beta bonds are not broken down
choracterislicolly found in seaweed. by human digestive enzymes. Thus, cellulose is not digestible by htunans and is classi-
lignins An insoluble fiber mode up of a fied as a dietary fi ber, not a starch. Because the lo ng glucose chains of cellulose arc Jin-
multiringed alcohol (noncarbohydrate) ear, they can pack closely togctl1er, forming fibrous strucrw-es with great strength.
structure. O verall, cellulose, hemicelluloses, and lignins form the structural part of the plant. A
cotton ball is pure cellulose. Bran fiber is rich in hemicelluloses. Since bran layers form
insoluble fibers Fibers that mostly do not
tlie outer covering of all seeds, whole grains (i.e., those witl1 the bran and other com-
dissolve in water and ore not generally
metabolized by bacteria in the large intestine.
ponents left intact) are good sources of this fiber (Figure 5-5 ).32 The woody fibers in
These include cellulose, some hemicelluloses, broccoli are partly lignins. As a class> these undigestible die tary fibers generally do not
and lignins; more formally coiled dissolve in water and thus are called insoluble fibers (or no nferme ntable fi bers).
nonfermentoble fibers. Pectins, gums, and mucilages are found inside and arou_nd plant cells. T hey help
"glue" plan t cells togemer (review Figure 5-5). These dietary fibers eithe r dissolve or
www.mhhe.com/wardlawpers7 1 57
Table 5-1 I Classification of Dietary Fibers
Type Noncomponent(s) Physiological Effects Major Food Sources

Insoluble (Nonfermentable)
Noncarbohydrate lignins Increases fecal bulk Whole groins
Carbohydrate Cellulose Increases fecal bulk All plants
Hemicelluloses Decreases intestinal transit time Wheat, rye, rice, vegetables
Soluble (Viscous)
Carbohydrate Pectins, gums, mucilages, Delays gastric emptying; slows glucose Citrus fruits, oat products {beta-glucan in
some hemicelluloses absorption; con lower blood cholesterol particular), beans, thickeners added to foods
Figure 5 · 5 I Various forms of fiber. (a} The

skin of on apple consists of the insoluble fiber
cellulose, which provides structure for the fruit.
The soluble fiber pectin "glues" the fruit cells
together. (b) The outside layer of o wheat
(a) ( kernel is made of layers of bran-insoluble
fiber-making this whole grain a good source
Cellulose in the skin: of fiber. Fruits, vegetables, whole groins, and
insoluble fiber _ ___..,,, ____1-- - legumes such as beans are rich in fiber.
I T}orrilrin(j
Endosperm
(b) Celia decides lo go on a diet and buys over-
/he-counter pills. You look at the ingredients
ond note that the pills conloin psyllium, a word
Bran layers you recognize from the nutrition course you're
(Hemicellulose: . . . . ._
insoluble fiber) "4 toking. What is one possible effect of the psyl-
lium in these diet pills?
Germ
sweU when put into water and thus are called soluble fibers (or viscous fibers ). Ll Some soluble fibers Fibers that either dissolve or
forms of hemicelluJose also fall into this soluble-fiber category. Soluble fibers such as swell in water and are metabolized (fermented)
gum a.rabic, guar gum, locust bean gum, and ,·arious pectins arc present in numerous by bacteria in the large intestine; these include
food products, especially salad dressings, inexpe nsive ice creams, jams, and jellies. pectins, gums, and mucilages; more formally
Other rich sources of soluble fibers include fruits and vegetables in general, soybean called viscous fibers.
fiber, rice bran, and psyllium seeds (found in many commercial fiber laxatives). psyllium A mostly soluble type of dietary fiber
One workable definition of fiber is "the foodstuftS that remain tll1digested as they found in the seeds of the plantago plant (native
enter the large intestine." There is really no common property that characterizes vari- to Indio and Mediterranean countries).
ous fibers except thei.r abil ity ta resist digestion in the small intestine. Since some
fibers-especially the soluble fibers- are fermented by bacteria in the large intestine, it
is nor acclu-atc to say that fiber is just what fibers arc found in cl1e feces. 11
Bacteria in the large intestine terment soluble fibers into products such as shorr-
chain fatty acids (e.g., acetic acid, butyric add, and propionic acid) and gases, such as
hvdrogen (H2 ) and methane (CH4.). These acids, especially butyric acid, prO\'ide fuel
158 Chapter 5 Corbohydrotes
urrently food labels use the term soluble for the cells in the large imcstine and enhance their healtb. 14" All these products c::1n
fiber rather than the more formal viscous also be absorbed into the bloodstream. As a result of bacteiial metabolism, soluble di-
fiber. We will use soluble fiber in this and other etary fibers yield about 1. 5 co 2 .5 kcal/g on average, although d1e acnial vnlue is still
chapters since it is still the term found on the in question. For this reason, hjgh-fiber foods should not be looked at as caloric-free,
Nutrition Facts label. It is likely that the term sol· though they arc often lower in energy content per serving d1on low-liber alternatives.
uble will be phased out in the future and re· When intake of fiber is high, its metabolism by bacteria can cause methane and hy-
placed with the term viscous. drogen to increase in the breath. This is not harmful. In addition, the body tends to
adapt over time to a high-fiber intake, karung to less gaseous symproms and adjusting
to the increased pressure that develops in the large intestine.
n outmoded term used for fiber is crude

fiber. This term arose during the early Concept I Check
1900s to reflect the amount of indigestible food· Am~rJose, amylopectin, and glycogen- all srorage forms of glucose-arc polysaccharides.
stuff present in animal feed. The animal feed Amylase and amylopeccin combine in rarying proportions to form food starch, such as char
was boiled for 1 hour in acid and for another found in potatoes wd bread. Glycogen is a storage form of glucose in humans. Li,·er glyco-
hour in an alkaline solution. The remains of that gen yields a ready source of blood glucose.
chemical digestion was called crude fiber; it con· Fiber is essentially me portion of ingested food that remains undigested as it enters the
sisted mostly of cellulose and lignins. All other large intestine. Fiber components include ccllulosc, hcmicclluloses, lignins, r1.:cti.ns, gums,
types of fiber were destroyed by the chemical and mucilages. There are two general classes of fiber: insoluble (nonfermcnrnblc ) and ~olu
action. blc {viscous). Insoluble fibers arc mostly made up of cellulose, hemicelJuloscs, and lignins.
Soluble fibers are made up mostly of pectins, gums, and mucilages. Borh insoluble and sol-
uble fibers arc resistant to human digestive enzymes, but bacteria in the large intestine ..:an
hreak down soluble fibers.
Carbohydrate Digestion and Absorption

Food preparation can be viewed as d1e start of carbohydrate rugestion because cook-
ing softens the rough fibrous tissue of plan rs, such as broccoli stalks. When starches arc
heated, the starch granules swel l as d1ey soak up water, making them much easier to
rugcst. All these effects of cooking generally make these foods easier to chew, swallow,
and break down dw-ing rugestion.
Digestion
The enzymatic digestion of starch begins in d1e month. Saliva contains an enzyme
In the search far fiber sources, don't overlook called salivary a mylase which mixes with the starch~, products during d1e chewing of
berries. Just 1/2 cup contains up to 3 g of the food. This amylase breaks down starch into many smaller units (e.g., disaccharides,
fiber. They ore also rich sources of various such as maltose) (Fignre 5-6 ). 14 You can observe this conversion while chewing a
beneficial phytochemicals.
saltine cracker. Prolonged chewing of the cracker causes it to taste sweeter as some
starch breaks down into the sweeter sugars, such as maltose. Still, food is in the mouth
for such a short amount of time drnt this phase of digestion is negligible. In addition,
once d1e food moves down the esophagus and reaches the stomach, the acidic em·i-
ron mcnt (pH 1- 2) inactivates salivary amylase.
After the carbohydrates ha\'e read1ed d1e small intestine-where the pH or 7 or
more is well-suited for further carbohydrate digestion-the pancreas rele,tscs c112ymes,
such as pancreatic amylase.
The original carbohydrates in a food will be present as such in the small intestine as
monosaccharidcs (mosdr any glucose and fructose present as such in food ). The di-
amylase Storch.digesting enzyme from the saccharides will include maltose from starch breakdown, lactose mainly from dairy
salivary glands or pancreas. products, and sucrose from food. T he polysaccharides in the food that were first acted
maltose An enzyme made by absorptive cells on in the mouth now are rugestcd fmrher by pancreatic amylase. Any disaccharides are
of the small intestine; !his enzyme digests digested to their monosaccharide units once d1ey reach d1e wall of d1c small intestine.
maltose to two glucoses. There specialized enzymes on d1c absorptivl.' cells digest each disaccharide into d1e
rnonosaccbaridc components. The enzyme m a.ltase acts on malrost.: ro produce rwo
www.mhhe.com/ wardlawpe rs7 1 59
Carbohydrates
l!l Some starch is broken down to maltose by

salivary amylase.
D Solivory amylase is inactivated by

strong acid in the stomach.
Pancreatic amylase breaks down

starch into maltose in the small intestine.
Enzymes in the wall of the small intestine break

down the disocchorides sucrose, lactose, and
maltose into monosoccharides glucose, fructose,
and goloctose.
1
:. Glucose, fructose, and golaclose ore absorbed
into blood to be token lo the liver by a portal
vein.
iD
Some soluble fiber is fermented into various
acids and gases by bacteria in the large
intestine.
Insoluble fiber escapes digestion and is excreted

in feces, but little other dietary carbohydrate is
present.
Figure 5 - 6 I Carbohydrate digestion and absorption. Enzymes mode by the mouth, pancreas, and small intestine participate in the process of
digestion. Most carbohydrate digestion and absorption take place in the small intestine. Note that Chapter 3 covered the physiology of digestion
and absorption in detail.
glucose molecules. Sacrase acts on sucrose to produce glucose and fructose. Lactase sucrose An enzyme made by absorptive cells
acts on lactose to produce glucose and galactosc. t 4 of the small intestine; this enzyme digests
When considering carbohydrate digestion, you should remember that the key di- sucrose lo glucose ond fructose.
gestive enzymes come from the pancreas and t he cells of the intestinal 'vvall. intestinal lactose An enzyme mode by absorptive cells of
diseases can interfere wi[h the digestion of sugars such as maltose, lactose, and sucrose. the small intestine; this enzyme digests lactose
Some of the carbohydrates therefore escape digestion and arc n01 absorbed. When to glucose ond galoctose.
these unabsorbed carbohydrates eventually reach the large intestine, the bacteria there
digesl the sugars, producing <Kids and gases as by-products (review Figure 5-6 ). If pro-
duced in large amounts, these gases can cause abdominal discomfort. People recover-
ing, from intestinal disorders, such as diarrhea or severe foodbornc illness, may need to
avoi<l lactose for a few weeks because of temporary lactose malabsorption. A few weeks
is sufficient time for the small intestine to resume producing enough lactasc enzyme m
allo\v for more complete lactose digestion (sec the larer section on lactose malabsorp-
tion and intolerance). 28
..,.
~o Na;-
Na+ No+•
Inside cavity {
of small /Glucose ~0-1' /Sodium
G G
intestine '<Yo"
Mk,,,.;11; {
~
..... ·D~-,
G
G
.·.
.· . G
'
I It
I I
I I
I I
G I
I
I I
I
I
G
G \
Absorptive cell
G: I I
: Cell spoce
l
I I
of the small I I G
intestine G I ,
m-t:::"HI:---.- -
Lacteal (lymph)
Capillary (bloodstream) ~~
l~
Potassium
Energy used
at this pump site
l\tOJI
Figure 5.7 I Active obsorplion of glucose in the absorptive cells lhot make up the villi in the small intestine. Glucose and sodium poss across the absorptive
cell membrane in a carrier-dependent, energy-requiring process. The energy is used for molnloining a low concentrolion of sodium in the cell. Once inside the
absorptive cell, glucose con exit by facilitated diffusion down its concenlralion gradient and enter the bloodstream.
Absorption
With the exception of fructose, simple sugars found naturally in foods and those
formed as by-products of earlier starch digestion in the mourh and small inresrine fol-
low an active absorption process. 14 Recall from Chapter 3 that this process requires a
specific carrier and energy input in order for the substance to be taken up by the ab-
sorprive cells in the small intestine. Glucose and its close rebrive, galacrosc, undergo
active absorption. They arc pumped into the absorptive cells along witb sodium
(Figure 5-7). The ATP energy used in the process is actually needed to pump Lhc
sodium ion back out of the absorptive cell.
Fructose on the otJ1er hand is taken up by tbe absorptive cells via facilitated dif-
fusion. In this case, a carrier is used, but no energy input is needcd. 14 This absorp-
tive process is slower than that seen with glucose or gaJacwse. Thus, large doses of
fructose are not readily absorbed and can col1[ribure to di<trrhea by remaining in the
small intestine and attracting water via osmosis. (Chapter 11 will discuss osmosi:. in
detail.)
Once glucose, galaccosc, and fructose enter the intestinal cells, g lucose and galac-
tosc rcmajn in rhat form, while some fructose is metabolized tu glucose. All the single
www.mhhe .com/wardlaw pers7 161
sugars in the absorptive cells are transported via a portal vein that is arrached to the
liYer. The liver then exercises its metabolic options:
• transforming the monosaccharides into glucose and then rdeasing this glucose di-
rectly into d1e bloodstream for transport tO organs, such as the brain, muscles, kid-
neys, and adipose tissues
• producing glycogen (the storage form of carbohydrate)
• producing fat
Of these du·ce options, prodncing fat is me least likely, except when corbohydrare is
consumed in \'ery high amounrs and energy needs are exceeded. 14
A small portion of search (about 10%) is called rcsistrt11t strwch because it resists di-
gestion. The reason for the lack. of digestion varies depending on the specific form of
resistant starch in a food. This resistant starch travels down to the large intestine. There
some of the search is metabolized by bacteria and the resulting acids ~rnd gases are ab-
sorbcd.14 This entire process also takes place for aoy uodjgested lactose present in the
large intestine. As mentioned before, scientists suspect mat some of d1ese products ac-
tually promote the health of the large intestine by providing a source of energy.
Concept I Check
Carbohydrate digestion is the process of breaking down larger carboh)'drates into their ab-
sorbable components. The enzymatic digestion of starches begins in the momh witJ1 sali-
vary amylase. Enzymes made by the pancreas and absorptive cclb of the small imescine
complete the digestion of carbohydrates to single sugars in the small inrestine. Primarily
following an active absorption process, the single sugars (glucose and galactose)-cirJ1er re-
sulting from the digestive process or present in the meal-are then taken up by absorptive
cells in rJ1e intestine. Fructose undergoes facilitated diffusion; once in the absorptive cell
most is metabolized to glucose. All the monosaccharidcs then enter a portal vein that ter-
minates in the li\'er. The liver finally exercises its metabolic options, primarily producing
glucose and glrcogen from the monosaccharides.
Functions of Glucose and Other Sugars lucose is also used to synthesize the ribose
and deoxyribose sugars used in RNA and
in the Body DNA synthesis, respectively.
Glucose yields energy, bnt it has many other functions as wel l. The functions also apply
to most carbohydrates because other sugars can generally be converted to glucose, and
more complex carbohydrates (e.g., starches) are broken down to yield glucose.
Yielding Energy
The main function of glucose is to act as a source of energy to body cells. Certain tis-
sues, such as red blood cells and most parts of the brain, derive almost all meir energy
from glucose. In fact, except when the diet contains almost no carbohydrates, d1e brain
and the rest of me centr al nervous system use most!)' glucose for fuel. Glucose can central nervous system (CNS) The brain and
also fue l muscle cells and other body cells, but many of mesc cells usually use forty acids spinal cord portions of the nervous system.
to meet energy needs. 14
Sparing Protein from Use as an Energy Source

Glucose is prorcin-sparing. Thor is, the amino acids that make up dietary protein can
be used to make body tissues or to perform other ''ital processes only when carbohy- gluconeogenesis The production of new
drate intake provides enough glucose for body needs. This is because if you do not glucose by metabolic pathways in the cell.
consume enough carbohydrate to yield that glucose, your body is forced to make it Amino acids derived from protein usually
from other nutrients, such as amino acids found in muscle tissue and other organs. provide lhe carbons for this glucose.
This process is termed gluconeogenesis, which means "production of new glucose"
162 Chapter S Carbohydrates
(review Chapter 4 for derails). 1-l ff the process continues for weeks, these organs can
become partially weakened. Generally, North Amcticans consume an1plc prorein, so
sparing protein is nor au important role of c<u·bohydrate in the diet. l t docs become
important i11 some energy-reduced diets and in starvation. (Chapters 7 and 20 discuss
spcci fie effects of starvation.)
The life-threatening wasting of protein that occu rs during long-term tasting (or
starvation) has prompted compmies that produce prod ucts used for rapid weight Joss
to include cnough carbohydrate to supply l 00 g/day or more. This significamly de-
creases protein breakdown and thus helps protect vital tissues and organs, includjng
the heart, du ring rapid weight loss.
Preventing Ketosis
An adequate intake of carbohydrates-glucose, other sugars, or starch-is necessary
for the complete metabolism of fats to carbon dioxide (C0 2 ) and water (H 2 0) in the
body. A low-carbohydrate intake, 50 to 100 g/day, leads to a decline in release of the
insulin A hormone produced by beta cells of hormone insulin into the bloodstream. This then leads to release of a large amount of
the pancreas. Among other processes, insulin fatty acids from adipose cells. The subsequent incomplete breakdown of these fatty
increases the synthesis of glycogen in the liver acids in the Liver then resu lts in formation of ketone bodies-acetoacetic acid and its
and the movement of glucose from the dcrivatives. L+ Chapter 4 covered in derail this condition, called ketosis.
bloodstream into muscle and adipose cells.
ln stan·ation, people do not consLune enough carbohydrate, so ketone bodies soon
appear in the blood. Again, this is the normal metabolic response to a fud sborrage.
Over time, pan of the brain and other tissues can use these ketone bodies for fuel. ln
fact, the use of ketone bodies by the brain and other organs, such as the beart, is an
important adaptive mechanism for survival during starvation. 1-l If parr of [he brain
could not use ketone bodies, the body wou ld be forced to produce much more glu-
cose from protein to support the brain's energy needs. The resuJting sd~:cannibaliza
tion wou ld rapid ly break down muscles, the heart, and other organs, severely limiting
he sweetness of sugars improves the taste of thl.'. body's ability to tolerate starvation.
many foods, such as grapefruit. In addition, ln untreated type l diabetes, excessive production of ketone bodies C•ln occur,
sugars provide certain functional properties to partly because there is not enough insulin to allow for normal glucose mct:ibofom. In
foods, such as texture, body, and browning such cases, the resulting ketosis can cause numerous complications (see the Nutrition
copo city. Forns near the end oftllis chapter for fLtrther discussion of diabetes). 2
Functions of Fiber
Fiber adds bulk to the feces, making bowel movements easier. This is especially true
for imoluble fibers. When enough fiber is consumed, tl1e stool is large and soft because
many types or plant fibers attract water. The larger size stimulates the intestinal mus-
cles, which aids dimination. Consequently, Jess pressure is necessary to expel the feces.
When too li ttle fiber is eaten, the opposite can occur: the stool may be small and hard.
Constipation may result, wluch can force one tO exert excessive pressure in the large in-
testi11e during detecation. This hjgh pressure can force parts of the large intestine wall ro
pop our from bet\\'een tl1e surrounding bands of muscle, forming small pouches called
diverticula Pouches that protrude through the diverticula.9 Mulciple divcrricula arc normally present (Figure 5-8). Hemon·hoids may
exterior wall of the large intestine. also result from excessive straining during defecation.
hemorrhoid A pronounced swelling of a large Diverticula arc asymptomatic in about 80% of aftected people; rhar is, they are not
vein, particularly veins found in the anal noticeable. The asymptomatic form of this d isease is called diverticulosis. If the di-
region. verticuJa eventually become i11Aamed, tl1e condition is known as diverticulitis. Intake
of fiber should then be reduced to limit farther b:icterial activiry. O nce the inflamma-
diverticulosis The condi tion of having many
tion subside~, a high-fiber diet, <tlong wich reguhu physical acti\·ity, is advised to case
diverticula in the large intestine.
bowel movements, and reduce the risk oF a funu·e attack. 9
diverticulitis An inflammation of the diverticula Additional health benefits can accrue from eating fiber-rich foods. A diet high in
caused by acids produced by bacterial fiber likely aids weight control and reduces the risk of developing obc~iry. 16 The bulky
metabolism inside the diverticula. nature of high-fiber foods fLl ls us up witl1out yielding much energy. The foods also take
a long time to chew. Increasing intake of foods rich in fiber is one srrarcgy for re-
Figure 5-8 I Diverticula in the large

intestine. A low-fiber diet increases the risk of
developing diverliculo. About one-third of
people over age 45 have the disease, while
lwo-thirds of people over 85 do.
Lorge - --::iill
intestine
(colon)
maining satisfied after a meal (review the discussion on energy density in Chapter 2).
Th.is is yet another reason to question low-carbohydrate diet claims-where is the
\.vholc-grain fiber going to come from? Karla has o family history of colon cancer, and
Over the past 30 years, many population srudies have shown a link between in- ol age 20 she is curious about the lifestyle fac-
creased fiber intake and a decrease in colon cancer development. However, some re- tors she con employ to prevent developing the
cent research has refuted the relationship between intake of fiber and colon cancer disease. What advice would you provide her?
development, while other research has been supportivc. 4 •22 C urrently, most of the re-
search on colon cancer is focusing on the potential preventive effects of rruirs, vegeta-
bles, whole-grain breads and cereals, and legume Lntakes (rather than fiber per se );
regular exercise; the use of aspirin and related pain medications; and meeting vitamin
D, folate, magnesium, selen ium, and calcium needs. S moking, o besity in men, exces-
sive alcohol use, starch- and sugar-rich foods, <md processed and red meat intake arc
under study as potential causes. 17•22 Overall, the health benefits to the colon that stern
from a high-fiber diet are for the most part due to the nutrients that are commonly
part of high-fiber foods, such as vitamins, minerals, ph}rtOchemicals, and in some cases
essential fatty acids. Thus it is more advisable to increase tiber intake using fibe r-rich
foods rather than mostly relyi ng on fiber supplements.
When consumed in large amounts, soluble fibers slow glucose absorption from the
small intestine and so contribute to better blood glucose regulation. This effect can be
helpful in the rreatmenr of diabetes. In fact, adults whose main carbo hydrate source is
low-fiber foods are much more likely to develop diabetes than those who have high-
fiber diets (see the Nutrition Focus near the end of this chapter). 24
A high intake of soluble fiber also inhibits absorption of cholesterol and bile acids
(cholesterol rich) from the small intestine, tl1creby somewhar reducing blood choles-
terol and possibly reducing the risk. of cardiovascular disease and gallstones. The short-
chain fat:ty acids resul ting from bacterial degradation of soluble fiber (e.g., proprionic
acid) also probably reduce cholesterol synthesis in the liver. Tn addition, the slower glu-
cose absorption that occurs with diets high in soluble fiber is Unked to a decrease in in-
sulin release. Because insulin sti mulates choksteroJ synthesis in Lhe liver, thil. reduction Oatmeal is o rich source of soluble fiber. FDA
in insulin may contribttte to the abiU ry of soluble Gbcr to lower blood cholesterol. allows o heollh claim for the benefits of
Overall, a fiber-rich diet containing fruits, vegetables, kgtunes, and whole-grain breads ootmeol to lower blood cholesterol that arise
and cereals (indudi.ng whole-grain breakfast cereals) is advocated as part of a strategy from the effects of this soluble fiber.
ecall from Chapter 2 that FDA has ap- to reduce risk of cardiovascular disease (coronary heart disease and strokc). 16 This is
proved the following claim: "Diets rich in the pri1mu-y reason why criticizing carbohydrates as a group is misguided_ The healrhy
whole-grain foods and other plant foods and sources of carbohydrates just listed are an important part of a diet.
low in total fat, saturated fat, and cholesterol
may decrease the risk for cardiovascular (heart) Concept I Check
disease and certain cancers."
Carbohydraocs provide glucose for the energy needs of red blood cells and parts of the
brain and central nervous system. Eating too little carbohydrate forces the production of
glucose (via gluconeogenesis), using carbons from amino acids. These amino acids are de-
rived from the breakdown of proteins in body organs. An inadequate carbohydrate intake
also inhibits efficient tar metabolism, which in ruro can lead to ketosis.
Fiber forms a vital part of the diet by adding mass to tl1c feces, which cases elimination.
Fiber-rich foods also help in weight control and reduce the 1isk of developing obesity and
cardiovascular disease. Soluble fiber can also be useful for controlling blood glucose in pa-
tients with diabetes and in lowering blood cholesterol. Whole grains, vegetables, legumes,
and fruits are excellent sources of fiber.
Carbohydrate Needs
The RDA for carbohydrates is 130 g/day for adu lts. 11 This is based on the amount
needed to supply adequate glucost: for the brain and central nervous system, without
having to rely on partial replacement of glucose by ketone bodies as :in cnerg}' source.
Exceeding this amounr somewhat is fine; d1e Food and Nutrition Board recommends
that carbohydrate intake should range from 45 to 65% of roral energy intake. 11 North
Americans consume about 180 to 330 g of carbohydrates per day. Tht: top five carbo-
hydrate sources for U.S. adtdts are white bread, soft drinks, cookies and cakes (includ-
ing doughnuts), sugars/syrups/j:1ms, and potatoes. Clearly, many of us should rake a
closer look at om main carbohydrate sources and strive ro improve these from a nurri-
tional standpoint.
In North America, carbohydrates supply abour 50% of dietary cnergy u1t.'lkc for adulrs.
Worldwide, howcver, carbohrdrates account for about 70% of all energy consumed. Tn
some cowmies, carbohydrates accounr for up co 80% of the energy consumed.
The Carbohydrate Continuum

later section entitled Health Concerns Currently, other recommendations for carbohydrate intake are made in the scientific
Related to Carbohydrate Intake provides a literanire and popular press. Aside from the low intakes used to induce ketosis as p<u-t
further look at o desirable amount of carbohy- of a plan for quick weight loss (note that tl1is diet is not n.:co111111cndcd for long-term
drate in a diet. use; see Chapter 13 ), recommendations vary from 40% of energy intake in T/Ji: Zom·
diet plans to more than 70% in the Pritillin Program and Ent More, Weig/; Less plan.
The Nutrition Facts panel on food labds uses 60% of energy intake as the standard for
recommended carbohydrate intake. In addition, one recommendation on which al-
most all experts agree is that our carbohydrate intake should be based pru11a.iily on
fruits, vegetables, whole-grain breads and cereals, and legumes, not mostly on refined
grains and sugar. 1•32
How Much Fiber Do We Need?

The Adequate Intake for fiber for adLLlts is 25 g/dav for women and 38 g/day for men .
This is based on a goal o( 14 g/1000 kcal in a diet. 11 After age 50 the Adequate lntake
falls to 21 g/day and 30 g/day, respectively. The rationale for tl1c Adequate Intake is
tl1e ability of fiber to reduce tl1c risk of ca.rdiovascular disease (and likely many cases of
diabetes). The Daily Value used for fiber on food and supplement labels is 25 g for a
r. Joanne Slavin discusses fiber in detail in 2000 kcal diet. In North America, the average intake of whole-grain breads and cere-
the Expert Opinion in this chapter. als is kss than one serving per day; fiber intake averages 14 g/day for women and
; Expert Opinion
Fiber-Finally a Nutrient
Joanne L. Slavin, Ph.D., R.D.
Dietary fiber hos a long and checkered post. In 300 BC, Hippocrates noted Constipation is more likely on low-fiber intakes and risk of colon cancer
that coarse brown bread produced a lot of feces and that this was good for is inversely related to stool weight. Still, the association of insoluble fiber with
us. This simple fact has been rediscovered many times, including al the start loxotion also is inconsistent. Fecal weight increases 5.4 g/g of wheat bran
of the modern cereal industry when the Kellogg brothers and C. W. Post got fiber (mostly insoluble), 4.9 g/g of fruit and vegetable fiber (soluble and in-
into the ad of promoting high-fiber foods. Loter, in the 1970s Dr. Denis soluble), 3 g/g of isolated cellulose (insoluble), and 1.3 g/g of isolated
Burkitt traveled the world showcasing pictures of large fecal specimens of pectin (soluble). Many other fiber sources are mostly soluble but still enlarge
rural Africans, who incidentally rarely developed Western diseases such as stool weight, such as oat bran and psyllium.
cardiovascular disease or colon cancer. As noted by Dr. Burkitt, having a Furthermore, besides food intake, other factors also affect stool size.
phone in the bathroom would be of no use lo the rural African because a Stress associated with exams or athletic competition can speed intestinal
high-fiber fecal sample is passed in much less time than it takes to make or transit. A morning cup of coffee con contribute to a regular bowel habit.
answer a phone call. Medications, both laxatives designed to speed transit and other drugs, alter
So what is this wonder compound? Dietary fiber is essentially the poly- bowel function and fecal composition. There is a large variation in doily
soccharide leftover of digestion. The physiological effect of fiber in intact stool weight even among subjects on rigidly controlled diets of the exact
foods is often greater than that found with isolated fiber fractions. In epi· same composition. A USDA study that examined the predictors of stool
demiologic studies, whole-grain breads and cereals, vegetables, and fruits weight when completely con trolled diets were fed to normal volunteers found
are often more protective against diseases than fiber supplements. Thus, fiber that personality was a better predictor of stool weight than fiber intake. In
intake may be a marker of a healthy diet rather than just a nutrient that can particular, outgoing subjects were more likely to produce higher stool
be isolated and added bock to the diet. weights than subject who were less so.
In 2002, the Dietary Reference Intakes (DRls) for the first time included
fiber as a nutrient. Dietary fiber was defined as nondigestible carbohydra tes
and lignin that ore intrinsic and intact in plants. Foods high in dietary fiber
include whole-groin breads ond cereals, legumes, vegetables, and fruits.
Another class of fiber, functional fiber, was defined as nondigestible carbo-
hydrates extracted from foods that hove beneficial physiological effects in hu-
mans. Functional fiber is found in bulk laxatives, forti fied foods, beverages,
and dietary supplements. Toto/ Fiber was then defined as the sum of dietary
fiber and functional fiber.
Soluble and Insoluble Fiber-Outmoded Terms

Previously, dietary fiber was divided into soluble and insoluble fiber in on at-
tempt ta assign physiological effects lo chemical types of fiber. Oat bran and
psyllium, two mostly soluble fibers, hove health claims for the ability lo lower
blood lipids. Wheat bran and other, more insoluble fibers ore linked to lax-
oHon. Yet, scientific support that soluble fibers lower blood cholesterol while
insoluble fibers increase stool size is inconsistent al best. A meta-analysis
(combined analysis of a number of studies) testing the effects of pectin, oat
bran, guor gum, and psyllium on blood cholesterol found that 2 to l 0 g/doy
of soluble fiber was associated with small but significant decreases in lotal-
ond LDL-cholesterol concentrations. Resistant starch and inulin, both consid-
ered soluble fibers under the new definitions do not, however, affect blood
cholesterol. Thus, not all soluble fibers lower blood cholesterol, and other
traits, such as viscosity of fiber, ploy roles. Make most of your grain choices whole grains.
Viscous and Nonfermentable Fiber- Fiber Needs and Intakes

A Better Classification?
Average fiber intakes in the United States foll woefully short of the current
The disparities belween the amounts of soluble and insoluble fiber measured Adequate Intakes set for various ages and genders. In contrast, vegetarians
chemically and the magnitude of their physiological effects led the Food and among us routinely consume this amount or more, and the fiber intake of
Nutrition Boord to recommend that lhe terms soluble and insoluble fibers Paleolithic man (the fruil and nul gatherer and wild game slayer) hos been
gradually be eliminated and be replaced by other properties, perhaps vis- estimated at about three to four times the current recommendations.
cosity and fermentability. Measuring dietary fiber and Functionol fiber by lhe
new definitions will also toke new approaches. First, we must decide on the
The Future of Fiber
criteria for functionality. If fermentobility and viscosity ore accepted as im·
porfont criteria, in vitro tests for these properties would need to be devel- Some research sludies support that stool size is protective against colon can-
oped. Tests for functional properties of dietary fiber could include a reduction cer and that fiber may be helpful for digestive diseases such as irritable
in blood cholesterol, improvements in bowel function, and modulation of bowel syndrome and diverticulosis. Many of the diseases of public health
blood glucose. Evaluation of these studies could be based on a biologically significance-obesity, cardiovascular disease, type 2 diabetes, colon can-
significant change. For example, does a particular functional fiber hove a cer, and constipation-may be prevented or treated by increasing the
similar blood cholesterol-lowering effect as oat bran, or does it increase wet amounts and varieties of fiber-containing foods. Promotion of such a food
stool weight similar to wheat bran? Does a particular fiber control blood glu- plan across lhe lifespan by health-core professionals and subsequent imple-
cose by on acceptable omounl, perhaps relative to a standard, effective mentation by our population should contribute to overall better health.
fiber? Another approach would be model systems for these otfribules. For ex-
Dr. Slavin is a professor in the Department of Food Science and
ample, a fecal bulking index hos been described in rats. Still, no perfect sys-
Nutrition, University of Minnesota, St. Paul. She has conducted many
tem will be found to evaluate and test the physiological effects of a complex
human feeding studies on dietary Fiber, whole grains, fruits, vegeta·
substance such as fiber.
bles, soy, and flax. Besides her pursuit of the fiber research, she
leaches Life Cycle Nutrition and Human Nutrition. She has published
more than 100 refereed scientific articles and speaks widely on
choosing carbohydrate sources wisely.
19 g/ day for men. This low intake is attributed to the lack of knowledge on the ben-
efits of whole-grain foods as well as the lack of ability to recognize whole-grain prod-
ucts at the time of pw-chase. Thus, most of us should increase our fiber i11take. At lcasr
three of your daily servings of grains should be whole grains. Eating a high-fiber cc·
real (;2: 3 g o f fi ber per serving) for breakfast is one easy way to increase fiber intake
(Figure 5-9 ). 18
he 2005 Dietary Guidelines for Americans
T provide the following advice regarding car-
bohydrate intake:
Table 5-2 shows a cliet contai11jng 25 or 38 g of fiber within very moderate energy
intakes. Diets to meet the fiber recommendations are possible if you regularly cat
whole-wheat bread , frui ts, vegetables, and beans. Use the first Take Action exercise in
• Choose fiber-rich fruits, vegetables, and this chapter to estimatt.: the fiber content o f your diet. What is yom• fiber score?
whole grains oflen. (In general, at least Note that manufactw·ers list enriched white (re.fined) flour as wheat flour on food
half one's intake of groins [3 ounces or labds. Most people d1ink that if "wheat flour" or "wbt:at bread" is on the label, they
more] should come from whole groins.) are buying a whole-wheat product. Not so. If the label does not list "whole-wheat
• Choose and prepare foods and beverages tlour" first, then the product is not p1imarily a whole-wheat bread and thus docs not
with little added sugars or caloric sweeten- co ntain as much fiber as it could . Careful reading of labels is important in the search
ers, such as in amounts suggested by for more fi ber- look especially for whole grains.
MyPyromid. Keep in mind, however, that any nurrienr can lead to heald1 problems when con -
• Reduce the incidence of dental caries by sumed in excess, includ ing carbo hydrate and fiber. The terms !Jigh-cn.rbo/Jydrate, /Jig/;-
practicing good oral hygiene and consum- fibcr, and !01P fat do not mean zero calories. Carbohydrates help modcratt: t:ncrgy
ing sugar- and starch-containing foods intake in comparison with futs, but high-carbo hydrate foods still conrriburc ro toral en-
and beverages less frequently. ergy intake, so t hc:y have ro be accounted for.l
Figure 5·9 I Reading the Nutrition Facts on
Nutrition Facts Nutrition Facts food labels helps us choose more nutritious
Serving Size: ~'<Cup (30g) foods. Based on the informotion from these
Serving Size 1cup (55o/2.0 oz.) Servings Per Package: About 17
Servings Per Container 1O nutrition labels, which cereal is the better
Cemlwttll ce...alWlth choice for breakfast? Consider the amount of
Amount 1Cup
Amount
Yi Cup
Vitamins A & D PM Serving c....., s..'t:~lk fiber in each cereal. Do the ingredient lists give
PetSenlng Ceml Skim Milk Calories 170 200 you any clues? (Note: Ingredients ore always
Calorles - 170 210 Calories from Fat 0 5 listed in descending order by weight on a
cafories from Fat 10 10 % D ally Value .. _ label.) When choosing a breakfast cereal, ii is
'• Dall)' Value··
Total Fat 0g· 0% 1% generolly wise to focus on those thol ore rich
Total Fat 1 0g· 2o/o ~
sat FatOg - -
·trans Fat Og
O"/o 0°10
Saturated Fat Og
Trans FatOg
0% 1%
*
- sources of fiber. Simple sugar content con also
be used for evaluation. However, somelimes
Cholesterol Omo- - Cholesterol Omg 0% 1%
0% 0%
Sodium 60mg 2% 4%
- lhis number does not reflect added sugor but
Sodium 300mg
Potassium 340mg
13%
10°·•
15%
16% Potassium 80mg 2% 8%
- simply the addition of fruits, such as raisins,
complicating ihe evaluation.
Total Total
9% 11 %
Carbohydrate 35g
Carbohydrate 43g
Dietary Fiber 7g- 28%
14% 16%
28% Dietary Fiber 1g 4% 4%
--
--
Sugars 16g Sugars20g
Other Carbohydrate20g Other
--
Protein 4g Carbohydrate 13g
V1tamin A 1_5j'.~1.. Protein 3g
Vitamin C 20% 22%
9a1~1um 2% 15% Vitamin A 25% 30%
l!Q.r]_ 65% 65% VitaminC 0% 2%
Vitamin D !O~i 25% Calcium 0% 15%
Th1am1n 2_5~~ 30% Iron 10% 10%
i:\ibofiavin 25% 35% Vitamin D 10% 20%
Ntac1n 25'· 25% Thiamin 25% 25%
Vitamin St; 25% 25% Riboflavin 25% 35%
!=ohc ac~ 30% 30%
V1tam1n~ 1,_ _ _ __ 25%
Niacin 25% 25%
0 35%
Ph()fillhorus 20% 30% Vitamin Bs 25% 25%
Magnesium 20% 25~. Folicacid 25% 25%
Zinc 25% 25% Vitamin 8 12 25% 30%
fo~ --- 10% 10~•- Phosphorus 4% 15%
•Amount in cereal One hall cup skim milk contnbutesan Magnesium 4% 8%
add1llonal •O cator1~s 65mg sodium 6g total car·
bohydrale 160 suga1s), and 4g protein. Zinc 10% 10%
.. Percent Dally Values are based on a 2,000 calorie Copper 2% 2%
diet Your dally values mav be higher or lower
depending on your ca1011e needs . ·Amount in Cereal One·~~I cup skim milk con
tributes an additional 65mg sodium. 6g total
Calories: 2.000 2.500 carbohydrate {6g sugars), and Jg protein.
Total fat Less 1tian 65Q - -Sbg-- -Percent Daily Values are based on a 2,000
5.11 fat L..ess than 20o 25g calorie diet Your daily values may be hlgh0<
Cholesterol Less lll3n 300mg 300mg or lower depending on your calorie needs:
Sodium Less 1han 2.400mg 2.400mg calories 2.000 2,500
Potassium 3.SOOmg 3 500mg Total Fat Less than 6sg 80g -
Total carbohyd1ate 300g 37Sg Sal. Fal Less than 20g 25g
01e1aryflbe1 25g 30g Cholesterol Less than 300mg 300mg Whole-groin foods, such as granola, ore
Catones per gram: Sodium Less 111iln 2.400mg 2,400mg
Fat 9 • C<lrbohydmle 4 Protein 4 Potassium 3,SOOmg 3,500n1g excellent sources of fiber.
'Intake ot tmns la1 should be as tow as POSSlble Total carbohydrate 300g 375g
Oielaly Fibef 25g 30g
Ingredients: Wheat bran with other parts of wheat.
raisins. sugar, com syrup, salt. matt flavoring. glycerin,
1ron.nlacinamide, zinc oxide, pyrkloxme hydrochlo11de
Fat 9 .
Calones per gram:
Carbohydrate 4 . Protein 4
'Intake of tmns fat should be as low as possible.
(vitamin 85) riboflavin (vitamin 82). vitamin A Ingredients: Wheat SJgar. Com Syrup
palm1tate, lhlamin hydrochloride (vitamin 81 ). Honey Caramel Color, Partially Hydrogenated
fOl1c acid, vitamin 812 and vitamin D. Soybean Oil, 5alt. Ferne Phosphate. ea/thy People 2010 hos the following
Niacinamide (Niacin), Zinc Oxide, Vitamin A goals related lo carbohydrate intake·
(Palm1tate). Pyndox1ne Hydrochlonde
(Vitamin 86). Riboflavin Th1amin Monomtrate, • Increase lhe proportion of persons age
Fohc Acid (Fotate).Vitamm 812 and Vitamin D. 2 yeors and older who consume ot least six
doily servings of groin products, with ot least
three being whole groins.
• Increase the proportion of persons oge
Concept I Check 2 yeors ond older who consume at least two
The RDA for carbolwdrare is 130 g/day. The typical North American diet prO\ ide~ 180 to doily servings of fruit.
330 g/da). A reasonable goal is to lm·c about half our energy incakc comtng from \l,m:h. • Increase lhe proportion of persons age
Tot'11 carholwdrare intake ~hould constinite about 60% of ow- energy imake, "ith .1 rnnge 2 yeors and older who consume al leost
of 45 to 65%. This goal should allow for the recommended intake of 25 w 38 g of three doily servings of vegetables, with ol
fiber/day for women and men, respectively. least one·third being dork green or orange
vegetables.
167
Table 5·2 I Sample of Menus Containing 1600 kcal and 25 g of Fiber, and 2000 kcal and 38 g of Fiber*
25 g Fiber 38 g Fiber
Carbohydrate Fiber Content Carbohydrate Fiber Content
Menu Serving Size Content (g) (g) Serving Size Content (g) (g)
Breakfast
Orange juice !with pulp) 1 cup 28 0.5 1 cup 28. 0.5
Wheaties 3/4 cup 17 2 3/4 cup 17 2
2% milk 1/2 cup 6 1/2 cup 6
Whole-wheal toast 1 slice 13 2 1 slice 13 2
Margarine 1 lsp l lsp
Coffee
Lunch
Leon horn 2 oz 2 oz
Whole-wheal bread 2 slices 26 4 2 slices 26 4
Mayonnaise 2 tsp 2 2 tsp 2
Lettuce 1/4 cup 0.2 1/4 cup 0.2
Cooked white beans 1/3 cup 15 4 1 cup 45 12
Pear (with skin) 1/2 12 2 1 25 4
1% milk 1/2 cup 6 1/2 cup 6
Snack
Corrot (as carrot sticks) 8 2 8 2
Dinner
Broiled chicken (no skin) 3 oz 3 oz
Baked potato (large, with skin) 1/2 15 l.5 l 30 3
Margarine 1 1/2 tsp 1 1/2 tsp
Cooked green beans l cup 10 4 1 cup 10 4
Margarine 1/2 tsp 1/2 tsp
1% milk 1 cup 12 l cup 12
Apple (with peel) 1/2 16 1.8 1 32 3.7
Snack
Raisin bagel 39 1.2 39 1.2
Total 226 g 25 g 300 g 3Bg
•The overall diet pattern is based on MyPyromid. Breokdown of opprox1mole energy content: carbohydrate, 55%; protein, 20%; fat, 25%.
I Health Concerns Related to Carbohydrate Intake

Aside from the health tisks related to ketosis, both excessive fiber and cxces~ivc sugar
intakes can pose health problems. Too much lactose in the diet is also a problem for
some people.
Problems with High-Fiber Diets

Very high inrakcs of fiber- for exampk, 60 grams per day-can pose some health risks,
especially when fluid intake is lo\\'. This combination can leave r.he stool very hard and
pain.fol to el iminate. In more severe cases, the combinatio n of excess fiber and [nsuffi-
cicnt t]uid may contribute w blockages in the intestine, which may require surgcr).
Aside from problems with the passage of materials through the GI tract, a very high here is a widespread notion that high-sugar
fiber diet may also decrease the availability of nutrients. Certain components of fiber intakes by children cause hyperactivity, typi-
may bind to essential minerals, keeping them from being absorbed. For example, when cally part of the syndrome called attention deficit
fiber is consumed in large amounts, zinc and iron absorption may be hindered. In chil- hyperactivity disorder (ADHD). However, most
dren, a verv high fiber intake may reduce overall energy i11take, because fiber can researchers find that sucrose may actually have
quickly fill a child's small sromach before food intake meets energy needs. the opposite effect. A high-carbohydrate meal, if
also low in protein and fat, has a calming effect
and induces sleep; this effect may be linked to
Problems with High-Sugar Diets
changes in the synthesis of certain neurotrans·
The main problem with consuming an overabundant amount of sugar is that it provides milters in the brain, such as serotonin. If there is
empty calories (i.e., is low in other nutrients) and increases the Lisk for dental decay. a behavior problem, it is probably the excite-
ment or tension in situations in which sugar-rich
Diet Quality Declines When Sugar Intake Is Excessive foods are served, such as at birthday parties
and on Halloween.
o,·ercrowding the diet with sweet treats can leave little room for important, nutrient-
dense foods, such as dairy products and vegetables. Children and teenagers are at the
highest risk for overconsuming empty calories in place of nutrients that are essential for n excess intake of sugared soft drinks has
growth. Many children and teenagers arc drinking an excess of sugared soft drinks and
other sugar-containing beverages and much less milk than ever before. Milk contains
A recently been linked to a risk for both
weight gain and type 2 diabetes in adults.25
calcium and vitamin D , both of which are essential for bone health; therefore, d1is ex-
change of soft drinks for milk can compromise bone hea lth.
Supersizing sugar-rich beverages is also a growing problem; for example, in the 1950s
a typical serving size of a soft drink was a 6M ounce bottle, and now a 20 otmce plastic bot-
tle is a typical serving. This one change in serving size contributes 170 extra kcal of sugars
to the diet. Most convenience stores now ofter cups that will hold 64 ounces of soft drinks.
Filling up on sugary soft drinks in place of foods is not a healthy practice, but enjoying an
occasional soft drink or limiting intake to one 12 tl. oz. serving a day is generally fine.
Switching to diet soft drinks is also an easy way to spare the simple sugar calmies.
The sugar found in cakes, cookies, and ice cream supplies extra energy that pro-
motes \\'eight gain, mtless an individual is physically active. Today's low-fol aod fat-free
snack products usually contain lots of added sugar to produce a product with an ac-
ceptable taste. The result is to produce a bigh-caJorie food that is equal ro or greater
in energy content than the high-fat food product it was designed to replace.
Wim regard ro sugar intake, the World Health Organization suggests that sugars
added to foods during processing and preparation ("added sugars" ) should provide no
more than about 10% of total daily energy intake; an upper limit of 25% has been set
by the Food and Nutrition Board. Diets that go beyond this upper limit become scarce
in more healthy foods. 11
A moderate intal<:e of about 10% of energy intake corresponds to a maximum of ap-
proximately 50 g (or 12 tsp) of sugars per day, based on a 2000 kcal diet. Most of the
sugars we eat come from foods and beverages to wbicb sugar has been added during
processing and/or manufactme. On average, North Americans cat about 82 g of
added sugars daily, amounting to about 16% of energy intake. Major somces of added
sbgars include soft drinks, cakes, cookies, fruit plll1ch, and dairy desserts, such as ice
cream. FoUowing tl1e recommendation of having no more than l 0% of added energy
intake from "added sugars" is easier if sugary soft drinks and sweet desserts such as cakes,
cookies, and ice cream (full- and reduced-fat) are consumed sparingly (Table 5-3 ). 1
Excessive Sugar Intake Can Lead to Dental Caries

S1.1gars in the diet (and starches that are readily fermented in the mouth, such as crack-
ers and white bread) also increase the risk of developing dental caries. 29 Recall that dental caries Erosions in the surface of a tooth
caries, also known as cavities, are formed when sugars and other carbohydxates are me- caused by acids made by bacteria as they
tabolized mto acids by bacteria that live in the moud1 (Figure 5-10). These acids dis- metabolize sugars.
solve the tooth enamel and underlying structure. Bacteria also use the sugars to make
plaque, a sticky substance that both adheres acid-producing bacteria to teem and di-
minisJ1es me acid-neutralizing effect of saliva. l
Table 5·3 I Suggestions for Reducing Simple-Sugar Intake

At the Supermarket
• Reod ingredient labels. Identify all the added sugars in a product. Select items lower in totol
sugor when possible.
• Buy fresh fruits or fruits pocked in water, juice, or light syrup, rather than those packed in heavy
syrup.
• Buy fewer foods that are high in sugor, such as prepared baked goods, candies, sugared
cereals, sweet desserts, soft drinks, and fruit-flavored punches. Substih.Jfe vanilla wafers, graham
crackers, bagels, English muffins, ond diet soft drinks, for example.
• Buy reduced-fat microwave popcorn to replace candy for snacks.
In the Kitchen
• Reduce the sugar in foods prepared at home. Try new low-sugar recipes or adjust your own.
Many foods we enjoy ore sweet. These should Start by reducing the sugar gradually until you've decreased ii by one-third or more. Consider
be eaten in moderation.
using Splenda to substitute for some sugar.
• Experiment with spices such as cinnamon, cardamom, coriander, nutmeg, ginger, and mace to
enhance the flavor of foods.
• Use home-prepared items (with less sugar) instead of commercially prepared ones that are higher
in sugar.
At the Table
• Use less of all sugars. This includes white and brown sugars, honey, molasses, syrups, jams,
and jellies.
• Choose fewer foods high in sugar, such as prepared baked goods, candies, and sweet desserts.
• Reach for fresh fruit instead of cookies or candy for dessert or between-meal snacks.
• Add less sugar to foods-coffee, tea, cereal, and fruit. Get used to using half as much; then see
if you can cut back even more.
• Cut bock on the number of sugared soft drinks, punches, and fruit juices you drink. Substitute
water, diet soft drinks, and whole fruits rather than fruit juice.
Modified from USDA Home ond Garden Bulletin No. 232-5 1986
Figure 5· 1 0 I Dental caries. Bacteria can

collect in various areas on o tooth. Using
simple sugars such os sucrose, bocterio then
Enamel ----,;.;.-
create acids thot con dissolve tooth enamel,
leading to cories. If the caries process Caries -------;::::~
Gum ---~~
progresses and enters the pulp cavity, damage
to the nerve and resulting pain ore likely. The Dentin -----,7;==-=ie:::~
bacteria also produce plaque whereby they

odhere to the tooth surface.
'1$'~~ Blood vessels

~~~~~~~~~~~~ and nerves
The worst offenders in rerms of promoting dental caries arc sticky and gummy
foods high in sugars, such as caramel, because they stick to the teeth and supply the
bacteria wit:h a long-lived carbohydrate source. Although liquid sugar sources (e.g., John and Mike are identical twins who like the
fruit juices) are not as potent at causing dental caries as sticky and gummy foods, they same games, sporls, and foods. However, Jahn
still warrant consideration. 29 likes to chew sugar-free gum and Mike doesn't.
Snacking regularly on sugary foods is also likclr to cause caries because it gives tbe Al their las/ dental visit, John had no cavities,
bacteria on the teeth a steady source of carbohydrate from which m continually make but Mike had two. Mike wants to know why
acid. Sugared gum chewed berween meals is a prime example of a poor dental habit. John, who chews gum after eating, doesn't
Still, sugar-containing foods are not the onl)' foods that promote acid prnduction by have cavities and he does. How would you ex-
bacteria in the mouth. As mentioned, if starch-containing foods (e.g., crackers and plain this lo him?
bread) are held in the mouth for a long time, they can be acted on by enzymes in the
mouth that break down the starch to sugars; bacteria can then produce acid from these
sugars. Overall, the sugar and starch contem ot' a food and its ability ro remain in the.:
mouth largely determine its potential to cause caries.
Fluoridated water and toothpastes have contributed to fower dental caries in North
Am.e rican chilciren over the past 20 years because of fluoride's tooth-strengthening ef-
fect (see Chapter 12). Research has also indicated that certain foods-such as cheese,
peanuts, and sugar-free chewing gum-can actually help reduce the amount of acid on
tccth. In addition, rinsing the mou th after meals and snacks reduces the <lcidiry in the
mouth. Certainly, good nutrition, habits that do not present an overwheLning chal-
lenge to oral health (e.g., chewing sugar-free gum), and ro utine visits to the dentist all
contribute ro improved dental healtb. 29
High Glycemic Index and G lycemic Load Also Deserve Consideration

Our bodies react uniquely to different sou rces of carbohydrates, such that a serving of
a high-fiber food such as brown rice results in lower blood glucose levels compared to
the same size serving of mashed potatoes. Researchers have developed t\.VO tools that
are useful in predicting the blood glucose response to various foods.
The first of these tools is glycem ic index (GI), wh ich is a ratio of the blood glu- glycemic index (GI) The blood glucose
cose response to a given food compared to a standard (typically, glucose or white response of a given food compared to a
bread ) (Table 5-4).5 Glycemic index is inflnenced by starch structure, fiber content, sta ndard (typically, glucose or white bread).
food processing, physical srructLu·e, food temperatu re, <tnd other 111acrom1trienrs in the glycemic load (GL) The amount of
meal, sucb as fat. Foods with particularly high g lyccmic index values are poraroes, es- carbohydrate in a food multiplied by the
pecially baking potatoes (due to higher amylopectin content compared to red pota - glycemic index of that carbohydrate. The result
toes), mashed potatoes (due ro greater surface area exposed), short grain white rice, is then divided by l 00.
honey, and jelly beans. A major shortcoming of glycem ic index is that d1e nw11ber is
based on a sen·ing of food that would provide 50 grams of carbohydrate. As you can
imagine, this amount of food may not reflect the amount t}11ica lly consumed.
Anod1cr way of describing how d ifferent foods affect blood g lucose (and insulin)
levels is glycemic load (GL ). The glycemic load takes into account d1e g lycemic i11dex
and the amount of carbohydrate consumed, and in doing so actually better reflects a
food's effect on one's blood glucose than glycemic index a lone. 5 To calculate the
glycemic load of a food, the grams of carbohydrate in a sen·ing of Lhc food are mu16-
term you might see on food labels is "net
plicd by the glycemic index of that food, and then divided by l 00 (since g lycemic
corbs." This term hos no legal FDA-
index is actually a percentage). For example, vanilla wafers have a glycemic index of77,
and a small serving contains 15 g of carbohydrate. This yields a g lycemic load of 12. opproved definition. It is used to describe the
content of carbohydrates that increase blood
(77 x 15 )-:- 100 = 12 glucose. Fiber and wgor alcohol content ore
subtracted from total carbohydrate content to
So even though the glycemic index of vanilla wafers is considered high, the glycemic yield "net corbs," because these hove a negligi-
load cakubtion shows that the impact of this food on b lood glucose levels is fairly low ble effect on blood glucose. Still, sugar alcohols
(review Table 5-4). and some fibers do yield energy.
172 Chapter S Carbohydrates Table 5.4 I Glycemic Index !GI) and Glycemic load IGL} of Common Foods
Reference food glucose = 100
low GI foods-below 55 low Gl foods-below 10
Intermediate GI foods-between 55 and 69 Intermediate GLfoods-between 11 and 19
High GI foods-more than 70 High Gl foods-more than 20
Serving Glycemic Carbohydrate Glycemic
Size (grams) Index (GI)• (grams) Load (GL)
Pastas/Grains
Brown rice l cup 55 46 25
White, long groin 1 cup 56 45 25
White, short groin 1 cup 72 53 38
Spaghetti l cup 41 40 16
Carrots, criticized in the popular press for Vegetables
having o high glycemic index (which isn't even
Carrots, boiled 1 cup 49 16 8
true), actually contribute o low glycemic load to 39 21
Sweet corn 1 cup 55
o diet. Potato, baked 1 cup 85 57 48
New (red) potato, boiled 1 cup 62 29 18
Dairy Foods
Milk, whole 1 cup 27 11 3
Milk, skim 1 cup 32 12 4
Yogurt, low-fat 1 cup 33 17 6
Ice cream 1 cup 61 31 19
Legumes
Baked beans 1 cup 48 54 26
Kidney beans 1 cup 27 38 10
lentils 1 cup 30 40 12
Novy beans 1 cup 38 54 21
Sugars
Honey l tsp 73 6 4
Sucrose 1 tsp 65 5 3
Fructose 1 tsp 23 5 1
lactose 1 tsp 46 5 2
ou might wonder why the glycemic index Breads and Muffins

and glycemic load of white bread and Bogel 1 small 72 30 22
whole-wheat bread ore similar. This is because Whole-wheat bread 1 slice 69 13 9
whole-wheat Aour is typically so finely ground White bread 1 slice 70 10 7
that it is quickly digested. Thus, the effect of fiber Croissant 1 small 67 26 17
in slowing digestion and related absorption of Fruits
glucose is no longer present. Some experts svg·
gest we focus more on minimally processed Apple 1 medium 38 22 8
Bonano 1 medium 55 29 16
groins, such as coarsely ground whole-wheat 1 medium 25 32 8
Grapefruit
flour and steel-cut oats, to get the full benefits of Orange l medium 44 15 7
these fiber sources.
Beverages
Apple juice 1 cup 40 29 12
Oronge juice 1 cup 46 26 13
Gatorade 1 cup 78 15 12
Coco.Colo 1 cup 63 26 16
Snack Foods
Potato chips 1 oz 54 15 8
Vanilla wafers 5 cookies 77 15 12
Chocolate 1 oz 49 18 9
Jelly beans 1 oz 80 26 21
• Bosed on o comparison lo glucose
Source: Fosler·Powell Kond others: lnlernotionol loble of glycemic index and glycemic load. American Journot of Clinical Nutrition
76:5, 2002.
w w w .mhhe.com/wardlawpers7 173
Why are we concerned with the effects of various foods on blood glucose? Foods
that have a high glyccmic load elicit a large release of insulin from the pancreas.
Chronically high insulin output leads to many harmful effects on the body: high blood
a·iglycerides, increased fut deposition in the adipose tissue, increased tendency for
blood to dot, increased fat synthesis in the liver, and a more rapid return of hunger
after a meal (insulin rapidly lowers the macronuticnts in the blood as it stimulates their
storage, signaling hunger). Over time, this increase in insulin output may actuaUy cause
the muscle cells to become resistant to the action of insulin and evenurally lead to di-
nbetes :lnd cardiovascular disease in some people. 5
There are many ways to address this problem of high glycemic load foods. The most
important is to not overeat these foods at any one meal. This greatly minimizes their
effects on blood glucose and the subsequent increase in insulin release. At each meal
consider substituting at least one food that has a low glycem.ic load for one with a
higher value, such as long grain rice or spaghetti for short grnin white rice. Combining
a low glycemic load food, such as an apple, kidney beans, milk, or snlad with dressing,
with a high glycemic load food also reduces the effect on blood glucose. In addition,
maintaining a healthy body weight and performing regular physical activity Jiu·t11er re-
duces the effects of a high glycemic load diet.
A focus on low glycemic load carbohydrates can help in the treatment of diabctes; 5
Chapter 14 discusses the use of foods with different glycemic load values in planning metabolic syndrome A condition in which the
diets for athletes. person hos poor blood glucose regulation,
hypertension, increased blood triglycerides,
and other health problems. This condition is
Sugars and Refined Starches and the Metabolic Syndrome usually accompanied by obesity, lack of
physical activity, and a diet high in refined
Despite the current nend to"d.emonize" carbohydrates, the only time a carbohydrnte-
carbohydrates; also called Syndrome X.
rich diet may not be recommended is when a person's blood niglycerides are high, in
tw-n cona:ibuting to the metabolic syndrome. (This syndrome will be covered further lactose maldigestion (primary and
in Chapter 6.) Note that about 25% of North American adults have this condition. secondary) Primary lactose maldigeslion
Acrually, the chief culprits con1:1ibuting to high blood triglycerides <U"e nor often car- occurs when production of the enzyme lactose
bohydrates as a class of nutrients but excessively large meals full of foods rich in sim- declines for no apparent reason. Secondary
ple sug-ars and refined starches bur low in fiber. In add ition, too little physical activity lactose maldigestion occurs when a specific
cause, such as long-standing diarrhea, results
(and obesity) worsens the metabolic syndrnme. 6 T hese practices should not form the
in o decline in lactose production. When
basis of daily habits, but unfornmately, they do for many adults. significant symptoms develop after lactose
intake, it is then called lactose intolerance.
Problems with Lactose Intake, Especially for Some People
Lactose m aldigestion is a normal pattern of physiology that often begins to develop
after early childhood, at about ages 3 to 5 years. [t can lead to symptoms of abdomi-
nal pain, gas, and diarrhea after consuming lactose, especially when eaten in large
amounts. This prirnary form oflactose maldigestion is estimated to be present in about
75% of the world's population, altl1ough not all these individuals expe1ience symp-
toms. (When significant symptoms develop after lactose intake, it is then called lactose I is hypothesized that approximately 3000 to
intolerance.) Another foi:m of the problem, secondary lactose maldigestion, is a tem-
porary condition in which lactase production is decreased in response to an underly-
I 5000 years ago, a genetic mutation occurred
in regions that relied on milk and dairy foods as
ing disease, sucb as intestinal diarrhea. 28 a main food source, allowing those individuals
The symptoms of lactose maldigestion and intolerance include gas, nbdominal (mostly in northern Europe, pastoral tribes in
bloating, cramps, and diarrhea. The bloating and gas are caused by bacterial fermen- Africa, and the Middle East) to retain the ability
tation of lactose in the large intestine. The diarrhea is caused by undigested lac rose in to maintain high lactose output for their entire
the large intestine as it draws water from the circu latory system into the large intestine. lifetime. This was not seen in other populations
In North Ame1ica, approximately 25% of adults show signs of decreased lactose di- in the world, and so such digestive capability
gestion in the small intestine. Many lactose maldigesters are Asian Americans, African was not retained in those areas of the world.
Americans, and Latino/ Hi~panic Americans, nnd the occurrence incre:ises :is peopk
:ige. Still, many of these indi' iduals can consume moderate amounts of lactose "irh
minimal or no gastrointestinal discomforr because of eventual lactose brcakdo\\ n b~
bacteria in the large imestine. 28 Thus, ic is unnecessary for these people to greatly re
strict their intake of lactose-containing foods, such as milk and milk products. These
calcium-rich food products arc important for maintaining bone health. Obtaining
enough calcium and \'itamin D from the diet is much easier when milk and milk prod
ucrs arc included in a diet.
Recent snidics have shown that nearly all indi,·iduals with decreased lactasc produc
tion can tolerate 1/2 to 1 cup of milk with meals, and that most individuals adapt to
intestinal gas production resulting from the fermentation of lactose by bacteria 111 the
large intestine. 28 Combining lactose-containing foods with other foods also hdps be-
cause certain properties of foods can have positiYe effects on lacrose djgestion. For ex
ample, fat in a meal slows digestion, leaving more time fo r lactasc action. Hard cheese
and yogmt also are more e<lsily tolen\ted than milk. Much of the lactose is lost in the
production of cheese, and the active bacteria cultures in yogurt digest the lactose when
Use of yogurl helps lactose maldigesters meet
tllese bacteria a.re broken apart in the smal l intestine aJld release thefr lactasc. In addi-
calcium needs.
tion, an array of products, such as low-lactose mi lk and lacrase pills, arc available ro as
sist lactose maldigcsters when needed.
Concept I Check
North Americans eat about 82 g of sugars each day. J\lost of these sugars arc added to
foods and beverages m proccss111g. To reduce consumption of sugars, one must reduce
consumption of items with added sugars, such as some baked goods, sweetened be,·erag~,
and presweetencd read\ to-eat brcakfasr cereals. This practice can help reduce the de,clop-
ment of dental caries and likel\' improve diet quality and Yarious other aspects of health.
High-fiber diets must be accompanied by adequate Huid intakes to a\'Oid constipation.
Lactose maldigestion is a condition that results when cells of the intestine do not make sul
ficienr lactase, dle enzyme necessary tO digest lacrosc, resulting in symptoms such as ab-
dominal gas, pain, and diarrhea. Mose people with lactose maldigestion can tolerate cheese~
and yogurt as well as moderate Jmounts of milk. When significant symptoms de,·clop after
lactose intake, it is c.1lled lactose intolerance.
Myeshia suspected she had a problem with milk because when she consumed ii
during one meal, she developed bloating and gas. She tried to reduce these symp-
toms by eating yogurt, and she was successful. As you just learned, yogurt is toler·
ated better than milk by people with lactose maldigestion because the bacteria that ore present
in yogurt digest much of the lactose. Note, however, that many people with lactose maldigeslion
can consume moderate amounts of milk wilh few or no symptoms from the lactose present.
When Blood Glucose Regulation Fails
Improper regulation of blood glucose can lead co well as increased glucose uptake b1 muscle cells,
either hyperglycemia (high blood glucose ) or adipose cells, and some other cells. Both of these
hypoglycemia (lo\\ blood glucose). High blood actions of insulin lower blood glucose and help re- hyperglycemia High blood glucose,
above 125 mg/di of blood on a fasting
glucose is most commonly associated with diabetes mrn it to the normal fasting r.111ge \\ithin a tcw basis.
(rechnically, dinlmes 111cllit11s), a dise.1se that affects hours after a person e.m. In addition, imulin re-
abom 6%of North Americans. The diagnostic cri- duces gluconeogcnesis b~· the liver. hypoglycemia low blood glucose, below
teria is based on a fasting blood glucose of Other hormones counteract the eftects of in- 40 to 50 mg/di of blood.
126 mg/di or greater (di represents 100 ml sulin. 'When J. person has nor eaten carbohydrates
[decilirerj). or those affected, it is estimated that for a fow hou rs, the amount of glucose in the blood
about one-third to one-half or these people do not is maintained by the hormone glucagon, which is
know that they have the disease. In addition, about also releaseJ from the pancreJs. Glucagon prompts reviously, a fasting blood glucose of
15%of our popul,1tion shows evidence of insulin re- the breakdown of glycogen in chc lirer, resulting in 140 mg/di was required to diag·
sismnce but not actual di.1beres (indicated by a fast- the release of gluco\c to the bloodstream. nose diabetes. Recently, though, amounts
ing blood glucose of 100- 125 mg/ di ).2 Diabetes Glucagon also enhances gluconcogenesis. In these in the 120 mg/di range have been found
leads ro about 200,000 deaths each year in North ways, glucagon helps re~rore blood glucose to nor- to cause tissue damage. For this reason,
America, and the number of new cases is climbing mal concentrations (Figure 5-11 ).14 the diagnostic cutoff for diabetes using
yearly. ~e\\ recommendations promote resting fast- When a person has not earen for a few hours, fasting blood glucose has been decreased
ing blood glucose in adults 0' er age 45 e\'cry the hormones epinephrine (adrenaline ) and to 126 mg/dl. The corresponding cutoff
3 year; ro hdp diagnose these missed c.1ses. In con- norepinephrinc also arc rdcased, bur from the ad- value token 2 hours after a 75 g glucose
trast, lo" blood glucose is a much rarer condition. renal gland~ and nearby ncrre endings. The:;e hor- load is 200 mg/dl.2
mones trigger the breakdcm n of glycogen in the
Regulation of Blood Glucose li,·er; the resulting glucose is released into the
bloodstream. These hormones arc responsible for
Under nornul circumstances, blood glucose usuallr the "fight or flight" reaction . They arc released in
\'aries between .1bout 70 and 99 mg/di of blood in large amounts in response to a perceived threat,
the fusting state, which is nonn.illy established a few such as a car ,1pproaching he.1d -on. The resulting
hours a~er a meal is eaten. If blood glucose rises rapid release of glucose inco the bloodstream pro-
above 170 mg/ dl, glucose begins to spill over into motes quick mental and physical reactions. Other
the urine. This leads to hunger and thirst, and evcn- hormones, such as corrisol and gm" th hormone,
mally to weight loss. If blood glucose falls below 40 also help regulate blood glucose (Table 5-5).
tO 50 mg/di, a person begins to foci nervous, irri- In essence, the action~ of insulin on blood glu-
table, and hungry .111d may develop a headache. (It cose arc balanced by rhe actions of glucagon, epi-
is nor roo surpiising that a headache results because nephrine, norcpinephrinc, cortisol , and od1er
d1c brain is fiteled almost entirely by glucose.) hormones. If hormonal balance is nor maintained,
The Ii, er is the main organ for controlling the such as during overproduction or underproduction
amount of gluco~e that is eventually found in the of insulin or glucagon, major changes in blood glu- Regularly checking blood glucose is port
bloodstream. Since it is the first organ to screen cose concentrations occur. 14 This system of checks of diabetes therapy today.
d1e sugars absorbed from the small intestine, d1e and balances for blood glucose regul.uion is rypical
li\·er sen·cs as a guard, hdpmg control the amount of ho" the body maintains blood and other tissue
of glucose that enters the bloodmeam afo:r a meal concentrations of its key consmuents \\ithin fairly
(rc\icw Figures 5-6).1 4 narrow ranges. type 1 diabetes A form of diabetes in
The p.mcreas is another important site of blood which the person is prone to ketosis and
glucose control. Small amounts of insulin arc re- Diabetes Mellitus requires insulin therapy.
lc.iscd tw the pancreas as soon .ts a person starts co
type 2 diabetes A form of diabetes in
ear. Once much of the dictarv glucose enters the There arc rn·o major forms of di;;betes: type 1 which ketosis is not commonly seen
bloodstream, the pancreas releases large amounts diabetes (formerly c.1llcd insulin dependent or Insulin therapy can be used but is often
of insulin, which .tffech blood glucose in a ''ariety juvenile-onset diabercs), and type 2 (formerly CJ!led not required. This form of the disease is
of ways. fnsulin promotes incre.1sed glycogen non-insulin -dcpendcm or adult-onset) diabetes often associated with obesiry.
synrhcsis and thus g\ucose storage in the li1·er as (Table 5-6 ). The clungc in n.1111es to type l ,1fld
175
B~lucose
transported
into cells _j
Pancreas Elevated
EJ r;cofonversion
releases insulin blood glucose
glucose
into glycogen
. - - - - - - - - --I-- +-- - - -- - --.- 99 mg/di
roditionol symptoms or diabetes,

known as the three polys, ore
.___ _ _ _ _ _.;._:_:........:...;:_:_:~----+-----,,___i_
l Normal
range
70 mg/di
polyurio (excessive urination), polydipsio
•~kOOw"J
(excessive thirst), and polyphogio (exces· fl]
sive hunger). No one symptom is diog· of glycogen
J
noslic of diabetes. Other symptoms-such to glucose
J
Pancreas low blood
as unexplained weight loss, exhaustion,
blurred vision, tingling in hands and feel, fJ Increased
-, releases
glucagon glucose
synthesis of
frequent infections, poor wound healing, glucose
and impotence-oken accompany lrodi·
tionol symptoms.2 Figure 5· 11 I Regulation of blood glucose. Insulin and glucogon ore key factors in
controlling blood glucose. When blood glucose rises above the normal range (1 l, insulin acts to
lower ii (2 and 3). Blood glucose then falls bock into the normal range (4). When blood glucose
falls below the normal range (5), glucagon leads to the opposite effect of insulin (6 and 7). This
then restores blood glucose to the normal range (8). Other hormones, such as epinephrine,
norepinephrine, cortisol, and growth hormone, also contribute to blood glucose regulation (see
Table 5-5 for delails). The some is true for the mineral chromium (see Chapter 12).
Table 5·5 I Role of Various Hormones in the Regulation of Blood Glucose
Effect
Target Organ on Blood
Hormone Source or Tissue Overall Effect on Organ or Tissue Glucose
Insulin Pancreas Liver, muscle, Increases glucose uptake by muscles and adipose tissue, Decrease
adipose tissue increases glycogen synthesis, suppresses gluconeogenesis
Glucogon Pancreas Liver Increases glycogen breakdown, wilh release of Increase
glucose by the liver; increases gluconeogenesis
Epinephrine Adrenal glands Liver, muscle Increases glycogen breakdown, wilh release of glucose by Increase
Norepinephrine and nerve endings the liver; increases gluconeogenesis
Cortisol Adrenal glands Liver, muscle Increases gluconeogenesis by the liver, decreases glucose Increase
use by muscles and other organs
Growth Adrenal glands Liver, muscle, Decreases glucose uptake by muscles, increases fat Increase
hormone adipose tissue mobilization and utilization, increases glucose output
by the liver
type 2 diabetes stems from rhc face char many Type 1 Diabetes
type 2 diabetics e\'entually must also rdy on insulin
injections as a part of their cream1ent. 2 In addition, Tvpe I diabetes often begins in late childhood,
man) children today ha\'C type 2 diabeLcs. A third around rhe age of 8 to 12 years, but can ocrnr :lt
form, i:alled gestational diabete~, oi:rnr~ in :.ome any age. The disease runs in certain families, indi
pregnant women (see Chapter 16). Ir i:. usually caring a dear generic link. Children usuallr arc .ul
treated with an insulin regimen and dicr, and re miued to the hospital with abnormally high blood
solves after delivery of the baby. However, preg- glucose and ketosis. 2
nant women who develop gestario1ul diabetes arc
The onset of cype 1 diabetes is generally a!l..-.od·
at high risk for developing diabetes later in lifc. 2 ated with decreased release of insulin from rhe pan
176
Tallle 5·6 I Comparing and Contrasting Type 1 and Type 2 Diabetes
Type 1 Diabetes Type 2 Diabetes

Occurrence 5-10'7o of coses of diabetes 90% of coses of diabetes
Cause Immune system attack of the pancreas Insulin resistance
Risk Factors Moderate genetic predisposition Strong genetic predisposition
Obesity
Sedentary life style
Ethnicity
Characte ristics Distinct symptoms (frequent thirst, Mild symptoms, especially in early phases
hunger, and urination) of the disease (fatigue and nighttime
Ketosis urination)
Generally ketosis does not occur
Cell Response Normal Resistant
to Insulin
common clinical method to deter·
mine o person's success in control·
Treatment Insulin " Diet ling blood glucose is to measure glycoted
Diet Exercise (also termed glycosyloted) hemoglobin
Exercise Oral medications to lower blood glucose (hemoglobin Ale). Over time, blood glu-
Aspirin Insulin (in advanced coses)
Medications to lower blood cose attaches to (glycotesJ hemoglobin in
Aspirin
cholesterol [e.g., stotinsJ Medications to lower blood cholesterol red blood cells, and especially when
(e.g., stotinsJ blood glucose remains elevated. A hemo·
globin A1c value of over 7% indicates
Complications* Cardiovascular disease Cardiovascular disease poor blood glucose control. An accept·
Kidney disease Kidney disease
Nerve disease Nerve damage able value is 6% or less. Elevated blood
Blindness Blindness glucose also leads to glycotion of various
proteins and fats in the body, forming
Monitoring Blood glucose Blood glucose what ore called advanced glycotion (also
Urine ketones HbAlc
called glycoxidotionJ end products. These
HbAlc
hove been shown to be toxic to cells, es-
' In bolh C0$11S moinloining o heollhy blood lipid profile ond na<mol blood pressure is vilol lo ovoid lhese complicohons (see Choplers 6 and 11 pecially those of immune system, circulo·
for stroteg1es). A new medicohon lo lower blood gluco$11 lhot con be used wilh insulin is promlintide (Symlin),l 7 tory system, and kidneys.2.12
creas. As insulin in rhe blood decline~, blood glucose porr:mt. Research on this b ongoing.
increase~, especi:illy allcr caLing. When blood glucose Before 1921, if a person had type I diabetes, a
exceeds the kidney'~ threshold, excess glucose spills bigh-fat, low-caloric diet wa~ recommended. This
over inro the urine- hence the term diabetes welfiP11.1; appro:i.ch was found Lo be the best way to control
\\ hich mean~ "llcm or much urine" (dinbctes) th:it is blood glucose. Tt was somewhat effective but re-
"sweet" (111ellit11s). rigure 5-12 shows a typical glu- sulted in poor grO\\ th in childhood and was diffi-
cose colerancc nir,·c obser\'cd in a patient with this cult to implement. In the early part of the 1900s, :i.
form of diaberes, fr>llO\,ing ,1 test load of 75 g (15 clinician could walk inco a diabetes ward in a hos-
teaspoons) of glucose. pital and sec scores of young, emaciated children.
An exciting finding regarding the cause of The isolation of insulin br Banting and Best in
type I diabcte~ may hdp physicians rreat this dis- 1921 .md the ti~t use of 1t soon after in children
c.ise or e,·cn prc\Cnt m on5ct m the future. Most opened a nc\\ door in diabetes care.
cases of type I diabetc~ begin with an immune sys- Today, type I diabcte' 1s created by insulin
tem disorder, "hich c.1mc~ destruction of the therapy, either \\1th 1111ccnons two ro Si\ times per
insulin-producing beta cells in the pancrc.1s. ~[o:.L day or with an insulin pump.~ rhe pump dispenses
likely, a \'irus or protein foreign to the body sets off insulin at a steady rate inro the bod~, with greater
the autoimmune destruction. ln response to their amounts ddi,ercd after .1 me.11. (Just .1pprovcd is an
destruction, the .1fkucd beta cells rele.isc other inhaled form of insulin. ) Dietary therapy includes
proteins, which stimul.iLc a more furious attack. three regular mc.1h and one or more snacks (Ln-
Evenruall}, the pancre:i.~ lo~cs its ability to srnthe- duding one at bcdrimc ), and a regulated ratio of
si7e insulin, and the clinical stage of thc disease be- carbohydrate:protein:fat to ma.\imize insulin m:tion autoimmune Immune reaction agoinsl
gins. 2 Consequently, early trc.rnncnt to stop the and minimize swings in blood glucose:~ If one does normal body cells; self against self.
immune-linked destruction in children may be im- not eat oft:cn enough, the injected insulin can cause
177
Figure S· 1 2 I Glucose tolerance test. A 300
comparison of blood glucose concentrations in
untreated diabetic and healthy (normal)
persons ofter consuming a 75 g test load of 250
i-
glucose.
-8
.......
OI
-200
-E
4J
VI
150
0
I.I
:::>
Di 100
"'O
0
0
ii Nondiabetic
50
+
Glucose Time (hours)
2 3
given
severe h}rpoglycemia, because it acts on whatever them into the urine. This seril.'.S of events can con-
glucose is available. The diet should, include ample tribute to a chain reaction that eventually leads m
fiber aod polyllltsaturated fut, supply an amoum of dehydralion, ion imbalance, coma, and even death,
energy in balance with energy needs, be lo\\' in ani· especially in patients with poorly cono·olled type l
mal fats, trans fats (e.g., stick margarine and short· diabetes. Treatment includes insulin and fluids as
enings), and cholesterol and be moderate in high well a5 sodium, potassium, and chloride. 2
gl~rcemic load carbohydrates. Meeting magnesium Other complications of diabetes can be degen-
needs is also helpfi.u, as is regular coffee consump- erarivc conditions, such as blindness, cardiovascular
tion (if desired). Both likely conttibure ro blood disease, and kidney disease; all are caused by poor
glucose reguJation. 21 •24 blood glucose regulation. Nerves can aL~o deterio-
Type l patients often make exccllcm candi- rate, resulting in many changes that decrease
carbohydrate counting A diet method dates for learning the concept of carbohydrate proper nerve stimulation. When this occurs in the
that assigns a certain number of food connting, a method that focuses on che amow1t of intestinal tract, intermittent diarrhea and constipa-
exchanges or carbohydrate grams to carbohydrates in each food choice. Type l patients tion result. Because of nerve deterioration in the
each meal and snack. Insulin is matched are often very familiar with the exchange system arms, hands, legs, and feet, many people with dia-
to carbohydrate intake (i.e., 1 unit of and are motivated enough to learn how to use it to betes lose the sensation of pain associated with in-
insulin per l 0 to 15 g of carbohydrates),
count carbohydrate intake. This med10d results in juries or infections. Nor having as much pain, they
and carbohydrate grams can come from
several combinations of exchanges.
improved blood glucose control with a wider selec- often delay treatment of hand or foot probkms.
tion of foods. 2 This delay, combined wid1 a rich environment for
Because people with diabetes {type 1 as well as bacterial growth (bacteria thrive on glucose), sets
type 2) arc at a high risk for cardioYascular disease d1e stage for damage and death ofrissues in die cx-
and related heart attacks, they should take an as- n·cmi[ies, sometimes leadi11g ro the need for ampu-
pirin each day (generally 75 mg/day to 162 tation of feet and legs. High blood glucoM.: also
mg/day) if their physicians find no reason not to contributes to a rapid buildup of fats in blood ves-
do so. As discussed in Chapter 6, this practice re- sel walls, which eventually limits the blood supply
duces the risk of hearc attack. Use of medications to various organs such as the hearr. 2
ro lower elevated blood cholesterol (e.g., Current research, such as the Diabetes Comrol
"statins," discussed in Chapter 6) is also widely and Complications T1ial (DCCT), and other recent
advocated.19 follow-up studies has shown rhar the development
The hormone imbalances that occur in people of blood vessel deterioration (e.g., cardiovascular
with Lmu·eated type 1 diabetes lead to mobilization disease and strokes) and nerve complications or di-
of bod}' fat, which is released into liver cells. Ketosis abetes can be delayed with aggressive treatment di-
follows because the fat is mostly converted co rected at keeping blood glucose within the normal
ketone bodies. These can rise excessively in the range.8.3I The therapy poses some risks of ii::. mrn,
blood, eventually forcing ketone bodies into the such as hypoglycemia, so it must be implemented
urine. These pull sodium and potassium ions with under rhe close supervision of a phy~ician.
178
Regular exercise is o key port of a pion to prevent (and control) type 2 diabetes.
A person with diabetes generally must work sulin production, there is an abundance of insulin,
closely with a physician and dietitian to make the cor- particular!)' during tlie onset of the disease. As tlie
rect alterations in diet and medications and to per- disease develops, pancreatic function can fail, leading
form physic:1J activit) safely. Physical activity enhances to reduced insulin output. 2 Because of the genetic
glucose uptake by muscle:. independent of insulin ac- link for cype 2 diabetes, those who have a fumily his-
tion, which in ntrn can lower blood glucose. 15 This cory should be careful to avoid risk factors such
outcomt: is beneficial, but people \\~th diabetes need as obesicy (especially fat stores in die abdominal
to be aware of their own blood glucose response to region); a diet rich in animal and trans fats, choles-
physical activity and plan approp1iatel)'. terol, and high gJycemic load foods; and inac-
t.ivicy.3·30·34·36 Meeting needs for vitamin B-6, folate,
ru1d vitamin B-12 to control homocysteinc levels in
Type 2 Diabetes
tl1e blood is also important (see the discussion on ho-
Type 2 diabetes rypically begins after age 40. This moc:ystcine in Chapter l 0 ro learn more about ho-
i:. the mo:.t common type of diabete:., accounting mocysteine and how it is related to these vitamins).27
for about 90% of the cases diagnosed in North Limiting red meat is also recommended, because the
America. Minority populations such as Latino/ iron present in it has been linked to tl1e development
Hispanic, African Americans, Asia11 Americans, of type 2 diabetes. Being tested regularly for hyper-
Native Americans, and Pacific islanders arc at par- glycemia is also important.33
ticular risk. 2 As n0te<l in this section's in troduction, Many cases of type 2 diabetes (about 80%) arc
the numbc.:r or people aftected with this form or di- associated \\~tl1 obesity (especially fat located in the
abetes is especiaJly on the rise, primarily because of abdominal region), bur the hyperglycemia is nor
widespread inactivity and obesity in our popula- directly caused by d1e obesity. In fact, some lean
tion . In fact, recently there has been a substantiaJ people can develop type 2 diabetes. Obesity associ-
olycystic ovary syndrome is another increase in type 2 diabetes in children, due mostly ated with oversized fat cells simply increases the risk
cause of type 2 diabetes in women. to an increase in overweight in this population for insulin resistance by the body, in mrn increasing
Excess facial and body hair, irregular (wuplcd wid1 limited physical activity). Type 2 di- the risk for type 2 diabetes.13,34
menstrual periods, infertility, and obesity abetes is also genetically linked, so family history is Type 2 diabetes linked Lo obesity often disap-
typically ore seen in these women as a very imporram risk faccor. However, the initial pears as weight is lost because u1c smaUcr adipose
well. 10 problem is not wirh the beta cells or the pancreas. cells become less insulin resistant and mak1.: more of
Instead, it .irises with the insulin receptors on the a beneficial hormone called adiponcctin. This hor-
cell surfuccs of certain body tissues, especially mu:.- mone aids in blood glucose regulation by increas-
clc tissue. In this case, blood glucose i~ not readily ing insulin action. Achieving a ht:altl1y weight
transtCrred into cdls, so the patient develops hy- should therefore be a primary goal of treatment,
perglycemia as a resu lt of the glucose remaining in but even limited weight loss can lead to better
tlie bloodstream. The pancreas attempts to increase blood glucose regulation. 13 Oral medications can
insulin ourpur LO compensare, bur tl1erc is a limit to also help. Some examples are medications that reduce
its ability to do tl'lis. Thus, r.1ther tlian insufl1cient in- glucose production by the liver (mcttormin
179
l Glurnphage]), increase the abiliry nf Ll1e pancreas co Hypoglycemia
rcle•he insulin (glipizide [Glucotrol I), and increase
reactive hypoglycemia low blood the body's response co its own insulin ( ro~iglitazone
glucose thot may follow a meal high in [A,·andia ]). Anod1er class of oral agenrs works b~ de- People with diabetes ''ho arc raking msul111 \ome·
simple sugars, with corresponding laying carbohydrate digt:Stion and glucose absorption times ha1·c hypoglycemia if the) don't e.11 frc ·
symptoms of irritability, headache, (.1Carbose [Precose ]). A tablet is ta.ken with d1e first quently enough. Hypoglycemia can aho dC\clop 111
nervousness, sweating, and confusion; bite of each meal and mav be combined \\ith od1er nondi.1betic indi\iduals. The rwo common fonm of
also called postprandial hypoglycemia.
thcr:ipy.2 (Note that pregnalll women cannot use nond1abc1ic hypogl\'cernia are termed rmrrii-1· .md
fasting hypoglycemia low blood glucose these oral medications bccau~c they will afl-ect d1e fnrtilllT· 2
that occurs after about a day of fa sting. blood glucose of the developing fotu~ . ) Fin.illy, a new Reactive hypoglycemia (also died pos1pran·
class of medication may be used but mu~r be 111jected dial hypoglycemia) is described as irritabilit), tll'r-
(exenaride [B}'etta]).r ,·ousncss, hc.1dachc, sweating, and conh1s1011 2 to 4
Sometimes it mar oc nece<>S,\r} m provide insulin hours ,1fier caring a meal, especi,1lly .1 me.ti high 111
injections in ty}X' 2 diabetes because nothing else is simple sugars The cause of reacti\·e lwpoglvcemi.1 is
able to control blood glucose. (This e\encually be- unclc.1r, but ir lllJ) be m·erproduction of 11N1l111 b1
1.'.omcs the case in about half of all case\ of type 2 di- the pancre:is in response ro rising blood gluw~c .
abetcs.)2 Regular physical aaiviry also helps die Some resc3rchcrs .1re un\\illi11g even to .1Cknowl-
musdes take up more glucose. 13 And regular meal cdge the existence of reacri\'e hypoglycemi,1, poinr
patterns, with an c m pha~is on conrrol or energy ining out thJt the ~ymproms :lre more likely tied to
rnkc, rnnsumption of low glycemic lo:td foods, with recent, intense exercise, psychologic.11 stress, med-
.unplc fibcr, is important ther.1py. Note that nuts fuJ- ication use, or excess alcohol consumption. Fasting
lill thc last two goals. (An .1lmos1 d.1il) l ~ 5X/weckl hypoglycemia usually is caused by p.111cre.HK can·
inrakc of nuts was even sho" n m reduce che risk of cer, \I lm:h may le.id to C\ccssivc insulin ~ecrct 1011. In
Jewloping rype 2 diabcte~ 111 one rccenr stud}.) this case, blood glucose falls ro km co11ccntr,u1ons
Some intake of sugars is tine wid1 meals, bur again after fasLing for about 8 hours ro 1 d.1~ . This t(mn
ecently people with diabetes have che~e muse be substituted for od1er c.1rbohydraces, of hypoglycemia is rare.
been cautioned not to cook high· not simply added to the mtal plan. 2 Distributing car- The di.1gno\is of hypoglycemia requires rhc si
protein foods at high temperatures for bohydr:ucs rhrougbom the day 1s al!.o important, be· multaneous presence of low blood gluco~e ,md rhc
prolonged periods of time. 12 This leads to cause this helps minimize the high and low swings in typical hypoglycemic symptoms. Blood glm:me of
the advanced glycation (also called gly- blood glucose concennatiuns. Moderate alcohol use 40 to 50 mg/J 00 ml is suggestive, but just h.wing
coxidation) end products discussed in this is line (one serving per day). 24 One recent stud)' low blood glucose after earing is not enough el'i -
section forming in foods. Use of a lower showed that this practice subst.rntiall) reduced heart dence to nuke the diagnosis of hypoglycemia 2
power setting with a microwave oven, .ir1.1ck risk in people with type 2 diabctc!>. Still, dia- Although many people rhink rhcy h.l\c hypo
lower oven temperatures, and minimal bcucs must be warned dm alcohol can lead to hypoglycemia, few acruall) do.
use of prolonged broiling and prolonged glyl.'.emia and d1at people \\ith rype 2 diabetes must Health> people mar occasional!\ C\pcnence
frying ore advised, as well as moderation test themscln:s regularly for this JXN1bil1ty. some hypoglycemic symptoms, ~uch a~ irritability,
in coffee and cola intake. (These latter People with type 2 diabetes who have high head:ichc, and shakiness, if rhcy ha\'e not eaten for
two foods also are sources of advanced blood triglycerides should moderate their carboh}'- a prolonged period of time. Although not d1;ignm
glycation end products.) Note that fruits, dr:ue in cake and increase their int.1ke of unsaru- tic or hypoglycemia, ir you sometime~ h,I\ c wmp
vegetables, starches, and milk are low in ratcd fat and liber.30 toms of hypoglycemia, the standard nu1ritwn
these substances. Although many cases or type 2 diabetes can be therapy is one we all couJd follow. You need to cat
relic\ Cd by reducing e:.:ccs..\ lat ~tnrcs, 36 many people regular meals, make sure you hm·e some protein Jnd
arc not able to lose weight. The)' rcnuin affected fat in each meal, .111d cat low glrccmic lo.1d c.:arbo-
with diabetes and may experience (he degenerative hydrates with ample soluble fiber. Avoid me,1b or
complications seen in rype I diaocte,. 15 Ketosis, snacks that contain lirdc more than sug:ir. II wmp-
h<m c\·er, is nor usually seen 111 type 2 d1aoctes. tom~ conunuc, tr) small protcin-cont.1ining snach
Finally, medications to lower cle\accd blood between meab or fruits and juice. Fat, prote111, .ind
or more information on diabetes, chobtcrol 11hould be emploved. 19 .Meeting mag- soluble fiber in the diet tend to moderate~" ings in
consult the following websites: nesium needs is also importaJ1t.21 ~ l odcrarc use of blood glucose. Fi nail), moderate intakes of c;1ftc111c
www.diobetes.org and ndep.nih.gov col!Cc may also be helpfol. and alcohol.
180
Carbohydrates in Foods
The food components that yield the highest percentage of energy from carbohydrates
are table sugar, honey, jam, jelly, fruit, and plain baked potaroes because these items
are rich sources of carbohydrate. Corn flakes, rice, bread, and noodles a.JI contain at
least 75% of energy as carbohydrates. Foods wiLl1 moderate amounts of carbohyd rate
energy arc peas, broccoli, oam1eal, dry beans and other legumes, cream pies, frcnch
fries, and foe-free milk. In these foods, the carbohydrate content is diluted either by
protein, as in the case of fat-free milk, or by fat, as in the case of a cream pie. Foods
with essentially no carbohydrates include beet~ eggs, chicken, fish, vegetable oils, but-
ter, and margarine.
In planning a high-carbohydrate diet, you should emphasize whole grains, fruits,
and vegetabks. 1•32 On the other hand, you can't create a diet high in carbohydrate en- Rice is a rich source of carbohydrate.
ergy from chocolate, potato chips, and fi·ench fries because these foods contain coo
much fat. Overall, the percentage of energy from carbohydrate must be considered
along wiL11 the total amount and rype of carbohydrate in a food when pla nning a
healthy high-carbohydrate diet.
The various substances that impart sweetness to foods fall into two broad classes:
nutrici"e sweeteners, whjch can be metabolized to yield energy, and alternative S\veet-
eners, which provide no food energy. As shown in Table 5-7, tbe alternative sweeten- Food Sources of Carbohydrate
ers arc much sweeter on a per-gram basis than rhe nutritive sweeteners. 1
Energy
Nutriitive Sweeteners Carbohydrate from carbo-
Both sugars and sugar alcohols provide energy along with sweetness. Sugars :ire fotrnd Food Item (grams) hydrate(%)
in many different food products, whereas sugar alcohols have rather limited uses. Baked potato
(l each) 51 91
Sugars
Cola drink
All the monosaccharides (glucose, fructose, and galacrosc) and disaccharides (sucrose, (12 fluid oz) 39 100
lactose, and maltose) that were discussed earlier in this chapter arc designated m1tri-
rivc s111ccte11ers (Table: 5-8).1 The sweetness of sucrose rn<tkcs it the benchmark against Plain M&Ms
(1.5 oz) 30 58
which all other sweeteners are measured. Sucrose is obtained from suga.rGme and sugar
beet plants. i\lost of the sucrose and rhe other sugars we cat arc from foods and bev- Bonano (l each) 28 96
erages to which sugar has been added during processing and/or manufacturing. The Cooked rice
major sources arc soii: drinks, candy, cakes, cookies, pies, frujt drinks, and dairy (1/2 cup) 22 90
desserts, such as ice cream. The rest of the sugar in our diets is present naturally in
Cooked corn
foods, such as fruits, or comes from the sugar bowl. During food processing, rhc.: sugar
(1/2 cup) 21 81
content is often increased. The more processed the food, gcnera.lly the higher the
simple-sugar content. Light Yogurl
A sweetener used frequently today by the food industry is high-fructose corn syrup, (l cup) 19 77
which is usually 55% fructose, but can range from 40 to 90% fructose. High-fructose Kidney beens
corn syrup is made by treating cornstarch with acid and enzymes. This treatment (1/2 cup) 19 72
breaks down much of the starch into glucose. Then some of the glucose is converted Spaghetti
by enzymes inro fructose. The final syrup is usually as sweet as sucrose. Irs major ad- noodles (1/2 cup) 19 87
vantage is that it is cheaper than sucrose. Also, it doesn't furm crystals, and it has bet-
Orange (l each) 16 94
ter freezing properties. High-fructose corn syrups a.re used in soft drinks, candies, jam,
jelly, other fruit products, and desserts (e.g., packaged cook.ies).1 Seven-grain bread
In addition to sucrose and high-fructose corn syrup, brown sugar, turbinado sugar, (1 slice) 12 75
honey, maple syrup, and od1er sugars are also added to foods. Turbinado sugar is a par- Fat-free milk
tially refined version of raw sucrose; it has a slight molasses flavor. Brown sugar is es- (1 cup) 12 56
sentially sucrose containing some molasses; either the molasses is not tota.lly removed Pineapple chunks
from the sucrose during processi ng or it is added back to the sucrose crystals. (l /2 cup) 10 89
Maple syrup is made by boiling down and concentrating the sap that runs during
Cooked carrots
the late winter in sugar maple trees. Most pancake syrup sold in supermarkets is not
ll /2 cup) 8 87
actually maple syrup, which is quire expensive. Jnstcad, ir is primuily corn syrup and
high-fructose corn syrup wid1 maple flavor added. Peanuts (l oz) 6 7
Table 5·7 1The Sweetness of Sugars and Alternative Sweeteners

Relative Sweetness•
Type of Sweetener (Sucrose = 1) Typical Sources
Sugars
lactose 0.2 Dairy products
Maltose 0.4 Sprouted seeds, some alcoholic beverages
Glucose 0.7 Corn syrup, honey
Sucrose 1.0 Table sugar, most sweets
Invert sugart 1.3 Some candies, honey
Fructose 1.2-1.8 Fruit, honey, some soft drinks
Sugar Alcohols
There ore many forms of sugar available for
purchase. Sorbitol 0.6 Sugarless candies, sugarless gum
Monnitol 0.7 Sugarless candies
Xylitol 0.9 Sugarless gum
Alternative Sweeteners
Cyclamote 30 Not currently in use in the United States, but
available in Canada
Aspartame (Equal) 180 to 200 Diet soft drinks, diet fruit drinks, sugarless gum,
powdered diet sweetener
Acesulfome-K (Sunette) 200 Sugarless gum, diet drink mixes, powdered diet
sweeteners, puddings, gelatin desserts
tevio comes from a South American shrub;
S it is I00 to 300 times sweeter than sucrose
and provides no energy. This sweetener hos
Saccharin {Sweet 'n Low)
Sucralose (Splenda)
300
600
Diet soft drinks
Diet soft drinks, tabletop use, sugarless gums,
jams, frozen desserts
been used in small amounts by the Japanese Neotame 7000 to 13,000 Tabletop sweetener, baked goods, frozen
since the 1970s. FDA hos not approved the use desserts, diet soft drinks, jams and jellies
of stevio in foods, but stevio con be purchased Togatose (Naturlose) 0.9 Ready-to-eat cereals, diet soft drinks, health
at natural· and health-food stores as a dietary bars, frozen yogurt, fa t.free ice cream,
supplement. 1 candies, frosting, chewing gum
from the Americon Dietetic Asscx:iotion, 1993, end other sources.
'On o per gram bosis
1Sucrose broken down info glucose and fructose
Table 5·8 I Names of Sugars Used in Foods

Sugar Honey
Sucrose Corn syrup or sweeteners
Brown sugar High-fructose corn syrup
Confectioner's sugar (powdered sugar) Molasses
Turbinado sugar Dote sugar
Invert sugo r Maple syrup
Glucose Dextrin
Sorbitol Dextrose
levulose Fructose
Palydextrose Maltose
Lactose Caramel
Mannitol Fruit sugar
Honey is a product of plant nectar that has been altered by bee enzyme!>. The en·
zymes break do\>vn much of the nectar's sucrose into fructose and glucose. As was noted
earlier in this chapter, honey offers essentiaUy the same nutritional value as other simple
sugars--a source of energy and litLle else. However, honey is not safe to feed to iJ1fanrs
because it can contain spores of the bacterium Clost1·idium botulinum. These spores can
become active, leading to faLal foodborne iJlncss. Honey does not pose the same threat mannitol An alcohol derivative of fructose.
ro aduJts because d1e acidic environment of an adu lt's stomach inhibits the growth of
the bacteria. An infant's stomach, however, does not produce much acid, making infants xylitol An alcohol deriva tive of the five-carbon
susceptible ro the threat that this bacterium poses (sec Chapters 17 and 19). monosocchoride xylose.
saccharin An alternative sweetener that yields

Sug ar Alcohols no energy to the body; ii is 300 limes sweeter
than sucrose.
The sugar alcohol sorbit0l, as well as mannitol and >..')Tlitol, are used as mmitive sweer-
eners. 35 Although sugar alcohols contribute energy (about 1.5-3 kcaJ/g), they are ab- cyclamate An alternative sweetener that yields
sorbed and metabolized to glucose more slowly than sugars. In large quantities sugar no energy to the body; it is 30 times sweeter
akohols can cause diarrhea. In fact, any products whose foreseeable consumption may than sucrose.
result in a daiJy ingestion of 50 g of sorbitol or mannitol must bear thi~ labeling state- aspartame An alternative sweetener mode
ment: "Excess consumption may have a laxative effect." from two amino acids and methanol; it is
Sugar alcohols must be listed on labels, and if only om: sugar alcohol is used in a 200 times sweeter than sucrose.
product it must be distinguished; however, if two or mon: arc used in one product they
are grouped together under the heading "sugar alcohols." The acrual energy value is neotame A general-purpose nonnulritive
sweetener that is approximately 7000 to
calculated taking in account each sugar alcohol, so that when one reads d1e total en-
13,000 times sweeter than table sugar. It hos a
ergy content of a product, ir includes the sugar alcohols in the overall amount.
chemical structure similar to aspartame.
Sorbitol and xylitol are used in sugarless gum, breath mints, and candy. These are Neotome is heal stable and con be used as a
not readiJy metabolized by bacteria in the mouth and thus do nor promote dental tabletop sweetener as well as in cooking
caries as readily as do simple sugars such as sucrose. Recall from Chapt(.:r 2 that louch a applications. It is not broken down to its amino
health cbim can be made on these products. acid components in the body ofter
consumption.
Alternative Sweeteners sucralose An alternative sweetener that hos

chlorines in place of some hydroxyl {-OH)
Often called artificial sweeteners, alternative sweeteners enable people with diabetes to groups on sucrose. It is 600 times sweeter than
enjoy the flavor of sweetness while controlling sugars in their diets; rhey also provide sucrose.
noncaloric or very- low-calorie sugar substitutes for persons trying to lose (or control)
body weight. Alternative sweeteners include saccharin, cyclamate, aspartame, neo- acesulfame·K An alternative sweetener that
tam e, sucralose, acesulfame-K, and tagat ose (Figure 5-13). 1 Alternative sweeteners yields no energy lo the body; ii is 200 times
sweeter thon sucrose.
rield little or no energy when consu1m:d in arnoLJnts typically used in food products.
All bur cyclamarc are currently available in the United States. Cyclamate was banned tagotose An isomer of fructose that is 90% as
for use in the United States in 1970, aJthough it has never been conclusively proved sweet as sucrose. Togo tose is poorly absorbed,
to cause health problems when used appropriately. Cyclamate is used in Ctnada as a so ii yields only 1.5 kcol/g lo the body.
sweetener in medicines and as a tabletop sweetener.
Sacchari n
The oldest alternati,·e sweetener, sacch<uin is currently approved for use in more than
90 countries. Saccharin was once thought to pose a risk of bladder cancer based on smd-
ies using laborJ.tory animals, but today it is no longer listed as a potential cause of can-
cer in humans because the earlier research is now considered weak and inconclusive. 1
INGREDIENTS: SORBITOL, GUM BASE, MANNITOL,
GLYCEROL, HYDROGENATED GLUCOSE SYRUP,
Aspartame XYLITOL, ARTIFICIAL AND NATURAL FLAVORS,
Aspartame is in widespread use throughout the world. Tt has been approved for use by ASPARTAME, RED 40, YEUOW 6 AND BHT (TO
MAINTAIN FRESHNESS). PHENYLKETONURICS:
more than 90 countries, and its use has been endorsed by the World Health CONTAINS PHENYLALANINE.
Organization, the American Medical Association, the American Diabetes Association,
and the American Academy of Pediatrics Committee on Nurrition. 1 V\Thcn the
NutraSweet company held the patent on aspartame, it was sold as NutraSwcct when Sugarless
added to foods and Equal when sold as ~1 powder. Now, though, other companies
manufacrnre aspartame.
Gutn
The components of aspartame arc the amino acids phenylalanine and aspartic acid, Sugar alcohols con be found in sugarless gum.
along witb methanol. Recall that amino acids arc rhe bui ld ing blocks 01· proteins, so as- The alternative sweetener aspartame is also
partame is more of a protein than a carbohydrate. Aspartame yields about 4 kcal/g, used lo sweeten this product. Note the warning
but it is 180 to 200 times sweeter than sucrose. Thus, only a small amount of aspar- for people with PKU that this product with
tame is needcJ ro sweeten a food or beverage, so rhc amount or em:rgy added is aspartame contains phenylalanine.
0
II
0 H C-O-CH3
II I I
C- N-C-H
I I H"
H3N+ - cH 2 - C-H CH 2 N -So3-Na+
/CH3 0
I I II I
CH2 /
I /
~
O= 0
0
N- Na t
' HO- C I
K"'N - -Sb2 II ~ 502
0
Acesulfame·K Aspartame . · Saccharin (sodium salt) Cyclamate (sodium salt) I

- • - A
0
II
0 H C-O-CH3
II I I
CH3 C-N - C - H
H H
I I I \/ 0
H C-C-CH -CH -NH-C-H CH
3 I 2 2 I I2
CH3 CH2 /
Ho-J II
II ~
0
Figure 5· 13 I Chemical structures of alternative sweeteners. Note that Cyclomote is available in Canedo, but not in the United Stoles.
insignificant unless the product is ;1bused. Today aspartam<: is used in beverages, gela-
tin desserts, chewing gum, toppings and fi llings in precooked baker)' goods, <tnd cook-
ies. Aspartame does not cause rooth decay. Like other proteins, however, aspartam<: is
damaged when heated fo r a long time and thus loses its sweetness if used in products
that are cooked or heatcd. 1
Some compla.inrs have been filed with FDA by people claiming co have had adverse
reactions to aspartame: headaches, dizziness, seizures, nausea, and other side effrcrs. It
is important for people who are sensitive to aspartame ro avoid it, even though the per·
centage of people being affected is likely tO be small. The relativdy limited number of
complaints about aspartame, considering its wide use in food products, means that
most people can use it.
The acceptable daily imakc of aspartame set by FDA is 50 mg/kg of body weight
per day. I This is equivalent to about 14 cans of diet soft drink for nn adu lt or about
80 packers of Equal. Aspartame appears to be safe for pregnant women and children ,
but some scientists suggest cnutious use by these groups, especially young d i ildrcn,
who need ample food energy to grow.
Persons with an uncommon genetic disease called phenylkeronurin ( PKU ), which
interferes with the metabolism of phenylalanine, should avoid aspartame because of irs
high phenyhtlaninc content. (PKU was discussed in Chapter -t }
Neotame
Neorame is approved by FDA for use as a general-purpose sweetener i11 a wide variety
of food products other than meat and poulu·y. Ncotarne is a nonnutritive, bigh-
intensicy sweetener that is approximately 7000 to 13000 times sweeter th~ui table sugar
depencting on its food application. 1 It has a chem ical su·ucrure similar to aspartame.
Neotame is heat stable and can be used as a tabletop sweetener as wd l as in cooking
applications. Examples of uses for \\'hich it has been approved include baked goods,
nonalcoholic beverages (inducting soft drinks), chewing gum, confections and frost-
ings, frozen desserts, gelatins and puddjngs, jams and jellies, and processed fruits and
fruit juices, toppings, and syrups. Neotame is safr for use by the general population,
inclurung children, pregnant and lactating women, and people with diabetes. ln addi-
tion, no special labeling for people wid1 phenylketonuria is needed because after con-
Soft drinks are typical sources of either sugars
sumption neotame is flOt broken down in the body to its <rn1ino acid componentS.
or alternative sweeteners, depending on the
type of soft drink chosen.
Acesulfame-K
The alternative sweetener acesulfame-K (the K stands for potassium ) is approved for
use in more than 40 countries and is sold for use in 1.he United State!> as Sunette.
Acesulfame-K is 200 times sweeter than sucrose. IL contribmes no energy to the diet
because it is not digested by the body, and it does not cause dental caries. 1
Unlike aspartame, acesulfame-K can be used in baking because it does not lose its
sweetness wheu heated. ln the United States, iris currcndy approved for use in chew-
ing gum, powdered drink mixes, gelatins, puddings, baJ<ed goods, tabletop sweeten-
ers, candy, rlu·oar lozenges, yogurt, and nondairy creamers; additional uses may soon
be approved. One recent trend is co combine it with a!>parrame in soft d rinks.
Suero lo se
Sucralosc, sold as Splcnda, is 600 times sweeter rlrnn sucrose. It is made by substitut-
ing rl1ree chlorines (Cl ) fo r three hydroxyl groups (-OH) on sucrose. 1 FDA has ap-
proved sucraJose's use as an additive to foods such as soda, gum, baked goods, S)'rups,
gelatins, frozen dairy desserts such as ice cream, jams, and processed fruits and fruit
juices and for tabletop use. Sucralose doesn't break dmvn under high heat conditions
and can be used in cooking and baki11g. Ir is aJso excreted as such in the feces. The lit-
tle tl1at is absorbed is excreted in rl1c u1ine. Canadians had access ro sucralose before
its U.S. introduction.
Tagatose
Tagatosc, sold as Narudose, is an isomer of fructose and is almost as sweet as sucrose.
It is poorly absorbed and so yields only 1.5 kcal/g to the body. Besides its low-energy
contribution, its use docs not lead to dental caries or an increase in blood gl ucose, and
it has a prebiotic effect because it is fermented in the large intestiJ1e ( revkw prebiotics
in Chapter 3 ). Tagatose is approved for use in ready-ro-eat cereals, diet soft drinks,
bealth bars, frozen yogurt, fat-free ice crean1, sofi: confectionary, hard confectionary,
frosting, aJ1d chewing gum.
Concept I Check
Foods that are essentially all carbohydrate arc sugars, jam, jelly, fruit, and plain baked pota·
toes. Grains and vegetables are also rich sources of carbohydrate. Six major alternative
sweeteners are available in the United States today: saccharin, aspartame, nwrame,
accsulfamc-K, sucralose, and ragarose. Cruiadians also ha\•e access ro cydamatc. These
alternative sweeteners i:an aid in the goal of reducing sugar intake.
Summary
1. The common monosacch::trides ru·e glucose, fructose, :tnd galac- to supply the body's needs, protein is mctaboli;;ed Lo provide g lu-
tose. Once rhcsc are absorbed into the small inrestine and de lil'- cose (gluconcogcnesis) for energy needs. However, rhe p1ice is
ere<l to the liver, much of the fructose and gal:lctose is converted los~ of bod)' protein, ketosis, and cvennially ,, gener.11 body weak·
to glucose. ening. For this reason, very-low-carbohydrate diets .:tre not rec-
2. Tbe major disaecharides are sucrose (glucose plus fructose ), malt- ommended for extended periods (greater than 4 ro 6 weeks).
ose (glucose plus glucose), and lacrose (glucose plus galact0se). 7. Insoluble (also called nonfcrmcnrabk) fiber provide:. bu.lk to the
When digested, these yield their componcnr mono!>accharidcs. feces, thus casing bowel moveme1m. ln high do~es, soluble (abo
3. Om: major group of polysaccharides consists of storage fOrms of called 'iscous) fiber can help control blood g lucose in diabetic
glucose: starches in plants and glycogen in humans. ln these poly- people and lower blood d1olesterol.
mers, the multiple glucose tmits are linked by alpha bonds, which 8. Diets high in complex carboh)'drates are encouraged instead of
cao be broken b)' human digestive enzymes, releasing the glucose h.igh-f.·u diets. A goa.1 of abour half of energy as complex carbohr·
units. The main plant starches-straight-chain amylase and drates is a good one, with about 45 to 65% of total energy inr.i.ke
branched-chain amylopecrin-are digested by enzymes in the coming from carbohydrates in general. Foods co con~ume are
moud1 and small inrcstine. In humans, glycogen is synthesized in whole-grain breads and cereals, pasta, legumes, fruit!>, and \'cgera-
the liver and muscle tissue from glucose. Under die iJ11lucncc of bles. Many of these foods are rich in fibCJ·.
hormones, lh·cr glycogen is readily broken down to glucose, 9. Moderating sugar intake, especially between meals, reduce!. the
which can enrcr the bloodscream. risk or dental caries. Other health benefits include a reduced
4. Fiber is composed primarily of the polysaccharides cellu lose, hcmi - glyccmic load for a meal or snack and an impro,•ement in diet
cellu.loses, pectins, gums, and mucilages as \\'ell as the.: noncarbo- quality. Alternati\'e sweeteners, such as aspartame, aid in reducing
hydrate lignins. These substances are not broken down by human intake of sugars.
digesti\'e enzymes. However, soluble (also called viscous) fiber is l 0. Table ~ugar, honey, jell~·. fruit, and plain baked potatoci. an: ~Oml'
fcrmemed by bacteria in the large intestil1e. ot' the most concenffated sources of carbohydrate~. Other high·
5. Some st.i.rd1 digestion occw·s in the mouth. Carbohydrarc digestion carbohydrate foods, such as pie and fat-free milk, are dilurcd br ei-
is completed in r.he small intestine. Some plam fibers are digested b) ther far or protein. Nuo·itive sweeteners in food include.: sucro~c ,
the bacteria presenr 111 d1e large intestine; undigested plant fibers be- high-fructose corn syrup, brown sugar, and maple syrup.
come pan of the f:Cces. Monosacchaiides in die intestinal contents 11. The ability to d igest large amounts of laccose often diminishes
mosdy follow ru1 active absorption pro..:e!>S. They are then trans- with age. People in some ethnic groups are cspeci.111) affected.
ported vie\ d1c portal vein d1at leads direcrly ro the liver. This condition develops early in d1ildhocxl and is reforred m as
6. Carbohydrates provide energy (on average, 4 kcal/g), protect lrrctose 111nldigcstio11. Undigested lactose travels to tbc large inces·
against wastcfol brcakdoll'n of body prorein, and prevent ketosis. tine, resulting in such symproms as abdominal gas, pain, and diar·
The RDA for carbohydrate is 130 g/day tc> meet the energy needs rhea. lvlost people with lactose maldigestion can wlerat<.: cheese
of die central nen·ous system. If carbohyru':ltc intake is inadequate and yogurr and moderate amounts of milk.
Study Questions
l. Identi~· the three major disaccharides. Describe how each plays a 8. Write a list of suggei>tions for :i patient who has been diagnosed
part in the human diet. wid1 lactose maldigcstion. Design a 1-day sample menu rh.u pro·
2. How do amylose, amylopectin, and glycogen differ from one an· vidcs .1dcquare cakilllll (1000 mg) for this paticnr.
other? Why can diesc differences be important metabolically and 9. How docs type l lliabctes differ from type 2 diaberc~ in cause and
in food processing? U"catment?
3. What arc some role~ that fiber plays in the diet? l 0 . Wh,11 treatment i~ recommended for thl' Lypical form of
4. What arc the possible el'tecrs ofa diet coo high in fiber (or roo lo\\' hypoglycemia?
in lluid relative to fiber content)?
5. BricAy describe the chemical structure, sweetness, and food uses BOOST YOUR STUDY
of alternative sweeteners. Check out the Pers pectives in Nutrition: Online Learning
6. WJ1y do we need carbohydrates i11 the diet? BrieJly describe two Center w ..,w, mbhe.L.>111/wc..rdl.:1..... t'ers7 for quizzes, Aosh
reasons. cards, activities, and web links designed to further help you learn
7. State the RDA for carboh)1drate and ~u111maJ·ize current carbohy· about carbohydrates.
drarc intake recommendations.
1. ADA Reporcs: Posirion of the Ameril:an 7. Diaber". M11_1•0 Clinic Hcnlt/J U:ttc1· (Suppl.} pmteiu foods cooked 01· otbcnvisc processed 111
Dictcti• A>'>Ociatfon: Use of nutritive .rnd non- Fcbru.ur 2004. high tcmperat111"cs 111·e ricb so111us IJ.f t/Jcs«
nurriti\t: sweeteners. fo11m11/ of rbc A111cric1111 £wdlrnr su111111111)• of di11bcrcs-fi·o111 en.uses to comp1111111is.
Dfrtoir A<sociari1m 104:225, 200+. n·e111mcuts. Wcw/Jt co11m1/, n benlrb_v dirt, n.nd 13. Hu G and others: Physical aclivicy, body mas~
TI'bo1 rttrrmt/1• rccommmrh'd diet pmuiccs nrc rc.111tlnr cxcrciu nn: 1111 i111po1"tnnt pnl"I tif r/Jc index, an<l risk of type 2 diabetes in patients
mu, me/; ns tbc Dittn1)' Guidcli1us for lattc1: with normal or impaired glucose regulation.
Amaicn 11s, 11st of som,· n 111 ritil't 1111d 110111111rri- 8. Diabm:s Control .md Complicauons Trial/ Arc/Ji11cs of Iritcrnnl Medicine l 64( 8 ):892,
ti11c n1wtc11~1·s t;ncccptn/J/i:. 171e rc•..;r ofrbc ai·ti- Epidcmiolog) of Diabct.:~ Intervention> and 2004.
dc t.1;p/111·(s in dmii/ lJ11tlJ c!nssc.i 1ifS111atc11tTs, in Complic,uions Rc:...:arch Srudy Group: Inten- lucrc11si11..11 pbysirnl nctir•ity cn11 rcdurc r/Jc risk
turn mpjitll"ti11g this m•cmll c1111c/usi11J1. sive diabetes rrcatmcnr and cardiovascular dis- of dc1•e/11ping f)'JIC 2 rlinbercs. Weight co11trol 1.r
e.l:ie in paricncs \\ it:b cypc 1 Jiaberc>. T71e Nc1JT nlso i111p11rtn11t; rbis wcigbt co1m·ol adpicc in·
2. American DiJbctcs A>~c1ciation: Smndards of
E11glt111d ]1111r11nl 11f Mcdicmc 353:2643, 2005. cl11d1•s pet1ple 111/Jo nb-endy /J11J7t: poor glttcosc ctm-
rnrc in diabccc,. Din/Jttcs C111-.· 28:536, 2005.
P,-oplc rl'itb dinbctd 1v/111 t[nl11~v co11rrol tbcir rrol 1111d nrc OJ'Crll'cight.
17Jts nnic/c pr0J1idcs 11 co111p1·d1ensi11e fool· nc tbc blood g/11cosc ca11 rtducc rbeii· risli ofheart nt- 14. Keim NL anti others; Carbohydrates. In Shils
trrnrmmr af dinbaes. Coals ji1r t/Jcrnpy nnd trrcks n11d .rtroka by nPJ11·11:i:i111rrt1·~1• 50 pcrrmt. ME and others ( cd~): ,'v/t1dem 1111 tririm1 in
mcrlicnl t1>11/s to help tcncl1 tbtliegonls nrc 7'bc 11111/Jors -"'!l!Jt"St rhnt doctors cnco11mgc tbcir /Jen!tb 1111d diseasr. 10th ed. Philadelphia, PA:
bigblrgbtcd. pntimts to embrn«: this llfl1TYmi1•c npprnncb 1111d Lippincon WUliams & Wilkins, 2006.
3. Andt:r>On JW .md 01 hers: Carbohydrate ,rntl wod: bnrdc1· 111 c1111trolli11g b/1wdglucosc levels. C11r·1'cn.t review oft/Jc 11n.rit111s dicrary cnrboiJy-
fiber recommendation~ for indh·iduals with dia- 9. ))ivcn:icular disease: The 1mpnrtancc or !:',C[ting rlmtes nnd tbefr 1·clnred 111ct11bo/ism. Digestion
betc>. /1111mnl of tbr A111ericn11 C11/legc of enough fiber. .lla_yo Cli11ic Health Lcttc1· 1111d nbsorpti<m of cnrbo/J_ydmtes is rrl.so co1•e1·cd.
Nnttitiou 23( 1 ):5, 200+. 23(2): I, 2005. 15. Kkin S and o rh crs: Weight management
17u cnrbol~vdmu: protein: /nt rnrio (in ta111s Meet111..lf yv111fibo·1· 11uds is l'c1·y i111porrn11t for through lifc>rylc modification for the preven-
of energy i11rnh·) ill n dinbrtir dier sho11/d be prcve111i11g rlii•crtic11/11r di.<cnst'. Tu do so, cnt t.io n and managemenr of rype 2 diabcte~.
55'\\ 11r 1111Wt' : 12%to I 5%: less thn 11 30%. T71c plc11t_v oj:fmirs. pc,_nctnblcs, 1111d 1v/Jolc-gmi11 Americrrn /1111r1111f of Clinicrrl N11rriti1111
dfrt should prwidt 25 rt1 50 gmms of.fiber per prod11m. Rc..1111/nr pbJ•sicnl nrtivity nlso bclps 80:257, 2004.
rim•, n11d /0111 glycc111ic /l)nd fonds s/)1)11/d fvr111 1bc p1·cpcut rbc p1·oblcm.
OJ>cr111cigbt rwd obesity arc impol'tnm causes of
bulk of dn i~v food cbt1ircs. I 0. l:.hrmann DA: Pulycyst.ic 01•ar)' svndromc. The type 2 rlinbetes. Morlcmte weight lo.rs n1lrl in-
New E11g/1111d /011n111I 1if Medicine 352: l223, crenud p/Jysicnl activity c1111 both fm'cstnll a11d
4. Ringham SA and others: Dietary fibre Ln food
2005. i111pro11c poo1· bloodglttcosi- n;g11fotio11.
and protcccion ngalmt colon:ctal cancer in 1.hc
European Prospccn,·c Investigation into 011e .rymptom thnt often 11ccomp1wies po(vcysr:ic 16. Koh-13ancrjec P and oth.:rs: Changes in whole-
Cancer and Nutrition ( EPIC): An observa - ol'llrJ sy11drn111c is bypulfl)·ce111i11 nnd 1·dntai iii· grain, bran, and ccr~-a.I fiber consumption in re·
tion.ti study. T71c L1111ccr36.J.:l.96, 2003. nbetc.r. H0111c11 nt riskf01· this discnse typically lation 1.0 8-~' weight gain among men.
b1111c i,-rqJ1tl111· 111emtr11nl cydc'S, i11ftrtiiiry, Amtrica11 Journnl of Clinical N11rr1tio11
A diet rich i11 higb-fib,·r foods is nssocintcd 111it/J
01>nrim1 ry.rts, scvci·c ncnc, excess f11cinl 11r /Jody 80:1237, 2004.
a 40% red11ctio11 i11 rnlorcctrrl c1111w· l"isk-
IJn fr, /Jypcrteusio11, obesity, (vpe 2 dinbeus, rwd A diet ricb in wbolegrnin breads n11d cerenls is
rspuinlly i11 tilt' colon-c11111pnrcd ro 11 diet loll'
11ther problems. 01'crprod11ctio11 of 11111/e /Jor· nssocintcd 111it/J less n•cight gain over time com·
111 fibei: It is not lmo11111 ifft/Irr per sc. 11r st1mc-
111011cs n11d ills11/i11 1·csisr1111cc n1·c nt the root of pand ro a diet 1·ich ill 1·cfi11cdgmins. T71is iJ cs-
tbi11g i11 rbr bigbjiber foods (.:,g., pbywclm11i·
r!JCSe pr11ble111.r. 7J1i.r nrtic/e discusses the di11g11osis pccinll)' tmc for foods with nt lenst 25% ivhok
mis), is t/Jr rcrrson for tbc ej)'cct. Tlms, u11c's focm
11nd 11·cntmmt of tbc discnsc. grniu c1mte11t.
sbould be 011 n diet 1·ic/1 in bigb-fiber foods, 11111
fiber s11pplc111c11ts. L1. Food and Nutrition Roard: Dietary refere11c1• 17. Larsson SC .rnd Others: Magnesium intike in
111tnkf.s for CUC1J1.Y. cntbohydrnre, jibt'I; fnr, fntty relation ro risk of colorcctal cancer in "omen.
5. Brnnd-i\!ilkr J: Glycemic load and d1ronic dis- ncids. cbolcs1rro/, protci11, nnd rr111i110 acids. j1111r1111l of tllr Amrricn11 .~fedicnl Ass11cintio11
ease. Nurririo11llcPfrn1s61 (5l:S49,2003. \Vashingcon, DC: Nation.ii Ac:id.:my Pres~, 293:86, 2005.
A ditr 1-ich ill bigb glym11ir fond c111·bohydmus 2002.
A diet rirb i11 111rrgr1rsiu111 is nssocinred 111it/J 11
mcrcnscs tbc risk of dei1dopi11g cnrrlilll'llsculn.r T71is rrp111·r /Wt1l'irle.< rhe /ntrsrg11idrr11ce flw lower risk ofde11clopmg colorecr.nl cm1Ccr. 71i.·
disc11sc nnd rypc 2 din.bcres. Such n dier 111ny rrfo1 11111ct·111111tric11r intakes. With rc._qnrd to rnrboby· 1111tbors rcco111111c11d rhnt 11d11/ts incrcnsc fruit,
m111rib11rr to obairy, wlt111 cn11co; 1111d brmst dmrc, tbr RDA bas bew srt nt 130._q/dny. 1•el1cm.blc, bc1111, and wlmlc grai11 imnl!c to meet
crr11ur. F11'/nn>i11g n diet 1·icb in Low g~vumic Cm·bob_vdrntt" intnkc sbo11/d rn11ge ji·mn 45 ro mng11csi1111111ccrls, ns ot/Jer compo11rnt.f iu t/Jtsc
fond m1·bol~1·draus is 1111the11rbcr /J1111d bc11cft- 65% of CllCllJJ' inmkc. Sugars nddcd ro foods jiiods (c._q., 11arill11s p1Jyt11cl1cmic11/s) 11/sn ron-
cirrl in tum· 1·c._n11rds1 cspcci11IZ1• if n11r is scrlm- sbo11/d c<1mti111rt· 1111 1111m· t/J1111 25% of wcrgy rribuu to 11 loll'er risk fo1' de1•el11pi11g c11/orccr11/
tai~v 111· ubc;·c. 111rni·r. c1111crr.
6 Deen D: ~kcabolic >yndromc: Time for ani<>n. 12. Goldberg T and other>: Adva1m:d glycoxida- 18. Liu S and others: I~ intake of breakf.tst cc:n:als
A11urirrr1t F11111i~1· Physir1111169( 121:2875, 200':1-. tion end products 111 commonlv consumed rdared LO total and causc-~pccitic mort::thrv in
food>. ]1111r11nl of tlJC Amcricnn Dietetic men: Amcricn11 Joumrrl of Cli11ical N11rr1rio11
rh,. 111crnbolir sy11dm111e lcndJ rt11111111.v ddetl'n- Amicintion I 04: 1287, 2004.
1111s 1ffi·cts 011 tin· body. lVt:i_qbt co11rn1/ rr11d ri:..1111 - 77:fi94, 2003.
lor 4Jb:'fiu:nl ncrn•iry Mc key pnns 1ifa p/1111 for F110rls rsprcrn/~1· low i11 nrll'n11rrdg/r({l:i:idntim1 Rc..q11/nr i11rnke of n wholc-grni11 brerrkfnsr u-
the pn·11cnrim1 nud n·rntmrnt of t/1c 111ttrrbolir eud points i11r/11d.:fr11its, Pcganblrs, srnrrbcs, renl rcd11ccs r/Jr tis~· ofcnrdiovnsm/111· 111111·tality
sw1dn1111c. 1111d milk. In rnntmst. mtflls 1111d 111ha high and tnrnl monn!tty in 111c11, while rqJlilrrr we of
rr rcfi11ulgmi11 arm{ /ms the opp11site effect. By 25. Schu lzc J\lB and others: SugaMwccrencd be\'· 3 I. Tcsfayc S and others: Va~cul.1r risk factor' .111d
mbstit11ci11g n hig/J-jibet· ccrcnf /01· n loll'-jibcr cragcs, weighr gain, and incidence of rypc 2 di- di;ibecic ncuroparhy. T7H New E11l1ln11d /1111mnl
cc1'enl, adults could cxpcrimcc n mbsrn11riaf i11J· abetc~ in young and middle-aged women. 11f Mcdici11e 352:341, 2005.
pact 11u overnIt /mi/th. jormur.l of thc Amcricn11 1\frrlical Ass11ciatio11 Ct111tr11fling bfaodgl11ct1se is nn 1111porm11t pnn
I 9 . Lo V and others: Statin the rap)' in paticnrs with 292(8):927, 2004. of 1·cd11ci11g 1/Je risk ofdeJ1elt1pi11..1111(1·1'e·rdnterl
cype 2 diabetes. American family Physicia11 A higb co11sumptio11 11fs11gnrcri soft drinks is ns· disease i11 pcoph- wir/J diabetes. C1111rrollht11 fmd.1•
72:866, 2005. s11cin rcd with wcighrgain a11tf type 2 din/mu. wci..,JTfJt, blood triglyet"1·idcs, nud blood p1·cssm·«
Kecp111g blood choksw·ol i11 n dcsimblc m119c 1.r 17JC kcyfaccm· is likc~v t/Je large nmmmts of rap- nrt' n/.so i111pqrrn111 mcano-a to tllkt-, ns wdl ns
i111p11r{(111f far 1'cd11ci1'.8 cnrdi01•nsc11lnr discnu idly nbsM·bcd s11gfll"s in time pn1dur.ts. n11t.r111oki119.
risk i11 people 111ith din/ictcs. Use ofsrnrin dmgs 26. 'khulzc J\IB and others: Gl)'Ccmic index, 32. The whole grain srory. T11fts U11iPcrsiry Hmlt/J
to rmni11 rhis rli11icalgonl is 111ide(y nd1>11cnted glyccm ic lo:ul, .md dicrnry fiber intake and inci· & N11triri11n Letw; p. 4, Ju ly 2005
(if 11ccdcd) i11 people 111it/J typr 1 diabetes. dcnce of rypc 2 diabc1es in younger and
R(1111Ja1· 111/Jo/c'lp·rri11 com11111ptio11 11111y hdp p1·,:·
20. J\llaycs PA, Bc1H.k r DA: Carbohydrarcs of phy,. middle-aged women. A111rritrr11 ]011mal of
1•e11t cn1·di0Msmlnr di.rcnse, 111111cces.rm:v wci_11br
iologicaJ signiticancc. ln Mu rray RK :ind ol'hcrs Clinical Nutrition 80:348, 200.J. gniu, nurf t/J( meta/Jolie S)?ldr11111i-. 171is i1 msfrr
(cd>); Harper's illmtrnred bioclmnistry. 26th ed. A diet ric/J in mpid(1• n/J.rnrbcd cn1·1Job_vdmrcs ro do so rorln_1· l1ccn11sc 111n11y who/c·gm111 prod·
New York, NY, LJnge J\lcdic:il Books/ nnd /rm> i11 cc1·cnf fibe1· is ns.<ori111cd witb nn ;,,. 11cts nrt· 111111• mmiln/Jle.
McGr.rn -Hill, 2005. omscd »isk oj'dt'11d11pi11g typr 1 din/Jctcs. 17ms
33. Tiro~h A Jnd other~: Norma l fa~ting. pl.1'111a
Concise 1·cvirll' of rbc c/Je111icaf .rtmcrtl1'cs n11d tbc 1_vpes of rn1·bo/Jydm res d1osc11 far a dicr n re
glu cose levels and rypc 2 di.ibctcs in ,·ouni:t
rdntl'd pnrm·cs of dic'tnry cnr/J11/Jydrnm. Bot/; ii11p1wtnnr t11 rnnsidct: mm. ·n1c Nr·11• Ei1filn11d ]011r11nf nf M.-dic111,-
mgnrs rmrl stare/Jc.< nrc incl11ded i11 ch,· 27. Soiuio M .rnd ocher>: Elc\11red plasma horno- 353: 1454, 2005.
disms.rio11. cyqcinc level is an indepcndcnr prcdinor of
Asfn.rti11g {J/11orf lff11cosr iuo·(nscs th,. ri.rk of r/,..
21. Mitka M: Rcscar~hcrscxam i m:cftcctsofd i.:tan• coronary hea rt disease cvcncs in p:ilicncs wirh
J1d11pit1fi rypc 2 diabetes nls11 i11rm1s(s. Tim.< II is
magnc,ium on type 2 di.1bctcs. journnl oft/Jr type 2 diabctc~ melliru~. A1m11fs ~/' J111nw1/
criricnl ro bm•c jhsti11l/ bf1111d .11fnrosc 111rns111-.·d
American Medicnf Associnrion 291:1056, 2004. ,\.frdici11c 140:94, 2004.
011 n rc..1f11/nr bnsis n11d 111rrk1· nppr11p1·inu di·
Mccri11g 111agnm111n nads is 1111p11rrnnt jiw pco· El<'Mtcd /J/011d /111111oc.1•s1d11t i.r n11 i11rlcpt11dmt ctm:i• nnd lifcsr_vlc ndj11.rt111c11ts to lowc1· It ll'bm
pie 1J1ill1 tfin/Jeres. T11i..r pmcricc fikrZv ccmrril111tt'.f l'isk fncto1·.fi1r tlc1•dopi11g rypc 1 dinbcw. 11arfcd.
m better bf1111d glucose ng11fnrio11. Rieb food Cr111.<mniug rrtlrqunte 11111111111/s 11f 1/Jc 11irrw1i11s 34. W3ng Y and others: Comp.1rison of Jbdrnninal
10111u.r, mc/Jcr r/Jm1 111ag11esi11111 mpplcmrnts, fi1/ntc, 11itn111i11 ll · ll, n11d 1•itn111i11 B-6 nn· i111·
adipo:.iq and t11•crall obcsirr in prcdicnng mk
nr1• ndl'omt.·d. p11rt1111r i11 co11rrolli11g blllod l111111oc_vsrei11e.
C>f rype 2 diabetes in men. Amrriam Joumal of
22. Park Y and other>: O ierary fiber inrake and risk 28. Swagerty D and orhcrs: Lactose inrolcrancc. Cliuicnl N11trition 8 1:555, 2005.
of colorcctal cancer. /tJtmrnl ~( t/Jc Amcricn.11 A111iTicn11 Fni11iZ1• Plt)'sicin1165:1845, 2002.
Obcsi~v mu/ e.-.:uss 11pp1.,. /Jod_vfn.t .rrm·c.r nn- both
Afrdirnf Association 28-1-9, 2005. Lncmsc mnldi._r1esno11 1111d iurolcm11ce n:sult ji·o111 rfrk factors for dn•dopiu._q typt 1 dinbcra.
Dietary fiber i11rnkc wns 11ot sbo11111 t11 p1·ci1c11r n d1ji<ime_1• i11 tb<" lrrctnsc·dL11csti11g mzy111t:, fn r- A11oidi11g botf; co11ditio11s is ii11porrn11r, esp«·
co/11rcctnl cn11ccr i11 tbis poolfd n11nz'l'sis of 1111- tnsc. 711is is /Wcscnt 111 up to 15%of Nort/Jcm rinlfy cxrrss 11ppcr /JodJ•fnt di.rtril111ri1111 .
111n·om studies exn111111i11g r/Jr 1·drrti1111s/Jip. Europmm, 12% 11/ Amfrimn W/Jiw, 70%11f
35. Warshaw HS: FAQs abour polyols. fodny's
Orhc1' dicrm~v fa cum, such ns 111ccri11g 11ced.s for 111dinw, 80% ofR/ncks aud HiJlit111ics, nud 100% Dietitian, p. 37, April 2004.
the 11irrr111i11 folatc n11d tbe 111i1uml cnfcium. 1!( Nnth•e A111LTicn11s nud Asin11s. J.losr indh•idu-
Po~\'lils (r.g., s1t_11m· nfco/Jols) yield fi"0111 0.2 111
and /imitiug nlc11bol n11d red mcnt i11rnl1c, nrc rrl.< ll'it/J lncto.rr 111aldigatiu11 mid i11ttJlcra11rc mu
co11m111c .mmlf n11101111rs ofdnir)' p1·nd11cts wit/J- 3.0 frnl/g, s11 tbc_v stiff 11ccd t11 bi: c1111sidrr..d
pn1bnb(v mort important to ro11sidc1:
out cxpcrimci11g symptoms, 1111d yogm'ts witfJ lhw wbcu cnfculnti11g tbc mngy cimtmt ~( rr d1rt. A
23 Salzman H, Lillie: D: Diverricular d isease.:: diag· 111nj11r rrttrilmfl· of tbes1· products is t/Jnr rbt)' d11
nosis .md trca1mcn1. Amrrim11 F11111i(v Pb_1•sicia11 c11lt11rc.r tend t/1 {1t csp,·cinl~v JJ1clf f/lltmtcd.
1wr i11crmsc tbr: nsk far dmtn.I mi-ics.
72:1229. 2005. 29. Sweeteners c.111 sour your health. Comu111cr
Reports 1111 Hcnftb. p. 8, January 2005. 36. \Vl'.in~rcinAR and others: Relationship of ph~ ,.
Mcui11g fiber 11ccds helps reduce t/Je risk of rle·
bod~ mass index \\1Ch rvpc 2 ch·
kal .Kciv1ry 1·s.
11elopi11g dh1crtiwlnr disease. Trmt111C11t of di- Li111iti11g si111plr sugrm i11 n diet is importn11t iJI
abet.:~ in women. f1111mnl of the tl111rrim11
11crtic11liris i11c/11du usc of antibiotics a11d some ord•.,. ro lessCIJ t/Jc risk oj'dcvdopiug obesity, dirr·
Mcdirnl Associntil111 292: 1188, 200-!.
dierrtl')' 1·..m·icri1ms, ns 1·cpfomerl b)' the n11tbors. bcrcs, nud dmtnf rnries M ll'df fl! i11crcnsi11g
dfrt IJllfllit,v. ,\fodcrnrc us« of' r/;c nltcrnrrrh•,· R11tb clcvntcd body 111nss i11de.x n11d pl~1'.rim/ in-
24. Schulz..: MB aud others: Dietary parcern, in·
.n11i:rrcnei-s fisted i11 t/Jc n1·ticle /Jdps mie 111tet nctiirity m·c i11dcpmdc11t predictors of dc1't:fopi11..11
lhmmacion, ,md incidence of type 2 d iabercs in
tl111 r.!Jfllll. dinbctcs. H11111t·Pcr, rbc nss11rin1io11 with ,·f.-l'flt«d
women. Amcricn11 Journrrl 11}' Cfiuicnf
{1ody 1111iss i11dt~\· is 11111ch grmtrr r/;1111 tbnr of
N11tritio11 82:675, 2005. 30. Tanase~cu J\ I .rnd others: Dietary rac
and cho-
pb_i•sical ·inncth•it,v.
A diet rich i11 n1JJnr·.<lJ'CeT&11ed soft drinks, re· lesterol and rhe risk of CJrdiovascular disease
fim:d gm ins, nnd processed 111ent IMS nss11cint1:tf among women wiLh qrpc 2 diabetes. A11w·icn11 37. Yarak.i L: New medications fbr diabetc' m.111·
ll'ith n 1hrcc·ri111esgrcnm· 1·i.rk oj'tfn•elopi1'.8 typr Jm1mal of Cli11.icnl NutntiOll 79:999, 2004. ngcmcnt. Torfrr;i•'s Dicriii1111, p. 20, Ju ly 2005.
2 di11llcm i11 tbi.s m11(v. f'rnrccri11c foods i11- A diet rid1 in rbo/1·stm1I n11d snrumud fnt n11d T11t· a11t/Jor rn•irn•s th.: /nr.:.rt medications n11111l-
c/11ded n;g11/nr i11tnkc of 11cgctnblrs as 1l'ell 11s loJ11 in po(r1111snt11mrcdfat i11o·mses cnrdiol'fl.<· nMc ji1r th« 1m1t111mr of dia/Jctes. 17Jt'u cn11 bt'
somr inrnke of wi11r n11d coffee. 171is 1ffca was ruftir disease ,.isk ill pn·s1ms wi1b type 2 diabetes. added to rb.· typical 111cdimti11111 tbflt lmvc {1cr11
espcfinlly s'1ow11 i11 pcopk ll'hll nls11 mai11rnmcd 171c n11t/Jors rcco111111rnd t/Jnr such people iime"lf m•nilnbft fi11· n 1111mbcr oj)cm·s, .ruch ns m·nf by-
n healthy bod)• !l'cighr. co11muu 1111we fnts rir/1 i11 m111101111Snt11mtt'd Jnr. fitl!Jfvcemic agc11ts n11d im11/i11.
Take I Action
I. Estimate Your Fiber Intake
To roughly estimate your doily fiber consumption, determine the number of servings that you ate yesterday from each food
category listed here. If you ore not meeting your needs, how could you do so? Multiply the serving amount by the value
listed and then odd up the total amount of fiber.
Food Servings Grams

Vegetables
{serving size: 1 cup row leafy greens or 1/2 cup other vegetables) x2
Fruits
(serving size: 1 whole fruit; 1/ 2 grapefruit, 1/ 2 cup berries or cubed fruit;
1I4 cup dried fruit) x 2.5
Beans, lentils, split peos
(serving size: I / 2 cup cooked) X7
Nuts, seeds
(serving size: 1/ 4 cup; 2 tbsp peanut butter) x 2.5
Whole grains
(serving size: 1 slice whole-wheal bread 1/ 2 cup whole-wheal pasta, brown
rice, or other whole groin; 1/2 each bran or whole-groin muffin) x 2.5
Refined groins
(serving size: 1 slice bread; 1/2 cup pasta, rice, or other processed groins;
1/ 2 each refined bagels or muffins) x
Breakfast cereals
(serving size: check package for serving size and amount of fiber per
serving} ___ x grams of
fiber per serving
Total Grams of Fiber =
Adopted from fiber Strands of prolect1on. Consumer Reports on Health. p. I August 1999
How does your lotol fiber intake for yesterday compare with the general recommendation of 25 to 38 g of fiber per doy for women
and men, respectively? If you ore not meeting your needs, how could you do so?
... ( '
.. .
• j.. ....
Take I Action
II. Can You Choose the Sandwich with the Most Fiber?
Assume the sandwiches on the blockboord here ore ovoiloble ot your local deli or sandwich shop. All the sandwiches provide about
350 kcal. The fiber content ranges from about 1 gram to about 7.5 grams. Rank the sandwiches from the highest amount of fiber to
the lowest amount; then check your answers at the bottom of the page.
•
• ..
..
.. ..
• •• ..
.•.. Jt . .. --
•
- . f-
..i
t. r'
'. ·6 l :Boa IOH ·9 16c;· 1 :y6nopJnos
uo ss!MS '!? woH ·c; 6 £ :f'!?tid ·v '6t :a.<~ uo ss!MS '!? .<a~Jnl '£ '6 L :1oayM a10YM uo po1os oun1 'l '6 c;·L :Ja6105.<os l
1
,~.~ ••M•uv ~I
LIPIDS

lipids. Common Properties and Main Types Jackie is o 21-yeor-old health-conscious individual in her third year of nursing
Fatty Acids The Simplest Form of Upids •
Essential Fatty Acids • Effects of a Deficiency school. She recently learned that o diet high in saturated fat con contribute lo high
of Essential Fatty Acids blood cholesterol and that exercise is beneficial for the heart. Jackie now tokes o -i
Triglycerides brisk 30-minule walk each morning before going lo class, and she hos storied lo cut I
m
Roles of Triglycerides in the Body m
as much fat out of her diet as she con, replacing it mostly with carbohydrates. A typ·
Providing Energy for the Body • Storing Energy
for Loter Use • Insulating and Protecting the icol day for Jackie begins with a bowl of Fruity Pebbles with 1 cup of skim milk and
zm
Body • Transporting Fat-Soluble Vitamins ?O
1/2 cup of apple juice. For lunch, she might pock a turkey sandwich on white G)
Phospholipids -;<
bread with lettuce, tomato, and mustard; a small package of fat.free pretzels; and o -<
Sterols
handful of reduced-fat vanilla wafers. Dinner could be o large portion of posto with m
Fol Digestion and Absorption .--
Digestion • Absorption CJ
some olive oil and garlic mixed in, and o small iceberg lettuce salad with lemon
Fats Carried in the Bloodstream
z
juice squeezed over ii. Her snacks ore usually plain popcorn, baked chips, low-fol G)
Carrying Dietary Fats Utilizes Chy/omicrons •
Transporting Lipids Mostly Made by the Body cookies, fat-free frozen yogurt, or fat-free pretzels. She drinks diet soft drinks z
Uses Very·Low-Density Lipoproteins throughout the day as her main beverage.
c
Nutrition Focus: lipoproteins and ~
Do you think Jackie hos found healthy ways to reduce fat in her diet? Point out m
Expert Opinion: Atherosclerosis: An Update some positive practices. How would you suggest that Jackie change her diet to
z
-i
(/)
Another Dimension of fat: Properties in Food make it more heart healthy? )>
Fat in Food Provides Some Sotiety ond Flavor •
Hydrogenation of Fatty Acids in Food
z
CJ
Production Increases Trans Fatty Acid Content • )>
Fol Rancidity Limits Shelf Life of Foods • .--
Emulsifiers Improve Many Food Products ()
Recommendations for Fat Intake

0
I
Fats in Food 0
.--
Fat Replacement Strategies Are Available • Fat
Is Hidden in Same Foods • Wise Use of
Reduced.Fat Foods Is Important
Cose Scenario: Follow-Up
Toke Action
Y our doctor informs you that your "triglycerides ore too high. " Your bill from a medical laboratory
reads "Blood lipid profile-$55." A health food advertisement suggests using garlic supplements
to lower blood cholesterol. Advertisers plug foods "lowest in satu-
rated fat. " All these substances-triglycerides, saturated fat, and CHAPTER OBJECTIVES CHAPTER 6 IS DfSIGNED
cholesterol-are lipids, a collective term referring to fats and
TO ALLOW YOU TO:
oils. 1. List four classes of lipids (fats) and the role of each in nutritional
health .
lipids contain more than twice the energy per gram (on ov-
2. Distinguish between fatty acids and triglycerides.
erage, 9 kcal) as proteins and carbohydrates (on overage,
3. Differentiate among soluroted, monounsoturoted, and
4 kcal each) . Consumption of most saturated fatty acids and
polyunsaturated fatty acids in terms of structure and food
Irons fatty acids also contributes lo the risk of cardiovascular dis· sources.
ease (CVD) .7 for these reasons, some concern about lipids is 4. Name the two essential fatty acids and explain why they are
warranted, but certain lipids also ploy vital roles both in the called '1essenlial."
body and in foods. Their presence in the diet is essential to good 5. Nome the classes of lipoproteins and classify them according to
their functions.
health. In general, lipids such as those in vegetable oils should
6. Discuss the implications of various fats1 including omega-3 fatty
comprise 20 to 35% of our total energy intake?
acids, with respect to cardiovascular disease.
This chapter looks al lipids in detail-their forms, functions,
7. Recognize dietary sources of Irons fats and how they affect
metabolism, and food sources. It will also look at the link between chronic disease risk.
lipid intake and the major "killer" disease in North America: car· 8. Identify available fat replacements.
diovosculor disease, which involves the arteries of the heart (coro- 9. Characterize the symptoms of cordiovasculor disease and
nary heart diseose) as well as other arteries in the body. highlight some knowri risk factors.

OF LIPIDS IN CHAPTER 6 , YOU MAY WANT TO REVIEW:
Legal definitions for various labeled descriptors, such as "low-fol" and "fat-free," in Chapter 2.
The concept of energy density in Chapter 2.
The process of digestion and absorption and gastrointestinal hormones in Chapter 3
The glycemic lood of foods in Chapter 5.
I Lipids: Common Properties and Main Types

Humans need very Little fat in their diet to maintain health. In fact, daily consumption
of2 to 4 tablespoons of plant oil incorporated imo foods and at least twice weekly con-
sumption of fatty .fish such as salmon or tuna meet the body's need for the essential
fatty acids.7 If fish is not consumed, the essential fatty acids in canola oil, soybean oil,
f:1ax seeds (and oils), and walnuts can contribute some of the same health benefits as
those found in fish. Thus, one cou ld follow a purely vegetarian diet containing about
10% of energy from fat and still maintain health. However, as long as saturated fat,
cholesterol, and partially hydrogenated fat (teclmically called trans far) is minin1ized ,
far intake can be considerably higher than that 1 0% allotment. Recent recommenda-
tions from the Food and Nutrition Board suggest that fat intake can be as high as 35%
of energy intake.7 After learning more about lipids-fats, oils, and related com ·
pounds-in this chapter, you can decide for yourself bow much fat you \\'ant ru con -
sume as well as how to track your daily intake.
Lipids are a dfrerse group of chemical compounds. They share one main character-
istic: They do not readily dissolve in water but do so in organic solvents, such ru. chlo-
roform, benzene, and ether. Think of an oil and vinegar salad dressing. The oil i!> nor
192
soluble in the water-based vinegar; on standing, the two separate into distinct layers,
\\'ith oil on top and vinegar on the bottom.
Triglycerides are the most common type of lipid found in the body and in foods. As
noted u1 Chapter 1, each triglyceride molecu le consists of three fatty acids attached to phospholipid Any of o doss of fot-reloted
glycerol. P hosph o lip ids, and ster ols such as cholesterol, arc also classified as lipids, a l- substances thot contain phosphorus, fatty acids,
though their structures can be quite different from the structure of triglyccrides. 20 All and a nitrogen-containing component. The
these lipid compounds are described in this chapter. phospholipids ore on essential port of
As explained in Chapter 1, lipids that are solid at room temperature are called fats, every cell.
and lipids that arc liquid are called oils. Most people use the word fat tO refer to all sterol A compound containing a multi-ring
Lipids because they don't realize there i~ a difference. As already noted, howe\'er, lipid (steroid! structure ond a hydroxyl group (-OH).
is a generic term that includes triglycerides and many other substances. To simplify the
discussion, rJ1is chapter primarily uses the term fat; however, as vou will see late r, not
all the substances called fats truly are fats. When necessary for clarity, rJ1e name of a
specific lipid, such as cholesterol, will be used. This word usage is consistent wirJ1 ilie
way many people use these terms in healrJ1 care settings.
Fatty Acids: The Simplest Form of Lipids

The fatty acid is common to most lipids, both those in the body and in foods. It is ba- n some coses n is used rather than omega
sically a long chain of carbons linked together and flanked by hydrogens. At one end of
0
I (w). Thus, the term you see may be either n·3
or w-3 fatty acids.
II
the molecule, designated the atpha end, is an acid (specifil.:ally a carboxyl [-C-OH])
group. At the otber end, called the omega(w) enrl, is a methyl group (-CH 3 ) (Figure 6 -ln).
ln the Greek alphabet, atpha is the first letter and omega is the last.
If all the chemical bonds bet:\veen the carbons are su1glc connections and the car-
bons are filled with hydrogens, a fatty acid is said to be saturated (Figure 6-la).20 To saturated fatty acid A fatty acid containing no
understand this concept, picture a sponge saturated (filled) with water. In this sense, carbon-carbon double bonds.
the fac:ry acid is sarurated wiili hydrogen.
monounsaturated fatty acid A fatty ocid
As noted earlier, most fats high in sarurated fatty acids, such as animal fats, remain
containing one carbon-carbon double bond.
solid at room temperature. A good example is the solid fat surrounding a piece of un-
cooked steak at room tempcratLu-e. Chicken far, semisolid at room tempcratme, contains polyunsaturated fatty acid A fatty acid
less saturated fut. In some foods, such as ·whole milk, satmated fats are suspended in liq- containing two or more carbon-carbon double
uid, so the solid narure of these fats at room temperatLu·e is less apparent. Any fut in milk bonds.
actually consists of a combination of liquid and solid futs, as will be discussed shortly. long·chain fatty acids Fatty acids that contain
If a fatty acid is unsaturated, hydrogens are missing from the carbon chain- 12 or more carbons.
specifically, at the area of the carbon-carbon double bonds. Tf :i fatty acid has one dou-
ble bond between the carbons, it is m o n m m saturatcd (Figure 6-1b).2 0 Canola and
olive oils contain a high percentage of mooounsanll'ated fatty acids. ff two or more
bonds between the carbons are double bonds, the fatty acid is polyunsaturated and
thus even less saturated with hydrogens (Figw·e 6-1 c, d). 20 Corn, soybean, sunflower,
and safflower oils are rich in polyunsaturated futty acids. Fats in foods arc not com-
posed of a single type or category of fatty acid. Rather, each dietary far is a complex
mixture of different fatty acids.
Saturated fatty acids are linear, allowing them tO pack tightly together. In contrast, un -
saturated fatty acids have a kinked shape and thus p:ick togerJ1cr only loosely (Figure 6 -2).
The loose organization of unsamrated fats is more easily disrupted by hear than is the
more ordered organization of saturated fats. Thus, dietary fats high in unsaturated
fatty acids melt at a lower temperature than fats high in saturated fatty acids (especially
long-chain ones [ 12 carbons or longer I).
As mentioned in Chapter l, monounsaturared and polyunsaturated fatty acids in
their natural form usually arc in me cis fonn. By definition, rJ1e hydrogens are on the
While plant oils may look similar, they con vary
same side of the carbon-carbon double bond. When oils arc solidified to aid in food for- in specific fatty acid contenl. For example,
mulation, some hydrogens are u-ansferred to opposite sides of the carbon-carbon double safflower oil is rich in polyunsaturated fol ,
bond, creating the trans configuration, or a t'nms fatty acid. fu. seen in Figme 6 -2, the while olive and conola oils ore rich in mono-
tm11s bond allows the backbone to rem:iin straight Like a saturated futty acid. The unsoturoted fat.
194 Chapte r 6 Lipids
(Methyl group) Saturate d Fatty Acid (stea ric acid) (Acid group)
l H H H H H H H H H H H H H H H H H 0 j
~II I I I I I I I I I I I I I I I II~
(a) H-c-c-c-c- c - c - c - c - c - c - c - c - c - c - c-c-c-c-o-H
Monounsaturated Fatty Acid (oleic acid; w 9)

H H H H H H H H H H H H H H H 0
I I I I I I I I I I I I I I
(b) H- C- C- C- C c - c - c-c-c=c-c-c-c - c - c - c - c c 0- H
I HI HI I I I I I I I I I I I I
H H H H H H H H H H H H H H H
Polyunsaturated Fatty Acid (alpha·linolenic acid; w·3)

H H H H H H H H H H H H H H H H H 0
I I I I I I I I I I I I I I I I I II
(c) H- C- C- C=C- C- C=C-C-C=C-c-c-c-c-c-c-c - c - o- H
I I
H H
I
H
I
H
I I I I I l I
H H H H H H H
Polyunsaturated Fatty Acid (linoleic acid; w·6)

H H H H H H H H H H H H H 0
I I I I I I I I I I I I I II
(d) H-C-C-C- C- C- C= C- C-C=C-c-c-c-c-c-c- c - c - o - H
Figure 6· 1 I Chemical forms of saturated, monounsaluraled, and polyunsaturated folly acids. Each of the depicted folly acids contains 18 carbons, but lhey
differ from each other in the number and location of double bonds. The linear shape of saturated fatly acids, as shown in (a), allows lhem to pack lightly
together and so form a solid al room temperature. In contrast, unsaturated folly acids have "kinks" where double bonds interrupt the carbon chain (see
Figure 6-2). Thus, unsaturated fatty acids pack together only loosely and are usually liquid at room temperature.
productio n and health effects of trrins fatty adds will be covered in mo re d t:tail later in
tht: chapter.
trans fatty acid A form of an unsaturated folly
Overall, .1 fat or an oil is classified as saturated , mo no unsaniratcd , o r po lyunsaturated
acid, usually a monounsaturaled one when
found in food, in which the hydrogens on both based o n the natm e of th e fu tty acids present in the greatest concentratio n (Fig ure 6-3 ).
carbons forming the double bond lie on Trig lycerides that cont;1in primarily satm atcd fatty acid s are solid at room tempera-
opposite sides of that bond. A cis folly acid hos tun~, especially if the fatty acids have a lon g chain . Medium-chain saturated fa tty ;Kids
the hydrogens lying on the some side of the (6 to 10 carbons lon g), such as th ose in coconut oil, produce liquid oi ls at roo m tem-
carbon-carbon double bond. perature. This remains true even tho ug h coconut o il cons ists primarily of saturarcd
fatty acids, because the sho rter chain le ngth overrides the e ffect of saturation. Short-
medium-chain fatty acid A folly acid that
ehain saturated fatty acids (less th<m 6 carbo ns lo ng) also form liquid o ils at room tem-
contains 6 to 10 carbons.
perat ure. Dairy fats arc sources o f these shorr-chain fatty acids. Trig lrccrides
short·chain fatty acids Fatly acids that contain containing prima1ily po lyunsaturated or monoLmsatLu-ated fatty acids are also usual!~
fewer than six carbon atoms. liq uid at roo m temperatu re. T h ese arc not affected by chain le ngth.
omega-3 (w-3) fatty acid An unsaturated fatty Essential Fatty Acids
acid with the first double bond on the third The actual location of the carbo n -carbo n d o uble bonds in the carbon chain of a cis
carbon from the methyl end (-CH 3 ). po lyunsaturated fatty acid makes a big d iffe rence in ho w the b od y me tabo lizes it. Lr the
omega-6 (w·6) fatty acid An unsaturated folly first do uble bond starts .tt three c:trbons from the 111 e th~1 I (omega) end of the fatty .Kid,
acid with the first double bond on the sixth it is an omega-3 (w-3) fatty acid (sec F ig ure 6- l c). lfrhc first d o uble bond starts .u
carbon from the methyl end (-CH 3). six carbons from t he methyl end o r the fatty acid , it is :Ul omega -6 (w-6) fatty acid
(sec Figure 6-1 rf). Following the same scheme, an o mega-9 fatty acid has 1.hc lirst double
Figure 6·2 I Cis and Irons isomers of fatty
acids. Cis fatty acids are more common in
foods 1han ore Irons fatty acids. The lotter ore
primarily found in foods conloining partially
hydrogenated fats-notably, stick margarine,
shortening, and deep fol-fried foods. The Food
and Nutrition Boord suggests limiting intake as
much as possible.7 Loter in lhis chopler you will
Cis form see why.
(Causes
backbone of Trans form
molecule to
bend)
Ole ic acid Elaidic acid
Polyunsaturated
Fatty Acids
Saturate d Fatty Acids
Coconut oil
-
••
Butter I
Palm oil I
Lord or beef fat I
Monounsaturated
Fatty Acids
Olive oil
Conolo oil•
Peanut oil
Soybean oil•
Polyunsaturated
Fatty Acids
Safflower oil
Sunflower oil
Corn oil
Trans Fatty Acids

Tub margarine
Stick margarine
Shortening
0 20 40 60 80 1000
I I
80 100 0
•• I
20 40
I I I
60 80 100 0 20 40
Note tho! fats ore also lypicolly rich in monounsaturoted fatty acids (40 to 50% of total fatty acids).
60 80 10
'Rich source of the omego-3 fatty acid olpho-linolenic acid (7% and 12% of total fatty acid content for soybean oil
and conolo oil, respectively).
"The natural Irons fatty acids in butter ore no! harmful and may even hove health-promoting properties, such as
preventing certain forms of cancer.
Figure 6 · 3 1 Saturated, monounsoturoted, polyunsoluroted, and trans fatty acid composition of common fols and oils (expressed os %of all fatty acids
in the product).
196 Chapter 6 Lipids
Figure 6 -4 I The essential fatty acid (EFA)

family. All ore available from dietary sources; Polyunsaturated Fatty Acids
linoleic acid ond olpho-linolenic acid ore the (PUFA)
essential fatty acids and musl be consumed
because body synthesis does not toke place.
The other fatly acids in lhis figure con be
Omega-3
synlhesized lo some extent from the essential
fatty acids. Alpho·linolenic acid
alpha·linolenic acid An essential omega-3 fatty Docosahexaenoic Eicosopentoenoic Di homo-gamma· Arachidonic

acid with 18 carbons and three double bonds acid acid linolenic acid acid
(C 18:3, w-3). (DHA) (EPA)
linoleic acid An essential omego-6 fatty acid

with 18 carbons ond lwo double bonds
(Cl 8:2, w-6).
bond sr:ir ting nine carbons from t he methyl end of the farry acid. ln foods, aJpha-
oleic acid An omego-9 fatty acid with linolenic acid is the major omega-3 futty acid; linoleic acid is the major omcga-6 fatty
18 carbons and one double bond (Cl 8: l, w-9). acid; and oleic acid is the major omcga-9 farty acid. 20
essential fatty acids Fatty acids thol must be Because we must obtain Iinolcic acid (w-6) and alpha-linolcnic acid (w-3 ) from
supplied by the diet to maintain health. foods in order to maint.tin health, they arc caUed essen tial fatty acid s (Figure 6--l-).
Currently, only linoleic acid and alpha-linolenic These o mega-3 and omega-6 fatty acids fo rm parts of viral body structures, perform
acid ore classified as essential. important roles in immune system fonction and vision, help form cell membranes, and
eicosanoids Hormonelike compounds produce hormonelike compOLmds called eicosanoid.s (Fig ure 6 -Sa, b, c, and d).21 This
synthesized from polyunsaturated fatty acids, lHetary necessity arises because cells in the hu 1mll1 body can produce carbon-carbon
such as orachidonic acid. Within this class of double bonds in ;1 fany acid only starting at the ninth carbon numbered from the methyl
compounds ore prostacyclins, prostoglondins, end. ln other words, human cells do not produce the enzyme to place double bonds be-
thromboxones, and leukotrienes. tween the methyl end and the ninth carbo n.2 0 On the o ther hand, oim:ga-9 fatty acids
can be synthesized in the body because the double bond falls after the ninth carbon. 20
0
II
C-OH
I I
I I OH OH
HO OH
""'·~,· • ~~! \_; .• . - •
~ .; " ' '. l .~Pro~t~gl~ndin E2 .I

.... _ll_:·~-· .. • _ .I _ ____ I
0
0
II II
C-OH
C-OH
OH
Figure 6 · 5 I The fami ly of common eicosonoids: prostacyclins, prostoglondins, thromboxanes, and leukotrienes.
Still, we need to consume only about 2 to 4 tablespoons of plant oils each day to
eicosapentaenoic acid (EPA) An omega·3 fatty
meet essential fatty acid nceds.7 We can easily gcr that much via mayonnaise, salad acid with 20 carbons and five carbon-carbon
dressings, rub margarine, and other foods. Regular consumption of whole-grain breads double bonds (C20:5, w·3) . II is present in
and cereals and vegetables also helps suppl}' essential fatty acids. large amounts in fish oils ond is slowly
We also need to specifically include a regular inrakc of alpha-linolcnic acid or one of synthesized in the body from alpha·linolenic
irs rclared omega-3 fatty acids, eicosapeotaenoic acid (EPA) and docosahexacnoic acid; it is a precursor to some eicosanoids.
acid (DHA). This wou ld almost certainly require at least twice week!)' consumption
docosahexaenoic acid (DHA) An omega·3 fatty
of broiled or baked (not deep fried, as this process increases f7·rms fatty acid content)
acid with 22 carbons and six corbon-corbon
farry fish, such as salmon, runa, sardines, herring, mackerel, whitefish , trout, swon.Jfish, double bonds (C22:6, w·3). It is present in
and halibut. All art: somces of o mega-3 fatty acids (Table 6 -1 ). Regular in rake of c.mola forge amounts in fish oils and is slowly
or soybean oil or consumption of walnuts or flax seeds and flax oil also supplies a steady synthesized in the body from olpho·linolenic
source of omcga-3 fatty acids.7 ocid. DHA is especially present in the retina
ond brain.
A Closer Look at Metabolism and the Role of Essential Fatty Acids dihomo·gamma·linolenic acid An omega·6
fatty acid with 20 ca rbons and three double
in the Body
bonds; the precursor to some eicosanoids.
Omega-3 and omcga-6 fatry acids are forther ml!tabolizcd by cel ls so they can con-
tribute to the synthesis of the biologically active eicosanoids nit:ntioned earlier. arachidonic acid An omega-6 fatty acid with
Eicosanoids arc referred to as local hormones because they act in the immediate vicin- 20 carbon atoms and 4 carbon-carbon double
ity of production and arc nor carried by the blood to some distant site like typical hor- bonds, a precursor to some eicosonoids.
mones. Eicosanoids are srnrhcsized from faery acids taken from phospholipids in the
cell membrane plus free fatty acids ~ll1d other sou rces within a ceU. The eicosanoids
then bind ro receptors on the cell membrane surface or to adjacent cell membrane sur- Table 6-1 I Omego-3 Fatty Acids in
faces to initiate a response. 2 l Fish (grams per 3 ounce serving)
Eicosanoids fall into three separate groups. One group (group l ) i~ dcrivt.:d from
dihomo-gamma-lin olenic acid, an o mega-6 fatty acid with 3 double bonds. Another Atlantic salmon 1.8
group (group 2 ) is derived from arach idonic acid, an omega-6 fatty acid with four Anchovy 1.7
Sardines 1.4
double bonds. A third group (group 3) is derived from eicosapcnt:u.:noic acid, the
Rainbow trout 1.0
omcga-3 fatty acid \\~th 5 double bonds discussed in the previous scction. 20 Coho salmon 0.9
To produce the parent fatty acids for group l and group 2 eicos:L11oid synthesis, Bluefish 0.8
linolcic acid is lengthened to 20 carbons and undergoes desaturation, in which hydro- Striped boss 0.8
gens arc removed to yield carbon-c.lrbon double bonds. The second reaction in this Tuna, white, conned 0.7
process ~~elds the group 1 fatty acid, dihomo-gamma-linolcnic acid . The lasr reaction Halibut 0.4
produces the group 2 fatty acid, arachidonic acid (Figure 6 -6 ).21 Ca~ish, channel 0.2
Omega-6 fatty acid metabolism Omega-3 fatty acid metabolism Figure 6 - 6 I Metabolism of omega-6 linoleic
acid to orochidonic acid, and omega·3 alpha·
Linoleic acid (ro - 6) (18:2) Alpha-linolenic (18:3) linolenic ocid lo eicosopentaenoic acid and
acid (ro- 3)
I
docosohexaenoic acid.
( - 2H) (desaturation)
Gamma-linolenic acid
(- 2H) (desaturation)
(18:3)
j [18:4)
(G•o"l') j
(+ 2C) (elongation)
[20:4]
(+ 2C) (elongation)
Dihomo-gamma-llnolenic (20:3) EPA

! (- 2H) (desaturation)
acid (eicosapentaenoic (20:5)
l
acid) (Group 3)
(- 2H) (desaturation) ! (+ 2C) (elongation)
A rachldonic acid DHA

! ( - 2H) (desaturation)
(Group 2) (20:4) (docosahexaenoic acid) (22:6)

198 Cha pter 6 lipids
cyclooxygenose An enzyme used to synthesize To produce d1e parent fatty acid for group 3 eicosanoid synthesis, alpha-linolcnic
prostoglondins, thromboxones, and other acid is elongated ro 20 carbon.s and two more carbon-carbon double bonds are added
eicosonoids. to produce eicosapantaenoic acid. (Eicosapantae no ic acid is also e lo ngated to 22 car·
lipoxygenose An enzyme used to synthesize bons and has one more carbon-carbon double bond added to produce docosa·
leukotrienes and some other lypes of hexaenoic acid; however, this compound does not form eicosanoids. )20
eicosanoids. Each of the parent fatty acids ( dihomo-gamma-lit1olenic acid, arachadonic acid, and
eicosapentaenoic acid) produces a particular set of eicosanoids. As the eicosanoids are
prostocyclin (PGI) Eicosanoid mode by the synthesized, they take up oxygen by one of two enzyme systems: cyd ooxygeoase and
blood vessel walls that is a potent inhibitor of
lipoxygenase, forming distinct groups of eicosanoids. ( Cyclooxygenase is the enzyme
blood clotting.
that aspirin and ibuprofen inhibit.) The eicosanoids made using cyclooxygenase (e.g.,
prostaglandin (PG) One of several potent prostacyclins, prost aglandins, thromboxanes) or lipoxygcnasc (e.g., leukotrienes)
eicosanoid compounds mode of arc important and potent regularors of vital body functions such as blood pressure,
polyunsatura ted fatty acids tha t produce labor, blood clotting, immune response, inflam mation, and secretions of the stomach.21
diverse effects in the body.
thromboxone (TX) Eicosanoid mode by blood A Closer Look at O mega-3 Fatty Acids
platelets that is a stimulant of blood clotting. The tbromboxanes derived from the cyclom.·ygenase pathway have a significant effect
leukotrienes ILn An eicosanoid involved in on blood clotting function. Thromboxane A is made by platelets and both stimulates
inflammatory or hypersensilivily reactions, such blood dotting and causes blood vessels ro constrict. Both are critical events when
as asthma. someone is bleeding profusely (hemorrhaging). (The name thromboxnnc comes from
its function of forming a thrombus, or clot.) In contrast, prostacyclin I, produced by
endothelial cells A layer of flat cells lining the
the endo thelial cells that line blood vessel walls, is an important inhibitor of blootl
blood and lymphatic vessels and the chambers
of the heart.
clotting. T hus the thromboxanes and the prosracyclins are amagonists. 2 1
There is one important caveat: the balancing act between the group 2 forms ( mad1.:
fro m arach idonic acid) oftbromboxane A and prostacyclin result in greater blood clot·
ting activity than the same combination of group 3 forms (made from e icosapenraenoic
acid). T he thromboxane A produced from arachidonic acid is an especially powerful
stimulator of blood clotting. All in all, the balance sheer is shifted toward less blood
clotting in people whose diet contains some cicosapentacnoic acid to offSct the effects
of arachidonic acid. 21
T hese eicosanoid actions were discovered many years ago in studies of Greenland
Eskimos. They exhibit diminished clottin g ability. T heir diet is very high in fish oils
containing cicosapcnraenoic acid. Some studies show that people who cat fish about
twice a week (total weekly intake: 8 oz [240g]) have lower 1isks for heart attacks than
do people who rare!)' eat fish. In these cases, the omcga-3 fatty acids in fish oil are
probably acting ro reduce blood clotting. As discussed in detail in the Nutrition Focus
section of this chapter, blood clots are part of the heart attack process. In addition,
Eating fish at least two limes a week is a omcga-3 fatty acids can have a favorable effect on heart rhythm in some people. This
healthy practice, because many fish ore rich in effect also reduces the risk of heart attack in those people.5
omega-3 fatty acids. Especially emphasize Remember, however, that blood clotting is a normal body process. Certain groups
species low in mercury, such as salmon and of people, such as Eskimos in Greenland, eat so much seafood that t heir blood-clotting
sardines (see Chapter 19 for details). ability can be significantly impaired. An excess of o mega-3 fatty acid intake can allow
uncontrolled bleeding and may cause h emorrhagic stroke. However, the risk of
stroke has nor been seen in studies using moderate amounts of o mega-3 fatty acids.
hemorrhagic stroke Damage lo part of the
Studies also have shown that large an1ounts of omega-3 fatty acids from fish (2 to 4 g/day
brain resulting from rupture of a blood vessel
or more; one 3 oz serving of fatty fish has about 1.6 g) can lower blood triglycerides
and subsequent bleeding within or over the
infernal surface of the brain.
in people with high triglyceride concentrations.7
In some instances, fish oil capsules can be safely substituted ( under a physican 's
guidance) for fish constm1ption if a person does not like fish. However, unless a physi·
cian recommends otherwise, individuals who have bleeding disorders, who are raking
anticoagulant medications, or who are anticipating surgery should not be taking fish
mego·3 fatty acids also ore suspected lo oil capsules because of the increased risk of hemorrhagic stroke. Generally, about 1 g
be helpful in managing the pain of inAam· of o mega-3 fatty a.cids (about three capsules) from fish oil per day is required ro enjoy
motion associated wi th rheumatoid arthritis (by the benefits of reduced risk for cardiovascular disease that are associated with fish con·
suppressing immune system responses) and may sw11ption t\.vice a week. Th1.: larger doses of o mega-3 fatty acids needed tO reduce
help with certain behavioral disorders and mild blood triglycerides would surely require fish oil supplements. (Note tlnr freezing fish
coses of depression.21 oil capsules before consumption will reduce tl1e fishy after taste. )
Effects of a Deficiency of Essential Fatty Acids he leukotrienes produced through the

lipoxygenase pathway cause slow, pro·
If humans fai l to consume enough essential fatty acids (linokic acid and alpha-linoknic longed contractions of smooth muscles in air·
acid), their skin becomes flaky and itchy, and diarrhea and other symptoms such as in- ways (and the gastrointestinal tract), especially
fections often arc seen. Growth and wound healing may be n:strictcd, and anemia can group 2 forms (mode from orochidonic acid).
develop. These signs of deficiency have been seen in people who were fod total par- Medication to block leukotriene production hos
enteral nutrition solutions contai ning little or no fat for 2 to 3 weeks as well as in in- been developed to treat some forms of allergies
f..tnts receiving formulas low in fat. However, because o u r bodjes need the equivalent and osthmo. 21
of only abour 2 to 4 tablespoons of plam oils a day, even a low-fat diet will provide
enough essential fatty acids if it follows a balanced plan, such as MyP~'rarnid. 7
Concept I Check total porenteral nutrition The intravenous

provision of all necessary nutrients, including
Lipids nre a group of compounds that dissolve in organic solvents but Jo not dissolve read- the most basic Forms of protein, carbohydrates,
ily in water. They include fatty acids, triglycerides, phospholipids, and stcrols. Fatty acids lipids, vitamins, minerals, and electrolytes. This
differ from one another mainly in the number ;md location of thi.: double bonds bcrwctn solution is generally infused for 12 lo 24 hours
carbons in the carbon chain. Saturated fatty acids contain no carbon-carbon doubk bonds; o day in o volume of about 2 to 3 L
that is, they arc folly sarur:ued with hydrogens. Monounsaturatcd fat~· Jcids contain one
carbon-carbon double bond, .md polyunsaturated farry acids comain two or more carbon-
carbon double bonds. These unsarurati.:d fatty acids exist in a cis configuration in their nat-
ural state. Food processing can change this cis configuration to a mrns configuration,
creating a tmns unsaturated fatty acid. ;t. "'"El'
Length of the carbon chain iu fut1y acids affects the consistency of a·iglycerides ,1t room
temperatLtre. Spcdfically, long-chain saturated fatty acids (grcarc.>r than or equal to 12 car- Advertisements often claim that fats are bad.
bons) form solid \•arieries at room rcmperauu-e, whereas medium-chain (6 ro 10 carbons) Your classmate Mike asks, "If fats ore so bod
and shorr-chain (less than 6 carbons) sarnrated fatty acids form liquid varieties at room for us, why do we need lo hove any in our
temperature, as do rriglyccridcs composed of monounsarurarcd and polyunsaturated forty diets?" How would you answer him?
acids.
If a doubk bond first occurs starting ar the th ird carbon from the methyl (- CH3 ) end
of the carbon chain, the fatty acid is an omega-3 fatty acid. Ir a double bond first ocmn,
starting at the sixth carbon, ir is an omega-6 fatty acid. Because humans can 'r synthtsiLc
omcga-3 and omega-6 fatty acids, which perform 'ital functions in d1e bod)' when made
into various eicos:moids, rhey are designated esse11ti11/ frmy acids, indicating that the) must
be included in rhe diet to maintain he<tlth. Eicosanoids made from omega-3 forty acids re-
duce blood clotting and inflanumtion compared to those made from omcga-6 fort)• acids.
I Triglycerides
Fats and oils in foods are mostly in the form of rriglyccridcs. The same is rrue for furs
found in body structures. Some fatty acids arc transported in the bloodstream attach<.:d
to proteins, but most fatty acids do not exisr in the body as such. lnsread, they form
into triglycerides. 22
Triglycerides contain a simple t hree-car bon alcohol, glycerol, which serves as a
backbone for Lhc three attached fatty acids. A fatty acid is auached to each of the three
hydroxyl groups (-OH) of glycerol. Three water molecules arc released in the process esterificotion The process of attaching fatty
of bonding thret fatty acids lo glycero l (Figu re 6-7). Note rhar triacylglyccridc is the acids to o glycerol molecule, creating on ester
bond and releasing water. Removing a fatty
chemical name of the molecule, because ncyl refers to a fatty acid that has lose ics hy-
acid is called deesterificalion; reattaching o
droxyl group, ,111d a bydro:-..·yl group is lost when each fatty acid attaches to glycerol. fatty acid is coiled reesterification.
The bonds between glycerol and each fatty acid are calkd c.<tel" bo11ds. The process
of chemically attaching fatty acids ro glycerol is called csterification . T he release of diglyceride A breakdown product of a
fatty acids from glycerol is called tiecster~fication. triglyceride consisting of two fatty acids
By breaking off (deestcrifying) one of the fatty acids of a triglyceride molccuk, a bonded lo o glycerol backbone.
diglyceride lglyccro\ with rwo attached forty acids) is fo rmcd. The dccstcrification of rwo monoglyceride A breakdown product of a
of the fatty acids on a triglyceride produces a monoglyceridc (glycerol with one attached triglyceride consisting of one fatty acid bonded
forty acid ). Free futl)' acids, monoglycc1ides, and glycerol-but nor triglycerides-can lo a glycerol backbone.
cross cell membranes becausi.: of their smaller sizc. 14
200 Chapter 6 lipids
Figure 6-7 I Forming a triglyceride via

esterificotion. This process yields water as a by- H 0 H 0
product as ester bonds ore formed. The R I
H-C-OH
I
HO-C-R
I II
represents the fatty acids. H-C - O-C - R + H20
I ~
H-C-OH + H O - C - R - - - + - H -C - O - C - R +Hp
I Ii
1 ;·-----; ~ I Ii
H-C-,OH HO-C - R H- C - 0 -C-R+HO
I L______ J I 2
H H
Ester bond
Glycerol + 3 fatty acids Triglyceride + 3 H20
During digestion, enzymes in the small intestine eventually break down the triglyc-
erides in the foods to free fatty acids and monoglycerides; oaly a small portion of di-
etary triglycerides is broken down completely to free fatty acids and glycerol. 14 After
the free fatty acids, monoglyceridcs, and any free glycerol enter the intestinal cells,
most of these components are rebuilt into new triglycerides (see the section in this
chapter titled Fat Digestion and Absorption). The reattachment of fatty acids to glyc-
erol is called reesterijication. Every time a triglyceride enters or leaves a cell, it must also
be deesterified; after entering a cell, the free fatty acids arc reesterified into triglyc-
erides. Thus, the body must continually break down and rebuild triglycerides. 2 2
Roles of Triglycerides in the Body

Many key functions of fat in the body use triglycerides. Triglycerides contribute to en-
ergy storage, insulation , and transportation of fat-soluble vitamins.
Providing Energy for the Body

When at rest or during light activity, the body
Triglycerides conraincd in the diet and stored in adipose tissue provide tl1e fatty acids
uses mostly fatty acids for fuel.
tl1at are the main fuel for muscles while at rest and during lighr activity. 22 Only in en-
durance exercise, such as long-distance running and cycling, or in short bursrs of in -
tense activity, such as a 200-meter run, do muscles oxi.d ize a lot of carboh)rdrare in
addition to futty acids supplied by triglycerides. Other body tissues also use fatty acids
for energy. Overall, about half the energy used by the entire body at rest and during
light activity comes from fatty acids. On a whole-body basis, tl1e use of fatty acids in
skeletal and cardiac muscle cells is balanced by the use of glucose in the nervous sys-
tem and red blood cells. Recall from Chapter 4 that cells also need carbohydrate to ef-
ficiently process fatty acids for fuel.
Storing Energy for later Use

Nucleus
We store energy mainly in the form of triglycerides. 22 The body's ability to store fat is
essentially limitless. Its fat storage sites, adipose cells, can increase about 50 times in
Cell weight. If tl1c amount of fat to be stored exceeds rhe ability of the cells to cxpand, thc
membrane-
body can form new adipose cells. (This topic is discussed further in Chapter 13. )
An important advantage of using triglycerides to store energy in the b od~r is that
Fot droplet~ they arc energy dense. Recall tl-iat these yield, on average, 9 kcal/g, whereas proteins
and carbohydrates yield less than half tl1ar much. In addition, triglycerides arc chemi-
Adipose cell cally very stable, so they are not W<.ely to react wirh other cell constituents, making
www.mhhe.com/ward lawpers7 201
them a sate form for storing energy. Finally, when we store n·iglyccrides in adipose cells, nabsorbed fatty acids also con bind miner-
we store little else in terms of energy-yielding compow1ds; adipose cells contain about als, such as calcium and magnesium, and
80% lipid and onJy 20% water and protein. 22 In contrast, imagine if we were to store draw them into the feces for elimination. This
energy as muscle tissue, which is about 73% •.vater. Body weight linked ro energy stor- can harm mineral status (see Chapter 11 ).
age would increase dramatically.
Insulating and Protecting the Body

The insuJating layer of fat just beneath the skin is made mostly of n·iglyceridcs. Fat tis-
sue also surrounds and protects some organs-kidneys, for example-from injury. We anorexia nervosa An eating disorder involving
usua!Jy don't notice the important insulating function of far tissue because we wear o psychological loss or denial of appetite
followed by self-starvation; related in part lo a
clothes and add more as needed. But a layer of insulating fat is quite apparent in ani-
distorted body image and to various social
mals, particularly those in cold climates. Polar bears, walruses, and whales all build a pressures commonly associated with puberly.
thick layer of fat tissue arotmd d1emselves to insulate against cold-wcatl1er environ-
ments. The e>.'tra fat also provides energy srorage for times when food is scarce. lanugo Downlike hair that appears after a
People wid1 anorexia nervosa often lose 25% or more of body weight and become person has losr much body fat through
about as fat free as is biologically possible. In turn, they lose the insulating property of semistorvotion. The hair stands erect and traps
fat srorage. [n place of the layer of far tissue under d1e skin, people with anorexia ner- air, acting as insulation for the body to
compensate for the relative lock of body fat,
vosa often develop downy hair, called Lanugo, aJl over their body. These hairs insuJate
which usually functions as insulation.
me body by standing up and trapping warm air.
Transporting Fat-Soluble Vitamins

Triglycerides and other fats in food carry fut-soluble vitamins to the small intestine and
aid their absorption. If the small intestine is diseased, however, it may not be able ro
adequately digest and absorb fat from foods. When this happens, the unabsorbed fat
carries the fat-soluble vitamins-A, D, E, and K-into the large intestine. From there,
they are eliminated in the feces, and the body loses the benefits of the vitamins. Tf the
disease doesn't resolve quickly, medical attention is necessary.
People wl10 absorb fat poorly, such as those with me disease cystic fibrosis, are also
at risk for deficiencies of fat-soluble vitamins. A similar risk accrues from taking min-
eral oiJ as a laxative at mealtimes. Because the body cannot digest or absorb mineral
oil, tl1e w1digested oil carries the fat-soluble vitamins from the meal into the feces,
where d1ey are eliminated.
Peanuts ore a source of lecithins, as are wheat
germ and egg yolks.
Phospholipids
Phospholipids are another class of lipid. Like triglycerides, they are built on a
backbone of glycerol. However, at least one fatty acid is replaced wim a com- H 0
pound containing phosphorus (and often other elements, such as nin·ogen). 14 I II
H-C-0-C -fatty acid
Many types of phospholipids exist in the body, especially in the brain. They
form important pans of cell membranes. The various forms of lecithins are
common examples of phospholipids. These are found in body cells, where they I ~
participate in fat digestion in the intestine. Peanuts contain lecithins in abtm- H-C-O~C-fatty::i~------=:~l~n: \
dance, as do liver, wheat germ, soybeans, and egg yolks. It is not necessary to
constune phospholipids, such as lecithins, in the diet because the body can syn-
•o •H H cH3 \ t
thesize tl1cm and use them when and where they are needed.
l II
Etl
H-c-o-+P-O-l-C-C-N-CH3)
\ lI I I
Cen membranes are composed prin1ari.ly of phospholipids. A cell membrane I :I :I 1 I I
looks much like a sea of phospholipids wim protein "islands" (review Figme C-1 H :0 e :H H CH3
in Appendix C). Among their many roles, the proteins form receptors for hor- ( I I I
Glycerol '- L.----------------J
~Phosphate
mones, function as enzymes, and act as n·ansporrers for nutrients. About 5 to
15% of cell membrane fatty acids is made up of arachidonic acid. This serves as
a source for eicosanoid synthesis.21 (Some cholesterol is also present in the cell
membrane.)
Some phospholipids, sucb as lecithins, ftmction as emulsifiers. These allow
fat and water to mix. By breaking fat globules into small droplets, emulsifiers
enable a far w be suspended in water. Herc's how the process works: The forty acid
emulsifier A compound that con suspend fat in
water by isolating individual fat droplets using ends of lecithins attraa fal. The phosphoru1, and nitrogen at the other end ofk:cithini.
a shell of water molecules or other substances form an area contain ing positive and negative charges. This area attracts water. Because
to prevent the fat from coalescing. water is :mracrcd to the charges on lecithin , this pare of lecithin is called h ydrophilic,
w hich means " loving water." The parts with furry acids are called hydrophobic, because
bile acids Emulsifiers synthesized by the liver rhcy don'r a[tracc (rhey "fear") water.
and released by the gallbladder during
When <Ul emulsifier is mixed with oil and water in rhc proper proportions, it forms
digestion.
spheric.11structmes in which the h ydrophobic parts of the emulsifier molecules :ue ori-
micelles Water-soluble spherical structures ented coward rhe interior and the hydrophilic pares toward the exterior (Figure 6-8).
formed by lecithin and bile acids in which the Tn this way, the emulsifier acts as a bridge between the oil and water by forming tiny
hydrophobic ports of the molecules face inward oil droplets surrounded by thin shells of water.
and the hydrophilic ports face outward. lipids The body's main emulsifiers are rhe lecithins and bile acids, which are produced b~·
enclosed within micelles do not separate out the liver and released into the small intestine via the gallbladder during digestion. By
into on oily layer os they normally do when
breaking up the fat globules, the emulsifiers create more fat surface for fat-digesting
mixed with water.
enzymes ro act on. These very stable emulsified products are called micelles (sec the
section in this chapter titled Digcstion). 1-1
Oil emulsified in water
Hydrophilic
head of lecithin
attracts water
Oil to
hydrophobic Hydrophobic
core toils of lecithin
attract lipid
Lecithin plus Water around
agitation hydrophilic
shell
Hydrophilic
portion
of lecithin
----::+-- Hydrophobic
P?rtion
of lecithin
Figure 6·8 I Emulsification and emulsifiers. Emulsifiers organize oil and water into droplets of oil surrounded by water. The emulsifier molecules form a
bridge between the oil and water molecules, isolating one from the other. In the droplet, oil enters the central core, while waler surrounds the core. The
emulsifier molecules ore sandwiched between the two. Formation of such emulsions is o key step in digestion of dietary fat and is important in the manufacture
of certain food products, such as mayonnaise and cokes.
I ii,;;:· I - •r
' • r Testosterone
=' ,; 1
''
Sterols
Stcrols are the last class of lipids this chapter covers. T heir characteristic multiringcd
structme makes them different from the other lipids already discussed. Consider the
sterol cholesterol. This waxy substance doesn't look like a triglyceride-it doesn't have
a glycerol backbone or any fatty acids. Still, because it doesn't readily dissolve in water,
it is a lipid. The main building block for the s~rnthesis of cholesterol in the body is
aceryl-CoA, a derivative of the two-carbon fatty acid acetic acid. (Synthesis of longer
fatty acids, triglycerides, and phospholipids also makes use of accryl-CoA.) 23
Cholesterol forms part of some important hormones, such as the estrogens, testos-
terone, and a form of the active vitamin D hormone-namely, l,25(0H2 ) vitamin D.
Cholesterol is also the precursor of bile acids, which arc needed for fat digestion.
Finally, cholesterol is an essential stmctural component of cell membranes and the par-
ticles that transport lipids in the blood, as cliscussed in the next section. 17 The choles-
terol content of the heart, liver, kidney, and brain is qu ire high, reflecting its critical
role in these organs.
Cholesterol is made by body cells (l:\vo-th irds of total daily body exposure) and is
consumed in the diet (about o ne-third of total daily body exposure). Each day, our
cells produce approximately 875 mg of cholesterol. Of this, about 400 rng is used to
make new bile acids to replenish those lost in the feces and about 50 mg is used to
make steroid hormones. With respect to diet, we consume about 180 to 325 mg of
cholesterol per day from anjmal-derived food products, with men consuming the
higher amount compared to women (Table 6-2). Of that, we absorb about 40 to 60%.
There is no need to consw11e cholesterol per se, because body cells cru1 make all that
they need.7
Plants do not produce cholesterol. When comp:in ies market their bottles of \'eg-
erablc oil with labels that say "cholesterol-free," they're trying to persuade uninformed
consumers to buy their brand. In fact, all brands of vegetable oil arc cholesterol-free. Eggs ore the principal source of cholesterol in
Ald10ugh plants do nor make cholesterol, they do make other sterols. 17 Ergosterol, for the North American diet. The Food and
example, can form a type of vitami n D. Plants also make a stcrol called sitostanol, Nutrition Boord suggests limiting intoke of this
ond other high-cholesterol foods.
which is now incorporated into Take Control margarine. Eating such a margarine in-
trodm:es a higher-than-usual amount of srcrols into d1c smalJ intestine, where die plant
sterols can interfere with the reabsorption of cholesterol and bile acids (which arc made
from cholesterol) and, hence, reduce the risk of cardiovascular disease. 18 Although
srudies show that sterol-rich margarine is effective in lowering blood cholesterol, die
product is quite expensive.
Table 6·2 I Cholesterol Content of Selected Foods in Ascending Order

Food Amount Cholesterol (mg) Food Amount Cholesterol (mg)
Fat-free milk I cup 4 Oysters, salmon 3 oz 40
Mayonnaise I tbsp 10 Clams, halibut, tuna 3 oz 55
Butter 1 pol 11 Chicken, turkey* (white meat) 3 oz 70
lord 1 tbsp 12 Beef,* pork 3 oz 75
Cottage cheese 1/2 cup 15 Lomb, crab 3 oz 85
Fat-reduced milk (2%) 1 cup 22 Shrimp, lobster 3 oz 110
Holf-ond-holf 1/4 cup 23 Heart (bee~ 3 oz 165
Hot dog 1 29 Egg (egg yolk)* t 210
Ice cream, - 10%fat l/2 cup 30 Liver (bee~ 3 oz 410
Cheese, cheddar* 1 oz 30 Kidney 3 oz 540
Whole milk* l cup 34 Brains 3 oz 2640
•Leading contributors of cholesterol to the North American diet.
tEgg whiles ore cholesterol-free.
Concept I Check
Triglycerides are the major form of fat in the body and in food. They arc used for and
stored as energy, they insulate and protect body organs, and they transport far-soluble \ irn-
mins. Phospholipids have bod1 hydrophilic and hydrophobic parrs and so arc effective
emulsifiers-compounds d1at can suspend fat in watt:r. Phospholipids also form p<u-ts of cell
membranes and various compounds in the body. Cells produce all the phospholipids rhe
body needs. Choksterol, a stcrol, forms part of cell membranes, some hormones, and bile
acids; it is essential to the body. Cholesterol is fow1d in animal products and is syndlesizcd
by body cells; if sufficient amounts arc not ingested, die body makes what it needs.
I Fat Digestion and Absorption

Given the right conditions, about 95% of fat consumed is digested J.nd then absorbed . 14
Digestion
Fat digestion begins in the month and stomach , using the enzymes lingual lipase
(mostly in infancy) and gastric lipase, respectively. 1+ These enzymes break down
1[e -
~ ~-
Fatty acid
Fatty acid
triglycerides containing short- and medium-chain fatty acids, such as tbose found in
milk far into free fatty ;1cids and diglycerides. Because fat may remain in the stomach
for up to 2 to 4 hours, there is an oppor tunity ro digest some of these triglycerides and
c;, m- Fatty acid
~ to absorb the fany acids released through the srom:ich wall. The shore- and medium-
i
Pancreatic chain fatty acids then enter the portal vein. In contrast, Jong-chain fatty acids are not
41 lipase
acted on until tl1C)' reach the small inrestine (Figtu·e 6-9).
~[
4)
u
)..
c;,
0
-
2:-
0
~
~ - Fatty acid
Once the fat reaches the small intestine, the hormone cholecystokinin (CCK) is re-
leased from certain intestinal cells. This hormone stimulates the release of bik from the
c O> gallbladder and lipase from the pancreas. 14 The bile contains bile acids, Jccirhin, and
0 cholesrcrol. The lipase travels dlrough the pancreatic duct ro be mixed with bile in the
~ + 2 free Fatty acids common bile duct; fu1ally, both enter rogethcr into the small intestine. In the small in-
testine, pancreatic lipase contributes ro fat digestion by digesting (specifically hy-
drolyzing) the ttiglyccrides into monoglycerides and free fatty acids. The amount of
[[I Very minor fot digestion

in stomach
IE1J Fat digested mainly

into monoglycerides
and free fatty acids by a
lipase enzyme released
from the poncreas
El Bile mode by the liver It

aids fat digestion and
absorption Ii
I
19 Fat absorbed is mostly

made into chylomicrons
and transferred into the
lymph
~ Less than 5% of
fat normally excreted
in feces
Anus
Figure 6·9 I A summary of fat digestion and absorption. Chapter 3 covered general aspects of this process.
pancreatic lipase released is much greater than what is needed in most circumstances
to digest the fat in a meal. This "overkill" makes fat digestion very rapid and thoro ugh
in the right circumstances, which include the presence of bile acids and lecithin from
the gallbladder and a protein called colipase. Col ipasc is found in pancreatic secretions, colipose A protein secreted by the pancreas
and it functions by ensuring the attachment of lipase to the Lipid droplcr.14 that changes the shape of pancreatic lipase,
Because fat is hydrophobic, it needs a medium that will carry it throughout the iH- faci litating its action.
testinal tract. Bile acids help do rhis by emulsifying the fatty substances in the small in-
testine into micelles, as previously discussed. Emulsification improves digestion and
absorption because as large fa t globules arc broken down inro smaller ones, the rotal
surfuce area for lipase action increases (Figure 6-10).J.J.
With regard ro phospholipid and cholesterol digestion, phospholipase enzymes
from the pancieas and glandular cells in the wall of the small [nrcstine digest phos-
pholipids. The eventual products are glycerol, fatty acids, phosphoric acid , and re-
maining constituents such as choline. Cholesterol esters (cholesterol with a fatty acid
attached) are broken down ro cholesterol and free fatty acids. l 7
Lorge fat droplets enter Lorge

small intestine aher meal fat
droplet
-~-- Bile acids
from
gallbladder
[fl Bile acids and lecithin
emulsify fats into smaller
particles, edseciolly
the bile oci s
I
Lipase
from
pancreas
EJ Lipase breaks dawn fat EJ
into fatty acids and
monoglycerides Q Most bile acids
;, eventually return
to gallbladder
g
W1 Monoglycerides and fatty
acids ore absorbed
throut villi via micelles
and t en re·form into
l
triglycerides
Monoglycerides Fatty acids )
-~
Triglycerides aggregate
and are combined with
cholesterol, protein, and
phospholipids to form
chylomicrons
f - Cholesterol
Phospholipids --\;,) ~
\ r Protein
Figure 6· 1 0 I A simplified look ot absorption of triglycerides mode up of long-chain fatty acids. These long-
choin fatty acids, which primarily form monoglycerides and free fatty acids, ore absorbed through the use of bile
acids and re-formed into triglycerides in the absorptive cells. The triglycerides ore then formed into chylomicrons
and enter the lymphatic system. Note that short- and medium-chain fatty acids for the most port poss directly into
the portal circulation (not depicted). Under normal conditions, about 95% of dietary fat is absorbed, primarily as
chylomicrons. Only o small portion is found in the feces.
Absorption
The ljpid content of rhe micelles is absorbed into the brush border of rhe absorptil'c
cells lining the duodenum and jejwmm. Through this process about 95% of dietary fat
is absorbed. 14 The -.:arbon chain length of furry acids and monoglyccridcs absorbed then
affects their fate after absorption. If a fatty acid is a short- o r medi um-chain vari<.:t)' (less
than 12 carbons), it is water-solu ble and probably travels out of the absorptive cell {en-
tcrocyte) and through the portal vein connected to the liver. If tht: futt)' acid is a long- Centrifuge tube
chain variety (12 or more carbons), it is first re-formed into a triglyceride molecule in
the absorptive cell. After further packaging (described in the next section), it enters cir-
culation via the lymphatic system carrying with it fat-soluble vitamins and absorbed
cholesterol (review Figure 6-10).1+ Chylomicrons
The leftover bile acids (and some of the cholesterol released in the bile) arc reab-
sorbed in the ileum and returned to the liver (by the portal vein) to be used again in
fac digestion (about 98% of bile acids <u·e recycled; on ly 1 to 2% arc eliminated in rhe
feces). I+ RecaU from Chapter 3 that this recycling is termed cnterohepatic circulation.
Using medicines thar block some of this reabsorption of bile tlcids is one way to a-eat
high blood cholesterol. The Liver takes cholesterol from the bloodstream to form re- LDL
placement bile acids. Soluble fiber in the diet can also bind tO bile acids ro produce the
same effect. 7
HDL
I Fats Carried in the Bloodstream

The incompatibility of fat and water presents a challenge in transporring fats rJ1rough One way lo measure the amount of
rJ1e watery media of blood and lymph systems. chylomicrons, VLDL, LDL, and HDL particles in
the bloodstream is to centrifuge the serum
portion of the blood at high speed for about
24 hours in o sucrose-rich solution. The
Carrying Dietary Fats Utilizes Chylomicrons lipoproleins settle out in the centrifuge tube
Once the various dietary fats are digested and absorbed imo the small intestine cells, based on their density, with chylomicrons at
most of the by-products of digestion-glycerol, monoglycerides, and fatty acids-are the top and HDls at the bottom.
re-formed into niglycerides. They are then packaged into lipoprotein particles-large
droplets of lipid surrounded by a rJ1in shell of phospholipid, cholesterol, and protein
(Figure 6-11 ). Tbe lipoprotein particles producl!d by intestinal cells are called chy- lipoprotein A compound found in the
lomicrnns.22 The shell around a chylornicron allows the lipid it is carrying to float bloodstream containing a core of lipids with a
freely in the water-based blood. Some of the proteins present-name!)', apolipopro - shell composed of protein, phospholipid, and
teins-also help other cells identify this particle as a cbylomicron. cholesterol.
After being assembled in intestinal cells, chylomicrons enter the lymphatic system
and traYel to the thoracic duct, which is located along the spinal column. This duct chylomicron Lipoprolein made of dietary fats
opens into a large ,·ein in the neck caUed the subclavian vein. Chylomicrons enter the surrounded by a shell of cholesterol,
phosphollpids, and protein. Chylomicrons are
general circulation of rhe bloodstream at d1at point (see Figure C-5 in Appendix C for
formed in the absorptive cells (enterocytes) of
a ,·iew of lymphatic circulation). the small intestine aher fat absorption and
Once chylomicrons enter d1e bloodstream, the triglycerides in the chylomicrons are travel through the lymphatic system to the
broken down by lipoprotein lipase into fatty acids and glycerol. This enzyme is at- bloodstream.
tached to the inside wall of blood vessels. Muscle cells, adipose cells, and od1er cells in
the vicinity then absorb most of the fatty acids. 22 Cells can immediately use absorbed opolipoprotein A protein attached to the
fatty acids for energy needs, or they can re-form them into triglyceride::. and srore them
surface of a lipoprotein or embedded in its
outer shell. Apolipoproteins con help enzymes
,1s such. Muscle cells tend to metabolize fatty acids, whereas adipose cells tend to store function, act as a lipid-transfer protein, or assist
than. (Table 6-3). in the binding of a lipoprotein to a cell-surface
After a person eats a meal, the whole process of clearing chylomicrons from the receptor.
blood via lipoprotein lipase activity takes about 2 to 10 hours, depending in part on
fat content. After 12 to 14 hoLu-s offasting, the chylomicrons should be total!~' absent lipoprotein lipase An enzyme attached to the
from rhe bloodstream. People should fast for 12 to 14 hours before having certain outside endothelial cells that line the capillaries
blood tests to ensure d1at chylomicrons, whose presence could affect rhe results, have in the blood vessels; it breaks down
triglycerides into free fatty acids and glycerol.
been cleared.
Transporting Lipids Mostly Made by the Body Uses Very·Low-

Oensity Lipoproteins
The liver produces some fut and cholesterol. 22 The sou rce of the needt!d carbon, hydro-
gen, and energy to make such substances as glycerol, forty acids, triglycerides, .md cho-
lesterol includes the carbohydrate and protein the liver rakes up from d1e bloodstream.
Figure 6· 11 I Structure and composition of

lipoproteins. This lipoprotein structure allows
fats to circulate in the bloodstream. Note that
for each class of lipoprotein, there are various
subclasses of slightly different composition,
including those based on their different
apolipoproteins.
Free cholesterol
Cholesterol bound
to fatty acids
Chylomicron.
LDL
75%~
50%
75%~
50%
25% ...___~-~~-~}~.--..
~- 25% .____._)----''---- .._-'-n_....__
#."fr ......# ~~ &.:$.

'O~
~ ·~ ~
~'G
'6° ddl ~~ '..,_~
"'>~ ,(J '~
~ Q ct 1$0)
Table 6·3 I Composition and Roles of the Major Lipoproteins in the Blood
Lipoprotein Primary Component Key Role
Chylomicron Triglyceride Carries dietary fat from the small intestine to cells
VLDL Triglyceride Carries lipids both taken up and made by the liver to cells
LDL Cholesterol Carries cholesterol made by the liver and from other
sources to cells
HDL Protein Contributes to cholesterol removal from cells and, in
turn, excretion of it from the body
Absorbed Fot Chylomicron

travels as remnant to Fat to body
chylomicron liver tissues via
lipoprotein
lipase
Chylomicron
Fat to body
cells ofter
breakdown
by lipoprotein
lipase
LDL taken up
by receptor
pathways
(in body cells) I
LDL
HDL arises from the liver LDltoken u~

and intestine and buds off by scavenger
other lipoproteins. HDL pathways (in
transfers cholesterol from blood vessels),
body cells mos~y lo other especially
lipoproleins For disposal oxidized LDL
Figure 6 - 1 2 I Lipoprotein interactions. (l ) Chylomicrons carry absorbed Fat to body cells. (2) VLDL carries lot taken up from the bloodstream by the liver, as
well as any fat mode by the liver, to body cells. (3) LDL arises from VLDL and carries mostly cholesterol to cells. (4) HDL arises from body cells, mostly in the
liver and intestine as well as from particles that bud off the other lipoproteins. HDL carries cholesterol from cells to other lipoproteins and to the liver for
excretion.
*lntermediote Den,ity Llpoprotein .
However, free fatty acids taken up from the bloodstream by the liver are the major
source for triglyceride synthesis. 22 The liver coats the cholesterol and triglycerides that
coUcct, including some raken up from the bloodsa-cam, with a sheU of protein and
lipids. This process produces what is called a very- low-density lipoprotein (VLDL) very-low-density lipoprotein (VLOL) The
fraction (Figure 6 -12). lipoprotein created in the liver that carries both
When the VLDL leaves the Liver, the enzyme lipoprotein Hpasc on d1e blood vessels the cholesterol and the lipids taken up from the
breaks down the triglyceride in the VLDL into fatty acids and glycerol. Again, fatty bloodstream by the liver and those that ore
acids and gl)'cerol are released into the bloodstream and are taken up by the body cells. newly synthesized by the liver.
Because fats are less dense than water, the VLDL becomes proportionately denser as receptor pothway for cholesterol uptake A
triglyceride is released. Much of what evenmally remains of the VLDL fraction be- process by which LDL is bound by cell receptors
comes particles called low-density lipoprotein (LDL) fraction. LDL is composed pri- and incorporated into the cell.
marily of cholesterol.22
LDL particles are absorbed from the bloodstream by receptors on cells, internal-
ized, and broken down. Most LDL is taken up by recepmrs oo liver cells.22 Diets low
in saturated fat and cholesterol encomage th.is process, whereas diets high in those
lipids can reduce LDL uptake by the Uvcr. 7 The cholesterol and protein parts absorbed
then are transported throughout the cell. By this process, caJJed d1e receptor pathway
for cho lesterol uptake, cells take up some of tbe building blocks necessary for cell
growth and development (Figure 6-13).1 4
Figure 6 · 1 3 I Transport of LDL into cells. LDL

receptors capture circulating LDL and release ii
inside the cell to be metabolized. Once free of
their load, LDL receptors return lo the cell
surface to awoil new LDL.
LDL receptor
"Pit" on cell surface/
Cells have pits on the surface, which contain LDL receptors.
I t appears that saturated fatty acids promote

on increase in the amount of free cholesterol
(not attached lo fatty acids} in the liver, whereas
unsaturated fatty acids do the opposite. As free
cholesterol in the liver increases, it causes the
liver to reduce cholesterol uptake from the
bloodstream, contributing to elevated LDL in the
blood. (Trans fatty acids ore thought to act in the
same ways as saturated fatty ocids.)14
LDL binds to the LDL receptors in the pits.
LDL
LDL receptor
Endocytotic vesicle
The LDL, bound to LDL receptors, is taken into the cell by endocytosis.
scavenger pathway for cholesterol uptake A A second process, called the scavenger pathway for cholesterol u ptake, can :i lso
process by which LDL is taken up by scavenger remove LDL from the circLLlation. T h.is pathway is carried out by certain "scavenger"
cells embedded in the blood vessels. white blood cells, whicb lca\'e the bloodstream and buJ·y themselves in blood vessels.
These scavenger cells detect modified LDL (e.g., oxidized LDL) wit hjn the \'csscl
oxidized LDL LDL thot hos been damaged by
free radicals. Such damage is seen both in the
wall , engulf it, and then digest it. Once within the scavenger cells, the oxidized LDL
lipids and proteins that make up this gene.rally is prevented from reentcting the bloodstrcam.24 O ver time, cholesterol
lipoprotein. builds up in the scavenger cells, and mo re so when the amount of LDL in the blood-
stream is excessi\'e.
When scavenger cells have collected and deposited cholesterol for many years at a
heavy pace, cholesterol builds up on the inner blood vessel walls-espcciall) in arreries-
and plaque deYelops (see Figure 6-14 in the Nutrition Focus). Diets rich in saturated plaque A cholesterol·rich substance deposited
fat, tnms fat, and cholesterol encourage this process. 7 The plague eventually mixes in the blood vessels; it contains various white
with connecti,·e tissue (collagen) and is then covcn::d with a cap of smooth muscle cells blood cells, smooth muscle cells, connective
and calcium. Atherosclerosis, also referred to as bnrde11i11g of thi· nrtaies, develops as tissue (collagen), cholesterol and other lipids,
plaque thickens in the vessel. This thickening cvenruall)' chokes off the blood supply and eventually calcium.
ro organs, setting the stage for a hearr attack and other problems, or it breaks apart atherosclerosis Buildup of fatty material
and lc.1ds to clor formation in this or another artery. Dr. Bernhard Hennig covers this (plaque) in the arteries, including those
ropic in more detail in the Expert Opinion in this chapter. surrounding the heart.
A final critical parricipanr in rhis extensive process of fut transport is high-density
lipoprotein (HDL). Its high proportion of protein makes it the heaviest (densest)
lipoprotein. The liver and intestine produce most of the HDL in 1.he blood . lr roams
the bloodstream, picking up cholesterol from dying cells and other sources. HDL do-
nates the cholesterol co other lipoproteins for transport back to the liver to be ex-
creted. Some HDL travels directly back to the liver. Another beneficial function of
HDL is that it blocks oxidation ofLDL. 22
Many studies demonstrate that the amount or
HDL in the bloodstream can closely
predict the risk for cardiovascular disease. The risk increases witb low HDL because lit-
tle blood cbolesrerol is transported back ro the li,•er and excreted. Wo1m:n tend to have
high amounts of HDL, especially before menopause, whereas low ,1111ounrs are more menopause The cessation of menses in
common in men. women, usually beginning of about age 50.
Because high amounts of HDL slow the development of cardiovascular disease, any
cholesterol carried b~· HDL can be considered "good" cholesterol. By convention,
then, cholesterol carried by LDL would be "bad" cholesterol because high amounts of
LDL speed the development of cardiovascular disease. Still, LDL is only a problem
when it is too high in the bloodstream; lower amounts an: needed as part of routine
body functions. 14
wo approaches hove been shown to cause

Concept I Check regression of atherosclerosis in the body.
In the mouth and stomach, lingual and gastric lipase, respecrh·el)', break down short- and One employs a vegan diet ond other lifestyle
medium-chain triglycerides into smaller components. A minor :imount is absorbed through changes that ore port of the Dr. Deon Ornish
the stomach wall. All end up in the porrnl vein and arc transported to rhc liver. In the small program. The other employs aggressive LDL low·
mrcsrine, the enzyme pancreatic lipase digests long-chain triglycerides inro monoglyccridcs ering with medications.
and free futty acids. These breakdown products diffuse into the absorptive cells of the small
intestine and arc mostly rcsyntl1esized into triglycerides. The bloodstream carries absorbed
dietary fat as ch)•lomicrons.
Lipid synthesized by the liver is carried in the bloodstream as very·IO\\'·density lipopro·
vegan A person who eats only plant foods.
tein (VLDL). Once a VLDL has most triglyceride~ remo\'ed by lipoprou:in lipase, it even·
tllally becomes low-density lipoprotein (LDL), which is rich in cholesterol. LDL is picked
up by receptors on body cells, especially liver cells. Scaveng<.:r cells in tl1e artcries may do
the same, speeding the development of atherosclerosis. This is especially true for any LDL
that has been modified (e.g., oxidized). High·densit)' lipoprotcin ( HDL) picks up choles-
terol rrom cells and transports it primarily to otht:r lipoprotcins for t:ventual transport back
to the liver. HDL also decreases LDL oxidation, thcreb\• reducing LDL in athcrosclcrotic
plaque. Elevated amounts of LDL in the bloodstream is a major risk factor associated 11·irh
cardiovascular disease, as is low amounts of HDL.
Lipoproteins and Cardiovascular Disease
A heart attack can Strike with the sudden force a or them had atherosclerosis in their arteries. This find
sledgeh.rn1mer, with pain radiating up the ned. or mg indicates that atherosclerosis buildup can begin
down the arm. It can sneak up al night, m.1s· in childhood, alchough it usu,111) goes undetected
qucrading as indigestion, \\ith slight pain or pre~ for quite some time.
ordiovosculor disease typically in· sure in the chest. Manv rime\, the S} mptonl\ .m: so Coronar~· heart disease and strokes arc Jssoci
volves the coronary orteries and thus subtle in \\'Omen thaL ir often is too I.He once she or .ncd with inadequate blood circulation in the heart
is frequently termed coronary heart dis· the health professional rcali7es that a heart mack i~ .111d brain. Blood supplies the heart muscle and
ease (CHD) or coronary artery disease raking (or has recently rnken ) place. ff then: is .rny brain- and other body organs-with oxygen and
{CAD). Because the buildup of atheroscle- suspicion at all that a heart attack is taking plJce, nutrients. When blood flow via the coronar)' .mer-
rosis slows blood flow in the arteries, the the person should lim chew an aspirin ( 32$ mg) its surrounding the heart is interrupted, Lhc hearr
disease is also called ischemic hear/ dis· thoroughly ,111d then call 911. Aspirin helps reduce n111scle can be damaged. A heart ,utack, or
ease {IHD) lschemia represents an ob- tJ1e blood dorLing 1hac prccipitares a he.m att.1ck. myocardial infarction, may resulr (Hgurc 6 14 ).
struction of blood Aow. The general term Trpical warning sign~ an:: This ma) cause the heart ro beat irregular\\ or w
for this obstruction is ste nosis. sLOp ,1ltogether. About 25% of people do nm s11r
• lmense, prolonged chest pain or prcmirc, \omc
\i\'c their first heart attack. If blood Am' to p.trts ol
times r.1diaring to other pans of rhe upper bod~
Lh1.: brain is interrupted long enough, p.1rt of the
ischemia lock of blood flow due to (men and women )
brain dies, causing a cerebrovascular accidenc
mechanical obstruction of the blood • Shormess of breach men and women )
(CVA), or stroke. When a strokt: c.m'>cs loss of
supply. mainly from arterial narrowing. • Swearing (men and women )
muscle control, death may occur.
• NauSl":t and \"Omiting (especiall) women )
stenosis Narrowing or stricture of o duct ~lore than 95% of all bean Jtta1.:ks arc c.msed
• Dizziness (especially women)
or canal. by blood dots that stop blood flo,, to the heart or
• \Veaknc~ (men and women)
myocardial infarction Death of port of brain. Continuous formation and breakdm\ 11 of
• Jaw, neck, and shoulder pain (espcci,111) '' rnrn:n )
the heart muscle blood clots in blood \'esscls is •l norm.ii prcice".
• Irregular hearrbcat (men and women )
I Im\ C\er, in areas where athcrosclemcic plaque lus
cerebrovoscular occident (CVA) Death of CardiO\·ascul.ir disease (C\'D ) i~ the m.11or buih up, clots are more likely w form a block.lgc,
port of the brain tissue due typically to a killer of North :\mcric.rns. Each yc.1r .1bo11t diminishing or cutting off the supply of blood w
blood clot; also termed o stroke. 500,000 people die of coronary he.m disease in the the .merics thar sen·e the heart (coronary anerb)
United Swes, abom 60% more th.in die of cancer. or brain (carotid arteries). Acwally, the mosr d,111
The figure ri~e~ co .umost 1 million ir srrokes .rnd genius lesions aren't the large, advan1.:ed ones but
other cin:ulatory diseases arc included in the global the smaller, unstable lesions covered by .1 thin fi.
ealthy People 2010 hos set o goal
H of reducing death from coronary
heart disease by 30% compared with
term cnrdio11nscular tiiscnse. About 1.5 million peo-
ple in the United States each year have a heart .ll·
brous cap. In essence, heart attacks g.encrall\ .m:
caused not b) total blockage of the coronary .mer
1
tack. The overall male-to-ICmaJc ratio for he.in ies lw plaque but by disruprion of a parri.11 block-
today's incidence.
disease is abom 2 :1. Women gener,111} hig. about age, k.iding to e\•enrual dot formarion.
10 year\ behind men in dc\'elop111g tht disease. Atherosclcrocic plaque is probably first de
Still, it evenruall) kill!. more women than an) other posited w repair injuries in a\ esscl Limng. It <level
disease-twice as man) as cancer. :\nd for c.1d1 per ops especially at points where an ,1rrcry branchc\
son in North America ''ho dies of cJrd1m ascul.1r imo two arteries. ~I uch stress is placed on .rn artcn
disease. 20 more (o\er 13 million people ) han: .u rhese points from the changes in blood Ihm rh.u
symptoms of chc discase. cx:<.:ur at the branch poior. l11e nt/Jao in nt/Jfl'o>cfr·
rosis comes from the Greek and means "gruel or
p.t~Lc." This process of damage repair 1s part of the
Development of Cardiovascular 1niti.uion phase of atherosclcrosi~.
homocysteine An amino acid not used
in protein synthesis, but instead arises Disease fhc damage chat ~cam plaque fornurion
during metabolism of the amino acid can be caused by smoking, diabetes, hypcrren,ion,
methionine. Homocysteine is likely toxic The sympwms of c,udim ascul,1r d1se.1se lb·clop homocystcioe (likely, but not a nujor factor ), .md
to many cells, such as those lining the over many )'Cars ,md oli:cn do noL hecome obnot1\ LDl itscl[4.\l,25 \'iral and bacterial inlccnons arc ,1bo
blood vessels. until old age. Nonetheless, .1utopsies of .1d11h\ implicated as wdl as ongomg blood vessel intl.1mm.1·
under 20 years of ag1.: ha\'e shown that nlJl1\ of uon. tl (There is a rest for this ongoing inflammation
2 12
left coronary
artery
Figure 6 · 1 4 I The rood lo o heart

attack. Injury to on artery wall begins
the process. This is followed by o
progressive buildup of plaque in the
artery walls. The heart attack represents
the terminal phase of the process.
Blockage of the left coronary artery by o
blood clot is evident. The heart muscle
that is served by the portion of the
coronary artery beyond the point of
blockage locks oxygen and nutrients
and is damaged and may die This
damage con lead to o significant drop
Complete in heart function and often total heart
blockage
failure.
lc\•idenced by elevated C-rcactive protein in the megadoses of antioxidant viLamin\ such .is vitamin number of large-scale trials testing
blood]). Note also th.It rhesc plaques Llll develop E ro do the same thing is controversial. Chapt1:r 9 the hypothesis that megodose vita·
in artc1ies throughom the body, not jusr in rhe "~ II discuss this controversy in detail. Currrntly, the min E therapy (e.g., 600 IU every other
coromry arteries. This explains the use of tht: rerm American Heart Associ.uion docs not support the use day) con help prevent cordiovosculor dis·
cnrdior>nsrnlnr dismsi: to describe the general of vitamin E in an effort ro reduce cardiovascular disease in otherwise healthy moles and fe·
condition. ease risk. 16 Luge-scale srudics of people with exist· moles ore underway. The results for the
Some nucritrm h.H e antioxidant properries. ing cardio\'ascular disea'e ha\'c shown no benefit females hove recently been reported. This
These likely reduce LDL oxidation in the blood- &om meg.1dose vit:lmin E therap~' (200-400 intervention generally foiled to show any
stream and thus slcm l DL uptake into scavenger mg/day; abour 400-800 IU/ d,l) ).16.t 9 Other slUd· dear benefit. Results for the men ore due
celli., a process that w.ls desaibed in this chapter in ies arc ongoing, u~ing people with c.irdio\'ascular by 2007.
the section ritkd Fats Carried in the Bloodstream. discai.c and chose with no C\i<lcncc of such disease.
Fruits, ,·egctablcs, nuts, .rnd plant orls .ire rich in Still, some experts suggest th.n meg:rdosc \'itamin E
such antioxidants (e.g., the '.lrious carotcnoids and use (up to 200 mg I-WO IU] per day) may be helpful corotenoids Plant pigments, in fruits and
\1tamin E). Earing fruits, \'cget.1blcs, nms, and plant for pn:1•c11tiltJT cardim':l\cular disease, but \hould be vegetables that range in color from
oils regular!} is one posim·e step we can cake to re- taken under a physician\ guidance. Th rs cauuon is yellow to orange to red.
duce cholem:rol buildup and \lo\\ the progrt:ssion bec::iuse, in ~ome l.'.ases, the mcgadose use of antiC>\·
of cardio\'ascul.1r discasc.6 Foods that arc especially ida.nt supplemrnrs rnn cause harm, especially if one
rich sources of ;1nr1oxidarm include red, black, .111d is raking cemin anticoagulant medil.'.ations or large
pinto beans; berries (blueberries, cranberries, black- d~cs of aspirin, which reduce blood clotting, be-
berries, srrawberrie~. et.:. ), fresh and dried plums cause \itamin E also reduces blood clmting. On the
(prunes ); d1errics; apples; pecans; .md potatoes. other hand, an cxcC\\i\'C intake of iron prob.1bly
(Coftl:e and tea arc also sources. ) Consuming speeds LDL 0>..idation, making it unwise w tak1: an
213
hen 28-yeor-old gold medalist iron supplcmem unless a physician prescribe~ it. For mosr people, ho\\'en:r, the most likeh risk
Sergei Grinkov died suddenly of People who experience iron smragc disease .uJd faaors arc:
a heort attack while ice skating, re- men in general should pay 'pecial attention to this
• Toc.11 blood cholesterol over 200 mg/ di esi)I:
searchers investigated the case and dis- \\ .1rning (sec Chapter 12 ).
ciall~ \\hen ic is ar or o\·er 240 mg/ di .md cou
covered o protein abnormality in his fn the next phase of the den:lopmcnr of ath-
pkd \\ich LDL-t:holesterol at or O\'cr 160
blood. This abnormal protein caused erosclerosis, called the progression phase, plaque
mg/di (130 mg/dJ is used for the t:uroff 1f ~per·
Grinkov's blood to dot more easily than thickens .1s layers of cholesterol (p.lrt of LDL),
son has two or more other risk farnm ). 10 fhe
normal. Grinkov was otherwise healthy, connecti\'C tissue (collagen ), smooth muscle, and
term LDL-c/Johstcrol land HDL-r/Jolmcr11/) ts
with on elevated total blood cholesterol, calciu 111 .1re deposited. Arteries harden .rnd narrow
used when expressing the scrum concemr.1tion
but normal HDL, blood triglycerides, and as plaque builds up, making them less elastic. They
because it is the cholesterol content of these
LDL. The main risk factor he hod was that arc thus unable ro expand to .1t:.:om111odate alter-
lipopmteins that 1s actually mea~ured. rl1t: rcll:r-
his father died of heort disease at the age .Ulons in blood pressure.
e1Kc st.111dar<l for expressing blood lipid rnm:en -
of 52. It is thought that up to 25% of Aflecred arteries become further d.1maged as
trat1ons also generally refers ro rhe 'erum
North Americans hove this some protein blood pumps through them and pressure 111-
t:ont:cnrrarion. Recall that serum wnccntr.nion
abnormality and that the only sign is a crcases. Finally, in the termmal phase of this entire
is what remains .1ftcr blood dots; blood is then
family history of heart-related deoth prot:css, a clot or spasm in a pl.1quc-dogged artery
centrifuged to rcmO\'C all red and \\ hnc blood
under age 60. For this reoson, it is wise lead\ to .1 myocardial infarctton.
cells .rnd cloning fuctors. Although blaod c/J11/ts-
for all adult North Americans to hove a Factors rhat typically bring on .1 hc.m mack i11
tcrn/ is a common rcrm, the value .inu.illy rcli:rs
careful evaluation of cardiovascular dis- a person at risk include dehydration, .mire emo-
to the concentration in the saum portion of rht:
ease risks conducted by a physician. tion:1I srrcss (such as firing .rn employee ), ~trenu
blood.
Olt~ physical acrivity when not otherwise plwsicaJJy
• Smoking. The smoking factor generally neg:ites
tit (sho\cling sno\\', for example ), \I .1kmg suddenly
the female ath-.un.1ge of later prcsrntation of tht
during the.: night or just gctung up Ill rhe morning
osl commonly, LDL-cholesterol is disc.1'e Jnd is the main cause 0L1bout 20',.. ofc.1r·
(linked roan abrupt increase in blood pressun: .ind
not actually measured in a serum d1m.isrnl.1r dise.1se dearhs. 25 A comb1natmn ol
stress), and cousunung high lat mc.1h (mt:reascs
sample but is calculated using the follow- smok111g .:ind oral contraccpri\·c u~e \\·or,ens m.u
blood clotting).
ing equation: LDL-cholesterol =total cho- tel"\ e\en more. Smoking greatly incrt'.1'es the ul-
lesterol - HDL-cholesterol - omate expression of a person's gencttc.illy linked
(triglycerides/5). This formula cannot be Risk Factors for Cardiovascular ruk for cardim ascular disease and e\ en 111cre.ist:s
used, however, if blood triglycerides ore risk if one's blood lipids arc kl\\. Smoking .1lso
Disease makes blood more likely to clot. E\'cn e\posure
> 350 mg/di. Recently laboratories have
also implemented a test that measures to secondhand smoke is discouraged.
Many of us arc free of the ri'k fanors that wn-
LDL-cholesterol directly (without the use of • H\•pcnension. Systolic blood pressmc mer
tributc to rapid dc\·clopment of .uherosdcrosis. If
this formula) Refer to Tobie 6-4 for typi- 140 (millimeter' of mercury) and diastolic
so, the .1thicc of healrh e\perts is to simpl) con-
cal LDL-cholesterol cutoff values. blood pressure m·er 90 indicate hypcrcens1on
sume a balanced diet, perform regul.1r phy~it:al ac-
~lore healthy blood pressure \alue; .ire 120
ti\ it), ha\'c a complete fastmi?, lipoprotcin analysis
and 80, rcspecri\'cly. (Treatment of hyputcn
performed at age 20 or be\'Ond, .111d rce\'aluan:
'1011 i' rc\'iewed in Chapter 11.)
risk factors every 5 years. 10
• Diabcte\. This disease neg:ites the f~m.1lc .1dv.m
People who face the highest risk for premature
ragt:. Insulin increases cholesterol synthe~i> in the
c:irdio\'ascular disease lmc gcnet1c defects that
li\'cr, in turn increasing LDL rt:lea~e into the
SU bstanti:iJly block the cJcar.111t:C of chylomicrons
bloodstream. Recently, diabetes h.1s even been
and triglycerides from the blood, reduce LDL up-
systolic blood pressure The pressure in remo1cd from the list of risk factors, bcc.m\c ib
take b} tht: li\·er, limit synthe\is ol' I IDL, or en -
the arterial blood vessels associated with presem:c \ irtu.1lh guarantees de\'clopmc111 ofc.1r-
hance blood clotting. Other mcdkal wndirions,
the pumping of blood from the heart. di0\ a:.cular di;casc and so puts >uch .l pc!"o11 in
st11:h .1~ certain form~ of IJ\t:r and ktdncy disease,
the hig.h ri~k group e\·en if LDL-chok,rerol ;,
diastolic blood pressure The pressure in l<l\\ concentrations of th} rrnd hormone, and use
not de\ •lted.4
the arterial blood vessels when the heart or t:crrain medicacions (() lrt'.ll lwpertenston, can
is between beats. im:rc.1sc LDL and thus inrn:a~e the risk for c;1rdio- This group of four 1isk factors describe; .1bout 90°1.
\ .1scular disease. of tl1e cmal risk for developing c.mlio\.l\~ubr
214
disease.9 Still, other ri~k facrors ,11\0 need to he Table 6·4 I Fasting Blood Cholesterol
I Thl11~•n,, considered: Profile lmg/di)
As port of his onnuol health checkup,
• HDL-cholcsterol under -J.O mg/di, espcciall} LDL, Cholesterol
Juon hos o blood sample drawn for the when the ratio of roral chobtcrol to HDI.-
meosuremenf of cholesterol values. The <70 Therapeutic: If one has car-
cholescerol is 3.5: l or less. Women often haYe
results of the fesf indicate rhot his tofol diovascular disease and
high values for HDL-cholesterol; rhereforc it i~
cholesterol is 210 mg/di, HDL choles- important for this factor to be measured in other risk factors, such os
ferol is 65 mg/di, ond triglycerides ore diabetes
women to establish cardiovasculor disease risk. A
100 mg/di. Juon hos reod that total < 100 Optimal
value ~60 mg/di is espcci:illy prmeccive.
cholesterol should be less than 200
• Age. ~kn O\'er 45 years ;md women over 100-129 Near optimal/
mg/di lo minimize cordiovosculor prob-
55 years are ac greater lisk. above optimal
lems. However, he 1s hoppy with the re-
• Family history of premature cardiov;1scular dis- 130-159 Borderline high
sults of the blood test. How would )uon
ease, especially before age 50.
explain his sotisfoction lo his 160-189 High
• Obesity (especiall) facaccumulanon in the \\,lisr).
porents2 2:'. 190
Typical aduJr wdghr gain is a chief wnuiburor to Very high
the increase in LDL-cholcsrerol that b seen wirh Total Cholesterol
.1ging. Obcsit)• leads to insulin resi\tance in many
<200 Desirable
people, creating J diabetes-like nsk." Obcsiry also
increases intl:unmation 111 d1e bo<l~ and reduces 200-239 Borderline high
the production of the hormone ad1ponectin b~ 2:'. 240 High
adipose cells. High amouncs of chi~ hormone in
HDL, Cholesterol
d1e bloodstream contribucc to a lmH:r nsk of de-
\·doping a heart attack. <40 low
• lnacrh;t)'. Exercise conditions d1e arteries to <!:60 High
adapt to physical so·ess. Regul:ir e\ercise abo im
Triglycerides
pro\·es insulin acrion in the body. The cor
responding reduction in insulin output leads to a < 100 Optimal
reduction in lipoprotein synthesis in the liver. 100-149 Near optimal
Both regular aerobic exercise and resist.mec exer-
150-199 Borderline high
cise are recommended.8•26 A person with existing
cardiovJScuJar disease should seek physician ap- 200-499 High
hyperlipidemio The presence of on proval before st:irting such a program, as should ~500 Very high
abnormally large amount of lipids in the older adults (see Chapter 14 ).
circulating blood
Table 6--1 outlines some blood cholcsrcrol
dyslipidemio Generally refers lo o stole profiles. Tf any of your blood cholesterol values foll
in which various blood lipids, such os LDL in the category labeled "High," con~ult your ro increased homocysreine in the blood.
or triglycerides, are markedly elevated phrsician because you may be ar risk for cardio\'a~ Homocysteine damages the cells Lining the blood
or, in the case of HDL, very low. cular disea.:.e. According ro che Nacion.ti Hean, \·esscb, in rum promoting atherosclerosis. h is
metabolic syndrome A condition in Lung, and Blood Insrinirc, about 50% of all probably only a minor risk factor, bur like(\ causes
which the person has poor blood American .ldulrs ha\'C ele\'ated blood cholesterol. some cases (see Chapter 10 for a derailed discus-
glucose regulation, hypertension, fhc combined or indi\'idual risk fawm of high sion of homocysceine).
increased blood triglycerides, and other LDL and high triglycemlcs arc referred to ·'' The term risL· fnctor is noc incendcd to mean
health problems. This condition is usually hyperlipidemia or dyslipidemia. causality; nc\'erchcless, the more nsk factor~ one
occomponied by obesity, lock of Researchers .ire curn:ndy trying m unr.wel .rnd has, t11e greater rhe ch:inces of ultimately dc\·clop·
physical activity; and a diet high in qu.111tif) sull other factor~ rh.lt may be linked to ing card10,·ascular disease_ A good example 1s ,1
refined cmbohydrates. Also called premature cardi0\·ascul.1r disease. An n:ample i~ person with metabolic syndrome, \\ho would
Syndrome X. the connection between inadequate intJkc of vita have abdominal obesity, high blood trigl}rccrides,
min B-6, f(1latc, and \'itamin B- 12, \\hich can lead low HDL-cholc..~terol, hypertension, and evidt·nce
215
s noted in the chapter, aspirin in of insulin resistance (e.g., high fasting blood glu- one of rwo ways. Statins (e.g., fluvasLarin [Lesco!],
small doses reduces blood clotting cose) and increased blood clotting. This profile lovasrarin [Mevacor}, sinwistatin [Zocor I), and
by reducing thromboxone A production; raises the risk for c.1rdiovascular disease consider- atorvastatin [Lipitor] reduce cholesterol syntl1esis
it is oken used under o physician's guid- ably.11 About 20 w 25% of North American adults in the liver. This then reduces the chobterol con-
ance to treat people ot risk for heart at- are so affected. On a positive note, premature car- tent in the liver cells. The cells respond by incre~·
tack or stroke, especially if one hos diovascular disease is rare in people who h;we low ing LDL receptor activity in order to pull
already occurred. About 80 to LDL-cholestcrol, have normal blood pressure, and cholesterol from the bloodstream to make up for
160 mg/day is needed for such benefits. do not smoke or have diabete~. By minimizing the loss. Recall that LDL is 50% cholcsrcrol.
Individuals who may especially benefit these four risk factors, by following the dietary Statins can reduce LDL-cholesterol up to as much
from aspirin therapy ore men over 40 if recommendations of the American Heart as 60%, depending on the drug used and tl1e pre-
risk factors are present, men over 50 Association on pages 223- 224 (such as limiting scribed dosage. The cost of being on one of the
even if risk factors are not present, post- satmatcd fut, trans fat, and cholesterol intake) and stati11 drugs ranges from $1600-$ J3000 per year,
menopousal women, and people with di- by staying physically active, you will most likely re- depending on the dose needed. Use can also lead
abetes, hypertension, or a family history duce many of the other controllable risk factors to side effects, sud1 as musde damage, and so re·
of cardiovascular disease.10 listed.l!,LS,i5 In other words, develop and fo llow a quires physician supervision. 2
total lifestyle plan. Medications may also be added A second group of medications binds bile
to lower blood lipids, as discussed later in this acids in the small intestine, as doe~ soluble fiber,
chapter. Finally, if a person has a family history of and leads to their elimination, forcing the liver ro
cardiovascular disease but the usual risk factors synthesize new bile acids. The liver removes LDL
aren't present, a rarer defect might be the cause. from tbc blood to do this. For this reason, tl1ese
In this case, having a detailed pb)rsical examination drugs arc called bile acid sequestrants or resins
for other potential causes is advised. (e.g., cholescyramine [Quesrran] and colestipol
[ Colestid ]). These medications taste grin:y and
therefore are not very popular \\~th patients.
Medical Interventions Generally, the resins are not used alone in adults
fo r Cardiovascular Disease because of this unpleasant texture.
A rhird group of drugs can be used to lower
Diet and lifestyle strategies to reduce cardiovascu- blood triglycerides by decreasing the triglyceride
primary prevention The attempt to lar disease risk are appropriate for both primary production of the liver. These include gemlibrozil
prevent o disease from developing in the prevention (where a heart attack. bas not yet taken (Lopid) and megadoses of the vitamin nicotinic
first place-for example, following a diet place but the person has risk fuctors or where clin- acid (extended-release form is called Niaspan ).
low in saturated fat and cholesterol in an ical symptoms of cardiovascular disease are evi- The use of nicotinic acid docs result in pesky side
attempt to prevent cardiovascular dent) and secondary prevention (after a heart effects (e.g., flushing), but these are typically man-
disease. attack has taken place). However, some people ageable. finaUy, a fomth, and relatively new class
secondary prevention Interventions to need even more aggressive therapy added to their of drugs reduces cholesterol absorbtion from that
prevent further development of o disease regimen. The dearest indication for this more found in bile in the small intestine (ezctimibe
so as to reduce the risk of further aggressil'c approach is in secondary pm·ention, [Zetia]). Today it is veqr common to combine two
damage to health; for example, smoking but its use in primar)' prevention in cases of verr or more medications to reach currencly accepted
cessation for a person who has already abnormal blood lipoprotein patterns and diabetes goals for primary and secondary prevention (e.g.,
suffered o heart attack. also deserves consideration. LDL of< 70 mg/di for those at very high risk; re-
Medications arc the cornerstone of this more view Table 6-4). 10
aggressive therapy. 10 The National Cholesterol It is troubling to note that, currently, many
Education Program in the United States has de- North American adults with evidence of cardio-
veloped a formula based on age, roral blood cho- vascular disease quit risk-reducing therapy \\~thin
lesterol, HDL-cholcsterol, smoking history, and the first year of diagnosis. Part of this problem is
blood pressure to determine who needs such med- due to the cost and side effects of some of the
ications. Check our this formula at http:// hin. medications typically used. Overall, mortality from
nhlbi.nih .gm·/atpiii/calculator.a:.p. Currently, cardiorascular disease is reduced when treatment
medications work to lower LDL-cholesterol in to lower elevated LDL-cholesterol in people who
216
he two most common surgical treat- are at bigh risk for such disease or who have had a lesterol from tl1e blood so ir can continue ro make
ments for coronary artery blockage heart attack is followed for a few years or more b)' bile acids. The studies done on the cholesterol-
ore percutaneous tronsluminol coronary a physician. Furthermore, new research shows that lowering effect of dlese margarines have found
angioplasty (PTCA) and coronary artery plaque even regresses in arteries when high LDL- that 2 to 5 g of plant stanols/sterols per day re-
bypass grok (CABG). PTCA involves the cholesterol is treated aggressive!)'· lO It is suspected duces tot:il blood cholesterol by 8 to l 0% and
insertion of o balloon catheter into on or- that these aggressive therapies to lower LDL- LDL-cholesterol by 9 to 14% (similar to what is
tery. Once it is advanced to the oreo of cholesterol stabilize the development of athero- seen with some cholesterol-lowering drugs).1 7,18
the lesion, the balloon is expanded to sclcrotic plaque, thereby lowering the risk of Benecol is made from plant stanols d1at are ex-
crush the lesion. This method works best rupture ;rnd reducing the chance of myocardial in- tracted from wood pulp. This product is sold as
when only one vessel is blocked, ond it furction caused by dot formation. margarine and has been added to salad dressings.
may be held open with metal mesh, Take Control is made from plant sterols that are
coiled o stent. CABG involves the removal isolated from soybeans. The recommended
Other Possible Medical amount for bodi is about 2 to 3 g per day as part
ond use of a saphenous vein from the leg
or use of the mammary arteries. The Therapies for Cardiovascular of at least two meals; this works out to about 2 ta-
sophenous vein or mammary artery is Disease blespoons of Take Control or 1 tablespoon of
sewn to the main heart vessel (oorta). It is Benecol per day. Use would cost about Sl.00 per
then used to bypass the blocked ortery. FDA has approved two margarines that ha\•e posi- day, because tl1ese margarines are more expensive
The procedure con be performed on one tive effects on blood cholesterol levels-Benecol than regular margarines.
or more blockages.3 and Take Control. As discussed in the section in For people \\'ho have borderline high total
this chapter titled Sterols, these margarines con- blood cholesterol (between 200 and 239 mg/dl),
tain plant stanols/sterob. The plant stanols/ d1ese margarines can be helpful in avoiding future
sterols work by reducing cholesterol absorption in drug therapy. Recently plant stanols/sterols have
the small intestine and lowering its return to the also been made :ivailabk in pill form and have
liver. The liver responds by taking up more cho- been put in some brands of orange juice.
Another Dimension of Fat: Properties in Food

Various fats play important roles in foods. Much ingenuity must go into the produc-
tion of fat-reduced products to preserve tlavor and texture. In some cases, "far-free"
also means tasteless.
Fat in Food Provides Some Satiety and Flavor

Fat in foods has generally been considered to be d1e most satiating of all the macroou- satiety A state in which there is no longer o
tricms. However, this assumption has been called into question because recent studies desire to eot; o feeling of satisfaction.
shO\.v that protein and carbohydrate prob:ibl)' lead to more satiety (gr:im for gram).
I-Ii.gh-fut meals do provide satiety, but primarily because one consumes a lot of energy
in the process. A high-fat meal is likely to be an energy-rich meal.
F:it components in foods provide importanc tcxrUJ-cs and c:irry flavors. If you've ever
eaten a high-fat yellow cheese or cn:am cheese, you probably agree that fat melting on
the tongue !eels good. The fat in reduced -fat and wholt: mi lk also gives body, which fot-
free milk lacks, and the most tender cuts of meat arc high in fat, visible as the marbling
217
Expert Opinion i
Atherosclerosis : An Update
Bernhard Hennig, Ph.D., R.D.
Atherosclerosis: More Than High Blood inAammotory processes mark all stages of atherosclerosis, from early endothe-
Cholesterol lial cell activation to eventual rupture of the atherosclerotic plaque and clot for-
mation. The inside lining of blood vessels is protected by the endothelium. The
An extensive body of experimental as well as epidemiological evidence es-
endothelial cells found there ploy on active role in physiological processes such
tablished o causal relationship between elevated blood cholesterol and oth.
as regula tion of muscle tone, permeability of a blood vessel, and blood clot-
erosclerosis. Cholesterol-lowering medications that block cholesterol synthesis ting. Activation and dysfunction of endothelial cells-for example, by oxidized
in the liver (e.g., otorvostotin [Lipitor] and other so-called stotin medications)
LDL, infectious microorganisms, or free radicals associated with cigarette
were developed to address this problem. Lorge clinical trials hove demon-
smoking-is a critical underlying cause of the initiation of the cardiovascular
strated that statins con effectively decrease low-density lipoprotein (LDLJ cho-
disease process. Endothelial cell activation, combined with on increase in the
lesterol and increase the activity of the LDL receptor. There is strong evidence
production of both inRammotory factors mode by white blood cells and adhe-
that the reduction of LDL<holesterol lowers the incidence of cardiovascular sion molecules, regulates not only the entry of white blood cells (primarily
events in primary prevenlion (where a heart attack hos not token place but the macrophages derived from circuloling monocytes) into the blood vessel wall, but
person hos risk factors or related clinical symptoms) and secondary preven-
also a switch from anticoagulant-stimulating to coagulant-stimulating activity.
tion (aker a heart attack hos taken place). However, new research findings
A fatty streak is formed as o result of macrophage uptake of oxidized
suggest that atherosclerosis is not just a passive process of lipid accumulation
lDL. Migrating and reproducing smooth muscle cells and platelets that ore
in blood vessels but rather is a chronic inflammatory process that resulls from
allrocted to the site further augment the otherosclerotic lesion process. The
the interactions between blood lipoproteins and cellular components derived continuous release of hydrolytic enzymes, inAommotory factors, and growth
from circulating white blood cells as well as from the endothelial cells, smooth factors by cells within the vessel wall induces further damage, and eventually
muscle cells, and the extracellular contents of the arterial wall. on atherosclerotic plaque with a fibrous cop forms. Eventual thinning and
rupture of the fibrous cop covering the otherogenic plaque then is a stimulus
Overall Pathology of Atherosclerosis to clotting events. Continued inflammation From the influx and activation of
The development of genetically modified laboratory animals has provided a macrophages and the release of protein-digesting enzymes causes degra-
powerful approach for studying individual genes and their relationship to dif- dation of the vessel. This rupture then leads to possible hemorrhage, clot for-
ferent phases of the pathology of atherosclerosis. Strong evidence suggests that mation, and final arterial blockage.
',_· -
r:
(a) Lumen Artery wall

of the
artery artery
Atherosclerosis. (a) Cross section of a healthy coronary artery. (b) Cross section of o coronary artery with advanced atherosclerosis.
New Developments in Atherosclerosis lein, modified (e.g., oxidized or otherwise altered) LDL, elevated blood ho-
mocysteine, and obesity. Even stress, depression, and loneliness are getting
Oxidative stress and o low level of chronic inflammation are believed to be
attention as Important factors to consider.
critical underlying factors in the pathology of atherosclerosis. A major factor
Obesity, in particular increased abdominal lot or lot accumulation
in inflammatory responses is nuclear factor Koppa B (KB). This nuclear fac-
around organs, is on especially important risk factor for atherosclerosis that
tor binds to specific sites on DNA and in turn activates associated genes. It
needs more attention because of ifs association with high blood lipids, dia-
resides in the cytosol of a cell in on inactive (bound) form. Once released
betes and insulin resistance, hypertension, reduced output of the beneficial
(now in unbound form) through the action of oxidative stress and various in-
hormone adiponectin by enlarged adipose cells, and the metabolic syn-
flammatory factors, it then travels to the nucleus and binds lo DNA. This ox- drome. There also is evidence tha t an increase in this overall oxidative stress
idative stress-sensitive process is critical in the regulation of inflammatory
and inflammation in the body may be an important mechanism by which
and immune system genes, cell reproduction, and cell death. Overall, as the
obesity increases the incidence of atherosclerosis.
binding of this nuclear factor to DNA increases, so does further inflammation
and oxidative damage. New research suggests that blood levels of ( .
Treatment Options for Atherosclerosis
reactive protein (CRP) provide a predictive value for this inflammation and
the degree of cardiovascular disease. Nutrition, including a healthy lifestyle and aerobic exercise, should remain the
Understanding molecular aspects of production and inhibition of cyclooxy- primary focus on prevention and treatment of atherosclerosis and related car-
genase enzymes (COX), and especially COX-2, will help explain the involve- diovascular diseases. A major goal for our diets should be decreased con-
ment of the eicosanoids in the overall pathology of atherosclerosis. Many sumption of refined foods (e.g., foods high in energy but locking nutrients and
studies also are underway lo understand regulatory mechanisms of nitric oxide phytochemical compounds that exhibit antioxidant and anti-inflammatory
synthesis. Nitric oxide is a signaling molecule that regulates many aspects of properties). Obesity and associated risk factors and a sedentary lifestyle with
atherosclerosis, including oxidative stress, platelet aggregation, white blood lack of physical activity ore cri tical obstacles in conquering blood vessel dis-
cell adherence, smooth muscle cell reproduction, and blood pressure. eases such as atherosclerosis. A diet high in whole foods; fiber and antioxi-
High-density lipoproteins (HDL) ore important in reverse cholesterol trans- dant nutrients, including micronutrients (e.g., zinc, selenium); vitamins E and
port by accepting cholesterol from cells throughout the body, including C; corotenoids; and numerous polyphenols (e.g., resverotrol, quercetin) will
macrophages, and by interacting with scavenger receptors and cholesterol help to control and reduce not only oxidative insults and inflammation but also
transporters. OF special interest ore also HDL-ossocioted enzymes coiled high blood lipids and high blood glucose typically seen ofter meals. For ex-
porooxonases, which protect blood lipids from oxidation, decrease ample, polyphenolic phytochemicals stabilize the blood vessel endothelium
macrophage uptake of oxidized LDL, and inhibit cholesterol synthesis. both as antioxidants and as molecules that help regulate these cells.
Exciting areas of recent research include the protective effects of peroxi- Furthermore, regular aerobic exercise induces protective cardiovascular
some proliferolor activated receptors. These are o family of nuclear receptors adaptations by, for example, inducing genes that code for antioxidant en-
that bind specific compounds, such as unsaturated fatty acids and certain med- zymes and ontiotherogenic signaling pathways !e.g., nitric oxide produced
ications. This binding to DNA via this receptor then ultimately controls the ac- by endothelial cells). The medications mentioned in this Expert Opinion, as
tivity of key genes involved in the regulation of metabolism, inflammation, and well as others that affect inflammatory processes and blood pressure regula-
clotting. The receptors ore found in blood vessels, including endothelial cells. tion, (e.g., medications that block the action of ongiotensin II) may also be o
Medications that increase activity of these receptors, such as fibrotes used in necessary port of the overall treatment approach for blood vessel diseases
treating elevated blood triglycerides (e.g., gemfibrozil [Lopid]) and glitazones such as atherosclerosis. Finally, individual genetic profiling and related tech-
used in treating diabetes (e.g., rosiglitozone [AvondioJ) hove been shown in nologies will assist in future therapeutic approaches in health and disease.
some (but not all) studies to reduce inflammation in response to o variety of
Dr. Hennig is Professor in Nufrifion and Toxicology at the Un iversity of
stimuli.
Kentucky. He received his Ph.D. in biochemistry and nutrition from
Iowa Stale University. A fter a postdoctoral appointment with the
Cardiovascular Center, College of Medicine of the University of Iowa,
New Risk Factors and Explanations
Iowa City, Dr. Hennig ;oined the University of Kentucky. His research
In addition to traditional risk factors, such as age, gender, blood cholesterol, emphasis can be summarized os the utilization of tissue culture and
blood pressure, and smoking, more recent risk factors include high blood animal models in the study of nutrition, toxicology, and atherosclero-
triglycerides (triglyceride-rich lipoprotein remnants, and free fatty acids as sis, with an emphasis in the role of nutrients and tox ins on biochemi-
well), diabetes (glycemic load of the diet and insulin resistance in the per- cal and molecular mechanisms of vessel endothelial cell function ,
son), smaller LDL particles, lipoprotein (a), angiotensin II (o factor involved in iniury, and protection. Dr. Hennig has published extensively and hos
blood pressure regulation; discussed further in Chapter 11 ), C-reactive pro- received several national award recognitions for his research.
of meat. In addition, many fl avorings dissolve in fat. H eating spices in oil intensifies the
flavors of an lnctian curry or a Mexican dish by carr ying the flavors to the sensory cells
in the mouth that discriminate taste and smell. For these reasons, a person who has
been following a typical North American diet will probably need some time to adjust
to thc taste of a lower-fat dier. For example, if one changes from d rinking whole milk
ro 1% low-fat milk but then after a few weeks switches back to the whole milk, it will
taste mo re like cream than milk. One has thus adjusted ro the flavo r ofrbc low-far milk
and wilJ likely now find the whole milk to be not as palatable.
Hydrogenation of Fatty Acids in Food Production Increases

Trans Fatty Acid Content
Fol is on important component of the flavor and
As mentio ned previously, most fats with long-chain saturated fa tty acids arc solid at
overall appeal of cheese. room temperature, and those with unsaturated fatty acids are liqu id ar room tempera-
ture. lo some kinds of food production , solid fats work better than liquid oils. In pie
crust, for example, soljd fats yield a flaky product, whereas crusts made with liquid oils
tend to be greasy and more crumbly. If they arc used to replace solid fats, oi ls with un-
hydrogenation The addition of hydrogen to a saturated fatty acids often must be made more saturated (with hydrogen), because this
carbon-carbon double bond, producing o solidifies the vegetable oils iuro shortenings and margarines. Hydrogen is acJdcd by
single carbon-carbon bond with two hydrogens bubbling hydrogen gas w1der pressure into liquid vegetable oils in a process called
attached to each carbon. Because h ydrogenation (Figure 6-15 ). T he fatty acids aren't fi.11ly hydrogenated to the sarurated
hydrogenation of unsaturated fatty acids in o
fatty acid form, because this would make the product too hard and btirrle. Partial
vegetable oil increases its hardness, this
hydrogenation-leaving some mo nounsaturated fatty acids--crcates a semisolid product.
process is used to converl liquid oils into more
solid fats, which ore used in making margarine
and shortening. Trans fatty acids ore a by·
product of hydrogenation of vegetable oils.
#d/iiG ~ Hydrogen
source
(b)
),
Figure 6· 1 5 I How liquid oils become solid
L_
fats. (a) Unsaturated fatty acids ore present in
liquid form. (b) Hydrogens ore added
(hydrogenation), changing some carbon-carbon (c)
double bonds lo single bonds and producing
some Irons fatty acids. (c) The partially
hydrogenated product is likely to be used in
-
Unsaturated vegetable
margarine or shortening or for deep-fat frying. oil (liquid)
Adding hydrogen
under pressure
Partially-hydrogenated fat
(semisolid)
The pron:s:. of hydrogenation produce~ trn11s fatty .icidi., .1!> wJs described e.lrlier in ou may be surprised to learn that some
this ch.ipter. ~lmt natur.11 monotms.iruraced .ind polyunsarur.iced furry .Kids e\N in rlu: trans fatty acids occur naturally. The bocte·
cis form, caui.ing :1 bend in the carbon d1ain, whereas the straiglm:r carbon form~ of tram rio that live in the rumens of some animals
far more drn.cl) resemble i.anir.ucd futty .icid~. This m,1y be the mechanism '' hen:b\ trnm (cows, sheep, and goats, for example) produce
fats increase l.DL. In add1cion, trrms fats lower HDL and increase inlbmmauon in the trans fatty acids that eventually appear in foods
body. People "ith ck\ aced LDL especially should limit intake of paniall) hydrogenated such as beef, milk, and butter. These naturally
fat and thu' tm11s fat. The .wcr.igc person need nor be m·crly concerned .l!> long .1s trnm occurring Irons fals ore currently under study for
fat intake is not e\CC'iSi\ C .llld the diet is adequate in pOl)Unsanmited fat. ( [m\·e\ Cf, be possible health benefits, including prevention of
cause tram fatty acid' sen·c no particular role in maimainmg bod) hc.ilth, the 1.uest cancer. About 20% of Irons fatty acids in our
Dietan· Guiddinc!. for Americans, rhe Amc1ican Hean AS!>od.ition, .md the Food .md diets come from this source. 17
Nutrition Bo.mi e.Kh recommend minimal trn11s fat inrakc. 7 •1;;
As public pressure has persuaded manufacturers ro diminau: the tropiG1l nib rich in
saruratcd fat (p.1 lm, p.11111 olein, and coconut ) from food processing;, partially hydro-
genated soybean oil rich in trnm far-has become the major replacement. Cmn:ntly,
trans fat intake in North America is estimated to conrribute about 3 LO 4% LOt::tl en- or
ergy intakes, amounting to 1Og per da~', on average. Table 6-5 lilltS typirnl sources.
FDA is now requiring the trnm far conrem in foods on the NULrition racts label.
(The food bbcb in C111.1d.1 also must lisr trnw far conrcnt.) FDA hopes LO make: con-
sumtTS more .1\\ ,m: of rhc .1moums of trnns far in foods as wclJ as the 11eg.1ti\e he.11th
consequences J\\Oci.ucd with their exccssi,·c consumption. Nonh American comp.mie~
are already responding to this issue by creating products rh.u arc free of trn11s fat. h>r
example, Promise, Sm.ire Beat, and some Fleischm.urn's nurgarines arc lower in or free
of tra11s fat (ks'> th.m 0.5 g/ser\'ing is t.hc labeling standard for mws-free) wmp.ired
to typical marg.mnes.
This addition of the trnus fat listing on labels helps consumers .it the supcnnarket,
bur when dining mil, con~umers arc "left in the dark" as to'' hich foods contain trnm
fat. KnO\\ ing which food~ arc IO\\ in tm11s fat \\hen ordering at .1 restaurant is diniculr
because information abour preparation method!> and precise fat compo'>ition i~ r.m:ly
a\·ailable. To minimi1c trn11s fat intake, a general guideline is to limit comumption of
Table 6·5 I Total Fat, Saturated Fat, and Trans Fat Content of Typical Sources
of Trans Fat (in descending order of trans fa t)
Serving Fat Saturated Trans

Food Item Size (grams) Fat (grams) Fat (grams)
French fried potatoes
(fast-food variety) Medium size 26.9 6.7 7.8
Doughnut 18.2 4.7 5.0
Coke, pound 1 slice 16.4 3.4 4.3
Shortening I tbsp 13.0 3.4 42
Potato chips Small bog 11.2 1.9 3.2
Margarine, stick I lbsp 11.0 2.1 28
Cookies (cream-filled) 3 6.1 1.2 19
Morganne, tub ltbsp 6.7 12 0.6
Butter 1 tbsp 10.8 7.2 0.3
Milk, whole 1 cup 6.6 4.3 0.2
Mayonnaise (soybean oil) 1 tbsp 10.8 1.6 0
Tub margarine is much lower in trans fat than
The five mo1or sources of from fol ore (in orderl cokes, cookies, crackers, pies. and bread. margarine; fried polotoes, potato chips, stick margarine or shortenings. Some newer
corn chips, and popcorn; and shor1enin9 used in the home brands of lub margarines ore even free of Irons
Source· http:/ / www.dson.ldo.gov/ ~dms/qatrons2.html fatty acids (< 0.5 g/serving).
fried (especially deep-fat fried) food items, any pastries or flaky bread products (such
as pie crusts, crackers, croissants, and biscuits), and cookies.
Limiti ng trans fat at home is a much easier task. Most importantly, use Uttle or no
stick margarine or shortening. I nstead, substitute vegetable oils and softer tub mar-
garines (those whose labels list vegetable oil or water as the first ingredient). Avoid
deep-fat frying any food in shortening. Substitute baking, panfrying, b roiling, steam-
ing, grilling, or deep-fat frying in unbydrogenated vegetable oils. Replace nondairy
creamers with reduced-fat or fat-free milk, because most nondairy creamers are rich in
partial ly hydrogenated vegetable oils. FinalJy, read the ingredients on food labels, using
the tips listed in this section to estimate trans fat content.
Fat Rancidity Limits Shelf Life of Foods

Decomposing oils emit a disagreeable odor and taste som and scale. Stale potato chips
are a good example. The double bonds in unsaturated fatty acids break down, pro-
ducing rancid by-products. Ultraviolet light, oxygen, and certain procedures can break
double bonds and, in turn, destroy tbe structure of polyunsaturated fatty acids.
SanLrared fats and trans fats can much more readily resist these effects because d1cy
contain fewer carbon-carbon double bonds.
French fries and other fri ed foods ore o
common source of fa t and Irons fatty acids for
Rancidity is nor a major problem for consumers because, although eating rancid oi ls
many adults. For those who choose to consume can cause sickness, tl1e odor and caste generally discourage us from eating enough ro
these products on a regular basis a small become sick. However, rancidity is a problem for manufactmcrs because it reduces a
serving size is recommended, especially if a product's shelf life. To increase shelf life, manufacrur ers often add partially hydro-
person hos elevated blood lipids. genated plam oils to products. Foods most Likely to become rancid are deep-!Tied
foods and foods with a large amount of exposed surface (such as powdered eggs o r
powdered milk). The fat in fish is also very susceptible to ran cid ity because ir is highly
polyunsaturated.
Antioxidants such as vitamin E help protect foods against becoming r ancid.
Antioxidants guard against the fut breakdown caused by various agents, such as metals
found as impu rities in vegetable oi ls. The vitamin E in plant oils reduces Lhe break-
down of double bonds in fatty acids. (The role ofvirami n E is explained more folly in
rancid Containing products of decomposed Chapter 9. ) When food manufacturers wane to prevent rancidity in polyunsaru rared
fatty acids; they yield unpleasant flavors and fats, they often add the synthetic antioxidants BRA and BH T. (Chapter 19 d iscusses
odors. the safety of these and other food additi\1es.) Look for tlJcse food additi\'CS in salad
BHA, BHT Butylated hydroxyanisole and dressings, cake mixes, and od1er products that contain fut. They can even be added ro
butyloted hydroxytoluene-two common a food's paper packaging. Vitamin C may also be added for die same reason.
synthetic antioxidants added to foods. Manufucrurers also tightly seal products and use other methods to reduce oxygen le\'-
els inside packages.
Emulsifiers Improve Many Food Products
Food manufactu rers add em ulsifiers in the preparatio n of many food products, prima-
rily to improve texrurc. For example, lecitl-1ins, monoglycerides and diglyccrides,
polysorbate 60, and other emulsifiers are added to salad dressings ro keep the vcgctablc
oil suspended in warcr (review FiguJ·c 6-8). Eggs added to cake batters likewise emul-
sify the fat with d1c milk. Monoglyceridcs and related compounds are also good emul-
sifiers and, for that reason, arc sometimes used in cake mixes and salad dressings. Over
the next few days, examine d1e labels of salad dressings and cake mixes, and sec how
many emulsifiers are ljstcd.
Concept I Check
Fae has a variety of roles in foods, including that of contributing to flavor and tcxtmc. Fat
also provides the pleasurable mouth tee( of many of our favorite foods, intensifies rhc r;1stc
of many spices, and tenderizes many popular curs of meat.
Hydrogenation of unsaturated furry acids is the process of adding hydrogen to carbon-
carbon double bonds to produce single bonds. This results io the creation of some tnms
fatty acids. Hydrogenation changes ,·cgcrable oil to solid fuc. It is wise to monitor trnns fat
intake, because this form of fat raises LDL, IO\\'ers HDL, and increases inlbmmation in the
body.
The carbon-carbon double bonds in pol)'unsaturated fatty acids arc easily broken, ~ridd
ing products responsible for rancidity. The presence or antioxidants, such as viramin E in
oils, naturally protects unsamrated fatty acids against oxidative destruction. r-.fanufacturers
can use hydrogenated fats and add natural or synrhctic antioxid:rnrs co reduce the likeli-
hood of rancidit:y.
Emulsifiers, i.ucb as lecithins, monogl yccridc~ and diglycerides, and polysorbate 60 an:
added to salad dressings and other far-rich products to keep the \'cgctable oils and other
fats suspended in d1e water.
Recommendations for Fat Intake

There is no RDA for totaJ far intake for adults, although there is an Adequate Intake set
for rotal fat for infants (sec Chapter 17). The most spcciJic rccommcndarions for fut in-
take come from the American Heart Association (AHA). l 5 Because many North
American!> are at risk for developing C<trdiovascular disease, A11A promotes dit:tary and
lifestyle goah aimed at reducing this 1isk. The AHA recom mendations for the genera.I
public are pr<:l>ented in Tabk 6-6. In Table 6-7, a more detailed list of recommenda- Trimming the fat from meats before cooking
rions is provided for people \\'ho currently are at fligh risk or have cardim·ascular d isease. helps reduce your saturated fat intake. Also,
To reduce risk for cardiovascular disease, the AHA recommends thar total fat intake limit use of meat that is highly marbled with fat
should not exceed 20 to 30% of total cnerg)' intake, which equates ro 47 to 70 g/day (seen as streaks of fot) .
for a rerson 1vho consumes 2100 kcal daily. Within tlrnt fat allowance, no more than
7 to 10% of total energy intal'e should come from saturated fat and tmm fat combined.
These <tre the primar)' facry acids that raise LDL. In addition, cholesterol should
amOLmt to a maximum of 200 to 300 mg/day. 7·L 5 Table 6-8 is an example of a diet
that ,1dheres ro these gnidelines. Compare these recommendations co North
Americans' actual dietary intake patterns of tbes<: fats: 33% of energy from total far,
about 13% of <:nergy from sarurated far, and 180 to 320 mg of cholesterol each day.
Both the National Cholesterol Education Program (NCEP) and rhe Food and oderating alcohol and sugar intake,
Nutririon Board arc in agreement with tl1e advice of the AHA. One exception in the avoiding overeating and obesity, con·
latest guidelines from the NCEP is that fat in take could be as high as 35% of tota l en- suming fish on a regular basis, not smoking,
ergy intake as long as intakes of sarurareu fat, cholesterol, and tm11s far are minimized. and performing regular physical activity ore the
The Food ~U1d Nutrition Boa.rd combines tht'. AHA and NCEP recommendations, primary lifestyle interventions to lower blood
suggesting that far provide a range of 20 to 35% of energy intake.7 Ir is important to triglycerides. 15
Table 6·6 I Current Dietary Guidance for the General Population

(2 Years of Age and O lder) from the American Heart Association
Population Goals
Overall healthy eating pattern
Major Guidelines
Include a variety of fruits, vegetables, grains, low-fol or
0 ne goal of Healthy People 2010 is to
increase the proportion of persons age
2 years and older who consume less than
fat.free dairy products, fish , legumes, poultry, and lean 10% of energy intake from so tu roted fat.
meats.
Appropriate body weight Match energy intake to overall needs, with appropriate
changes to achieve weight loss when indicated.
Desirable blood cholesterol profile Limit foods high in saturated fot and cholesterol, and
substitute unsaturated fa t from vegetables, fish, legumes,
and nuts.
Desirable blood pressure Limit salt and alcohol {see Tobie 6-7); maintain a healthy
body weight; and follow a diet with on emphasis on
vegetables, fruits, and low-fot or fat.free dairy products.
Table 6·7 I Specific Dietary Recommendations from the American Heart

Association, Especially for Those People at High Risk or Who Currentl y Have
Diet Consume at least:

• 5 servings of fruits and vegetables each day. Up lo 9 servings per day is
advised if the person hos hypertension.
• 6 servings of grains, including some whole groins, each day.
• At least 2 (3-oz) servings of fish per week (or 1 g of a combination of
E xercising for at least 45 minutes four times a
week can increase HDL by about 5 mg/di.
losing excess weight (especially around the
omego-3 fatty acids from fish oil supplements per day).
• 25 g of fiber each day, including some sources of soluble fiber.*
waist) and avoiding smoking and overeating Consume no more than:
also help maintain or raise HDL, as does moder- • 30% of energy intake from total fat or 20% if blood lipids are still loo high.
ate alcohol consumption.15 • l 0% of energy intake as saturated fat, or 7% if blood lipids are still too
high, as well as limit Irons fat intake (included in saturated fol gram
allowance).
• 300 mg of cholesterol per day (on average), or 200 mg per day if blood lipids
are still too high or the person has diabetes or cardiovascular disease.
• 6 g of soh each day (6 g equals 2400 mg of sodium).
• 2 alcoholic drinks per day for men or one drink for women or anyone
age 65 and older.
Additional advice includes:

• Specifically meeting vitamin B-6, folate, vitamin B-12, and potassium needs,
limiting sugar intake, and possible use of soy protein and stonol/sterol-
containing margarines. Megadose vitamin E supplements ore not recom-
mended al this time, and vitamin C and beta-carotene supplements provide
no benefit.
Body weight • Maintain a body mass index between 18.5 and 25. Waist circumfer-
ence should not exceed 40 inches (102 centimeters) in men or 35 inches
(88 centimeters) in women (see Chapter 13 for details).
Physical activity • 30 to 60 minutes of brisk activity on most, if not all, days of the week.
These specific recommendations apply to individuols 2 years of oge and older. The latest guidelines from the National Cholesterol
Education Progrom in the United Stoles also concur with this advice for high-risk individuals, except that fat could be os high as
35% of total energy intake if saturated lat intake is 7% of energy intake or less ond cholesterol intake does not exceed 200
mg/day.
*Note that the latest guidance for fiber from the Food and Nutrition Boord is that men consume 38 g/day, while 25 g/doy is fine
For women.
note that in addition to fat intake, controlling total energy intake is also significant, be-
cause weight control is a vital component of cardiovascular disease prevention.
Regarding essential fatty acids, the Food and Nutrition Board has issued recom-
mendations for both omega-6 and omega-3 fatty acids. The amounts listed here work
out to about 5% of energy intake for the total of both essential fatty acids.7 Infants and
children have lower needs (see Chapter 17). Consumption offish at least twice a week
is one step toward meeting requirements for essential fatty acids.
Men (g/day) Women (g/ day)

Linoleic acid (omega-61 17 12
If you ore looking to decrease the amount of
Alpha·linolenic acid (omega·3) l.6 l. l
saturated and trans fats in your diet, it is a
good idea to opt for lower-fat substitutes for
some your current high-fat food choices. How The typical North American diet derives about 7% of energy from polyunsaturated
do you think this meal com pores with the fatty acids and thus meets essential fatty acid needs. An upper lirnir of l 0% of energy
chicken nuggets and french fries meal on intake as polyunsaturated fatt)' acids is often recommended, in part because thi.: break·
p. 222? down (oxidation) of those fatty acids present in lipoproteins is linked to increased cho·
Table 6·8 I Doily Menu Examples Containing 2000 kcal and 30 or 20% of
Energy as Fat
30% of Energy as Fat 20% of Energy as Fat
Food Fat (g) Food Fat (g)
Breakfast
Orange juice, l cup 0.5 Some 0.5
Shredded wheat, 3/4 cup 0.5 Shredded wheat, l cup 0.7
Toasted bagel 1.1 Some 1.1
Tub margarine, 3 teaspoons 11.4 Tub margarine, 2 teaspoons 7.6 onitoring by o physician is important if
l % low-fat milk, 1 cup 2.5 Fol-free milk, 1 cup 0.6 fat is restricted to 20% of energy intake
because the resulting increase in carbohydrate
lunch intake con increase blood triglycerides in some
Whole-wheat bread, 2 slices 2.4 Some 2.4 people, which is not a heohhFul change. Over
Roast beef, 2 ounces 4.9 light turkey roll, 2 ounces 0.9
time, however, the initial problem of high blood
Mayonnaise, 3 teaspoons 11.0 Mayonnaise, 2 teaspoons 7.3
triglycerides on a low·fot diet may self-correct,
lettuce Some
Tomato Some os hos been shown in people following a vegan
Oatmeal cookie, 1 3.3 Oatmeal cookie, 2 6.6 diet for a year or more. Their blood triglycerides
increased initially on the diet but, within o year,
Snack fell to normal values os long os they emphasized
Apple Same carbohydrate sources high in fiber, controlled (or
Dinner improved) body weight, and followed a regular
Chicken tenders frozen meal 18.0 fat.free chicken tenders exercise program.
Dinner roll, l 2.0 Some 2.0
Margarine, 1 teaspoon 3.8 Some 3.8
Bono no 0.6 Some 0.6
I% low-fat milk, l cup 2.5 fat.free milk, 1 cup 0.6
Carrot sticks, 10 Some
Snock
Raisins, 2 teaspoons Raisins, l /2 cup
Air-popped popcorn, 3 cups 1.0 Air-popped popcorn, 6 cups 2.0
Margarine, 2 teaspoons 7.6 Some 7.6
Totals 73.1 44.3
lesterol deposition in the arteries. Depression of immLrne fonccion is also suspected to

be caused by an excessive in take of polyunsaturated futty acids.7
Major sources of fat in the typical North American diet include anjmal flesh, whok
milk, pastries, cheese, margarine, and mayonnaise. ln contrast, the major somces of fat
in the Mediterranean diet include liberal amounts of olive o il and the fat found in the
sma ll amounts of animal flesh and dairy products in the diet. The main sources of fat
in a "egan diet plan arc a scant amount of vegetable o il used in cooking and the small
amounts found in various plant foods.
In summary, the general consensus among nutrition experts suggests that limitation
of satu rJtcd fat, cholesterol, and tram fat intake shou ld be the primary focus and that
the diet needs to contain some o mega-3 and omega-6 futty acids (Table 6-9).
Furthermore, if far intake exceeds 30% of total energy intake, the extra fat should come
from mon0Lu1sarurated fat.7
Most people probably have no idc•l how much of the energy content of their dict5
comes from for. Using the information on food labels and re..:ording and analyzing
daily food intake allows you to track your fat intake.
I Fats in Food
Table 6-9 proYides an example of the amount of fat in foods in .1 day's menu. The
foods 1ichest in fat arc salad oils, butter, marg.u-ine, and mayonnaise. All contain close Manufacturers now offer a variety of low
ro 100% of energy as fut (Table 6-10 ). In fat-reduced margaJ·it1cs, ,,·art:r rep bees some cholesterol foods.
Table 6·9 I Tips for Avoiding Too Much Fat, Saturated Fat, Cholesterol,
and Trans Fat
Eot Less of These Foods Eat More of These Foods
Groins, cereals, rice, • Posto dishes with cheese • Whole.groin breads
and pasta or cream sauces • Whole.groin pasta
• Croissants • Brown rice
• Pie crust
Vegetables • French fries • Fresh, frozen, baked, or
• Vegetables cooked in butter, steamed vegetables
cheese, or cream sauces
Fruit • Fruit pies • Fresh, frozen, or conned
fruits
Milk, yogurt, • Whole milk • Fat-free and reduced-fat milk
and cheese • High-fat cheese • Reduced-fat/port-skim cheese
Meats, Poultry, fish, • Bacon • Fish
dry beans, eggs, and nuts • Sausage • Skinless poultry
Many manufacturers offer products that ore • Organ meats (e.g., liver) • Lean cuts of meat (with for
lower in fat than the traditional product. Even
though these products ore lower in fat, portion • Egg yolks trimmed away)
size and the total calories supplied still must be • Soy products
considered. • Egg whites/egg substitutes
Fats, oils, and sweets • Butter and stick margarine • Angel food coke
• Cheesecake • Fig bars
• Pastries • Animal or graham crackers
he advice to consume 20 to 30% of energy
• Doughnuts • Air-popped popcorn
as fat does not apply to infants and toddlers
• Ice cream • Low-fat frozen desserts {e.g.,
below the age of 2 years. These youngsters ore
• Potato chips yogurt, sherbet, ice milk)
forming new tissue that requires fat, especially in
• Cancio oil or olive oil
the brain, so their intake of fat and cholesterol
• Tub or liquid margarine (in
should not be greatly restricted.7
small amounts)
of the fot. Typic.il margarim:!> arc 80% fat by weight ( 11 g/Lbsp ). Some far- reduced
margJrines an.: a~ low as 30% far by weight ( 4 g/ tbsp ). The extra m1ler added tc> the~c
marg.11ines can cause texture and volume changes w hen u1'.ed in recipes. 1 Cookbooks
can provide guidanc<.: for .tppropri.lk' U/>e of these products by suggesting alteratiom in
n:cipcs to ..:ompcnsate.
\Valnuts, bologna, avocados, an d bacon ha\'e about 80% of energy as fat. Peanur
butter and cheddar cheese have about 75%. M•lrbkd srcak and hamburgers (ground
chuck ) have abouL 60%, and chocol.ue bars, ice cream, doughnuts, and whok milk
h:we .1bout 50% of energ~ as fat. Eggs, pumpkin pie, and cupcakes have 35%, as do lean
cuts of me.1t, such as rop round (and ground round) and sirloin. Bread contains :ibom
15%. C'ornOakcs, sug:u-, and nonfat milk have cssenrial ly no foe. Cardi.ii l.1bcl reading
is necessary to determine the true fat content nf food-chcsc arc only rough gu iddincs.
Animal fatli, "hich contain about -W to 60% or roral fat .is sarunued fatty acid'>, ar<.:
holesterol is found only in the animal foods rhc chicf contributors of saruratcd fatty acids to die North American diet. Salllrn tcd
C we eat {review Tobie 6·2). An egg yolk con·
loins about 210 mg of cholesterol. This is our
fart~ acids with 12, 14, and 16 carbons (lauric acid, myristic acid, and palmitic acid, rc'-
specti\'cly) arc the: primary contributors to elevated LDL. Of these, the 14-carbun
main dietary source of cholesterol, along with myristic acid is m•1inly responsible fc>r elc\·aring U1L. 7 Dair~· fats arc rich sources of
meats and whole milk. Some plants contain re· myristic acid. The 16-c:i rbon paL11iric acid also increases LDL, pri marily when thcrc is
lated sterols, but none we typically eat contains more rhan 200 to 300 mg of chole~tcrol in the dier and LDL is alrca<ly cle\'atcd. The
cholesterol. 17 saturated fatty acids wiL11 12, 14, or 16 carbons gcner~1ll y conscirute abom 25 to 50%
Table 6· 1 0 I Food Sources of Fat
Food Item Fat (g) Energy from Fat (%)

T-bone steak (3 oz) 17 66%
Mixed nuts (1 oz) 16 78%
Cancio oil (1 tbsp) 14 100%
Hamburger with bun (1 eoch) 12 39%
Margarine (1 tbsp) 12 100%
Avocado (I /2 cup) 11 86%
Cheddar cheese (l oz) 10 74%
Whole milk (l cup) 8 49%
Chicken breast with skin (3 oz) 7 36%
Whole milk yogurt (8 oz) 7 28%
Snack crackers (1 oz) 7 45%
Baked beans (1/2 cup) 7 31%
M&M chocolate candies (1 oz) 6 39%
Flax seeds (1 tbsp) 3 62%
Fig Newton cookies (2 each) 3 23%
of rhc toral far in animal foods. In general, dairy fats and meat are rich in the fatty acids The North American diet contains many high-
that rJise LDL In some plant oils, these samrated fatty acids also make up a notable fol foods-including candy, cookies, and
percentage of the total rat-for exam pk, cottonseed oil (27%) and coconut oil ( 89%). desserts. Porlion conlrol is the key to enjoying
lhese foods while slill controlling energy inloke.
Plant oils contain mostly unsaturated fartv acids, ranging from 73 to 94% of total
far. Canob oil, olive oil, and peanut oil contain moderate to high amounts ofrotal fat
as monounsamrated fatty acids (49 to 77%) . Some animal fats .lre also good sources of
monounsaturated fatty acids (30 to 47%) (review Figure 6-3) . Corn , cottonseed, sun-
t1owcr, soybean, and safflower oils concajn mostlv polyunsatw-ared fatty acids ( 54 to
77%) in terms of total fat. These planr oils supply the majority of the linoleic .lCid and
alpha-linolcnic .Kid in the North American food supply. Note that plant oils vary in
their content of polyunsaturated farry acids. Oils rhat are sirnilJJ· in appearance still may
,·ary signilicantly in fatty acid composition.
Fat Replacement Strategies Are Available

Currently, five types of fat replacements are available to food manufacturers. Addition
of these substances during manufacturing yields products th.at, co varying degrees, sat-
isfy consumers' desire for reduced-fat products that are still tast:y. 1
Water, Starch Derivatives, and Fibers

The first and simplest fat replacement is •.vater. The adrution of water yields a product,
such as diet margarine, with less fat per senfog tl1an the normal product. Starch deriv-
ati\'eS that bind water form a second type of fat replacement. The resulting gel replaces
some of the mouth feel lost b)' tl1e removal of fat. Z -trim is one example. lt is made
from the hulls or bran of various planes, including oats, peas, soybeans, rice, com, and
\\·hear. Otl1er starch deri\'atives commonly used by food manufacturers include the fiber
ceUuJose, Maltrin, Stellar, and Oatrim. These substances are used in a variety of foods,
incluiling luncheon meats, salad dressings, frozen desserts, table spreads, rups, baked
goods, and canrues. Most starch derivatives yield some energy, but ar least half the
amount that is in fat. Note that these starch derivatives cannot be used in fried foods. I
Gum fiber extracted from plants can also be used to replace fat. This thickens a
product and replaces some of the body that fat provides. Diet salad dressings and fat-
reduced ice cream have gums adtkd for this reason.
Protein-Derived Fat Replacements

Still another type of fat replacement on the market consists of proteins that have been
u-eated to produce microscopic, rnistlike protein globules. Both egg and milk proteins
can be used. When these substances replac<.: fut in a food product, they fed like fat in
the mouth, although t11c product does not contain any fatty acids. One example i ~
Dairy-Lo, which is t1sed in milk and other dairy products, baked goods, frosting!> , salad
dressings, and mayonnaise-type product!>. Such fat replacement!) yield some cnergy-
but on ly about 1 to 2 kcal/g. They have this low-energy value for two reasons: pro-
teins contain only 4 kcal/g, and the products have a high water contcnr. 1
Engineered Fats and Related Products

The last form of fat replacement is engineered fat. This type of product is srnthcsized
in the laboratory from various foud constituents. Olcstra (Olean ) is a good example.
1t is made by chemically bonding fatty acids to sucrose (tabk sugar). The resulring prod-
Fat replacements such as gum fiber ore uct cannot be digested by eit11er the human digestive enzymes or bacteria that live in the
typically seen in soft serve ice cream. intestinal tract. Therefore, olestra is noL absorbed and so provides no energy for the body.
Olcstra can replace much of rhe for in salad dressing and cakes and was the first fat
replacement that could be used in fried foods. Olestra was approved by FDA in 1996
for use in fried snack foods, such a~ potato chips. 1
The major problem associated with the use of olcsrra is that ir binds the fat·!>oluble
vitamins A, D, E , and K, thus reducing their absorption. To compensate, the manu-
fucturer adds these vitamins tu food products containing okstra. Other suspc.:ctcd
problems, such as GI tracr d.iscomforr, have not been supported by carefu l research.
Thus, warnings .ibout use of olestra and GI tract disturbances, which used to be re-
quired on labels for olestra-conraining foods, arc no longer mandatorv.
o for, fat replacements hove hod little im· Food manufacturers a.re working on orher types of engineered fats thal either \\'holly
poet on our diets, portly because the cur· or panially esc.ipe absorption by the body. One example is salatrim, which ill marketed
rently approved forms either are not very under the name Benefar and yie lds onlr about 5 kcal/g. It is composed of some satu-
versatile or have not been used extensively by rated fatty acids thar are poorly absorbed by the body. This product has b<:cn u~ed in
manufacturers. The public, in fact, has shown reduced-fat chocolate.
very little interest in the use of fat replacers such
as olestra. In addition, fat replacements are not
practical to use in the foods that contribute the
greatest quantity of fat lo our diets-beef,
cheese, whole and reduced-fat milk, and
pastries.1
- Fotty acid
0
/
CH2 0
- Fatty ocid
Fotty ocid - o-(

\_o\ iH'
\ 2 /o"-.. .
\ C- o-C ~ -CH 2 -0-Fottyac1d
c;,__c/ \ I
/ \
o IG--€"..
/ 0 0 0
fotty ocid \ \ "..
Fatty ocid Fatty ocid Fatty ocid
anada has not approved the use of oleslro

in food products; the United Stales is the
only country that permits the use of this fat sub-
stitute in foods. l
Fat Is Hidden In Some Foods

Some far ruscussed so far is obvious: butter on bread, mayonnaise in potato salad, and
marbling in raw meat. Fat is harder ro detect in other foods that also contribute sig-
nificant amounts of fat to our diets. Fat is hidden in whole milk, pastries, cookies, cake,
cheese, hot dogs, crackers, french fries, and ice cream. When we try LO cut down on
fat intake, hidden fars need to be considered along with the more obvious sources.
A place ro begin searching for hidden fat is on rhe Nutrition Facts labels of foods
you buy. Some signals from the ingredient list tlut can alert you ro the presence fat or
are animal futs, such as bacon, beef, h.un, lamb, pork, chicken, and wrkey fats; lard;
vegetable oils; nuts; dairy fats, such as butter and .:ream; egg and egg-yolk solids; and
partially hydrogenated shortening o r vegetable oil. Conveniently, the l:lbel lists ingre-
dienrs b) order of weight in the product. If fat is one of the first ingredients listed, you
are probably looking at a high-fat product. Use food labels to learn more •lbout tl1C fat
content of tl1e foods you eat (Figure 6-16 ).
Table 2-14 in Chapter 2 listed the definitions for various fat descriptors on food la-
bels, such as " low-fat," "fat-free," and "reduced -far." Recall that " low-far" indicates,
in most cases, that a product contains no more tl1an 3 g of fat per serving. Products
that arc marketed as "fat-free" musr have less th;u1 l /2 g of fat per serving. A claim of
"reduced-fat" means tl1e product has at least 25% less fat than is usually found in mat
food. When there b no Nutrition Fact~ label co inspect, controlling portion size is a
good way to control far intake.
Whether or nor to choose a fat-Lich food should depend o n how much fat you have
eaten or will car for that particular day. If you plan ro ear high -fat foods at your en:ning
meal, you could reduce your fat intake ar a previous meal in order to balance overall
fat intake for tlit: day.
Wise Use of Reduced-Fat Foods Is Important

In recent years, manufacturers have introduced reduced-fat 'crsions of numerous food
produces. The fat content of these alternatives r:mgcs from 0% in fat-free Fig Newcom to
about 75% of the original fat content in ocher products. However, the total energy con-
tent of most fat-reduced producrs is not substantially lower tlun that of tl1cir c011\'entional
,·ersions. Generally, when fat is removed from a product, something must be addcd-
commonly, sug;lrs-in its place. It is very difficult to reduce both the fut and sugar con-
tents ol"a product at the same time. For this reason, many reduced-fat products (e.g.,
Figure 6· 16 I Reading labels helps locale

Nutrition Facts hidden fol. Who would think that wieners (hol
Serving Size 1 Link (45g) dogs) con confain about 85% of energy conlenf
Servings Per Container 10
as fat? Looking at the hot dog itself does not
Amount Per Serving
Calories 140 Calories from Fat 120 suggest rhar olmosl all ifs energy con tent comes
from fat, but the label shows otherwise. Do rhe
o/. Dall~ Value•
Total Fat 13g 20% morh: (13 g X 9 kcol/gl/140 kcal = 0.84, or
Saturated Fat Sg 23% 84%.
1HOR£01£/ITS p: R• l'.AltR, sm SkLT flJ;;\)R1~0S ~~·1 SiffUP souos. OEXTROSi Trans Fat Og -- **
HVOPQL\ 'f' SOY ' 'iO PillAIO PROTE'!/ SOOIWM PtiOSrtl>l'tS tXIPAC' OF P~PRll>A. SOOlt".l Cholesterol 20mg 7%
.RYllt ·~5 l"t soaJJl.l 'IORllE. Sodium 420mg 17%
Total Carboh~drate 2g 1%
KEEP REFRIGERATED Dietary Fiber Og 0%
Sugars 1g
Protein Si
NET WT. 16 OZ.
(1LB.) 454~. Calcium 0% .
Vitamin A 0% • Vitamin C 0%
Iron 2%
·Percent Dally Values are based on a 2.000
calorie die!
• • 1n1ake of trans fat shOuld be as low as
Q possible
hen many North Americans think of a cakes and cookies) are still very energy dense. Use the Nua-ition Facts label to guide
low-fat diet, they include reduced-fat the portion size you choosc. 1
versions of pastries, cookies, and cakes. When
health professionals refer to a low-Fat diet, they
often have a very different plan in mind: one
that focuses primarily on fruits, vegetables, and
Jackie's approach to lowering blood cholesterol does not incorporate the best
whole·groin breads and cereols.6,13
choices; she has excluded a great deal of fa t in her diet by merely replacing ii
wi th refined carbohydrates. To make a shift to o more heart-healthy diet, Jackie
would need lo include at least two fruit and three vegetable servings a day along with more
whole-groin products (such os whole-wheat bread and o breakfast cereal tha t hos at least 3 g of
fiber per serving). lowering fat as drastically as she hos is not really necessary, especially for a
21-yeor-old female who is physically active. Jackie could allow a more liberal amount of fat in
her diet by including more monounsoturated fats (canola oil and olive oil as well as fats found
in nuts and avocados). These do not increase blood cholesterol. In addition to allowing more
liberal fa t intake from monounsoturated oils and including more fruits, vegetables, and whole-
grain breads and cereals, Jackie would benefit from including good sources of omego-3 fatty
acids !fatty fish, lloxseeds, walnuts, or soybean and conolo oil). One option is to use a conolo
oil-and-vinegar dressing on her salad rather than lemon juice.
Concept I Check
There is no RDA for rota! fat intake. We need about 5% of rota! energy intake from plant oils to
meet the Adequate fntakcs set fur essential ratty acids. Eating fish at least m~ce a week is also
1'h..... ''lC" advised ro suppl)' omega-3 fart}' acids. M::mr health-related agcncics recommend a diet com.Un·
ing no more than 35% of energy intake as fat, with limited amounts or saturated fut, cholesterol,
Alliso(l has decided to start eating a low-fat and tra11s fatty acids. The current North American diet contains about 33% of energy content
diet. She has mentioned to you that all she as far, \\~th about 13% of energy content as saturated fut and about 3%as tmns fatty acids. Far·
needs lo do is odd less butter, oil, or mar· dense foods-those with more than 60% of total energy as fut-include plant oils, butter, mar·
gorine lo her foods and she will dromalicol/y garine, mayonnaise, walnuts, bacon, avocados, peanut butter, cheddar cheese, steak, .ind
lower her fat intake. How con you explain to hamburger. Of the foods we 1.ypicall~· cat, cholesterol is found narurally only in those of animal
Allison that she needs lo be aware of the hid- origin, with eggs being a prim.try sow·ce. Fat is often hidden in foods such as whole milk, pas-
den lots in her diet as well? tries, cookies, cake, cheese, hot dogs, crackers, french fiies, ice cream, and fast food. Fat !Tee
doesn't mean calorie free; moderation in the use of fut-reduced products is still important.
Summary
I . Compared with carbohydrates and proteins, lipids are a group of 3. Triglycerides are formed from a glycerol backbone with three fatty
relatively oxygen-poor compounds dJax dissolve in organic sol- acids. Triglycerides rich in long-chain saturated Km~· acids rend to
''ents, such as chloroform, benzene, and ether. Saturated fatty acids be solid at room temperature, whereas those rich in potyunsam·
contain no carbon-carbon double bonds. Monounsaruratcu fatty rated fatty acids arc liquid at room tcmperam re. Triglyceride is the
acid~ contain o ne carbon-carbon double bond. Tmm fun:y acids major form offal in both food and the body. It allows for efficient
also typically contain one carbon-carbon double bond, but it is in a energy storage, protects ccrt:.'li.n organs, transports fur-soluble vita-
trn11s rather than ci.r co11figuracion. Polyunsaturated fatty :icids con- mins, and helps insulate the body.
tain rwo or more carbon-carbon double bonds in the carbon chain. 4. Phospholipids arc derivatives of triglycerides. Phosphotipids are im-
2. In omega-3 polyunsatlu-arcd furry acids, rhc first of the carbon- portant parts of cell membranes, and some act as efficient emulsifiers.
carbon double bonds is located three carbons from the methyl end 5. Cholesterol forms vital biological compounds, such as h ormone~,
of the carbon chain. In omcga-6 polyunsaniratcd fatty acids, the first components of cell membranes, and bile acids. Cells in the body
carbon-c.u·bon double bond couming from the methyl end occurs at make cholesterol whether we eat it or not. It is nor :1 necessary
the sixth carbon. BodJ omcga-3 and omega-6 furty acids are essential part of an adult's diet.
furn' acids; these must be included in the diet to maintain health. 6. Fat digestion rakes place primarily in the small intestine. Lipase en-
Body cells can synthesize hormone compow1ds called eicosanoids zyme released from the pancreas digests the long-chain triglyc-
ti-om bod1 omega-3 and omcga-6 fatry acids. Eicosanoids made from erides into smaller breakdown products-namely, monoglycerides
omcga-3 furry acids reduce blood clotting and inflammation more so (glycerol backbones with single fatry acids attached) and futrr
than cicosanoids made from omega-6 furry acids. acids. The breakdown products are d1cn taken up by d1c absorp·
www.mhhe.com/ wardlawpers7 23 1
rive cdls of the small incestine. These producrs arc mostly rcmadc saruration. Hydrngenation of fum• Jcid~ in vegetabk oils changes
imo rriglyceridcs and combined 11irh cbobtcrol, protein, .md the oib w solid fats ,111d helps reduce rancidit), which rcsull!> from
other substances LO yield a chylomicron. Chylomicrons enter Lhc the breakdown of fatty acids. Hydrogenation al&<> mcrca'>e~ the
lymphatic system, in turn passing into rht: b lombtream. t1"fllJJ fatty acid rnntcnr. High .unounts of trans fat()' acids in the
7. Lipids arc carried in the b loodstream by variou~ lipoprorcin~, which dier <ll'l' Jiscou1-.1ged, because rhcy increast: LDL and reduce HDL.
arc P•lfticles consisting of a central rriglyccndc core ern;ased in .1 11. There 15 no RDA for coral fat mrakc. \Ve need about 5% of total
shell of protein, cholesterol, and phospholip1d. Chylomicrons are energy intake from pl;inr oils tQ obtain the needed essential fatty
released from intestinal cells and carry lipids arising from dietary in- acids bascd on rhl' Adequate lnr.lke for thcse nuuienrs. ri\h i' ~
take. Very-lo\\·-density lipoprorein (VLDLJ and lo\\ -densit~ rich somcc of omega-3 Eury acidi. <tnd should be t·omwncd a1 h:ast
lipopron:in (LDL) carry lipids borl1 taken up and synrhesized in the twice .1 week.
liver. High-densi ty lipoprotein (HDL) picks up chobtcrol from 12. Many he.11th <tgencies anJ ~cientilic groups suggest .1 fat intake ol
cells and ai:ts in allowing transport of it back LO the liver. no more than .~O to 35% of energy intake. If fat intake exceeds 30%
8. 111 the blood, elevated amounts ofLDL and low amoums ofHDL of wtal energy intake, the diet should emphasize monounsaru-
are strong prediccors of the risk for cardiovascular disc;isc. rated fat. Tbe typical North American diet contains about 33% ot
9. Fat adds tfavor and texture w foods and p rO\ idl'.s some saticry afrcr ICltal encrgy as fat.
mcals. Some phospholipids arc use.cl in foods .1s emulsifiers, whid1 13. f-at-rcducc;:d products .1id in the goal or reducing far intake, but
suspend fut in water. When furry acids break down, food becomes they ~ti ll mu\l be eaten in moderate amounts to maintain i::ontrol
rancid, resu lting in a foul odor and unpleasant llamr. or tot.11 energy intake.
10. Hydrogenation i!> rhe process of co1werting carbon-carbon doubk
bonds in to single bonds by adding hydrogen ar the prnnr of un-
Study Questions
1. Describe tl1e chemic1l srrunures of saturared and polyumarura ted 8. List the four main 1isk factors for tl1c development or cardirn as
fom acids and t heir differcnL effects in bmh food and the human rnbr discasc.
body. 9. What three lifestyle factors dccrea5C the risk of cardim·ascular dis·
2. Relate rhc need for omcga-3 fut~' acid}. in the diet to the: recom- case tkvdopmcnr?
mend.ition m consume fah twice a \\eek. I 0. Whcn .tre medic.1tiom mmt needed in cardim·ascul.ir dise;i~e 1her-
3. Describe rhc stru.:LUrcs, origin~. and roles oftht four m.1jor blood .1py, .rnd how in gcner.il do the '.irious classc\ of ml'.di.::ations op-
lipoprotcins. cratc co reduce risk?
-!. \Vhar arc the recommendations of hcJ lth-cin: profrssio1ub rc-
garding. fat intake:? What do these recommendaticms mean 111
terms 0 1· acnial f<iod d1oiccs? BOOST YOUR STUDY
5. \·Vhat arc two importanr an:ribuccs of fat in food? Ho\\ arc thl'.sc
difkrem from the general funcriom or lipid5 in the hum.in body? Refe r to Perspectives in Nutrition: Online learning Center
6 . Describe 1he signiricJncc of ,lJld possible uses R>r reduced-fin www.mhhe.com/wardlawpers7 for quizzes, flosh cords, activ-
foods. ities, and web links designed to further help you lea rn about dietary
7. Docs a person's choksrcrol inrnkc: tell the whole: sror~· with respect lipids.
to cardim·ascular disease riskl
\DA Rcpom: PosiLion of the Amcric3n L)icreric 3 Corn1ury byp.l~· ,\Jny,-, C'linu HL"nltb Lrrtc_.,. :>. Cm ine;tc111 MB: Omcg.a-3 !Jnv .Kid, .
•\ssod.11ion: Far rcptacers. founinl of i/Jc 22(4 ): 1, 2004. .A111rricm1 1-irmi~v P/J.1·sicin11 70( I ): l .B. 200+.
A111t'l'irn11 Diamr Am1ri11rio11 105:266, 2005. C11111plrtr rfrsO'ipti1111 rif r111·1111m~11 by/mss 1111t1a')' 0111i:qn-3.fi1t1y 11<id1 m11 n·d1m· t/Jc' ri.<I.· 11fm1I·
17,,. 111n;ol'if)• ofjirr nplncffs, w/Jm used 111 '-' p1·m•idrd. 1io1t'flrdinr1fr11rl1 in pm/J/c 1Ptil1 r11rd1111•1Hmln1·
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ndJ1t11CTs to lowffi11g r/Jc fflf cu11rmr oj}iJOfls 1111d rc,iM.HKl" ~ymlromr:: A pol<'llt culpri1 111 <'.1rJ10- il~fln111mtt101:1• 1j)'i:rts.
mny pin_,, rl l'lllt in durcnsing tlltnl dicurry .:n- ''JSculM J1scasc jo1ll'111JI ~r tl1t Am1·1·1cnJJ 6. J)jou~;c l .111d orhcr,. hui1 and \cgc1.1hk ..:on
o:.qy n11d fnt mtnk.:. Dfruric Aswcitrtiun I 0.+( 2 r 176, 200-L sumpnon .md Ll)I cholc~tcrc>I A111t'l'1cn11
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Ci111m111cT R1·1mrrsr111 Hmltb, p. 8, i'vl:m:h 2004. /// frw illJI /!111r1rl J1l11rosr lt'flds t11 111n11y 1frltw1·i- R.;_q11lnr.fh1ir 1md 1•1:tft'tnl1k irm1/.·,· cn11 1·td11rr
(;11od 1·1"J1in1> 1!f rhr diet find 111cdun1i1m r1;t11 · 1ms <:/]i'as 011 r/Jr bod\'. tv.:(n/Jc loss I 11'/Jrn f.f)I. clJ11l1.·.rurnl. Ir 111111p11rta11r 111 put rhur 1w·
111m111scd t11 luu•cr /!11111d r/Juh·srfml. Dcspi1< r!J,· 11ad(li) 11l1111l/ wit/J n:flltlnl' pl;yric11I nrth•ity 1111111,.·11dnr11111s 111111 pmcrirr.
po>J1rr of 111t1licntiom 111 lowc1· blood c/Jolcstt'rnl, nnd n dur 1·idJ 111 11•/J()ft-/1"11111s. /h11t.r, 1•i:qcta- 7 hiod J.nd ~uuillon llo.JTd: Dicrn1:v ri:/i'rmr<" i11-
lijeslyle c/11111l1es nrc nls11 needed flllftt r/Jr.fi11l cf' lt/cs, tt11fl low-jirr dnii'y p1'111i11as /Jdp.r rrmt th« 1nlwfi>1 omm, cnrb11l1ydmte,ji/!c1:ji1t,fi'lm· nwfs,
_tfrr 11/the mtdmrtiou.s. cviuiitiu11. c/J11lrsrn·nl, pl'otei11, nud n111il111 n.C1ds. \Va~b111gwn
DC: The Narion.tl Academ)' Press, 2002. l 3. Jensen MK and others: Intakes of whole No sig11ijicn11t diffirmccs n>t1'r 1wn-d bcm•em
TJ11s rt'pon prni•idc.< r/Jc Incestl/ttidance fo1· gr;iins, bran, and germ and the risk of .:oro- tbc 11itnmin E supplc111c11mtio11 ~11ro11p allif tilt"
111rrcro1111wimt i11takr. TVit/J regard ro fat in- narv heart disease in men. A111c1-icn11 ]011mal coutrol g1·011p i11 r/Je iucidrnn· of cancer or
take, Adcqurru llltrrlw· 111crc set for omcgrr-6 11/ Cliuirnl N11h-irio11 80:1192, 2004. deaths rdn.tul to cn11ccr i11 t/Jis st11rly.
rr11d ouugrr-3 Jarry ncids. lutrrkc oftotrrlfnr mu TJ1is study s1tpporrs t/Jc 1·eponcrl bcncftcilll 11sso- 20. Mayes PA, Botham K.t\il: Lipids of physiological
m11gc from 20 r11 35% of rotnt t11C1;g)' i11mke. cirrrio11 of w/Jol,.-gmin i11takr witb co1·0111wy significance. In MLLrmy RK amt others (eds),
lmrrkc ofsnrurarcd frrt, c/Jolc~TtTol, rrnd trrrm /Jcn,.t discnSI' and m11_11c.sts tbnt thr bm11 compo· Harper's illmrrnrrd billdm11i.rt1:1•. 26th ed. Nc11·
fat s/Jo111rf bt• 111i11i111rrl bcrn11se these dietm·y con· nwr of 1J1/Jolc grnins could be 11 kq fnrtor i11 tbis York, 1'T\', Lange J\\cdical Books/ J\kGr:iw llill,
.rrimmtJ rrre 1111t tssmti1il 1111trie11ts rr11d nrc n.r- rdatio11. 2003.
socirmd ll'ir/J incrmsiug 1·isk for crmfiovnsculm· 14. Jones TH, KuhO\\ S: Lipids, sccrob, md their Co11cisc rei•fr11' of rbe rhcmirnl srr11rr11ra n11d rt·
dismsc. mcrnholitc..~. In Shils ME and others (eds): fated ftnt11m of dirtm·y lipids.
8. Ford ES .111d others: Scdcnrary behavior, physi - Alodcm 11 mritin11 i11 /u:rrlt/J 11111{ disease. I 0th c:d.
21. i\!ayes PA. Botham K.J\I: Mcmboli~m oi'unsac-
cal .1ctivirv, .1ml the metabolic syndrome among Philaddphia, PA: Lippin.:on Williams & urated farcy acids and eicosanoid; sigmfican1.-.:.
U.S. adults. Obesity Rucnrch 13(3):608, 2005. Wilkins, 2006.
In Murray RK and others (eds ): Hn.rpcr:r illus·
Sedmtrrn bcbrrrior is 1111 importrrnt p11te11tirrl Currwr rc11icw of the pm·ious dit'1m:1•lipids n11d trntcrl bioc/Jw1ist,.,v. 26th ed. NC\\ York, NY,
derer111i111111t of tl1t· presence uf 111ctnbolic syn- tlJt'ir rdntal 111..irrboli.m1. Dige.rtio11 nud n.bsm·p- Lange Medical Books/McGraw- Hill, 2003.
drome. An incrcrrsc ill pl1_ysicnl nctir•ity coulrf in rio11 of tbcsc lipids is also co1•e,.al.
co11rrns1 rrmlt i11 mllftrr11tinl dccrmsc.r ill tbc 01>crvieiv 11frhe 111ctnb11lis11111ffarty arids, wit/J
15. Krauss R.Jvl and others: AIIA Dietary
prcllfllc11u 1~( metabolic sy111frome. a spccinl ji1rw 1111 dcosanoirls.
Guidelines: Rc\•ision 2000: A -;ratemc111 for
9. Greenland P :md others: J\lajor risk facror11 as hcalthcan~ profossionals from the Nutrition 22. Mayes PA, Botl1am KM: Lipid \tor.1ge .tnd
antecedents of fatal :111d n<>nfoxal coronary heart Commincc of the Amcri.:an Hcarr A~sociation. r:ransporr. In Murra)' JU{ .md othc~ ( eds );
disease ewm~. ]u11mal of r/Jt Amerimu Medical Cimdario11 102:2284, 2000. Hn,.pe,.'s il/11stmud bioc/Jemist,.y. 26th ed. New
Associatio11 290:89 l, 2003. 17Jis 1·cp1,,.r co11tni11s t/Je lntc.rt adl'tt"tjor r1,,. York, NY, Lange: i\lcdical Booko/ M..:Graw-
Cm·dio1•asc11/nr d1srrrs1: dl'fitbs p1·cdomi11ntc iii public rcgm·diu.tr dicr n11d cnl'dioJ>rrsrnlnr dis- Hill, 2003.
peoph· n>tfh four mnjorfrrctors: dcJ>ntetf rotrrf enscf/'0111 rhr Americn11 Henn Associnrio11. 111c Dcta.i/ed depiction 11f r/Jt pntbwrr_r.r med i11
c/Jolcsrcrol, drl'f!tcrl blo11rl p1·,.xs11rt". cig11rcttc 1·c1•1scdl'1tiddinc.r pince 1111 i11crcnscd m1p/Jas1s lipoprotciu 111ctabu/is111 in tbc body.
s111oki11g, n11d dinbctrs. Prrsrncc of01u 01· mon 1111 r/11· 11ccd f11r 11•tL1JIJr ro11h·11' n11d n henrr-
23. Mayes PA, Ber.ham KM: Cholcrn:rol -.y11t11c,i>,
of rbcse risk frrtrors predicted such dcnt/Js i11 nl- lmllt/Jy dirt. rranspon:, and excretion. ln J\lurray RK and
mo.rt 90%1!f'nll cnsc.r, cmp/Jnsi::.i1lg the il//po1·- 16. Kris- Etherton PM and oLhcrs: Antioxidanr vita· others (eds); Harper's illustrntt"d biodm11is11:1·.
m11u of c11nsir/eri11g 111/ rbcse major risk fflftors. min supplcmcms .lUd cardiovascul.1r disease. 26th c.:d. New York, NY, Lange Medi.:al
l 0. Grundy SM and orhcrs: lmplic,1Lions of rcccnc Cirmlntirm 110:637, 2004. Books/McGr,\w-Hill, 2003.
clinic.ii tri:ils for the N:i.tim1al CholcsLcrol 111crc is 110 srirnrijic datn w cltnr~1· jusri[v t/Jr 01•crvi&ll' of the 111ctnbolim1 ofr/10luten1I, as
EducJtion Progrnm Adu le Trcam1cnt Panel Ill mi· of anrio..,,..idn11t s11pplc111ems such rrs J>itnmi11
well ns n nn•icrv of its specific comri/Jutio11 10
Guideline~. Cfrrnlnrio11 1l0:227, 2004. Ejnr rbr prenmrio11 ufcnrdim•asrnlrrr dfrense. It various forms of dr11atcrl blond lipids scm i11
T71is repon 011tli11cs rbc ~qnnls for LDL c/Jolcsm·ol is m11d1morl'1111p1wtnnt to forns 1111 n /Jcnltl~v
l111111a11s.
fnr peuplr nt various risk dtmijications far de- diet, ,.eg11/rrr pb,vsirnl acriviry, nnd cn11h·nl of
blood pnss11rc. 24. J\leising.cr C and othcrl>: Pla,nl.l ox1di1cd lo\\ -
1•dupi11g cnrr/11mmc11Jm· disease. TI1c newest
deasicy lipoprorcin, a Mrong predictor for .1cme
g111rldinr is to /0111er LDL c/Jolestcrol to less thn11 17. Kritchcvsk) D: Cholesterol and orhcr dictar}
srcrols. In Shils J\IE and others led~): Modt"m coronary heart disease events in apparend)'
70 mg/di for 1/Josc nr big/J i·isk for or who ha1>c
1111triti1111 in /Jrntrh n11d disensr. LOrh ed . health)', middle -aged men from the gcncr.11
rnrdiwasculrrr disease.
f'hil:idclphia, PA: Lippincott Williams & population. Circulntio11 112:65 1, 2005.
l l. Grundy SM and mhcrs: Diagnosis and managc-
mcnr of the merabolic ~)•ndromc. Circulario11 Wilkins, 2006. Elt:11ntcrl co11cc11trntio11s of o:ddiz.:rl ftlw-dwsiry
l 12:2735, 2005. C11rrrnt re r•irn• (lftbc 1·ole of cholestn·of in hen/th tipoprorein an- prcdictiJ>c '!(future cnr011a,._v
rr11d disease, i11c/1uli11g t/Jc 11m·io11sfn.crors t/Jflt hcm··t disC11sc c11cuts m nJ1/mrrn1ly benlrb_v mm.
TJJt cnwtc!/ati1111 of 11ict11b1llic risk fnctors lmoJ1111
11s mctn/Jolir sy11rlro111c is strongly a.rsociaterl with influrncc its p1·01foctio11 i11 r/Jc body. 25. Millen BE and orhcro: Dict.1ry pattern~, ~mok
t')'pc 2 diabetes 111dlit11s 01· the 1·iskfo1· rbis condi- l 8 . Lau V'v\T\' and others: Plant sterols arc cftica- mg, and subdinical hea rt· d1sc.1~" 111 Wl)t11Cn.
t1011. 711csc metabolic risk factors consist of cious in lowering plasma LDL and non-HDL }01mml of the Amcricn11 J)icrctic Assorirrtio11
ar/Jeroge11ic dyslipidcmia (eltr•n.ted triglycerides cholesrerol in hypcrchoksu:rolemic cypc 2 diJ- 104:208, 2004.
1111d np11lipoprt1tci11 B, small LDL particles, n11d betic and nondiabctic pcrwm. Amaim11 A pu/Jlic bcrrltb pl'iorityji1r 11•11mm is fll pi•omou
10111 HDL-cholesu:rnl ro11Cf11trn.tiom), e/c1>nted ]011mrrl of Clillicnl N11n·iri1111 81 . 135 1, 2005. benltl~ylifestyle bdJt111i1ws, c.rpccml~v hmltb,v eat-
blood prt!ss11re, dt!r•aud plrrrmn glucose, a pro- 71Jc 1-isk rrf de1•1•/oping cm-dim•rrswlm· disease is ing n11d the n11oirla11cc ofs111oi·111..n
tln·ombotic strut, 111uf 11 proiujlnm maro,.y ;mtt. twofold ro sc11mfolrl /Jig/gr i11 type 2 diabetics
171c mosr i111pon1111t 11fthrsr 1mdcrlyi11g riskfnr- t/Jn11 i11 11011dinbetir persons, n11d this study 26. T hompson PD and others: hxcrcioc: and phy,i·
fors 1irc nbdominnl obesity nnd i11mli11 rerirtnncc. s/Jnws t/Jnt pfam stc1·ol ccmm111pti1m dcrtcnscs the cal acci1 icy in rhc prevent ion and rrc.11 mcnt of
risi• of cnrdi1ll'11rc11lnr discast· i11 r/Jis pop11lntio11. :uherosckrotic cardiovascular dis1:asc.
12. Hansson UK: lnfl,unmation, atherosclerosis,
Circulrrtio11107:3109, 200.~.
and coronar y artery disease. New England 19. I.onn c and od1crs: Effects of long-term vi ram in
/1um111l of /'..frdirilli- 352: 1685, 2005. E ~upplc:mcntat.ion on cardiovascubr events and H11birual pl~vsiml nctir•iry 1m·1•mt> tbo· dn•f/11p-
711is nnid.- et111tni11s n11 cxcdlmt rc11icw of t/Jt c;mccr: A randomized cona·ollcd riial. /1111run/ of mmt of cm·dioi•nswlnr disen.rc nud n:duas
role l!fi11Jlnmmnt1011 in causing w1·dio1>nswlnr the Amfricn11 Mrrlicnl Ass11cinrio11 293: 1338, symptoms in pntimrs 11•ith established cnrdi1111a.r-
dism.1c. 2005. mla.r rlisc11sc.
Take I Action
I. Are You Eating a Diet That Includes Many Saturated Fat and Trans
Fatty Acid Sources?
Instructions: In each row of the following list, circle your typical food selection from either column A or B.
Column A Column B
Bacon and eggs or Ready-to-eat whole-grain breakfast cereal
Doughnut or sweel roll or Whole-wheat roll, bagel, or bread
Breakfast sausage or Fruit
Whole milk or Reduced-fat, low-fat, or fat-free milk
Cheeseburger or Turkey sandwich, no cheese
French fries or Plain baked potato with salsa
Ground chuck or Ground round
Soup with cream base or Soup with broth base
Macaroni and cheese or Macaroni with marinara sauce
Cream/fruit pie or Graham crackers
Cream.filled cookies or Granola bar
Ice cream or Frozen yogurt, sherbet, or reduced-fol ice cream
Butter or stick margarine or Vegetable oils or sofi margarine in a tub
loterpretatfon
The foods listed in column A tend lo be high in saturated fat, trans fatty acids, cholesterol, and total fat. Those in column B generally
are low in these dietary components. If you want to help reduce your risk of cardiovascular disease, choose more foods from column B
and fewer from column A.
..
..• .. 4f ' l .
• •
'L . . .--.
' - " .. --... 1
....
Take I Action
II. Applying the Nutrition Facts Label to Your Daily Food Choices
Imagine that you ore at the supermarket looking for a quick snack to help you keep your energy up during afternoons. In the snack sec-
tion, you settle on two choices (see labels a and b). Which of the two brands would you choose? What information on the Nutrition
Facts labels contributed to your decision?
Nutrition Facts Nutrition Facts

Serving Size: 2 bars (42g) Serving Size: 2 cookies (38g)
Servings Per Container: 6 Servings Per Container. about 12
Amount Per Serving 2 bars Amount Per Sen1ing
Calories 180 Calories from Fat 50 Calories 180 Calories from Fat 70
% Daily Value• % llaltwValue•
Total Fat 6g 9% Total Fat 7g 11%
Saturated Fat 0.5g 3% Saturated Fat 2g 10%
Trans tat Og Trans tat 2g
Cholesterol Omg 0% Cholesterol Omg 0%
Sodium 160mg 7% Sodium 100mg 4%
Total Carbohydrates 29g 10% Total Carbohydrate 26g 9%
Dietary Fiber 2g 8% Dietary Fiber 1g 4%
Protein 4g Protein 2g
Iron 6% VilaminA 0% Vitamin C 0%

Not a slgn1licant source of V1tamln A, Vitamin C, and Calcium 0% Iron 2%
caleium •• illlake of trans lal should be as low as
possible.
" Intake ol trans Isl should be as low as possible.
• Daily values are based on a 2,000 calorie diet. Your • Daily values are based on a 2,000 calorie diet. Your
daily values may be higher or lower depending on your daily values may be higher or lower depending on your
calorie needs: calorie needs:
•• Intake should be •• Intake should be
as low as possible. Calories 2,000 2,500 as low as possible. Calories 2.000 2,500
Total Fat Less than 65g BOg Total Fat Less than 65g 80g
Saturated Fat Less than 20g 25g Saturated Fat Less than 20g 25g
Cholesterol Less than 300mg 300mg Cholesterol Less lhan 300mg 300mg
Sodium Less than 2,400mg 2.400mg Sodium Less lhan 2.400m~ 2.400m9
Total Carbohydrates 300g 375g Total Carbohydrates 300g 375g
Dietary Fiber 25g 30g Dietary Fiber 25g 30g
INGREDIENTS: WHOLE GRAIN ROLLED OATS, SUGAR, Calories per gram: • Fat 9 • Carbohydrala 4
CANOLA OIL, CRISP RICE WITH SOY PROTEIN (RICE
FLOUR, SOY PROTEIN CONCENTRATE, SUGAR. MALT, • Pro tein 4
SALT), HONEY, BROWN SUGAR SYRUP, HIGH
INGREDIENTS: ENRICHED FLOUR (WHEAT FLOUR,
FRUCTOSE CORN SYRUP. SALT, SOY LECITHIN,
NIACIN, REDUCED IRON, THIAMINE MONONITRATE,
BAKING SODA, NATURAL FLAVOR, PEANUT FLOUR.
RIBOFLAVIN, FOLIC ACID), SUGAR. VEGETABLE Oi l
ALMOND FLOUR, HAZELNUT FLOUR, WALNUT FLOUR,
SHORTENING (PARTIALLY HYDROGENATED SOYBEAN,
PECAN FLOUR
COCONUT, COTTONSEED, CORN AND/OR SAFFLOWER
AND/OR CANOLA OIL), CORN SYRUP, HIGH FRUCTOSE
CORN SYRUP, WHEY (A MILK INGREDIENT). CORN
STARCH, SALT, SKIM MILK, LEAVENING (BAKING SODA.
(a) AMMONIUM BICARBONATE), ARTIFIC IAL FLAVOR,
SOYBEAN LECITHIN. COLOR (CONTAINING FD&C
YELLOW #5 LAKE)
(b)
PROTEINS

Proteins-Vital lo life Shannon is a freshman m college. She lives in a campus residence hall and teaches
Amino Acids • Amino Acid Form and Function
• Tronsominotion and Deominotion • Essential aerobics in the afternoon. She eats two or three meals a day al the residence hall
and Nonessential Amino Acids in Perspective cafeteria and snacks between meals. Shannon and her roommate both decided lo -i
Proteins-Amino Acids Bonded Together become vegetarians because they recently read on the Internet on article describing I
Protein Synthesis • Protein Organization • m
Denoturotion of Proteins the health benefits of a vegetarian diet. Yesterday her vegetarian diet consisted of a m
Protein Digestion and Absorption danish pastry for breakfast and a tomato-rice dish (no meat) with pretzels and a diet
z
m
;;o
Digestion • Absorption soft drink for lunch. In the afternoon, after her aerobics class, she had two cookies. G)
Functions of Proteins -;<
Producing Vital Body Structures • Protein Al dinnertime, she hod o vegetarian sub sandwich with two glasses of fruit punch. -<
Turnover-Adopting to Changing Conditions • In the evening, she had o bowl of popcorn. m
r-
Maintaining Fluid Balance • Contributing to 0
What is missing from Shannon's current diet pion? Which foods should be em-
Acid-Bose Balance • Forming Hormones and
Enzymes • Contributing to Immune Function •
z
phasized on a vegetarian diet? How could she improve her new diet to meet her G)
Forming Glucose • Providing Energy •
Contributing to Satiety nutritional needs? z
Protein Needs
c
-i
~
Does Eating o High-Protein Diet Harm You? m
Expert Opinion: A New Appreciation for the z
-i
Nut in Nutrition (/)
Protein in Foods )>

The Value of Plant Protein z
0
A Closer Look at Soy Protein • Evaluation of
Protein Quality )>
Nutrition Focus: Vegetarian Diets ()
I
Protein-Energy Malnutrition 0
Kwashiorkor • Morosmus • Kwoshiorkor and r-
Morosmus Malnutrition in the Hospital
Toke Action
235
C onsuming enough protein is vital for maintaining heolth. 10 Proteins form important structures in
the body, make up o key port of the blood, help regulate
many body functions, and con fuel body cells. 18 This term pro-
tein comes from the Greek word profos, which means "to come CHAPTER OBJECTIVES CHAPTER 7 IS DESIGNED
TO ALLOW YOU TO:
first." In the developing world, such o primary focus on protein in
diet planning is important because diets in those areas of the 1. Describe how amino acids make up proteins.
world con be deficient in protein. In contrast, diets in industrialized 2. Distinguish belween essential and nonessential amino acids.
countries ore generally rich in protein, and therefore o specific 3. Explain why adequate amounts of each of the essential amino
acids ore required for protein synthesis.
focus on eating enough protein for the most port is not needed.
4. list the primary functions of protein in the body.
High-protein diets hove come and gone over the past
5. List the factors that influence protein needs, and calculate the
30 years. Recently, these hove become very popular as weight- RDA for protein for on adult when o healthy weight is given.
less diets, with some con taining about 35% of energy as pro-
6. Describe what is meant by positive nitrogen balance, negative
tein.16 This figure falls within the latest advice for protein intake nitrogen balance, and nitrogen equilibrium in terms of protein
from the Food and Nutrition Board (10 to 35% of energy intake), status in the body.
so in general these diets ore appropriate if otherwise nutrition- 7. Distinguish belween high-quality and lower-quality proteins and
the sources of each, and describe how lwo lower-quo lily
ally sound (e.g., they follow MyPyromid).10 Still, as discussed in proteins con be complementary for each other and so provide
Chapter 13, these types of weight-loss diets ore hardly o magic enough of all the essential amino acids for o diet.
bullet for weight loss. 8. Outline two methods used to measure protein quolity'of foods,
including assessment of biological value.
This chapter tokes o close look at protein, including the ben-
9. Describe how protein-energy mol nuJ~ilion con eventually lead to
efits of plant proteins in a diel. It will also examine vegetarian
disease in the body.
diets: their benefits, and their risks if not properly planned.
10. Develop vegetarian diet plans that meet the body's nutrient
needs.

OF PROTEINS IN CHAPTER 7, YOU MAY WANT TO
REVIEW:
The anatomy and physiology of digestion and absorption in Chapter 3.
Amino acid use iri energy metabolism in Chapter 4.
The processes of gluconeogenesis and ketosis in Chapter 4.
The disease phenylketonuria (PKUJ in the Nutrition Focus in Chapter 4.
The immune system in Appendix C.
Proteins-Vital to Life
T housands of substances in the body are made of proteins. Aside from water, proteins
form the major part of lean body tissue, totaling about 17% of body weighr. 18 Much
of this lean body mass is made up of muscle tissue. Amino acids-the building blocks
fo r proteins-contain a special form of nitrogen: essentially, nitrogen bonded ro car-
bon. Plan ts combine nitrogen from the soil wirb carbon and otber elements ro fo rm
amino acids. They then bond these amino acids together to make proteins. We get the
nitrogen " 'c need by consuming clietary proteins. Proteins are thus very impo rtant be-
cause they supply nio·ogen in a form we can readily use-namely, amino acids. Directly
using simpler forms of nitrogen is, for the most part, impossible for humans.
Proteins are crucial to the regulation and maintenance of the body. Body functions
Small amounts of animal protein in o meal such as blood clotting, fluid balance, hormone and enzym e production , \'isuaJ
easily odd up to meet doily protein needs.
processes, and cell repair require specific proteins. T he body makes proteins in many
configurations and sizes so that th ey can serve these greatly varied fun ctions. 18 All
236
these proteins use the amino acids in the protein-containing foods we eat, plus some R 0
arising from cell synthesis. Proteins also can be broken down to supply energy for the I JI
body--on average, 4 kcal/g.10 NH2- r- c-oH
If you fail to consume an adequate amount of protein for weeks at a time, many H
metabolic processes slow down. This is because the body does not have enough amino "Generic" am.ino acid
acids available to build the proteins it needs. For example, the immune system no
longer functions efficiently when it lacks key proteins, thereby increasing the risk of in - H 0
fections, d isease, and eventually death.18 I II
NH - C -C-OH
i I
H
Amino Acids Glycine
Amino acids contai11 carbon, hydrogen, oxygen, ai1d nitrogen, and some contain sulfor.
Body proteins arc made using the 20 common amino acids, each with different meta- CH 3 0
bolic destinies in d1c body (e.g., some can be made into glucose or hormones) and vary- I II
NH-C-C- OH
ing composirion. 18 Each amino acid is composed ofa ccno-al carbon bonded to four groups. i I
The first tlm.!e oftl1ese groups are a nitrogen group (-NH2 ), called an amino group (or H
0 L-aJaninc
II
amine group), an acid group (-C-OH), and a hydrogen (- H). The fourth group,
often signified by R, completes the amino acid. In the margin is the basic model of an
amino add and structures of rwo amino acids, glycine and alanine. The chemical srruc-
rures of the rest of the amjno acids are shown in Appendi:-. A. he l isomer, rather than o D isomer, is the
form of amino acid used by lhe body for
protein synthesis.
Amino Acid Form and Fundion
The form that the R portion of the amino acid ral;:es determines the type name of d1e
amino acid. If R is a hydrogen, t he am ino acid is glycine; if R is a methyl group
(-CH3 ), me :muno acid is alanine; and so on. Somt: amino acids have chemically sun-
ilar R portions. These related amino acids fonn special classes, such as acidic amino
acids, basic amino acids, or branched-chain amino acids. This distinction with regard
tO classes of <Unino acids has important practical implications. For instance, branched-
chain amino acids are used for fuel by the muscles, especially during injury and other
related forms oftrauma. 18 Liquid formu las used to feed hospitalized patients may be en-
riched \\'ith branched-chain amino acids in ordc.:r to pro,1dc ample amounts. The same
holds true for some fluid replacement drinks marketed co athletes (see Chapter 14).
The body needs to use 20 common forms of am ino acids to function. Altl1ough
d1ey are all important, 11 of tl1ese amino acids arc considered n o nessential (also called nonessential amino acids Amino acids that con
dispmsablc)-ir isn't necessary to consume them because our bodies make them using be synthesized by o healthy body in sufficient
other amino :Kids we consume (Table 7- 1). The nine amino acids the body cannot amounts; there ore 11 nonessential amino
make arc known as essential (also called indispcmnb/c)-rJ1cy must be obtained from acids. These ore also called dispensable amino
foods. This is because body cells cannor make rJ1e needed carbon backbone (also called acids.
carbon skeleton ) of the amino acid, cannot put a 1utrogen group on the needed car- essential amino acids Amino acids that cannot
bon backbone, or just cannot do the whole process fast enough ro meet body needs. l O be synthesized by humans in sufficient amounts
Two amino acids-cysteine and tyrosine-art: synthesized in the body from me- or at all and lherefore must be included in the
thionine and phenylalanine, respectively. Both methionine and phenylalanine arc es- diet; there are 9 essential amino acids. These
sential amino acids. Cysceine and tyrosine must be made from their essential amino are also called indispensable amino acids.
acid coumcrparrs unless they are consumed in the dier. If cystcine and tyrosine arc semiessential amino acids Amino acids that,
consumed, me body can synthesize protein from them directly. Thus, consumption of when consumed, spore the need to use an
cysteine and tyrosine then frees the essential amjno acids methjonine and phenylalanine essential amino acid for their synthesis.
to connibute directly to protein synthesis. Therefore, cysteine and tyrosine are classed Tyrosine in the diet, for example, spores the
as semiessential (also called conditionnl~,, dispensnblc) amino acids. In some scenarios, need to use phenylalanine for tyrosine
such as infancy or adult:.~ with traumatic injury, other amino acids are a lso considered synthesis. These ore also called conditionolly
sem.icssential ( revie\\' Table 7-1 ).10 essential amino acids.
Both nonessential and essential amino acids are present in foods that contain pro-
tein. If you don't consume enough food to yield a sufficient supply of essential amino
acids, your body first struggles to conserYe what essential amino acids it can. However,
238 Chapter 7 Proteins
ecouse two cysteine molecules can bind to Table 7·1 I Classification of Am ino Acids
form o new amino acid called cystine, the
number of nonessential amino acids is some- Essential Amino Acids Nonessential Amino Acids
times listed as 12. If this form of cysteine is not Histidine Alanine
counted os o unique form, then there are
lsoleucine* Argininet
11 nonessential amino acids. The discussion in
this chapter does not count cystine and thus uses Leucine* Asparogine
the figure of 20 amino acids in foods: 9 essen-
lysine Aspartic acid
tial and 11 nonessential.
Methionine Cysteinet
Phenylalanine (Cystinel
Threonine Glutomic acid
Tryptophan Glutaminet
Valine* Glycinet
Prolinet
Serine
Tyrosinet
•A branched-chain amino acid

llhese amino acids ore also dossed as semiessentiol.
eventually your body progressively slows production of new proteins until at some
point you will break down protei n faster than you can make it. When this happens,
health deteriorates. Therefore, the rwo main fonctions of proteins in our diets arc
(1) to provide the nine essential amino acids needed by our bodies and (2) w provide
either the nonessential amino acids our bodies use, or n.itrogen from an am.ino acid that
in turn can be used to make the nonessential amino acids. t.o
Transamination and Deamination

A common metabolic process for synthesizing nonessential amino acids is called
transamination The transfer of an amino group transam.ination. This process requ ires vitamin B-6. Figure 7-1 illusu·ares transamina-
from an amino acid lo a carbon skeleton to tion: pyruvic acid ( this is not an amino acid ) accepts the amino group (-NH 2 ) from
form o new amino acid. the amino acid glmamic acid <Uld becomes tbe amino acid alanine. 10
deamination The removal of an amino group
Some amino acids, such as glutamic acid , can simply lose their amino group with-
from an amino acid. out transferring ir to another carbon skeleton. Tb.is process is called d eamination. The
amino group, in the form of ammonia, is incorporated into urea in the liver. The urea
urea Nitrogenous waste product of protein is then transferred through the bloodsu-eam to the kidneys and is mostly excreted in
metabolism; The major source of nitrogen in the urine. Once an amino acid breaks down to its amino-free carbon skeleton, the car-
0 bon skeleton can be used for fuel or synthesized in to otJ1er compounds, such as glu-
II cose (review Chapter 4).10
the urine; chemically NH2-C-NH 2.
Essential and Nonessential Amino Acids in Perspective

Eating a balanced diet can supply us with both the essential and nonessential amino
acid building blocks needed to maintain good health. This section takes a more de-
tailed look at this concept of essential amino acids, especially in relation to nonessen-
tial amino acids.
Physio logica l Aspects

The disease phenylketonuria (PKU) illustrates the importance of one essential amino
acid. Recall from Chapter 4 that a person with PKU has a Limited ability to metabolize
the essential amino acid phenylalan.ine. Normally, the body uses an enzyme to convert
Figure 7-1 I Tronsominotion. This pathway

0
allows cells to synthesize nonessential amino
II acids. In this example, pyruvic acid gains an
0 0 C- OH
amino group to form the amino acid alanine.
II II I By looking only ol the bottom hair of the
CH - C - H
CH3-C-C-OH
3 I reaction, deomination is seen when glutamic
acid loses its amino group, but there is not a
-----~ NH2 transfer of the amino group to a carbon
skeleton.
Pyruvic acid Alanine
I
I
I
I
I
0 I
0
II
C-OH
I
I
I
I
0 0 0
~ I I'
HO-C-CH2-CH2-C-H I
I
II II I
I HO-C-CH2-CH2-C-C-OH
I
NH
_, I
I
GJutamic acid Alpha-ketoglutaric acid
much of" our di<.:tary ph<.:nylalan.ine intake imo th<.: nonessential amino acid tyrosine by
adding a hydroxyl group (-OH).
ln PKU -tk1gno~ed persons, thi~ enzyme Jcti\'iry may be grossly or mildly insurfi - Rina is 7 months pregnant and hos read about
cient in processing phenylalanine to cyrosin<.:. vVhcn the enzymes cannot synthesize various tests that her baby will undergo when
enough tyrosine, both amino acids must be dcrivi;d from foods. The key point here is he or she is born. How con you explain lo
d1Jt no\\' tyrosine becomes essential in terms of dietary needs bcc.rnse the body can 'r Rina the purpose and significance of one of
produce c1~ough ofit.10 · · lhose tests, the one that screens for PKU2
Dietary Considerations-Protei n Q uality

Aninul and plant proteins can differ greatly in their proportions of essential and
nonessential amino acids. Animal proteins contain ample amounts of all nine essen-
tiaJ am.ino acids. (Gelatin-made from the animal protein collagen-is an exception
because it lost:s one essential amino acid du1ing processing <Uld is low in other cs-
senti<ll amino acids.) Wirh the exception of soy prOLein, planr proteins don't match
high-quality (complete) proteins Dietary
our need for essenrial amino acids as precisely as animal proteins. Many plant pro- proteins that contain ample amounts of all nine
teins, cspcciaUy those found in grains, are km in one or more of the nine l!sscntial essential amino acids.
amino acids. 14
A-; you mighr expect, !rnman tissue cumpusitiun rcscmbks animal tissue more than lower-quality (incomplete) proteins Dietary
it dot:s plant tissue. These similarities enable us ro use proteins from any single animal proteins that are low in or lack one or more
essential amino acids.
source more efficiently to support gro\\'th and maintenance than we do those from .rny
single plant source. For this reason, animal proteins, e).ccpt gelatin, arc considered limiting amino acid The essential amino acid in
hig h -q uaJity (,1lso called complete) pro te ins- they contain all nine essential amino the lowest concentration in a food or diet
acids we need in sufficient amounts. Individual plant sources of protein~, t:xcept for relative to body needs.
so~rbcans, arc considered lower-q ua lity (also ca lled incom plete) proteins when com-
complementary proteins Two food protein
pared to high-quality proteins because d1e~1 arc ei ther quite low in or missing one or sources that make up far each other's
more of the nine essential amino acids. Thil> ~uisi.:s because their amino a<.:id parterm. art.: inadequate supply of specific essential amino
quite different from oms. Thus, a single plant prorein, such as corn, cannot support acids; together they yield a sufficient amount of
body growth and maintenance if constu11cd a.lone. To obtain a sufficient amount of the oil nine and so provide high-quality (complete)
nine essential amino acids, a va1iety of planr proreins nc<.:ds to be consumed, bcc,mse protein for the diet.
each planL protein lacks adequate amounts of one or mon: ofrhc csscnrial amino acids. 14
his chapter has a section titled "Evaluation "When only lower-quality protein foods are consumed, enough of the nine essential
of Protein Quality," which describes meth· amino acids needed for protein synthesis may not be obtained. Therefort:, except fur
ods to measure protein quality. As you might soy protein, a greater amount of this type of protein is needed to meet the needs of
guess, the result depends on how closely the es· protein synthesis. Moreover, once any of tbe nine essential amino acids in thc plam
sential amino acid pattern in a food resembles protein is used up, fu rther protein synthesis becomes impossible. T he remaining amino
that found in human tissue. acids are used for energy or converted to carbohydrate or fat and stored as such.
Because the depletion of just one of the essential amino acids prevcnrs protein synthe-
sis, the process illustrates the all-or-rume principle: either alJ nine essential amino acids
are avai lable or no ne can be used. The remai11ing amino acids would then be used for
energy or converted to carbohydrate or fat. The essential amino acid in smallest supply
in a food or diet in i·clation to body needs becomes the limiting factor (caHcd the lim-
iting amino acid ) because it limits the amount of protein the body can synthesize.18
For example, assume the letters of the alphabet represent the 20 o r so different
amino acids we consume . If A represents an essential amino acid, we need four of these
letters to spell the hypothetical protein ALABAMA. If the body had an L, a B, and an
M, but only three As, the "synthesis" of ALABA.MA would not be possibl.e. A would
then be seen as the limjting am.ino acid.
When rwo or more dietar)' proteins are combined to compensate for deficiencies in
essential amino acid conte nt in each protein, the proteins arc called complementary
proteins (Table 7-2). Mixed diets generally provide high-quality protein because a
complementary protein pattern results. Therefore, healthy adults should have little
concern about balancing foods to yield tl1c proteins needed to obtain enough or all
nine essential amino acids. Evcn o n plant-based diets, complementing proteins need
nor be consumed at the same meal by adLLlrs. Meeting amino acid needs over the
coLu·se of a day is a reasonable goal because there is a ready supply of amino acids from
When combined with vegetables, high-protein those present in body cells and in the blood (see Figlll"e 7-8 on page 249 ). 18 [n addi-
foods such as meats also help balance the tion, adults need only about 11 % of their total protein requirement to be supplied by
amino acid content of the diet. essential amino acids. (The estimated needs for essential amino acids for infants and
preschool children arc about 40% of total protein intake.) Typical diets supply Jn a\"·
erage of 50% of protein as essential anlino acids.
Ir 'ff fl'lf..1 .. 1 Concept I Check

The human bod}' uses 20 diffrrenc amino acids from protein -containing foods. Because a
Leon, a vegetarian, hos heard of the "al/-or-
healthy body can synthesize 11 of tl1e amino acids, it is not necessary to obtain all amino
none principle ~ of protein synthesis but doesn't
acids from foods-only 9 of tl1ese must be obtained from the diet and arc therefore termed
understand how this rule applies to protein syn-
essential amino acids. Foods that contain all aine essential amino acids in about the propor·
thesis in the body. He asks you, "How impor·
tions we need are considered high-quality (complete) protein foods. Those low in one or
font is this nutritional concept for diet
more essential amino acids are lower-quality (incomplete) protein foods. When different
planning?'' How would you answer his
lower-quality protein foods are eaten together, the total im.ake of amino acids generall)'
question? makes up for shortcomings of each individual food co yield a high-qualiry protein meal.
Proteins-Amino Acids Bonded Together

One way of classif~,ring proteins is based on tl1e number of amino acids present. Two
anlino ac.ids chemically bonded together form a dipeptide, and three amino acids form
a tripeptide. An oligopeptide has more than 3 but fewer than 50 amino acids. A
polypeptide Fifty to 2000 or more amino acids poly peptide has 50 or more amino acids. Most proteins in foods contain polypeptide
bonded together.
c hains. JO However, specialized liquid meal replacement supplements used in hospitals
peptide bond A chemical bond formed to link often contain various small peptides because these show enhanced absorption com-
amino acids in a protein. pared with larger polypeptides (see the section in this chapter tided Protein Digesrion
and Absorption) .
Table 7·2 I Limiting Amino Acids in Plant Sources of Protein
Limiting Good Plant Sources of the Traditional Food Combinations in Which

Food Amino Acids Limiting Amino Acids' the Proteins Complement Each Other
Beans and mosl other Methionine Wheat germ, seeds, peanuts, dry roosted soybeans Hummus and whole-wheat Aatbread
legumes Tryptophan Seeds, peanuts, dry roosted soybeans, wheat germ
Tree nuts and seeds Methionine Wheat germ, peanuts, dry roosted soybeans Whole-wheat bread and cashew butter
Lysine Wheat germ; whole-groin bread; cornmeal; dark Roosted soybeans with almonds
rye bread; soybeans, and other legumes
Groins (wheat, Lysine Wheal germ; whole-grain bread; cornmeal; dork Rice with beans
rice, oats) rye bread; soybeans, and other legumes
Vegelobles Melhionine Wheat germ, seeds, peanuts, dry roasted Green beans and sunAower seeds
soybeans
lysine Wheat' germ; whole-groin bread; dork rye bread; Beans in vegetable soup
cornmeal; soybeans, and other legumes
Source: USDA Notional Nutrient Ootobose for Standard Reference, Release 18, Agricultural Research Service, Nutrient Doto
Nate As you might suspect from the information in this table, the amino acids most likely lo be low in a diet are lysine, methionine, threonine, ond lryptaphon. If a diet is low in an amino acid, nutrition ex·
perts recommend finding a good food source la supply it. finding the right combinations of amino acids, soc:h os a dish of ricn and beans, 1s recommended. Forget about amino acid supplements-they
con lead to problems, such as d11Creosed absorption of other, similar amino acids. Amino acid supplements also hove a disagreeable odor and RoYO< and are much morn expensive than food p<atein
·Animal products in the diet serve the some purpose, such os when rice is consumed with fish
Amino add~ .ire joined b~ a !>trong, 1.'.0V<llem (e.g., electron-sharing;) pept ide bo nd .
0
II
An amino group (- NH 2 ) reacts \\'ith a carboxyl g roup (-C-OH), and a water mole-
cule i:. split off in .rn e tnyme-catalyzed rc:iction. The body can synrhesize many d iffer-
ent protc.:ins by joining; the 20 types of common am ino acids with such pept id1: bonds.
Protein Synthesis
Since the human gcnome was deciphered in 2000, interest in human genetic!. and the
role it plays 111 disease has increased. This ropic was discussed in Chapter I . \ Vhat "asn 't
covered in detail in th.u chapter is how cells use the genome to m:ike body proteim.
This discussion bcgms with the wmposition of D~A, pn:sent in the nudcus or the
cell. Recall !Tom Chapter 1 that D~A 1s a double-stranded molecule in a helical form.
Each strand of D~A is composed offour nucleotides: adenine (A), guanine (G ), q to
SH
sine ( C), and thymine (T). Each of the nucleotides is complemenrar~ to (binds w) .m- I
other nucleotide; A and T arc complemenrarv, as are C and G. Soon you ''ill sec '' hy
that is import.mt.
D~A contains coded imtructions for protein synthesis corn.isting of a ~cquencc of
H-N
HE1H2
I II
C-N
c~
C-OH
three nucleotides per unit of instruction (e.g., which specific amino .1cid is to be pl.1ced '\. I II
in .1 protein .111d in \\hich order). 10 These nuclcmide units (e.g., GAG ) ar1: called C H 0
codons and c.ich DNA codon represents a specific amino acid. For example, L111: wdon
CTC represent!> the amino acid glutamic acid. Some amino acids ha,·c only om: rossiblc
tH 3 \Peptide bond
• •.
. .......•.
codon, whereas others have as many as six. The amino acid gluramic acid ar.:ruall)' ha:.
... ;~.4
I . . ·~· • .._
rwo codons: CTC and CIT. Having the correct codons in the DNA is critical for pro-
. ·~., '·~·\:
,,. \.,.·.
d ucing the correct protein, since the order of the codons in the DNA indicates the.:
order of the specific amino acids needed to synthesize a particular protein. 18 This is im-
:e-.. ~· . ~. ~· ~~.•,•··..~ •, -~( .'.}.. portant, because mistakes in the order or types of amino acids in a protein can rcsuJr
.
,· .·~ in profound hc:tlth consc::quences (sec the discussion of sickle-cell disease in the next
section of rbis chapter).
. :f·
.•
.
•
.
..
l '
·r··, .,..
. -,
. "' <e . .... .
.......
.~-~ ' .,• "
Protein syntl1esis in a cell takes place in the cytosol, not in the nucleus. Thus, rhe
-
w • • .. . . .
: ...: •
_ • ... DNA code used fur synthesis ofa specific protein must be transfrrred from rhe nucleu:.
.
. ·~· ·~ " ,J. .·r-..'
·.~ . to the cytosol to allow for such synthesis. This transfer is the job of messenger fu'JA
(mRNA). To produce mRNA, the DNA in the nucleus unwinds from its supen.:oiled
~... ... .. ...~
· - ..... .1,. . . .
. .
~ ~ .
- state. Enzymes rt:ad the code.: on the DNA and transcribe that code into a comple-
mentary single-stranded mRNA molecule, called t he p rimary tr:.lllscript (Figure 7-2).
Genes ore present on DNA-o double-stranded Th.is is the DNA transcrip tion phase of protein synchesis. The segmenr that is read is
helix. The cell nucleus contains most of the the gene. In this process, A becomes uraciJ (U), C becomes G, T becomes A, and G
DNA in the body.
becomes C. You might wonder why A did not become T, considering that A and T .m:
compkmenrary. Ir nirns out that mRNA uses uracil (U) instead of thymine (T) in it~
DNA transcription Process of forming code. Thus, d1t: DNA code ACTGAT yields an mRNA of UGACUA. The actual DNA
messenger RNA (mRNA) from a portion codons ru·e ACT and GAT:
of DNA.
A C T G A T
mRNA translation Synthesis of polypeptide
chains at the ribosom e according to f f f f f f
information contained in strands of messenger U G A C U A
RNA (mRNAJ .
T he pri mary transcript mRNA undergoes processing in the nuckus to remove any
parrs of the DNA code that do not codt: for protein synthesis, called introns (these ac-
t-ually make up much or the DNA). (The portions of the DNA d1at code for protein
synthesis are called exons.) Some additional processing then takes place, ,111d the fln,11
(mature) mRNA u-anscript is ready ro ka\'e the m1clcus.
The mRNA travels to the ribosomes in the cytosol, present on the rough endoplas-
mic reticulum. The ribosomes read tl1e codons on the mRNA and translate thrn.e in-
Synopsis of the Ste ps in Protein
structions in order to produt:c a specific protein. Th is is the mRNA translation phase
Synthesis Port of DNA code (gene) is
of protein synthesis. Amino acids are added one ar a time to the polypeptide chain a.~
transcribed to mRNA in the nucleus.
directed by tl1e instructions on the mRNA. Energy input from ATP is needed to add
•f
mRNA leaves the nucleus and travels lo cylosol.
each amino acid to the growing polypeptide chain, making protein synthesis very
"costly" to tl1e body in terms of energy use. Many ribosomes can combine to simulta-
neously translate a large mRNA.
Protein synthesis begins at a specific starting point on the mRNA, indicated by
Ribosomes in the cytosol and rough
AUG. It then continues unti l a specific ending (stop) codon is reached, such as UAA,
endoplasmic reticulum read the mRNA code
UAG, orUGA.
and translate tha t into directions for a specific
O n e key participant in protein synrhcsis in tl1e cyrosol is mmstcr RNA (t.RNA).
order of amino acids in a polypeptide chain.
These units bring amino acids to the ribosomes as needed during protein syntl1esis (re-
To produce the polypeptide, tRNA brings the

appropriate amino acid to the ribosome as
• view Figure 7-2). The tRNA c~lrriers have a complementary code to the mRNA-such
tbat, if an arginine were necded dlU'ing synthesis, the AGA on rhe mRNA would cor-
respond to UCU on the transfer RNA. Numerous tRNA carriers are present during
dictated by the mRNA code. The amino acid is protein synchesis to continmlll}' supply the ribosomes with needed amino acids.
added to the existing amino acid chain, which O nce synthesis or the polypeptide is completed, indicated by the ending codon, it is
begins with the amino acid methionine. released from the ribosome, ai. is die mRNA. The polypeptide now twists and folds inm
a very complex three-dimensional strucnire (see tl1e follo\\~ng section on protein or-
f ganization for details). 18 Some polypeptides, such as the hormone insuliJ1, also undergo
When synthesis of the polypeptide is complete,
fu rth er metabolism in the cell befi:n-e they are ti.mctional. Generally, if synthesis of :i par-
it is released from the ribosome.
ticular protein needs to be increased in a cell, more mRNA for that protein is made.
+
Oken the polypeptide will undergo further cell
T he important message in this discussion is the relationship between DNA and rhc
pro reins evearually produced by a cell. If the DNA contains errors, an incorrccr mRNA
metabolism in order lo function as o specific 'Will be prod uced. The ribosomes will then read this incorrect message .111d produce <\11
body protein once it folds into its active form. incorrect polypeptide chain. As discussed in Chapter 1, Ltlcimardy we may be .1ble to
(a ) Figure 7 - 2 1Protein synthesis {simplified). (a} DNA present in the

nucleus of the cell is composed of four nucleotides: adenine (A}, guanine
(G}, cytosine (C}, and thymine (T) (l}. The DNA code is read, three
nucleotides at a time, with each specific unit being called a codon. Each
DNA codon represents a specific amino acid. The DNA unwinds from its
supercoiled state and the code embedded in the order of the nucleotides
is transcribed into a complementary messenger RNA (mRNA; labeled as
the primary RNA transcript) (2). The mRNA is processed in the nucleus
and then is ready lo leave the nucleus. The mRNA travels to the cytosol,
where the ribosomes then read the codons on the mRNA and translate
those instructions in order to produce a specific protein (3). (b) Protein
synthesis at the ribosomes begins at o specific starting point, indicated
pore by AUG (4). Protein synthesis then continues by adding one amino acid
al a time to the growing polypeptide chain until a specific ending (stop)
codon is reached, such as UAA, UAG, or UGA (5). Transfer RNA (tRNA)
units bring amino acids lo the ribosomes as needed during protein
synthesis (6). The tRNA carriers hove a complementary code to the
Tronslation JIJ mRNA-such thol, if on arginine were needed during synthesis, the
Iby ribosomes AGA on the mRNA would correspond to UCU on the tRNA. Numerous
tRNA carriers are present during protein synthesis lo continually supply
the ribosomes with needed amino acids. ATP is used to supply the
energy needed to activate tRNA in order to form each new peptide
Cell bond. The polypeptide is then released from the ribosome when it
membrane Protein
encounters the ending (stop} codon (7). Appendix A contains the
/. abbreviations used for the amino acids in this figure, such as "met" for
"methionine."
(b) Cytosol of the cell
met met
Amino odd
j
Ribosome
The initiation complex forms A tRNA carrying the amino A peptide bond for ms As the first tRNA detaches Polypeptide released when
when the ribosomal subunits acid specified second in the between the adjacent amino from the mRNA template, the the ribosome eventually
and the first tRNA molecule mRNA sequence plugs into acids. second moves over, trailing encounters the ending (stop)
lock into o strand of mRNA the complex. its small amino acid chain. codon, which in this
at the slorl codon (AUG). A third tRNA sits down of example is UAA.
the vacated site, which is
now situated over the next
codon in the sequence.
correct gene defects such that the correcr DNA code can be placed in the nucleus so
thac the correct protein can be made by the ribosomes.
S ulfur-conta ining amino acids stabilize many

compounds, such as the hormone insulin.
Sulfur atoms can bond together (-S- S-), cre-
Protein Organization
The sequential order of che amino acids in the polypeptide chain, called primm·y stmc-
ating a bridge between two protein strands or
ture) determines a protein's shape. The key point is that only correctly positioned
two parts of the some strand. This stabilizes the
amino acids can interact and fold properly to for m the intended shape for the protein
structure of the molecule and is also part of what
and, in ttm1, allow for the chemical attractions to form between amino acids near ead1
is called secondary structure.
other rhat are needed to stabilize the su·ucture, such as hydrogen bonds (see Appendix
A for details) . This is part of what is called secondary stmcture. The resulting unique
three-dimensional conformation, called tertia1·y stritcture) dictates the function of each
protein. I fa protein lacks the appropriate configuration, it cannot function. 10
In some cases, two or more separate polypeptide un its interact to form an even
larger new protein form, termed a tptaternary structure (Figure 7-3 ). This level of o r-
ganization becomes significant when it is important to have a protein active only at cer-
tain times. A protein may be active when the units arc joined but inactive when the
units are separate.
sickle-cell disease (sickle-cell anemia) An illness Sickle-cell clisease (also called sickle-cell anemia) illustrates what h:lppens when
that results from a malformation of the red amino acids a.re out of order in the primary structure of a particular protein. African
blood cell because of an incorrect primary Americans (about 3 cases per 1000 births) are especially prone to this genetic disease.
structure in part of its hemoglobin protein It o riginates from a mutation in the DNA sequence and results in defective production
chains. The disease can lead to episodes of
of the protein chains of hemoglobin, a protein that carries oxygen in red blood cells.
severe bone and joint pain, abdominal pain,
In t\:vo of its four protein chains, an error i11 the amino acid order occurs, one on each
headache, convulsions, paralysis, and even
death.
chain. This c:rror produces a profound change in hemoglobin structme: It can no
longer form the shape needed to carry oxygen efficiently inside tl1e red blood cell.
Instead of forming normal doughnuc-shapcd disks, the red blood cells collapse into
crescent (or sickle) shapes (Figme 7-4). Healtl1 deteriorates, and eventt1aUy episodes of
severe bone and joint pain, abdominal pain, headache, convulsions, and paral~1sis may
occur because t he sickled cells clump in the c~1pillar y beds, hampering blood flow ro
the target tissue. Treatment for this disease iodudes blood transfusions, medications
(e.g., hydroxyurea) to increase red blood cell synthesis, and bone marrow transplants.
denaturation Alteration of a protein's three. Denaturation of Proteins

dimensional structure, usually because of
treatment by heat, enzymes, acid or alkaline Exposm·e to acid or alkaline substances, heat, or agitation can alter a protein's srruc-
solutions, or agitation. tt1re, leaving it in a denatured state (Figure 7-5). T he protein can no longer perform
its function . For example, once the bacteria in yogu rt have synthesized enough acid
Figure 7-3 1Levels of protein structure. Four

Ala~ine ',,',,,
different levels of structure are found in
proteins. The primary structure of a protein is Glycine
the linear sequence of amino acids in the I
polypeptide chain . Secondary structure consists Serine
of areas in the polypeptide chain tha t have a
specific shape stabilized by hydrogen and Valine
I
other bonds. The total three-dimensional shape
Leucine
of entire proteins is coiled tertiary structure.
I
Some proteins also show quaternary structure
Lysine
where two or more protein units join together lo I
form a larger protein, such as hemoglobin Glycine
depicted in the figure. I
Valine , ,-',-
Primary Se<ondary Tertiary Quaternary

(b)
(a )
Figure 7-41 An example of the consequences of errors in DNA coding of proteins. (o} Normal red blood cell; (b) red blood cells from o person wi th sickle-
cell disease: note their abnormal crescent (sicklelike) shape.
and enzymes to denature some of the milk protein, the product solidifies irreversibly.
Note that this or any denamration does not affect the primary strucmre.
Unraveling a protein's shape often destroys its normal fw1Ctioning such that it loses
its biological activity. That characteristic is usefo l for some body processes, such as di-
l
(a )
gestion. 18 The secretion of hydrochloric acid in the stomach denatures some bacterial
protein, p l~rnt hormones, many active enzymes, and other forms of proteins in foods. Heat /Acid
The beat produced during cooking likewise denatures proteins. Both processes make
foods in general safer to eat. Digestion is also enhanced because the w1raveling in-
creases exposure of the food to digestive enzymes. Denaturing proteins in some foods
1
can also reduce their tendencies to cause allergic reactions.
Recall that we net:d proteins in the diet to supply essential amino acids-not the ac- (b)
tive proteins themselves. \Ve dismantle dietary proteins an d use their amino acid build-
ing blocks to assemble the proteins we need.
Concept l Check Figure 7·5 I Denoturotion. (o} Protein

Amino acids are linked together in specific sequences to form distinct proteins. DNA pro- showing o typical coiled stole. (b) Protein is
vides the directions for synthesizing these new proteins. Specifically, DNA directs the order now portly uncoiled, exhibiting a denatured
of the amino acids on the protein. The amino acid order within a protein determines its ul- state. This uncoiling typically reduces or
eliminates biological activity.
timate shape and function. Destroying the shape of a protein denatures it. Acid cond itions
prescnr during the body's digestive processes, heat, and other faccors can denantre proteins,
causing them to lose their biological activity.
Protein Digestion and Absorption

As in carbohydrate digesrion, the first step in protein digestion takes place in the cook-
ing of food. Cooking unfolds (denan1res) proteins and softens tough connective tissue
in meat. Cooking also makes many protein-rich foods easier to chew, swallow, and
break down during later digestion and absorption.
Digestion
The enzymatic digestion of protein begins in the stomach .10 Once proteins are dena- pepsin A protein-digesting enzyme produced
tured by stomach acid, pepsin, a major enzyme for digesting proteins, goes to work by the stomach.
(Figure 7-6 ). Stomach acid tmravels the proteins, which allows pepsin to attack the
Protein
0 Partial protein digestion

by the enzyme pepsin
and stomach acid
Further protein digestion

by enzymes released by
the pancreas
Amino acids absorbed
into the portal vein a nd
transported lo the liver.
From there they enter
the general bloodstreom.
El Final digestion of protein
to amino acids tokes
place mostly inside cells
of the small intestine.
Little die.tory protein is

present in feces.
Figure 7 · 6 1A summary of protein digestion and absorption. Enzymatic protein digestion begins in the stomach and
ends in the absorptive cells of the small intestine, where the lost peptides ore broken down into single amino acids.
Stomach acid and enzymes contribute to protein digestion. Absorption from the intestinal lumen into the absorptive cells
requires energy input.
polypeptide chains and break them down into shorter chains of amino acids. Pepsin
does not completely separate proteins into amino acids because it can break o nly a few
of the man y peptide bonds fo und in these large molecules. The reaction that takes
place is a hydrolysis reaction, because water is used to break down the bond (see
Appendix A).
zymogen An inactive form of on enzyme that Pepsinogen, the inactive form of pepsin (called a zymogen ), is produced by the
requires the removal of o minor part of the chief cells of the sromach. In proximity are acid-forming cells (parietal cells) and
chemical structure for it to work. The zymogen mucus-forming cells in the stomach (review Figure 3-7). If pepsin were not stored as
is converted into an active enzyme at the an inactive enzyme, it would digest the stomach glands while waiting to be secreted
appropriate time, such as when released into from the pits. Once pepsinogen enters the stomach's acidic environment (pH between
the stomach or small intestine. 1 and 2), part of the molecule is split off, forming the active enzyme pepsin.
gostrin A hormone that stimulates enzyme and The release of pepsin is controlled by che ho rmone gastrin (review Table 3-3 ).
acid secretion by the stomach. Thinking about food or chewing food stimulates gastrin-producin g cells in the termi-
nus of the stomach to release the hormone. Gastrin also strongly stimulates the stom-
ach's parietal cells to produce acid.
The partially digested proteins move with the resr of the nutrients and other sub-
stances in a meal (chyme) from the stomach into the duodenum, the first part of the
small intestine. Once in the smal l intestine, the polypeptide units (and any fats accom-
panying them) trigger the release of the hormone cholecystok.inin (CCK) from the
walls of the small inrestinc. CCK, in turn, travels through the bloodstream to its tar-
ger organs, the pancreas and gallbladder. I tS arrival causes the pancreas to release the
protein-splitting enzymes t r ypsin, chymotrypsin, and carboxypeptidase, which arc re- trypsin A protein-digesting enzyme secreted by
leased into the small intestine in their zymogen forms and then activated by digestive the pancreos to act in the small intestine.
secretions. Together, these digestive enzymes further divide the polypeptides imo
short peptides and amino acids. Eventually, digestion of all peptides into amino acids
occurs using other enzymes secreted into the intestinnl lumen by glands located in the
wall of the small intestine as well as enzymes present inside Lhe absorptive cells of the
small intestine. 1O
Absorption
The smalJ peptides and amino acids in the lumen of the smalJ intestine are actively ab-
sorbed into the cells of the small intestine (Figure 7-7). 18 Eleven or so different transport
mechanisms in the intestinal tr;.icr have been described. The absorbed small peptides,
Figure 7-7 1Protein digestion takes place in
B ~· Polypeptides
} ,9a,h
the stomach (1) lumen of the small intestine
(2) and the absorptive cells of the small
intestine (3). Then, in a sodium-dependent,
energy-requiring process (active absorption), all
r--~~~~~~~---.7"'.-..~~~~~~~~~~~ of the end products of protein digestion are
absorbed at the microvilli surface. Any
Amino D remaining peptides ore broken down to amino
acids acids within the absorptive cell. These free
Lumen of amino acids ore released into the bloodstream
small intestine
(4). The enzymes used come from the stomach,
Tripeptides Di peptides pancreas, and absorptive and glandular cells
'- tho! line the small intestine.
Absorptive
cell of
small
intestine
Amino
acids
247
then, arc eventually broken down to individual amino acids inside tbc intestinal cells.
The amino acids travel via the portal vein that drains the intestinal tract and connects
to the liver. There the amino acids are combined into protein, converted to nonessen-
tial amino acids, carbohyd1·ate or fat, used for energy needs, or released into the blood-
stream. Of these options, conversion to far is the least likely.
Except dui-ing infancy, it is w1conunon for intact proteins to be absorbed from the
digestive tract. In rl1e period of infancy (up to 4 to 5 months of age), the gastroin-
testin:il tract is somewhat permeable to small proteins, so some whole proteins can be
absorbed. Because proteins from some foods (e.g., cow's milk and egg whites) may
predispose an infant to food allergies, pediatricians and registered dietitians recom-
mend waiting until an infant is at least 6 to 12 months of age before introducing com-
monly al lergenic f()ods (see Chapter 17 for details).
Concept I Check
Enzymatic protein digestion begins in the stomach. [n the small intestine, protein break-
down products formed in the stomach separate inro dipeptides and tripeptides and finally
into amino acids as these further breakdown products enter the absorptive cells of tht: small
intestine. T he amino acids tl1en n-avel via the portal vein that connects w the fiver.
Functions of Proteins
Proteins function in many crucial ways in human metabolism and in the formation of
body strucrures (Figure 7-8). We rely on foods to supply the amino acids needed to
form tl1ese proteins. Note, however, that only when we also cat enough carbohydrate
and fat can food proteins be used most efficiently. If we don't consume enough energy
to meet energy needs, some amino acids from proteins are broken down to produce:
energy, rendering them ll11available to build body proteins.
Producing Vital Body Structures

Every cell contains protein. Muscle tissue, connective tissue, mucus, blood-clotting
fuccors, transport proteins u1 the bloodstream, 1ipoproteins, enzymes, immune bodies,
some hormones, visual pigments, and rl1c support structure inside bones are mainly
made of protein. 18 Half of body protein is made up of the so:ucru.ral proteins collagen,
actin, and myosin as well as the oxygen-transporting protein hemoglobin. This struc-
tural role is tbe primary ftmction of protein in the body. Measurements of the amounts
of certain body proteins, particularly some of rl1ose in the blood, are used as indicators
of health or disease. Excess protein in the diet doesn't necessarily enhance the synthe -
sis of body components, but eating too little can impede it.
Protein Turnover-Adapting to Changing Conditions

Most vital body proteins are in a constant state of breakdown, rebuilding, and repair,
protein turnover The process by which a cell especially in the bone marrow and the small intestine. This process, called protein
breaks down existing proteins and then turnover, allows cells to adapt to changing circwnstances. 10 For example, when we eat
synthesizes new proteins. Thus the cell con more protein than necessary for health, the liver needs to make more enzymes to process
adopt to changing conditions: it will have the the waste product from the resulting amino acid metabolism-namely ammonia-into
necessary proteins as the need for them arises. urea. The amino acids needed to make the enzymes can come from the diet and from
slough To shed or cast off. amino acids released from the breakdo\vn of other proteins in cells. For example, the
GI tract lining is constanrly slou gh ed off. The digestive tract treats sloughed cells
just like food particles and absorbs the amino acids released during their digestjon.
In fact, most protein breakdown products-amu10 acids-released thi-oughout the
body can be rec)rded and are added ro t he pool of amino acids available for future
protein synthesis. Overall, protein turnover is a process by \\'hich a cell can respond
Figure 7 · 8 I Amino acid metabolism. The

Amino acids from Amino acids amino acid pool in a cell con be used lo
cell breakdown from diet
supply amino acids to form body proteins, as
well as to form a voriely of other possible
products-such as fot and glucose-from
Synthesis of nonprotein amino acid carbon skeletons. The urea that
nitrogen-containing results is a waste product made from the
Synthesis of body proteins
for cell structure and other compounds. such as
serotonin nitrogen-containing ammonia (NH 3) released
needed components, such during amino acid breakdown. It is excreted in
as enzymes, hormones, and
muscle contractile proteins ( the urine.
Fat made from amino
Amino acid
acid carbon skeletons
pool in cell (liver cells only, and
generally not much)
Energy production from
~
lucose production
amino acid carbon skeletons
for body cells: yields on
overage 4 kcal/ g from amino acid carbon
keletons {liver and
kidney cells only)
pool The amount of a nutrient found within the

body that con be easily mobilized when
needed.
carbon skeleton What remains of on amino

acid ofter the amino group hos been removed.
to its cbanging environment and produce needed proteins while reducing the quan- Somontba s mother's blood concentration of
tity of proteins not cmrently needed. urea is high. From a health status point of
During any day, an adult makes and degrades about 250 to 300 g of protein, a.nd view, whal might this indicate?
many of the amino acids arc recycled. By comparing 250 to 300 g with the 65 to 100 g
or more of protein typicall y consu med by ad ul ts, you can see d1e impo rtanc<.: of recy-
cling amino acids in the body when possible. to
Hormones that increase protein syntllesis are insulin and growth hormone. In con -
acquired immunodeficiency syndrome (AIDS) A
trast, the hormone cortisol incr eases protein breakdown. disorder in which a virus (human
A practical example of the concept of protein turnover occurs in unu·eated acquired immunodeficiency virus [HIV]) infects specific
immunodeficien cy syndrom e (AIDS), as seen in the developing world (see Chapter 20). lypes of immune system cells. This leaves the
Rates of protein synthesis are similar in healthy people and tl1osc with L1ntrcared o r un- person with reduced immune function and, in
a·eatable cases of AIDS, bur the rates of protein degradation are much higher because;: turn, defenseless agoinsl numerous infectious
of the effects of the disease. Over time, these higher rares reimlr in much prorein wasr- agents.
ing in people with AIDS.
If a person's diet is deficient in protein for a long period of time, the rebuilding and
repairing process slows. Even tually, skeletal muscles, heart, liver, blood proteins, and
other organs decrease in size or volume. Only tbe brain resists protein breakdown.
Maintaining Fluid Balance

Blood proteins-albumins and globulins-maintain body fluid balance. Normal blood
pressure in the arteries forces blood into capillary beds. The blood Auid then moves
capillary bed Minute vessels one cell thick tho! fi-om the capillary beds into the spaces between nearby cells (extracellular spaces) to
create o junction between arterial and venous provide nutrient~ to those cells (Figure 7-9). Proteins in the bloodstream such as al-
circulation. Gos and nutrient exchange occurs bum.in are too large, however, to move out of the capiUary beds into the tissues. The
here between body cells and the blood. presence of these proteins in the capillary beds attracts the proper amount of fluid back
extracellular space The space outside cells. to the blood, partially counteracting the force of blood pressmc. This is especially rrue
in the areas of tbe capillary beds right next to their venous connections.
edema The buildup of excess fluid in With inadequate protein consumption , the concentration of proteins eventually de-
extracellular spaces. creases in tbe bloodstream. Excessive fluid then bujjds up in the surrounding tissues
because the counteracting force produced by the smaller amount of blood proteins is
too weak to pull enough of the fluid back from the tissues into the bloodstream. As
fluids accumulate in rhe tissues, the tissues swell, causing clinical edema. 18 Because
edema sometimes can be a sign of serious medical problems, the cause must be iden -
F igure C-5 in Appendix C provides ode-

tailed view of a capillary bed.
tified. An important step in diagnosing the cause is to measure the concentration of
blood proteins, although many other medical problems also cause edema.
Contributing to Acid-Base Balance

Proteins help regu late the acid-base balance in the blood. Proteins located in cell mem-
branes pump chemical ions in and out of cells. The ion concenrrations that result from
buffers Compounds that cause a solution to the ptunping action, among other factors, keeps the blood slightly alkaline. Buffers-
resist changes in acid-base balance. compounds that maintain acid-base conditions withi11 a narrow range-arc another
Figure 7-9 I Blood proteins in relation to

Auid balance. (o) Blood proteins ore important
for maintaining the body's fluid balance, since
they draw fluid back into the capillary bed.
(b) Without sufficient protein in the
bloodstream, edema develops because the Fluid forced
counteracting force to blood pressure provided (a) into ti ssue
by blood proteins declines. spaces by
blood pressure Fluid drown into
generated by l:iloodstreom by the
pumping action of , proteins as blood pressure
heart declines in the capillary bed
Blood pressure
Blood pressure
exceeds
balanced by counteracting force
counteracting of protein, and so
force of protein fluid remains in the
(b) tissues
Normal tissue Swollen tissue {edema)

means ofregulating acid-base balance in the blood. Some blood proteins are especially eurotransmilters, released by nerve end·
good buffers for the body. Hemoglo bin is extremely important in maintaining normal
blood pH. 10
N ings, are often derivatives of amino acids.
This is true for dopamine (synthesized from the
amino acid tyrosine), norepinephrine (synthe·
Forming Hormones and Enzymes sized from the amino acid tyrosine), and
serotonin (synthesized from the amino acid
Amino acids are required for the synthesis of most hormones-our internal body mes- tryptophan). 10
sengers. Some hormones, such as the thyroid hormones, are made from only one
amino acid, tyrosine. Insulin, on the other hand, is composed of 51 amino acids. These
and other hormones classified as proteins perform important regulatory functions in
the body, such as conrrolling the metabolic rate and amount of glucose taken up from
the bloodstream. Almost all enzymes are also proteins or have a protein componcnt. 18
Contributing to Immune Function

Proteins are a key component of the ceUs used by the immune system, such as lettko-
cytes and lymphocytes. Also, the antibodies produced by one type of immune cell
(13-lyrnphocytes) are proteins. LS These antibodies can bind to foreign proteins in the
body, an important step in removing invaders from the body. Without sufficient di-
etary protein, the immune system lacks the materials needed to function properly.
Thus, immune incompetence-anergy-and a protein-deficient diet often appear to- energy Lock of on immune response lo foreign
gether. Anergy can rum measles into a fatal disease for a malnourished child. It also can compounds entering the body.
encourage unusual infections, such as widespread yeast (Candida) growth in the
mouth and throat of a hospitalized adult. 10
Forming Glucose
In Chapter 5 you learned that the body must maintain a fairly constant concentration
of blood glucose ro supply energy for red blood cells and nervous tissue, such as the
brain. At rest, the brain uses about 19% of the body's energy requirements, and it gets
most of that energy from glucose. ff you don't consume enough carbohydrate ro sup-
ply the glucose, your liver (and kidneys, to a lesser extent) will be forced to make glu- he vitamin niacin con be made from the
cose from amino acids present in body tissues (review Figw-e 7-8). Recall from Chapter 4 amino acid lryptophan, illustrating another
that this process is called gluconeogcnesis ( review Figure 4-16). 10 role of proteins.
Malung some glucose from amino acids is normal. For example, \Vhen you skip
breakfast and haven't eaten since 7 P.M. the preceding evening, glucose must be man-
ufactw·cd. In an cxa·eme situation, however, such as starvation, the conversion of
amino acids into glucose wastes much muscle tissue and can lead to cach ex.ia. cachexia Widespread wasting of the body due
lo undernulrilion.
Providing Energy
Proteins supply very little energy for a weight-stable person. Two exceptions are pro-
longed exercise (sec Chapter 14 for information about the use of amino acids for en-
ergy during exercise ) and energy restriction, such as with a low-caloric diet. In these
cases the carbon skelerons of amino acids are metabolized for energy.
StiU, under most conditions, cells use primarily fats and c.'1.rbohydrates for energy.
Although proteins and carbohydrates contain the same amount of usable energy--on av-
erage, 4 kcal/g-proteins are a very costly source of energy, considering the amount of
metabolism and processing the liver and kidneys must perform to use this energy source. 10
Contributing to Satiety
Compared to the other macronutrients, proteins provide the highest feeling of satiety
after a meal. Thus, including some protein witl1 each meal helps conu·ol overall food satiety A stale in which there is no longer a
intake. Many experts warn against skimping on protein when crying to reduce energy desire lo eat; a feeling of satisfaction.
intake to lose weight. Meeting protein needs is still important and exceeding needs
oo little protein in the diet also contributes to somewhat may provide an additional benefit when dieting ro lose weight (see Chapter
poor bone health. This effect has been 13 for details). 16
shown in older people who do not eat enough
protein. for anyone following a balanced diet, Concept I Check
this is not a concern. B
Vital body muctures-such as muscle, connective tissue, blood transport proteins, en·
zymes, hormones, buffers, and immune factors-are mainly proteins. The breakdown of ex-
isting proteins and synthesis of new proteins rakes place on a minure-by-minure basis,
amounting to a turnover of about 250 to 300 g a day for the entire lmman body. Proteins
can also provide fuel for the body and can be used for glucose production.
Protein Needs
How much protein (actually, amino acids) do we need to eat each day? People who
aren't growing need to eat only enough protein to match daily losses as evidenced by
protein breakdown products in the urine and protein lost as such from feces , skin, hair,
nails, and so on. In short, people need to balance protein intake with protein losses,
producing a state of equilibrium. 10
When a body is growing or recovering from an illness, it needs extra protein to sup-
ply the raw materials required to bujJd new tissues. To achieve this, a person mL1st cat
more protein daily than he or she loses. In addition, the hormones insu lin, growth hor-
mone, and testosterone a.lJ stimulate this building of new tissue. Merely eating more
protein does not produce adrutionaJ body tissue unless the right hormonal conditions
associated with the growing years or pregnancy exist. Resistance exercise (weight c:ra.in-
ing) also enhances protein synthesis.
For healthy people, d1e amow1t of dietary protein needed to compensate for a.lJ evidence
of prorcin losses can be determined by increasing protein intake until it just equals such
losses. (Energy needs must be met so d1at amino acids are not diverted for energy use.)
To determine this balance between protein grun and loss by the body, researchers
actually track niu·ogen intake and loss (Figure 7-10 ). 10 It is much easier to quantify ni-
trogen intake and loss. Nitrogen makes Lip, on average, 16% of the weight of :.u1 amino
acid, so nitrogen intake or output divided by 0.16 yields a rough estimate of protein
intake or output. One can also multiply by die reciprocal of0.16, which is 6.25:
nitrogen (g) X 6.25 = protein (g)
To measure nitrogen balance, first a person's protein intake is monitored: this mea-
surement includes protein that comes in t he for m of fluids and foods. The grams of
protein consumed is ruvided by 6.25 to yield the approximate grams of rutrogcn (N )
consumed. This value is then compared with the amount of nitrogen lost from che
body. Urine output for the same 24-houT period is collected and analyzed for urea 11i-
1:rogcn content. This value is d1en put i11to one of various formulas available to esti-
mate total nitrogen loss from the body. Because most of the nitrogen lost from the
body is in the form of urea, this approach is fairly accurate. The other facrors in a spe-
cific formula account for nitrogen loss in the urine that is not in the form of urea (e.g.,
0.2 X mi.nary urea N) ai. well as ruu·ogen loss from all other body sOL1rces, such as hair,
skin, feces, and od1er nonurine sources (e.g., 2 g).
nitrogen balance = protein intake - . .

g unnary urea N - (0.2 X urmary urea N) - 2 g
6.25 g
For example, suppose a person consumes 70 g of protein in a 24-hour period ; during
that time he excreted 7 g of nitrogen as urea. His state of nitrogen balance is 0 .8 , based
on the following calcularion:
nitrogen balance = _2Q_ - 7 - (0.2 X 7) - 2
6.25
= 0.8
(a) (b) (c)
Positive Nitrogen
Balance
Nitrogen Nitrogen
intake excretion•
Nitrogen
intake
I
Situations in which nitrogen balance
is positive:
' Situations in which nitrogen balance
is in equilibrium:
Healthy adult meeting nutrient needs,
Situations in which nitrogen balance
is negative:
Inadequate intake of protein
Growth
Pregnancy notably protein and energy needs (fasting, intestinal tract diseases)
Recovery stage ofter illness/injury Inadequate energy intake
Athletic training.. Conditions such as fevers, burns, and infections
Increased secretion of certain hormones, Bed rest (for several days)
such as insulin, growth hormone, and Deficiency of essential amino acids
testosterone (e.g., poor-quality protein consumed)
Increased protein loss (as in some forms of
kidney disease)
Increased secretion of certain hormones, such as
thyroid hormone and cortisol
•Sosed on losses of ureo ond other nitrogen-containing compounds in the urine as well as protein itself lost from feces, skin , hair, nails, and other minor routes.
••Only when additional lean body moss is being gained. Nevertheless, the athlete is probably olreody eating enough protein lo suppor1 this extro protein
synthesis; protein supplements ore not needed.
Figure 7•10 I Nitrogen balance in practical terms. Determining this balance requires measuring nitrogen inloke and loss.
Becau~e this number is positive, the person is in a slightly positive nitrogen balam:e and
tlms in a positi,·e protein balance. Through measuremenr error, however, he could also
simply be in equilibrium.
Today the best estimate for the amount of protein required for nearly all adults to
maintain protein equilibrium is 0.8 g of protein per kiJogram (kg) of healthy body
weight (the concept of healthy weight is discussed in Chapter 13). This 0.8 g/kg is the
RDA for protein. Healthy weight is used as a baseline because excess rat storage doesn't
contribute much to protein needs. This RDA works out to about 56 g of protein daily
for a 70-kg (154-lb) man and about 46 g of protein dail)' for a 57-kg (125- lb)
P regnant and lactating women and infants
and children under 19 years of age hove
different RDAs for protein (see Chapters 16
woman. 10 and 17).
Convert weight from pounds to kg: 154 pOlrnds = 70 kg

2.2 pounds/kg
125 pounds
2.2 pounds/kg
57 kg
T he RDA for protein translates into about 8 to
I 0% of total energy intoke. 1OThe Notional
Cholesterol Education Program in the United
States recommends up to 15% of total energy in·
k X 0.8 g protein = 56 take to provide more flexibility in diet planning,
Calculate RDA: 70 in turn allowing for the variety of protein-rich
g kg body weight g
foods North Americans typically consume. This
0.8 g protein amount also generally provides enough protein
57 kg x = 46 g
kg body weight for the active athlete.
Table 7-3 l The Protein Contents of a 1600 kcal Diet and a 2400 kcal Diet*
1600 kcal Diet Protein (Grams) 2400 kcal Diet Protein (Grams)
Breakfast
l % low-fat milk, 1 cup 8 2% reduced-fat milk, l cup 8
Cheerios, 1 cup 2 Cheerios, 1 cup 2
Orange l Eggs, soft cooked, 2 12
Orange 1
Lunch
Whole-wheat bread, 2 slices 5 Whole-wheat bread, 2 slices 5
Chicken breast, 2 oz 17 Chicken breast, 2 oz 17
Mayonnaise, l tsp Provolone cheese, 2 oz 15
Tomato slices, 2 Tomato slices, 2
Carrot sticks, 1 cup l Mayonnaise, l tsp
Oatmeal-raisin cookie, 1 2 Ootmeol-roisin cookies, 2 4
fig, 1 large 0.5 Figs, 2 1
Diet soft drink Diet soft drink
Dinner
Mixed green salad, 1 cup Mixed green salad, 1 cup
Italian dressing, 2 tsp Italian dressing, 2 tsp
Beef tenderloin, 3 oz 21 Beef tenderloin, 4 oz 28
Spinach pasta, l cup, with garlic butter, l tsp 7 Spinach pasta, l cup, with garlic butter, 1 tsp 7
Zucchini, l /2 cup, sauteed in oil, 1 tsp 0.5 Zucchini, 1/2 cup, sauteed in oil, I tsp 0.5
l % low-fat milk, 1 cup 8 Carrot sticks, 1/2 cup 0.5
2% reduced-fat milk, 1 cup 8
Snack Snack
Bagel, toasted, 1/2 of a 3 1/2" bagel 4 Bagel, toasted, I /2 of 3 I /2'' bagel 4
Jam, 2 tsp Jam, 2 tsp
Fruited yogurt, 1 cup 10 Fruited yogurt, 1 cup J.Q
TOTAL 87 123
•This table illustrates how little energy needs to be consumed while still meeting the RDA for protein h also shows how much protein we eal when we consume typical energy intakes
Approximate protein needs are listed in the inside cover of this textbook. Ir is easy to
consume the ,1mount of protein currently suggested each day to meet body needs
(Tabk 7-3). North American men typicaJly consume about 100 g of protein daily,
whereas women rypicaily consw11e 65 g daiJy. 1O
Most of us consume much more protein than RDA amounts bccau:.e we like many
high-protein foods and can afford tO buy them. Excess protein eaten cannot be stored
as such, so the carbon skeletons are put to use for other purposes or metabolized for
energy needs (rc,'iew FigLrre 7-8). Note also that mentaJ stress, physical labor, and rou·
tine weekend sporrs activities do not require an increase in the protein RDA. 10
To support the o·aining needs of endurance and highly trained athletes, protein con-
sumption may need to exceed the RDA. The Food and Nutrition Board does not sup·
port an increased need, but some experts suggest that an intake of 1.2-1.7 g/kg of
protein per day may be needed (see Chapter ] 4). However, studies supporting these
high intakes arc fevv. Many North Americans also already consume that much protein,
especially men. The Food and Nutrition Board also suggests that protein imake nor
exceed 35% of energy intake. 10 AthJere!> can calcuJate this amotuit :10d use it as an
upper limit for protein intake. In addition, athletes do not need indi,idual amino acid
Animal protein foods ore typically our main supplements. These are a needless expense. All of us, athletes included, can meet our
sources of protein in North America. protein needs using basic foods (see Chapter 14 for details).
Does Eating a High-Protein Diet Harm You?

You may wonder abom the potential ham1 of protein intakes greatly in excess of the igh·protein diets increase urine output, in
RDA. If diets high in protein rely mostly on animal sources for prorein, rhey may be turn posing a risk for dehydration. This is a
simultaneously low in plant sources .:lnd therefore low in nber, some \'it.lmins (e.g., fo- special concern for athletes (see Chapter 14).
lare ), some minerals (e.g., magnesium ), and phytochemicals. AJditionally, high-
protein foods from animnls are often rich in s.tturated fat and diolescerol and thus do
nor follow the recommendations of the Dierarv Guidelines for Ameril:ans or the Food
and Nutrition Board in terms of reducing the .risk for cardiovascular discase. 10
Some, but not all, studies show that high-protein diets can increase calcium losses
i.n mine. This effect when seen, howe,er, is very minimal. For people with adequate
calcium intakes, little concern about this relationship is warranted.
Excessive intake of red meat, especialJy processed forms, is linked ro colon cancer.6
111crc are several possibk explanations for this connection. The curing agents used to
process meats such as hot dog5, ham, an<l saLuni may cause cancer. Substances thar form
during cooking of red meat ,\t high temperatures (hererocydic ami11es) may also cause
cancer (for a discussion ofheterocydic amines, see tl1e Nutrition Focus section in Chapter
12). The t'.Xcessi\·e fat or low fiber contents ofdiers 1ich in red meat in general may also be
a connibuting factor. Because of these concerns, some nutrition experts suggest we focus
more on poultry, fish, nuts, legumes, and seeds to meet protein needs. In addition, any red
and other types of meat should be a·imrned of all \~sible fut before g1i lling.
Some researchers have expressed concern tliat a high protein intake may overbur-
den the ki<lneys by forcing them to excrete the extra nitrogen as urea.9 Additionally,
animal proteins ma\· contribure to kidney stone formation in susceptible pcople. 5 To nfonts' diets must be limited in protein be·
prevent these problems, there is some s11pport for nor exceeding protein needs. For in- cause their kidneys hove difficulty excreting
sram:e, for people in the early stages of kidney disease, low-protein diets some\\'har large amounts of urea and minerals, which re·
slow the decline in kidney ti.111ction. Because preserving kidney function is especially main ofter protein metabolism. Thus, regular
i.n1purtant for people "i th diabetes :i.nd early signs of kidney disease, these people arc cow's milk must not be used for feeding young
ad,·iscd against consuming a high-protein dicl. For people withour diabcrcs or kidney infants- it is loo high in protein and other nutri·
dise.1se, the risk of suf1ering k.idney failure is minimal. ents (see Chapter 17 for details).
The .1mino acids most likely to CJusc toxicity \Yhen consumed in large amounts arc
methionine, cystcim:, and histidine. 12 The potemi.tl for a mino acid imbalance and
toxiciC) is too great to recommend dut .my be taken indi\'idu:i.lly as supplemcnrs. As
cmplusized earlier, the body is designed to handle whole proteins as a dietary source
of Jmino Jcids. When individual amino acid suppk1rn.:nt:. arc taken, they can over-
" helm the absorpti\'c mechanism in the small intestine, triggering amino acid imbal -
ances in the body. These imbalances ocrnr because groups o!' chemic.illy similar amino
acids compete for absorption sites in Lhe absorptiYc cells. An excess of one caiJ hai11per
other amino acids from being absorbed. Overall, every <lmino acid taken in excess can
be harmful. We should stick to whole foods JS sources for amino acids.
Protein in Foods
Rased on the typical foods we eat in North America, about 70% of protein comes from
animal sources. The mosr nutrient-dense somce of protein is water-packed nma, which
has 87% of irs energy .1s protein. Other good sources <lrc meat, poultr~', fish, milk and
some milk products, beans, and nms. Worlcfo·ide, 35% of protein comes from animal
sources. In Amca and East Asia, only about 20% of the protein eaten comes from <ln-
imal sources.
The Value of Plant Protein

Plant sources of proteins deserve more .1rtention and use fi·om North Americans. J'vlany
plant foods-in proportion to the amount or energy they supply-provide not only
much protein but also ample magnesium and fiber (especially soluble Ciber), along with
Expert Opinion ! •
A New Appreciation for the Nut in Nutrition
Penny M. Kris-Etherton, Ph.D., R.D.
A marked shift hos token place in our thinking about the role of nuts in a frequent nut consumption (> 5 oz/week) was associated with a 35% re-
healthy diet thanks to a substantive and growing body of scientific evidence duction in cardiovascular disease risk. The magnitude of risk reduction was
demonstrating the health benefits of nut consumption in a number of disease similar for both fatal coronary heart disease and nonfatal myocardial in·
slates. The story began with benefits being shown for nut consumption and lorction. The Physicians' Health Study, conducted with 21,454 male partici-
coronary disease; ii has expanded to benefits for other diseases. Data from pants, reported that those who consumed nuts 2 or more times/week hod
four large epidemiologic studies hove convincingly shown that frequent con- reduced risks of sudden cardiac death (by 47%) and of total cardiovascular
sumption of nuts (1 oz of nuts consumed Five times/week) is associated with disease death (by 30%). Colleclively, this epidemiologic evidence is com-
a decreased risk of coronary heart disease morbidity and/or mortality in the pelling and hos established a dose-response relationship between nut con-
range of approximately 30 to 50% in many different population groups. sumption and reduced cardiovascular disease risk. Moreover, subsequent
Frequent nut consumption (l oz of nuts consumed ~ five times/week) hos analyses conducted with these databases hove shown that the protective ef-
been shown to decrease risk of type 2 diabetes in women by 27%, and con- fect of nut consumption is consistent among many different population sub-
sumption of peanut butter five times or more per week reduces risk by 21 %. groups including men and women (as noted), younger and older subjects,
Similarly, comparable nut consumption decreases risk of gallbladder stones those with or withou t hypertension, and subiects who vary in weight, smok-
in women by 25%. In addition, there is intriguing evidence that nuts con help ing status, and physical activity level.
regulate body weight; the available evidence shows that frequent nut con- The emerging evidence from the Nurses' Health Study that demonstrates
sumption is not associated with a higher body moss index or tendency to beneficial associations with nut consumption and decreased risk of diabetes
gain weight. and gallbladder stones is exciting because ii has expanded the health benefits
of nut consumption to other diseases. Both epidemiologic and controlled clini-
cal trials consistently show either a lower body weight or no weight gain when
What the Specific Research Studies Show nuts are included in the diet. This weight result may contribute to the beneficial
association of nut consumption on diabetes and gollbladder disease. Nuts moy
The Adventist Health Study, a landmark prospective epidemiologic study con-
well exert beneficial effects on other diseases linked to overweight/obesity.
ducted with 34, 198 Seventh-Day Adventists in California, was the first study
to report a protective effect of nuts on cardiovascular disease. Individuals
who ate nuts ~ 5 times/week experienced a 51 % reduction in risk of hav-
ing a myocardial infarction. Those who ate nuts 1 to 4 times/week had a
22% reduced risk compared with a group who ate nuts < 1 time/week.
Put Nuts into Focus
Since this pioneering study, other epidemiologic studies hove reported Researchers hove conducted numerous controlled clinical studies with differ-
cordioprotective effects of nut consumption. These studies include the Iowa ent nuts os well as peanuts (which ore a legume). These studies differed in de-
Women's Health Study, Nurses' Health Study, and Physicians' Health Study. sign and dietary control. Some studies were specifically designed to evaluate
In the Iowa Women's Health Study, which followed 34,500 postmenopausal the effects of nuts on blood lipids and lipoproteins. Other studies used nuts
women for live years, coronary mortality was inversely associated with nut and other fat sources to achieve a fatty ocid profile of an experimental diet
consumption. Women who consumed nuts > 1 lime/week had a 40% re- that was evaluated. The studies in general evaluated diets that were low in
duction in cardiovascular disease risk compared with women who ate nuts saturated lot and cholesterol because nuts were used to replace food sources
less frequently. In the Nurses' Health Study, which involved 86,016 women, of saturated fat. Both moderate-fat and low-fat diets were studied. Across di-
efory fat levels, experimental diets containing nuts reduced total cholesterol Nuts as a Source of Nutrition
and low-density lipoprotein (LDL) cholesterol concentrations by about 4 to 16%
and 9 to 20%, respectively. In addition, the diets that contained nuts did not Nuts ore a powerhouse of nutrients including unsaturated fats (both mono-
reduce high-density lipoprotein (HDL) cholesterol, nor did they increase blood unsaturated and polyunsaturated), plant protein, fiber, vitamin E, folic acid,
triglyceride levels os did the comparative low.fat, high-carbohydrate control vitamin B-61 niacin, magnesium, copper, zinc, and potassium, o!! of which
diets. It is evident that the decrease in total and can contribute to heart health. In addition, o wide range of biooctive com-
LDL cholesterol levels with the nut diets reflects the pounds such as ellogic acid, f!ovonoids, phe-
decrease in saturated fat and increase in unsatu- nolic compounds (including the polyphenol
rated fat. In addition, the effects of the nut test resveratrol), and isoflovones ore present in nuts
diets on HDL cholesterol ond triglycerides could and could ploy a role in heart health.
be explained by their higher total fat content. Mechanisms of action of these bioactive com·
A key question is whether the effects of nuts pounds that could account for the cardiopro·
on blood lipids ore solely due to their fat and fatty tective effects of nuts include decreased
acid profile, or whether there ore other biooctive lDL oxidative susceptibility, decreased platelet
compounds in nuts that con tribute to the blood aggregation, increased synthesis of cardiopro·
lipid and lipoprotein responses noted. tective eicosonoids, and enhanced antioxidant
Nonetheless, it is clear that when nuts replace status. In addition, the omega-3 fatty acid
food sources of saturated fat, total cholesterol (alpha-linolenic acid) in nuts may protect
and LDL cholesterol ore reduced, resulting in o against sudden death and secondary coronary
decreased risk of cardiovascular disease. The events. Nuts also are a source of plant sterols,
American Hearl Association Dietary Guidelines which inhibit cholesterol absorption . Thus,
(2000) advise that to attain o desirable blood there are multiple mechanisms by which nuts
cholesterol profile, one should limit foods high in con protect against heart disease.
saturated fol and cholesterol and substitute unsatu· Incorporating nuts into your diet con be as One ounce of nuts !on amount that fits In the
roted fat from vegetables, fish, legumes, and nuts. simple as adding walnuts to banana bread. palm of a hand) provides about 160 to 180 calo-
Thus, this dietary recommendation acknowledges ries. Thus, nuts and legumes must be incorporated
the health benefits of unsaturated fats and recog· in the diet to ensure that calorie control is main·
nizes nuts and legumes as important food sources of unsatura ted fots. fained. This con be done by substituting nuts for other fats. For example,
season vegetables with nuts in place of butter or margarine; use nuts on
salads with less salad dressing; use nut butters rather than dairy butter,
Peanut and Tree Nut Allergies margarine, or cream cheese. Eat o sandwich with peanut butter rather
than lunch meat. Finally, nuts can be enjoyed as o healthy snack as well
Food allergy occurs in 6 to 8% of children 4 years of age or younger and in 4%
as a savory snack. So now, with a new appreciation for the nu/ in nutri-
of adults. Eight foods account for 90% of all food-related allergies; peanuts and
tion, enjoy nuts in moderation for good nutrition and heart health!
tree nuts are two of these foods. (The other foods ore milk, egg, fish, shellfish, soy,
and wheal). The allergic reactions can range from a mild intolerance to a fatal Dr. Kris-Etherton is Distinguished Professor of Nutrition in the
allergy due to onophyloxis. Current guidelines advise that children < 3 years of Department of Nutritional Sciences al Pennsylvania State University.
age should not eat peanuts or tree nuts. In addition, peanuts and/or tree nuts Her research focuses on different interventions, which include the use
should be avoided by older children and adults with nut and peanut allergies. of nuts, lo reduce cardiovascular disease risk.
ecall from Chapter 4 that consumption of Food Sources of Protein

beans con lead to intestinal gos because
our bodies lack the enzymes to break down cer· Food //em and Amount Protein (g) Energy from protein (%}
loin carbohydrates that beans contain. An over· Canned tuna, 3 oz 21.6 87
the-counter preparation called Beano con
greatly lessen symptoms if token right before the
Broiled chicken, 3 oz 21.3 40
meal. It is also helpful to soak dry beans in Beef chuck, 3 oz 15.3 30
water, which leaches the indigestible corbohy· Yogurt, l cup 10.6 35
drotes into the water so they can be disposed.
However, intestinal gos is not harmful. In fact, Kidney beans, 1/2 cup 8.1 29
fermentation products of indigestible carbohy· l % low-fat milk, 1 cup 8.0 31
droles promote the health of your colon (review Peanuts, 1 oz 7.3 18
Chapter 3 for more information on probiotics
Cheddar cheese, 1 oz 7.0 25
and prebiotics).
Egg, I 5.5 32
Cooked corn, l /2 cup 2.7 12
Seven-groin bread, 1 slice 2.6 16
White rice, 1/2 cup 2.1 8
Pasto, 1 oz 1.2 16
Banana, 1 1.2 4
other benefits, such as ample vitamin E, folate, iron, zinc, copper, and numerous phy·
tochemicals. 15 The p lant proteins we eat also contain no cholesterol and little saturated
fat, unless these arc added dLU"ing processing. Regu lar use of plant proteins makes a
valuable addition to a diet because these supply a variety of other nut1icnts. 1 Nuts are
receiving much attention roday. 17 Dr. Penny M . Kris-Etherton discusses why in the
Expert Opinion.
Legumes are a plant fam ily with pods that contain a single row of seeds:
garden and black-eyed peas; green, black, red, great northern, lima, kidney,
Total Fot 0.:&
pinto, and garbanzo beans; lentils; peanuts; and soybeans. Dried varieties
T"'"' FolOg
Cholesterol Omo 0%
of the marure seeds-what we know as beans-also make an impressive
Sodium S30mg 22%
Total Carbohydrate ?3a 8%
contribution to the protein, vitamin, mineral, and fiber content of a meal.
Oistqry Dbu 99 36%
Sugon Jo
Regularly consuming these legume protein som ces can add substantial
amounts of nutrients to a diet (Figure 7-11 ).
•
Vi1qminc<•
Iron )Qtt
As a way to add more plant proteins in general to your diet, consider
··c..,...._,1."....,,fl"'H"'°'...,.0e'''"°""e1 these suggestions:
·"'4-tWll
·~ o.._i, ...~ - t..M ... 2000Cfllor..
4« ,,,.,..daJyool•...., .. ~.~ .. ~
d . . . . . . . . . . . .lff"COMlho . . . . .
C:e,.rie• 2.000 2.100 • At your next cookout, try a veggie burger instead of a hamburger. These
are available in the frozen foods section of the grocery store and come in
a variety of delicious Aavo rs. Many restaurants have added veggie burgers
to their me nus.
• Sprinkle sunAowcr seeds or chopped almonds o n top of your sabd to add
taste and texture .
• Mix chopped walnuts into the batter of bamu1a bread, muffins, or pan ·
cakes to boost your intake of monounsarurated fats.
• Eat soy nuts (oil-roasted soybeans) as a snack when you're on the go.
• Spread some peanut butter on yam bagel instead of butter or cream
cheese.
• Instead of having beef or chicken tacos for dinner, beat LIP a can of beans
Figure 7· 11 I Legumes ore rich sources of (any variety; drained) in yam skillet with one-half of a packet of taco sea·
protein. One-half cup meets about l 0% of saning and chopped tomatoes. Use this as a filfu1g in a tortilla shell .
protein needs, but contributes only about 5% of • Consider using soy milk, especially if you have lactose maldigesrion or
energy needs. lactose intolerance. Look for varieties that arc fortified with calcium .
A Closer Look at Soy Protein

Plant prorcins from soy in particular have recenrly received much publicity for their
supposed ability to combat a host of medical problems, including cardiovascular dis-
ease, cancer, osteoporosis, and menopausal symptoms. In 1999, it was given an FDA-
approvcd health claim for lowering blood cholesterol. This claim is limfred to foods
high in soy protein, and the recommended d.ii ly intake is 25 g of such protein to ac-
quire the benefits. Soy products were then toured as "wonder toods" and sales rose
steadily. More recent ~mdies, however, have failed to confirm much of soy's original
promise~ scienti!>ts are reevaluating many of the initial clairm.. 17 This recent saga of soy
is a reminder that there are no "\Yonder foods." Soybeans, like most legumes, are rich
in protein and ph~'tochemicals, and can be pan of a healthy, varied dier. To replace the
beef pa try in your hamburger wirb a soy parry is one to reduce your inrnke of choles-
terol and sarurated fat. Little more can be said f(>r this form ofplant protein.
Concept I Check
The Recommended Dietary Allowance (lli)t\ ) for adults is 0.8 g of prorcin per kg of
healthy boJy weight. This is approximate!)' 56 g of protein daily for a 70-kg ( 154-lb) per-
son. The :l\'erage Norrh Arncric<tn nw1 consu1m:s .tbour 100 g of protein daily, and a Beans are rich sources of plonl proteins and
woman consumes about 65 g. Thus, rypicall) we eat more rhan enough protein LO meet odd much nutritional value too diet.
our needs. Diers high in protein can compromise kidney h<.:alth in pcopk with diabetes and
those with kidney disease. Diets rich in animal protein sources arc gcnt'rall)· high in satu-
rated far and cholesterol and likely increase risk of kidney stones, colon cancer, •llld caTdio-
rnscular disease.
Most protein in the North American diet comes ti-om meat. Plant protein sources con-
tain a wide variery of nuoients and should play an important role in one's dier.
Evaluation of Protein Quality

A final consideration with regard to proteins in foods is protein quali10•, which is the abil-
ity of a food protein to support body growth and maintenance. Methods e:xisr to borh
measme and estimate protein quality. Each has its uses and limitations. Keep in mind, also,
that the concept of protein quality applies only wider conditions in which the amount of
protein consumed is cqu.ll ro or less than the .-imounr of protein required ro meet the need
for essential amino acids. \Vhen protein intake c:xcl.!eds thil> ammmt, efficit'ncy of protein
use declines regardJcss of the balance of amino acids present. This occurs even with d1e
highest-qualit:y proteins because, after the need for cssc:ntial ,1mino acids has been met, the
remaining essential and nonessential amino acids cannot be stored on a long-term basis
and will prima1ily be degraded and used as a source of energy.
Biological Value
The b iological value (BV) of a protein is a measurl.! of how efficiently food protein,
BY = g nitrogen retained X l OO
once absorbed from tlie GI tract, can be nirncd imo body tissues. If a food possesses
g nitrogen absorbed
enough of all nine essential amino acids, it should allow a person ro efficiently incor-
porate the food protein into body proteins. The biological value of'' food, then, de-
pends on bow closely irs am.ino acid pattern retlects the amino acid pattern in body he concept of biological value hos clinical
tissues. Tbc better tlie match, tl1e more completely food protein mrns inro body pro- importance whenever protein intake must be
rein.18 We measure protein retention by measuring nitrogen retention in the body. limited. This is because we wont what little pro-
Both humans and laboratory animals are used to generate data for determining bio- tein that is consumed lo be used efficiently by
logical ,·alue of food proteins. the body. For example, protein intake during
If the: amino acid pattern in a food is quite unlike tissue amino acid patterns, many liver disease and kidney disease may need to be
amino acids [n tl1e food wiJJ not become body prorein. They simply become "left- controlled in order to lessen the effects of the
overs!' Their nitrogen groups are removed and excreted .i n the urine: as urea (re\'icw disease. In these coses, most of the protein con-
Figure 7-8 ). Because not much of the nitrogen is retained, the ratio of retained nitro- sumed should come from high biological value
gen to absorbed nitrogen, and the consequent biological ,·alue, is low. sources, such os eggs, milk, and meal.
he protein efficiency ratio (PER) is an- Egg-white protein has a biological val ue of 100, the highest biological value of any
other means of measuring a food's protein single food protein. [n other words, essentiall~r all nitrogen that is absorbed from egg
quality. FDA uses this method rather than the protein can be retained. Milk and meat proteins also have high biological values. This
PDCMS to set standards for the labeling of makes sense because humans and other animals have similar tissue amino acid compo-
foods intended for infants. The PER compares the sitions. Plant amino acid patterns differ greatly from tbose of humans. For example,
amount of weight (in grams) gained by a grow- corn has only n moderate biological \'aluc of 70; it is high enough to support bod~·
ing rat to the grams of protein the rat consumed maintenance, but not growth. Peanut~ consumed as the onl)' source or protein ~how a
during 10 days or more of eating a standard low biological Yaluc of about 40.
amount of protein (9.09% of its energy intake)
from a single protein source. The PER of a food Chemical Score and Related Protein Digestibility Corrected Am ino
reAects its biological value, since both tests basi-
cally measure protein retention by body tissues. Acid Score (PDCAAS)
Plant proteins, because of their incomplete na- Protein quality of a food can be estimaced by its chemical score. To c:ilculate a food's
ture, generally yield low PER values, whereas the ch emical score, rhc amoum of each essential amino acid provided by a gram of the
values for animal proteins are higher, o~en food's protein is diYidcd by an "ideal" amount for that esscnciaJ amino acid per gram
above 2.0. 18 ot· food protein. The "ideal" protein pattern is based on the minimal amount (in mil-
ligrams) of each of the uine essenrinl am ino acids that is needed per gram of food pro-
tein. The lowest ami1lo acid ratio calculated for any t:ssential amino acid is thl'. chemical
g weight gain
PER = ~~~~- score. Scores vary from 0 to 1.0.18
9 protein consumed To then calculate the P rotein Digestibility Corrected Amino Acid Score (PD -
CAAS), the most widely used measun.: of protein quality, the chemical score of a pro-
actual mg of each tein is multiplied by the digesribiliry of the protein (generally, 0.9 to 1.0). For example,
essential amino acid the chemical score for wheat is 0.47. The PDCAAS for wheat is then csrimared :tr
per g of protein 0.47 X 0.90, which cqu:ils about 0.40. The maximum \•alue for PDCAAS is 1.0, which
Chemical score=--~~-~---
Required mg needs of is the v:iluc of milk, eggs, and soy protein. A protein totall)' lacking a ny of the nine es-
that essential amino semial amino acids has a PDCAAS of 0, since its chemical score is o. t O
acid per g of protein For nutrition labeling purposes, protci11 conrenr when listed as% Dai ly V<tluc is re-
duced if the PDCMS is less than 1. For example, if the protein content of 1/2 cup of
PDCAAS -= Chemical score X digestibility spaghetti noodles is 3 g, only 1.2 g will be counted when calculating % D:iily Value,
since the PDCAAS ofwhe:ir is 0.40 (3 g X 0.40 = 1.2). Other PDCAAS values arc
egg white, 1.0; soy pro[ein, 0.92 to 0.99; beef, 0.92; and black beans, 0.53. Currently
the Nutrition Facts panel rarely contains the % Daily Value for protein because the
manufacturers do not want to spend the money needed to determine the PDCAAS.
Concept I Check
Protein q11nlity refers to thr ability of a protein to contribute to protein needs. Using any of
the methods available for resting, individual foods with ample amounts of all nine essential
amino acids show high protein quality.
Vegetarian Diets
\'egcr.11i.111ism h~ crnhed orcr the centuries from a thar 20% of its customer. "ant a 'egct.1rian option
necessi[) into an option. Historic.ulr. \·egctarianism when they eat out. ~l.lm nisromet'l> cite health and
\\'JS linked ''irh sped tic philosophies and religions or t~te as rc.u.ons for d10ming ,·egetarian fare.
with science. In chc sixth century B.C., Pythagoras :\s nutrition science h.1' grm1 n, llC\\ informa-
JdvcK.m:d a meatless Jicc tor its physical h1.:alth, eco· tion has enabled the de ..ign of nutrttionally ade-
logical, religious, .llld philosophic.11 benctits. 14 quate vegetarian diet.,, It b importanc lor
Tod;iy, abour I in 40 adults in the United States vegetarians w take .1thant.1ge of this information
(and Jbout l in 25 .1dults in C111ada) is a \'egecarian. because a diet of only planlS has rhe porenti.11 LO
This 1ise in imercst has encouraged the develop- promote various nucriem ddkicncies ,111d substan-
ment or new food products such al> soy•-based tial growth rcr.mbtion in infants and childn.:n. 1
sloppy jncs, chili, tJcos, burgers, and more. ln addi· People who choose :l 'cgcuri.111 dier can meet rheir
tion, cookbooks that IC:trure the use of a variety of nucrition:il need~ by follow111g .1 tcw lni,ic rules and
fi-uits, vegccablcs, and seasonings arc enhancing knowlcdge:ibly planning their diets (1~1ble 7-4 ). 14
food selection for n:gcrarian~ of all degrees. Studies sho" that Jc.uh rare' from ~omc
\'egerarianism i\ popular .1mong college sru- chronic dbea.\es, such ·'' ccn;tin forms of cardim .'ls
dents. 14 Fifteen percent of college sn1dc1m in one cular discasc, hyperten\ton, m,111\' frmm of cancer,
surYC) s.1id the\ :.ckct 'cgctarian options JI lunch or [)'pc 2 diaherc~. and obe'>itv, are kmcr for \Cgctari
dinner on am ghcn day. ln n:sponse, dining scn·ices am d1an for nomegerari.m'>.4.11 U,1-116.18.19.21.22
ofl~r 'ega.irian options Jt crcry meal, the most Hcalchful litesnb (not 'molung, .1b.. r.uning from
common being p.mas '' ith mcatbs sauce and pizza. alcohol and drugs, and engaging in regular phy'i
Many teenager.; arc .1lso curnmg to ''egetariarusm. A cal acrivity) .rnd social class bi.1s prob.1blr parnally
sun ey by d1e Nauon.11 Rest.n1r.111t ,.\!isoci.ltion found account for these findmgs.
Table 7-4 I Food Group Pion for Loctovegetorions and Vegans That Also Follows
MyPyrarnid
Servings
0
Group lactovegetorianb Vegan< Key Nutrients Supplied
Grainsd 6-11 8- 11 Protein, thiomin, niacin, folole, vita-
min E, zinc, magnesium, iron, and fiber
Beans and other 2-3 3 Protein, vitamin B-6, zinc, magnesium,
legumes and fiber
Nuts, seeds 2-3 3 Protein, vitamin E, and magnesium
Vegetables 3-5 !include one 4-6 (include one Vitamin A, vitamin C, and folate
dark green or dark green or
leafy variety doily) leafy variety daily)
Fruits 2-4 4 Vitamin A, vitamin C, and folole
Milk 3 Protein, riboffavin, vitamin D,
vitamin B-12, and calcium
0
Bose setving size on 1hose listed for MyPyrom1d lsee Chopler 2). This pion yields oboul 1600 lo 1800 kcal Increase the number of servings, 0<
odd other foods to meel higher energy needs Amino acids in vegetables ore best used
bContoins oboul 75 groms of protein in I650 k.col. when o combination of vegetable
<A calcium-fortified food. such as orange juice or soy milk, 1s needed unless o calcium supplement is used. In odd11ion, use of o supplement protein sources is consumed. Tobie 7-2,
source of vilom1n ~12 or foods fortified with vitamin ~12 is o musl. Overall, fortified soy milk makes o voluoble contribulion lo o vegon diet. earlier in this chapter, lists traditional
This pfon contoins obout 79 groms of prolein in 1800 kcal. dishes in which vegetable proteins
00ne serving of vilomin· and mineral-enriched reody·lo-eol breokfosl cereal is recommended. Alternately, a bolonced multivitamin and mineral combine to provide high-quality
supplemenl con be used to meet possible nutrient gops. (complete) protein in the meal.
261
Why Do People Become \'ariety 111 one's diet, the easier it is to meet nutri ·
cional needs. Thus, the praccice of eating no anim.11
Vegetarians? sources of food significant]~· separares the \'egarn.
and fruitarians from all other semivegetarian ~ryles.
People choose vegerarianisrn for a \'aricn of rea- Most people who call themselves ,·egec.1rians
sons. Some believe that killing .rnimals for rood is consume :n least some dairy products and eggs. A
unethical. Hindus and Trappist monks eat vcgccar food -group plan has been developed for lacrovegt:
i,111 meals as a practice of their rdigion. In the Larians and vegans (review Table 7-4). This plan in·
United States, many Seventh-Day Adventists base eludes servings of nuts, grains, legumes, and seed~
their practice of vegetarianism on biblical texts and 10 help meet protein needs. There is aho a veg-
believe it is a more healthful way co live. etable group, a fr uit group, and a milk group. 14
People might choose vegetarianism after realiz- A vegan diet requires even more knowledge
hapter 6 noted that a vegan diet ing that animals are not efficient protein factories. and creative planning to yield high-quality protein
coupled with regular exercise and Animals actually use much of rhe protein they cat and other key nuu'ients without animal product'"
other lifestyle changes can lead to a re- just to mainrain rhcmsd\'es rather than to sy111he- Earlier in this chapccr, )' OU learned abour complc
versal of atherosclerotic plaque in the si;:e new muscle tissue. Note thar 40% of rhe mcnling proteins, whereby the essential ammo
world's grain production is U\ed co raise meat :icids deficient in one protein source arc supplied hr
coronary arteries.
producing animals. Animals that humans eat \Ome- those of anorher consumed at the same me,11 or the
cimes eat grasses that human~ c.mnot digest. i\1any, next. Recall that many legumes arc deficient in thl·
howe\'cr, abo eat grains thar humans can cat. es~ential amino acid methionine, while ccreab an:
People might also practice \'eget.uianism be limited in lysine. Eating a combinacion of legumes
cause it encourages a high intake of complex carbo- and cereals, such as beans and rice, will supph rhL
hydrares; ,·iramins A, E, :md C; c;1rorenoids; body \\'ith adequate a.mounts of all e)St:nu.11 amino
magnesium; and fiber "'hile it limits saturared fat and acids. Variety is an especially important cll.lr.tcccri~
cholesterol intake. 15 This produces a diet doscl~ retic of a nutririous vegan diet.
sembling that suggested in the 2005 Dierary Low intakes of certain micronutrients can .11~<> lx
Guiddincs tor Americans, cm·ered in Chapter 2. .t problem tor the vegan. Ar the forefronr of nuui
tional co1Kerns ,1re 1ibothwin, vitamins D .rnd Il-12,
Food Planning for Vegetarians iron, zinc, and calciw11. L4
A major source of both riboflavin and vitamin D
vegan A person who eats only plant There are a ,·ariety of vegetarian styles. I-I Vegans in the typical North American diet is milk, which is
foods. eat only plant foods (and as well may not use ani- omitted from the vegan diet. Howc1·er, riboll.1'in
mal producrs for other purposes, such as leather can be obtained from green leaf)• vcgerablc),
fruitarian A person who eats primarily
fruits, nuts, honey, and vegetable oils. shoes or feather pillows). Fruitarians primarily cal "hole-grain breads and cereals, yeast , and
fruits, nuts, hooey, and vegetable oils. This pl.111 is legumes-components of most \egan diets.
lactovegetarian A person who not recommended because it can lead to nutrient Alternate sources of vitamin D include fortified
consumes plant products and dairy deficiencies such as ,;ramin B 12 and C•tlcium in foods (e.g., margarine) and dietary supplements .1~
products. people of all ages. Lactovegetarians modi~· ,·ege- well as regular sun exposure (see Chapter 9 ).
lactoovovegetarian A person who tariauism a bit-they include <lain· produces and Vitamin B-12 occurs narurally only in animal
consumes plant products, dairy plant foods. Lactoovovegetarians modi!\ the diet foods. Plants can contain soil or microbial contam-
products, and eggs. e\'en further and eat dair~ products and eggs as inants that pro,·ide trace amounts ohitamin B-12,
\\'eU as plant foods. Including these animal prod· bur rhese are negligible sources of the \itamm.
UL'tS makes food planning easier because these Because the body can store ''itamin B-12 for abom
foods are ricb in some nutnents that .1re missing or 4 years, it may cake a long rime after rcmm-.11 of an·
present in low amounts in plants (c.g., the \'itamin imal foods from the diet for a deficiency to surface.
B-12 and calcium just mencioned ).2•23 The more If dietary B-12 inadequacy persists, deficienc~ c.111
262
lead to a form of anemia, ncrYc d.unagc, .md mental Special Concerns for Infants
dysfunction. These dire consequences of deticienC\'
ha\c been noccJ in the mfanb of' egctari.m mothers
and Children
whose brcdSr milk w.ls lcl\\ in \'ltJmin B-12.13 The populations ar highest 1isk for nutrient deficien-
Chronically low ,;umin B 12 consumption may also cies~ a result ofimpropcrl) pl.urned vegetarian diets
result in cxc™ blood conccncr.lcion ofhomocysreine, arc infarm and children, who arl' notoriously picky
which is likdy a risk factor for c.irdio\'.m:ular disease. eaters in the firM place . 1 ~ \Virh tht: use of comple-
To prevem a \itamin B-12 deficiency, vegans must mentary proteins ~\l\d good ~ourcc~ of problem nu- Yegelorion adaptations of traditional
find a reliable source of vir.1min B-12, such as forti - trients discussed in this section, the cnagy, protein, foods ore a growing trend in our society.
fied soy milk, ready-w -car brcakfusr cereals, and spe- ''iramin, and mineral m:eds of \'egetari:in .md vegan
cial yeast grown in media rich in \itamin B-12. Use infams and children c.111 be mer. The most common
of J balanced \icamin and mmcrnl supplement con- nutrition.ii concerns for infams and children follow-
caining. vit.mlin B-12 is anmhcr option. ing vegetarian and vegan diets .lre deficiencies of
For iron, vegans c.in consume whole-grain iron, \itamin B 12, \itamin D, and calcium.
breads and cercab, dried fruit\ and nucs, and Vegetarian Jn<l ,·cgan dieb rend to be high in
kgumes. 14 Note that the iron in these foods is not bulk.')', high-fiber, Im' -caloric foods that c.iusc: full·
absorbed JS "'di as iron 111 animal foods, but a good ness. While this side ctli:ct can be a welcome ad-
source of vitamin C taken with these foods helps \'antage tor adults, children ha'c ,, small stomach
somewhat ,,;th iron absorption. Thus, a recom- Yolume and rclathdy high nutricnr needs com
mrn\kd \lratrl:'~ I\ rn crnN1nw ,·it.lmin C with pared m thdr siLe and therefore m.l) tccl hill be
ever) meal that cont.lins iron ~ rich plant foods. fore their energy needs arc met. l·or this reason, the
Cooking in iron pots .llld \killers can also add iron fiba content of a child's dice ll1J) need to be de-
to the diet (sec Chaprer 12 ). creased by replacing high-fiber \Ourcc\ "irh some
\'egam can find 1.inc in whole-grain breads and refined gr.tin product~. fruit 1uice~ . ;tnd peeled eeting omego-3 fatty acid needs
cereals, nuts, .llld legumes, but phytic acid and fruit. Other conccntr.ncd sources of energy for also becomes on issue for vege-
other substances in these foods limit zinc absorp- vegetarian and vegan children include fc>rutled soy tarians who do not eol fish. Regular use
tion. Grains arc mo~t nutritious when consumed as milk, nuL~ , dried fruits, a\Ocados, .rnd cookies of conolo oil, soybean oil, Rax seeds, or
breads, because the leavening (rising of rhe bread made with vegetable oils or cub marg.irinc. walnuts is then advised lo obtain olpho-
dough ) reduces the influence or phytic aciu. 14 Overall, 'cgerari•ln ,111d vcg.111 diets can be .lp- linolenic acid, the omego-3 fatty acid.
Cakium-fonific<l food~ arc the vegan's best prnpriarc during infancy ;rnd childhood, but these Seaweed and microolgoe ore also possi-
option for obt.lining calcium. These include forti- diets musr be implemented with knowledge and, ble sources of omega-3 fatty acids.7
fied soy milk, fortified orange juice, calcium-rich ideally', protessional guidance. 1 An especially in-
cofu (check the label ), and certain ready-to-eat formati\'e website on \'egcrarianism in general is
breakfrm cereals, breads, and snacks. Green lea~· ''""'"" ivu .or~, supported by rhc 1nrern;uional
"egecablcs and nuts abo cont.lin calcium, but the Vegetarian Union. '>cc ,\!so "' ri• o 'I! and
mineraJ is either not well absorbed or not very ' " ,,t,,,. ar 111 Hll 1 1 n t.
plentiful !Tom these sources. Calcmm supplements
ari: another opuon (sec Chapter LI ). Special
diet planning is required, because c\'t:n a typical
.t) Case Scenario Follow-Up
mulri,·iramin and mineral supplement will nor Shannon's dietary intake for lhis day, although loclovegelorion, is not as healthy
supply enough calcium m meet the bod)\
needs.3 l' as ii could be because ii does not come close lo following the recommendations
provided in lhis chapter's Nulrilion Focus. Many components of a healthy vegetar-
ian diet-whole groins, nuts, soy products, beans, two lo four servings of fruit, and three to five
servings of vegetables per day-ore missing. With so few fruits and vegetables, her diel is also
low in the many phytochemicals that are under study for numerous heollh benefits. It is apparent
that Shannon has not yet learned lo implement the concept of complementary proleins, so the
quality of protein in her diel is low. Unless she makes a more informed effort al diet planning,
Shannon will not reap the health benefils she hod hoped for when she chose to follow a vege·
!orion diel.
263
protein-energy malnutrition (PEM) A condition Protein-Energy Malnutrition

resulting from regularly consuming insufficient
amounts of energy and protein. The deficiency Rarely an isolated condition, protein deficiency usually accompanies a deficiency of di-
eventually results in body wasting, primarily of etary energy and other nutrients resulting from insuffi cient food intake. [n developing
lean tissue, and on increased susceptibility lo areas of the world, people often have diets low in energy and also in protein. T his stare
infections.
of undemu trition stunts the growth of children and makes them more susceptible to
morosmus A disease that results from disease throughout life. (Note that tmdernutrition is a main focus of C hapter 20.)
consuming a grossly insufficient amount of People who constune too little protein and food energy eventually develop p rotein-
protein and energy; one of the diseases classed en ergy malnutrition (PEM), also referred to as protein-calorie malnutrition (PCM). 18
as protein-energy malnutri tion. Victims hove In its milder form , it is difficult to tell if a person with PEM is consuming roo little en-
little or no fat stores, little muscle mass, and ergy or protein, or both. But if the nutrient deficiency- especially for energy-is quite
poor strength. Death from infections is common. severe, a deficiency disease caUed m arasmus can result. When an inadequate intake of
kwashiorkor A disease occurring primarily in nutrients, including protein , is combined with an already existing disease (such as in-
young children who hove on existing disease fection ), a form of malnutritio n caJJed kwasbiorkor can develop. Botb conditions are
and who consume a marginal amount of seen primarily in children, bu t may aJso develop in ad ults. These two conditio ns fo rm
energy and considerably insufficient protein in the tip o f the iceberg wid1 respect to states of undernutrition, and sympto ms of dicse
relation to needs. The child generally suffers two conditions can even be present in d1e same person (Figure 7- 12).
from infections and exhibits edema, poor
growth, weakness, and an increased Kwashiorkor
susceptibility to further illness. Kwashiorlwr is a word from Ghana that means "the d isease that the fi rst child gets
when the new child comes." From birth, an infunt in developing areas of the world is
usuaJly breastfed . Often by the time the child reaches 1 to 1.5 years of age, the mother
is pregnant or has already given birth again, and breastfeeding is no longer possible for
the first child. This child's diet then abruptly changes from nutritious burnan milk to
starchy roots and gruels. T bcse foods bavc low protein densities compared with total
energy. AdditionaUy, the foods arc usually full of plant fibers, wbich are often bulky,
Figure 7·12 I Schema for classifying

undernutrition in children. The presence of
subcutaneous fat (directly underneath the skin)
r Protein Energy Malnutrition
is a diagnostic key for distinguishing Moderate energy deficit

with severe protein deficit,
kwoshiorkor from marasmus.
especially in light of increased I
needs due to infections Severe energy and
or other diseases /l protein deficit
f Edema with maintenance "Skin and bones" oppeoronce

of some subcutaneous fat with little or no subcutaneous
tissue fot tissue
making ir difficult for tl1e child to consume enough to meet energy needs. The child
rypicaUy also has infections and parasites, which acutely raise energy and protein needs,
or could be exposed to toxins found in moldr grains. Overall, energy needs of these
children are just barely met, at best, and their protein needs are not met, especially in
view of the increased amount needed to combat infections. Usually, many vitamin and
mineral needs are also far from being fuUilled. Famine victims face similar problems.
The major symproms of kwasbiorkor are apathy, diarrhea, listlessness, failure to
grow and gain weight, \'arious infections, and withdra•val from the c1wironment. These
symptoms complicate other diseases present. For example, a condition such as measles,
a disease that normally makes a healthy child iJJ for only a week or so, can become se-
verely debilitating and even fatal. Further signs and symptoms of the disease are
changes i11 hair color, potassium deficiency, flaky skin, fatty infiltration in the liver, re-
duced muscle mass, and massive edema in tl1c abdomen and legs. The presence of
edema in a child who has some subcutaneous far still present is rhc hal lmark of kwa-
shiorkor (review Figure 7-12). In addition, these children seldom move. If you pick
them up, they don't cry. When you bold them, you feel the plurnpness of edema, nor
muscle and fat tissue.
M~U1)' symptoms of kwasb.iorkor can be explained based on what we know about
proteins. Proteins play i.mportam roles in fluid balance, lipoprotein tnmsport, immune
function, and production of tissues such as skin and hair. We should not expect chil-
dren with <U1 insufficient protein intake to grow and mature normally and they don't.
If children with kwashiorkor are helped in time-if infections are treated and a diet
ample in protein, energy, and other essential nutrients is provided-the disease
process reverses. They begin ro grow again and may even show no signs of their pre-
vious condition, except perhaps shortness of stature. Unforrw1arely, by the time many
of these children reach a hospital or care center, they already have severe infections.
In spite of the best care, they still die. Or if they survive, they return home only to
become ill again.
Marosmus
Marasmus typically occurs as an infant slowly starves to deatl1. lt is caused by diets con-
taining minimal amounts of energy as well as too little protein and other nutrients. As
previously noted, this condition is also commonly referred to as protein-enet;gy mnl-
nntrition, especially when experienced by older children and adults. Tbe word rnaras-
mus means "to waste away." Victims have a "skin and bones" appearance, witl1 little or
no subcutaneous fat (review FigL1re 7-12).
Marasmus commonly develops in infams who either are not breastfed or have
stopped breastfeeding in the eru·ly months. Often the weaning formula used is im-
properly prepared because of unsafe water and because the parents cannot afford suf-
ficient infant formula for the child's needs. The larter problem may lead the parents to
di.lute the formula to provide more feedings, not realizing that this provides only more
water for the infant.
Marasmus in infants commonly occnrs in tl1e large cities of poverty-stricken coun-
tries. When people ru·e poor and sanitation is lacking, bottle-feeding often leads to
marasmus. In the cities, bottle-feeding is often necessary because the infant musr be
cared for by others when tl1e motlier is working or away from home. An infa.nt with
marasmus requires large amounts of energy ru1d protein-Ji kc a prcterm infant-and
unless the child receives tl1em, full recovery from the disease may never occur. The ma-
jority of brain growrn occurs between conception and the child's first birthday. In fact,
the brain grows fastest at the time of birth. If the diet does nor support brain growth
during the first months of life, the brain may not grow to its full adult size. This re-
duced or retarded brain growtli may lead to diminished intellecruaJ function. Both
kwasbiorkor and marasmus plague infants and children; mortality rates in developing
countries are often 10 to 20 times higher tl1an in tbc United States.
Kwashiorkor and Marasmus Malnutrition in the Hospital

Kwash iorkor can result when a h ospitalized patien t is fed primarily glucose intra-
venousJy for many days, such as when a slow recovery fi-om surger y prevents n o rmal
food consumption. Or a person may fed too sick to eat, ifl spite of the increased nu-
trient needs caused by his or her disease. Intravenous g lucose feeding can meet energy
needs to some extent but provides no protein. As a result, the person develops edema,
an d often the immune function is dimi nished , leaviDg the patient at great risk for
in fections.
Studies have demonstrated that a hospitaJ patien t with a low body weig ht , low
blood alb umin , and a low white blood cell (especially lymphocyte) coun t fuces a risk
of complications and death that is fou r to six times greater than that of a patient with
normal vaJues for those three fuctors. In response, nutrition supporr teams have been
formed in h ospiraJs. One of thei r missions is to ensm e that patients receive eno ugh oraJ
or baJanced intravenous rotaJ parenteraJ nutrition suppor t to meet their needs for en-
ergy, protein , carbohydrate, and other m m ienrs.
Marasmus occw-s in a hospitalized patient who simply does no t receive enou gh en-
ergy and other nutrients. This can be cau sed by anorexia aervosa, cancer, HIV/ AlDS,
and some intestinal disorde rs. T he person either does not eat eno ug h food or docs not
absorb enough nutrients from the intestinal tract to meet nutritio naJ needs. Muscle,
vitaJ o rgan tissue, and fat stores \.vaste away, and the person even rnally look1. like ''skin
Some hospitalized patients ore al risk of and bones." Skinfold measuremen ts of the arm can be used as an indication of maras-
protein-energy malnutrition. This includes older m us. (C hapter 13 reviews this technique.) However, appearance alone is often enough
adults recovering from surgery. to ind icate the d isease. Death from starvation or heart failure can result. A hospitalized
person may also have mixed kwashiorko r-m<lrasrnus. T his is characterized by cd<.:ma in
a person with greatly diminished fat stores.
Concept I Check
Most undernutrition consists of mild deficits in energy, protein, and often other nutrients.
lf a person needs more n utrients because of disease and infection bur does not consume
enough energy and protein, a condition known as kwashiorkor can develop. The person
suffers fro m edema :ind weakness. Children around age 2 are especially susceptible to kwa-
shiorkor, particularly if they already have other diseases. Famine situations in which only
starchy root products arc ,wailable to eat contribute to this problem. Marasmus is a condi-
tion wherein people-infants, especially- starve to death. Symptoms include muscle wa5t-
ing, absence of fat stores, and weakness. Both an adequate diet and the treatment of
concurrent diseases must be promoted ro regain and then maintain nutritional health. This
also is true in an adult suffering from anorexia ncrvosa, cancer, or HN/ AIDS. The symp-
toms of marasmus, especially, are seen in these situations.
Summary
1. Amino acids, the building blocks of proteins, contain a very usable 3.lndi\~ dual amino acids are linked t0gether ro form proteins. The
form of nitrogen for humans. Of the 20 common amino acids sequential order of amino acids determines the protein's ultimate
fotmd in food , nine must be consumed as food (essc::ncial ) :u1d the shape and fi.111crion. This order is directed by DNA in the cell nu-
rest can be synthesized by the body (nonessential). cleus. Diseases such as sickle-celJ anemia can occur if tJ1c .imino
2 . High-qualiLy, also called complete, protein foods contain ampk acids are incorrect on a polypeptide chain. When rhc dircc-
amounts of all nine essential amino acids. Fw-d1ermore, foods de- dimensional shape of the prorei.t1 is w1folded-den.itured- by
rived from animal sources provide high-qualiry, or complete, pro- treatment with heat, acid o r alkaline solutions, or other processes,
tein. Lower-quality, or incomplete, protein foods lack sufficient the protein ;1lso loses its biological activity.
amounts of one or more essential amino acids. This is typical of -t Prorein digestion begins in the stomach, dividing the proteins inm
pl.ant foods, especially cereal grains. Different rypcs of plant foods bre.tkdown products conraining shorrcr polypeptide chains of
eaten cogether often complement each other's amino acid deficits, amino acids. In the small intestine, these polypeptide cha.ins even-
thereby providing high-qualiry protein in the diet. rually separate into mostly dipcptidcs and amino acids. Thc~e lrc
.1bsorbcd by the enrerocytes and are broken down inw <lmino energy ..-ontenr .is protein; however, legumes :tre a11 excdlenr source
acids. The free amino acids rhen cravel via the porral vein that con - of high-quality prorein if earen witb gr.illlS or animal products.
necrs ro the liver. 8 . Protein quality can be measured b~ determining the extent ro
5. Importanr body componenrs-such as muscles, connective tissue, which the body can retain the nitrogen contained in the amino
n·anspon proreins in rhe bloodsm:am, visual pigments, enzymes, acids absorbed; dus is called biological value. Tn addition, the bal-
some hormones, and immune bodies- arc made of proteins. ance of esscnti.tl .1mjno acids in a food can be 1:omp.m:d with an
These proteins arc in a stare of constanc rnrntwer. Proteins abo ideal pattern. The comparison with the ideal pattern b referred to
prmide carhon skeletons which can be used ro synrhesize glucose as the chemical score. When multiplied by the degree of di -
when necessttry. gesribiliry, the chemical score yields the Prorcin Digestibi lity
6. The protein RDA for adults is 0.8 g per kg of healthy body Corn~cred Amino Acid Score (PDCAAS ).
weight. For a typical 70-kg (154-lb) person, this corresponds tO 9. Underm1tririon can lead to protein-energy malnua·icion in the form
56 g of protein daily; for a 57-kg ( 125-lb ) person, this corn~ ofkwashiorkor or marasmus. K\\'ashiorkor results primarily from an
sponds to 46 g/day. The Norrb Amc1ican diet generally supplies inadequate energy and protein intake in compariJ.on with body
plenty of prorcin: men rypicaUy consume about 100 g of protein needs, \\'hich often increase ";th concLtrrcnt disease and in!Cction.
daily, <rnd women consume about 65 g. These usual protein in- Kwashiorkor ofo:n occurs when a child is \\'Caned from human milk
rakc5 an.: also of sufficient quality to support body functions. and fed mostly st;trchy gruels. Marasmus results from extreme
7. Almost all animal products arc rich sources of protein. The high starvation-a negligible intake of both protein and energy. Marasmus
quality of rhcse proteins means that they c:m be c:lSily cn1wcrted inro .:ommonly occur~ during famine, especially in infants. Variations of
body protein5. Plam foods generally conrain k!iS than 20% of their tliese disease~ appc;u· in some hospitalized North American~.
Study Questions
1. Discuss Lhe rebtivc impormnn: of essenti.11 and nonessential 8. What characreristics of plant proteins could impro\'e rhc North
amino acids i11 die dice. \Vhy is ir important for essemial amino
American dicL> Whar foods would you include to provide :i dii:t
acids lost from rhc body to be replaced in the diet?
that has amp le protein from bor.b planr <ll1d animal sources bur is
2. fa.plain the.: process for syntl1tsizing nontssential amino acids. moderate in fat?
Whar is the chemical reaction called when an amino aciJ loses it!!
9. Outline 1hc major differences berween kwashiorkor and mamsmus.
amino grnup \\'irhout rransfcning it to •lll<>ther carbon skcleron?
10. Wh.u .1rc the po~siblc long-term effec~ of an inadequate intake of
3. What is a limiting amino acid? Explain why this 1:onccpr is •l con- dietary protein among children between the age~ of 6 months ,md
cern in a \'egcr:irian diet. How can a vegetarian compensate for
+years?
limiting amino ;icids in specific foods?
4. Bridl\' describe the organization of proteins (e.g., primary ~mic
rure, etc. ). How can this organization be altered or damaged? BOOST YOUR STUDY
What mighr be a result of damaged protein organi1.arion?
;i. Describe four tUnctions of proteinI>. Providt Jn txamplc of hm' Check out the Perspectives in Nutrition: Online Learning
the strucrnrc of a prorcin relates to its function. Cente r www.rnhhe.com/ wardlawpers7 for quizzes, flash
6. Ho\\' arc DNA .111d protein synthesis relartJ? cords, activities, and web links designed to further help you learn
7. Whar would be one hcalrh benefit of preventing prmein-energy about proteins.
malnutrition in children?
ADA Reports: Position ol the i\.111eric.\n It is 1•1tnl tlmt n 1«:nclnl'ln11.tows011 111rctt11J/ l'1 · Pc_r1cmblcs. h:f/11111cs. nrzd >1111s lll mc/J a 1ifr1 Ii-ad
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Dfrmic Assodnri<111 103:748, 2003. ::>. Borghid, l Jnd other': Comparison of nrn
mppl1·111,•11r nrt rn•11 11ptiom.
dicrs for the prcvcncion of rccurrcm sronc.. in
It is rhr /111siti1111 rifrbf A111crfrn11 Dfrraic .i. Aron.on D: \"eg.ecarian 11uLri11rn1 'fi1dny 's idiopathic hyper~akimia. f1g New bt._1Tln11d
Associnti1m nnd Dutirinns ofCn1111dn t/Jnt np- Dit'tit1n11, p. 3. i\l.m.:h 2005. /111m111l 1if Mcdici11c 346:77, 2002 .
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/Jcalt/J bmtfirs i11 rlx prrl'cutiun nnd trenrmmt 1111rf ex/Jibi1i11._11 im·rrnscd rnlci11111 i11 1/J.- 1n-i11t·,
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of crrt11i11 rfi.rms.-s. Ill some cnscs, /Jowcrnj usr of
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fonificd jiwrfs m· 11 11111lm•itn111i11r111d111i11rnrl c11111bi11ctf wit/J 1101·11rn/ cnlci11111 111111frs, prii-
mpplt11101T 11111_1· bt 11adtd ro meet rero111111e11rfn - .J.. lkrko11 SE, B.:irnard ND: Blood JWC~'lll'C rq;.u - Pidcd protection a_rrnmst l'fClll'rt'll•'t• 11/mr/J
tio11s j'or i11dil'id11nl 1111trimrs. lacion and 1•cg.e1ari.111 diet,. N11tnm111 Rt·1•iclf's .rt"OllCS.
2. Anrony J\C: \'cg,cr.mant~m and vit.unin B- 12 63: t, 2005.

6. Cluo A .md other;: ;\k.ir com11mp1ion .111d
l cobal.1min ) dcticicncy. A111crim11 Journnl of 1':afurr11111 durs are associnird with lml't'l' lil11nd colorecrJ.1 cancer. j111w11nl 1if tbt Amairrrn
Clinirnl N11rriti1111 78:3, 2003. prcst111·t 111 Im1111J11S. It fr likcl1· t/Jnt 1/J1· jt-ltir, Jfrd1rnl Assodnrio11 293:172, 2005.
Diers l'icb ill red meat, especial~)' processed meat, 771c most coxic nmi1111 acids fll'I' 111er1Ji1111i11e. cys· Replacing n11i111nl protcius 111 n diet ll'ith some
i11crcnsc tbe 1·isk 11f colrm ca11ce1: Protci11 from tci11r, nnd histidine. Pos.riblc benlt/J risks fr/Jm soy prqtci11 hdps nducc mtt11·ntrd fnr intnke,
poultry 1111d fish, i11 ctmtra.rt, does 11ot pose the c...:ussii1e intakcJ of ot/Jcr 1i111i110 aC11is art n/;-11 rc- ivhicb 1s be11eficial to /Jealth. Otbcr p111'jl1Wted
s11111c nsk. 11icived. These riJk.r nre Jt:ell with amino acid bealth benefits 1>fs11y proteills rlmnsdves, mc/J ns
7. Davis BC, Kris-1::.thcrron PM: Ach ieving opti- s11pplc111mts, not wbole food si111rccs. lowering blood c/1(1lcstcrol, lmvt 1111r bcm mp-
mnl essential fatty acid scarus in vcgecarians: 13. Hu F: Plant-based toods and prevention of portcd b)' rece11t studies.
Current knowledge .ind practical implications. cardiovascular disease: An overview. A meric1111 18. Marthews DE: Proteins and amino acid~. In
Amuican f 011rnal of Cli11icnl N11tritio11 ]1111nial of C/i11icnl Nutrition 78(suppl): Shi.ls ME and otl1ers (eds): Mor/em 111arit1011 in
78(~uppl): 6405, 2003. 5.i.4S, 2003. bmlth n11d discnsc. 10th ed. Philadelphia, PA:
•\fnsc 1if t/J1·fnr i11 n P1'fletnrin11 diet sbo11/d comr Pln11t-bnsrd diets prm•idc 1111111e1·1111sfnrmn Lippincott Williams & Wilkins, 2006 .
ft·o111 nuts, seeds, olives, avocados, so;•foods, aud t/Jnt 1•cd11cr cal'dioJ>nsrnlnr disense risk, such 115 Detailed cxnmi11ntio11 11/111/Jnt is k111>w11 nb1111t
11101101111mt111·nted-ric/J 11ils, mc/J ns cn11oln 11il, 1msn rurnred fats, pbytochcmicnls, n11d fiber. prorei11s ingcnernl. T/Jis inc/11da n 1niicll' of
olii>c nil, n11d 1111t oils. 7J1is pmctice proPidcs 11 17ie ll'/Jolc-grni11 fn·cnds n11d ccr.-als, fmits, 111ethods to dtt<'l'lllillc the p1'1Jtcin q11nlif) 1if i11-
0
sufficient n11101111t of rsscnrinl fntty acids. 1111d J't'g&tnbles m mcb a diet ll f f tbc primm·y rlii1id ual Joor! proteins.
Scnll'eed and micronlgnc nrt two possible so11rccs source nf tlu·se fnctr1rs. If duired, some lcn11/- 19. Ncwbr PK: Ri>k of overweight .tnd obcsiry
far vtg1111s of tbc 1•crrlo11g·cbai11 omegn-3 fatty lmvjh.t animal prod11cts cn11 be ndrled 111 among scmivcgcrarian, l:tcrovcgctari.in, and
nridsfntmd i11 Jisb. ro1111d out n pla11t-bnscd dirt wit/Jo11i d.-a·e11s-
vegan women. A111crirn11 /1111mnl <Jj' Clinicnl
8. Dawson-Hughes B: Interaction of dicrary ..:al- i11g it.r ln•ncfits. Nutrition 81:1267, 2005.
cium and prorcin in bone health in hu mans. 14. Johnsrnn PA, Sabare J: Nurritional i111plicarion~
Sc111iveget11rin11 w11111rn in tlJiJ .r/Jld)' ll'at 1.-.rs
/011r1111I of N11rririi111 133:8525, 2003. of vegerarian diets. Ln Shils /\IE .md oche rs
like~\' to be m•c1·111,.ight n11d 11bese rn111pa1·«d m
It is i111portnu.t ro men rnlri11111 needs to officr (eds): M11der11 111m·iti1111 i11 hen/th n11d discnst'.
muniJ•orous 1111111u·11. Co11s11111i11;1 mor.: pln11t
n11y pus:tible pr11rei11-reliired cnlci11111 loss i11 t/Jr 10th i:d. Philadelphia, PA: Lippincou \Villi.1ms
foods rich in pmrri11 n11d fr.rs 1111i111nl p1·11rei11
11ri11e. ill rhis 1vn.1• t/J,- r1i111!Ji11nti1111 of meeting & Wi lkins, 2006
111n_1• /Jclp i11divid11nls c11111rnl rbeir 111t·(qbr.
prorcin n11d rnlci11m 11uds mn be bmcficinl ro Current 1·cpicJV of the 1111tnt1011a/ ndJ>antagcs
bo11r /Jen Ith. 20. Nurs arc on .i rull. UC Rcrkrli:y \I'd/nm Law-,
1111d pos.riblr 11urrir11111nl problems 11risi11,11 from
p. I, May 2003.
9. Eating ,1 high prorcin diet mar a.:eeler,uc kidnC)' jiillo1Pi11,111111rio11s f)pcs of Pcganrinn dfrts. 171.-
problems. Tt1dny's Dictitinn, p. 26, April 2004. a11r/Jt1n cmphnsi::;e the 111n11y br11cjits of i11d11d· Nuts nre n rich s1111rc1· 11f 111n11v 1111rrimu n11d
i11g plant pmrdw in n dirr plnt1. fiber but nlm 11rc ,,,.,)' t1wnv-dmsc. '/1ms it is
Htnb-protci11 dias 111ny nrcdcmtt: kiduey disco.re
i11 pcopk 11•/Jo sb11w c111drncc of rbc disease. Nolf LS Lcitzmann C: Vcgcr.irian diCl>: \\fhat .ire the best to mbsritutr 1111tsjiw 11tlAT /m11t'in som-rcs,
tlmt rh,· Nari111111I Kid11q F111mdnrio11 mggrsts •1dvant.1~cs? Fom11111fN11n·itio1157:147, 2005. apccinlly thost ric/J in mt11rntt:dfn1.
one 111 11iur N11n/J A111c1·icn11 adults shoJ11 cl'i- Tbt bettrftt.r of n 1•cgcrnrin11 diet rm· n loll't'I' 2 I . S.1batc J: The: comribulion of vcgc r~nJn dic1>
dwc1• 11f nt lcnst mild kid11<)' discnse. iurnke 11fsnt11rnredfnt, clJ11lattT1Jl, n.11d n11i- ro human health. Formu.r nf N1111·iti1111 56:
10. Food and Nuoition B1J.trd: Dict111:1• l't:fermu i11· 111nl pr11rei11 as well ns n J1i._r1bcr i11tn!t.- oj'cam- 218, 2005.
tnkt•sjiJ1· .:nc1J1y, mrbnbydmtc,fibc1;filt,fntty nrids, plrx rru-/111/J.i•dm us, film; 111n~f/111·si11111, .foln It", Co111po11e11rs o/n IJCnlrby Pcgctnri1111dut111d11dt'
c/10/csrcrnl. prorciu, n11d 1111111111 ncids. \Vash.ingLOn vitnmi11 C, Pirn111i11 E. cnmtc1111ids. 1111d 11t/Jcr n l'lll'icty 11f1•c._11ct11/ilc.<,fr11iu, ll'lmfr:rrmi11 <'<Tc·
DC: The N.1lio1ul A.:,1dcmy Press, 2002. pJ~vrorbc111icnls. m·l!·/111ln11rcd l'<;gctnriau diets nl.<, legumes, nnd mas. Suc/J n d1er co11rrib11ta
771fr l'cpurt pm1•1des rhc lnrc,sr JJ11idn11cc for tirt' npprt1printr ;ur 111/ srn.fTl'S of th<' !if.- eye/<' co 1Tl't:rnll henlr/J nud i11n·,·nsrd lr111.11ri•it.Y ll'hm
111nrro1111tl'imt i11tnkcs. \l'it/J r(11nrd rt1 pn1ui11 7J1r nniclr proP1dcs rv1drncc to .mppnrt rhcsr time f11od.s nrr t"mp/Jnsb:d.
i11mkc, t/Jr RfJA Jms bcrn set nt 0.8 glkg p..,. Jtnu11101ts n11d ffPirws r1t/Jt'I' pnssi/Jfr brnlth
22. "Vegging our" for bcttc1 hc:ilth? HmltbNnl'.<,
tiny. Prnui11 imnk.· cn11 1·nitg«fro111 IO ro 35% bmcftts.
p. 8, November 2003.
ufc11o;gy i111akt. 11JC 10% 11/11m11c11r nppro:d· 16. Lejeune /\ I P .ind others: Addiriona.l protein i11-
mntcs rh.- RDA, lmscd 1111 rypicnl c11e1lJY i11mkcs. t:tkc limi~ Wt'.ight rcg;1in .ifkr weight lo>> in hu - Wdl-bnln11n·d pln11r·bnscd dins rn11lendrn1111 ·
111.rn~. Brilisb /1111r11nl ufN11triti1111 93:28 1, 2005. merrms /Jmlt/J l1c11cji1s. One lmufit 111ny b.- n
J l. Gardner \D and others: The eftcct of a plant·
b,i:;cd diet on plNm lipids in hypcn:holcs- !1111110· lifi;.
Addiu.n 30 .IT 11fprorti11 pa dn)' to tht'il- usual
rcrokm1c adulcs. A111111/s 1111 lntcmnl Alerlici11f dirrs l1l'lpt'd pc11plr i11 tin's ftlld_l• limit 11'c1ghr 1-.-- 23. Weiss R :u1d OU\CJ"1': Severe 1~r.1min n - 12 deli·
142:715, 200:; .!lll i11 nftcr ll'CiJ7!1r lo.rs. 771.- diet of tlJC cxpcrimm • dency in an inf.1111 <lSSO<.:iatcd wi1 h .1 m,11cm.ll defi-
Adding plnnt prnrtim t11 n diet nfrmrly lml' ill rnl .fll'flll/I i11cl111frd 18% of flm;gy intake hS ciency and 3 soict vcgcraria11 dil'L /011mnl 1!}
mtumud /ht nnd d111/rstrn1I pnwidi:s ndrli- protein c11111pni·t"d r11 15% 111 the Ct1111rof.rrro11p. Pcdintric Hr111ntoltLtr)' n11d 011col11..rn.• 26:270, 200-1-.
tiimnl bc111:fits rqwrding tbr: lumrri11g of blood 771is p1wd11 i11rnkr i11 1/Jr r:...:pcm11c11rnl Jfl'llllfJ A p;·eg11a11t 1J10111n11 11111s1111cc/' 11it11111i11 B·/2
r/J11lcst1•r11/. 77Jr nut/Jon n11p/Jnsizc thi· impor· w11111tf 1111r be cousidcrcd txcc.<sir't· ~11i1•m the upper 11eer!s ll'brn j'ol!owi11..1111 11t;gdnl'in11 dir1. 71us nr·
rn11cc of i11cl11di11.11 jbms, l'cgcrnblcs, lcg11111c.r, limit 11/35% 1fwo:g_r i11rn!tc srt /~\' rhc Food n11d tide dcscribt>J wbnt /Jnppms w/Jw n p1·i:1111nm
1111d whokl1rni11s i11 n diet. 1\11triri1111 Ron1·d. 1111m11111dcftczcnr111 a>itai11i11 B-11gocs 011 ro
t 2. Garlick Pl: The n.1rnrc of human hazards a!>Jio· 17. Magic soybeans? Tc..,ting the promiw of 50) brmstfccd her i11fn11t, 1111tnbly, dc11r/11p111mt of'
dated with cxcc~i'e imakcs of amino add~. prorcin. Tufts U11ii•e1-sity Hmlrb c- .'Vutritio11 s.:1•cre nt1e111111 arid 11cr1Jt" d1g.-11cm11011 m t/Jt'
fm1mnl 11,f N11rriri1111 L34: 1633$, 2004. Lm,·r p. 4, Occcmbcr 200!'. infant.
Take I Action
I. Protein and the Vegetarian

Alano is excited about all the heolih benefits that might accompany a vegetarian diet. However, she is concerned that she will not con·
sume enough protein lo meet her needs. She is also concerned about possible vitamin and mineral deficiencies. Use NutritionColc Plus
or Appendix N to calculate her protein intake and see if her concerns ore valid.
Protein (g)
Breakfast
Calcium fortified orange juice, l cup
Soy milk, l cup
Fortified bran flakes, l cup
Banana, medium
Snack
Calcium-enriched granola bar
Lunch
GardenBurger, 4 oz
Whole-wheat bun
Mustard, l tbsp
Soy cheese, 1 oz
Apple, medium
Green leaf lettuce, 1 1/2 cups
Peanuts, 1 oz
Sunflower seeds, 1I4 cup
Tomato slices, 2
Mushrooms, 3
Vinaigrette salad dressing, 2 tbsp
Iced tea
Dinner
Kidney beans, l /2 cup
Brown rice, 3/4 cup
Fortified margarine, 2 tbsp
Mixed vegetables, 1I4 cup
Hot tea
Dessert
Strawberries, l /2 cup
Angel food coke, 1 small slice
Soy milk, I /2 cup
TOTAL PROTEIN (g) _
Alana's diet contained 2150 kcal, with _ _ g (you f~I in) of protein (Is this plenty for her?), 360 g of carbohydrate, 57 g of total di-
etary fat (only 9 g of which came from saturated Fat), and 50 g of fiber. Her vitamin and mineral intake with respect to those of con·
cern to vegetarians-vitamin B-12, vitamin D, calcium, iron, and zinc-met her needs.
Take I Action
II. Meeting Protein Needs When Dieting to Lose Weight

Your father hos been gaining weight for the lost 30 years ond now has developed hypertension ond type 2 diabetes as o result His
physician recommends that he lose some weight by following on 1800 kcal diet. You know that ii will be important for your father lo
meet protein needs as he tries to lose weight. Design o 1-doy diel for him that contains about 20% of energy intake os protein
Tobie 7-3 will provide some help. Will this diet meet his protein RDA? Does the diet look like o pion you could also follow?
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..
ALCOHOL

Alcohol-An Introduction Alyssa and her boyfriend Todd are college juniors. Todd was o very serious student
How Alcoholic Beverages Are Produced in high school and achieved excellent grades, but as a college student he has
Alcohol Metabolism begun binge drinking. His grades hove fallen sharply and he is becoming socially
Alcohol Dehydrogenose Pathway • Microsomal -I
isolated. He was even orrested once for drunk driving. I
Ethanol Oxidizing System (MEOS) • Cotolose m
Pothwoy lost night, Todd hod eight beers and three shots of whiskey at an off-campus m
Benefits of Moderate Alcohol Use
party he attended with Alyssa. Unfortunately, everyone who knows Todd says he
z
m
Health Problems from Alcohol Abuse
A Closer look at Cirrhosis lends to get angry and says things he doesn't meon when he drinks too much. He '°
G)
-;<
Why Does Alcohol Abuse Typically lead to often becomes cruel and destructive to those he cores for and respects. He also hos ~
Cirrhosis? m
been involved in several fights. r-
Expert Opinion. Alcohol and Nutrition 0
Guidance Regarding Alcohol Use
As the party began to die down, Alyssa tried to gel Todd to leave. He re-
sponded rudely and forcefully grabbed her arm. She became frightened with his ag-
z
G)
Alcohol Dependency and Abuse
Genetic Influences • The Effect of Gender • gressive behavior and left without him z
Ethnicity ond Alcohol Abvse • Other Conditions c
• How Is Alcoholism Diagnosed? • Do You The next morning, Alyssa noticed a large bruise on her arm where Todd hod -I
Hove o Problem with Alcohol? grabbed her. She decided to e-mail Todd lo express her anxiety about the events '°
m
Treatment of Alcoholism from the night before and his alcohol abuse. She did not wont to see everything he
z-I
(/)
Nutrition Focus: Binge Drinking hod worked so hard for be ruined by alcohol. )>
Toke Action
What should Alyssa soy in the e-mail? What long-term problems associated with z
CJ
such alcohol abuse should she mention? Where could Alyssa suggest that Todd go )>
r-
to get help with his drinking problem? ()
0
I
0
r-
r
'
271
A lcohol use is an issue requiring careful oltention by health professionals, low enforcement offi-
cials, the courts, elected officials, the entertainment industry, university professors, parents, stu-
dents, and businesspeople engaged in the production and distribution of alcoholic beverages. Although
not on essential nutrient, alcohol is o source of energy for about half of all adults, constituting about 3%
of total energy intake in the North American diet when averaged across 1he population. Moderate con-
sumption of alcohol by a person of legal age is on acceptable practice and has some health benefits.10
But when consumed to excess, alcohol leads to many unfortunate consequences. It is by for the most com-
monly abused drug, ond alcohol use con cause automobile and booting accidents; destroy families and
friendships; and spur deadly behaviors such os suicide, rope, and violence. Alcohol abuse is in fact the
third leading cause of preventable death in adults (behind smok-
ing ond obesity}.3
About 55% of adults in North America drink alcohol. Nearly
CHAPTER OBJECTIVES CHAPTER 8 IS DESIGNED TO
4% of adults ore currently classified as having alcoholism. Many ALLOW YOU TO:
current drinkers ore under the legal oge of 21 . From feenoge l. Describe the process of olcohof metabolism.
years through later years in life, excess alcohol intake hos dam· 2. Describe some benefits of moderate alcohol consumption ond
aging effects on one's nutritional status and overall heolth.13, t 8 define "macerate drinking."
Alcohol abuse is also a major problem in Canada. 3. List some nutrients that ore most likely to be deficient in the diet
of a person who abuses alcohol.
The American Medical Association defines alcoholism os on
4. Explain how alcohol abuse damages body organs, such as the
illness characterized by significant impairment directly related to
liver, heart, brain, and kidneys.
persistent ond excessive use of alcohol. Impairment con involve
5. Identify body organs most likely to develop cancer because of
physiological and social dysfunction, and for psychological, so- alcohol abuse.
cial, ond genetic reasons some people ore more vulnerable to 6. Outline the methods used to diagnose alcohol abuse.
this disorder than others.1 4 Because alcohol abuse touches many 7. List the typical strategies used in treating alcoholism, including
lives, this chapter examines this substance in detail. the typical medications employed.
8. Describe binge drinking ond its risks.

STUDY OF ALCOHOL IN CHAPTER 8, YOU MAY WANT TO REVIEW;
The role of the GI tract, liver, and pancreas in digestion and absorption in Chapter 3.
Oxidalion and reduction reactions in Chapter 4
Glycolysis, the citric acid cycle. and electron transport chain in Chapter 4
The term fermentation defined in Chapter 3 and the actual chemical reactions in Chapter 4
Forms of carbohydrates in Chapter 5.
Protein-energy malnu!rilion in Chapter 7.
Alcohol-An Introduction
alcohol abuse Alcohol consumption thot results Given the v.ride spectrum of alcohol use and alco hol abuse-often starting in teenage
in severe physical, psychological. or social and college years-knowledge of alcohol consumption and its relationship to overall
problems. health is esscm:ial to the study of nutrition. Alcohol, chemicaUy known as ethanol, has
played many roles rJ1roughout history. Alcohol contributes e nergy to the diet (about
ethanol Chemical term for the form of alcohol
found in alcoholic beverages. 7 kca1/g) (Table 8-1). 13 It is also used socially because it takes away inhibitions. In ad-
dition, alcohol ic beverages are thirst quenchers when used as safe a.ltern:itives to pol-
luted water (such as when water is contami11ated with certain microorganisms).
Alcohol requires no digestion. It is absorbed rapidly from Lhe GI rracr by simple
diffusion-no specific transport mechanisms are required for alcohol ro enter a cell-
so it is the most efficiently absorbed of aU energy soLu-ces. Different parts or the Gl
212
Table 8-1 I Energy, Carbohydrate, and Alcohol Content of Alcoholic Beverages*
Amount Alcohol Carbohydrates Energy

Beverage (fluid oz) (g) (g) (kcal)
Beer
Regular 12 13 13 146
Light 12 11 5 99
Distilled Spirits
Gin, rum, vodka, bourbon,
whiskey (80 proon 1.5 14 96
Brandy, cognac 1.5 14 96
Wine
Red 5 14 2 102
White 5 14 1 100
Dessert, sweet 5 23 17 225
Rose 5 14 2 100
Mixed Drinks
Manhattan 3 26 3 191
Martini 3 27 189
Bourbon and soda 3 11 78
Whiskey sour 3 14 13 144 The following servings of each type of alcoholic
beverage provide the same amount of alcohol
'There i$ little lo no fat or prolein contribution lo energy conlenl. [about 15 g): wine-5 oz, hard liquor-
Source· USDA. 1.5 oz, beer or wine cooler-12 oz. In
determining a safe level of intake, it is
important to observe these serving sizes.
tracr absorb alcohol at different rates. The upper parts of the small intestine absorb al-
cohol fastest, depending on how quickly the stomach empties, which in turn depends
on the kinds of foods consumed along with the akohol.8 Alcohol then goes on to act
on various organs, but has no cell ular receprors per se, unlike other compow1ds that
affect the body such as insulin and some fat-soluble vitamins. 13
How Alcoholic Beverages Are Produced

Any number of natural foods can be fermented. Recall from Chapter 3 that fermenra-
cion represents the breakdown of carbohydrates without the use of oxygen. Alcohol,
carbon dioxide ( C02 ), and various acids are by-products. Production temperatures
and composition of the foot! itself determine the characteristics of t11e final product.
High-carbohydrate foods especially encourage the growth of yeast, the microorganism
responsible for alcohol production. Brewer's yeast is one source of the enzyme that is
necess<try to make alcohol production possible.
During glycolysis, glucose is first convened to pyruvate. Yeast cells t11en ferment Beer is a source of alcohol and carbohydrates.
pyruvare to alcohol and carbon dioxide in a simple, two-step process. In the first step,
rhe 3-carbon pyruvate is converted to t11e 2-carbon acetaldehyde in an irreversible re-
action with the release of C02 . In the second step, another enzyme donates a pair of
hydrogen ions and electrons to acetaldchyde to form et11anol. Th.is enzyme uses the B-
''itamin niacin in the form of the cocnzyme NADH + H + (review Chapter 4 for de-
tails). Ethanol and C02 are the end products of the process.
CC02 H H
l. G lucose )Ir )Ir Pyn1vate Acetald ehyde I I
H-C-OH C=O
N ADH + H+ NAD+ I
2. Acetaldehyde '>.. ,dEthanol
C~3
Ethanol
CH3
Acetaldehydc
274 Chapter 8 Alcohol
The O\·erail reaction is

C 6H 120 6 + 2 ADP+ 2 P ; - ---- 2 C2 H 5 0H + 2 C0 2 + 2 ATP+ 2 H 2 0
Glucose Ethanol
Thus, under anaerobic conditions, one glucose molecule is fermented by yeast to two
ethanol, two carbon dioxide, and two water molecules. T he 2 ATP that result arc used
by the yeast for energy.
T he carbohydrate must be a simple sugar, such as maltose or glucose, in order for
the yeast to use it as food. If the carbohydrarc is a starch, such as tbat found in cereal
grains, it must be broken down to simpler fo rms, or " malted." During malting, d1c ce-
real grain seeds arc allowed to sprout to produce the enzymes that break down the
starches to simple sugars. The sprouting is then stopped by heating, and yeast cells and
Wine is a historic beverage. It has been water are added to the malt. The yeast grows using the sugars for energy. When the
produced ond consumed for more than oxygen in d1e vat (the mixnu·e of water, yeast, and malt} is used up, the yeast formenrs
10,000 years. the remaining sugar to produce alcohol and carbon dioxide. After fermentation has
ceased, the product is finished in a variety of ways. In some cases, the alcohol itself is
recovered from the product.
Beer is made from malted cereal grain, such as barley; it is flavored with hops and
brewed by sJO\v fermentation. The carbon dioxide released is collected and used to car-
bonate the beer, thus producing the desirable fizz associated with a quality beverage.
W ine is the fermented juice of grapes. Climate, geographic region, ,md \'ariety of
grape determine the character of the wine. After fer mentation, wines arc often aged in
barrels to decrease the acidity and remove undesirable impurities.
distillation A physical method used to separate Distilled spirits are made from the distillation of the alcohol after ferm~macion. The
liquids based on their boiling points. difference between the boiling point of water and the boiling point of alcohol allows these
two liquids to be separated by distillation and the alcohol to be recovered. Any number
of fruits, vegetables, and grains can be fermented and the resulting mash distilled.
lcohol proof represents twice the volume of Alcohol Metabolism

A alcohol in percentage terms in the product.
Thus 80 proof vodka is 40% alcohol. After a person drinks an alcoholic beverage, his or her blood concentration of alcohol
rises rapidly. Alcohol is readily absorbed into the blood from different segments of the
GI tract by simple diffusion. You've probabl~· been warned, with good reason, not to
drink alcohol on an empty stomach. AJcohol absorption depends partly on the rate of
stomach emptying. Food slows the stomach's emptying rate and stimulates se..:retions,
such as hydrochloric acid, which dilute the alcohol and slow its absorption inro the
bloodstream. 8
Alcohol is readily distributed into aU d1e Auid compartments within the body be-
cause alcohol is found where\'cr water is distributed in the body. Alcohol moves easily
th.rough the cell membranes; however, as it does, it damages proteins in rhe mem-
bra.nes.13
Most of .1Lcohol's damaging effects are seen in the liver because mis is the first organ
rhar is exposed to alcohol after absorption. The liver is also the chief sire for alcohol
merabolism. Although cells of the GI tract are in conract with alcohol, they are con-
stantly being replaced because of tl1eir naturally short Life span. Thus, they an: not sub-
ject to tl1e same degree of damage as Liver cells, whicb have a much longer life span. 8
Metabolism or alcohol is dependent on numerous factors, such as gender, race, size,
physical condition, \\'hat is eaten, the alcohol content o!' the beverage, and even how
alcohol dehydrogenase An enzyme used in much sleep one has had. The ability to produce tl1e enzyme alcohol dehydrogenase
olcohol (ethanol) metabolism; the major is tbe key ro alcohol metabolism, because ir acrs on about 90% of rl1c alcohol con-
enzyme used in the liver when alcohol is in low SLLmed. I 3 Women absorb .md metabolize alcohol differently rhan men do. A woman
concentration. cannot metabolize: much alcohol in the cells that line her stomm.:h bcc,rnse of low ac-
t ivity of alcohol dehydrogenasc. Men metabolize about 30% of the akobul ingested in
this manner, bur women metabolize only 10%. vVomcn also have less body watc:r in
which to d ilute d1e alcohol than do men (the same is also true for older men and older
women). So, when a young man and a woman of similar size drink equal amounts of
alcohol, a larger proportion of ilie alcohol reaches <lnd remains i.n the\\ ornan's blood-
stream. This explains why women develop alcohol-related ailments, such as cirrhosis cirrhosis A loss of functioni ng liver cells, which
of the liYer, more rapidly d1an do men with the same <lkohol-consumption habits.2 ore replaced by nonfunctioning connective
Most of ilie remaining alcohol consumed is then metabolized in d1t: liver in rhc tissue. Any substance that poisons liver cells
same 'my (by alcohol dehydrogenas<.:) to carbon dioxide and water. Only a small per- con lead to cirrhosis. The most common cause
centage of alcohol imake is excreted unmetabolized through the lungs, urine, and is o chronic, excessive alcohol intake. Exposure
lo certain industriol chemicals con also lead to
swear. t3 (Because the alcohol conrcnr of exhaled air mainrains a constant relationship
cirrhosis.
ro the blood alcohol concentration in d1c lungs, it is used as the basis of ilie breatha-
lyzer test.) As one continues to drink, one's blood alcohol concentration (BAC) con- microsomal ethanol oxidizing system
tim1cs to rise (Figure 8-1 ). A social drinker who weighs 150 pounds and has normal (MEOS) An alternative pathway for alcohol
li\'er function metabolize~ about 5 to 7 g of alcohol per hour. Thi:. is about one half of metabolism when alcohol is in high
a beer or one fourth of an ordinary-sized drink. When the rate of alcohol consumption concentration in the liver; uses rather than
exceeds tbe li\·er's metabolic capacity, blood alcohol rises and symptoms of intoxica- yields energy for the body, in contrast to
tion appear as d1e brain begins robe exposed to alcohol (Table 8-2 ). 19 alcohol dehydrogenose activity.
Bec.iuse alcohol cannot be stored in d1e body, it h:1s absolure prioriry in metabolism catalase pathway An alternative enzyme
:1s a fuel source, taking precedence O\'cr other energy stores such as fat. When needed, pathway to alcohol metabolism; alcohol is
the li1·er .1lso has two other pad1ways ro metabolize akohol. Each-.1long with alcohol broken down in conjunction with the
dchrclrogenasc-produces acetaldchyde. The ocher pat11ways .1re the mkrosomal breakdown of hydrogen peroxide (H 20 2) by
ethanol oxidizing system (MEOS) and that uti lizes the enzyme catalase. These this enzyme.
other two pad1ways .ire also acti\·e in other cells in the body. 13
.08 ... -. .A. A

-------i ~3 drinks
..r• ... ~ _,,..... ~ .07
4 drinks -----------i
.06
A-~_;- .... .05

3 drinks ----- 1------~~ drinks
.04
.03
.02
.01
Blood alcohol
concen fro ti on
Mole Female
170 pounds 137 pounds
Figure 8-1 I Approximate relationship between alcohol consumption and blood alcohol concentration (BAC; units are% or mg of alcohol per 100 ml of
blood). Nole that effects con vary among people and whether food is also consumed. A BAC of 0.02 begins to impair driving One is legally intoxicated at a
BAC of 0.08 in the United States ond throughout Canada. Recall that the following servings of each type of alcoholic beverage provide the same amount of
alcohol (about 15 g): wine-5 oz, hard liquor- 1.5 oz, beer or wine cooler-12 oz.
Table 8·2 I Blood Alcohol Concentration and Symptoms

Hours for Alcohol
Concentration• Sporadic Drinker Chronic Drinker to Be Metabolized
50 (party high) (0.05%) Congenial euphoria; decreased tension; No observable effect 2-3
noticeable impairment (e.g., in driving)
75 (0.075%) Gregarious Often no effect 3-4
80- l 00 (0.08-0.1 %) Uncoordinated; 0.08% is legally drunk (as in Minimal signs 4-6
drunk driving) in the United Stales and Canada
125-150 (0.125-0. 15%) Unrestrained behavior; episodic uncontrolled Pleasurable euphoria or beginning of 6-10
behavior uncoordination
200-250 (0.2-0.25%) Alertness lost; lethargic Effort is required to maintain emotional 10-24
ond motor control
300-350 (0.3- 0.35%) Stupor to como Drowsy and slow 12-24
> 500 (>0.5%) Some will die Coma >24
•Milligrams of okohol per l00 milliliters of blood (mg/di).
Modified from Wyngoorder JB, Smilh LH· Cecil Texlbook of Medicine, fourth edition, Philodelphio, 1988, WB Sounders. Used wilh permission.
lcohol dehydrogenase requires the mineral Alcohol Dehydrogenase Pathway

A zinc for its activity.
During chc firsr step, alcohol at a lo\\' to moderate quantit)' is converted tu acetalde-
hydc by the action of alcohol deh}1tfrogenasc and the cocnzymc NAD +. NAD+ picks
up two h)•drogen ions and rwo electrons from thc alcohol to form NAD H + H + ,rnd
produces the intermediate acctaldcbydc (Figure 8-2 ).
NAD+ NADH + H+
Ethanol ""-- 4 AcetaJdchyde
Distinctly difkrcnt lorms of alcohol de hydrogcnase are found in the li\·cr and Lht:
sromacb. Each Yarics in its rate of alcohol metabolism.
The accraldehyde formed is then converted ro ac.:etyl-CoA, again yielding NADH +
H + with the aid of aldehyde dc hydrogcnasc and coenzyme A.
NAD+ NADH + H+
( Coenzyme A
Acetaldehyde -"'--
-"""~-4"'-'I~ Acetic acid ., ., Aceryl-CoA
~ l!!:====/===::;;;;~~;::;:;;;;=======i>;:.I. . _A_c_ei_a_ld_eh_y_d_e_.
Figure 8 · 2 I Alcohol melobolism. At low
alcohol intake, the alcohol dehydrogenase ..._
E_th..,..an_o_I
pathway in the cytoplasm is used. At high
alcohol intake, the microsomal ethanol NAO }
oxidizing system (MEOS) in the cytoplasm also NADH
is used. The MEOS uses rather than yields Aldehyde
energy and accounts in general for aboul 10% dehydrogenase
of alcohol metabolism. High doses of ethanol
NAOH + H
MEOS
Acetyl-CoA
_
NADPH
.... NADP
.I
For any acetyl-CoA that enters the citric acid cycle, the NADH + H +, FADH 2 , and ~C02 +H 20
GTP molecules produced can then be used to synthesize ATP via the electron trans-
Acetyl - CoA~ Fatty acid
port chain (review Chapter 4).
Structurally, ethanol with its hydroxyl group (-OH) resembles a carbohydrate. Glucose
However, because edianol is converted directly into acetyl-CoA, alcohol carbons can- Metabolic fates of acetyl-CoA.
not support glucose production. Thus, alcohol is metabolized more like a fatty acid
than a carbolwdrate and is considered fat in metabolic terms. 8 The related increase in
NADH + H + also promotes fatty acid synthesis and reduces fatty acid use in d1e liver,
widi accLUnularion of bod~' fat, especially in the abdominal region of the body.9
Microsomal Ethanol Oxidizing System (MEOS)

vVhen a person drinks moderate to excessive amounts of alcohol , the enzyme alcohol
dehydrogenase cannot keep up witli die demand to metabolize all the alcohol into ac-
etaldehyde. For this and other reasons, anod1er enzyme system exists to metabolize al-
cohol. This system is called d1e microsomal ed1anol oxidizing system ( MEOS).
The liver (and other body cells as well ) uses the MEOS co metabolize drugs and
other substances foreign to the body. \\Then die liver is ovenvhelmed wid1 excess
amounts of alcohol, it treats die excess as a foreign substance and acti,•ates th<.: MEOS,
T his system uses oxygen- anodier niacin coenzymc (NADP+ )-and produces warer
and acctaldehyde. Once the MEOS is active, alcoho l tolcra111.:e increases because the
rate of alcohol metabolism increases. 13 Compared with whites, some Asians and
O, Native Americans make little of the active form
~
of aldehyde dehydrogenase, and so ore more
likely to suffer from hangovers.
Ethanol /-~~~-1•.- Acetaldehydc + 2 H 20
NADPH + H+ NADP+
There are two interesting aspects of the body's reliance on MEOS. First, rather than
forming the niacin-containi ng cocnzymc NADH + H +, as with alcohol dehydrogc-
nase, the MEOS uses rhe niacin-containing coenzymc NADPH + H +, a compound
analogous to NADH + H +. Rather than yielding "potentiaJ" ATP molecu les from die
first step in alcohol metabolism, by using NADPH + H + the J\ilEOS uses "potential"
ATP energy in the form ofNADPH + H +. NADPH + H + is converted to NADP+.
This partly ex.plains why alcoholics do not gain as much weight as might be expected
from the amouur of alcohol-derived energy tl1ey consume. 13 The liver inefficiently uses
excessive amounts of alcohol because it requires energy for the initial step in metabo-
lism. A person with alcoholism wastes some energy by inducing this alternate meta-
bolic pathway. Liver damage from alcoho l, which causes other metabolic pathways to
be hampered, also is implicated in the reduced energy yield associated with high alco-
hol consumption. ln addition, aJcohol slightly increases the metabolic rate of the body.
Use of die MEOS also increases the potential fo r a drug overdose. While the MEOS
is metabolizing alcohol, the liver's capacity for metabolizing other drugs, such as many
sedatives (barbiturates), is reduced, since both pathways compete for the same enzymes. Of all the alcohol sources, red wine is often
singled out as the best choice because of the
If large amounrs of alcohol and sedatives arc consumed simultaneously, the alcoho l gets
added bonus of the many phytochemicols (e.g.,
preferential treatment. Because tlie liver is not able to metabolize the sedatives as fast as
resveretrol) present. These leach out from the
usual, d1c user may lapse into a coma and even die. Alcohol itself is roxic in high quan- grope skins as the red wine is mode. Dork beer
tities. Mixed with sedatives, it creates <tn extremely lethal combination. 19 contains some phytochemicols, bul a lower
amount.
Catalase Pathway
The catalase enzyme found in the liver and other cells contributes to a minor pathway
for metabolizing alcohol. It is located in the peroxisomes, a cell organcl le.13
H 20 2 2H 2 0
_ ___,,,__,4"-ll.- Aceta1dehyde
Ethanol "-._
Benefits of Moderate A lcohol Use

The benefits of alcohol use arc Jinked to specific intakes of about one drink a da\ for
men and slightl)' less tl1an one for women. The type of alcoholic drink consumed does
not significantly affect the benefit. Note that beer ranges considerably in its alcohol
content, wirn malt liquor being higher in alcohol than most other forms of beer.
The benefits of moderate ~llcohol consumption begin with the many pleasurable and
social aspects of its use. People enjoy meeting a friend over a beer or settling down to
a g lass of wine in t he e''ening with di1uier. These behaviors are not considered exces-
sive as long as they are practiced by people of legal drinking age, remain under con-
trol, and cause no obvious harm. Other benefits include reduced risk of developing
cardiovascular disease and cardiovascuhr disease-related deaths, such as from coronary
heart disease. This benefit applies, however, only ro middle-aged and older adults at
risk for tl1e disease who consume moderate amounts of alcohol, and not to younger
adulrs. 1 Ischemic stroke risk also is decreased in light-ro-moderate drinkers as op-
posed to tbosc wbo abstain from alcoholic beverages. 16 Other potential health bene-
fits arc listed in Table 8-3.
Many of rbe benefits of moderate alcohol use arc effcCLivc only in the shon term,
Much of alcohol's popularity is due to the
pleasurable and social aspects associated with
such as on an almost daily basis. More intermittent users and previous consumer<; of
its use. alcohol no longer experience rhe bendlts of alcohol when consumption ceases.
Concept l Check
ischemic stroke A stroke caused by the
AJcohol is not an essential nutrient. lt requires no digestion, and alcohol metabolism takes
absence of blood flow loo port of the broin.
precedence over metabolism of tbe other energy-yielding nutrients. Alcohol is meraboli1ed
in the liver and orhcr tissues. ~letabolism mostly depends on the enzyme alcohol dchydro-
genase. A number of individual factors, such as gender, race, and body composition, llcter-
ruine how a person reacts to alcobol. The microsomal ethanol oxidizing system (1'v1EOS ) is
used whenever the li\'cr detects more alcohol than can be processed by the alcohol dchy-
drogcnasc enzymes. Once the MEOS is active, alcohol tolt:rance increases because alcohol
is being metabolized more rapidly.
The benefits of alcohol use .u·e realized with moderate consumprion. Under the correcc
circumstances, alcohol can be pleasurable, add co social occasions, and decrease the risk of
coronary heart disease- related deatl1s and iscbemic stroke. Mortality risk is some\\ hat
greater i11 people who abstain from alcohol, and the risk appears to be decreased in men
consuming up to two diinks per day. Furthermore, the protective dose of alcohol is some-
what less in women.
I Health Problems from A lcohol Abuse

Despite tl1e benefits of regular, moderate alcohol use, tl1e risks of abuse arc more nu -
merous and harmlitl. Alcoholism, in and of itself, is the third leading cause of pre-
ventable death in North America.3 In fuct, excessive consumption of alcohol
contributes significantly to 5 of the J0 leading causes of death in Norm America-
heart failure, certain forms of cancer, cirrhosis of the liver, motor veh icle and od1cr ac·
cidenrs, and suicides (review Table 8-3). Tobacco, often used simultaneously, interacts
with alcohol in a way drnt reinforces its effects and causes esophageal and oral cancer.
In addition, excessive alcohol drinking increases the risk of hearr rhythm disrurbances,
hypertension, hemorrhagic srroke, osteoporosis, brai11 damage, colorcctaJ and breast
cancer, inflammarion of rbe stomach lining, suppression of the immune system (and,
thus, an increased risk of infections), sleep disturbances, impotence, hypoglycemia, and
high blood triglyceridcs. 1•2 •4 •7 •13· L8 Figure 8-3 illustrates many of these risks. A~ men-
Excessive alcohol intake, notably binge tioned bcfure, alcohol ingestion also reduces use of fut by liver cells and promotes a
drinking, encourages fol deposition, especially positive energy baJauce, thus contributing to risk for obesity, especially abdominal obe-
in the abdominal region. sit:y.9 Finally, by reducing the action ofantidiu retic hormone, alcohol increases urinarion
Table 8·3 I A Summary of Benefits and Risks of Alcohol Use4· 7, l l, l 3, 17,20,24
Benefits Risks
Coronary heart disease Decreased risk of death in those at high risk for Heart rhythm disturbances, heart muscle damage,
coronary heart disease-related death, primarily increased blood triglycerides and homocysteine,
by increasing HDL-cholesterol in some people, and increased blood clotting
decreasing blood clotting, and relaxing blood
vessels
Hypertension and stroke Mild decrease in blood pressure; fewer ischemic Increased blood pressure (hypertension); more
strokes in people with normal blood pressure; ischemic and hemorrhagic strokes
reduced death in people with hypertension
Peripheral vascular disease Decreased risk due lo reduced blood clotting No risk
Blood glucose regulation and Some increase in insulin sensitivity and a Hypoglycemia, reduced insulin sensitivity, and
type 2 diabetes decreased risk of death from cardiovascular damage lo pancreas (site of insulin production)
disease
Bone and joint health Some increase in bone mineral content in women, loss of active bone-forming cells and eventual
linked to increased estrogen output osteoporosis (many nutrient deficiencies also
contribute lo the problem); increased risk of gout
Brain function Enhanced brain function and decreased risk of Brain tissue damage and decreased memory,
dementia by increasing blood circulation in especially in the teenage and young adult years
the brain
Skeletal muscle health No benefit Skeletal muscle damage
Cancer No benefit Increased risk of oral, esophageal, stomach, liver,
lung, colorectol, and breast cancer, lo name a few
(especially if the person's diet is deficient in the vitamin
folote); breast cancer risk is elevated even more if a
woman is on estrogen replacement therapy (e.g.,
for menopausal symptoms)
Liver function No benefit Fat infiltration and eventual cirrhosis, especially if a
person is also infected with hepatitis C; iron toxicity
GI tract disease Decreased risk of certain bacterial infections in Inflammation of the stomach (and pancreas);
the stomach absorptive cell damage leading to molobsorption
of nutrients
Immune system function No benefit Reduced function and increased infections
Nervous system function No benefit Loss of nerve sensation and nervous system
control of muscles
Sleep disturbances Some relaxation Fragmented sleep patterns and snoring; worsens
sleep opneo
Impotence and decreased libido No benefit Contributes to the problem in both men and women
Drug overdose No benefit Contributes to the problem, especially with sedatives
Obesity No benefit Increased abdominal fat deposition, contributes
to positive energy balance
Nutrient intake Moy supply some B vitamins and iron leads to numerous nutrient deficiencies: protein,
vitamins, and minerals
Fetal health No benefit Variety of toxic effects on the fetus when alcohol
is consumed by pregnant women (see Chapter 16)
Socialization and relaxation Provides some benefit to socialization and leads Contributes lo violent behavior and agitation
to relaxation by increasing serotonin and
dopamine neurotransmitter activity
Traffic deaths and olher violent deaths No benefit (and likely even on increase in traffic Contributes to both traffic death and violent
accidents) death; note that the cost of a conviction for drunk
driving is about $8000-$10,000 when the figure
includes increased automobile insurance premiums.
The risks from alcohol obl)!>e begin 01in1oke of more !hon 1wo lo 1hree drinks per doy for men and one lo two drinks per day for both women and odulls over oge 65 21 Binge drinking (more !hon lour
drinks in o row for women and more than five drinks for men) con be especially harmful (see the Nutrition Focus in !his cbopler). The Swiss chemlsl Porocefsus (1493-1541 J mode 1he observolion rho!
•1he dose de1ermines the poison." l his is especially true for alcohol, because alcohol abuse lypicolly red11Ces o person's life expecloncy by 15 years.)
279
(ill Impaired brain function and resulting brain damage
EJ Vosodilotion and resulting Rushing of the skin

EJ Cancer of the esophagus
IJ-- -------------- ----------- -------·
Heart muscle domoge ond resulting heart failure
~ Irritation of the stomach lining ond stomach cancer
Fatty infiltration of the liver ond ultimate liver failure
1fJ Impaired pancreatic function and related

hypoglycemia and pancreatic cancer
Malabsorption of nutrients in the small intestine
fJ Abdominal fat deposition and Auid accumulation
ooJ -- C~n~;r-;f th~ -c~I~~ ~~lr~~,;;-- - - - -- - - -- - -
Figure 8·3 I Some effects of alcohol abuse on the body. Virtually every organ system is affected by alcohol. The mind-altering effects of alcohol begin soon
ofter it enters the bloodstream. Within minules, alcohol inhibits nerve cells in the brain. As a drug, alcohol eventually produces a narcotic effect on the body.a
As Shakespeare wrote in Macbelh: "It provides lhe desire but takes awoy the performance." The heart muscle strains lo cope with alcohol's depressive action.
If drinking conlinues, rising blood alcohol causes impaired speech, vision, bolonce, ond judgmenl. With on extremely high blood alcohol content, respiratory
failure is possible. Over lime, alcohol abuse increases the risk of liver and pancreas fai lure and certain forms of heart domoge and cancer, among other
disorders. Tobie 8-3 summarized oll the negative effects of excessive alcohol use on physical health.
narcotic An agent lhol reduces sensations ond and the risk for dehydration. Death from alcohol abuse usually results from respiraton·
consciousness. failure or inhalation of vomit (the laner if the blood alcohol concentration is lower).
As a nutrient source, alcohol has litde nutritional value, and thus, nurrienr deficien-
cies are also a common result of alcoholism. 12 The protein and vitamin content i~ ex-
tremely low, except in beer, where it is marginal. Iron content varies from drink to
drink, with red ,,;ne ranking especially high in iron. Excess use of some alcoholic be'
erages can even lead to iron toxicity, as well as toxicity from lead or cobalt.
Alcoholism produces many micronutrienr deficiencies. These arise mostly because ol
f o person were to use beer os o nutrient poor nutrient intakes, but fut malabsorption linked to poor pancreatic function and in-
source, he or she would need to consume creased urinary losses are also important in some cases. 13 On the other hand, micronu -
doily: trient toxicity is also of concern, particularly with \icamin A and iron. In both case~.
• 40 to 55 bottles ( 12-oz) to meet protein damage to the GI tract and liver enhance rhe potential for toxicity from these nutrienr~.1 3
needs Dr. Charles Halsted discusses these problems in derai l in the Expert Opinion. The im-
• 65 bottles for thiamin needs mediate aim in nutritional treatment of alcoholism is eliminating alcohol intake. Then
• 6 bottles for niacin needs attention turns to replenishing nutrient stores, general ly with nutrient supplements.
280
A Closer Look at Cirrhosis

Long-term alcohol use causes fatty liver, inflammation of the liver (alcoholic hepatitis),
and eventually cirrhosis.5 Cirrhosis is a chronic and usually relentlessly progressive dis-
ease characterized by fatty infiltration of the liver. Fatty liver occurs in response to in-
creased synthesis of fat and decreased utilization of fat for energy needs by the liver.
Eventually, the enlarged fat deposits choke off the blood supply, depriving the liver
cells of oxygen and nutrients. Liver cells can accumulate so much fat that they burst
and die and are replaced by connective (scar) tissue. This scarring process is called cir-
''hosis. When too many liver cells die, the liver dies, and the alcoholic patient dies. In
North America, most cases of cirrhosis are caused by alcohol consumption. Cirrhosis
develops in about 10 to 15% of cases of alcoholism and affects about 2 million people
(a) (b)
in the United States alone. 15 It is the second leading cause of the need for liver trans-
plants. In addition to the amount and duration of alcohol consumption, genetic fac- (o) Healthy liver; (b) liver with cirrhosis.
tors and individual differences determine one's risk for the disease, such as obesity,
exposure to heparotoxins (e.g., acetaminophen rTylenol]), and infections with hepati-
tis C.1 5 (Note that about 4 million people in the United States arc infected with the
virus that causes hepatitis C.) Once a person has cirrhosis, there is a 50% chance of
death within 4 years, a far worse prognosis tban many forms of cancer. Most of the ascites Fluid produced by the liver,
deaths from alcoholic cirrhosis occur in people between the ages of 40 and 65 years. accumulating in the abdomen, that is a sign of
The actual death rate in the United States is 8.8 per 100,000 people. In 2001, 35,000 liver failure associated with cirrhosis.
Americans died of cirrhosis. 15
Why Does Alcohol Abuse Typically Lead

to Cirrhosis?
A number of possible mechanisms underlie the liver damage from alcohol abuse. In
du·onic alcoholism, acetaldebyde concentration increases in the liver and is thought to
be the underlying cause of the toxic effects of alcohol. Another cause of liver damage
T he overt signs of liver failure associated with
cirrhosis are jaundice (the whites of the eyes
and the skin turn yellow), ascites, and signifi·
is the production of free radicals from alcohol metabolism. These highly reactive mol- cant enlargement of the veins in the neck.15
ecules destroy cell membranes and DNA and lead to chronic intlarnrnation. 13
No specific amount of alcohol consw11ption guarantees cirrhosis. Cirrhosis is com-
monly associated with a 10-year or longer consumption of approximately 80 g of al-
cohol (the equivalent of 7 beers) per day. Some evidence suggests that damage is
caused by a dose as low as 40 g/day for men (3 beers) and 20 g/day for women
(11/2 beers). Early stages of alcoholic liver injury are reversible, bm moderate to ad-
vanced stages usually are not. If a person is terminally ill, a liver transplant is necessary
for smvival. 15
A mmitious diet helps prevent some complications associated with alcoholism, but
usually alcoholism brings about serious destruction of vital tissues regardless of die
quality oftbe food consumed. Laboratory animal studies show clearly that even when Who~ risks and diseases could correlate with
a nutritious diet is consumed, alcohol abuse can lead to cirrhosis. StiJJ, nutrient defi- the combination of smoking and excessive al-
ciencies compound d1e problem of cirrhosis because it makes the liver more \ruL1era- cohol use?
ble to roxic substances such as free radicals by depleting supplies of antioxidants, such
as vitamin E. If present in adequate a.mounts, this vitamill can reduce free radical dam-
age to the liver. A folate deficiency also compounds dte damage. 13
Concept I Check
Excessive alcohol use can result in an array of medical problems. Ir increases the risk of de-
veloping hypertension, certain forms of strokes and heart damage, birth defects, inJhmma-
tion of the pancreas, damage to the brain, and maLrnt.rition, to name a few.
Expert Opinion
Alcohol and Nutrition
Charles H. Hoisted, M.D.
Nutritional problems ore common among alcoholics. Alcohol abuse con in- suiting in increased vitamin B-6 urinary excretion. If the alcoholic consumes
terfere with nutrient intake if alcohol replaces some or oil of the food in the o diet with inadequate amounts of vitamin B-6, he or she is at risk for devel-
diet. When on individual relies on alcohol for the majority of his or her en- oping sideroblastic anemia ond peripheral neuropothy.
ergy needs, protein-energy malnutrition con result. The symptoms of this Excessive alcohol intake con also impair the absorption of vitamin B-12 os
protein-energy malnutrition ore similar to those seen in children with moros· o result of decreased release of the digestive enzyme trypsin by the pancreas.
mus {see Chapter 7). In addition lo potential protein ond energy deficiencies, Trypsin is needed to release vitamin B-12 from the R-prolein so that it con then
deficiencies of o variety of other nutrients ore possible, particularly certain be bound by intrinsic factor ond be absorbed by the body (see Chapter 10).
vitamins ond minerals. Insufficient intake of folote by an individual who abuses alcohol con be
especially problematic. Folate deficiency may lead to a decreased number
of absorptive cells in the small intestine, which then can result in decreased
Water-Soluble Vitamins
absorption of many other nutrients. Megaloblastic anemia is not uncom·
Excessive alcohol intake con lead to deficiencies in the water-soluble vitamins man in folate-depleted patients who consume excess alcohol.
thiomin, niacin, vitamin B-6, vitamin B-12, folote, ond vitamin C (see Chapter Vitamin C deficiency con ultimately lead to the development of scurvy
10 for more details on these effects). Thiomin deficiency con be caused by de- When more than 30% of total energy intake comes from alcohol, vitamin C
creased intake or decreased absorption of thiomin. The typical symptoms in- intake is usually less than the RDA. Daily supplementation may be required
clude polyneuropathy ond nervous system problems. Ohen patients with for weeks or months to restore blood and urinary vitamin C concentrations
extreme thiomin deficiency ore admitted to the hospital and must be given thi· bock to normal ranges
omin injections to recover from this medical emergency, which, if untreated, con
result in irreversible paralysis of ocular muscles, neuropathy with loss of sensa-
Fat-Soluble Vitamins
tion in lower extremities, loss of bolonce with abnormal gait, and memory loss.
In patients with decreased thiomin stores, administration of large amounts of in· Excessive alcohol intake can also result in deficiencies in the fat-soluble vita-
trovenous glucose con accelerate the symptoms of thiomin deficiency. mins A, D, E, ond K (see Chapter 9 for more details on these effects). Vitamin
The metabolism of alcohol requires large quantities of niacin os NAD+ A deficiency may be caused by o deficient diet, by increased metabolism
and NADP ·, thus limiting the amount of niacin available for other metabolic and biliary excretion, or by an inability of the liver to produce the vitamin A
activities in the body. If alcoholics consume o diet low in niacin and consume (retinol)-binding protein that delivers the vitamin to all parts of the body.
insufficient protein, they ore al risk for niacin deficiency and the correspond- Vitamin A stores in individuals with alcoholism ore diminished regardless of
ing classic deficiency disease, pellogro. whether dietary vi tamin A intake is low, adequate, or high. Vitamin A con-
Acetoldehyde, the primary metabolite of alcohol, con interfere with vita· centra tions ore especially low in individuals with alcoholic cirrhosis. Chronic
min B-6 metabolism. Acetoldehyde displaces B-6 from its binding protein, re- alcohol consumption is thought lo induce metabolic systems in the liver that
polyneuropathy A disease process involving a Guidance Regarding Alcohol Use

number of peripheral nerves.
The U.S. Surgeon General'~ office, the National Academ~· of Science, and 1he
sideroblastic anemia A form of anemia
USDA/DHHS do not spccilkally recommend drinking alcohol, but do not specificalh
characterized by red blood cells containing on
d iscourage irs use. The text oft he 200S Dietm:v Guideli11es[01· Amcricnus ( di-,,cui:.scd in
internal ring of iron granules. This anemia moy
respond to vitamin B-6 treatment. Chapter 2) docs mention alcohol imakc. It conrains these statements:
megaloblastic anemia A form of anemia • Those "ho choose to drink alcoholic beverages should do so sensibly and in
characterized by large, nucleated, immature moderation-defined as the consumption of up to one drink per day IC)r women Jnd
red blood cells tha t result from the inability of adults age 65 and older, and up LO L\\'O drinks per day for men. The definition i~ nm
precursor cells to divide normally. intended, however, as an average over !.cvcral days, bur rather as tht: amount con·
sumed on a single day.
II
i
- -
hasten the degradation of vitamin A. In addition, o Minerals

pancreas damaged by alcohol releases a smaller
Individuals who abuse alcohol can also develop problems with magnesium,
amount of the enzymes needed lo digest fat than o
zinc, and iron metabolism (see Chapters 11 and 12 for more details on
healthy pancreas, that, together with decreased bile
these effects). Severe alcohol abuse con result in magnesium deficiency by
secretion in alcoholic liver disease, results in de-
increasing urinary excretion of this mineral. Alcoholics con develop low
creased capacity to solubilize fat-soluble vitamins
blood concentrations of magnesium, which con result in tetany, character-
and reduced vitamin A absorption. Finally, alcohol
ized by muscle twitches, cramps, corpopedal spasms, and seizures. In ad-
can interact with beta-carotene, a precursor of vita-
dition, impairment of the central nervous system con also result. Magnesium
min A, ultimately reducing the amount of beta-
deficiency is portly responsible for the hallucinations experienced by people
carotene converted to vitamin A Many alcoholics
withdrawing from alcohol intoxication.
have trouble seeing in the dark (night blindness) be-
Alcoholics con develop zinc deficiency os o result of decreased zinc ab-
cause of this alcohol-induced vitamin A deficiency.
sorption as well os increased urinary excretion. The consequences of alco-
Vitamin D deficiency can result from inade-
holism combined with zinc deficiency include changes in taste and smell,
quate dietary intake of the vitamin and/or lack of
loss of appetite, trouble seeing at night, and impaired wound healing.
exposure to sunlight. A pancreas damaged by al-
Both iron deficiency and iron overload ore possible in alcoholics.
cohol releases fewer fat-digesting enzymes, result-
Excessive alcohol consumption con damage the gastrointestinal tract and
ing in decreased fat absorption and consequently,
cause GI bleeding. This bleeding con eventually result in on iron deficiency.
decreased vitamin D absorption. A liver damaged
In contrast, alcohol con also increase the uptake and storage of iron in the
by alcohol is compromised in its ability to convert
liver, which can hasten the development of cirrhosis.
vitamin D lo the biologically active hormone form.
Clinicians need to be aware of the nutrition-related problems that can
Vitamin D deficiency can also result in reduced
Alcoholism is a occur in alcoholism. Nutrient repletion is an important aspect of the treatment
calcium absorption and increased parathyroid
common cause of pion for alcoholic patients.
hormone secretion, both of which con lead to the
micronutrienl
malnutrition in North development of osteoporosis.
America. Deficiencies in vitamins E and K also occur in in-
dividuals who have alcohol-damaged pancreases.
Here again, the damaged pancreas is less able to release necessary digestive Dr. Halsted is Professor of Internal Medicine and Nutrition in the
enzymes, leading lo impaired digestion and absorption of fat and fat-soluble nu- Division of Endocrinology, Clinical Nutrition and Vascular
trients. Individuals with alcoholic liver disease are less able lo synthesize vitamin Metabolism at the University of California- Davis School of Medicine.
K-dependent clotting factors, while individuals with vitamin E deficiency con de- Dr. Halsted is editor of the American Journal of Clinical Nutrition and
velop peripheral neuropothy and tunnel vision. has published widely on the effects of alcohol on nutritional health.
• Alcoholic beverages should not be consm11ed by some individuals, including those ea/thy People 2010 set on important goal
\vbo cam10t restrict their alcohol intake, women of childbearing age who may be- regarding alcohol use: reduce by 25% the
come pregnant, pregnant and lactating wo men, children and adolescents, individu- proportion of adults who exceed the guidelines
als raking medications that can interact wich alcohol, and chose with specific medical for appropriate alcohol use (currently, 73% of
conditions. those who consume alcohol).
• Alcoholic beverages shoLlld be avoided by individuals engaging in activities that re-
quire attention, skill, or coordination, such as drh·ing or operating machinery.
There is no recommendation for a nondrinker to stare consuming alcohol for health
benefits, but people of legal age who are not prone ro abuse alcohol should know
there's nothing wrong with moderate drinking. In fact, many snidies have shown d1at
light-to-moderate alcohol consumption has some health bendits. 10
Currently, about 32% of all North American adults have rb.ree drinks or le~~ each
week, about 22% have two drinks or less a day, and only about 11 % have more than
t:wo drinks a day.
Alcohol Dependency and Abuse

Many factors determine a person's chances of developing a lcoho l d ependence. Stu die!>
have shown links tying gender, genetics, ethnjcity, parental in fluence, nurture, and de-
pression. For some people, alcohol can be addicci\'e and dangerous, and c:u1 eventual!)
lead to a lco ho l a b use. Such alcohol abuse leads to 100,000 deaths in d1e Urured
Stares each year.18
Young people benefit most from o heolthy diet Genetic Influences

and exercise to decrease future risk of About 40 to 50% of a person's risk for alcoboUsm comes from genetic factors, although
cardiovascular disease. There is no related
the gene or genes have not been identified. 14 The genetic influence on alcohol depen-
benefit at this age for alcohol use.
dency and abuse has been shown by a n umber of studies, including twin and adopLion
research. Twins and first-degree relatives share a tendency toward alcohol addiction.
alcohol dependence Repeated alcohol-related Children of alcoho lics have a fourfold -increased risk of developing a.lcohoUsm, even
difficulties, such as a person's inability to when adopted b~ a family with no history of alcoholism. This finding suggests that in-
control use, spending a great deal of time dividuals \\~th a family history of alcoho lism need to be especially alcn for C\'idence of
ossocioted with alcohol use, continued use of the early signs of alcohol dependence.
alcohol despite physical or psychological Children with a family history of alcoholism should be warned of the dangers of
consequences, persistent desire or unsuccessful dri nking by the agt: of 10. At: this age, they are o ld enough to understand d1e conse-
efforts to cut down or control alcohol use, quences of alcoholism but a.re not yet under the strong inflL1cnce of their peers.
increased physical tolerance to alcohol's Children as young as 10 may begin experimenting with alcohol to feel grown up, to
effects, and withdrawal symptoms. lit in and belong to a group, to relax and feel good, to take risks and rebel Jgainst au -
thority, or simply to satisfy cwfo~ity. When alcoholic beverages are available in the
home, it is easy for a child to sample a \'ariery of drinks and to share them with friends .
bility to "hold one's liquor" compared to Tolerance to alcohol may be genetic. A person tolerant to alcohol requires greater
the overage person is o strong indicator of amounts of alcohol to produce cl1e desired cffecr. Still, any one of us can become ad-
genetic risk. dicted ifwc drink. long enough and consume ever-increasing quantities ofalcohoL The
Ufrci me risk of developing alcohol dependence is about l 0 to 15% for men and 5 to
8% for women. 15
The Effect of Gender

Gender plays a key role in alcohol meta.boUsm, dependency, and surprisingly, treat-
ment. The malc:female ratio of alcohoJ dependency is 4:1, but d1ere is e,·idence that
women delay seeking treatment for alcohol abuse. As previously noted, the recom-
mended Limit for alcohol use is also different for men and women, because women 's
bodies have more fat and less muscle tissue and body water than do men's. 8 Alcohol
can be djJuted by water-holding muscle tissue, but not by adipose tissue. As also men-
tioned before, \.VOmen cannot metabolize alcohol as quickly as men so ir remains in
their blood longer. Higher blood alcohol concentrations make women more suscepti -
ble to alcoholic Liver rusease, heart muscle damage, cancer, and brain injury. 2
Ethnicity and Alcohol Abuse

Many ethnic distinctions play an impor tant role in the probability of alcohol depen-
dency and abuse. Compared with Caucasians, Asians and Native Americans arc very
susceptible to the damaging effects of alcoho l for reasons d iscussed earlier (e.g., less
aldehyde dehydrogenase activity in the liver) . The major cause of death among Native
Americans is motor vehicle accidents and unintentional injuries related to alcohol use.
Od1er alcobol-relared mortality statistics con_fronting Native Americans arc suicide,
homicide, domestic abuse, and fetal alcohol syndrome. African American alcoholics are at
greater risk than other racial groups for n1berculosis, hepatitis C, HN/AIDS, and other I I T 'rl /l\]
infectious diseases. Hispanic A.t11ericans are at particular 1isk for cirrhosis-related death. Jose is a well-liked 17-year-ofd. It always
seems as if everything is going his way-an A
Other Conditions on a test, a scholarship lo his dream school,
you name it. Lately, however, Jose has experi·
Depression and alcohol abuse often go hand in hand. Researchers have discovered that enced some disappointments. His grandfather
the risk for heavy drinking is higher among women with a history of depression than has ;ust passed away, and he and his girl-
among women with no such bistory. 18 This finding holds up even when other factors friend of 6 months have broken up. When he
that increase the risk of heavy drinking are account<:d for, such as age, famil)' history arrived home late with the smell of alcohol on
of drinking, and pcrsonalfry disorder. The more symptoms of depression women re- his breath, his parents started to worry. They
port, the more likely they are to drink heavily. T here may be several reasons for th is as- talked to his school counselor, who suggested
sociation. One reason is self medication to relieve the symptoms of depression, they fook for certain signs that could indicate
possibly by increasing serotonin and dopamine activity in the brain. Research has depression and/or alcohol dependence. What
shown that, although alcohol ma)' alleviate depression in the short term, it tends to in - might those signs be?
crease depression over time. A second reason is that women who are more depressed
may nor pay attention to their drinki ng and may not be concerned about the effects it
can have on their health and behavior. 2
The majority of suicides and interfamily homicides are akohol-rclatcd. Clinicians serotonin A neurotransmitter synthesized from
need to be ca.refol when dealing with depressed alcoholic patienrs to determine the psy- the amino acid tryptophan that affects mood
chological reasons for their drinking and how these behaviors might cause the death of (sense of calmness), behavior, appetite, and
the alcoholic or a ~family member. Alcohol consumption appears to be associated with induces sleep.
rourh suicide. The }'Ounger the drinker, the more lil<ely he or she is to commit suicide. 22
dopamine A type of neurotransmitter in the
Alcohol dependence is the most common psychiatric disorder, aftecting 13% of the central nervous system that leads to feelings of
North American population. Overall, about $185 billion is spent annually i11 the euphoria, among other functions; it is also used
Unfred States in terms of lost productivity, premature deaths, direct treatment ex- to form norepinephrine, another
penses, and legal fees associated with alcoholism in tbc United States alone. A liver neurotransmitter molecule.
u·ansplant costs about $150,000 and is needed in cases of excessive alcohol use. On tbe
positive side, a typical counseling program costs only about $5000 to treat a person
who is abusing akohoJ. 15
How Is Alcoholism Diagnosed?

Alcoholism is often considered a two-phase problem. Initially, it begins as problem
drinking. This includes the repetitive use of alcohol, often to ~llleviate anxiety or solve
other emotional problems. Alcohol addiction, the second phase, is defined as a true
addiction following the repeated use of alcohol.
The diagnosis of alcoholism is based on a list of major criteria. Alcoholics may ex-
hibit some or all of the following factors:l8
• Physiologic dependence on alcohol with evidence of withdrawal symptoms when in-
take is interrupted
• Tolerance to the effects of alcohol, prompting greater alcohol intake to achieve the
desired effect:
• Evidence of alcohol-associated illnesses such as alcoholic liver disease or irreversible
brain damage exhibited by memory loss, inability to concentrate, <md decline in in-
tellectual functions
• Continued drinking in defiance of strong medical and social contraindications and
disruptions in normal life
• Depression and blackouts as well as impairment in social and occupational functioning
Other signs of alcoholism include the basic alcohol stigmas: alcohol odor on the
breath, flushed face and [eddeoed skin (the latter due to breakage of small blood ves-
sels, which allows blood to seep under the skin), and nervous system disorders, such Because of a higher incidence of alcohol
as tremors. 8 Unexplained work absences, frequent accidents, and falls or injmies of addiction among the homeless, many homeless
vague origin may all lead a clinician to consider the possibility of alcoholism. individuals suffer from a wide range of alcohol-
Laboratory tests are also helpful. These tests include measures of impaired liver related health problems.
lcoholics who stop drinking may substitute function, enlarged red blood ceU size (to check for a deficiency of the B vitamjn fo-
for their alcohol by increasing their intake late), and triglyceride and uric acid concentrations in the blood: 13
of caffeine, nicotine, and simple sugars. This in-
crease con lead to a worsening of overall nutri-
Do You Have a Probfem with Alcohol?
tional status. Because heavy drinkers have poor
nutrient intakes to begin with and because alco- Asking a person about the quantity and frequency of alcohol consumption is ;rn im·
hol in itself creates so many nutritional problems, portant means of detecting abuse and dependence. The CAGE qucstioimaire is com -
such a shift in intake hos the potential to cause monly used in routine health care. 2 3
lifelong health consequences and so should be
addressed. C: Have you ever felt you ought to cul down on drinking?
A: Hove people annoyed you by criticizing your drinking?
G: Hove you ever felt bad or guilty about your drinking?
E: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a
hangover (eye-opener)?
More than one positive response to the CAGE questionnaire suggests on alcohol problem. Another
key point to probe is tolerance: Does it take more to make you inebriated than it did in the post?
Other questions to ask along with the CAGE questionnaire arc:

1. Have you had memory lapses or blackouts due to drinking?
2. Do you continue to dtink even though you have heald1 probkms caused by alcohol?
3. Do you get withdrawal symptoms, such as headaches, chills, shakes, and a strong
craving for alcohol and, as a result, drink more ro get rid of these symptoms?
4. Do you take pan in high-risk behaviors, such as having unsafe sex in a nonmonog-
amous relationship or driving a car or boat when under die iniluence of alcohol?
5. Has drinking caused trouble at home, at work, o r in relationships \\'ith others?
6. Do you have to drink alcohol for any of the following reasons?
a. To get dirough the da~ or unwind at the end of die day
Compared to men, women more readily
b. To cope with sLressful life events
develop alcohol-related health problems.
c. To escape from ongoing problems
Answering yes to any of these questions shou ld prompt the respondent w consult ,1
family physicjru1 or a certified counsdor for he lp. 18
I Treatment of Alcoholism
Once a diagnosis of alcohol abuse or dependence is established, one should seek the
gLLidance of a physician to arrange appropriate treatment and counseling for (be per-
son and family. An imponam goal of counseling is to identify ,~vays ro compensate for
A nether common screening tool is the
Michigan Alcohol Screening Test (MAST).
It contains 22 questions. Briefer versions ore also
the loss of pleasure from drinking. This helps the drinker confront die immediate prob-
lem of how to stop drinking. Total abstinence must be the ultimate objective. For al -
ovoilable.23 Check out these and still other coholics, there is no such thing as controlled drinking. A problem drinker caru1ot
screening tools at the Notional Institute on return safely to social drinking. 19
Alcohol Abuse and Alcoholism websi te: The person should enter an Alcoholics Anonymous (AA) 12-step program (AJ-
http:/ /www.niooo.nih.gov I publications/ A.non for the spouse) or another reputable therapy program for people with ako-
niooo·guide. holism.18 One can check with a local mental health treatment center to find programs
available in the commwlity or call 800-245-4656. Substance Abuse and Mental Health
Services can be reached at 800-729-6686 o r WW\\ I1e,1lth.nrg, for alcohol and drug in-
formation. In adrution, one may visit the AlcohoEcs Anonymous web page'. at \\ \\'\\
akohuli..\- 1111 >11\ m1 n1s 11r~, '' ,, .,, .•11 .:11111n .al.uccn nrg or contact AA at:
AA World Se1Yiccs, Inc.
P.O. J3ox 459
New York, NY 10163
212-870-3400
Binge Drinking
College m1dencs arc drinking more hea,·ily and the O\erall probkm is the focc char approximatd~
more fn:qucntlv chan e\·cr before. Excessi,•e alcohol ha.If of all colkge students are nor yet of legal
consumprion is .rn even bigger problem than illicit drinking age. In fact, rhc annual O\"erall cost related
drug use on college campuses roday (Table 8-4). ro underage alcohol use is esrim.ued at more than
~lany college srudcnts consider drinking alcohol to S58 billion. This figure includes costS associated
be a "rite of p<1ss~1gc" inro adulthood. The largest with \'iolent crime, cra!fa: ,1ccidcnc11, treatment, and
drinking population in North Ame1ica consists of alcohol poisonings. 22
young, Caucasian college srudcnts. Bars near cam- Binge drinking-h.wing four or more drinks in
pus typically promote heavy drinking. Alcohol pro- a row for women, or five or more for men- is com-
ducers frequently target college students with mon among college sn1dcncs. Only a minority of
ad\'ertising and other marketing efforts. Adding to drinking by this group is done so in moderation,
Table 8·4 I Sobering Statistics on the Impact of Binge Drinking on College Campuses
Death: 1400 college students between the ages of 18 and 24 die each year from alcohol-related
unintentional injuries, including motor vehicle crashes.
Injury: 500,000 students between the ages of 18 and 24 ore unintentionally injured each year under the
influence of alcohol.
Assault: More than 600,000 students between the ages of 18 and 24 ore assaulted each year by another
student who hos been drinking.
Sexual abuse: More than 70,000 students between the ages of l 8 and 24 ore victims of alcohol-related
Although many young adults do not
sexual assault or dote rope each year.
recognize the true impact of binge
Unsafe sex: Each year about 400,000 students between the ages of 18 and 24 hove unprotected sex and drinking habits, it is inherently risky in
more than 100,000 students between the ages of 18 and 24 hove been too intoxicated to know if they terms of their nutritional health, overall
consented to having sex. health, and safety.
Academic problems: About 25% of college students report academic consequences of their drinking,
including missing class, falling behind, doing poorly on exams or papers, and receiving lower grades overall.
Health problems/Suicide attempts: More than 150,000 students develop on alcohol-rela ted health
problem and between 1.2 and 1.5% of students indicate that they tried to commi t suicide within the post year
because of drinking or drug use.
Drunk driving: 2.1 million students between the ages of 18 and 24 drive under the influence of alcohol
each year.
Vandalism: About 11 % of college student drinkers report that they hove damaged property while under the
influence of alcohol.
Property damage: More than 25% of administrators from schools with relatively low drinking levels and
more than 50% from schools with high drinking levels soy their campuses hove a "moderate" or "major"
problem with alcohol-related property damage.
Police involve me nt: About 5% of 4-yeor college students ore involved with the police or campus security
as a result of their drinking, and on estimated 110,000 students between the ages of 18 and 24 ore arrested
for on olcoho~reloted violation such as public drunkenness or driving under the influences.
Alcohol abuse and dependence: 31 % of college students met criteria for a diagnosis of alcohol abuse eolthy People 2010 includes on im-
and 6% for a diagnosis of alcohol dependence in the post l 2 months, according to questionnaire-based portant goal regarding binge drink-
self·reports about their drinking .
ing: Reduce by at least one-half the
number of high school and college stu-
The consequences of excessive and underage drinking affect virtually all college campuses, college
communities, and college students whether they choose to drink or not. dents engaging in binge drinking
(currently estimated at 32 and 40%,
Source: www.collegedrinkingprevention.gov/ focts/snapshot.aspx respectively).
287
and the maiJ1 reported purpose of drinking is "to light drinkers or abstainers. Property damage, as a
get drw1k." About 50% of coUege students en- result of vandalism and accidents, can be another
acute alcohol intoxication A temporary gage in binge drinking. Acute akohol intoxica· consequence of binge drinking. 6 Students who live
deterioration in mental function, tion, which can result from such rapid around binge drinkers experience more un\\'anted
accompanied by lock of coordination consumption of a large quantity of alcohol, is a sexual advances, assaults, and insults/humiliations.
and partial paralysis, arising from major cause of suicide and hazing deaths related Despite the array of negative outcomes, binge
drinking alcoholic beverages loo
to binge drinking. drinkers often do not think t11cy have a problem,
rapidly.
Binge drinking has a variety of contraindica- because their beha\'ior has become so acceptable
tions. It can lead to unplanned sexual activity, in- on coUege campuses.
jury to oneself or others, and even death. Death According to U.S. law in all 50 states, an in-
due to alcohol misuse can result, for example, dividual must be 21 years old to drink. In
from inhalation of vomit. In ocher cases, the body Canada, the legal age is 18 or l9, depending on
systems slowly shut down because of alcohol's tbe province. However, alcohol use often begins
overpowering depressant effect (Table 8-5 ). Other in adolescence. For example, 31 % of twelfrh-
injuries can occur, resulting in paralysis or other graders in the United States reported frequent
Imagine you ore president of a university
lifelong medical problems. for example, in 2000, drinking during 1999, and about 11 % of all alco-
where there is a tradition of the "fourth·
a student at the University of Michigan rapidly hol is consumed by youths under age 21.
year fifth," a long-standing practice of
dnnk 20 shots to celebrate his 21st birthday and Influences on premature alcohol use are often
seniors fo consume a fifth of liquor
clied shortly afterward, with a blood alcohol con- seen in conjunction with athletics, if older, highly
during the semester prior to graduation.
centration of 0.39 percent. A student at Old visible role models advertise products or arc seen
Every weekend between 3 and 70
Dominion University choked to death on his own consuming alcohol. Peer pressure at school and
students arrive in the local emergency
vomit during a pledge-week dJ'inking binge. A stu- on sports teams can cause many adolescents to
room with alcohol poisoning or alcohal-
dent on the diving team at Ohio State University drink. Dangerous habits become deadly when
related iniuries, and there are several
became so intoxicated tbat he dove headfirst while young adults choose to drive drunk or ride with
alcohol-related deaths each year. As the
diving into a mudpile at a party. He sw-vived but friends who are intoxicated. Drinking habits cre-
head of this institution, how do you and
is paralyzed from the neck down. Two female stu- ated in youth may continue and worsen over
the Board of Trustees tackle this
dents in Colorado died of alcohol poisoning in time. Education and prevention strategies should
problem?
2004. Other students have drowned while intoxi- focus on behavioral and psychosocial conse-
cated despite knowing how to swim. quences because athletic performance typically
Problems associated v.~th binge drinking can does not suffer initially.
affect all aspects of life. Regular binge drinking can Overall, it is important that binge drinkers be
lead to academic failure, because binge drinkers are aware that these habits can cause lifelong problems,
more likely to miss class than are students who are especially when drinking becomes habirual. 6
Table 8·5 I Signs and Symptoms of Alcohol Poisoning

Being aware of the warning signs and dangers of alcohol poisoning is important. It could help save the life of
someone you love. The warning signs and symptoms include lhe following:
• Semiconsciousness or unconsciousness
• Slow respira tion of eight or fewer breaths per minute or lapses between breaths of more than 8 seconds
• Cold, clammy, pole, or bluish skin

• Strong odor of alcohol, which usually accompanies these symptoms
Alcohol use often begins in young
adulthood and is carried into later years. Nole: Although these ore obvious warning signs of alcohol poisoning. the list is certainly not oll·indusive.
288
According w AA'"<> literature, "At\ is a fellowship of men and women wbo share
their experience, strength, and hope with each other thal they may so lve their com-
mon problem and help others recover from alcoholism." fu an informal society char-
tered in 1935, Alcoholics Anonymous includes more than 2 million recovered
alcoholics. The only requirement for membership is the desire to stop drinking. There
are no rules, regulations, dues, or fees. In addition, rhc group is not a political or for-
mal organization.
It is helpful Cor rbe spouse to join the crearmenc program as well. AA has rwo types
of meetings-open and closed. Alcoholics and their families and fi-iends are invited ro
the open meetings, whereas d1e closed meetings 3J'C reserved for alcoholics only.
Current research does not support the generally negative public opinion about the
prognosis for alcoholism. In most job-related alcoholism treatment programs, wherein
workers arc socially stable and-because of the risk to jobs and pensions- well moti-
vated, recovery rates reach 60% or more. 19 This remarkably high cure rate is probably
accounted for by early detection. Once a person moves from problem drinking to an
advanced stage of alcoholism, success of treatment seldom exceed 50%. Early identifi -
cation and intervention remain the most important step!> in the treatment of alco-
holism. Success is usually proportional to particip.ition in AA, other social agencies'
programs, and religious counseling. About 2 years of a·eatment should be expected.
Tbrec medications are available to treat alcoholism. 18 •25 The medication naltrexonc
(ReVia) blocks the craving for alcohol and the pleasure of intoxication (Figure 8-4 ).
Disull11.\tn (i\n1.il1u!>c ) 1:.lll'<>C!> phy~k.t11cadiu11~, Mtd1 .1::. vtunili11g,, "hi.:o d 1i11ki11~ <1 1·
cohol. It does so by blocking acetaldchyde metabolism. Acamprosate (Campral ) is
thought to act on nelll'oa·ansmitter pathways in the brain related to alcohol abuse, de·
creasing the desire to drink. Detoxification drugs arc also importanr in treating alco-
holism, as is using some form of psychotherapy.
Alcohol molecule Figure 8-4 I The euphoria that arises from

alcohol use involves alcohol binding to specific
receptors in the brain. It is likely that this
binding, in turn, causes a release of the
neurotransmitter dopamine. The increase in
dopamine in the brain is thought to cause the
characteristic high associated with alcohol use.
Endorphin Naltrexone (ReViaJ works by blocking alcohol's
receptor ability to bind to brain receptors. This, then,
reduces dopamine release and blocks the
pleasant feelings elicited by alcohol use.
~ Dopamine pathways
o learn more about alcoholism, visit these

websites: Concept I Check
www.niaaa.nih.gov Treatment of alco holi&m often includes the use of medicine, counseling, and social supporr.
www.asam.org The clinici~ms invol\•ed must trc;tt the entire person. Alco holics Anonymrnts and other sup·
www.mentalhelp.net/ selfhelp port groups arc ''c ry helpful. Naln·exonc can be prescribed to decrease alcohol intakes, as
www.nlm.nih.govI medlineplus/ can aca mprosacc. Anmhcr option is disulfirarn, which produces an ill (·ecLl11g when the pa-
alcoholconsumption.html tienr consumes both the medicine and alcohol. With all d1e treatments for alcoholism, it is
www.findtreatment.somhsa.gov important to fi nd 1.he o ne that wo rks best for the individual wi th alcoholism.
http:// www.nocoo.org
Case Scenario! Follow-Up

Alcohol is a central nervous system depressant and narcotic that affects both respi·
ration and heart rate. In large quantities, alcohol con depress both systems to the
point of terminating respiration and cordioc function. Obviously, this is fatal.
Alcohol abuse is a common problem, and continued alcohol abuse con lead to dependence
problems, although alcohol abuse and dependence ore different.
As a close friend, Alyssa hos a responsibility lo hold Todd accountable for his actions.
Sometimes it is difficult lo realize that one hos o drinking problem, although it may be obvious
lo olhers. Alyssa should lalk privately lo Todd when he is sober and calm about the most recent
incident. It is important to deal with situations such as these very carefully, because the problem
drinker will probably respond defensively. She could explain how his drinking is causing prob-
lems for both of them, she could tell him about the harmful consequences of his drinking, and
she could refuse to go with him to any alcohol-related events, but she must be prepared to ca rry
out her refusal. This is especially important for her because she does not wont to risk further
physical harm from Todd. Alyssa could folk with o counselor, who may help her learn ways lo
approach Todd effectively. Offering to go with Todd to a treatment program or an M meeting
and gel help is one idea. There is strength in numbers, so other members of Todd's family or
close friends also should be enlisted lo help, under the guidance of a therapist trained in treat·
ing alcoholics.
Summary
1. Akohol use is a complex issue because it ilwoh'cs psychological, death in North America. Alco hol increases the 1isk of developing
social, economic, health, legal, and fumily issues. certain forms of hearr damage, inflammatio n of t he pancreas, GI
2. Alcohol is metabolized in d1c liver and orher tissues. Metabolism t ract damage, vitamin and mineral deficie ncies, cirrhosis of di e::
depends o n rhc rnzymc alcohol dehyd rogenase. A number of fac- liver, cenail1 forms of cancer, hypertcmio n, tuid hcmorrhJgic
tors, such as gender, r;J.ce, and body compositio n, dererminc ho\\ stroke-re name a fow.
a person reacts to alcohol. 6. lf alcohol is cons umed, it sho uld be consumed in modera tion \\i th
3. The bod) LL~es the microsomal erhanol oxidizing system ( i\<!EOS) meals. \¥omen arc advised to dtink no mo re than one drink per
wheneYer the liver detects mo re alcohol than can be processed by day, as are adul t.~ 65 yea rs and older; men are advised ro limit in-
the alcohol de hydrogenase enzymes. Once d1e MEOS is active, al- take to two drinks a day.
cohol tolerance increases because alcohol is being metabolized
man: rapidlr. 7. Ge nder, genetics, ethnic backgro und, and o ngoing depression all
4. The benefits of Jlco hol use Jre associated with low-ro·mode rate play ,1 role in a person's chances of becoming alcobol dcpendem.
alcohol consumption. These benefits incl ude the pleasurable and 8. Early dctccriou of alcoholism is key to successtiil a·eatmt:nt and a
social aspects of alcohol use, a red uctio n in ,·arious forms of c.1r- red uction of health·ctu·e costs. T he CAGE q uestionnaire can help
diovascul:u disease-related deaths, increase in insu_li n sensici\'ity, a person determine whed1er he o r she has an alcohol problem.
and protection against some harmfi.11 sto mach bacteria. 9. Many methods are available to treat alcoholism. Alcoholic~
5. Alcohol use also creates many heakh risks. Excessive consumption Anony mo us a nd the medicatio n ReVia arc among d1e typical
of alcohol contributes sig nifican tly to 5 oftbe 10 leading causes of approaches.
Study Questions
l. Where in the body does most of the metabolism of alcohol take 9. Describe a method used in treating alcoholism. 'What are the ben-
place? What is a by-product of alcohol metabolism? efits and drawbacks?
2. Why does it take a woman lo nger than a man to metabolize 10. What is binge drinking? Within which segment of rhc population
alcohol? is d1is activity increasing in populariryl
3. List rwo potential health benefits of alcohol use.
4. List four problems associated with alcohol abuse.
5. Which two nutrient deficiencies arc common in alcoholism? Why?
BOOST YOUR STUDY
6. Deffoe the term one drink. How much alcohol use is considered
ro be moderate for men? for women? Check out the Perspectives in Nutrition: Online Learning
7. Why can some ethnic groups hold their liquor better than others Center wwv ·.mht a.com/,. ardfa, ers7 for quizzes, flash
can? cards, activi ties, and web links designed to furlher help you learn
8. Name four criteria that mighr indicate t har someone has a prob- about issues surrounding alcohol use and abuse.
lem with alcohol. What is this group of criteria checklisr called?
1. Alcohol and health: The pros and cons. Mayo Binge hmkiug is m·oiig6•associated 1J>ith vio- a11cc of alcohol is mcded to St!JfJ the progrcssiJ>c
Cli11ir Hc11/tli Lctte1> p. 4, November 2003. le11ce. 711is is an importallf 1·cns1111 m rlisco11mge 11n.t111·t of nlco/Jol-rdnted Lii1cr diserrsc.
T11c pms 11111{ com of alco1Jol 11Si" nrc rn•itwcd. /Jin,_rrc dri11/1i'.tig. I 2. Lieber CS: Relationships between nuwuon, al-
Alrb1111gb there arc henlt/J bmcfits fi·om alcobol 7. Cho E and others: Alcohol inrake and colorec- cohol use:, and liver disease. Alco/Jal Rescm·rh
use, 111odcrttrio11 is a key tbcmc, mu! there is no tal cancer: A pooled anal)'Sis of 8 cohon studies. nnd Health 7( 3 ):220, 2003.
recommcndarion to starr dri11king merely t11 A111111ls of lntemttf Alerlici11e 140:603, 2004.
Ma11y ttlcobulics buo111c 111alno11rishetl becnme
gain tbc health bwcfits. Dri11ki11g moi·e rbn11 nvo drinks fl day nppean t/Jey co11s11me ton few nutrients and because of
2. Alcohol- an imporranr women's health issue. to i11crcnu the 1·isk for colon:cml mnccr. 17n's the porenti11l ofalcohol it»elf to reduce 11tttrie11t
Alcohol A/err 62: 1, 2004. finding is irue far 111e11 a11d wome11 tmd is true absorption.
\Vbrn n 1J10111a 11 drinks alcobol, tl1e alcohol in for tbe various nlcoholic bc1•eragcs typically
13. Lieber CS: Nutririon in liver disorders and rhc
bcr bloodstream typical~\' reaches tt higlm· C01lS/tl/ICd.
role of alcohol. ln Shils ME and others (eds):
amo1111 t: than in a 11ui11 even if thr. two arc 8. Clairmon t MA: Alcohol dependence & abuse. Modem 1wrrition in /Jealth and discnse. lOrh ed.
drinking the m111e m1101mt of ttlcob11/. This is be- Today's Dietitin11 p. 14, S.:ptember 2005. Philadelphia, PA: Lippincott Williams &
cause ivomm ha1>c less body water tbau men. J!s Alcohol 11b11se can lead to a number of nutrient Wilkins, 2006.
a result, wome11 arc pcry msceptible to afcohol- deficiencies a111{ nther hettltb problems. D1·i11ki11g
rclrr red O/lTtttl damage. Detailed examination of ttlcohol mernbolism
rrLcohol ll'itbout co11cnmitn11t food inmke is espe-
and its rtlated role i11 n11tritio11-rdated health
3. Akohol-amiburable deaths and years ofpoten- cittLL)• risky as food slows a/colJ11I absorptio11 and
disot·ders.
cial life lost. Jormtttl of the Amcric1111 Medical thus reduces some of its 11cgrrtive social and
Ass11ciario11 292:2831, 2004. IJcaltb effects. 14. Liu l-Chao and others: Generic and cnviron-
E..-.:cessiPc alcobol co11.rumptio11 is tbc rbird lead- 9. Dorn JM and others: Alcohol drinking patrerns menral conoibutions to tbe development of al·
ing cm1u ofprcr•mtablc dent/; in rhe U11itcd differential!} affect central adiposit}' as mea- cohol dependence in male twins. Archiw:s 11f
Sttttcs. 1Jiese deaths i11c/11dc livet· cirrh11.fis, 1111ri- sured br abdominal height in women and men. Gmcral Psychintry 61:897, 2004.
ous m11cers, 1111inte11tio11al i11j11ries, 1md i>iotence. ]011rnaf 11f N1mirio11133:2665, 2003. Genetir i11fl11e11cc acco11nted for nb1mt 50% of
4. ;\Jcohol's damaging effects on the brain. Alt11hol 11sc i11c1"cnses the risk fi1r nbdominal fat the risk of alcot111I depe11dence in rhis swdy. 111c
Alcohol AIC'l·t 63:1, 2004. deposition. Binge tlri11ki11g cspainlly ll'M fo1md effect 1va.s even seen after acco1mti11g far ot/Je1·
Alen/Joi ca11 p1·od11cc duccmbte impairn1mts in to be a risk f11cco1: psychiarric diSOt·ders, bur wns closer to 40%.
memm-y nfter 011(y n fell' d1·i11ks. As the 1111101111t 10. Klarsky AL: Drink co your health? Scimtiflc 15. Mail liard MR, Sorrell MF: Alcoholic liver dis-
of alcobnl i11crcnses, so dots tbc deg1·cc of America11, p. 75, Februaq• 2003. ease. ln Kasper DL and othns ( eds.):
1 mpairmmt. Mndcmrc rrlcohol 11sc /ll"OPidcs some lm1ltlJ be111:- Harrison's Principles of lntcn1al Mcdici11e. New
5. Alcoholic liver disc:ase. Alc11bol Alerr 64:1, 2005. flts, lmt ttlto/Jol tt/Jmc poses 111n11_v lu:altb risks. ln York: McGraw-Hill, 2004.
Alcubolic liva· disease inc/11dcs tf11·cc co11ditinm: lig/Jt of wrrent k110111ledgc, a peno11 Jl'itb an es- Alcohol is a p01ve1j11l toxin t11 tbi: cells of tbc
fntn•lh1c1~ 11/coholic hepatitis, nnd cirrhosis. The tnbfishcd morfernrc drinking pattem sbonldgw- lii•cr a11d leads ro lii•cr cin·hosis in nbnur 10% rr1
fatty liver ttage is re1•asible 111bc11 11./cobol illtrrke crnll,v 11ot be adm'scd to abm1i11 fi·0111 11lcohol. 20% of crrses ofalcoholism. Women ,,,., 11111cb
stops, bttt the nr/Jei· strrgcs arc not. 17ms, &l'Cll Ho1vcvc1; 11011rfri11kcn slJ011lti 11ot be nd11ised to more susceptible to this disease tha 11 111cn, nnd so
1vbm sroppi11g drinl<i11g, 11/cobolics ll'ill still mf stttn drml<i11g for /Jealth rettsom. sbould be especially crr11rio11s about 11/colJ11I i11rakc.
fer tbc ejfccrs nf rhesc larrcr tJJ>o smgcs. 1 I . Leevy CM., Moroianu SA: Nuoitional aspects of 16. Mukamal KJ and others: Alcohol and risk for is-
6. Brewer RD, Swalrn MH: Binge drinking and lh·cr disease. Clinics in li11c1· Disease 9( l ):67, 2005. chemic stroke in men: The role of drinking pat-
violence. Jo11r1111I of tbc A11w·icm1 Mrdical N11t1'itio1111l defiCJwcies rrrc pa rt of tbc crrttsc of tern and usual bc\·er:iges. Annals of lntemal
Associatiotm 294:616, 2005. lii•rr tfiscnse related to alc11hol 11se. Sri//, ai•oid- Medicine 142:11, 2005.
lnmke of mm·c tbnn t1110 drinks n dn)• i11c1·enses Excellent J'Cl•it.111 of alcobolism is presented. V1is 23. US Preventive Sen•iccs Task Force: Screening,
t/Jc risk of iscf1e111ic stroke. h1 co11tmst, lesser chnpw· 1Pns used to 11erifj much of rhe contcn r of and behavioral cowtsdi.ng intcrvcncions in pri-
1111101t.11t.s of alcobol, spccificn/~1· red wine, is nsso· C/Japtt'I' 8. mary care to reduce alcohol misuse: Recom-
ciated ll'ith a red11ced risk of iscbcmic m·okc. mendation sraremenr. American Fn1111/y
20. Srampfer MJ and other~: Effects of moderate
17. Renaud S and others: Moderate wine drinkers alcohol consumption on cognitive function in P/Jy.ricifm 70:353, 2004.
ha,•c lower hypcrrension-relarcd mortality: A women. "n1c Nell' E11gla11d Jo11rnal of Medici11c T11e US Pn:pcnthw Scri•ices Tns/; Force recom·
prospective cobon srudy in Prencb men. 352:245, 2005. mends screc11ing n11d bchaviom/ co1111seliug Ill
American ]ounrnl of Clinical N11tritio11 reduce nlcohol misll!e. The CAGE q11cstiom111f1'c
Up to one dri1tll per day may i1tc1·c1Ue cognitii>e
80:621, 2004. is one tool that can be 11.Jcd for scnming pur·
fit11ctio11 ill women. A11 intake of mort th1m thnt poses. Other roofs fl.re also presented.
A 11111dcrnte i.ntnkc of wine is nssocintcd wit/J a is nor protective and tl't:ll hn.s the opposite effect.
/01ve1· ris/1 of monnlfryfrom nil cnnscs iu pu·sons 24. Wannamcthce SG and others: Alcohol drinking
21. Su·andberg AY and others: Alcohol consump- patterns and risk. of type 2 diabetes mellims
n•ith /Jypcrtmsiou. Tbi.s result 1Pns seen mith 1Pi11~
tion, 29-yr meal morrality, <tnd quality oflifc in among yorn1ger women. Anhii•cs of Jnun1nf
drinking, but because tbc stwt:v wns do111: i11 men in old age. A111.:ricn11 ]ounin/ of Clinical
Pm11ce, 1111 cjJer:t fin· orbcr forms of alcobolic Medicine 163:1329, 2003.
Nurrition 80:1366, 2004.
b.11.-mges r.u11s11111cd by otbcr wlt11res c111wot be Light to moderate n lwbo/ cousu 111ption mny be
1·u/ed our. Gi'eate1· rJ1a11 t/J1u: drinks per day 11101~·cued tbc associated with a lower 1'isk of type 2 dinbcm
quality of life of 0Jd.:r 111c11 in rbir smdy. Lo111e1· amo11g womw. fotakcs in e:.;ccss of t/Jis a m01111t
18. Sail"Z R: Unhealthy akobol use. Tl1c Ncn• intnkts win• unr /Jmwjitl but also 11'e1'C 11ot ni·c 110t more prntccri11e, bo111e11c1; nnd nattn/~)'
E11._fJ/a11d }1mr11al 11f Medicine 352:596, 2005. fa1111d to be /Jdpf11l in 1/Jisgroup of mw. i11rrcased mch l'isk.
V1is arrick pmY:ms n cnse srud.v 11fn 111n11 111/Jo fr 22. Underage drinking. Alco/Joi Alci·t 59:1 25. Williams SH: Medications for treating akohol
al111si1ig a/co/Jot. Botb diag11osif a11d trcat111c11t (April ), 2003. dependence. American F11111i~y Physician 72:
of alc11h11lism arc 1·cvic1Pcd i11 the p1·occss. U11dcrngc d1·i11ki11g may lead to a /J11st of health 1775, 2005.
19. Schuckit MC: Alcohol and alcoholism. Io problems, i11c/11di11g tmffic accidmrs n.nd mi· Couci.re 1·c11icw of tht· 111edicntiom nmilablt to
K.'lspcr DL ,111d others (eds.): Harrison 's cide. Enr~v i11tfl"Pt11tin11 tll rnrb 11t1dcrag" treat n.tcobol depc11dmcc. Nnlt1·ox1J11/' n11d arnm·
Principles 11.f Inrcmnl Afcdiciuc. New York: drinki11g is essential to prc1•c11t tbesc and other p1·osa tc arc the most uscjitl of the C1t1'n-11 tly
McGraw-Hill, 2004. hrnlrb p1·oblc111s. mmilabte 111edicnrio11s.
Take I Action
I. Could You or Someone You Know Have a Problem with

Alcoholism?
Problem drinking ohen hos its seeds in the teen years. Significant health consequences of this practice typically arise in adulthood.
Alcohol obuse is o prominent contributor to 5 of the 10 leading causes of deoth in North America. The social consequences of alcohol
dependency include divorce, unemployment, and poverty. The followi ng questionnaire was developed by the Notional Council on
Alcoholism. With this assessment, you con determine whether you or someone you know might need help.
Yes No
I. Do you occasionally drink heavily oher disappointment, oher o quarrel, or when someone
gives you a hard time?
2. When you hove trouble or feel under pressure, do you drink more heavily than usual?
3. Hove you ever noticed that you're able to handle liquor better than you did when you first
started drinking<!
4. Do you ever woke up the morning oher you've been drinking and discover that you can't
remember port of the evening before, even though your friends tell you that you didn't
poss out?
5. When drinking with other people, do you try to hove a few extra drinks when others won't
know it?
6. Are there certain occasions when you feel uncomfortable if alcohol isn't available?
7. Hove you recently noticed that when you begin drinking, you're in more of a hurry to get
the first drink than you used to be?
8 Do you sometimes feel o little guilty about your drinking?

9. Are you secretly irritated when your family or friends discuss your drinking?
10. Hove you recently noticed on increase in the frequency of memory blackouts?
11. Do you often find that you wish to continue drinking oher your friends soy they've hod
enough?
I
I 12. Do you usually hove o reason for the occasions when you drink heavily?
13. When you're sober, do you ohen regret things you hove done or sOJd while drinking?
14 Hove you tried switching brands or following different plans to control your drinking?
15 Hove you ohen foiled to keep promises you've mode to yourself about controlling or .;
slopping your drinking?
16 Hove you ever tried to control your drinking by changing jobs or moving to o ne~ location?
17 Do you try to ovoid family or close friends while you're drinking?
18. Are you having on increasing number of financial and work problems?
19 Do more people seem to be treating you unfairly withou1 good reason?
20 Do you eat very little or irregularly when you're drinking?
Take I Action
Yes No
21. Do you sometimes hove lhe "shakes· in lhe morning ond find that ii helps to hove o little
drink?
22. Have you recently noticed lhat you can drink more lhan you once did?
23. Do you somelimes stay drunk for several days al o lime?
24. Do you sometimes Feel very depressed and wonder whelher life is worlh living?
25. Sometimes oher periods of drinking do you see or heor lhings that aren't there?
26. Do you get lerribly frightened aher you hove been drinking heavily?
Interpretation
These ore all symptoms thal may indicale alcoholism "Yes· answers to several of the queslions indicate lhe following stages of
alcoholism:
Questions 1- 8. Polentiol drinking problem

Gueslions 9-2 1: Drinking problem likely
Questions 22-26: Definite drinking problem
II is vital thal people assess lhemselves honeslly. If you or someone you know demonstrates some or a number of these symptoms, ii is
important to seek help. If there is even a question in your mind, go talk to a professional aboul ii.
II. Investigate the Energy Cost of Alcohol Use

On an upcoming weekend (Friday night through Sunday night). have a few friends keep o careful log of !heir alcoholic beverage in·
lake. Include moles and females. Then use Table 8-1 or your nulrient analysis sohware lo calculate lhe amount of energy provided by
alcoholic beverages over !hot lime period. Assuming !hat an active man needs about 2800 kcal/day and an active woman needs
about 2200 kcal/day, is the amount of energy provided by alcoholic beverages large (e.g., 25% or more of needs) or small (e.g
10% or less of needs) in comparison?
THE FAT-SOLUBLE VITAMINS
CHAPTER NINE
...
~
Vitamins: Vital Dielory Components
Historical Perspective on the Vitomins • Storage
Kristen works nights al a local package distribulion cenler lo make some extra ...~
%
of Vitamins in the Body • Vitamin Toxicity • money. The combination of laking a full course load al college and working nights ::a
Mo/absorption of Vitamins • hos created a lol of stress for her. Kristen's many commitments also make it imper· '"
m
-i
The fol.Soluble Vilomins lonl that she not become ill. On a recent coffee break at her job, a coworker sug· I
Absorption of the Fat·Soluble Vitomins • m
Distribution of the Fot·Soluble Vitamins gested she lake Nutramego supplements lo help prevenl colds, flu, and other
<
~
Vilomin A illnesses. The product's label suggesls thol Nutromega helps prevent such problems,
Absorption, Transport, Storage, and Excretion
especially those ossocioled with lhe changing of seasons. The label recommends
of Vitamin A • Cellular Retinoid·Binding
Proteins • Retinoid Receptors in the Nucleus • toking two to three tablels every 3 hours al the first sign of feeling ill, and two lo z
(./)
Functrons of Vitamin A • Vitamin A Analogs for
Acne • Possible Corotenoid Functions • Vitomin A lhree tablets doily for health maintenance. Kristen looks at the Supplement Facts )>
in Foods • Vitamin A Needs • label on the bottle and finds that each tablet contains (as a percentage of the Doily z0
Vitamin A-Deficiency Diseases • Upper Level
Value): 33°10 for vilomin A (lhree-quorlers of which is preformed vitamin A), 700%
for Vitamin A ~
Vitamin D for vitamin C, 50% for zinc, and l 0% for selenium. A month's supply also costs zm
Vitamin 0 3 Formolion in the Skin • Absorption about $50.
of Vitamin D2 from Food • Metabolism,
Should Kristen use lhis product? Are !here health risks ossocioled wilh this prod·
~
r-
Transport, Storage, and Excretion of Vitamin D (/)
• Functions of Vitamin D • Vitamin D in Foods uct, especially considering the dosage recommended on the label?
• Vitamin D Needs • Vitamin O.Deficiency
Diseases • Phormacologic Use of Vitamin D
Analogs • Upper Level for Vitamin D
Experl Opinion- Miracle Vitamin D: lmporlonce
for Bone Health and Prevention of Common
Cancers, Autoimmune Diseases, and Other
Disorders
Vitamin E
• Natural and Synthetic Vitamin E •
of Vitamin E • Functions of Vitamin E • Vitamin E
in Foods • Vitamin E Needs • Vitamin E·
Deficiency Diseases • Upper Level for Vitamin E
Vitamin K
of Vitamin K • Functions of Vitamin K • Dietary
Sources of Vitamin K • Vitamin K Needs •
Vitamin K-Deficiency Diseases
Nutrition Focus: Nutrient Supplemenls: Who
Needs Them and Why?
Toke Action
295
W hen it comes to vitamins, we often heor, •If a little is good, then more must be better.• Some
people believe that consuming vitamins for in excess of their needs provides them with extra
energy, protection from disease, ond prolonged youth. About 40% of adults in the United States toke vi-
tamin and/or mineral supplements on o regular basis, same at unsafe levels.1 They are spending about
$17 billion annually on supplements. The health-related value of this practice is hotly deboted.7· 14
Our total vitamin needs to prevent deficiency ore actually quite
small. In general, humans require a total of about 1 oz (28 g) of
vitamins for every 150 lbs. (70 kg) of food consumed. Vitamins CHAPTER OBJECTIVES CHAPTER 9 IS DESIGNED
are found in plants and animals. Plants synthesize all the vitamins TO ALLOW YOU TO:
they need. Animals vary in their ability to synthesize vitamins. For 1. Define the term vitamin ond list three characteristics of vitamins
example, guinea pigs and humans ore two of the very few or- as a group.
ganisms that ore unable to make their awn supply of vitamin C.9 2. Classify the vitamins according to whether they are fat-soluble
or wa ter-soluble.
These vital nutrients ore divided into two groups: the fat-soluble
3. list the major functions and deficiency symptoms for each fot-
vitamins and the water-soluble vitamins. This chapter focuses on
soluble vitamin.
the functions and sources of the fat-soluble vitamins and human
4. State the conditions in which deficiencies of fat-soluble v1tam111s
needs for them. (Chapter 10 reviews the water-soluble vitamins.) are likely lo occur.
This chapter also explores the current controversy over vitamin and 5. List three important food sources for each fol-soluble vitamin
mineral supplement use. 6. Describe toxicity symptoms from excess consumption of certain
fat-soluble vitamins.
7. Evaluate the use of vitamin and mineral supplements with
respect lo their potential benefits and hazards to the body.
REFRESH YOUR MEMORY AS YOU STUDY CHAPTER 9

ON FAT-SOLUBLE VITAMINS, YOU MAY WANT TO REVIEW:
Implications of the Dietary Supplement Health and Education Act (OSHEA) in Chapter 1.
The gastrointestinal system for the digestion and absorption of lot-soluble nutrients in Chapter 3.
Oxidation and reduction reactions in Chapter 4.
The digestion and absorption of dietary lipids and the formalion of lipoproteins in Chapter 6.
Protein synthesis in Chopler 7.
Vitamins: Vital Dietary Components

vitamin Compound needed in very small By definition, vitamins are essential, organic (e.g., containing carbon bonded co hy-
amounts in the diet to help regulate and drogen ) substances needed in small amounts in the diet for the normal function,
support chemical reactions and processes in growth, :ind mainren::mce of body tissues. Although vitamins themselves provide no
the body. energy to the body, some can facilitate energy-yielding chemical reactions. Vitamins A,
fot·soluble vitamins Vi tamins that dissolve in fot D , E, and K dissolve in organic solvents, such as ether and benzene, and arc referred
and such substances as ether and benzene but to as fat-soluble vitamins. T he B-vitamins and vitamin C, in contrast, dissol\'e in
not readily in water. These vitamins are A, D, water and are the watet'-soluble vitamins.
E, and K. Vitamins arc generally indispensable in human diets because they can't be svmhe-
sized in sufficient quantities to meet individual need , or synthesis is curtailed b~ e1wi-
water-soluble vitamins Vitamins that dissolve in
ronmenta1 fuctors, or they can't be synthesized at all. Vitamins such as niacin and
wafer. These vitamins ore the B vitamins and
vitamin C.
vitamin D can be synthesized by the body under certain conditions, and \'itamin Kand
biotin are synthesized to some extent by bacteria in the intestinal tract_s.to
To be classified as a vitamin, the compound must be o rganic and must meet the cri -
teria robe an essential nutrient: ( 1) the body is unable to synthesize enough of the
296
compound to maintain health; and (2) absence of the compotmd from the diet for a
defined period of time produces deficiency symptoms that, if caught in time, are
quickly cmed when the substance is resupplied. A substance does not qualify as a vita-
min merely because the body can't make it. Evidence must suggest that health declines
when the substance is not consumed.8,9,l O
In addition to their use in correcting deficiency diseases, a few vitamins have also
proved useful as pharmacological agents in treating a limited number of nondeficiency
diseases. These medical applications often require the admi11istration of megadoses,
vvell above the typical htunan needs for the vitamin. For example, as noted in Chapter 6,
megadoses of a form of niacin can be used as part of blood cholesterol- lowering treat-
ment for appropriately selected individuals. Another example is the use of vitamin D
analogs for psoriasis. Nevertheless, at this time any claimed benefits for the use of vi-
tamin supplements, especially intakes in excess of the Upper Level (if set) should be Vegetables are rich sources of many vitamins.
viewed critically because many unproved claims are continually being made.8,9 ,io
Both plant and animal foods supply vitamins in the human diet. Whether isolated
from foods or synthesized in the laboratory, vitamins are the same chemical com- megadose Intake of a nutrient beyond
pounds and generally work equally well in the body. Contrary to claims in the heaJth- estimates of needs to prevent a deficiency, or
food literatme, ''nattu·aJ" vitamins isolated from foods are for the most part no more what would be found in a balanced diet; 2 to
l 0 times human needs is a starting point for
healthful than those synthesized in a laboratory, but there are exceptions. Vitamin E is
such a dosage.
about twice as potent in its natural form compared to irs synthetic form. 9 On the other
hand, fo lic acid, the synthetic form of the vitamin. added to grain products, is 1.7 times analog A chemical compound that differs
more potent than the nam ral for m, folate. 1 Some vitamins ex_ist in several related forms slightly from another naturally occurring
that d iffer in chemical or physical properties. These forms exist both in nature and in compound. Analogs generally contain extra or
synthesized vitamin supplements. It is important to have enough of the specific vita- altered chemical groups and may have similar
min forms that the body can use; the various forms will be identified throughout this or opposite metabolic effects compared with
the native compound; also spelled analogue.
chapter and Chapter 10.
Historical Perspective on the Vitamins

Long before any vitamins had been identified, certain foods were kJ1own to cure ill-
nesses brought on by what we now recognize to be vitamin deficiencies. The ancient
Egyptians, for example, treated night blindness with topical applications of juice ex-
tracted from liver, a rich somce of vitanlli1 A. As you'JJ see, vitamin A plays a critical
role in vision. 10 Du1ing the fifteen th and sixteenth centmies, British sailing ships did
nor carry sufficient amounts of fresh fruits and vegetables with them for long sea voy-
ages. This resulted in a tremendous loss of life. In one expedition, LOOO men set om
from England for the Pacific, but only 145 remrned. The rest had died from the dis-
ease known as scurvy. Scientists eventu:tl.1)1 discovered that cirrus fruits cured scurvy;
after lemons and limes were included as a routine part of British sailors' rations, cases
of scurvy declined greatly. We now know that this disease, marked by weaJrness, blood
vessel rupmre, and poor immune fi.mction, results from a deficiency of vitamin C.9
As scientists began to identif)r various vitamins, related deficiencies, such as scurvy,
were dxamatically cured. For the most part, as the vitamins \Vere discovered, they were
named alphabetically: A, B, C, D, and E. Later, some substances originally classified as
vitamins were found not to be essential for humans and were dropped from the list,
such as vitamin P. Other vitamins thought at first to have a single chemical form turned
our to exist in many fo rms, so ''vitamin B" now comprises eight separntt> entities.
It took some time to uncover the true nature of the various vitanlli1s. For example,
when scientists realized that both protein foods and nicotinic acid (a form of the vita- vidence suggests that health declines when
min niacin) can cure pellagra, they eventually went on to discover that the amino acid choline, a substance the body makes, is not
rryptophan can be synthesized into niacin. Finally, as mentioned, it was determined included in o diet during some life stages, such
that some vitamins (such as biotin and vitamins D and K) can be synthesized by the as growth spurts. Thus, choline has on Adequate
body or bacteria present in the intestirral tracr.8,IO Intake (Al) set for it and may one day be added
We can be relatively confident that all vitamins needed by humans l1ave been dis- to the list of known vitamins. Choline is dis-
covered. The ability of total parenteral nutrition (TPN) to support human life for years cussed in more detail in Chapter 10.
298 Chapter 9 The Fat-Soluble Vitamins
strongly supports this view. With TPN, the pariem receives ina-avenously a carefully
fonnuhted prepararion containing all necessary nutrients. The gastrointestinal tract is
completely bypassed, because no food or beverages arc consumed. People who receive
protein, carbohydrate, fat, and all known vitamins and essential minerals in this man-
ner may continue not only to ljve but also to build body tissue, have a baby, heal
wounds, and combat existing diseases.
Storage of Vitamins in the Body

Except for vitamin K, the fat-soluble vitamins arc not rearuJy excreted from the
body.s.9 .io In contrast, most water-soluble vitamins are generally lost from the body
quite rapidJy, partJy because the water in cells dissolves these vitamins and flushes rhem
out of the body ,;a tht: kidneys. Two exceptions arc vitamin B-12 and vitamin B-6,
which are stored much more readily than the otJ1er water-soluble vitamins. Because of
tJ1e limited storage of many vitamins, they shouJd be consumed in the diet daily, al-
though an occasional lapse in the intake of even water-soluble vitamins generally causes
no harm. An average person, for example, must consume no vitami n C for 20 to 40 d.iys
before developing the flrsr signs and symptoms of a related deficiency. 9 The signs and
symptoms of a vitamin deficiency occu r only when that ' 'itamin is lacking in th<: diet
and body stores are essentially exhausted.
Vitamin Toxicity
Although a toxic effect from an excessi,·e intake of any vitamin is theorcrically possi-
ble, toxicity of tJ1e fat-soluble vitamin A is the most likely to occu r. 10 Viramin D can
also cause toxic effects, esrecially in infants. 8 Tbese vitamins are unlikely to cause toxic
}Aany vitamin supplements supply nutrients in effects unless taken in supplemen t (pill) form. However, viramin A can cause toxicity
amounts that exceed the Daily Values listed on with long-term intake beginning at just 2 to 4 Limes hLm1an needs, especially in older
the lobe/. Miguel believes that "more is better." adults and pregnant women. JO
How can you explain to him that the supple- Because daily use of a bal:mced mu ltivitamin and mineral supplement usually sup-
11
ment he is about to start toking is "worse, plies less tJ1<U1 2 times tJ1e Daily Values of the components, this practice is unlikely to
because ii contains amounts that exceed the cause toxic effects in adults. But consuming many vita min pills can cause probkms. See
Daily Values by I 0 times for many nutrients, the Nmririon Focus at the end of this chapter te> explore whether you should take a
including vitamin A? multivitamin and mineral supplement and, if so, how to do it satdy.
Malabsorption of Vitamins
Vitamins consumed in food~ must be absorbed efficiently from the intestine to meet
body needs . If absorption of a vitamin is defective, a person must consume larger
amounts of it to avoid deficiency symptoms. As discussed in the fo llowing section, fat
malabsorption resulting from various GI nact and pancreatic diseases is associated with
poor absorption of the fat-sol uble vitamins.s.9 ,io Alcohol abuse and certain inrestin.iJ
ruseascs aJso can lead to malabsorprion of some B-viramins (e.g., thiarnin and folate),
as covered in detail in Chapter l 0.
Concept I Check
In gent:ral, the fut-soluble vitamins-A, D, E, and K-are less readily excreted rhan are the
water-soluble B vitamins and vitamjn C. Regular consumption of foods rich in both warcr-
soluble and far-soluble vitamins is important for hcaltJ1. Ho\\ ever, the occasional inade-
guatt: consumption of any one vitamin is of little health concern, because even
water-soluble ''itamins persist in the body to some extent. For example, when a person in-
gests a ,·itamin-frec diet, the first deficiency signs (due to lack of tJ1iamin) will not appear
for about 10 dars. When taken in supplement form, the fur-soluble \'itamin A poses rhc
greatest risk of toxicity. For the most part, there is little risk of toxicity when vit.unins arc
obtained from foods.
I The Fat-Soluble Vitamins

The discussion of the indi' idual fat-soluble vitamins-A, D, E, and K- bcgins by look-
ing at ho\\ they arc absorbed.
Absorption of the Fat-Soluble Vitamins

You can see from the chemical structures at the beginning of each \"iramin section that
these ,·itamins are lipidlikc molecules. Because these \"itamins arc absorbed along with
dietary fat, adequate absorption of the fut-soluble ' 'iramins depends on efficient fat ab-
sorption. This, in turn, depends on fat digestion, the utilization of bile salts and pan-
creatic lipase in the small intestine, and adequate absorptive capacity from a healrhy
intestinal wall (Figure 9-1 ). Under these conditions, about 40 to 90% ofLhe fat -solu ble
Digestive processes in
the stomoch release
vitamins from food
Digestive enzymes
released by the pancreas
El help to further release
vitamins, especially
I vitamin A.
Bile produced in liver

ond stored in gallbladder
E a ids in fat-soluble vitamin
absorption.
11
Essentially oil vitamin

obsorption tokes place
in the small intestine.
la Fat-soluble vitamins ore
absorbed along with
dietary fot.
Small amounts of vitamin

K ond biotin ore made
by bocteria in the
terminal port of the small
intestine and in the large
intestine; some may be
absorbed.
Figure 9· 1 I An overview of the digestion and absorption of vitamins. Key participants in the process include bile, pancreatic enzymes, intestinal enzymes,
and o healthy small intestine absorptive surface. Adequate fat digestion ond absorption ore critical for the ultimate absorption of fat-soluble vitamins.
Carotenoids ore absorbed mainly in the small intestine in con junction with dietary fat.
eople with cystic fibrosis, celiac dis· vitamins consumed are absorbed when they are taken in typical amounts. Ab~orption
ease, Crohn's disease, or any other efficiency generaU) falb \\hen intake~ greatly exceed human needs. 8 •9 •10
disease that hampers fat absorption absorb fat·
soluble vitamins poorly. Some medications, such
Distribution of the Fat- Soluble Vitamins
as the weight·loss drug orlislol (Xenicol) dis·
cussed in Chapter 13, also interfere with fat ob· Once absorbed, fat-soluble vitamins arc packaged and delivered to t.1rget cdb
sorption. Unabsorbed fat carries these vitamins tl1roughout the body in a manner similar to that used for dietary fats-namdy, by" .w
lo the large intestine, where they ore incorpo· of chylomicrons and other blood lipoprotcins. 8 •9 •10 This process is needed bccau!>e the
roted into the feces and excreted. People with vitamins are not water-soluble. Recall also from Chapter 6 mat, as a chylornicron cir-
such conditions ore especially susceptible lo vita· culates in the bloodstream, much of its triglyceride concem is removed by body cell\.
min E and vi tamin K deficiencies. A multivitamin What remains-the remnant-is taken up by the liver. This remnant contains the fat·
and mineral supplement, token under o physi· soluble vitamins absorbed from the diet. The liver can then "repackage" fat-soluble' i·
cion's guidance, is port of the treatment for pre· tamins with new blood proteins !Or transport in the blood, or they can be stored in the
venting the nutrient deficiencies associated with liver for future use.
fat molobsorption. Extra vitamin E may be rec·
ommended for people with cystic fibrosis.
Vitamin A
cystic fibrosis A disease that o~en leads to North Americans have little risk of developing a severe deficiency of vitamin A bccau~e
overproduction of mucus. Mucus con block the mis vitamin is abundant in our food supply. 10 But vitamin A deficiency constitmes one
pancreatic duct, in turn decreasing enzyme of the major public health problems in developing countries. Worldwide, vitamin A de
output. ficieocy is the leading cause of nonaccidental blindness. Children from impO\erished
celioc disease An immunological or allergic
nations in Africa, Asia, and South America arc especially susceptible because their in-
reaction to the protein gluten in certain groins, adequate intake and diminished stores of\·iramin A fuil to meet tile incrcJSed needs .1!>·
such os wheat and rye. The effect is to destroy sociated ,,;r11 rapid growth. In the world's most destinite nations, hundred~ of
the intestinal enterocytes, resulting in o much thousands of children become blind each )'C.lr because tliey lack ''itamin A.
reduced surface area due to Aottening of the Vitn.111i11 A refer~ to the preformed retinoids, plus the provit amin A carotenoids
villi. The elimination of wheat, rye, and certain that can form retinoids. 10 Vitamin A is a ring structure " ·ith a fatty acid tail. As pre-
other groins from the diet restores the intestinal formed vitamin A, it exists in three !Orms: retinal (an alcohol ), retinal (an .1kkhydel,
surface. and ret:inoic acid. The tail terminates in one of these tl1ree chemical groups.
Crohn's disease An inflammatory disease of
the gastrointestinal tract, but generally more OH
pronounced in the terminal ileum. A family I
history is o ma jor risk factor. The disease limits - C- H 0 0
the absorptive copocily of the small intestine. I II II
H - C- H - C- 0 - H
retinoids Collective term for the biologically
active forms of vitamin A including retinal, Rctinol Retinal Retinoic acid
retinal, and retinoic acid.
To some extent these forms can be intcrconverced (Figure 9-2 ).
provitamin Substance that con be mode into o The tail of the vitamin A molecu le can vary from cis to trans configuration. This ori
vitamin. encation influences the function of the specific retinoid (sec tile section titled
carotenoids Pigment materials in fruits and Functions ofVitamin A).
vegetables that range in color from yellow to
orange to red. H H H
I I I
- C= C- -C=C-
1
H
Cis TI·am
ee Appendix A to review cis and trans Preformed vitamin A is present in animal foods as retinal, the alcohol form, and
isomers. retinyl ester-compound<> that have a fatty acid attached to retinal. The retinyl c~ter'
don't exhibit vitamin A activitv but are broken down to retinol and the attached fott\
acid in tl1e intestinal tract. 10 • ·
he retinyl ester retinyl palmilote is a com· Proviramin A carotenoids also can be enzymatically split to form retinal within the
mon form of vitamin A added lo foods. intestinal cells or liver cd ls.9 Some is also made into rctinoic acid. The provitamin A
Figure 9-2 l lnterconversions of beto-

corotene and the various retinoids. Notice that
synthesis of retinoic acid is a "dead end" in
metabolic terms.
!
"""!'_ _ _ _ _ _ _ _.,. Retinal
- - - - - - -...~ acid
Retinoic Beto·carotene
carotcnoids arc alpha-carotene, beta-carotene, and beta-cryptoxanthin. (The yellow-

orange pigment in fruits and vegetables is due to provitamin A beta-carotene.) Other
carotenoids in nature, such as lycopcnc, do not have vitamin A activity in humans. 9
2 molecules of retinal
Absorption, Transport, Storage, and Excretion of Vitamin A

In the small intestine, rctinyl esters are broken down, leaving free retinal. This process ~CHpH
requires bile to make Lhe retinyl esters soluble and aJso to activate the enzymes used,
Retinal
such as pancreatic lipase. 0
Up to 90% of retinal is absorbed into the cells of the small intestine . After absorp· II
tion, a fatty acid is then attached to retinal to form a new retinyl ester. These retinyl ~C-OH
esters are packaged into chylomicrons, along with other lipids, before entering the
lymph. The chrlomicrons deliver vitamin A to tissues for storage or to be used. Over
90% of the body's vitamin A storage can be found in the liver, but retinoids also arc
found in adipose tissue cells, kidneys, bone marrow, testicles, and eyes. Normally, the
liver stores enough vitam in A ro last for several months, so some time will pass before
the signs and symptoms of vitamin A deficiency arise. 10
Carotenoids arc absorbed inmct; this causes their absorption rate to be much lower
than that of retinal. After being absorbed in the small intestine, carotenoids can be
cleaved to yield retinal, which is then formed into retinal. This retinal can then ha\'e a
fatry acid attached to it to become a retinyl ester and enter the lymph as part of a chy-
lomicron. Carotcnoids also can enter the bloodstream directly; however, the mecha-
nisms that allow this to happen aren't well understood.9
\Vhen vitamin A as a retinoid is released from the li,·er into general circulation, it is uring protein·energy malnutrition, synthesis
bound to a protein called retinal-binding protein, produced mainly by the li,·cr. In the of retinal-binding protein and transthyretin
bloodstream, retinal-binding protein is then bound to another protein called (preolbumin) is reduced by the lock of sufficient
rransthyrctin (commonly known as prealbumin).10 In contrast, when carotenoids are availability of amino acids and energy. These
released from the liver, they are carried by the lipoprotein VLDL. 9 proteins ore used as clinical indicators of protein
Vitamin A is not readily excreted by the body; only some is lost in the urine. Kidney synthesis in a person because decreased con-
disease and aging in general increases the risk of vitamin A toxicity as tl1is urinary route centrations in the blood suggest inadequate pro·
of excretion is compromised. 10 tein and energy intake.
Cellular Retinoid-Binding Proteins

Reti11oids are bound to specific retinoid-binding proteins within cells that take up
retinoids. There is a family of cellular retinoid-bind.ing proteins; these hold retinoids
and direct them to functional sites withi n the cell. Nearly all cells contain one or more
se of some synthetic retinoids hos been of these binding protcins. 10 Besides transport, these binding proteins also protect
shown to lead to o remission in various retinoids from breakdown.
forms of cancer. The mechanism is probably
through the fundamental role of retinoids in cell
differentiation.
Retinoid Receptors in the Nucleus
One way the retinoids influence health is tO bind to two main families of retinoid re-
RXR, RAR The abbreviations for retinoid X ceptors in the cell nucleus (called RAR and RXR). Once these receptors within the
receptor ond retinoic acid receptor. These two cell nucleus bind forms of retinoic acid, the complex then binds to DNA. This bind-
subfamilies of retinoid receptors in the nucleus
ing regulates the formation of mRNA and the subsequent production of body proteins
interact with retinoic acid ond bind with
(and body processes) known as gene expression. This gene expression can go on to
specific sites on DNA, allowing for gene
direct cell differentiation (Figu re 9-3 ). 10
expression.
gene expression The activation of o specific

site on DNA, which results in either the
Functions of Vitamin A
activation or the inhibition of the gene. The active forms of vitamin A retinoids-retinol, retinal, and retinoic acid-perform
cell differentiation The process of transforming three basic functi ons. These biochemical or physiologic actions are vision, the growth
an unspecialized cell into a specialized cell. and development of many types of tissues, and immw1ity.10
Vision
Vitamin A (as retinal) is needed in the retina of the eye to turn visual light inro nerve
signals to the brain (Figure 9-4). In addition, vitan1in A (as rctinoic acid) is needed ro
maintain normal differentiation of the cells that make up the various structural com-
ponents of the eye, such as the cornea and rod cells. 1o
The sensory clements of the retina consist of specialized cells known as rods and
cones. Rods are responsible for the visual processes that occur in dim light, translating
Figure 9 . 3 I The mechanism of the action of

vitamin A (as retinoic acid) on the target cell.
(1) Vito min A is carried by retinal-binding
protein and tronsthyretin in the blood. (2) Upon
release vitamin A enters the target cell, ond
(3) binds to cellular retinoid-binding protein.
(4) Once released from this protein, vitamin A
then enters the nucleus and binds to its nuclear-
retinoid receptors (RAR and RXR). (5) This
complex then binds lo DNA, activating gene
transcription. (6) The resulting messenger RNA
(mRNA) hos the code for the protein that
(7) ultimately produces the cellular responses
(see Chapter 7 for details on protein synthesis
using mRNA). Nearly all cells have at least one
member of the RAR and RXR families of
vitamin A-binding proteins. It is interesting that
vitamin D in its active hormone form acts in o
similar way. However, the retinoic acid
receptor (RAR) portion is replaced by the
vitamin D receptor (VDR) .
In the darlc In the light Figure 9-4 I The bleaching and

regeneration of rhodopsin (J-6). The yellow
Rhodopsin obsorbs
background indicates the bleaching events that
photon of light
occur in the fight; the gray background
indicates the regeneralive events that can occur
in eilher light or dork conditions. Note that 11-
cis retinal hos o kink in the molecule, but al~
trans retinal is a straight chain. As shown in
Chapter 6 1 this change in configuration is
11-cis retinal lypicol when lipidlike molecules convert from
cis to Irons shapes.
11-cis retinal
isomerizes lo
oil-trans retinal
in rhodopsin
........r '
~l~~mopsin
-Tro" ' "'I
. ~
Op~n triggers reaction
cascade message
sent to brain , ¥I '"'°'' '"
El
Cessation of dark current
objects into bbck-and-whitc images and detecting motion. Cones arc responsible for
the visual processes occurring under bright light, translating objects into color Images.
Tn the rods, 11-cis-retinal binds to a protein called opsin to form the visual pigmenc
rhodopsin. The absorption of a photon of light catalyzes a change in the shape of rhodopsin A photoreceptor in rod cells
11-cis-retinal to all-tram retinal, causing opsin to separate from all-tm11s retinal. 10 This composed of 11-cis-retinal and opsin.
isomerization event leads to a cascade ofblochemical evems, which trigger a change in
photon A unit of light intensity at lhe retina
ion permeability of the photoreceptor cells. This, in turn , initiates a signal to the nerve having the brightness of one candle.
cells that communicate with the brain's visual center. Actually, thousands of rod cells
containing millions of molecules of rhodopsin are triggered simultaneously. bleaching process The process by which light
In order co keep the visual processes functioning, the l 1- cis-retinal in the rod cells depletes the rhodopsin concentration in the
must be regenerated in the pigment-containing cells in the eye. AIJ -trans retinal is eye. This foll in rhodopsin concentration allows
the eye to become adapted to bright light.
eventually converted back to 11 -cis-retinal. This slow process can take several minutes.
The 11-cis-rctinal then moves back to the photoreceptor site, where i1 recombines wid1 dark adaptation The process by which the
opsin and is ready for another cycle. rhodopsin concentration in the eye increases in
The release of 11 -cis-retinal from opsin is a bleaching process. Dw-ing exposure to dork conditions, allowing improved vision in
bright light, the rods' rhodopsin is completely activated and cannot respond to more the dork.
light until it ren1rns to its resting state. Enzymes regenerate the initial form of night blindness A vitamin A deficiency
rhodopsin so that it can respond to light again. When there is a limited amount of condition in which the retina in the eye cannot
rhodopsin in the rod cells, it is difficult to adapt to seeing in dim light (night blindness). ad just to low amounts of light.
Nor all retinal is reused, so there is a pool of retinyl esters in the eye to keep a sup-
ply of vitamin A on hand. Should the pool of vitamin A be low, the process of d ark epithelium The covering of internal and
external surfaces of the body, including the
adaptation is slowed down, and a condition known as n igh t blindness develops. 1O
lining of vessels and other small cavities. It
consists of epithelial cells joined by a small
Growth and Differentiation of Cells amount of cementing material.
Various cells in the retina, cornea, and epit h elium of the eye depend on retinoic acid
for maintaining structural integrity. Vitamin A is delivered to these cells by tears.
Vitamin A then acts in its role in gene expression <rnd ultimate cell differentiation. Two
ost forms of cancer arise from cells that forms of vitamin A, all-trans retinoic acid and 9-cis-retinoic acid, regulate fmely tw1ed
ore influenced by vitamin A. Coupled gene expression through its binding to DNA. Retinoic ac:id is also necessary for the
with its ability to aid immune system activity, vi· production, the structure, and the normal function of epithelial cells in the lungs, tra-
tomin A may be a valuable tool in the fight chea, skin, GI tract, and many other systems. It is also important for d1e formation and
against cancer. This is especially true for skin, maintenance of mucus-forming cells in d1ese organs. 10 Because of its effect on cells
lung, bladder, and breast cancers. Still, because chat make up the skin, forms of retinoic acid (e.g., tretinoin [Retin-A]) are used to
of the potential for toxicity, unsupervised use of treat skin damage, such os wrinkles. It bas a modest effect.
megadose vitamin A supplements to reduce con·
cer risk is not advised. Immunity
As early as the 1920s, researchers recognized d1at vitamin A (mostly as retinoic acid)
is important for in1mLu1e system functions, and a vitamin A deficiency is associated with
decreased resistance to infections. 10 The severity of some infections, such as measles and
diarrhea, is reduced by vitamin A supplementation in people who show a deficiency.
Vitamin A Analogs for Acne

The acne medication tretinoin (Retin-A) is made of one analog form of vitamin A. Ir
is used as a topical tream1cnt (applied to die skin) for acne. It appears to work by ini-
tating the skin, which leads to open pores and a generalized peeling of the ski n layer.
Many vegetables, such as asparagus and
It also can block the deleterious effects that skin bacteria have on acne lesions. Another
broccoli, ore rich in provitomin A carotenoids.
de1ivative of vitamin A, 13-cis retinoic acid (Accurane), is an oral drug used ro treat se-
rious acm:. It acts in part to regulate development of cells in the skin (the gene ex-
pression role discussed earlier). Note that taking high doses of vitamin A itself would
not be safc. 10 Even Accutane, a less potenrially toxic form, can induce toxic symptoms
as well as birth detects in the offSpring of women using it during pregnancy. A preg-
nancy test is required before Accutane is prescribed to women.
Possible Carotenoid Functions

Carotenoids may play a role in preventing cardiovascular disease in persons at high risk,
possibly linked to carotcnoids' antioxidant capabilicy. 17 Unti l definitive srudic.:s an:
complete, many scientists recommend that we consume a total of at least S servings of
a combination of fruits and vegetables per day as part of an overall effort to reduce the
risk of cardiovascular disease.
Cawtenoids by themselves also may help prevent cancer, acting again as antioxi-
dants. Population studies show that regular consumption of foods rich in carorenoids
decreases t11e risk of lLmg and oral cancers. The d ietary carotenoid lycopenc (the red
pigment found in tomatoes, watennelon, and several oilier fruits) protects against can-
prostate gland A solid, chestnut-shaped organ cer of the prostate gland. The proposed biological role of lycopene again may be th:ir
surrounding the first part of the urinary tract in of· an antioxidant. Because of this link to prostate cancer, some food companies (e.g.,
the mole. The prostate gland secretes Campbell Soup Company) are even marketing their products as important sources of
substances into the semen. lycopene. T bc carorenoid lycopene also may decrease skin cancer risk.
In contrast to me potential benefits from carotenoids in foods, recall !Torn Chapter l
t11at recent sn1dics from the United States and Finland failed to show a redm:tion in
lung cancer in male smokers and nonsmokers who were given supplemenrs ol the
carotenoid beta-carotene for 5 or more years. In fact, beta-carotene use in male smok-
ers increased the number of lung cancer cases compared with tbe control groups. No
comparable srudies have been done wid1 women. Although further research continues,
most researchers are now convinced. that beta-carotene supplementation offers no pro-
tection against cancer. Thus overwhelming advice is to rely on food sou rces of this or
any other carotenoids .
macular degeneration A painless condition .Age-related macular degeneration (Figure 9-5) is a leading cause of legal blindness
leading to disruption of the central port of the among Norm American odulrs over the age of 65. The disease is associated wirh
retina (in the eye) and, in turn, blurred vision. changes in t11e macular areo of the eye, which provides me most detailed vision. Age,
smoking, and genetics arc risk factors. The macula contains the carotenoids lutein and
Figure 9·5 I Further research is needed to

better understand the relationship between
mocular degeneration and carotenoids. While
supplementing one's diet with specific
corotenoids hos not yet been shown to reduce
the risk of moculor degeneration, research has
shown thot smokers ore ot three limes greater
risk lhon nonsmokers to develop this disease.
Normal vision The same sce ne as viewed b y a pe rson

with macular degene ration
zcaxanthin in high enough concentrations to impart a yeUow color. In some studies, Food Sources of Vitamin A
the higher the total number of carotenoids (beta-carotene, lutein, and zea.xanthin)
consumed in the diet, the lower was the risk for age-related macular degeneration. Vitamin A
These carotenoids may also decrease the Lisk of cataract.s in the eyes. I 8 Although these Food Item and Amount {µ.g RAtr
hypotheses are interesting, the risk for these eye disorders may be reduced by a gen- Cooked beef liver, 1 oz 3042
eral consumption of fruitS and vegetables h igh in carotenoids rather than the intake of Sweet potato, 1/2 cup 958
these specific carotenoids. Note that multivitamin and mineral supplements formulated
Spinach, 2/3 cup 494
for older adults (e.g., Cenrrum Silver) arc being marketed as a source oflutein.
Mango, l 402
Vitamin A in Foods Baby carrots, 5 375
Retinoids (preformed vitamin A) are found in liver, fish, fish oi ls, fortified milk, and Acorn squash, 2/3 cup 244
eggs. Margarine is forti.fied with vitamin A, as are fat-free, low-fat, and fat-reduced Cooked kole, 1/2 cup 206
milks. Provitamin A carotenoids are mainly found in dark green and yeUow-orange
Fat-free milk, 1 cup 150
vegetables and some fruits. Carrots, spinach and other greens, winter squash, sweet po-
tatoes, broccoli, romaine lettuce, mangoes, cantaloupe, peaches, and apricots are ex- Broccoli, 1 cup 138
amples of such sources. About 70% of the vitamin A i11 the typical Nortb American diet Apricot, 3 137
comes from anin1al (preformed vitamin A) sources, whereas provitamin A predomi-
Cheddar cheese, 1 oz 78
nates in the diet among poor people in other parts of the world.
Beta-carotene accounts for some of the orange color of carrots. In vegetables such Romaine lettuce, 1 cup 72
as broccoli, this yellow-orange color is masked b~r the dark-green pigment chlorophyll. Morgorine, 1 pol 50
StiU, green vegetables contain provitamin A. Consuming a varied diet rich in green
Scallions, I tbsp 32
vegerables and canors will provide enough vitamin A to meet needs.
Peach, 1 26
Retinol Activity Equivalent (RAE) RDA for adult men, 900 µg RAE;
At one time, the an10Lmts of most nutrients in foods were expressed in international adult women, 700 µg RAE
units (IUs), a crude measure of vitamin activity. Today we can directly measure very *Relinot octivity equivalents
small quantities of nurrienrs more precisely; consequently, milligrams (1/1000 of a
gram) and micrograms ( 1/1,000,000 of a gram) have generally replaced international
units as customary muts of measure, although vitamin supplements may still display the
older TU values.
interna~onal unit (IU) A crude measure of
For vitamin A, the current unit of measurement is tl1e retinol activity equivalent
vitamin activity, often based on the growth role
(RAE), wluch is basicalJy 1 µg of retinal. In this system, 12 µg of beta-carotene yield of animals. Today these units often have been
l µg of vitamin A activity, ai1d 24 µg of tbe otl1er two provitamin A carotenoids replaced by precise measurements of actual
(alpha-caroteae and beta-cryptoxanthin) yield l µg of vitamin A activiry.10 quantities in milligrams or micrograms.
The total RAE value for a food is calculated by adding the acrual weight of retinol and
the adjusted equivalent weights of provitamin A carotenoids present in the food. For ex-
ample, a diet that contains 500 µg retinol, 1800 µg beta-carotene and 2,400 µg alpha.-
carotene supplies 750 µg RAE (500 + (1800 ..;- 12) + (2400 + 24) = 750 µg RAE).
Calculating Retinol Activity Equivalents

Table 9-1 is a tool for converting amounts of vitamin A and carotenes expressed in one
unit of measure into another wlit of measure.
Table 9-1 I Conversio n Values for Retinol Activity Equivalents
1 retinal activity equivalent (RAE) l JU vitamin A activity

= l µg of oll-lronHetinol = 0.3 µg of oll-lrons-retinol
= 12 µg of dietary all-trans-beta-carotene = 3.6 µg of dietary all-trans-beta-carotene
= 24 µg of other dietary provitomin A corotenoids = 7.2 µg of other dietary provitomin A carotenoids
The retimtl equivalent (RE) is an older tuiit for vitamin A. This RE assumed that
there was a greater contribution to vitamin A needs from carotenoids than we assume
today. Food composition tables and nut1ienr databases ma)' contain this older RE stan ·
<lard. It will take some time to update these resomces.
To compare the older RE (or HJ) standards ro current RAE recommendarions, as-
sume that for any preformed vitamin A in a food or added to food, l RE (or 3.3 IU )
= l RAE. There is no easy way tO convert RE or ru units to RAE units for foods tlur
naturally contain provitamin A carotcnoids, such as carrots, spinach, and apricots. A
general rule of thumb is to divide the older values for foods containing c1rotcnoid!> by
2, and then do the con\'ersion from RE or JU to RAE as shown in Table 9 -1. There
is also no easy way to do this calculation for food containing a mixrnrc of preformed
vitamin A and earotcnoids. We will jusr have to wait for all the food tables ro be up-
dated. Generally speaking, any values listed for such foods provide less vitamin A than
the RE or IU values suggest.
Vitamin A Needs
M eosuring vitamin A in the blood is one
way to assess a person's status. This
measure is insensitive, however, because con-
The RDA for vitamin A is 900 µg Retinol Activity Equivalents (RAE) per day !c>r adulL
centrations do not foll until vitamin A stores in
men and 700 µg RAE per day for adult women. At this intake, adequate body srores
the liver ore very low.
of vitamin A are maintained, which is the basis for setting the RDA. 10 Average intake~
for adult men and women in North America meet the RDA. Most adults ha\'c livt:r re-
serves of vitamin A that are three to five times greater than needed to provide good
health. At present, there is no separate RDA for beta-carotene or any of the other
provitamin A carotenoids.9
Vitamin A-Deficiency Diseases

Deficient vitamin A status may be seen in preschool children who do not cat enough
vegetables. The Ltrban poor, older adults, and people with alcoholism or Liver disease
(which limits vitamin A storage) can also show diminished vitamin A status, especially
with respect to stores. Fi.nail)', children and adults with severe fat-malabsorption syn-
dromes, such as celiac disease, clu-onic diarrhea, pancreatic insufficiency, Crohn's dis·
ease, cystic fibrosi1>, HN, and AIDS, may also experience vitamin A deficiency. Such a
deficiency can have widespread effects on the body_lO
When the retinal in the blood is insufficienr to replace the retinal lost during the vi·
sual cycle, the rod cells in the eye recover from flashes of light more slowly. The resulr-
i_ng night blindness is a common early symptom of vitamin A deticicucy, as discussed
earlier. As well, without enough retinoic acid, mucus-forming cells deteriorate and arc
no longer able to synthesize mucus, the essential lubricant used throughout the body.
The eye, especially rhe cornea, is adversely affected by the loss of mucus, which keeps
Figure 9 · 6 I Vitamin A deficiency can
eventually lead to blindness. Note the severe
the eye surface moist and washes away dirt and other particles that settle on the eye.
effects on this eye. This problem is commonly Deterioration of the eye results from bacterial invasion because retinoic acid pl.1ys an im-
seen today in Southeast Asia. In contrast, the portant role in resistance to infection. Conj1mctival xerosis (abnormal dryn~s of the
leading causes of blindness in North America conjunctiva of the eye) •Uld Bitot's spots (drying out oftl1e eye and appearance of hard-
ore accidents in children and diabetes in ened epithelial cells) appears as vitamin A deficiency worsens. The corm:al ulcera[ion
adults. and kerat0mabcia (softening of the cornea) result in sc~u-ring (Figure 9-6). The ultimate
scarring may be barely detectable, or it could lead to loss of sight. Thjs sequence of conjunctiva The mucous membrane covering
changes in the eye-collectively known as xerophthalmia-causcs irreversible blind - the anterior surface of the eyeball and the
ness in milJjo ns of people worldwide. posterior surface of the eyelids.
Vitamin A deficien cy also produces skin changes referred to as follicular
hyperkeratosis. Keratin, the normal component of the outer layers of skin, protects xerophthalmia A condition marked by dryness
the inner layers and reduces water loss tbrnugh lhc skin. During severe ' 'itamin A deficiency, of the cornea and eye membranes that results
from vitamin A deficiency and can lead lo
keratinized cells, which are normally present only in the omer layers, replace the normal ep-
blindness. The specific cause is a lock of mucus
ithelial ceUs in the underlying skin Jayers. H air follicles become plugged with keratin, giv-
production by the eye, which then leaves it
ing a bumpy appearance and rough tcxrurc to the skin, and the skin becomes very dry. more vulnerable to surface dirt and bacterial
In areas of the world where vitamin A defi ciency exists, poor growth follows. If liver infections.
Yirarnin A stores are established after an infant is weaned , they can supply retin a l for
several months or even longer. Vitamin A deficiency in children occurs most often dur- follicular hyperkerotosis A condition in which
ing the postweaning period. Giving supplements of 15,000 to 60,000 µ.g to young keratin, a prolein, accumulates around hair
follicles.
children at risk may protect them for up to 6 months. Finding a suitable food to im -
prove intake is a must for a long-term solution to vitamin A deficiency. Also, i.nsuffi .
cient fat in the diet of these children inhibits the absorption of what little vitamin A
there is in the diet.
Upper level for Vitamin A

Signs and symptoms of toxicitv from excessive vitamin A-called hypervitaminosis A-
can appear with long-term supplement use at 2 to 4 rimes the RDA for preformed vi-
tamin A, especially in pregnant women and older adLLlts in general (Figure 9-7). L0,20
Correspondingly, the Upper Level is set at 3000 µ.g/day of retina l, about 4 ti mes wh at
the typical adult needs.IO (This ainotmt is based on the presence of birth detects oc-
curring dming pregnancy and liver toxicity in general with chronic intakes above thjs
amo unt.)
Figure 9 - 7 l Consuming the right amount of

Toxicity Death vitamin A is critical to overall health. A very
low {deficient) or a very high {toxic) vitamin A
Teratogenic Acute Chronic
Fetal malformation Gastrointestinal upsets/ Liver damage intake {as relinoids) con produce damaging
Spontaneous nausea Hair loss signs and symptoms and even lead to death.
abortion Headaches Bone/muscle pain The severity of effects and the intake range
"'"'QI Dizziness Loss of appetite vary among individuals.
~ Muscle uncoordinations Dry skin and
w mucous membranes
Hemorrhages
Coma
Fractures
Normal functions _ ... J
Black/white and color vision

Cell differentiation
Immunity
Deficiency symptoms
Night blindness
Keratinization of epithelial tissue
Xerophthalmia
Blindness
- - - -- - - - - Increasing vitamin A intake - - - - -- - -_..

Three kinds of vitamin A toxicity exist: acute, chronic, and teratogenic. Acute cox -
teratogenic Tending to produce physical
defects in a developing fetus (literally, Nmonster icit:y is caused by the ingestion of one very large dose of vitamin A or several large doses
forming"). taken over several days (about 100 Limes the RDA). The effects of acute toxicit} are
largely GI tract upset, headache, blurred \'ision, and poor muscle coordination. Once
the dosing is stopped, these signs disappear. Exrraordinarily large doses, about 12 g
( 13,000 times the RDA), howe\'er, can be faral.
In chronic toxicity, infants and adults show a wide range of signs and symptoms:
bone and muscle pain, loss of appetite, various skin disorders, headache, dry skin, hair
loss, liver damage, double vision, hemorrhage, vomiting, hip fractures, and coma.
Vitamin A also is particularly harmful in early pregnancy, a time when many women
do not know that they arc pregnant. Hypcrvicaminosis A may cause a spontaneous
abortion or birth defects.20
Toxicity of vitamin A probably causes instabi lity in retinoid-sensitive membranes
P eople in developing countries typically pose
on exception to the rule that moderately
large doses of vitamin A con cause toxicity.
and the inappropriate expression of certain genes. T he treatmenr is simply co discon-
tinue the supplement. Effects then decrease over the next fow weeks to a month as
Because of their minimal storage of vitamin A, blood concentrations fall co within n normal range. Permanent damage co the liver,
these people con tolerate intermittent large doses bones, and eyes as well as recurrent joim and muscle pain, however, can occur with
of the vitamin. chronic [ngestion of excessive amounts of the vitamin.
The most serious and tragic effects of hypervitaminosis A are teratogenic-most no-
tably, the birth detects just mentioned. Vitamin A and its related analog fonm, all-
trans-retinoic acid (topical tretinoin [e.g., Retin-AJ) and 13-cis-retinoic acid (oral
isotretinoin, or Accutane), ha,·e been subjects of concern for years. These vitamin A
analog medications arc used to treat various skin disorders, such as acne and psonasis
Accucane causes spontaneous abortion and birth defects in laboratory animals. The ri'k
is significant for pregnant women taking large doses of vitamin A analogs. Their off
spring shO\\ congenital malformations of the head, probably because neural cre:.t cell:.,
which are important in the de,·clopmem of the head and brain, are k.no\\'n to be 'en
sensitive to excess a.mounts of vitamin A. As mentioned before, women of childbear-
ing age need to take oral contrnceprives immediately before, during, and for some time
after taking these medications to prevent pregnancies that could result in such fetal
maJformations.
Check oul /he ready-lo-eat breokfosl cereals al It is even possible for women to gee too much vitamin A from food if they consume
your loco/ supermarket. Which ones hove beto- high-vitamin A foods such as li"cr and fortiticd ready-co eat breakfast cereals. For this rea-
carolene added? Why do you lhink lhe manu· son, pregnant women shou ld especially limit their intake of these foods, and if using sup
faclurers are pursuing /his kind of fortification? plements, they shouJd check that much of the vitamin A is in the form of beta-carotene .
FDA recommends that women of childbe:iring years limit their intake of prefixmed vi-
tamin A to about 100% of the Daily Value listed o n food and supplement labels.
Consuming carotenoids [n large amounts from foods does not readily result in tm.-
icity in most people. The carotenoids' rate of conversion into vitamin A, when possi-
ble, is relatively slow. In nddition, the efficiency of carotenoid absorption from the
small intestine decreases markedly as the oral intake increases.8
If someone consumes large amouncs of carrots (e.g., in the form of carrot juice) or
if an inf.mt eats a lot of winter squash, the resulting high carotenoid concenrratiom in
hypercarotenemia Elevated amounts of the body can rum skin a ~·ello\\ -orange color. The result is termed hypercarotenemia,
carotenoids in the bloodstream, usually caused or just carotenemia.s (Recall that IJ_vpe1· means "high" and emia means "in the blood-
by consuming o diet high in carrots or squash stream.") The person appears to have jaundice; however, unlike a true jaundice, the
or by toking beto-carotene supplements. sclerae (whites of the eyes) arc white rather than yellow and the liver is not enlarged.
Carotenemia is generally thought co be harmless. Lycopenodermia results from exces-
sive intake of foods 1ich in lycopene, such as tomatoes. A deep orange discoloration of
the skin is evident.
Concept I Check
Vitamin A has diverse functions. The binding of a form of vitamin A (retinoic acid) co
DNA can influence cell growth and differentiation through regulation of gene expression.
Vitamin A is important for maintaining vision and cpitheli:il cissues, reproduction , growth,
and ensuring proper fimction of the immune system . Vitamin A in the diet comes in two
fmms: retinoids (preformed vitamin A) and certain carotenoids (provicamin A). A diet that
meets the RDA for vitamin A and contains plenty of carotenoid -containing fr uits and veg-
etables is considered sound nutrition. Major food sources of vitamin A include liver, car·
rots, eggs, tomatoes, milk, and many vegetables. North Americans most at risk for poor
\1tamin A srarus are preschool children and alcoholics. Large doses of retinoids can be
toxic, even at chronic dosages only about 2 to 4 times the RDA, especially during early
pregnancy and one's older years.
Vitamin D
T he stants of vitamin D as a vitamin is am biguous because, in the presence of sunlight,
skin cells are capable of synthesizing a sufficient su pply of the vitamin from a deriva-
tive of cholesterol. Because a dietar y source is not required in this case, the vitamin is
more correctly classified as a "conditio nal'' vitamin, o r prohormo ne (e.g., a p recursor prohormone Precursor of a hormone.
of an active hormo ne ). Vitamin D achieves vitamin stauis because the d iseases rickets
rickets A disease characterized by inadequate
and o st eomalacia can be p revented and, to some extent, treated by the consumption
mineralization of the bones caused by poor
of \~tam.in D-rich foods .8
calcium deposition during growth. This
For North Ame1icaus in general, Strn exposm e provides 80 to 100% of o u r vitamin D deficiency disease arises in infants and children
needs. 8 The am0tmt of sun exposure need ed by individ uals to prod uce vitamin D with poor vitamin D status.
(speci fi cally vitamin D 3 ) depends on their skin color, age, time of d ay, season, and lo -
cation. Experts recommend that people should expose their hands, face, and arms at osteomalacia The weakening of the bones that
least two to three times a week for 25% of the time it takes tO turn o ne's skin pink (e.g., occurs in adults as a result of poor bone
mineralization linked to inadequate vitamin
5 to 10 m inutes) to make eno ugh vitamin D. Person with dark ski n would need addi -
D status.
tional exposure, about 3 to 5 ti mes the amoun t just recomme11ded (or maybe even
umons produce vitamin D3 (cholecolcif·

erol), whereas supplements and fortified
foods may contain vitamin D2 {ergocolciferol).
This lotter compound hos vitamin D activity in
humans, but not as much as compared to
vitamin D3.
l
Addition of hydroxyl groups
(- OH) by liver (carbon #25)
and then by the kidney (carbon #1)
yield the final product
HO
Cholecolciferol
{vitomin 0 3) OH
HO
1,25 (OHh vitamin 0 3
The Form produced by the body is called cholecalciferol

(vitamin 0 3). A form lypically found or added to foods is
ergocalciferol (vitamin 02). It has a double bond in the starred
position in the top structure.
Vitamin D Family
more). The large amounr of melanin pigment in dark-skinned people is a potenr nat-
A ging decreases production of vitamin 0 3 in
the skin by about 70% when one reaches
the age of 70. Older people ore advised to get
ural sunscreen. Sun exposure is effective for vitamin D synthesis only if sunscreen over
SPF 8 is not used and if exposLu·e takes place between about 8 A.M.. and 4 P.M. Even
some sun exposure, especially during early this exposure is not effective at all in the winter in northern climates (e.g., above a line
morning and late afternoon. In this way they will connecting Los Angeles, Calif., tO Atlanta, Ga. ). Some people may be able to use the
receive the benefit of vitamin 0 3 synthesis with- vitamin D that was stored from summer months in tl1eir adipose cells, but most peo-
out also significantly increasing their risk of skin ple in northern climates should find alternate vitami11 D soLu-ces in the winter months.5
cancer. Overall, anyone who does not receive enough sunshine to synthesize an adequate
amount of vitamin D (the most reliable source) should seek a dietary source of the vi-
tamin, but obtaining some sun exposure is still important. 8
Vitamin D3 Formation in the Skin

Syntl1esis of vitamin D3 begins with provitamin D 3 (7-dehydrocholesterol), a precur-
sor of cholesterol syntl1esis located in the skin. During exposure to sunlight, one ring
previtomin 03 The precursor of one form of on the molecule breaks open creating previtamin D 3 . Over d1e next few hours, pre-
vitamin D, produced os o result of sunlight viramin D 3 undergoes a chemical transformation aided by body hear, forming d1e
opening a ring on 7-dehydrocholesterol in more srable vitamin 0 3 . This change allows vitamin 0 3 tO enter the bloodstream,
the skin. bound to a protein. It is now on its way to becoming a hormone.6
In Boston, Massachusetts (42° N), production of previtamin D 3 in the skin is ade-
quate co meet needs from March tlu·ougb October. From November through
February, t he UV light is too low on d1e horizon ro produce previtamin D 3 . In Los
Angeles (34° N), production of previta111in D 3 occurs throughout the year. Prolonged
exposure doesn't increase the production of vitamin 0 3 beyond needs, because any ex-
cess is rapidly degraded.6
Absorption of Vitamin D2 from Food

Following the consumption of vitamin D 2 -containing foods, about 80% of vitamin 0 2
is incorporated into micelles in the small intestine and then absorbed and transported
to the liver by chylomicrons through the lymphatic system. Patients with chronic far-
ma.labsorption S}rndromes (e.g., cystic fibrosis, Crohn's disease, and celiac disease) have
trouble absorbing vitamin D 2 and may develop a deficiency.8
Metabolism, Transport, Storage, and Excretion of Vitamin D

When vitamin D (either D 3 synthesized in the skin or D 2 consumed from food or sup-
plements) enters genera.I circulation, it is bound to a protein. The formation of the hor-
mone form of vitamin D from its precursor occurs in the Liver and kidneys (Figme 9-8).
In the liver, the vitamin is hydroxylated on carbon 25, converting it to 25-0H vitamin D.
This i_nactive form circulates in d1e blood for weeks. The next stop is the kidney, the
principal (but not exclusive) site for tl1e production of l,25(0H)i vitamin D, also
known as calcitriol or d1e hormone form of d1c vitan1in. This form is active for about
l day. People wid1 chronic kidney failure have very low concentrations of circulating
l,25(0H) 2 vitamin D, and they are ro utinely treated with it.6
Once vitamin D enters general circulation, it can be stored in adipose cells for later
People who remain almost fully covered during use or converted to 25-0H vitam in D in the liver. When there is a shortage of calcium
the day, such os for religious reasons, produce in the blood, the paratl1yroid glands increase production of parathyroid hormone
little vitamin 0 3 . ( PTH ). Parathyroid hormone tl1en increases the production of l,25(0H)i vitamin D
in the kidney. Evenmal excretion of vitamin D takes place mostly via the bik, with
small amounts leaving via the urine. 8
Functions of Vitamin D
Vitamin D has hormone fi.rnctions that affect the body's use of calcium and phospho-
rus (Figure 9-9). The effects on calcium can have two somewhat opposite impacts on
bone. On the one hand, vitamin D hormonal actions (as l,25(0H)i vitamin D) in-
crease intestinal absorption of calcium from foods (review Figure 9-3 for the general
Ultraviolet
light
Vitamin 0 2 in food or supplements
Ultraviolet light from sun converts

a form of cholesterol to vitamin D3
(cholecolciferoll in the skin.
Bl Dietary vitamin D2 is absorbed

with dietary fat in the intestine.
B Vitamin D from both dietary

sources and synthesis in the skin is
bound to carrier protein in blood-
stream and transported to the liver.
Metabolism by liver to 25·0H

vitamin D.
[] Metabolism by kidney to 1,25

(OHh vitomin D
Figure 9-8 I The many facets of vitamin D metabolism. Whether synlhesized in the skin or obtained from
dietary sources, vitamin D ultimately fu nctions os o hormone: 1,25(0H)i vitamin D.
mechanism ohitamin D action ). This makes calcium J\".libblc for body cells as well for
incorporation into bone when there is more calcium in the blood than is needed for the
other basic life funcLions of calcium.6 On the other hand, vitamin D l1ormonal actions
can release calcium from bone into the blood, working with parathrroid hormone. The
!:mer action occms ro the greatest extent\\ hen blood calcium levels stare to fall. This fall
is re,·ersed by vitamin D hormone-induced release of calcium from the bone. Although
this action, if it occurs too much and too long, can weaken the bones, there is a benefit to
iL Calcium is needed for many basic lilc functions, including heartbeat (sec Chapter 11 ).
If the bones did not supply calcium !Or these functions, a person could quickly have
Figure 9·9 I The active vitamin D Parathyroid

harmone-1,25(0Hb vitamin D-and 1,25(0Hb hormone
parathyroid hormone interact to control blood vitamin D /
calcium concentration. low blood calcium is a El
trigger for many hormonal responses. E1
(1) Parathyroid hormone and 1,25(0H)i
vitamin D mobilize calcium from the bone.
(2) Parathyroid hormone also reduces calcium
excretion by the kidneys and stimulates
synthesis of 1,25(0Hb vitamin D by that
organ. (3) 1,25(0Hb vitamin D by itself
stimulates intestinal calcium absorption. All
Intestine
these responses raise blood calcium.
Conversely, when calcium in the blood
becomes too high, the hormone calcitonin
responds by promoting calcium deposition in
the bone (see Figure 11-10 in Chapter 11).
(4) Normal amounts of calcium in the blood are
needed to support nerve function, muscle
action, bone health, and other functions. Blood calcium
(contributes to
b lood clotting)
calcitonin A thyroid gland hormone that
inhibits bone resorption. Function of
neuromuscular
junction
M ineralization of
bone when there
is excess calcium
in the blood
Cell metabolism
serious, even fatal, health consequences. Thus, vitamin D preserves these important func-
tions of calcium even if djetar)' calcium intakes are not optimal.6
Vitamin D hormonal actions also help calcium with some of this mineral's rcgula-
rory functions. A prime example is providing enough calcium to maintain the function
neuromuscular junction A chemical synapse of the neuromuscular junction (sec Chapter 11). In addition, vitamin D hormonal
between a motor neuron and a muscle fiber. actions affect the body's use of phosphorus, which again partners with cakiwn to form
calcium phosphate, the mai n component of bone structu re.6
Human epidermal cells have receptors for 1,25( OH) 2 vitamin D in the nucleus.
Activated receprors then affect the differentiation of skin cells. At present, 20 dfffcrem
cell types u1 the human body are knovvn to be sensitive to the hormonal effects of vi-
tamin D. 6 Its ability to ,1ffect muscle cells has been linked ro a decreased risk of falling
and decreased gum disease in older adults. Vitamin D is also capable of influencing dif-
ferentiation in some cancer cells, such as skin, bone, and breast cancer cell~. Indeed,
adequate vitamin D status has been linked tO a reduced risk of developu1g breast, O\'ar-
ian, colon, and prostate cancer. Vitamin D may also contribute to lower blood pres·
sme. Dr. Michael Holick further discusses the potential benefits of adequate vitamin D
status in the Expert Opuuon.
Vitamin D in Foods
Because some people may not receive enough sun exposure to generate sufficient vi-
tamin D for the body's needs, they need to pay attention to dietary sources. Acn1ally,
few foods contain appreciable amotmts of vitamin D. 8
Good food somces of vitamin D arc fatty fish (e.g., sardines and salmon), fortified milk,
and some fortified breakfast cereals. In North America, milk is generally fortified with
10 µ,g (400 IU) per quart. Although eggs, butter, liver, and a few bnmds of margaiine
contain some \'itamin D, large servings must be eaten to obtain an appreciable amount
Food Sources of Vitamin D
of the \'itamin; thus, these foods are not considered significant sources.
Food Item Vitamin D Vitamin D
and Amount (µg) (IU)
Vitamin D Needs Baked herring,
The Food and Nutrition Board has set an Adequate [make for ' 'itamin D (sec Chapter 2 3 oz 44.4 1775
tor details about Adequate Intakes and how these standards differ from RDAs ). A Smoked eel,
more precise RDA could not be set because the amount ohitamin D produced by ~un I oz 25.5 1020
light is too ,·ariablc between individuals. The Adequate Intake for vitamin !) is Cod liver oil,
5 µg/ day (200 IU/ dar) for people under age 51 and increases to 10 µg/ day I tbsp 11.3 453
(-!00 JU/ day) for people between 51 and 70 and 15 µg/day (600 fU/day ) for older Baked salmon,
adults. 8 A number of experts suggest that older adults, especially those age 70 and 3 oz 6.0 238
over, \\'hO have limited sun exposure, receive about 20 to 25 µg (800 to 1000 TU)
Sardines,
from a combination of vitamin D-fortifted foods and a mulrivimmin <lnd mineral sup-
1 oz 3.4 136
plement, with an individual supplement of vitamin D added if needccl. 2 ·5 Providing
1250 mg (50,000 l U ) once a month is another strategy. Young, light-skinned people Conned tuna,
can produce enough vit:11njn D from casual sun exposure on just the fuce and hands. 3 oz 3.4 136
The marker used to determine the Adequate Intake for young adults is the concentra- 1% milk, 1 cup 2.5 99
tion of 25-0H vitamin D in the blood, the precursor to the active form of the vita Fat-free milk,
min. For older persons, indices of bone maintenance are also uscd. 8 1 cup 2.5 98
Infants arc born with a supply of vitamin D. Still, rhe American Academy of Sok margarine,
Pedfarrics recommends that breastfed infants be given a \itamin D supplement of 1 tsp 1.5 60
5 µg/ day (200 JU per day) until they are weaned ro infant formula and arc consum-
Italian pork
ing at least 500 ml of it. Note that inf.mt formulas are fortified with 'itamin D . sausage, 3 oz 1.1 44
Soy milk, l cup 1.0 40
Vitamin D·Deficiency Diseases Raisin Bron
Without adequate calcium and phosphorus in the blood cereal, 3/4 cup 1.0 38
available for deposition in the bone, the skeleton fails to Baked bluefish,
minerali:te properly and bones weaken and bow under 3 oz 0.9 34
pressure. When these effects occur in the growing bones Special Kcereal,
of a child, the disease is called rickets (Figure 9-10). Signs 3/4 cup 0.8 30
of rickets include enlarged head, joints, and rib cage; a de-
Cooked egg
formed pelvis; and bowed legs. In North America today, yolk, 1 0.6 25
rickets is most commonly associated with fat malabsorp-
tion, such as is seen in children "~th C)'Stic fibrosis, but an Adequate Intake for adults,
until age 50 5 µ.g (200 IU)
increase in cases has been seen related to a decrease in
milk consumption and the use of clothing that, fo r reli-
gious or social reasons, limits skin exposw·e to the sun. 8,1 J
Rickets in adults is called osteomalacia, which means
"soft bones." It is characterized by poor calcification of
newly synthesized bone. It can cause fracrures in the hip,
spine, and other bones. (Do not confuse this with the dis-
ease osteoporosis, which will be discussed in Chapter 11.)
OsteomaJacia is most likely to occur in people "ith kid-
ney, stomach, gallbladder, or intestinal disease (especially
when most of the intestine has been remo,·ed) and in
those with cirrhosis of tl1e liver. 8 These diseases affect
both vitamin D metabolism and calcium absorption.
Combinations of sun exposure and treatment with vita-
min D or l,25(0H), vitamin D can be used to treat
osteomalacia. -
Srudie~ ~uggest that older people and other individuals
who stay indoors most of the day and ingest little or no
vitamin D are at risk for developing a vitamin D defi- Figure 9-10 I The bowed legs of rickets, o
ciency. T his concern is particularly important for older vitamin D-deficiency disease.
Expert Opinion I:
Miracle Vitamin D: Importance for Bone Health
and Prevention of Common Cancers, Autoimmune
Diseases, and other Disorders
Michael F. Hol ick, Ph.D., M.D.
Adequa te vitamin D nutri tion is associated with the prevention of rickets in Unlike most fat-soluble and water-soluble vitamins that ore plentifu
children; therefore, little thought hos been given to the consequences of vi- healthy diet, very few foods naturally contain vitamin D. Consurrption c
tamin D deficiency in adults. However, it is now becoming clear that fish, such as salmon or mackerel, three to four times a week, or ingesti
vitamin D ploys an important role in maintaining bone health from birth until cod liver oil on a doily basis, ore two natural sources. Some foods, su
death. Of equal importance is that vitamin D has a multitude of other bio- milk and some breads and cereals, ore fortified with vitamin D. ~ owevE
logic functions in the body tha t may be important for the prevention of com- vi tamin D con tent in milk in the post hos been found to be highly vo
mon cancers, hypertension, and type 1 diabetes as well as a host of other and, in some cases, absent.
common maladies that afflict older adults.
Vitamin D Deficiency: How Common Is It?

Vitamin D Sources: Exposure to Sunlight
Vitamin D deficiency is extremely common in the U.S. adult popu otion.
and Dietary Intakes
than 50% of free-living and institutionalized older adults hove been rep
It is not appreciated that most of our vitamin D requirement, that is, 80 to to be vitamin D deficient. It hos been assumed lhot young and 1niddle-
100%, comes from our exposure to sunlight. The body has a huge capacity adults are not at risk for vitamin D deficiency. However, the lifostyle c
to produce vitamin 03 . A person in a bathing suit exposed to sunlight or ultra- young and middle-aged adults is such that they ore constantly worki1
violet B radiation for an amount that would cause a light pinkness to the skin doors and when outdoors they wear a sunscreen because of ti eir co
(l minimal erythemal dose; 1 MED) will raise the blood levels of vitamin D3 to of sun exposure and risk of skin cancer. A study in Boston report~d thol
the some degree as if the individual took between l 0,000 and 25,000 IU of of medical students and residents aged 18 to 29 years were vitJmin C
vitamin 02. Anything that alters the amount of ultraviolet B radiation that pen- cient al the end of the winter. The NHANES Ill study reported ·hat 4 ·
etrates into the skin will have a dramatic infl uence on the skin production of vi- African American women of childbearing age (15 to 49 years) were
tamin 03 . Increase in skin pigmentation, use of sunscreens, increase in latitude, to be vitamin D deficient al the end of the winter.
increase in the Zenith angle of the sun due to seasonal changes, and aging all Chronic vitamin D deficiency hos subtle and insidious conseque ices lo
dramatically infl uence the skin production of vitamin D3. The topical application bone health and overall health and well-being for all adults and in por1
of a sunscreen with on SPF of 8 will reduce it by 97.5%. older adults. Vitamin D deficiency con precipitate and exacerbate )steop
people who live in northern climates or reside in nursing homes. Not only do these
people experience little sun exposme, d1ey also can have reduced l,25(0H)i ,;t;lmin D
production from kidney resistance, which decreases conversion to the active form of
the hormone.
A person with a low circuJating concentration of 25-0H vita.nun D should take 20
to 25 µ,g (800-1000 IU) of vitamin D each day lLiltil the concentration reaches me
midnormal range. 2 •5 People who are likely to fall into this category are dark-skinned
T he best way to assess a person's vi tamin D
status is lo determine the concentration of
25-0H vitamin D in the blood.
people, older people (especially those with osteoporosis), and people with malabsorp-
tion syndromes, liver failme, and k.id.ney disease or failure. After blood concentrations
are normal, 10 µg (400 IU /day) from a multivitamin and mineral supplement should
be sufficient for most people.8 Some sun exposure would also be helpful.
Some hwnans show resistance to the action of certain vitamins, including vitamin D.
Resistance to vitamin D can be caused eid1er by a lack of l ,25(0H)i vitamin D
because of the accompanying increase in release of parathyroid hormone. produce 1,25(0Hb D locally. This may be the explanation for why chronic
Vitamin D deficiency also causes osleomolocio, which is oken associated with vitamin D deficiency, oken associated with living al higher latitudes, is as·
muscle pain, muscle weakness, bone pain, and increased risk of fracture. socioted with increased risk of dying from colon, prostate, breast, and ovar-
ian cancer. Exposure to ultraviolet B radiation is effective in treating
moderate hypertension. In animal models 1,25{0H)i D treatment was effec-
Vitamin D: More Than Just Bone Health
tive in preventing multiple sclerosis-like disease and type 1 diabetes. The re-
Vitamin Dis biologically inert and is metabolized in the liver to its major cir- cent observation that vitamin D supplementation of children resulted in a
culating form 25-hydroxyvitomln D [25(0H) D). 25(0H) D is converted in decreased risk of type l diabetes by 80% is noteworthy.
the kidney to 1,25-0ihydroxyvito- Overall, there is a great need to increase our awareness of vitamin D nulri·
min D [I ,25(0H)i DJ, which is re- tional status and its health implications. The only method to determine vitamin D
sponsible for regulating intestinal status is to measure circulating concentrations of 25(0H) D. Recently, the Notional
calcium absorption and stimulating Academy of Sciences hos recommended that vitamin D intakes be increased for
bone cell synthesis. Vitamin D re- older adults to 600 IU/day. However, in the absence of exposure to any sunlight,
ceptors (VDR) ore present in the this amount is probably inadequate. It is now estimated that in this case l 000 IU
DNA of most tissues and immune of vitamin D a day would be required to satisfy the body's needs and maintain
cells in the body. l ,25(0Hb D is circulating concentrations of 25(0H) D of at least 20 nanograms/ml, which is
one of the most potent inhibitors of thought to be important lo maximize bone health and cellular health.
cellular growth. In addition,
1,25(0Hb D alters both activated Dr. Holick is Professor of Medicine, Physiology, and Biophysics;
T and B lymphocyte function. VDR Director of the General Clinical Research Center; and Director of the
is present in the kidney, and re- Bone Health Care Clinic and the Heliotheropy, Light and Skin
cently it was demonstrated that Research Center al Boston University Medico/ Center. After complet-
1,25(0H)i D down-regulates the ing o postgraduate degree in biochemistry, o medical degree, and o
renin/ongiotension system involved research postdoctoral fellowship al the University of
-.. in blood pressure regulation (more

on this system in Chapter 11).
It is now recognized that the
Wisconsin- Madison, Dr. Holick completed a residency in medicine
of the Massachusetts General Hospital in Boston. He has mode nu-
merous contributions to the field of the biochemistry, physiology, me-
Solar radiation on the skin provides
about 80 to l 00% of the vitamin D kidney is not the sole source for the tabolism, and photobiology of vitamin D for human nutrition. These
humans use. This is also the most production of l ,25(0H)i D. Many observations provide new insights info the role of sunlight and vita-
reliable way to maintain vi tamin D other organ systems, including min D nutrition in prevention of osteoporosis, some common cancers,
status. Dietary vitamin D is also colon, prostate, breast, and skin type I diabetes, and other disorders. Dr. Holick has been the recip-
effective, but less so. hove the enzymatic machinery to ient of numerous awards and honors for more than three decodes.
synthesis in the kidner or by an inability of l,25(0H)i Yitamin D to bind to its re-

ceptors in the nucleus throughout the body. In both cases, the treatment is a large dose
of l,25(0H)i vitamin D. This creacmenc works well in the first case but is not as suc-
cessful in Lhc second.
Pharmacologic Use of Vitamin D Analogs

Normal keraLinocytcs (skin-producing cells) requfre 28 to 44 days to move from the
basal cell layer of the skin to the surface of the epidermis. Among patients with psori-
asis, the movement takes o nly 4 days, which results in a scaly and embarrassing der-
matitis. Today, vitamin D analogs applied to the skin are used as a sale, effective
m!atmenr of psori asis.
Upper Level for Vitamin D

The Upper Level for vitamin D is 50 µ,g/day (2000 IU/day). Too much vitamin D
taken regularly can create problems, especially in some infants and young chj ldren.8
For adults, intakes somewhat above the Upper Level appear to be safe. The Upper
Level is based on the risk of overabsorption of calcium and eventual calcium deposits
i.n the kidneys and other organs. The person also suffers the typical symptoms of high
blood calcium: weakness, loss of appetite, diarrhea, vomiting, mental confusion , and
increased urine output. Calcium deposits in organs cause metabolic distw-bances and
cell death. However, vitamin D toxicity does not result from tanning in the sun coo
long because d1e body regulates the amount made in the skin.
Concept I Check
Vitamin D is a vitamin only for people who fail to produce enough from exposure to sun-
light. Most people can synthesize adequate \~tamin D by the action of sunlight on the skin.
Older people and breastfed infants are at risk of a vitamin D deficiency. Vitamin Dis acti-
vated by the liver and kidneys to form the hormone l ,25(0H)i vitamin D. This hormone
Milk is usually fortified with vitamin D as well increases calcium absorption in the intestine and works with other hormones to mainrain
os vitamin A. proper blood cakiwn concentrations and calcium metabolism in bones and other organs in
the body. The hormone l,25(0H)i vitan1in Dis also an important regulator of ceU differ·
entiation in many tissues of the body. Fish oils and fortified milk are good food sources of
vitamin D. An excess of vitamin D can be quite toxic, espcciaUy dwing infanC)'. Sun expo-
sure poses no risk of vitamin D toxicity.
Vitamin E
N orth Americans ore spending more than
$1 billion on vitamin E supplements
each year. Vitamin E is the major fat-soluble antioxidant fou nd in cells. A vitamin E deficiency in
laboratory animals can result in muscular dystrophy, inability to produce viable off-
spring, and impotence. The link between vitamin E deficiency and inabiJjry to repro-
duce in rats, first noted in 1922, gave vitamin E its chen~cal name tocopherol ( t()co
means "related to childbirth"). Overt vitamin E deficiency in humans is not common,
though it does occur in a few situations.9 Most of the interest in vitamin E is not from
d1e deficiency standpoint, but more in terms of an optimal intake for promoting
health. This area is still controversial; ongoing research may provide more insighr.
Natural and Synthetic Vitamin E

It is important to take a close look at vitamin E chemistry in order to understand not
only the units used to express vitamin E activity but also food and supplement labels
and issues regarding potential vitamin E toxicity. As you can see in the figure on the
next page, vitamjn E has a long carbon tail. In this tail, the three carbon atoms with a
star can exist in two different spatial orientations, designated Rand S (sec Appendix A
to learn more about Rand S stereoisomers). Such a compound with Rand S possibil-
ities at three different sites yields eight different isomers (2 3 = 8). Only vita.min E iso-
mers d1at have the R configuration at d1e first starred site are active in the body; the S
form leads ro an unwanted "kink" in the tail of the vitamin E molecu le. All the Yita·
min E fow1d namraUy in foods has Rat that first starred carbon atom and is therefore
considered active. (Acmally it is R in all 3 positions, and is therefore RRR vitamin E.)
Synthetic vitamin E will only have Ron the fiJ·st starred carbon atom in half of the iso·
mers present, while the others will have the S configuration. Thus, only about half of
the vitamin E in synthetic formulations is active in the body.9
When you look at food or supplement labels, however, you will not see Rand S des-
ignations concerning the type of vitamin E in the product. Instead, you will see "d"
and "I." These designations are another way of describing isomers, but they have been
OH
Alpho·tocopherol
The carbon chain attached to the ringed structure

exists in many possible isomer forms. The specific
carbons that have isomer forms (termed Rand S)
ore starred.
Vitamin E
inappropriately assigned to vitamLn E. T he d and I isomers an: only appropriate when

just one carbon atom m a compound has different orientations, and you know that vi-
tamin E has three carbon atoms that have different orientations. Food and supplement
labds, howe,·er, still use this older terminology because researchers did not understand
much about \'itamin E chemistry until recent years, and the label terminology has nor
been updated. From a practical standpoint, if you sec d next to vitamin E on a label,
all of that vitamin E \\ill be acti,·e in the body. If you sec dJ on a label, only about half
of that vitamin E will be active in the body.
What we call vitamin Eis actually a family of eight naturally occurring compounds-
four tocopherols (alpha, beta, gamma, delta) and four tocotrienols (alpha, beta, tocopherols A group of four structurally similar
gamma, dclta)-with widely varyi ng degrees of biological activity. T he most active compounds that hove vitamin E activity. The
form of t he vitamin is the so-called "d" isomer of alpha-tocopherol (again, actually RRR ("d") isomer of olpha-tocopherol ls the most
RRR).9 This is the form found in nature and in varying amounrs in vitamin supple- active form.
ments. However, recent n:search shows that other forms, such .is gamma-tocopberol, tocotrienols A group of four compounds with
may also be important to the bod}•.9 the same basic chemical structure as the
tocopherols but containing slightly altered side
chains. They exhibit much less vitamin E activity
Absorption, Transport, Storage, and Excretion of Vitamin E than the corresponding locopherols.
The degree of absorption of vitamin E depends on the total absorption of dietary fat.
Like the other fat-soluble nutrients, vitamin E must be incorporated into miceUes
within the lumen of the small intestine, which in rurn is dependent on bile and pan-
creatic enzymes. Once taken up b>' the absorptive cells, vitamin E is incorporated into
chylomicrons for transport by the lymph and eventually the bloodstream ro tissues and
the liver.9 The precise degree of absorption is nor known.
The chylomicron remnants release the Yitamin E to the lin:r, which can then deliver
the 'itamin to the lipoprotems VLDL and HDL. Vitamin E can be stored in the liver
and in adipose tissues and skeletal muscle. E\'enrually, vitamin E positions itself in cell
membranes, where it is associated wid1 phospholipids.9
Excretion of vitamin E is via the bile and urine. Because of the limited absorption
of vitamin E from the intestinal tract, there is a significant amount in the feces.9
free radical The short-lived form of a
Functions of Vitamin E compound tha t has on unpaired electron,
causing it to seek an electron from another
Besides fimctioning as a lipid-soluble antioxidant, vitamin E also can affect a number compound. Free radicals are strong oxidizing
of other body processes, such as platelet aggregation, but it is not yet known if these agents and can be very destructive to electron·
eHects are directly related co antioxidant actions. As an antioxidant, \'itamin E func - dense cell components, such as the DNA and
tions as a chain-breaking molecule that prevents the propagation of chain reactions cell membranes.
caused b}' free radicals.9 oxidative stress The domoge to lipids,
Free radicals are reactfre species with unpaired electrons th.lt St<lrt oxidant chain re- proteins, and DNA produced by excessive
actions that then create oxidative stress. Strictly speaking, an oxidam-rclated reaction production of free radicals.
is any reaction in which electrons arc donated to another molecule. T his definition
318 Chapter 9 The Fat-Soluble Vi tamins
Figure 9 · 1 1 I Fat-soluble vitamin E con

insert itself into cell membranes, where it helps
stop free radical chain reactions. If not
interrupted, these reactions cause extensive
oxidative damage to cells and ultimately cell
death.
Neutralized----_;;:-.
free radical
Vitamin E
includes reai:tions that arc part of aerobic respiration. However, when the term oxidff·
tive stress is used, these reactions involve free radicals and produce damage to biologi-
cal molecules (Figure 9-11 ). The health consequences of oxidative stress have been
publicized extensively in regard to cardiovascular disease, cancer, skin aging, and
arthritis, but oxidative su·ess also compromises immune function and may have many
other less obvious effects.
An antioxidant is any agent that can in some manner work against the damage of
oxidative stress. This can happen in a variety of ways. Vitamin E works mainly as a
chain-breaking antioxidant in lipid environments.9 A free radical reacts \.Vi th an unsat-
urated fatty acid in a phospholipid located in a cell membrane or lipoprotein, which
can start a series of reactions that includes breaking fatty acids apart and creating one
peroxyl radical A peroxide compound type of free radical, a lipid peroxyl radical. The lipid peroxyl radical is symbolized by
containing o free radical; designated R-0-0'. the term R-0-0' , where Risa carbon- hydrogen chain broken off a fatty acid and the
dot is an unpaired electron. This compound is also termed a reactive oxygen species
reactive oxygen species (ROS) Several oxygen
(ROS), because it is a free radical that contains an oxygen radical. This lipid pcroxyl
derivatives produced during the forma tion of
ATP. Formed constantly in the human body and
radical then reacts with a new unsaturated fatty acid, which creates a new lipid peroxyl
shown to kill bacteria and inactivate proteins, radical. Th.is radical continues the chain reaction Lrntil two radicals meet and neutral-
they ore implicated in a number of diseases ize each other. By that time, however, many fatty acids have been broken apart.
and inflammatory processes. Vitamin E reacts with the lipid peroxyl radical and srops the chain reaction. Thus,
we use the term chain-breaking antioxidant (R' + 0 2 ~ R-O-O· and then R-0-0'
+ vitamin E-OH ~ R-0-0-H + vitamin E-O·). In effect, the cell a-aded a very re·
active free radical for a much less reactive vitamin E radical. T his chain-breaking reac-
tion is important both to protect cells from dying and limit LDL oxidation, a
contributor to atherosclerosis.
A ''itamin E molecule is "used up" during its chain-breaking action. However, there
is some evidence that vitami11 C may be able to regenerate some vitamin E to allow it
to function again. This works well in vitro (in a test tube ), but we don't know yet ho''
well it works in the human body, especially since vitami11 C tends to be located in wa-
tery environments while vitamin E tends to stay with lipids.9
redox agents Chemicals that can readily

Antioxidan ts vs. Redox Agents
undergo both oxidation (loss of an electron) Because an antioxidant protects other compotrnds by becoming oxidized itselt: in .1
and reduction (gain of an electron) . chemical sense antioxidants arc more properly termed redox agents. 1n other words,
they can readily undergo both oxidation (loss of an electron), and later reduction
(regaining an eb:tron ). Nevertheless, antio.•irfant is still the most common term, even
in the scientific lirerarurc.
Also keep in mind chat free radicals arc not all bad. As pare of the unmune system's
O xidizing agents that cells encounter
include highly reactive oxygen species
such as singlet oxygen (10 2), hydrogen
arsenal against invading p.uhogens, white blood cells (leukocytes) generate free radi- peroxide !H20 2), hydroxyl radical (•OH),
cals to destroy the agents thaL cause infections. Also, free radicals stimulate normal cel l superoxide (02•-1, ozone (03) and nitrogen·
growth and division. Overall, exposure to fret: radicals is part of lift: and for the most oxygen combinations that are typical of air
parr essential, but the body must be able to regulate this exposure and avoid the un- pollutants (NO•).
desirable dlt:cts, a task assigned to antioxidants. 9
Other Antioxidant Systems in the Body

In addition to Yitamin E, the body has various other mechanisms for protecting itself
from oxidant d.image (Figure 9-12 ). The body also contains numerous antioxidant en-
zymes such as glutathione peroxidase, catalase, and supcroxide clismutase.9 glutathione peroxidase A selenium-containing
Glutathione peroxidase catalyzes the breakdown of hydrogen peroxides enzyme that can destroy peroxides. It acts in
( H-0-0-H) and lipid peroxides ( R- 0 -0-H). Thest: compounds an: not r.:tdfrals, but conjunction with vitamin E lo reduce free
they can easily become radicals. Glutathione peroxidase eliminates peroxides before radical damage lo cells.
thi!. happens Consequently the need t()r vitamin E decreases because fewer free radi cotolose An enzyme that breaks down
cals will be formed. Glutathione peroxidase thus aids 'itamin E ia reducing oxidative hydrogen peroxide lo water.
damage to cells. The activity of glurathionc peroxidase tkpcnds on the mineral sele-
superoxide dismutose Enzymes containing
nium (the functional part of this enzyme) and the vitamin riboflavin. (Thiorcdoxin is
manganese, copper, or zinc that destroy
.111mher selenium-dependent antioxidant enzyme [see C hapter 12 for der.1ils].) An ad-
superoxide.
equate dietar~ intake of selenium reduces the need for vir.1min E, "hereas an inade-
quate intake of selenium increases the need. The en.z.ymc caralase performs a function
'>imilar co that of glurathionc peroxidase but has a differcn1 cell location ( pcroxisomcs).
Another important defense system in cel ls, ll1e family ol' enzymes known as supcr-
oxide dismut.1sc, eliminate.: one particul.:tr free radical callcd superoxidc. Two of the su-
pnoxide dismutase enzymes conrajn coppcr .rnd zinc. One is located in the cell cytosol
and the other is found outside: of cells. lm.1kc of the essential nutrient copper can af-
fect the activities of these two superoxide dismmase enzymes, bur zinc intake seems to
have major dlccrs only on the enzyme that is folmd outsidt: the cells. The third su-
peroxide dismurase enzyme is found in the mitochondri:1 .md requires die mineral
manganese for fonction. our metabolic compounds-bilirubin, uric
In addition co ''itamin E and antioxidant enzymes, there arc still other antioxidants. acid, lipoic acid, and ubiquinone (coenzyme
Phyrochemicals (such as many carorenoids) can neutralize free radicals and pos1>ibly Q· 10)-also ore thought to provide antioxidant
prevent certain radicals from forming. 9 protection.
Figure 9· 1 2 I The body does not rely solely

Superoxide dismutose
(various forms requi res on vitamin E for antioxidant protection. Such
copper, zinc, manganese) protection is a team effort that utilizes o number
of nutrients, metabolites, and enzyme systems.
Metal-binding Glutothione
proteins peroxidase (requires
selenium)
lipoic acid
Cotolose I
(requires iron) j
Uric acid
Vitamin E J
Bilirubin Various corotenoids
Vitamin C (likely)
'- __:,____J
roleins in the blood also bind metals-this Because there arc Limits to how much of any one antioxidant compound can accu-
limits the ability of metals to catalyze free mulate in any one cell, it may be advantageous to consume a variety of antioxidant phy-
radical production. Systems also exist in cells lo Lochemicals along with vitamin E and vitamin C. Funhermore, some phywchemicab
repair molecules that have been oxidatively may be bctrer at protecting against certain free radicals than others. for example,
damaged, such as DNA carorenoids may be especially good at dealing with singlet oxygen, which 1s not a rad-
ical itself but can mitiatc oxidant srress. The bottom line is that antioxidant prmection
is a team effort involving a number of nutrients.
This discussion raises the question ol the relative role of vitamin E in oxidant pro-
tection in the body. lt is Lmknown whether taking vitamin E supplements confers any
additional protection against cardiovascular disease and cancer than that .1chicved by
improving one's diet, performing regular physical acti,·ity, not smoking, .llld conrrol-
ling (or imprming) body weight.
Food Sources of Vitamin E
All major long-term trials using megadose vitamin E therap) ha\'e failed to show an~
Food Item Vitamin E Vitamin E benefit in reducing heart attacks or cardiovascular disease-related death in people \\ho
and Amount (mg) (IU) have the disease. These studies have included thousands of people and had duration~
Sunflower oil, of approximately 5 to 7 years. As noted in Chapter 6, these results have caused most
2 tbsp 16.3 24.3 experts and some leading cardiologists to discount the benefit of megadosc vitamin F
Dry-roosted therapy in high-risk people. There is C\'cn a risk of heart fail me among people with di-
sunRower seeds, abetes or existing cardio\'ascular disease who take mcgadoses of \'itamin 1:-.
1 oz 14.3 21.2 Cmremly, the major hope is that mcgadose \'itamin E therapy ( 50 ro 200 mg/da}
Dry-roosted [100 to 400 IU/day]) in healthy people will pre11cutfuturc development ofc,m.tiovas-
almonds, 1 oz 7.5 l l.1 cular disease. A large trial using men is currently testing this hypotl1esis, and results will
Safflower oil, be available by 2007. The dose used is 600 IU of natural vitamin E taken every other
I tbsp 5.9 8.7 day (recall from Chapter 6 that results of the similar trial in women showed no clear
Conola oil, benefic in reducing cardiovascular disease-related deaths, except in a subset of older
2 tbsp 5.7 8.5 women \\'ho showed a somewhat lo\\'er risk for sudden cardiac death 13 ). At this time
Wheat germ, the American Heart Association states that it is premature ro recommend 'itamin E
1/4 cup 5.2 7.7 supplements to the general populations, based on current knO\dedge. This conclusion
Almonds, 1 oz 4.5 6.8 is in agreement with the latest report on vitamin Eby the Food and NuLrition Board.9
In addition, FDA recently denied the request of the supplement industry ro make a
Oil-roosted health claim that "itamin E supplements reduce the risk of cardiovascular disease.
sunflower seeds,
l tbsp 3.4 5.0
Italian dressing, Vitamin E in Foods
2 tbsp 3.1 4.5
Good food sources of vitamin E are plane oils (e.g., corn, soybean, samower, sun-
Mayonnaise, flower, cotconseed, and wheat germ oil), wheat germ, asparagus, and peanuts.
1 tbsp 3.0 4.5
Products made from tlle plant oils-margarine, shortenings, and salad dressing-arc
Avocado, 1 2.7 4.0 also good sources. Fin.fish and shellfish add vitamin E to the diet. ln addition, grain
Chunky peanut meals such as oatmeal, nuts (e.g. , almonds), and seeds (e.g., sunflower seeds) are od1er
butter, 2 tbsp 2.4 3.6 good sources. In milling whole grains, most of the vitamin E is lost and not restored.
Mango, 1 2.3 3.5 Animal futs have practically no viramin E.
Peanuts, 1 oz 2.1 3.1 The actual vitamin E content of a food depends on harvesting, processing, st0rage,
and cooking because vitamin E is highly susceptible to deso·uction by oxygen, metals,
Cooked asparagus,
2.1 3.1 light, and deep-fat frying. In any case, a varied diet supplies die vitamin E needed for
1 cup
good health. Synthetic antioxidants, such as BHA and BHT, also add w the cellular
RDA for adults, 15 mg protection pro\'ided by ,·iramin E (see Chapter 19 for more on BHA and BHT).
Vitamin E Needs
The RDA for vitamin Eis 15 mg/day of alpha-cocopherol for botl1 men and women .
The RDA is based on the amount of vitamin E needed to prevent breakdown of red
hemolysis The destruction of red blood cells, blood ceU membranes, a process called h emolysis. The 15 mg allotment is equi\'alenr
caused by the breakdown of the red blood cell to 22 IU of a natural source and 33 JU of a syntl1etic source. 9
membrane. This causes the cell contents to leak Adults consume on average about two-thirds of the RDA for vitamin E each day. 15
into the fluid portion (plasma) of the blood. Daily intake of nu rs and seeds, or a ready-to-eat breakfast cereal conraining vitamin E,
or use of a mu ltivitamin and mineral supplement would close this gap between typical
vitamin E intakes and needs.
To convert from the older IU system, J IU equals about 0.45 mg, based on the syn-
thetic (dl isomer) form of vitamin E found in most supplements. If vitamin Eis from
a natural source (d isomer), 1 IU equals 0.67 mg, because the natural form of vitamin E
is more potent than the synthetic form. 9 Thus the 200 mg/day maximum recom-
mendation made by some experts actually represents 300 IU (d isomer) (200/0.67 =
300) ro 450 IU (dl isomer) (200/ 0.45 = 450). lncidentally, 200 mg/day is thought
to supply the maximum amount of vitamin E that can be retained by the body over
Lime.9 The Daily Value used on food and supplement labels for vitamin Eis 30 lU.
Vitamin E-Deficiency Diseases

Smokers are especially likely to develop a \~tamin E deficiency and related oxidative
damage in the body.4 (Smoking readily destroys \itamin E in the lungs, but there is no
easy way to test for this problem in clinical practice.) But studies have shown that even
using megadoses of vitamin Eis ineffective in preventing th is damage. Others at con-
siderable risk of a viramin E deficiency include adults on very low-fat diets or those
with fat malabsorption. Preterm infants are particularly susceptible to the hemolysis of
red blood cells, first because they arc born with limited tissue stores of vitamin E and
arc inefficient in absorbing vitamin E from the intestinal tract. Second, the rapid
growth of preterm infants exhausts what little vitamin E stores exist. To prevent he-
molytic anemia, special formulas and supplements for preterm infunts are prescribed to
prevent vitamin E-relared disorders of prctcrm births. Plant oils are rich sources of vitamin E.
Vitamin E deficiency occurs also as a result of a genetic abnormality in lipoprotein
synthesis, because lipoproteins distribute vitamin E throughout the body. In these
cases, the primary '~tamin E deficiency symptom is nervous system damage. Immune
preterm An infant born before 37 weeks of
function is also reduced.9 gestation; such on infant is also referred to as
premature.
Upper Level for Vitamin E hemorrhage An escape of blood from blood

vessels.
Thi.'. Upper Level for vitamin E is 1000 mg/day of supplemental alpha-tocophcrol.
Excessive amounts of vitamin E can interfere with \itamin K's role in the clotting
mechanism, leading to hemorrhage.3 •9 The risk of insutliciem blood clotting is espe-
cially high if vitamin E is taken in conjunction with anticoagulant medications (e.g.,
Coumadin or heavy aspirin use). In international units, the Upper Level is 1500 JU for
vitamin E isolated from natural sources (d isomer; 1000/0.67 = 1500) and 1100 IU
for synthetic vitamin E (di isomer; 1000/0.45/2 = 1100). The lower IU value for the
synthetic form reflects the greater number of forms present in the synthetic product,
only half or less of which contribute to vitamin E acti\it)• in cells, but are still absorbed
and reduce blood clotting.9 This Upper Level is set for a healthy population. Again,
individuals who are vitamin K deficient or who are taking anticoagulants or heavy ne way to assess the vitamin E status of o
doses of aspirin are especially at risk for hemorrhage from megadose vitamin E use. person is to incubate o sample of his or
There is additional concern that taking large amourltS of alpha-tocopherol might her red blood cells with peroxide for 3 hours
decrease gamma-tocopherol activity in the body. Gamma-tocopherol is a potentially and then measure the extent of red blood cell
beneficial form ofvitamin E (It may reduce prostate cancer risk in men). To compen- destruction. A newer method uses the some pro-
sate, some experts recommend that any \itami.n E supplement should contain a mix- cedure but measures the amount of o break-
ture of natural (RRR) tocopherols (e.g., mixed tocopherols). This form is more down product of polyunsaturated fatty acids.
expensive, however, than natural or synthetic alpha-tocophcrol alone. These tests con be used in addition to measuring
vitamin E in the blood.
Concept I Check
EnZ}'l11es and other bod)' mechanisms scavenge and minimize the formation of free radicals
and other oxidative compounds, but they are not 100%effecch·c. Hence, diet-derived an-
tioxidants may be critical in diminishing cumulative oxidative damage and helping us to
stay healthy. Vitamin Eis one such nutrient that functions primarily as an antioxidant. By
providing electrons to free radicals, vitamin E helps prevent oxidative damage, especially of
cell membranes. The best sources of vitamin E arc plant oils. When more plant oils arc
conmmed, more vitamin Eis needed to protect the double bonds found in plant oils from
oxidation. However, the vitamin E content in plant oils is usuaUy high. Because of their
poor vitamin E status, preterm infants are particularly susceptible to oxidative breakdown
of their red blood ceU membranes (hemolysis). Among ad ults, people who smoke or expe·
rience long-term fat malabsorption run the biggest risk of vitamin E deficiency. At present,
there is contro\'ersy about whether taking large amom1ts of vitamin E in supplement form
over a long period of time pro\'idcs any special health benefits; research is ongoing.
Megadose use of '~tamin E reduces blood clotting, possibly leading to a hernorrh~1gc .
Vitamin K
Vitamin K is essential for blood clotting. A Danish researcher first noted the relation-
ship between vitamin K and blood clotting and named the fat-soluble vitanJin "K"
after koagnlation, the Danish spelling for coagulation.
• •
0
Phylloquinone (Ki)
Vitamin K '
Vitamin K as phylloquinone. Menaquinones have o corbon-

carbon double bond al the starred posilions.
phylloquinone A form of vitamin K thot comes The family of compounds known as vitamin K includes phy llo quino n e (vitamin K 1 )
from plants; also called vitamin K1. from p lants and a fami ly of menaquinones (vitamin K2 ) fOLmd in fish oils aJ1d meats.
The menaguinoncs are also synthesized by bacteria in the human intcstine. 10
menaquinone A form of vitamin K found in fish
oils and meals. It is also made by bacteri a in
the human intestine. Absorption, Transport, Storage, and Excretion of Vitamin K
Ir appears that up to 80% of dietary vitamin K as phylloquinone and menaquinone is
taken up by cells that line the small intestine and is incorporated into chylomicrons.
prothrombin One of the numerous proteins that The process requires bi.le and pancreatic enzymes. The rnenaquinones synthesized by
participate in the formation of blood clots. bacteria in tbe colon are absorbed, but the amount absorbed likely provides only 10%
Conversion of its precursor protein lo the active of the vitamin K we need. Some vitam in K is stored in the liver and some is incorpo-
blood-clotting factor in the liver requires rated in the lipoproteins VLDL, LDL, and HDL for transport throughout the body.
vitamin K. Nlineral oil and other nonabsorbable lipids interfere with vitamin K absorption, so
osteocalcin A protein produced in bone that is their use close to meals should be discouraged. Most vitamin K excretion occLu·s vil
thought to bind calcium; the synthesis of the bile, with a small amoun t of excretion via the urine. 10
osleocolcin is aided by vi tamin K.
Functions of Vitamin K
Vitamin K is needed for the synthesis of seven b lood-clotting factors by the liver
(Figure 9- 13). Vitamin K is required for the conversion of some precursor proreins ro
the active clotting factors. In these reactions, carbon dioxide (C0 2 ) is added ro a glu-
tamic acid in the precursor protein, yiddi ng the active factor containing the unique
amino add gamma-carboxyglutam ic acid. .Proteins that have undergone this conver·
sion are caUed Gia proteins, wbere ''Gia" stands for gamma-carboxyglurarnic acid. Om:
Intrinsic pathway for Ex trinsic pathway for
synthesizing prothrombin synthesizing prothrombin
activating factor activating factor
Blood vessel domoge couses Tissue injury couses initiotion
initiotion of the dotting of the dotting coscode by
-
process releosing certoin blood proteins
V. .~ K
1tom1n octs ot \ Vitamin K octs ot \
two of the steps one of the steps
of the pothwoy of the pothw! Y
~
Multistep pothwoy Multistep pothwoy
Precursor Prothrombin Prothrombin Thrombin

protein octivoting Fodor
Vito mi~
thi: ~eo;ts ot )
Fibrinogen i
(soluble .----•·
Fibrin Clot formed using
...
(insoluble ---1~,,. threods of fibrin
~ protein) protein) protein thot trop
blood cells, plotelets,
ond fluid
Figure 9-13 I Vitamin K metabolism. Forming a blood clot requires the participation of vitamin K in both the intrinsic and extrinsic blood-clotting pathways.
Note that although the two pathways ore activated by different events, there is some overlap in the pathways, but for simplicity we hove not shown that
Vitamin K specifically imports calcium-binding capacity to the proteins in these pathways, as in the conversion of a precursor protein to prothrombin, on active
clotting factor.
example of rhis process is rbe co1wersion of a precursor protein to proth rombi11, a par- Food Sources of Vitamin K
ticipant in both parhways of the blood-clotting cascade. All these vitamin K-depend-
Food Item Vitamin K
enr cloning proteins depend on calcium interaction \\'ith gamma-carboxyglutamic acid and Amount (µ9)
to participate in the clotting reaction. 10
In the body, ,·itamin K is convened co an inactive fonn once it has acted. It must then Cooked kale, 1/2 cup 530
be re.Ktivatcd for its biological action co persist. The body reacti' ates \itamin K readily. Cooked turnip greens,
Ho\\'c,·er, drugs such as warfarin, which sa·ongly inhibit thii. reactivation process, act as l cup 520
powerfol anticoagulants. People taking warfarin to lessen blood clotting should not con- Cooked spinach, l cup 480
sume \'itamin K supplements and should have a consistent vitamin K intake.
Cooked brussels sprouts,
Viramin K also participates in the conversion of protein-bound glutamic acid 1/2 cup 150
residues to gamma-carbm.·yglucamic acid residues and the synthesis of two bone Gia
proteins. The first protein is osteocalcin, secreted by bone-building cells. The second Row Spinach, 1 cup 144
bone protein, called matrix Gia protein, is found in the protein matrix of bone. Low Cooked asparagus
concentrations of circulating \itamin K have been associated with lo\\' bone mineral l cup 144
densiry. 12 le may be rbat inadequate intake ohitamio K increases the risk of hip fracmrc Cooked broccoli, 1/2 cup 110
in womcn. 10 Finally, \'itamin K may also participate in ,·arious blood \'essel functions.
Looseleaf lettuce, 1 cup 97
Cooked green beans,
Dietary Sources of Vitamin K 1/2 cup 49
Good food sources of vitamin Kare liver, green leaf)1 vegetables (e.g., kale, turnip greens, Row cabbage, 1 cup 42
salad greens, cabbage, and spinach), broccoli, pc:as, and green beans. One reason to con- Sauerkraut, l /2 cup 30
swne a diet rich in green \'egetables is to obtain sufficient vitamin K. Other sources are
Green peas, 1/2 cup 26
,·egetable oils, such as soy and canola. Vitamin K also is quite resistant to cooking losses.
Soybean oil, 1 tbsp 25
Vitamin K Needs Cooked cauliflower,
l cup 20
For adult women the Adequate Intake for vitamin K is 90 µ.g/day, and for adult men
the amount is 120 µ.g/day. These Adequate Intakes are based on the amount adults Conolo oil, l tbsp 17
usually consume. 10 The Daily Value used on food and supplement labds for vitamin K Adequate Intake for adult men, 120 µg;
is 80 µ.g. Average conswnption is 60 co 200 µ.g/day, with men showing higher intakes. for adult women, 90 µ.g
323
T he most reliable clinical evidence of

vitamin K deficiency is an increase in dot·
ting time, which is a measure of how quickly
Amino acid
I
Amino acid
I
Gamma·carboxy-
Glutamic acid - glutamic acid
prothrombin in the blood can form a clot. The
. I 'd
Vitamin K
actual vitamin K and prothrombin concentration Ammoac1 . I
Am1noac1.d
in the blood con also be measured.
Protein chain of inactive Protein chain of prothrombin
prothrombin after vitamin K action (now
in an active form, capable
of binding calcium)
Vitamin K-Deficiency Diseases

A deficiency of vitamin K most like ly occurs when a person takes certain rypes of an-
tibiotics that clisrupt vitamin K metabolism or has impaired fat absorption. 10
Vitamin K deficiency also can occm in newborns. Their vitamin K stores are typi-
cally low at birth. Infants are at risk of defective blood clotting and eventual hemor·
rhagc because of a lack of vitamin K. To prevent this possible vitamin K deficiency,
physicians in North America routinely provide vitamin K by injections within 6 hours
of delivery. Final ly, some older people may be at risk of deficiency because of scant
green vegetable intake.
Laborat0rv animal studies have shown rhar excessive amounts of vitamin A and vita-
min E are lm"own to antagonize the actions of vitamin K. 3 •10 Vitamin A is thought ro
ost vitamin K consumed in a day disap· interfere with the absorption of vitamin K !Tom the intestine. Large doses of vitamin E
pears from the body in the next few can lead to a decrease in ''itamin K-dependent clotting factors and increased bleeding
days. Thus, no Upper Level for vitamin K has tendency. Ln either case, mega.dose supplements of these vitamins may pose a risk to \'i·
been set. tamin K status, as noted in this chapter's discussions of upper levels for these vitamin!>.
The fat-soluble vitamins are reviewed in Table 9 -2.
A salad containing dark greens (or other green

vegetables) each day provides obundanl
vitamin Kfor o diet.
• •• J ti111..."\<J Concept I Check

Vitamin K is important for blood clotting because it stimulates the conversion of precursor
Tim was diagnosed as having blood clots in proteins to active clotting facrors, such as prothrombin. This conversion involves the addi-
his leg and has been using anticoagulant med· tion of carbon dioxide to glutamic acid in the precursor protein, yielding gamma·
ications for 2 months. On examination, the carboxyglutamic acid, which in Lum can bind calcium. About 10% of the vitamin K we
doctor is surprised lo find that the clots he ex· absorb every day comes from bacterial synthesis in the intestines, but most comes from the
pected lo have dissolved are still there. What diet. The amount in the diet alone generally meets our needs. Thus, except for newborns
is a possible nutritional explanation for this and possibly some older people, a deficient.')' of vitamin K is w1likdy, even though it is read-
finding? ily excreted from the body.
Table 9·2 I A Summary of the Fat-Soluble Vitami ns: Their Functions, Deficiency Cond itions, and Food Sources
Deficiency RDA or Toxicity

Major Vitamin Functions Symptoms People at Risk Sources Adequate Intake Symptoms•
Vitamin A Vision in dim light Poor growth, night Rare in United Preformed vi· 700-900 µg RAE Headache, vomit-
Preformed and color vision, blindness, blind- States but com- tamin A ing, double vi-
relinoids and cell differentiation ness, dry skin, mon in preschool (retinoids): liver, sion, hair loss,
provilomin A ond growth, xerophtholmio children living in fortified milk, fish dry mucous mem·
corotenoids immunity poverty in devel- liver oils brones, bone and
oping countries, Provitamin A joint pain, froc-
alcoholics (carotenoids): lures, liver dam-
red, orange, dork oge, hemorrhage,
green, ond yellow coma, teratogenic
vegetables; effects: sponto-
orange fruits neous abortions,
birth defects.
Upper level is
3000 µg of pre-
formed vitamin A
(10,000 IU},
based on the risk
of birth defects
and liver toxicity.
Vitamin D Moinlenonce of Rickets in chil- Dork-skinned indi- Vitamin D-forlified 5-10 µ.g Calcification of
Cholecolciferol D3 intracellular and dren, osteomolo- viduols, older milk, fish oils (200-400 IU} soft tissues,
Ergocolciferol D2 extracellular cio in older adults adults, breastfed 15 µg > 70 yrs growth restriction,
calcium infants (600 IU} excess calcium ex-
concentrations crelion via the kid-
ney. Upper level
is 50 µg
(2000 IU), based
on the risk of ele-
voted blood
calcium.
Vitamin E Antioxidant, pre- Hemolysis of red Patients with fol- Plant oils, seeds, 15 mg alpha- Inhibition of vita-
Tocopherols venlion of propo· blood cells, de- molobsorplion nuts, products tocopherol for min K metabolism.
Tocotrienols gotion of free generation of sen- syndromes, smok- mode from oils men ond women Upper level is
radicals sory neurons ers (overt defi- (22 IU natural 1000 mg (1100
ciency is rare) form, 33 IU syn- IU synthetic form,
thetic form) 1500 IU natural
form), based on
the risk of
hemorrhage.
Vitamin K Synthesis of Hemorrhage, Those toking on- Green vegetables, 90-120 µg No Upper level
Phylloq uinone blood-clotting foe- fractures tibiotics for a long liver, synthesis by hos been set.
Menoquinone tors and bone period of time, intestinal microor-
proteins older adults with gonisms, some
scant green veg- calcium
etable intake supplements
'For vitomins D ond E, toxicity is $8en only with supplement use; foods pose no lhreot.
Nutrient Supplements: Who Needs Them
and Why?
The term 11mltiPita111i11mu{111i11ernl mppleme11t has out any evidence to prO\'e tl1at the product actually
been mentioned many time~ so far in this textbook. works, but a product that claim~ to dec:reasc the
Often, these and other supplements are marketed as risk of cardio\'ascular disease by reducing blood
cures for anything and e\'erything. This cure-all ap- cholesterol musr haw results from scientific m1d1es
ecouse recent research on o variety proach is promoted by the ~upplcment mdustry and that jusri~· the claim.
of nutrient supplements hos revealed countless he-J.lth-food stores, pharmacies, and su- Why do people cake supplements? Rca~ons 1hat
o lock of product quality, the USP (United permarkecs. Should you take a supplement? This de- arc frequently given include the follO\I ing:
Stotes Phormocopeio) designation is cision is up ro you. Currently, opinions vary even
• To reduce susceptibility to health problems (e.g.,
being extended to on increasing number among knowledgeable scientist~ regarding the wis-
colds)
of nutrient supplements. The USP ston- dom and safety of supplement usc.1 ,7,14,19
• To prevent heart attacks
dords designole strenglh, quality, purity, According to the Dieran Supplement Health
• To prevent cancer
pockoging, labeling, speed of dissolution, and Education Act of 199-1- (discu~ed in Chapter 1),
• To reduce stress
ond occeptoble length of storage of in- a supplement in the United Smes is a product in-
• To increase "energy"
gredients for drugs. The purpose of ap- tended to supplemcnr the diet that bear~ or con-
plying them to vitamin ond mineral tains one or more of the following ingredienrs: Recently the U.S. Pre\'entive ~enice!> Task
supplements is to establish professionally Force noted there is insufficicnr c\·idcncc to sup-
• A vitamin
accepted stondords for these products. port the recommendation of use of a mulnvita111111
• A mineral
Consumers who buy nutrient supplements and mineral supplement by the general popul.1tio11.
• An herb or another botanical
should look for o USP label when com- They did not discourage the practice, howcver. 19
• An amino acid
paring similar products, such as calcium Two nutrition experts from Tufts Uni1crsin
• A dietary substance to supplement the diet, which
supplements. If no USP label is present, (Dr. Alice Lichtenstein and Dr. Roben Russel )
could be an extract or a combination of the first
the next best opprooch is to purchase no- found after a careful m~ew of tl1e scientific liter:1ture
four ingredients in this li~t
tionally advertised brands. Most brand tl1at nutrient supplements prO\~ded no health ad\ an·
nome nutrient supplements aren't labeled The definition is \'Cry broad and co\·ers a wide rage to chc average adult, but noted in some cases
USP because the manufacturers prefer to \ ariety of nutritional subsranccs. The use of dietary such use is appropriate (see the next section in th!!>
guorontee the products via their brand supplcmentS is a common practice among North feanirc for specific examplcs).H On chc ocher hand,
names. Americans and generates abour $1 7 billion annually O\'Cr the last fe\\ years some reputable nutrition and
for the industry in the United States alone. 1 Recall medical scientists have recommended supplcmenta
also from Chapter 1 that unless FDA has evidence tion of specific nutricncs for mosr (or all ) adults.7
that a supplement is inherently dangerous or mar- The rationale for widespread use is primarily
kered with an illegal claim, it will nol regulate such because many North Americans have been unwill-
products closely. (The vitamin folate is an excep- ing co change their food habits, such as eating
tion.) Currently, FDA has limited resources to po- ample fruits, vegetables, and whole grains. This gap
lice supplement manufacturers, and it has to act can lea\'e dices low in the \itamin folate. Adequate
against tl1esc manufacn1rcrs one at a time. Thus, \\'e folace status when a woman becomes pregnant
cannot rely on FDA to protect us from \'itamin and helps reduce the risk of certain birth defects
mineral supplement O\'eruse and misuse. We bear (400 µg/da)' of synthetic folic acid 1s recom-
that responsibility ourselves, coupled \\ith profes- mended). Folate also limits homocysreine in the
sional advice from a physician or registered dietitian. 1 blood, a likely risk factor for cardiovascular disease
Currently, tl1e supplement ma.nufucturers can that can affect all of us. In addition, the committee
make broad claims about their products under the appointed by the Food and Nutrition Board that
"structure or function" prO\·ision of the law. The sets current nuuient standards for vitamin B-12
manufucturcrs and their products, howe\·er, cannot suggested that adults O\'er age 50 consume 1·icamin
claim to prevent, treat, or Lure a disease. Because B-12 in a synthetic form, such as tha1 added co
menopause in women and aging are nor diseases ready-co-car breakfast cereals or present in suppk·
per SC , products alleging CO treat S)'mpto111S of these mcnrs. S)•nthetic \·itamin B-12 is more easily ab-
conditions can be marketed \\ithouc FDA appro,·al. 1 sorbed than chat found in food; this helps
Focus first on foods that meet nutrient For example, a product that cl,1ims co treat hot compensate for the fall in \'itamin B-12 absorption
needs. flashes arising during menopause can be sol<l with- often seen in older adults.
326
I
- - - -- -- - - - - - - -
Recently two articles in the Journnl of tht ready-to-cat brc.1kfost cereals to increase ,;ta min E,
A111aict111 Medical Association also supporced the folic acid, and \itamin B-6 intake and to prO\idc
use of a daih' balanced multivitamin and mineral highly absorbablc forms of \'itamin B-12. C.ilcium·
supplement ..:. Still, these and other experts, fortified orange jutcc could be used to increase cal-
whether they support use of a multi\'itamin and cium intake. ~!ilk and yogurt intake could be
miner.ii supplement or not, emphasize that many of increased to pro\'ide more ,·iramin D and calcium.
the health-promoting effects of foods cannot be You need to be careful with high!~· fortified food~,
found in a bottle. Recall the discussions of phyto· howe\'cr, because eating these products may pro·
chemicals in Chapter 2 and the benefit~ of fiber in vide the appropriate amount of nutrients in 1 scrv·
Chapter 5. Supplements may contain few or no ing, but caring more than l ser\'ing can lead lO an
phyrochemicals and typically contain no fiber. excessive intake of some nutrients, such as vitamin A,
MuJti,·itamin and mineral supplements also conrain iron, and synthetic tOlic acid.
little calcium in order to keep the pill size small, If you wish ro use a supplement, discuss your
and the forms of magnesium, zinc, and copper decision with a physician or registered dietitian, be-
used in many supplements (oxides) are not as well cause some supplements can interfere with certain
absorbed as forms found in foods. medicines. 1•14 For example, ''itamin B-6 can offset
Q,·crall, supplement use cannot fix a poor diet the action of L-dopa (used in treating Parkinson's
in all respects. Uninformed megadose supplement disease), high incakes of \'itamin K or vitamin E
use also can lead to harm-currently, most nutrient alter the action of anriclotting medications, large
roxicity is a result of supplement use. 11 Thus, you doses of vitamin C can interfere with certain cancer
are ad\'ised to first take a good look at your dietary therapy regimens, excessi,•e zinc intake can inhibit
habits and then imprm·e them, as outlined in copper absorption, and large amounts of folatc can
Chapter 2 (see also Figure 9-14). Then you should mask signs and symptoms of a Yitamin B-12 defi-
find out which nutrient gaps remain and identil)• ciency. Remember, you ca11 get too much of a
food sources chat can help. Such a source could be good thing. 1
•
Possible
--
multivitamin and
mineral supplement use•
Fortified foods
Healthy diet rich in vitamins and minerals
Fruits Oils Meat & Beans
Figure 9 - 1 4 I Supplement savvy-A MyPyramid approach to the use of nutrient supplementation Emphasizing the
bottom portion of the pyramid is always the best option. Exira benefits include fiber, numerous phytochemicals, and
omega-3 fatty acids.
*Men in general and older women should use iron-free formulas
**Iron and calcium supplements for younger women ore two possible examples.
327
People Most Likely to Need Which Supplement Should You
Supplements Choose?
Various medical and health-related organizations If you decide to take a multi,•itamin and mmcral
suggest that the following vitamin and mineral supplement, which one should you choose? As a
supplements can be important for certain groups of start, choose a nationally recognized brand (from a
healthy people: 1•14•19 supermarket or pharmacy) that contains about
• Women of childbearing age.: may need extra syn·
l 00% of the Daily Values for the nutrients present.
A multivitamin and mineral supplement should also
thccic folic acid if their dietary patterns do not
generally be taken 1vith or just after meals to maxi-
supply the recommended amount (400 µg/day).
mize absorption. Make sure also that intake from
• Women \\ith excessi,·e bleeding during menstrua-
the total of this supplement, any other supplements
tion may need extra iron.
used, and highly fortified foods such as ready-to-cat
• Women who are pregnant or breastfeeding may
breakfust cereals prO\ide no more than the Upper
need extra iron, folate, and calcium.
Level for each \'itamin and mineral. (See the inside
• People ,,;th very low energy intakes (less than
co\•er of this textbook for Upper Le\•els.) This m·
about 1200 kcal per day) may need a range of vi-
su·uction is cspeciall)' important \\~th regard to pre-
long-term intake of just two times the tamins and minerals. This is rrue of some women
formed vitamin A (retinol ) intake. Two exceptions
Doily Value for some lot-soluble and many older people.
• Strict vegans may need extr:i calcium, iron, zinc,
ro this upper limit cutoff are (1) both men and
vilomins-porliculorly preformed
older women should make sure any product used is
vi tamin A (retinoids)--<:on cause toxic and vitamin B-12.
low in iron or iron-tree to avoid possible iron over·
effects. Know what you ore toking if you • Newborns need a single dose of vitamin K, as di-
use supplements. load (sec Chapter 12 for details), and (2) somewhat
rected by a physician.
exceeding the Upper Level for vitamin D is likelv a
• Some older inf.mts ma~ need fluoride supple-
safe practice for adults. Read the labels c.1refully to
ments, as directed by a dcntisr.
be sure of what you are taking (Figure 9-15 ).
• People with limited milk intake and sunlight ex-
Another consideration in choosing a supple-
s you might guess, generally the posure may need extra \'itamm D. This includes
ment is avoiding superfluous ingredients, such as
most healthy people in our populo· breastfed infants and many older people.
para-aminobenzoic acid (PARA), hcspcridin com·
lion toke supplements. Ironically, these • People \vitb lactose maldigestion or intolerance,
plex, inositol, bee pollen, and lecithins. These com·
are the people who least likely need to and those with allergies to dairy products, may
pounds arc not needed in our diets. They are
toke supplements.16 need extra calcium.
especially common in expensive supplements sold
• Adults over age 50 may need a synthetic source of
in health-food stores and b)' mail. ln addition, use
\'itamin B-12.
of 1-tryprophan and high doses of beta-carotene or
• People on very IO\\ fat diets or diets low in plant
fish oils is discouraged.
oils and nuts may need some extra vitamin E.
Five websites to help you e\•aluare ongoing
lndi,~duals ''ith certain medical conditions (e.g., claims and evaluate safety of supplements arc:
vitamin-resistant diseases or long-standing fut malab- \\ wv .•1csh .org,
sorption) and those who use certain medications also WW\\,quackwatcl1.com
may require supplementation with specific vitamins www.ncahf.org
and minerals. Children who arc picky eaters may re- diet.1 ry· supplements.info. nih. gm
quire supplementation as well (see Chapter 17). WW\\.Catl'ig,ht org
Finally, smokers and alcohol abusers may benefit from The sites are maintained by groups or indh·iduab
supplementation, but cessation of these two acci"ities committed to providing reasoned and authontat1,·c
is far more beneficial chan any supplemcntation.-l nutricion and health ad,ice to consumers.
328
Made to U.S. Pharmacopeia (USP) quality, purity and potency
standards. Laboratory tested to dissolve within 30 minutes.
Supplement Facts Serving size
Serving Size 1 Tablet .:.------r---
Each Tablet Contains % Daily Value
Vitamin D 200 I.U. 50%
Calcium600 mg 60%
% Daily Value
Nutrients INGREDIENTS: Calcium Carbonate, Maltodextrin, Starch,
and amounts Hydroxypropyl Methylceilulose. Talc, Cellulose. Croscarmeliose
Sodium, Hydroxypropyl Cellulose, Titanium Dioxide, Silicon
Dioxide, Magnesium Stearate, Polysorbate 80, Cholecalciferol,
Polyethylene Glycol 3350. Sodium Citrate, 6 Lake.
DIST. BY NUTRA·VITE ASSOC .. INC. Manufacturer
700 WHITE POINT RO, SKOKIE, IL 60077
Suggested use Suggested uS11: Take one tablet one to two times daily with a
full glass of water, preferably after a meal.
Vitamin 0 assists In the absorption or calcium. A heathful diet Structure/function
with adequate calcium 1s essential claim
FDA disclaimer
Figure 9· 1 5 I Nutrient supplements display a nutrition label that is different from that of foods. This
Supplement Facts label must list the ingredient(s), omount(s) per serving, serving size, suggested use, and
% Doily Value if one hos been established. Note that this label also includes structure/function claims. Thus, it
also must include the FDA warning that these claims hove not been evaluated by the agency.
329
330 Chapter 9 The Fat·Soluble Vitamins
Case Scenario Fol low-Up

Use of Nutramega poses some health risks for Kristen. Taking 2 to 3 tablets every 3 hours
would mean taking at least 16 tablets per day. This alone would provide a n intake of vitamin A,
vitamin C, and zinc well in excess of the Upper levels for these nutrients. Intake of preformed vi-
ta min A would be 1.3 times the Upper level, intake of vitamin C would be 3.4 times the Upper
level, and intake of zinc would be 3 times the Upper Level. Intake of selenium, however, falls
well below the Upper Level set for that nutrient. This is how the math works out:
Vitamin A
33% (0.33) times the Daily Value of 1000 µ,g RAE equals 330 µg RAE per tablet. Sixteen
tablets would yield 5280 µg RAE. The Upper Level is 3000 µg RAE for preformed vitamin A.
Because 75% of the vitamin A is preformed vitamin A, this yields 3960 µg RAE of preformed vi-
tamin A (5280 X 0.75 = 3960), or 1.3 times the Upper level (3960/3000 = 1.3).
Vitamin C
700% (7) times the Doily Value of 60 mg equals 420 mg per tablet. Sixteen tablets would yield
6720 mg . The Upper level is 2000 mg. This would then yield 3.4 times the Upper level
(6720/2000 = 3.4).
Zinc
50% (0.5) times the Daily Value of 15 milligrams equals 7.5 mg per tablet. Sixteen tablets
would yield 120 mg. The Upper level is 40 mg. This would then yield 3 times the Upper level
(120/ 40 = 3).
Selenium
10% (0.1} times the Daily Value of 70 µg equals 7 µg per tablet. Sixteen tablets would yield
112 µ,g . This is less than the Upper Level of 400 µg .
The maintenance dose of two to three tablets per doy poses no risk per se, but Nutramega 1s
very expensive compared to the cost of the typical multivitamin and mineral supplement (a 1-
month supply would cost about $2 compared to about $15 for Nutramega) . Overall, Kristen is
smart to be concerned about meeting her nutrient needs, but the stress she is under does not in-
crease nutrient needs. A healthy diet, as shown in Table 2-11 in Chapter 2, should be her pri-
mary focus. Toking a balanced multivitamin and mineral supplement is a lso a reasonable
practice. Actually, however, it is most important for Kristen to get adequate sleep; this health
habit will best help her through her current schedule.
Summary
l . \ 'ic.rn1ins arc essential, organic compounds needed for important 3. Fae soluble ,·ir.imins arc absorbed along wic:h dietar~ fac The~
met,1bolic reactions in the bod}. T hcr arc not a source of energy. tra,·cl bv way of the lympharic system into general circulanon, ~.1r
Instead, they promote man) energy-ridding and other reactions ricd by 1.'.hylomicrons. ln disease states in which fur digcmon "
in the bod\\ thereby .tiding in the growth, de,·elopment, and linmcd, far-soluble ,·itamin status may be compromised. eltpC'1ally
maincenanl.'.e of \'arious body tissues. \ 'itamins A, D, E, and Kare "irh ,·icamins A, F, and K.
far-soluble, \\ hereas the B ,·it.tmins and ,-itamin C are warcr- -! Vitamin A consists of a family of retinoid compounds: retinal,
solublc. Eu-solubk \ itamins arc excreted less readily from the rcunol, and retinoic acid. A plant dcri,·ativc ki10" n J\ beta
body and .ire less ~usceptible co cooking loss than arc \\'ater· c:irotcnc, along \\·ith two other carotenoids, yields ,·icamin A after
soluble viramim. metabolism b\• che intestine or liver. Vitamin A contributes to the
2. Some fuMoluble vitamins pose a potential threat for coxiciry, es· 111<\intcnance of vision, rhe proper de\ elopmem of celb ( especi.111~
peci.tlly vitamin A. T he water-soluble \i tamins niacin , \i tamin B-6, mucus forming cells), and immune fonction. Vitamin A is found
and \'itamin C can .llso induce Loxic signs and symptoms, but only in foods or animal origin, such as liver, fi sh oils, and fortified milk.
at dosel> much higher than their RDAs. Ctuotcnoids arc obmincd from plants and arc especially plrntiful
in dark green and o range vegetables and in some fruits
o. Norrh Americans a t risk for poor vitamin A srams are people ex- agents. Vitamin E is plentiful in planr oiJs and food products thar
hibiting limited fat absorption and alcoholics. Vitamin A can be coma.in tl1ese oils. Overt vitamin E deficiency is rare; marginaJ Sta-
quite toxic when taken at doses 2 to 4 times or more the RDA, rns is usually associated witl1 problems in fat absorption and smok-
but only with preformed vitamin A ( retinoids). Use is espe- ing. To date, the use of megadose supplements of vitamin E by
ciRlly dangerous during pregnancy because it can lead to fecal healtl1y adults to limit cardiovascular disease risk (and certain
malformations. other healtl1 problems) is stiU a research question. Use in l1igh-risk
6. For most people, vitan1in Dis more correctly '~ewed as a hormone people has been proven ineffective in major clinjcal trials. Toxicity
rather tl1an a vitamin because sufficienr amoums of it can be pro- from megadose tl1erapy involves inhibition of vitamjn K activity
duced by the body. Provitamin D 3 is synthesized in rhe skin from and, correspondingly, an increased risk of hemorrhage.
a derivative of cholesterol in a process tl1at depends on ultraviolet 8. Vitamin K contributes to the body's blood-clotting ability by fa.
light. With adequate SLU1 exposure, no dietary iorake ofvimmin D cili tating the conversion of precursor proteins to active clotting
is needed. The proviramin, whether produced in the skin or ob- factors, such as prothrombin, which promotes blood coagulation.
cained fi-om the diet, is metabolized in the Liver and kidneys to Viramin K also plays a role in bone metabolism. About 10% of the
}~eld l,25(0H), vitamin D (or calcitriol), me active hormonal ''itam.in K absor bed each day likely comes from bacteiial synthesii.
form of vitamin D. 1,25(0H) 2 vitamin Dis important for calc.iLUn in the imest.inc; most comes from foods, primarily green leafy veg-
absorption fr.om the intestine, and witl1 other hormones, it helps etables and vegetable oils. Vitamin K is readily excreted from tht·
regulate bone metabolism. Vi tamin D is foLL11d in fish oils and for- body, but tl1e usual daily intake from diet alone meets one's needs.
tified milk. 9. Taki11g a mu ltivitamin and mineral supplement to help meet nu·
7. Vitamin E fonct.ions as a cha.in-breaking Rntioxidant. By donating trient need:, is recommended by some experts, while other experts
electrons to electron-seeking compounds (oxidizing agents), it suggest tl1at only some people need to take supplements. Taking
neutralizes their action. One group of electron-seeking com· many nutrient supplements can lead to nmrient-related toxicity, so
pounds, known as free radicals, can cause widespread destruction, any such use should be carefully considered. The clearest evidence
both to ceU membranes and to DNA. Vitamin E is one of several for good nutrition is a diet rich in fruits and vegetables and whole-
components .in the body's defense system against such oxidizing grain breads and cereals, nor a primary reliance on supplements.
Study Questions
1. Dehcribe t\Yo forms of ,·iramin A that are ~wa i lable in common 9. What properries of vitamin A make it ,1 greater risk for toxiciry
foods. than vitamin K?
2. Explai11 how retinal functions in vision. 10. Identify the North Americans most at risk for fat-soluble vitamin
3. Describe how retinoic acid participates in protein synthesis. deficiencies.
4. What fucrors determine whether a person needs a dietary source of
vitamin D or can rely on self.synthesis?
5. Describe how vitamin D, paratl1yroid hormone, md cakit0ni11
regulate the concemration of calcium ia tl1e blood.
BOOST YOUR STUDY
6. Define a free radical and explain how vitamin E controls free rad-
ical damage. Perspectives in Nutrition: Online Learning
Check out the
7. List several important dietary sources for each of the fut-soluble \l· Cente r www.mhhe.com/wardlawpers7 for qui=es, flash
tamins. Identify the Adequate Intake or RDA and the Uppe r Level cords, activities, and web links designed lo further help you learn
for each of the fat-so luble vitamins. about the fat-soluble vitamins.
8. Identify the two primary functions oh'itamin Kin the body.
I. ADA Reports: Position of the American 2 . Bischoff-Fcrr:ui HA and others: Fracture prc- S11pplt:mcntn.tio11 with higb doses 11.f 11i1n.111iu E dr-
Dietetic Associ~cion: fortification and nuai- vcncion with vitamin D supplementation. crcnsi:d tbc .9•11tbcsis ofprotbro111bi11, n 1•itnmi11 K-
tional supplements. Jo1m1r1I of tbc Amcricrm ]oumnl of tbe A111cricn11 Mcdictil Asi11ci111io11 dcpwdcnt protein. Furrbcr research is rcq11il"t'd r11
Dii:tetic Assorinti1m l 05: 1300, 2005. 293:2257, 2005. cl11cidn.tc tbi· imporrm1cc of rb.- i11/Jibi1m~v cJJi:ct
171.: best 1111t1'itio11nl stmti:gy for promotillg opti· Pr0Pidi11g about 800JU/ dn.v1if r1itnmi11 D to tbnt 11ita111i11 E has 011 11itn min ]( stnt11s.
mnl bcnlth n11d rcdttcing the ris/1 of chronic dis· ofdc1· nd11lts rtd11ccd rlJc risll of hip frnctm·e i11 4. Bruno RS and others: Alpha-tocophcrol dhap-
east: is to wisely choose n wide 11111·icty ~ffiwis. rbis swdy. ft appears tbnr 400 !U/d11y is 11or pearancc is faster in cigarctti: smokers and is
Additiounf 11itnmins 1111d mini:rnls from foni- mfficicnr t11 pnmide tile rnmc bmejit. inversely related to their ascorbic acid status.
ficd foods n11d/1w mpplmtenrs ca11 bclp smne po- 3. Booth SL ,rnd others: Effect of vitamin E sup- Amcrict111 }llttrual t1f Clinicttl N11triti1m
plc meet tl;cir 111tt>·itio11al mcds as set by plemenrarion on l'it:rn1in K status in adults with 81 :95, 2005.
scimce-bnscd 1111tritio11 st1111rlants (&.!J., tbc normal coa!,'ltlarion sratus. Amcricn.11 ]ounrnf Gream· rares ofnlp!Jn-rocophcro/ dimppcnmucc
Dietnr_r Rcferrnce fotn.kcs). of Clirtirnf N11n-itio1180:143, 2004. i11 s11111kcn appear to be n:ln.ted to i11c1·ensed
332 Chapter 9 The Fat-Soluble Vita mins
oxidnri11e ftn-ss a11d b.~ loll'cr U/ood 11iram111 C ofo:pcrts 011111m·iwt 11adsf11r diemr.v 16. t-.lcNaughton SA and o thers: Supplement Ul>C: .,
(ascorbic ncid) co11cmrrntio11s. 17ms, smokers n11tioxidn11rs. associarc:d with health scacus and hcalrh-rclatcd
/Jni1c n11 i11Cl'tnscd rtq11irc111mt far borb nlp/Ja· 10. Food and Nurrition Bo,1rd. lmtitute of bdmfors in che 1946 Bri tish birch .:ohort
tocopbt'rol a11d ascorbic ncid. Medicine: Dietnr.t lfrftrmcr llltaku fa1· ritn· jo11mnl of N11n·itio11 135: 1782, 2005
5. OJ\\:.On-Hughc:~ B: Radal/cthnic conMdcra- 111i11 A. 111tn111111 K, 11rsr11ic, bor1111, c/11·0111111111, 171c btnlt/Jiest indfrid11n.ls in tbis /111'lJ.-gro11p of
tion~
in making rccommcml.uiom for \'itJmin D copper, iodine, 1ro11, 111n11.t1n1u!t', 1110Zvbdt1111111, people sr11dietf 1rcre e/Je 011es 111011 lilu~1· tu b,· mk·
for aduh and ddc:rl~ men Jnd \\'Omen. uickt:L, silicon, and ::.111c Wa~hingmn, DC i11g 111pplt11wus. 171isft11rli11g Ill.!1!JtstI tlmt rlJ.-
A111rricn11 jo11mnl of Cli111cnl l\'11rritio11 National Acadenn Pres\, 200 I. ptoplt n•/Jo ncmnlZr benefit 1/Jc lcnsr fi·11111 t/Jt
80(suppl).1763S, 2004. Reco111111mdntio11s for 11itn111i11 A n11d l'irn111i11 K practice of tnki11g mpplemmts nre t/Jc rt1:1· pt11·
fo r/Jc ll'mtrr mmlf/J.r, b1·und-bnsaf 11irn111111 J) i11tnkc m·f littrtf. 17Jr m111111nlc mrd to ser tbt' pie 1p/Jo nrc t11ki11g tbe mpplcmmts.
s11pplc111mtnt1011 to 1000 IU/dny 11111_1• be 11udcd RDA or Arlcq11ncc lmnkc n11d (./ppc1· Le1 1c/ fiJr 17. Osganian SK and others: Dietary ..:arotcn<>1<h
to nrrni11 ndcq11nu 11itn111i11 D srntur i11 ntf11lts. t/Jesr 1111trimrs is diswsscd 111 demi/. a nd the.: risk of coronary artery d1scJ'c
Tim rcco111111mdnt1011 11'011/d cspcrinlZ1• brnrfir 11. Harun S and od1ers: Subdinic31 \·icam111 D de- Americn11 }011rnnl of C/i11irnl N11tr11i1111
blnrk nd11lts. ficiency i~ increased in adolc\ccni girls who 77: 1390, 2003.
6. De Luca H !-': 01'cn ic" of general physiologic wear conceali ng clotlung. j111m1nl rlj' N111rit1n11 Rcg11l11.1· intnke offoods rich i11 cnrott'lloids i.< ns·
katur~ and lt111ction~ of\'i t.1111in D. A111rrirn11 135:2 18, 2005. sorintcd with n 1·cd11ctio11 in r/Je l'isk 11/ r111·1111111:v
Juunml oj'Cli111cnl N11tririo11 80: I 689S, 2004. Vitn.111i11 D d~ficimry is n11 i111p11rtn111 prob/rm in nrfcl')' disease. 1J11· n11t/Jors cQ11.c/11d1· rl1111,111·mtri·
Jlitn111i11 0 3 i.s n prolJ11r111m11· protf11utf i11 sh11 T11rkisb nd11lcscmt1_7irls, cspccin/~1· tlmst 111/111 j/1111111• com 11111ptio11 of fmirs n11d 11cgcrnblcs i11 /frttcrnl
thro11g/J 11ltm1•irlltt irrndintio11of7- n i·cligious dn'SS code in 11'/Jic/J r/Jc borf.v rm111i11.r cs· 1·m111i11s n11 i111portn11t public health policy
dc/J_vdl'llrholcsro·ol. It is bi11/o,11im/~,, inert n11d sen tinily covcrd. l'itn111i11 /) mpplm11·11111ti1111 np· l'CClll/111/ClldntiOll.
must be metnboli::.ed 111 t/Jc /i11,·1-. rhm i11 the pen.rs t11be11ccc.rsnr.v ji>r rbt•sc ndolrscc11t g11·/s. 18. Ribaya·Mcrcado JD, Blumberg JR: Lumn .md
kid11e_v, btf't1n'f1111ffi1111. 17u· /J111wo1ml jllrm uf 12. K."llkwarf HJ Jnd other\: Vitanun K, hone ze:ix.rnthi n :ind their pote ntial role~ 111 dtwJ'c
v1tn111111 D3 nets tlmnt11h n 1wtpt11r 1111 rhr cell rurnon:r, and hom: m.l!>\ 111 girl\. A111crirn11 pre1•cntion. }111m111/ of t/Je A111trirn11 Coll(nt 1>f
1111deus r11cnrr_r11111irs111n11_r ji111rtio11s, 111c/11d· Jo11mnl ofCli11icnl N11tr1ti1111 80.1075, 2004. N1m·irio11 23:6:567S, 2004.
i11,11 cnlw1111 nbs11rprio11, p/Josplmu nbsorprio11, Bcncr l'irn111i11 K srnws 1s nssucintcd 11•/fb dt°" L11u111 n11rl ~nxnm/Jiu nrc cnrotmoids fo1111d
cnlci11111 111obili:;ati1111 in b1mc, and cn/ci11111 1T- pnrtimlarZv in dnrk-grcm fen}} l'cgrtnbll's 1111d
creased bo11c t11mo11cr i11 hmlt/J_Y g11·u co11m111·
nbsorptio11 i11 tilt' kid11q l'irn111i11 /) nls11 lms ing n typunl U.S. dut. J{n11d11111i:;t'rl t1·inls Ill'<' 111 l'_fllf yolks. 171e,y nr.: ll'irle~y distrilmtcrl i11 ris·
urtrnl 1w11-cnlri11111·rdnud ji11uti1111s iu the 11adrd 111 fi1rtbo· u11drntn11d tht p11tmt1nl brnr· mu nnrl nn: tbe pri11cipnl carorwoufs i11 rb,· c_iY
bod_'Y- 171i.r 111·0·11ie11• pr1w1drs n /Jrirf ducrip1ion fits 1if1'1ta111111 K 011b111u11cq11isiri1111 ill,nrtm'" /ms n11d mnculnr r<',8io11 of tbt rrti11n.
of t/J,· pl1_rsiulll,nic, r11doC1"i11olt~nir, nud 1110/cwlar ing c/Jilrlrm. Ep1dc111iologic studies indicntmg nn inl'Cl"S<" r1"-
cbnrnrtrrirrics 1f rlfn111111 /), lntto11sbip between l11tei11 nud ::.en:m11tbi11 111 •
13. Lee I and others: \'i1.1min r in the prim.uy pre·
7. 1-'a1rfidd K, Fktd1cr R: \'icamms for chronic ,·enrion of cardio\'a~rnlar d1~Ca\c and cancer: rnkr nnd srnt11s n11d bot/J cnrnrnrt n11d
dbca\c prc\Clllion m Jdults. 'icicnrilk re\ic1\ The womc:n's hc:Jlth >tt1d1·: A r.mdomi1cd c:on - n,nr-relnred 111nmlnr dcgmcrntw11 Sll.!1..flCJt tlmt
and dimc.11 .1pplic.111on\. J1111mnl 1>[ tbt' trollc:d trial. j1111r11nl of 1/H At111Tun11 ,\/cdirnl 1/Jur co111po1111ds rn11 pln:1' n protcctirc r11lr i11 tbt
A111cricn11 ,\frdw1/ Ass11C1nt1011 287:3 I 16, 2002, Associntio11 294:56, 2005. qc..\rmu smdics s/Joll' time l11tcfo n11d zcnxn11·
and 287.3127, 2002 1/Ji11111n_y nlso help 1·ed11ce t/Jc risk 11fb1-rnsr rn11·
TI1c dntn from t/1is lmzff n·inl 111dicntcd tlmt
rri; ltmg en 11cn; /Jcnrt disease, n 11tf strnloc
While 1•1tn111111 d1jiat119• dumm nrl' 1111 /011grr 600 IU 1f11nt11rnl-so11rrt' 1•irn111i11 I- rnkrn r1•1·ry
co1111111111 in Nunh Amfl·irn, mn11,l' pl1_1•s1cin11s nrl' 111-/Jer dn.1• proPidrd 1111 r111anl/ bmt'fit ft11· 11in1or 19. U.S. Preve nti\'C Scn•iccs T3'k Force: Ro111inc
st'.!l!JCSl;,t!I tlmt 111m~11h111/ i11ml·c.r 1!f'111rmy Pim· cn.rdiol'llsm/m· l'l'fllts UI- c1111ci•1: 771cst· d11111 do 1•i t;1min suppleme ntation ro pre\•em c.111ccr
111111s nud 111i111Tnlr by sa111r North Amcricmu 1111t mpport 1w11111111cndi11.11 1•i1n111i11 E mpplt· .rn d cardiovascular disease: Rc:commc.:nd.uium
111ny iucrcnsr tbr risk t1ftfr11cl11pi11...11 Siii/i<' dm111ic 111c11tntio11 f01· cnrdioMsculnr drsMse or cn11a1· :i nd rarionale . .Am1n/.f uf 111tcr11nL ,\ftrl1t111t
discmcs, i11c/11d11~11 c1111cc1· nurl cnnfim•1uculm· dis· 139:5 1, 200 3.
p1·w c11ti1111 nw1111g hcnfthy 11'111111·11, {mT 111111·r 1·r·
tnsc. 1i1 btlp e11s1m· 11p1i111nl i11tnkt·s 11f 11111s1 oft/Jr senrc/J is wmTn.utctf, bun me 11 dccrenst in .wd· The hcnlt/J /Jmefits of 1111tricm mpplcmm111t11111
i1itn111i11s 1111d 111i11rmlr, the n1111Jors rcro111111rutf tfm cnrrlinc dcnt/J 1Ms scrn i1111s11bsa1>f o/d,·r rcmniu 1mccl'tn.i11, wbcrens 11111c/J rl'irfc11Ct" mp·
thnt 11d11lt No1·tb A111cricn11s C1J11t11111t' n dni~v 11'11/llCll ill tlJiJ sttlli,V. ports 11 diet bigh in f m it, vegernblcs, 1wd
11111/tii•itnmi11n11tl111i11crnl mppltmmr. 14. Lichrenstc:i n AH, Rm~cll RJ\.I: Esscmi.11 n ucri · lcg11111cs. C11rl'e11tly the clcm·cst 11sc 11f mpplr·
rnrs: Food or 'upplcmcnt'.? Where \hould chc mm ts is 1/Jnt ofJolie ncid far the p1·t1•wti1111 1if
8 . 1-'<>od .rntl Nutrition Board, l nsrirutc of
empbasi;, be? f1111m11I 1if' r/Jr A11uncn11 Jfrdicnl 11wrnl mbc defects thnt develop d11ri11..11 p1·<:n-
Medicine Dianrv Rcj<·rr11u "1mkcs ji1r en/·
Aswciatitm 294:351, 2005 11n1u_v. Ot/Ja· pormtint benefits ofs11pplmw1tn.·
c111111. p/J11splJ1Jr11s, 111n.n11n111111, 111tn111i11 D, a11rl
tio11, suc/J as n lowering of blood /Jo111oc.vrrci11c,
fl11orid,·. \\',1~htn~mn, DC ~arional Ac:ademr TI1.-rc is 111111ffiC1c11t n•1dmff to j11stift. n s/Jift in 11ud to be estnblis/Jed by further studies.
l'rc.-.\, 1997. public /Jcnlt/J polic,v from 1111« r/Jnt <'mplmsi::.cs n 20. Viramin A: "'Magic bullet" that c.m bJddirc
'n1t· RD..U nurl rdnurl stn11rlnrrls for 1•irn111i11 D food-based diet co ji1/jill 1111nimt rcq111re11wus Tufts U111vcrsit_Y Hea/t/J nnd N1111·i1io11 l.rtt<r,
1111d somt 111111t·1·als 111·.- discussed iu dttnil. A n11d promote opti11inl l1tnlt/J to 011t t/Jnr cmp/Jn· p . 4, February 2005.
111n111r cbn11...nr ;,, srrti11,11time1u11• (n11d nil si::;c.s dictnr_v s11pplc111rntnt1011. Tnr.,wtt:d 1111tr1·
Virnmi11 A n11tf its tferi11nrives (t·.g., ban-
other) esrimnus of l111111n1111erds 1s r/Je 11se ofn mt mpplc111c11tnt1011 is npproprintr i11 some
cnrotc11c) nrc mic1·01111trie11ts cr11cinl to .fll'11wtb,
sp,·cijic bioh~11irnl 111111·krr or esrimntr of rurrmr rnses, bon•eur, ns rn•ic11•rd b,1• thac' 1111tbol'S.
11111111111c ft111ctio11. rcprod11ai11e p1·occ%cs, n11d
i11rnka rbnr sbo11•1 ndcqunn. 15. Maras JE and others: Intake of J ·1ocopherol" ((// p/Jysiolog_1" W/Jilr it is 1l'cll-k111111•11 1/Jnt 1•ri:1·
9 . Food and Nutritton Ro.1rd, l1mi1urc ofi\kdicine: limicc:d .1mong U.S. adults. J1111mnl of t/Jr bt11b doses of 1•ila111i11 A nre to:>:u, It 11011' np·
Diet111:1· R.tfcrmu bttnkcs .fiw 111tn111i11 C, 1•1tn· Amc1·icn11 Dietcric Associnri1111 104-:567, 200.J. pen1·s that c11en moderntdy /Jigh dosrs cn11 i11·
mi11 E. sde11i11111, n11d rnmrmuitfs \\'a•hmgron, l'itnmi11 E co11s11111ptio11 111 t/Jc U111tcd ~tntu owsr cbn11ccs ofbirt/J defects, 11f li1•fl' di.<ms<".
DC: Nauonal t\cJdc1111 Pre~, 2000. doc.r 1111tgwcrnlZ1• 111ert t/Jt r111·n'11t /{DA. n11d possibly of hip fmctm·cs iu posrmmopn 11snl
17Jr fi111ct10111of1111t10xidnt11 111111·it-1m; boll' Gnntcr me 1if'1111ts, seeds, 11'bolr:11mi11 b1·rnds 1110111c11. l1I t/Jr U11ircd Strttcs, 1/Jt 1111/_v pt11plt.fi1r
RDA n11d rclnrtrl ;111111/nnf.f were dcrcr111i11cd, nnd w-enls. 11.11tf 11itn111i11 £-ric/1 pln11t oils is ll'h11111 1•itnmi11 A s11pplc111ents m·c 11•nrm11ud
n11d 1l~ficfr11q nud rt1.\'icir.1• s:i•111pt1m1S n1·1· ex· nd porn.ud t11 dusr tbc gnp bdll'CCll i11tn~'l'l t111d nre th11sc ll'h11 h111•t cl11w1ic GI n·nct rfism.rt'! t/Jnt
plnmcd. 'l71is is r/Jc d~fi11itil'c l'l'f!Ol'f by rbe pn11c! needs. lend ro dUJiwlty iu 11bso1·biii.g 1111tl'imts.
www.mhhe.com/ w ardlawpers7 333
Take I Action
I. Preservation of Vitamins in Foods

Substantial amounts of vitamins in foods con be lost from the time a fruit or vegetable is picked until ii is eaten. Heat, light, exposure lo
the air, cooking in water, and alkalinity ore all factors that con destroy vitamins. The sooner a food is eaten ofter harvest, the less
chance there is ol nutrient loss. The following list provides some tips to oid in preserving the vitamins in food. How many of these sug-
gestions do you employ on a regular basis?
What to Do Why
• Keep frui ts and vegetables cool. Enzymes in food begin to degrade vitamins once the fruit or vegetable is
picked. Chilling reduces this process. Refrigerate fresh produce (except
for potatoes, tomatoes, onions, and bananas) until consumed.
• Refrigerate foods in moisture-proof, air-tight Nutrients keep best al temperatures near freezing, al high humidity, and
containers. away from air
• Trim, peel, and cut fruits and vegetables Oxygen breaks down vitamins foster when more surface is exposed.
minimally-just enough to remove rotten or Outer leaves of lettuce and other greens hove more vitamins ond miner·
inedible ports. ols than the inner, tender leaves or stems. Potato skins and apple skins
hove more vitamins and minerals than the inner ports.
• Microwave, steam, or use a pan or wok with More nutrients ore retained when there is less contact with wa ter and
very small amounts ol fat and o light-fitting lid to shorter cooking time. W henever possible, cook fruits or vegetables in
cook vegetables. their skins.
• Minimize reheating food. Prolonged reheating reduces vitamin content.
• Avoid adding fots lo vegetables during cooking Fol-soluble vitamins will be lost in discorded fot. If you wont to odd fats
if you pion to discord the liquid. to vegetables, do so ofter they ore fully cooked and drained.
• Avoid adding baking soda lo vegetables to enhance Alkalinity destroys much vitamin D, thiomin, and other vitamins.
the green color.
• Use frozen rather than conned fruits and Freezing helps retain vitamin content much better than conning. In fact,
vegetables. frozen vegetables ore often as nutrient-rich os fresh-picked ones.
• Store conned foods in o cool place and use Conned foods vary in the amount of nutrients lost, largely because of
them wisely. differences in storage lime and temperatures. To obtain maximal nutritive
value from conned goods, serve any liquid pocked with the food
whenever possible.
f
.. I LI-1
Take I Action
II. A Closer Look at Supplement Use

With the current popularity of vitamin and mineral supplements, it is more important than ever to understand how to evaluate a supple-
ment. Study the label of a supplement you use, or one readily available from a friend or the supermarket. Then answer the following
questions.
l . What is the recommended dosage of thi s supplement?
2. Based on the recommended dosage, are there any individual vitamins for which the intake would be greater than l 00% of the
Daily Value? list these vitamins.
3. Are any suggested intakes above the Upper Level for the nutrient?
4. Are there ony superfluous ingredients, such as herbs or flavors, in the supplement? You can often determine these by looking for
ingredients that do not have a percent of Daily Value.
5. Does at least 50% of the vitamin A in the product come from beta-carotene or other provitomin A corotenoids (to reduce risk of
preformed vitamin A toxicity)?
6. Are there any warnings on the label as to populations who should not consume this product?
7. Are there any other signs that tip you off that this product may not be safe? I .-
-
THE WATER-SOLUBLE VITAMINS
....
~
~
General Properties of the Water.Soluble Vitamins -t
B-Vitomin and Vitamin C Status of North Americans
Suzanne and Ted ore planning to hove their first child. Ted (who completed one
::c
university-level nutrition course) hos been trying to persuade Suzanne to eat o folic ~
Enrichment and Fortification of Foods with B-Vitomins
Thiomin
acid-rich breakfast cereal or toke o multivitamin-mineral supplement every morning. "'
"'
-f
Absorption, Tronsport, Storoge, and Excretion • Ted is concerned because Suzanne's sister gave birth to o child with spine bifido I
m
Functions • Thiamin in Foods • Thiamin Needs lost year. Suzanne doesn't like to be hassled about her eating habits but admits her
• Deficiency Diseases <
~
diet is "awful." Breakfast is usually o sweet pastry and coffee, lunch is whatever
Riboflavin
Absorption, Transport, Storage, and Excretion • snack is available from o vending machine, and dinner is frequently eaten at a fost-
Functions • Riboflavin in Foods • Riboflavin
Needs • Deficiency Diseases
lood restaurant. She consumes no more than one or two servings of fruits and veg- z
(/)
Niacin etables per day. )>

Absorption, Transport, Storage, and Excretion • Is Ted correct in his concern? How concerned should Suzanne be, especially z
Functions of Niacin • Niacin in Foods • Niacin CJ
given her current diet?
Needs • Niacin Deficiency • Phormocologic ~
Use of Niacin and Upper Level for Niacin z
m
Pontothenic Acid
Absorption, Transport, Storage, and Excretion • '°
)>
,--
Functions • Pantothenic Acid in Foods • (/)
Pantothenic Acid Needs • Deficiency Diseases
Biotin
Absorption, Transport, Storage, and Excretion •
Functions • Sources of Biotin • Biotin Needs •
Deficiency Diseases
Vitamin B-6
Functions • Vitomin 8-0 in Foods • Vitamin B-6
Needs • Deficiency Diseases • Pharmacologic
Use and Upper Level
Folote
Absorption, Tronsport, Storage, and Excretion •
Functions • Folate in Foods • Fa/ate Needs •
Deficiency Diseases • Upper Level
Vitamin B-12
Functions • Vitamin S.12 in Foods • Vitamin S.12
Needs • Deficiency Diseases
Choline
Functions • Choline in Foods • Choline Needs
• Deficiency Diseases • Upper Level
Vitamin C
Functions • Vitamin C in Foods • Vitamin C
Needs • Deficiency Diseases • Intake above
the RDA • Upper Level
Expe1I Opit\iOI\" Vitamin C: Antioxidant and Pro-
Oxidont Functions and the Keystone of Tight
Control
Nutrition Focus: Vitamin-Like Compounds
Toke Action
335
A s defined in Chapter 9, vitamins ore essential organic substances needed in very small amounts
to support the metabolism, growth, and maintenance of cells. The water-soluble vitamins dis-
cussed in this chapter include eight B-vitomins, vitamin C, and o newcomer lo the list of important nutri-
ents, o dietary component called choline. The B-vilomins form coenzymes--0rgonic compounds that
enable certain enzymes to function. As o group, the B-vilomins ore necessary for energy metabolism,
transforming nutrients into characteristic cell structures and creating various proteins, lipids, and corOO.
hydrotes.1 1 Vitamin C participates in o wide variety of metabolic
processes, although not in the form of o coenzyme. 12 Choline is
needed lo form lecithin and other compounds.29 CHAPTER OBJECTIVES CHAPTER 10 IS DESIGNED
The Nutrition Focus briefly describes some vitamin-like com- TO ALLOW YOU TO:
pounds. People may require these compounds in their diets I . Identify the water-soluble vitamins.
under atypical circumstances. These compounds, however, cur- 2. list the ma jor functions and deficiency symptoms for each woter-
rently ore not classified as true vitamins both because a healthy soluble vitamin.
person does not require o dietary source of them and because 3. list three important food sources for each water-soluble vitamin
no specific deficiency disease results when they ore absent from 4. Describe toxicity symptoms from excess consumption of certain
water-soluble vitamins.
the diet. 8
5. Distinguish between vitamins and nonvitomins, such as inositol
and tourine

OF THE WATER-SOLUBLE VITAMINS, YOU WILL WANT TO REVIEW:
The gostrointestinol system for the digestion ond absorption of nutrients in Chapter 3
Energy metabolism, especially glycolysis, the citric ocid cycle, ond the electron transport choin in Chapter 4
Oxidation-reduction reoct1ons in Chapter 4
The metabolism of corbohydrotes in Chapter 4.
Amino acid metabolism ond the link between DNA and protein synthesis in Chapter 7
General Properties of the Water-Soluble Vitamins

For most o f human histor y, diseases such as scurvy and pellagra caused eno rmous suf
fering and death. Early in rhe twen tieth century, scientists began to recognize t hat
these illnesses were cau sed bv rh e absence of certain vital substances fro m the dict-
no w called the B-vitamins and vitamin C. t 1•12 T he scientists discovered that restori ng
these vitamins to the d iet dramatically reve rsed th ese d efi ciency diseases if do ne bcfi:>rc
beriberi The thiomin-deficiency disorder significant deterioration of the bo dy took place.
characterized by muscle weakness, loss of The second vitamin to be discovered was design ated vitamin B, according to t he let
appetite, nerve degeneration, and sometimes
ter conventio n discussed in C hapter 9. T his water-soluble substance, w hich can cure
edema.
b eriberi, was initiall}• though t to be a single chemical compound. When subsequent
coenzyme A compound that combines with on research sh owed that this substance actually consists of several compounds, they were
inactive protein, called on opoenzyme, lo form named the B-vitamins, and n um bers were added to the letter B to disting uish them.
a catalytically active protein, called a O f the eight B-vitamins, only rwo are still commo nly re ferred to by letter and number:
holoenzyme. In this manner, coenzymes aid in vitamin B -6 and vitamin B-12. T he o thers now are usually refe rred to by the follow-
enzyme function. ing names: thiamin (p revio usly B- l ), ribo flavin (previo usly B-2 ), niacin (previously
cofactor An organic or inorganic substance B-3 ), pantoth enic acid, bio tin , and fo late. T he o lde r designations, h owever, are some-
that binds to o specific region on on enzyme times used o n vitamin supplement labc.:ls.
and is necessary for the enzyme's activity. AJJ B-vitamins functio n as coenzym es. t 1 T his classification ful ls under the general
term cofactor , w hich also includes ino rganic ions. C ofactors as a class are necessary for
336
certain enzymatic reactions co take place. Cocnzymes specifically arc molecules con-
sisting of a vitamin, such as a B-\•iramin, plus other chemical units. The body can make Inactive
the other units and put the coenzyme together, but cannot make the B-vitamin. enzyme
Because coenzymes fall under the cofactor designation, they also work with certain
body enzymes to allow chemical reactions in a cell to proceed (Figure 10-1 ). All the
eight B-,·icamins participate in energy metabolism; some also have other roles in Lhe
chemical reactions that take place within cells. 11 Although vitamin C docs nor function
as a coenz)rme, it plays a role in the synthesis of several important compounds. 19 +
The B-vitamins arc present in foods in their coenzyme forms bound to specific pro-
teins. After ingestion, die bound vitamin coenzymes are released as part of the general Vitamin
digestive processes that occur in the stomach and small intestine. The free vitamins are coenzyme
then absorbed in the small intestine.
Typically, about 50 t0 90% of the B-vitamins in the diet arc absorbed . 11 Once in-
side cells, the coenzyme forms of the vitamins an~ resynthesized. Health -food stores
sell the coenzyme forms of some vitamins, although they have no specific benefits to
the consumer, because vitamins arc not absorbed in this form. 1
Because they are water soluble, most of the B-vitamins and vitamin Care more eas-
ily excreted from the body than are the rat-soluble vitamins.8 Moreover, some of die
water-soluble vitamins are readily destroyed during cooking because of heat or alkalin-
ity; all are subject to leaching into die cooking water. Retention of the B-vitamins and Active
' 'itamin C is greatest in foods that are prepared by steaming, stir-frying, microwaving, enzyme
or simmering in minimal moisture (review the first Take Action in Chapter 9 ).
B-Vitamin and Vitamin C Status

of North Americans Flgure 10·1 I The enzyme<oenzyme
interaction. The B-vitamins form coenzymes,
The nutritional starus of most North Americans \vith respect to me B-vitamins and vi- which ore compounds that enable specific
tamin C is generally good. Our typical diets contain ample and varied natural sources enzymes to function.
of these vitamins. 11 •12 In addition, many common foods are enriched or fortified with
one or more of the water-solu blc vitamins. (Table 2-14 in Chapter 2 reviewed d1c
proper use of d1e terms em-iched and fortified.) In some developing countries, how-
ever, deficiencies of die water-soluble vitamins are more common, and Lhc resulting
deficiency diseases pose significant public healm problems. (A detailed discussion of
nutritional deficiencies worldwide is presented in Chapter 20.)
Despite the generally good B-viramin and vitamin C starus of North Americans,
marginal deficiencies of the water-soluble vitamins may occur, especially in smokers
and older adults. 11 •12 Another group that is susceptible to B-vitamin deficiencies is al-
coholics. The extremely unbalanced diets of some people with alcoholism, in combi- ecouse of their role in energy metabolism,
nation with alcohol -induced alteration of vitamin absorption and metabolism, create a needs for many B vitamins increase some-
significant risk. 11 (Chapter 8 covered this topic in detail. ) The long-term effects of what as energy expenditure increases. Still, this
marginal deficiencies are as yet unknown, but increased risk of cardiovascular disease, is not o major concern because this increase in
cancer, and cataracts of die eye is suspected. However, in the short run, marginal de- energy expenditure usually results in a corre-
ficiency in most people likely leads onJy to fatigue or other bothersome and unspecific sponding increase in food intake, which con-
signs and symptoms.11 ,12 tributes more Bvitamins to a diet.
Enrichment and Fortification of Foods

with B-Vitamins
In the milling of grains, the seeds are crushed and me germ, bran, and husk layers
arc removed. This process leaves just the starch-containing endosperm, which is
used tO make flour, bread, and cereal products. Because the discarded fractions arc
rich in many nut1icnts, this time-honored milling process leads to loss of vitamins
and minerals.
338 Chapte r 10 The Water-Soluble Vitamins
The Whole-Grain Advantage To counteract this n uu·ient loss, for many ye:lrs bread and cereal products made
(whole vs. refined) from milled grains have been enriched with fom B-vitamin s-thiamin, riboflavin,
niacin, and folic acid-and with the mineral iron. This enrichment program has helped
Bread:
protect North Americans from the common deficiency diseases associated wirh a di·
vitamin E i 17%
vitamin B-6 i 60%
ctary lack of the added nutrients. 11 This practice, however, still leaves the produces
potassium i 92% with less vitamin B-6, vitamin E, magnesium, and zinc (and fiber) than that present in
magnesium i 70% the whole gra ins. Nutrition experts therefore advocate the regular consumption of
fiber i 66% whole-grain products, such as whole-wheat bread, rather than en1·iched grain products.
Rice: Another reason not to depend too much on enriched foods for vitamins is that
vitamin E i 800% whole grains, as well as fruits and vegetables, contain mai1y phytochemicals.
vitamin B-6 i 93% Phytochemicals are not vitamins, nor even absolutely essentiaJ nutrients. However,
potassium i 280% they may still be helpful tO good health (e.g., they may decrease the risk of ccrrai11 dis·
magnesium i 450% eases, sucb as camracts in the eyes7 ). RccaJI that phytochemicals were mentioned in
fiber i 550% Chapter 2, where a list of examples of phytochemical compounds was given.
I Thiamin
ThiamiJ1 consists of a central carbon to which is attached a six-member nitrogen·
containing ring and a five-member sulfur-containing ring. The name comes frorn tbio,
meaning "sulfur," and ffminc, referring to the nitrogen groups in d ie molecule. In
modern spelling, the c is dropped from t he word. Its coenzyme form, thiamin py-
rophosphate (TPP), participates chiefly in carbohydrate metabolism. 4
The chemical bond between each ring and the central carbon in th iamin is easil)'
broken by prolonged exposure to heat (overcooked foods ), thus destroying the func-
tions of the vitamin. This destruction also occms if food is cooked in alkaUne solutions
(pH > 8.0). Sometimes baking soda is added to tl1e water in which fresh green beans
arc cooked to retai11 their bright green color; this practice is not recommended.
Thia min 1
Thia min has two phosphate groups a dded here (red asterisk)
to form the coenzyme thiamin pyrophosphate (TPP).
Absorption, Transport, Storage, and Excretion of Thiamin

Thiamin is absorbed mainly in the small intestii1e by a sodium-dependent active ah·
sorption process. It is b-ansported in tl1e blood as such or in its coenzyme form by red
blood cells. Srorage is poor; only a small reserve is found i.n muscles and the liver. Ai1y
excess intake is promptly excreted in the urinc. 4
decarboxylation The action of removing one

molecule of carbon dioxide from o compound. Functions of Thiamin
lransketolase An enzyme whose functional Thiamin pyrophosphate (TPP) functions in the metabolism of cai·bohydrntes and of
component is TPP (thiomin pyrophosphate); it branched-chain amino acids (leucine, isolcucine, ai1d valinc) (Figure 10-2 ). Ir specifi-
converts glucose to various other sugars. cally participates in removal of carbon dioxide (decarboxylation) from these various
compmmds and in the action oftbe enzyme trans ketolase.4 Transkerolase is the enzyme
Glycogen Triglycerides II Proteins

1} PLP
I THFA
B- 12 coenzymesJ
Figure 1 0~2 I Many metabolic pathways,
including those involved in energy metabolism,
t~
use coenzyme forms of the B-vitomins: thiamin
{t. J1l) ____., as thiomin pyrophosphate TPP; riboflavin as
flovin adenine dinucleotide (FAD) and flovin
------- Some
Glucose I Fatty acids and Amino acids components
mononucleotide {FMN); niacin as nicotinomide
adenine dinucleotide (NAD) and nicotinamide
glycerol of DNA
and RNA adenine dinucleotide phosphate (NADP);
pantothenic acid as coenzyme A; vitamin B-6
NADP as pyridoxal phosphate (PLP); and folote as
~iotii;,,.. '
NAO TPP, NAO , tetrahydrofolic acid (THFA). Vitamin B-12 exists
~A~ ) Nr:~.~~D) PLP, B-12 in two coenzyme forms. Biotin exists as a
~
Pyruvic acid
~ ~ cofactor. Other, minor pathways associated
with energy metabolism also exist but ore not
depicted in this figure.
Biotin
~ Acetyl-CoA
ATP TPP, NAO

.....____...... FAD, CoA
Vitamin B-12
Electron
transport
chain
)t:--•lh•-. _~ ,..
ATP /
... ~
NAO
FM~9'
responsible for the formatioo of the five -carbon sugar components of RNA and DNA
from the six-carbon glucose usi11g a series of reaccions caLLed the pcntose phosphate
pathway.
The conversion of pyruvate to acet:yl-CoA is an example of the action of thiamin;
this conversion is the critical transition reaction in the aerobic metabolism of glucose.
Thiamin as TPP n November 1996, the United Stoles began
to experience a shortage of multivitamins for
CoA NAD+ NADH + H+ total parenteral nutrition feedings. Patients who
Glucose • • Pyruvate ~ ~ Acetyl-CoA ~Citric acid cycle did not receive ode<iuale thiomin for more than
7 days developed lactic acidosis, because pyru-
C0 2 vote could not be converted to ocetyl-CoA.
In die citric acid cycle, TPP in a similar fashion converts the intcrmediace compound Instead, the pyruvale was turned into lactate.
alpha-kecoglutaratc to succinyl CoA.
Thiamin as TPP
Alpha-ketoglutarate
CoA
~
NAD+
< •C0 2
NADH + H+
Succinyl-CoA
TPP also plays a role in nerve function. It may aid in the synthesis of neurotrans-
micters and participate in the conduction of nerve impulses.
340 Chapter 10 The Water-Soluble Vitamins
Food Sources of Thiamin Thiamin in Foods

Food Item ond Amount Thiamin (mg) Thiamin is fow1d in a wide variety of foods, although generally in a small amount.
Brewer's yeast, 2 tbsp 2.4 Major individual contributors of thiamin to our diets are wh ite bread and rolls, crack-
ers, pork, hot dogs, ltmcheon meats, ready-to-eat cereals, and orange juice. White
Conned lean horn, 3 oz 0.9
bread, bakery products, and cereals are usually enriched with thiarnin.
Pork chops, 4 oz 0.6 Foods rich in thiami.n are pork products, sm1flower seeds, legumes, wheat germ, and
Wheat germ, l / 4 cup 0.5 watermelon. Whole grains and enriched grains, green beans, asparagus, organ meats
Canadian bacon, 2 oz 0.5 (such as liver), peanuts and other seeds, and mushrooms also arc good sources. Eating a
vatiety of foods in accord with My Pyramid is a reliable way t0 obtain sufficient thiamin.
Acorn squash, 1 cup 0.4
Soy milk, 1 cup 0.4
Thiamin Needs
Flour tortilla, 1 0.4
Hom lunch meat, 2 pieces 0.3 The RDA for thiamin for adult men and women is approximately 1.2 mg/day and
1.1 mg/day, respectively (refer to the inside cover of this text for vitamin recommen-
Watermelon, l slice 0.2
dations for other age groups). 11 The Daily Value for tb.iamin used on food and sup-
Fresh orange juice, l cup 0.2 plement labels is 1.5 mg. Providing for sufficient activity of transketolase in red blood
Cooked green peas, l /2 cup 0.2 cells is used tO set the RDA.
Baked beans, l /2 cup 0.2 The average daily intake for thiamin in the United States for young men is close to
2 mg per day_ For young women, it is approximately 1.2 mg/day. Canadian studies
Navy beans, 1/2 cup 0.2
show a slightly lower intake. There appear to be no adverse effects with excess intake
Corn, l /2 cup 0.2 of thiamin from food or supplements because it is readily excreted in the urine. Thus,
RDA for adult men, 1.2 mg; adult no Upper Level is established for this nuttient. 11
women, 1. 1 mg
Thiamin-Deficiency Diseases
The classic thiamin-dcficiency disease beriberi has afflicted polished rice-eating popula-
tions for centuries. Tf little besides polished rice is eaten for weeks at a time, the disease
develops. Because thiamin is so important to energy metabolism and because all cells
need energy, it might seem that a thiamin deficiency should affect every o rgan and
organ system. 4 However, three parts of the body are especially vulnerable to a deficiency
of tl1iamin, as well as otl1er B-vitamins involved in energy metabolism . One part is the
nervous system because nerve cells use a lot of energy compared to most cells. ln addi-
tion , the skin and GI tract are very sensitive to deficiencies of thiamin or o ther B-
vitamins involved in energy metabolism. The reason is that skin and GI tract cells are
replaced frequently, wliich requires much energy input. As symptoms are listed for E-
vita.min deficiencies, notice how many can involve the nervous system, GI tract, or skin.
Pork is a good source of thiomin. Beriberi

In Sinhalese, tbe language spoken by the inhabitants of Sri Lanka, the word bei·ibcri
means "I can't, I can't." Tbiamin-deficient individuals are very weak and poorly coor-
peripheral neuropathy Impaired sensory, dinated because of impaired fw1ction of the cardiovascular, muscular, nervous, and
motor, and reflex functions affecting arms and gastrointestinal systems.
legs and causing coif muscle tenderness and The clinical signs of tl1iamin deficiency include anorexia, weight loss, aparhy, loss or
difficulty in rising from a squatting position. short-term memory, confusion, GI rract distress, irrirabi lity , pei-iph er aJ neuropathy,
and m uscle weakness. 4 There are two distinct types of beriberi: wet and dry. In wet
beriberi, in addition to peripheral ncuropathy, edema occurs along with an enlarged
heart and congestive heart failure. In dry beriberi extreme muscle wasting occurs in ad-
hen physicians see a person suffering
W from unexplained delirium in the emer-
gency room, they must consider whether it may
dition to peripheral oeuropathy. Some of the clinical signs of beriberi can be observed
after only 7 days on a thiamin-free diet.
be caused by a thiamin deficiency related to al-

coholism. The treatment is on injection of thi- W ern icke-Korsakoff Syndrome
omin. Dietary supplementation will not suffice The thianun-deficiency disease fouJld primarily in North Ametica is an1ong people witl1
because thiomin is absorbed slowly, especially in heavy alcohol consumption and is called Wernicke-Korsakoff syndrome. Alcoholics ha\'e
a person with alcoholism. a three-pronged problem related to tluamin. Alcohol diminishes thiamin absorption,
www.mhhe.com/ wardlawpe rs7 3 41
alcohol increases thiamin excretion , and alcoholics consume such a poor quality diet
that there mar be little, if any, thiamin in the foods and beverages consumed. Because
the \'itamin is not readily stored, the symptoms can occur rapidly. Changes in \'ision
(e.g., double ,;sion, crossed eyes, and rapid eye mo\'ements ) ataxia, a scaggering gait; ataxia An inability lo coordinate muscle
and deranged mental functions characterize ir. The disorientation, listlessness, memory activity during voluntary movement;
loss, and otl1er symptoms, including alcohol withdra\Yal, are due co lesions in the brain. incoordinalion.
Riboflavin
Riboflavin contains three linked six-membered rings, with a sugar alcohol attached to
the middle ring. The name comes from its yellow color (flavi11 means "yellow" in
L.1.tin ). Riboflavin is a component of two coenz)rmes that play key roles in energy me·
Gory suffers from alcoholism and pays no at-
tabolism: flavin mononucleotide (FMN) and flavin adenine dinuclcor:ide (FAD). 23
tention lo his diet. In oddition lo the detrimental
effects on the liver, excess alcohol consumption
Absorption, Transport, Storage, and Excretion of Riboflavin can cause deficiencies in certain B-vitomins.
Explain why this problem can occur.
In the stomach, HCI releases riboflavin from its bound forms. Absorprion is primarily
vi:i active transport or facilitated diffusion in the small intestine. In the blood, ri-
boflavin is transported by protein carriers. Ribofla\•in is converted to its cocn7yme
forms, FMN and fAD, in most tissues, but mainJy in the small inrcsrinc, liver, heart,
and kidney. A !>mall amount of riboflavin is stored in the Liver, kidneys, and hearl. Any
excess intake is excreted in the urine. 23 For people who take excessive amoums in sup-
plement form, riboflavin imparts a bright yellow color to the urine.
Functions of Riboflavin
Ribofl.1"in coenzymcs have oxidation-reduction (redox) reaction functions.23 These
cocnzymcs either take electrons from a substrate or gi,·e electrons to a substrate. In the
first case, the riboflavin cocnzyme undergoes reduction (gains electrons) and the sub-
strate undergoes oxidation (loses electrons). In other cases, the sequence is reversed
(the riboflavin is oxidized and the substrate is reduced). Un like some rcdox reactions,
ribofla,in docs not exchange isolated electrons, but rather exchanges hydrogen atoms.
Riboflavin cocnzymes arc involved in many enzyme reactions, a number of which
arc critical to energy metabolism. For example, the enzyme succinatc dehydrogenase
is a FAD-containing enzyme that accepts hydrogens from succinatc tO form fumarate
during the citric acid cycle. The hydrogens are then passed on to the electron trans·
port chain.
FAD FADH 2
Succinate '>-._ ,4 Fumarate
Another FAD-containing enzyme participates in the breakdown of fatty acids (beta
oxidation ) to acetyl-CoA, the entry compound for the citric acid cycle. And another
ribotla\'ll1-containing coenzyme, FMN, shuttles hydrogen atoms into the electron
transport chain. Still other FAD-containing cnzrmes help form the vitamin B-6 cocn-
zyme, synthesize the amino acid tryptopban inro the B-vicamin niacin, and participate
in folate metabolism (and in this way participate indireccly in homocystcine metabo-
lism ) . .Metabolism of the oxidized form of glutathione (abbreviated GS; this binds to
another GS ro form GS-SG ) to the reduced form (2 GSH) is dependent on the FAD-
requiring en.lyme glutathione reductase. Recall from Chapter 9 that this process is part
of the cell's antioxidant defense system .
FADH2 PAD
GSSG _'>-._-=----""4--. 2GH
Riboflavin (oxidized)
. . .
-
Riboflavin (reduced)
- -
For riboRovin, the italicized R denotes H in the

Food Sources of Riboflavin free vitamin; phosphate in FMN; ond on adenine
dinudeotide in FAD. In the reduced form of riboflavin,
Food Item and Amount Riboflavin (mg) the hydrogens ore shown in red in this figure.
Multigrain Cheerios,
3/4 cup 1.3
Fried beef liver, 1 oz 1.2 Riboflavin in Foods
Steamed oysters, 10 1.1 One-quarter of the riboflavin in our diets comes from mill< products. The rest of our ri-
Plain yogurt, I cup 0.5 boflavin intake typically comes from eruiched white bread, rolls, and crackers as well as
Brewer's yeast, 2 tbsp 0.5 from eggs and meat. Foods rich in riboAavin are liver, mushrooms, spinach and other
Row mushrooms, 5 0.5 green leafy vegetables, broccoli, asparagus, low-fut and fat-free milk, and cottage cheese.
Exposure to light (ultraviolet radiation) causes riboflavin to break down rapidly. To
Brounschweiger sousoge, 1 oz 0.4 prevent this light-induced breakdown, paper and plastic cartons-not glass-should be
Cooked spinach, 1 cup 0.4 used in packaging riboflavin-rich foods such as milk, milk products, and cereals.
l % milk, l cup 0.4
Buttermilk, l cup 0.4 Riboflavin Needs
Boiled egg, I 0.3 The RDA for riboflavin is 1.1 to 1.3 mg/day for adults. T he most commonly used
Sirloin steak, 3 oz 0.3 method for assessing riboflavin Stanis involves the maintenance of normal erythrocyte
Feto cheese, 1 oz 0.2 (red blood cell) glutathione reductase activity and urinary ribof:l:.win excretion. These
Tortillo, 1 0.2 tests were used to establish the RDA. 11 The Daily Value for riboflavin used on food
and supplement labels is 1.7 mg. North Americans have an intake of approximate!}'
Leon ham, 3 oz 0.2 2.1 mg/day for men and 1.5 mg/day for women. There appear to be no adverse ef-
RDA for adult men, 1.3 mg; adult fects from consuming large amounts of riboflavin because of its limited absorption and
women, 1.1 mg rapid excretion via the wine, and so no Upper Level has been set. 11
Riboflavin-Deficiency Diseases
The signs and symptoms associated with a pure riboflavin deficiency (technically called
ariboflavinosis ) include inflammation of the tongue (glossitis), cracking of tissue ariboflavinosis A condition resulting from o
around the corners of the mouth (chcilosis), seborrheic dermaLitis (a disease of these- lock of riboflavin. The a means "without," and
baceous glands of the skin), inflammation of the mouth (stomatitis) and throat, vari- the osis stonds for "a condition of."
ous eye and nervous system disorders, .rnd confusion and headaches (Figure 10-3). 23
At pre.sent, little is kno\\'n about the possible consequences of a marginal riboflavin de-
ficiency. One possibility is that people may become tired more quickly du1ing physical
acti\·ity, although e\·idence for thjs is not conclusive.
The first e\·idence of a severe deficiency is inflammation of the mouth and tongue.
The complete picture of a deficiency develops after approximately 2 months on a
riboflavin-deficient diet (consuming one-fourth of the RDA ). Diseases such as cancer,
certain forms of cardiovascular disease, and diabetes also arc known to precipitate or
worsen a riboflavin deficiency. However, a deficiency disease associated with an isolated
lack of dietary riboflavin is rarely seen in otherwise healthy people . And because ri-
boflavin functions along with other B-vitamins (e.g., vitamin B-6, niacin, thiam.in, and
folatc ) in numerous metabolic pathways, some symptoms ascribed to riboflavin defi-
ciency arc actually caused by the failure of metabolic pathways associated with a lack of
other nutrients. As alread\• noted, an assortment ofB-,·itamins, such as ribofla,m, thi-
an1i.n, and niacin, is often. found in the same foods. 11
Alcoholics risk a ribofla,·in deficiency because they often eat a very nutrient-deficient
diet. Long-term use of phenobarbital may also compromise ribotla\'in status because
this drug produces metabolic changes in the liver that increase the breakdown of the
vitamin. Marginal intakes may also be seen in people who do not consume milk or milk
products. All such people would be wise to search for another, plenrifu l dietary source
of riboflavin, such as enriched breads or ready-to-ear brcakfust cereals.
Niacin
The B-dtamin niacin actually exists in two forms-nicotinic acid ( niacin ) and nico-
tinamidc (niaci.namide). In the body, both forms of the \itamin perform the functions
asi.oci.ued with niacin. The two coenzyme forms of niacin are nicotinanude adenine
dinucleotide (NAD+) and nicotinamide adenine dinucleotidc phosphate (NADP+).
Both forms participate in numerous chemical reactions in the body.3
Absorption, Transport, Storage, and Excretion of Niacin

Nicotinic acid and nicotinamide arc readily absorbed from the stomach and the intes-
tine by active rransporc and passi\•e diffusion, so that almost all niacin consumed is ab-
sorbed . Niacin is transported from the liver to aJJ tissues, \\here it is converted to its
Figure 10·3 I A painful, inflamed tongue
coenzymc forms, NAD+ and NADP+, which function in either oxidized or reduced
(glossitis) con signal a deficiency of riboflavin,
forms . Niacin coenzymes are stored in the liver. Any excess niacin intake is excreted as
niacin, vitamin B-6, folate, or vitamin B-12.
a \'ariety of metabolic products in the urine. 3 Ohen more than one deficiency Is the cause.
Because other medical conditions can also
cause glossitis, further evaluation is needed
Functions of Niacin before a nutrient deficiency can be diagnosed.
Like the cocnzyme forms of ribotla\'in, the coenzymc forms of niacin, NAD+ and
NADP , arc active participants in oxidation-reduction reacrion:.. 3 The niacin coen-
zymcs function in at least 200 reactions in cellulru· metabolic pathways, especially those
used to produce ATP. NAD+ participates in catabolic reactions, acting as an electron
and hydrogen ion acceptor in glycolysis (e.g., the conversion of glucose to pyrm·ate)
and the citric acid cycle. Under anaerobic conditions, the resulting reduced form,
NADH + H +, is used in converting pyruvate to lactate, thereby regenerating NAD +.
Glucose to Pyruvate
2ADP 2 Pi 2NAD+ 2NADH + 2H+
Glucose \... \.._ ~ _/ • 2 Pyruvate
'
2ATP
Pyruvate to Lactate
NADH + H+ NAD+
Pyruvate "---.. -4 Lactat e
The Citric Acid Cycle
NAD+ NADH + H+
Isocitrate "---.. -4 Alpha-ketoglutarate
NAD+ NADH + H+
Alpha-ketoglutarate _"---..~--4~~ Succinyl - CoA
NAD+ NADH + H+
Malate "---.. -4 Oxaloacetate
Under aerobic conditions, NADH + H + also donates an electron and hydrogen to
other acceptor molecuJes in the electron-transport chain.
NADH + H+ NAD+
~ 2 H+ + 2e- + 1/2 0 2 ---'I•~ H 20
The enzyme alcohol dehydrogenase also uses NAD to convert alcohol to acetaldehyde
(review Chapter 8 ).
Each of the reactions shown here starts with an oxidized form of a niacin coenzymt:.
However, synthetic pathways in the cell-those that make new compounds-use a re-
Food Sources of Niacin duced form of the niacin coenzyme, specifically NADPH + H +. This coenzyme is im-
Food Item and Amount Niacin {mg) portant in the biochemical pathway for fatty-acid synthesis. Cells that synthesize a lot
of fatty acids (e.g., those in the liver and female man1111ary glands) have higher con-
Tuna, 3 oz 11.3 centrations ofNADPH + H + than do cells not involved in fatty-acid synthesis (e.g.,
Roosted chicken, 3 oz 10.l muscle cells).
Peanuts, l /2 cup 9.9
Baked salmon, 3 oz 8.6
Niacin in Foods
Turkey lunch meat, 3 oz 5.4
Ground beef, 3 oz 5.0 Niacin can be found in foods as the vitamin itself or as the amino acid tryptophan,
which can be synthesized into niacin by the body. About 25% of the preformed niacin
Row mushrooms, 5 4.7 in North American diets comes from poultry and mixed dishes that include meat, fish,
Leon steak, 4 oz 4.5 and poul try. Another 11% comes from enriched bread and bread products.
Chunky peanut butter, 2 tbsp 4.4 If a person is on a high-tryptophan intake, much of the tryptophan is available for
4.1 synthesis of niacin, because tryptophan needs for protein synthesis a.re met (each
Fried beef liver, l oz
60 mg yields 1 mg of niacin) . The overall number of milligrams of niacin supplied by
Raisin Nut Bron cereal, 3/4 cup 3.8 dietary protein can be estimated by dividing dietary protein intake (in grams) by 6.11
Tortilla, l 2.6 For example, if one consumes 90 g of protein, the body will synthesize about 15 mg
Baked cod, 3 oz 2. 1 of niacin. In this way we synthesize much of our need for niacin. Note that this syn-
thesis requires input from riboflavin and vitamin B-6.
Potato, l 2.1
Rieb sources of niacin are mushrooms, wheat bran, tuna (as well as other fish ),
Broiled halibut, 3 oz l.6 chicken, turkey, asparagus, and peanuts. Animal proteins (except gelatin) are especially
RDA for adult men, 16 mg NE; rich in rryptopban. Unlike some other water-soluble vitamins, niacin is very beat sta-
adult women, 14 mg NE ble, and little is lost in cooking.
www.mhhe .com/wardlawpers 7 345
Coenzyme
forms using
nicotinamiC!e
The two coenzyme forms of niacin, NAO and NADP, contain

nicotinamide linked to adenine dinucleotide or adenine
dinucleotide phosphate, indicated by the italicized R. Both
coenzymes undergo oxidation and reduction by loss or
addition of on electron and a hydrogen (red in this figure).
Because food composition tables list only preformed niacin, they can underestimate
the total niacin supplied by protein foods. For example, although eggs and milk lack
niacin, they contain abundant tryptophan and thus indirectly contribute substantial
amounts of niacin.
Populations that eat corn as a staple food are prone to a niacin deficiency caJJed pel-
lagra. You might therefore be surprised co learn that the niacin content of corn is suu-
ilar to that of rice and considerably higher tl1an iliac of most other vegetables.
However, the niacin in corn is marginally absorbed because it is tightly bound by a pro-
tein. Soaking corn in an alkaline solution such as lime water (calcium hydroxide dis-
solved in water) releases bound niacin, rendering it more usable by the body. Look for
e"idencc of this form of processing on the label when you buy corn-meal products
such as tortillas. Because this practice was common among native peoples of Mexico
and Central and South America, they did not suffer from a niacin deficiency. Early
Spanish explorers of the New World took corn-a crop native to the Americas-back
to Europe, but they were unaware of the importance of soaking corn in lin1e water.
Thus, as the use of corn as a staple spread in Europe, niacin deficiencies became wide-
spread dming the 1700s. In contrast, Spanish settlers in Latin America learned from
the native populations to soak corn meal in lime water before using it in cooking. The
Hispanic populations descended from these settlers continued this practice and rarely
suffered from niacin deficiencies, whereas other Nortl1 Americans who used w1treated
corn as a staple food often did.
Niacin Needs
For adult men the RDA for niacin is 16 mg/day, and for adul t women it is 14 mg/day.
The RDA for niacin is expressed as niacin equivalents (NE) to accoum for niacin re-
ceived preformed from the diet as well as that synthesized from tryptophan. The pri-
mary criterion used to establish tl1e RDA for niacin is tl1e mi.nary excretion of a niacin
metabolite, N-methyl nicotinamide. 1 l T he Daily Value for niacin used on food and
supplement labels is 20 mg.
Chicken is a good source of niacin. The
About the only population groups to exhibit a niacin deficiency in Norm Ame1ica
tryplophan present can also be metabolized lo
niacin. today are people with rare disorders of tryptophan metabolism (e.g., Hartnup's dis-
ease), alcoholics, and people with diseases tl1at greatly impair food intake.
Niacin-Deficiency Diseases
The first official record of the niacin-deficiency disease pellagra was made by Spanish
physician Casal in 1735. It was named ma/ de ta 1·osa, or "red sickness." The typical
red rash appears in areas exposed to sunlight, especially arou.nd the neck, whicl1 is
today called "Casal's necklace." Later d1e disease was renamed pellagra (from Italian
pelle, meaning "skin," and agra, meaning "rough").
Because almost every metabolic pathway uses eitl1er NAD+ or NADP+, it is not sur-
prising mar a niacin deficiency causes widespread damage in me body. The effects of
pellagra are known as the three Ds-dementia, diarrhea, and dermatitis (Figure 10-4 ).
If the disease is not successfully treated, death (the fourth D) follows. 3 Clinical evi-
dence of pellagra develops 50 to 60 days after instituting a niacin-deficient diet. Early
symptoms include diminished appetite, weight loss, and weakness.
Pellagra is the only dietary deficiency disease ever tO reach epidemic proportions in
me United States. During the early 1900s, cases of pellagra increased dramatically in
the southeastern region of d1e country, where com-a poor source of naturally avail-
able niacin and the amino acid tryptophan-was being increasingly used as a primary
component of the diet. More man 10,000 Americans died of pellagra in 1915. From
the end of World War I until the end ofWorld War II, an estimated 200,000 Americans
suffered from tl1e disease. Many people had such severe dementia that tl1ey \Vere forced
to live out their lives in mental institutions. One reason tl1at pellagra remained a prob-
lem in me soutl1easten1 United States for so long was me misimpression mar it was an
infectious disease. This assumption was disproved by Dr. Joseph Goldberger, a public
healtl1 specialist. He and some coUeagues exposed themselves in a variety of ways to bi-
ological samples from pellagra patients to demonstrate that d1e disease was not infec-
tious i.n nature. Goldberger also induced and cured pellagra in a p1·ison population
using dietary interventions.
The introduction of niacin-enriched grains in 1941 and improved intake of dietary
protein resulting from post-wartime prosperity eventual ly led to the disappearance of
pellagra in tl1e United States. Pellagra is still fotrnd today throughout Soud1east Asia
Figure 1 0·4 I The dermatitis of pellagra.
and Africa among populations whose diets lack sufficient protein and niacin.
Dermatitis on both sides of the body (bilateral)
is o typical symptom of pellagra. Sun exposure
worsens the condition. Pharmacologic Use of Niacin and Upper leveJ for Niacin
Consuming 1.5 to 2 g of nicotinic acid per day-about 75 to 100 times me RDA-
can decrease LDL-cholesterol and increase HDL-cholesterol.3 When combined with
diet, exercise, and other cholesterol-lowering drugs, megadoses of niacin can slow and
even reverse the progression of atherosclerosis. Niacin prescribed for high LDL-
cholesrerol must have a time-release coating. Otherwise, such megadose therapy may
have adverse effects, indLtding flushing of the skin (the initial adverse effect), itching,
GI n-act upsets (such as nausea and vomiting), and liver damage. These effects (GI
tract disturbances and liver damage) have been observed at doses ofl.5 g nicotinic acid
per day. Some people experience symptoms at dosages as low as 50 mg/day. Even with
the time-release coating, rnegadose use must be supervised by a physician because of
the potential for side effects. The use of various other medications can lessen the side
effects. For example, premedication with aspirin reduces the flushing reactions. ,[ n+.1... ~1~
The flushing seen \\~d1 excess niacin intake was considered the most appropriate ef-
fect on which to base the Upper Level. For adults, this amount is 35 mg/day of sup- Boih the vitamin niacin and protein-rich Foods
plemental niaci.n and/or that from fortified foods, the point at which this symptom can. cure pellagra. Why are both effective?
may begin. Note that niacin naturally found in food is not cow1ted. 11
Concept I Check
The B-vitamins thiamin, niacin, and riboflavin function in various biochemical pathways
used for the metabolism of glucose, amino acids, and fatty acids. Enriched grains are ade-
quate sources of alJ three vitamins. Otherwise, pork is an excellent source of thiamin; milk
is an excellent source of riboflavin; and protein foods in general are excellent sources of
niacin. Deficiencies of all three vitamins can occur with alcoholism; of the three, a thiamin
deficiency is the most like!)'· The specific deficiency symptoms typically occur iJ1 the brain
and nervous system, skin, and GI tract. Cells i.n these tissues are very metabolically active,
and those in the skin and GI tract are also constantly being replaced. Only niacin leads to
toxic effocts when consumed in high doses.
Pantothenic Acid
Panrothenic acid is part of coenzyme A (CoA), which plays a pivotal role in energy me-
tabolism. This coenzyme is formed when d1e vitamin combines with a derivative ADP
and part of the amino acid cysteine. Cysreine provides the sulfur atom, which is the
functional end of the coenzyme. 27
~I Acetyl-CoA
TH Amino acids I
~
of Pantothenic Acid
The pant0thenic acid portion of any coenzyme A in the diet is released dw-ing diges-
tion in the small i.ntestine. It is d1en absorbed as such or as a slight derivitive. Storage
is minimal and is as the coenzyme form, such as is fotmd in d1e liver. Excretion of pan-
tothenic acid is via d1e urine.27
Functions of Pantothenic Acid

Coenzyme A is essential for the formation of ATP from the breakdown of carbohy-
drate, protein, alcohol, and fat. 27 The formation of acetyl-CoA from the two-carbon
acetate that arises from thcis metabolism allows the acetate to enter the citric acid cycle.
In another series of reactions, acetyl-CoA combines with carbon dioxide to begin the
synthesis of fatty acids:
C02
Acetyl-CoA \:.... • Malonyl-CoA ............,... Fatty acid
2 carbons 3 carbons
Pantothenic acid also forms part of a compound called the acyl carrier protei11. This
protein attaches to fatty acids and shuttles them through the metabolic pathway de-
signed to increase their chain length. Finally, pantotl1enjc acid as coenzyme A also
donates fatty acids to proteins jn a process that can determine tl1eit· location and func -
tion witl1in a cell.
I H3 IH ~ ~
HO-CH2-C-CH-C-NH-CH -CH -C-OH
I 2 2
CH3
- - - .1-- ~-~1·1=- --- -, -~ "I': - - - -
·· Pantothenic acid 1
. ~-~:~ ~- -- ~--~--· _-
CH3 OH 0 0
RO - CH2 -
I I
C - CH-C- NH- CH2 -
II II ,----------------
CH2 - ( - - , NH -
-
CH2 - CH2 - SH :
I ·-----------------
Dietary Sources of Pantothenic Acid
cH3
Pantothenic ' --r11 -~ -. - - - -- ' -
Food Item and Amount Acid {mg} , Coenzyme A (CoA)

-~"'11"· -:~- • -
I_ ..._ I - \ __
Total corn flakes cereal,
3/.4 cup 11.8 Pontothenic acid is converted to coenzyme A by combining with o port of the amino acid cysteine (box)
and with o derivative of adenosine diphosphate (ADP), represented by the italicized R.
Power bar, 1 10.0
Luna bar, 1 9.9
Sunflower seeds, 1/4 cup 2.3
Pantothenic Acid in Foods
Fried beef liver, 1 oz 1.7
Raw mushrooms, 5 1.7 The Greek word pantotben, meaning "from every side," reAects the ample supply of
pantotl1enic acid in foods. Common sources include meat, mi lk, and many vegetables.
Plain yogurt, 1 cup 1.5 Rich sources of pantothenic acid are mushrooms, liver, peanuts, eggs, yeast, broccoli,
Acorn squash, 1 cup 1.2 and milk.
Peanuts, 1/2 cup 1.0
1% milk, 1 cup 0.9
Roosted chicken breast, Pantothenic Acid Needs
3 oz 0.8
For aduJts, the Adequate Intake set for pantothenic acid is 5 mg/day. (Recall that an
Broccoli, 1 cup 0.8 Adequate Intake is an acceptable intake established by tl1e Food and Nutrition Board
Baked potato, 1 0.7 for some nutrients for wrucb insufficient data are available to set an RDA. ) Adults gen -
Legumes, 1/2 cup 0.7 erally consume the Adequate Intake or more. The primary criterion used to estimate
an Adequate Intake for pantothenic acid is the amount needed to replace urinary ex-
Cooked egg yolk, I 0.6
cretion.11 The Daily Value for pantothenic acid used on food and supplemenr labels is
Adequate Intake for adults, 5 mg 10 mg.
Pantothenic Acid-Deficiency Diseases

A deficiency of pantotbenjc acjd might occur in cases of alcoholism in which a very nu -
a-ient deficient diet is conswned. However, the effects would probably be rudden
among deficiencies of tbjamin, riboflavin, vitam in B-6, and fobtc, so the pantotbenic
acid ddiciency might go unrecognized. W hen a deficiency was experimentally ind uced
in humans, symptoms of headache, fatigue, impaired muscle coordination, and GI
tract <lisrurbances were seen. There is no known coxicity for pantothcnic acid, and so
no Upper Limit is set. 11
Biotin
Bimin participates in reactions in which carbon ilioxide is added to a compound. Mushrooms ore o good source of
pontothenic acid.
Absorption, Transport, Storage, and Excretion of Biotin
Biotin is commonly fow1d in two forms in foods: the free vitamin and the protein-bound
coenzymc form, called biocyt:in. In the formation of biocytin, biotin forms a bond with
t11e amino acid lysine in a protein. Biotin is absorbed from me small intestine, whereas
tl1e biocytin form is not absorbed until tl1e enzyme biotinidasc, wluch is present in me
small intestine, cleaves me bond linking biotin to a protein, releasing rhe free vitamin.
Biotinidase also is i1wol"ed in recycling biotin after biocytin is released rrom breakdown
of biotin-dependent enzymes. Biotin is stored in smal l amounts in che muscles, U\'er, and
brain. Biotin excretion is mostly via me urine (via bile is another route). 24
' '
Biotin
I
The vitamin biotin ottoches to o protein by formation of a bond between

its corboxyl group (red asterisk) and lysine in o protein, yielding the
bound cofactor form coiled biocytin.
Abour l in 60,000 infants is born wim a generic defect tl1at lcaYes tl1e infant "ith
very low amounts of the enzyme biotinidase. Because the infant cannot reailily break
down biocytin arising from dietary intake and body metabolism to the free form, a bi-
otin deficiency is likely to develop. The infant is a-eated with 100 µg of biotin, wruch
is abollt three times typical biotin needs.
Functions of Biotin
Biotin functions as an essential cofactor for five carbo:1..·ylase enzymes mac add carbon iliox-
ide to various compounds. 24 Four of the five enzymes are uwolved in energy and amino
acid metabolism, and me other is involved in making certain furry acids. The specific func-
tion of the first two is related to furry acid syntl1esis, namely adiling carbon ilioxide to
acetyl-CoA to form maJonyl-CoA (review the previous section on pantotl1enic acid for tl1e
specific reaction). This reaction is the first step in tl1e elongation of the carbon chain to
form a ratty acid.
Food Sources of Biotin

A third enzyme adds carbon dioxide to the 3-carbon p)rruvate to yield Lhe 4-
carbon oxaJoacetate, an intermecliate in the citric acid cycle. This reaction repknishcs
Food Item and Amount Biotin (µ.g) lost oxaloacetate and so helps keep the citric acid cycle functioning. In the liver and
Smooth peanut butter, kidney, oxaloacetate also can be converted to glucose when glucose supplies arc run-
2 tbsp 30. l ning low; this conversion is an initial step in gluconeogencsis.
Cooked lamb liver, l oz 11.6
ATP co?
Boiled egg, 1
Cooked egg yolk, 1
9.3
8.1
Pyruvate .....\...... ~~---·······,...... Oxaloacetate ..\.........,._ G lucose
3 carbons ' 4 carbons ~ Citric acid cycle
Low-fat yogurt, 1 cup 7.4 ADP+ Pi
Wheot germ, 1/4 cup 7.2
lf biotin were missing, the citric acid cycle could not run effectively, and the result
Roosted peanuts, 5 6.5 would be a buildup of lactate, the anaerobic by-product of glycolysis. This condition
Wheat bran, 1/4 cup 6.4 would also be accompanied b)r a decrease in aerobic metabolism.
Skim milk, I cup 4.9 A fow-th biotin-dependent enzyme contributes to the breakdown of the amino acid
leucine for energy needs, and a firrh does the same for the amino acids threonine, me-
Salmon, 3 oz 4.3 thionine, and isoleucine. Clearly, biotin is required for the metabolism of carbohy-
Egg noodles, l cup 4.0 drates, amino acids, and fatty acids.
Swiss cheese, 2 oz 2.2
Cheddar cheese, 2 oz 1.7 Sources of Biotin: Food and Microbial Synthesis
Row cauliflower, 1 cup 1.5 Biotin content of food has been determined for only a small number of foods, so foods
American cheese, 2 oz 1.4 containing biotin are not included in most food composition tables. Biotin is widely
Adequate Intake for adults, 30 µg distributed in food bur concentration varies considerably. Sources include whole
grains, eggs, nuts, and legumes.
It is likely that the intestinal synthesis of biotin by bacte1ia supplies at least part of
our needs, as evidenced by the rather rare iJicidence of biotin deficiency. In fact, we ex-
crete more biotin than we consume. However, questions remain about the actual
bioavailability of the biotin synthesized b)' the intestinal bacte1ia, because this produc-
tion rakes place mostly in tl1e large intestine, whereas biotin is most efficiently ab-
sorbed from the small intestine.
avidin A protein found in row egg whites that A protein called avidin in raw egg whites binds biotin and inhibits its absorption.
con bind biotin and inhibit its absorption; (Note that cooking denatures avid.in in such a way that it can no longer bind biotin. )
cooking destroys ovidin. Feeding many raw egg whites to animals leads to the classic "egg-white injury" defi-
ciency disease. An occasional raw egg would not cause this problem because it would
take a regular daily consumption of 12 to 24 raw eggs to produce a biotin deficiency.
Biotin deficiency resulting from consuming raw eggs has been reported, however, in
people with alcohoHsm who eat as few as three raw eggs a day. These peopk also prob-
ably exist on very deficient diets.
Biotin Needs
The Adequate Intake for biotin for adults of 30 µ,g/day is extrapolated from the in-
take seen in exclusively breastfed infants. The results of such an extrapolation likely
overestin1ate the amount needed for adults because adults require biotin only for main-
tenance, not for growth. l l Diets of adults generally meet the Adequate I make. The
Daily Value for biotin used on food and supplement labels is 300 µ,g, 10 times our cur-
rent estimate of needs. There is no Upper Level for biotin. 11
Biotin-Deficiency Diseases
If w1detected, a lack of biotinidase activity leads to a severe biotin deficiency in infants.
Signs and symptoms may appear within a few months ofljfe, beginning with a skin rash
and hair loss. Other signs and symptoms include convulsions, other neurological dis-
orders, and impaired growtl1. Most other weU-documented cases of biotin deficiency
have occmred with rotal parenteral nutrition when the biotin was omitted from the
formula. OveraU, a biotin deficiency is rare. 24
Vitamin B-6
Vitamin B-6 is actually a family of three compounds: pyritloxal, pyridoxine, and pyri-
doxamine. All tlu·ee forms can be phosphorybtcd to the active \'itarnin B-6 coenzymes,
the prim3ry one being pyridoxal phosphate (PLP). The cocnzymcs p.micipate in nu-
merous metabolic reactions. The;: generic name for the vitamin is B-6, or pyridoxine. 20
Absorption, Transport, Storage, and Excretion of Vitamin B-6

Both the coenzyme and free forms of' itamin B-6 can be absorbed by passive means.
\ Titamin B-6 as such is transported to the li,·er ,·ia the portal blood, "here ultimately
the three forms of the vitamin arc phosphorylated. From the liver the phosphorylatcd
forms (mainly PLP) are released to general circulation bound to a blood protein (al-
bumin ) for transport. T he main storage of vitamin B-6 in the bod)' takes place in mus-
cle tissue. Excess vitamin B-6 is generally excreted in the urine. 20
0
II
C-H
I
~ c .........._ .
HO-C C-CHpH
I ~
H3C-C ~ ~
Vitamin 8-6
(represented by pyridoxal)
Pyridoxol, one form of vitamin B-6, is converted to on
active coenzyme-pyridoxol phosphate (PLP)-by the
addition of a phosphate group to the hydroxyl group,
indicated in this figure by the red asterisk.
Functions of Vitamin B-6 omocysteine is receiving much attention

Vit.imin B-6 as PLP plays a coenz)1me role in more than 100 enzymatic reactions, al-
H today, especially regarding development of
brain disorders, bone disorders, and cardiovas·
most .tlJ of which im·oJve nitrogen -containing compounds. cular diseose. 14•15,16, 17,25,28 Meeting Bvitamin
needs (riboAavin, vitamin B-6, folate, and vita-
Amino Acid Metabolism min B-12) and choline needs allows for metabo-
A major role of PLP is to participate in amino acid metabolism. 1-or example, PLP partic- lism of homocysteine to nutrients, such os the
ipates in reactions to form nonessenLial amino acids via transaminarion. (Ifwe didn,t have amino acids methionine and cysteine. This keeps
the services of PLP, every amino acid would be essential because it would have to be sup- homocysteine low in the blood and so protects
plied by Lhe diet.) PLP acts to loosen the bond between the nitrogen group (-NH?) and the body from its potentially toxic consequences.
the central carbon on the amino acid, allowing ir to be remo\'ed (Figure 10-5).20 -
PLP is responsible for the interconversion of D- md L-arnino acids- it acts as a
racemase. Recall from Chapter 7 that humans only use the L form of amino acids for racemase A group of enzymes that catalyzes
protein synthesis. PLP is also involn:d in the con\'ersion of homocystcine to cysteine, reactions involving structural rearrangement of
which occurs during methionine (an amino acid ) metabolism . o molecule (e.g., conversion of D-olanine
isomer to l-olanine isomer).
-CH3
Homocystcinc - - -1•- 4cystcinc
Vit,1111in B-6 part.icipates in both steps of the reaction. The methyl (-CH3 ) group is
accepted by a larger molecule (the amino acid serine; sec Appendix B for derails).
Figure 10- 5 I An example of a 0

transaminase enzyme pathway that utilizes II
vitamin B-6. This pathway allows cells to C-OH
synthesize nonessential amino acids. In this I
example, pyruvic acid gains an amino group 0 0 CH3-,-H
from glutomic acid to form the amino acid II II
alanine. CH3-C-C-OH _., NH 2
/ .----------~
Pyruvic acid I / Alanine
.---- >-+<
G-lu-to_m_ic~
o
II
ac-id-~I
I
I
f ~A-lp-ho---ke-lo_g_lu-lo-r-ic_o_c_id~
0 0 0
0 C-OH I II II II
HO-C-CH2-CH2-C-C-OH
II I
HO- C-CH2-CH2-C-H I
n the early 1950s, some infants were acci· I /

I dentally fed a commercial formula in which
vitamin B·6 hod been destroyed by oversteriliza·
NH2 --/
tion. The infants developed abnormal electroen·

cephologram (EEG) readings and experienced Heme Synthesis
convulsions. The reason was probably associ· In the red blood cell , PLP catalyzes a step in the synthesis of heme. Heme is a nitrogen-
ated with a lack of neurotransmitter synthesis in containing ring. It is inserted into certain proteins to hold iron in place. The best known
the brain. The situation was successfully treated of t hese proteins is hemoglobin, which uses the iron to transport oxygen in the blood. 20
with vitamin B-6.
Carbohydrate Metabolism
PLP is part of the enzyme that releases glucose from glycogen during glycogen break·
down. Therefore, vita111i11 B-6 helps maintain blood glucose concentrations. This ac-
tion is an exception to the rule that vitamin B-6 works with nitrogen-containing
compow1ds. The chemistry of PLP with this glycogen breakdown enzyme diffors from
the typical chemistry of PLI' with cnzymes. 20
Food Sources of Vitamin 8·6
Food Item and Amount Vitamin B-6 (mg} Neurotransmitter Synthesis
Baked salmon, 3 oz 0.8 Not only a.re amino acids used to buiJd proteins, but they are also used to make non-
Baked potato, 1 medium 0.7 protein nitrogen compoWlds. Many of these compoW1dS are ne w·otransmitters, which
Bonano, 1 0.7 are important for brain function. PLP plays in the synthesis of the ne urotransmitters
Avocado, 1 0.6 serotonin from tryptophan, dopamine (DOPA) and norepinephrine from tyrosine, his-
tamine from histadine, and gamma-aminobutyric acid (GABA) from glutamic acid. 20
Brewer's yeast, 2 tbsp 0.5
Roosted chicken breast, 3 oz 0.5 Vitamin Formation
Acorn squash, 1 cup 0.5 PLP participates in the conversion of the amino acid t.ryptopban to the B-vitamin
Special Kcereal, 3/4 cup 0.5 niacin. 20
Whole wheal bread, 1 slice 0.5
Fried beef liver, 1 oz 0.4 Immune Function and Lipid Metabolism
Roosted turkey lunch meal, 3 oz 0.4 PLP affects immune function and lipid metabolism, probably via its roles in anlit10 acid
0.4 metabolism, hormone production, and possibly other functions. 20
Sirloin steak, 3 oz
Leon ham, 3 oz 0.4
Vitamin B-6 in Foods
Watermelon, 1 slice 0.3
Sunflower seeds, l / 4 cup 0.3 Vitamin B-6 is stored in the muscle tissues of animals, and thus meat, fish, and poul-
try arc some of the best sources of this vitamin. Although vitamin B-6 in animal foods
Cooked spinach, l /2 cup 0.2 is often more readily absorbed than that in plant foods, whole grains also are good
RDA for adults, 1.3 mg sm1rces of vitamin B-6. However, vitamin B-6 is lost during the refining of grains, and
it is not one of the vitamins added during enrichment. Most fruits and vegetables are
not good vitamin B-6 sources, but there are some exceptions: carrots, potatoes,
spinach, bananas, and avocados. Other sources of vitamin B-6 include peanut butter,
garbanzo beans, and ready-to-eat breakfast cereals.
Vitamin B-6 is not stable under heat or alkaline conditions. Heat pro<.:essing and
other destructive processing technologies can reduce the vitamin B-6 content of a food
by 10 to 50%.
Vitamin B-6 Needs

The adttlt RDA for \'itamin B-6 is 1.3 to 1.7 mg/day. The RDA is based on the
amount needed to maintain adequate PLP in the blood . 11 The Daily Value used on
food and supplement labels is 2 mg. Average daily consumption of vitamin B-6 for
adult men and women is somewhat above rhe RDA.
Vitamin B·6-Deficiency Diseases

The srmptoms of \itamin B-6 deficiency include seborrheic dermatitis, microcytic
hypochromic anemia (and occasionally a sideroblastic anemia, as desc1ibed in Chapter 8 ), Bananas are a good plant source of vitamin S-6.
convulsions, depression, and confusion. 20 The anemia reflects a decline in heme syn-
thesis due to an inadequate amount of PLP; the accLmmJation of abnorn1al metabolites
of tryptophan in the brain or a lack of neurotransmitters may cause the convulsions. microcytic hypochromic anemia An anemia
Be<.:ause \itamin B-6 is essential for the formation of a type of white blood cell, a defi - characterized by small, pale red blood cells
ciency is associated with dinUnished immune function. These deficiencies arc rare, but
that lock sufficient hemoglobin and thus hove
reduced oxygen-carrying ability. It is often also
there are some documented occurrences, sometimes du..: to akoholism or to a genetic
caused by on iron deficiency.
condition that causes an anemia that can often be reversed by increased vitamin B-6
intake. When alcohol is metabolized in the body, an intermediate, acetaldehyde, is pro-
duced. Acctaldehyde decreases the formation of PLP by cells and perhaps competes
with PLP for protein-binding sites.
A number of medications-especially L-DOPA, used tO treat Parkinson's disease,
and isoniazid, a common antituberculosis medication-reduce blood concentrations of
PLP. Patients taking these medications should be advised to obtain extra vitamin B-6
under a physician's guidance. Finally, some adults have been found to exhibit signs of
a mild deficiency, su<.:h as reduced immune function, a high con<.:emration of homo-
cysteine in the blood, and coronary artery disease. 11 •14
Pharmacologic Use of Vitamin 8-6 and Upper Level

for Vitamin B-6
Carpal tunnel syndrome, a nerve disorder in the wrist, has been treated with large daiJy
doses of vitamin B-6. Resulrs have been inconsistent, leading experts to caution about
any use of megadoscs of vitamin B-6 for such a purpose.
Srudies of vitamin B-6 and premenstrual syndrome (PMS) indicate that the evi- premenstrual syndrome (PMS) A disorder
dence is so shaky that it is not possible to make a definitive recommendation for tak- found in some women o few days before a
ing vitamin B-6. Because there are no laboratory testS for PMS and the cause of menstrual period begins. It is characterized by
symproms has not yet been elucidated, well -conrrolled trials are needed to clarify the depression, anxiety, headache, bloating, and
possible benefits and side effects of vitamin B-6 in the treatment of PMS. Some physi- mood swings. Severe coses ore currently
<.:ians, however, advise doses of 50 to l 00 mg/day as a possible part of therapy. Such termed premenstrual dysphoric disorder (PDD).
large doses may also help treat nausea that develops dming pregnancy (see Chapter 16 ).
The Upper Level for adults is set at 100 mg of vitamin B-6 per day, based on dc-
\'elopmem of nerve damage. LI Intakes of 2 to 6 g of vitamin B-6 per day for 2 or more
monrhs especially can lead co irre\'ersiblc nerve damage, as can long-term intakes of
greater than 200 mg/day. 20 Body builders and women attempting to treat themselves
for PMS have developed symptoms such as walking difficulties and hand and foot
numbness. Some nerve damage in individual sensory neurons is probably reversible,
but damage to ganglia (where many nerve fibers converge) is probably permanent.
Concept I Check
Panrothcnic acid and biotin both participate in metabolism of carbohydrate, protein, and
fut. A deficienC) of ciLhcr vitamin is unlikely because pantothenic acid is found in a wide va·
riery of foods and our need for biotin is partially mc.:t by synthesis from intestinal bacteria.
Vitamin B-6 is important for protein metabolism, neurotransmitter synthesis, and other key
metabolic fimctions. Headache, anemia, nausea, and vomiting can result from a 'itamin B-
6 deficiency. Animal protein sources and plant foods such as potatoes, spinach, and b.rnanas
are good sources of \'itamin B-6. Doses of vitamin B-6 in excess of approximately 1500
times rbe RDA for a few months or 150 times the RDA for long-term use can cause ncm:
destruction.
I Folate
The word folntc derives from the Latin word for leaf (folimn) because dark green, leaf)'
vegetables arc among the best sources of this vitamin. It was once thought that a
folare-deficil.!nt diet was virtually impossible to produce unless the diet w~ls grossly de-
ficient in many nutrients. Today, this attitude has changed as dietary folare inr.ike has
become a major issue of interest because of its many roles in metabolism.
Folate and 'itam111 B- 12 produce a number of identical deficiency signs and svmp·
toms when omitted from the diet. These t\\'O water-soluble \1tamins share a close re-
lationship because a vitan1in B-12 coenzyme is needed to recycle a folate cocnzymc for
repeated function. 11
What we call folaLe today was known earlier as either folic acid o r fo lacin. Today, the
term folatc is a generic name for the vitamin and also refers to the various forms of' thc
vitamin found n:nurally in foods. Folic acid refers specifically to the form of the vita·
min found in supplements and fortified foods.
Leafy green vegetables ore good sources of Folate consiscs of three parts: pteridine, para-aminobenzoic acid (PABA ), and one
folate. or more molecules of the amino acid gluramic acid (glutamate). If only one glutamate
molecule is present, it is designated folic acid (folate monoglutamate). In food, about
90% of the folate molecules have three or more glutamates attached and arc known ,1s
polyglutamatcs. 26
ABA by itself is sometimes added to supple·

ments, but there is no current scientific ro·
tionole for this.
Pteridine Para·aminobenzoic Glutomate

acid
Folic acid, also called folate monoglutamate, is the form absorbed in the intestine. Most of
the folate naturally found in foods, however, contains addi tional g lutamate molecules linked
to the carboxyl group, indicated in this figure by the red asterisk. (These addi tional
g lutamates need to be removed before absorption. )
Absorption, Transport, Storage, and Excretion of Folate

To be .lbsorbed, folate polyglutam.ltcs must be broken down (hydrolyzed ) to the
monoglutamate form in the GI tract. Enzymes, folate conjugases, located in the ab- conjugase Enzyme systems in the intestine thot
sorptive cells, allow for the removal of the excess gluramatcs. The monoglutamate enhance folate absorption; they remove
form is then actively transported across rhc intestinal wall. Ver)' large doses of folk acid glutamate molecules from polyglutamate forms
from supplcmenrs are also absorbed by p.lssive diffusion. When synthetic folic acid is of folote.
consumed .is a supplement and without food, it is nearly 100% bioavail.lble. Consumed
with food, as in fortified cereal grains, ,\bsorption is slight!) reduced . 11
The portal blood draining the small intestine deli\'ers the monogluramate form of
folate to tile lher, where it is changed back to the pol\'glutamate form once in a cell.
(This change allows folate to be trapped in a cell. ) Folare is then either stored in the
li,·er or released into the blood or bile. Most of the urinary excretion of folare exits as
metabolic products. Biologically active folate is also excreted into the bile and is reab-
sorbed by enterohcpatic circulation. Alcohol interferes with this process, which is one
reason alcoholics often become fo late deficient.
Functions of Folate HFA transfers the following single-carbon

groups: methyl (-CH 3), formyl (-CH= O),
In cells, all forms offolate are readil) convened to the basic cocn6yme form, that trans- methylene (- CH2-), and metheynyl (-CH= )
fers a single-carbon group called terrahydrofolic acid (THFA). There arc actually five
acti'e coenz)'me forms ofTHFA. These forms participate in metabolic reactions by ac-
cepting and donating the single-carbon groups listed in the margin.
Metabolic Reactions
Transfer of these si ngle-carbon units is needed for the synthesis or DNA and the me- lthough folate deficiency can be induced lo
tabolism of various amino acids and their deri,·ati\•es. A crucial reanion requiring lreol cancer, folate deficiency may also
THFA is the transfer of a one-carbon methylene group (-CH 2-) to uridylate, forming cause concern with regard to cancer. Because
thymidylate, an essential component of DNA and thus cell replication: folote aids in the transfer of methyl groups for
DNA synthesis, even mild folote deficiency may
THFA( - CH2 - ) THFA (free) contribute to abnormal DNA integrity, which in
uridylate ·········~················~ thymidylate ······~·····~ DNA turn affects certain cancer-protecting genes. A
doily intake of 400 µ.g (the RDA) is thought to
THfA is also needed for the synthesis of adenine and guanine of DNA, so DNA syn- be chemo·preventive.
thesii. and repair may decline as a result of a folate shorrage.
Because THFA is needed for DNA synrhesis, folate deficicnC..:)' may be induced dur-
ing a common form of cancer therapy. One example is the cancer drug metl1otrexate.
lr inhibits a kcr aspect of folate metabolism. When methotrexate is taken in high doses,
it reduces DNA synthesis throughout the body by inrertcri11g with folatc metabolism.
This reduction in DNA synthesis can halt die growth of cancer cells, but it also affects bout 10% of the North American populo·
other r.lpidly proliferating cells, such as intestinal cells and red blood cells. Therefore, lion hos a defect in one aspect of folate
1.he typical side effects of methorrexate therapy are the same as for , folate deficiency metabolism. They may need up lo twice the RDA
(e.g., anemia and dfarrhea ). Metllotrcxatc acting as a folate antagonist is also used to lo compensate for the reduced activity on an en·
treat rheumatoid arthritis, psoriasis, asd1111a, alcoholic cirrhosis, and inflammatory bowel zyme thot converts folote to a related
disease. When people are given mcthotrexate, they need to follow a high-folatc diet coenzyme form.s Currently, testing for this defect
and/or rake folic acid supplcmcms to reduce the toxic side effects of the drug. High is not routine in medical practice, but one day it
supplemental doses generally bavc little or no influence on methotrexate 's effectiveness. may be.
Another kC}' function of folatc is the formation of neurotransmitters in the brain. 5
Meeting folate needs can improve the depressed state seen in some C<\Ses of mental illness.
Other Functions
THFA is important in amino acid metabolism, especially the inten:onversions of amino
acids. 5 Ir accepts one-carbon groups from various amino acids and is responsible for
the glycine to serine reaction, (this reaction is the main methyl group source for
THFA), the histidine to glutamatic acid reaction, and one of the pathways in the ho-
mocysccinc to medi.ionine reaction.
Food Sources of Folate -CH3

Food Item and Amount Folate (µg} Homocysteine -4 Methionine
Asparagus, 1 cup 263 Folate p<u·ac1pates in this reaction (and needs vitamin B-12 input to do so; see
Cooked spinach, l cup 262 Appendix B for derai ls).
Cooked lentils, l /2 cup 179 Folate may also help maintain normal blood pressure and reduce the risk of devel-
oping colon cancer. 13•22
Block-eyed peas, l /2 cup 179
Romaine lettuce, 1 1/2 cups 114 Folate in Foods
Great Groins cereal, 3/4 cup I 14
The biologicaJ availability of folatc varies with the source of the vitamin. The best
Tortilla, I 89 soul'ces, from the standpoint of amount and availability, are liver, fortified ready-to-eat
Cooked turnips, 1/2 cup 85 breakfast cereals and other grain products, legumes, and dark green, leafy vegetables i.n
Cooked broccoli, I cup 78 general. Other, less rich somces of folate include eggs, dried beans, and oranges.
Food processing and preparation can destroy 50 to 90% of the folate in food. Folate
Sunflower seeds, 1/4 cup 76
is extremely susceptible to destruction by heat, oxidation, and ultraviolet lighr.
Fresh orange juice, l cup 75 (Vitam in C in foods helps protect folate from oxidative destruction.) It is important ro
Cooked beets, I/2 cup 68 cat fresh frujts and lightJy cooked (or raw) vegetables on a regular basis to gain the full
Kidney beans, I /2 cup 65 benefits of their folate contents.
Fried beef liver, I oz 62 Folate Needs and Dietary Folate Equivalents
Brewer's yeast, l tbsp 60
The RDA for fobte for adults is 400 µ,g/day, as is the Daily Value used on food and
RDA for adults, 400 M supplement labels. This guantity is based on the amount needed to maintain red blood
cell folate, control blood homocystcine, and maintain normal blood fobtc concentra-
tions. Also considered was the intake necessary ro prevent neural tube defects for
women capable of becoming pregnant (see the next section 011 folare deficiency). L1
T he use of dietary folote equivalents (DFEs)

instead of the actual amount of folote in o
food hos some important implications. Typically,
Dietary fol ate equivaleats ( DFEs) a.re tJ1e units used to express fo late needs for all
stages of lite except childbearing years. (As you will learn in the next section, women of
child-bearing age should meet such recommendations with syntJ1c1:ic folic acid.) These
many foods will be richer in folote than the DFE units reflect the differences in absorption of food fo late and syntJ1etic folic acid.
Nutrition Facts label suggests because folote To estimate tJ1e aniotmt of DFE reguires some calculations. Fil'St, determine bm'
conlenl is due primarily to synthetic folic acid much of a day's food intake comes from food fol::tte and how much comes from syn -
added lo the foods, such as in enriched groins thetic folic acid added to foods. When in doubt, assume ail folate in a diet is derived
and ready-lo-eat breakfast cereals. This addition from food in that form, except that coming from ready-to-eat breakfast cereals and re-
contributes substantially to the DFE calculation. fined grain products. Also include in this second category any folic acid consumed as
Another implication is that food composition ta- part of dietary supplements. To calculate tJ1e DFE for the cliet, multiply total synthetic
bles (such as the one in the bock of this book) folic acid intake by l.7 and add that value to the total food folate intakc. 11 The fol-
and nutrition analysis software programs also lowing is an example. The Daily Value for a serving of ready-to-eat breakfast cereal
underestimate the true folote contribution of a consumed is listed on the label as 50%, so the amow1t of folic acid is 200 µg per serv-
diet compared to folote needs because these ing (Daily Value of 400 µg X 0.50). Because this folate is synthetic folic acid, the 200
hove not been updated to DFE units. µ,g is multiplied by 1.7, yielding 340 µg DFE. Assu me the diet also contains 300 µg
of food folate. To obtain the total DFE intake for the day, add the 300 µg to the 340
µ,g, which equals 640 µg DFE, more tJ1an enough for a man or older woman.
Folate-Deficiency Diseases
Folate deficiency can result from a low intake; inadequate absorption, which often is as-
sociated with alcoholism; increased need, most commonly occW"ring in pregnancy; com-
promised utilization, typically associated \.vitb vitamin B-12 deficiency; use of certain
cl1emotherapy mecli.cations; and excessive excretion, linked to Jong-stancling diarrhea.
Megaloblastic Anemia
A deficiency of folate fast affects cell types that arc actively synthesizing DNA; such
cells have a short life span and rapid turnover rate. 5 Thus, one of the major folate-
deticiency signs is changes in the early phases of red blood cell synthesis, because tJ1ese
cells tW'n over every 120 days. Without folate, the precmsor cells in the bone marrow
cannot di,·ide normally to become mature red blood cells because the~ cannot form
new DNA. The cells grow larger because there is continuous formation of R.i'!A, lead-
ing ro increased synthesis of protein and other cell components ro make ne" cells.
Hemoglobin synthesis also intensifies. However, when it is time for the cells to tfo•ide,
they lack sufficienc DNA for normal di'ision. The cells thus remain in ''large, imma-
ture form in the bone marro''• kno\\'n as m egalo blasts (Figure 10-6). megaloblast A large, nucleated, immature red
Unlike normal, mature red blood cells, megaloblasts retain their nuclei. ~lost of blood cell in the bone morrow that results from
these cells do not make it out of the bone marrow. Any of these cells that do enter the the inability of a precursor cell to divide when it
bloodstream are called macr ocytes. Their presence results in a form of anemia called normally should.
megalo blastic (or macr ocytic) anemia. macrocyte Literally "large cell," such as a
Large, immature cells also appear along the entire length of the GI tract during large red blood cell.
chronic folate dctic:icncy. 5 This occurs because these cells are replaced very th.:quently,
which means that DNA for the new cells has to be produced rapidly. In a folare deli- megaloblastic anemia A form of anemia
cicncy, cell division in the G I tract is impaired. This change contributes to decreased characterized by large, nucleated, immature
red blood cells that result from the inability of a
absorptive capacity of the GI tract and a pe rsistent diarrhea. White blood ce ll synrhc-
precursor cell to divide normally.
sis also is disrupted by a fol:i.te deficiency because these cells arc made in rapid bursts
du1·ing imm une challenges (e.g., infections). T hus, im mune function can be dimin- mocrocytic anemia Anemia characterized by
ished during a folate deficiency. This effect likely can occur with milder folate defi- the presence of abnormally large red blood
ciency than i!. needed to prod uce anemia. cells in the bloodstream.
Figure 1 0-6 I Megolobloslic anemia occurs

when blood cells ore unable lo divide, leaving
large, immature red blood cells. Either a folote
or vitamin B-12 deficiency may cause this
condition. Measurements of blood
concentrations of both vitamins are token to
help determine the cause of the anemia.
~ 4/
~
Foloteand
vitamin B· 12 Cells divide
Normal blood cells in the bloodstream.
The size, shape, and color of the red
blood cells show that they ore normal.
Mature red blood cells hove lost their
{ { "~\ adequate normally nuclei.
Folote or
Red blood cell vitamin B· 12
precursor deficient
(stem cell)
I )
Cells ore unable " '
to divide
Megaloblostic blood cells seen here

in the bone morrow ore arrested at on
immature stage of development. They
still hove their nuclei and ore slightly
larger than normal red blood cells.
Spine Affected
Healthy Spine by Spina Bifida
Skin on back -
Spinal card----;:=;::~.:.:.._;~~.,;
Spinal fluid----'~:-:::,--;~~....
Vertebra---- --:
Figure 1 0·7 I Neural tube defects result from a developmental failure affecting the spinal cord or
brain in the embryo. Very early in fetal development, a ridge of neural-like tissue forms along the back
omen who have had a child with a neu·
of the embryo. As the fetus develops, this material differentiates into the spinal cord and body nerves al
ral tube defect are advised lo consume the lower end and into the brain at the upper end. At the same time, the bones that make up the back
4 mg/day of folic acid beginning at least one gradually surround the spinal cord on all sides. If any part of this sequence goes awry, many defects
month before any future pregnancy. This must be can appear. The worst is total lack of a brain (anencepholy). Much more common is spine bifido, in
done under strict physician supervision. For fur· which the backbones do not form a complete ring lo protect the spinal cord. Deficient folate status in the
ther information about neural tube defects, see mother during the beginning of pregnancy increases the risk of neural tube defects, as does o genetic
the website www.sbaa.org. predisposition.
Neural Tube Defects

A maternal deficiency of folate and a genetic predisposition have been linkcd to the de-
neural tube defect A defect in the formation of velopment of neural tube defects in the fems (Figure 10-7) . These defects include
the neural tube occurring during early fetal spina bifida (spinal cord or spinal fluid bulge through the back) and anencephaly (ab-
development. This type of defect results in sence of a brain). Approximately 2000 infants arc born so affected annually in rhe
various nervous system disorders, such as spina United States. Victims of spina bifida may exhibit paralysis, incontinence, hydro-
bifida. A very severe form is anencephaly. cephalus, and learning disabilities. Children born with anencepbaly die shortly after
Folate deficiency in the pregnant woman birth. Adequate folatc nutriture is crucial for all women of childbearing years, because
increases the risk that the fetus will develop this neural nibe closure begins 21 days after conception and is completed by day 28, a time
disorder.
when many women arc not even aware that tl1ey are pregnant. Perhaps as many as 70%
of tl1cse defects could be avoided by adequate folare stams before conception.2 All re-
search has been done with synthetic folic acid supplementation, and it appears that
even women with varied diets may not consume adequate syntl1etic folic acid to pre-
vent neural tube detects (400 µ.g/day) unless specific attention tO synthetic folic acid
somces, such as many ready-to-cat breakfast cereals, is given. Most grain products are
now enriched or fortified with folic acid.
Because tl1e metabolism and functions of fol ate and B-12 are linked, rcgu lar con-
sumption oflargc amounts offolate can mask (e.g., prevent tl1e appearance) of the pri·
mary early warning sign of vitamin E-12 deficiency-enlarged red blood cells. 11 To
prevent such masking of vitamin B-12 deficiency, it is the goal of FDA t<> increase the
synthetic fo!ic acid intake of women of childbearing years tl1rougb grain enrichment
\\ithour producing excessin: intake by other groups(> 1 mg/ day offolic acid). This teps in Folate De6ciency
enrichment currently supplies adults in cl1e United States with about 200 µg/day of
synthetic folic acid. 1. Decrease in blood folate concentration
2. Decrease in red cell folote
3. Defective DNA synthesis
4. Change in slrucfure of certain white blood
cells
Suzanne and Ted should remember that spino bifido is caused by a failure of the 5. Increase in blood concentration of homacys·
spinal cord to close during the first 28 days of pregnancy, a time when neither Ted teine (and methylmalonic acid)
nor Suzanne will realize that Suzanne is pregnant. The B-vitamin folote must be 6. Megaloblastic changes in bone morrow and
available at the time of conception to prevent spino bifida and other birth defects. The fact that other rapidly dividing cells
a close relative of Suzanne's has already produced a child with this birth defect should be a 7. Increase in the size of circulating red blood
warning sign. Suzanne and Ted would be wise to seek the advice of a registered dietician to cells
ensure that Suzanne's prepregnancy diet provides enough synthetic folic acid. 8. Megaloblostic (mocrocytic) anemia
Other Folate Deficiency States

Folate dcfkiencics sometimes appear in pregnant women. They need exLra folate co
meet an increased rate of cell di\'ision and mus of DNA synchesis in their own bodies
and in me dc\'cloping fetus (600 µg DFE/day). 11 Today, prenatal care ofcen includes
prenatal multh·itamin and mineral supplements fortified with folate co compens:ne for
me extra needs associated with pregnancy.
Young women in general also often show low blood folate \'alues. Ir is important
for mem to seek good sources of syomeric folic acid mat they enjoy eating and then
to eat mose foods regularly, such as ready-to-eat cereals. The use of a balanced multi·
\'itamin and mineral supplement is another option. Older adults arc also at risk for fo.
late deficicncr Finally, persons suffering from alcohol abuse or taking certain
prescription drugs need to recognize mat mey may develop a folate deficiency.
Upper level for Folate

The Upper Level for synrhetic fo lic acid is 1000 µg (1 mg), based on its ability to mask
a vitamin B-12 deficiency when synthetic folic acid is given in high doses. 11 (However,
the Upper Level docs not apply to folate in foods because absorption is limited.) In re-
sponse to this problem, FDA limits the amount of folic acid in nonprescription vita-
min supplements for nonpregnant individuals to 400 µg when no statement of age is
listed on the supplement label. When age-related doses arc listed, there can be no more
man 100 µg for infanrs, 300 µg for children, and 400 µg for adults. Prenat:il supple-
ments sold over me counter can contain 800 µg.
Vitamin B-12
'Vhar we call 'itamin B- 12 includes the free vitamin cyanocobalamin and rwo active
coenzymes-merhylcobalamin and 5-deoxyadcnosylcobalamin. This \itamin has a
complex structure containing the mineral cobalt.6
All ,·iramin B- 12 compounds are synmesized exclusively by b:icceria, fungi, and
alg:ie. Animals such as cows and sheep obtain vitamin B-12 either from bacterial syn-
thesis in the multiple compartments of their stomachs (rumen ) or from the soil they
ingest while c;1ting and grazing. The only reliable source of the vitamin for humans is
animal foods. Plants do not synthesize vitamin B-12. There is minor contaminarion of
vegetable products by bacteri:i :ind soil, but it is not a reliable source. The proccsl> or
formentarion also contributes a small amount of vitamin B- 12 to a food.
I
Vitamin B· 12 (cyanocobalamin) ,
'
The cyanocobolomin form of vitamin B-12 is converted to the active

coenzyme forms by replacement of the cyono group (red) with another
group, such os o methyl group or a hydroxyl group.
Absorption, Transport, Storage, and Excretion of Vitamin B-12

Absorption ofvicamin B-12 is very complex. In the stomach, vitamin B- 12 in food i~
released from proteins b) the action of HCI and pepsin in gastric juice. The free B-12
R·protein A protein produced by the salivary binds to a protein, designated R-protein, that originates in the salivary gland!. in the
glands that enhances absorption of mouth and is swallowed along with the food. The R-protein/vitamin B-12 comple:.
vitamin S.12, possibly by protecting the vitamin travels to the small intestine, where it encounters pancreatic protease enzymes (e.g.,
during its passage through the stomach. trypsin), which rekasc the vitamin. Awaiting the free B-12 is intrinsic factor, a pro-
intrinsic factor A substance present in gastric tcinlike compound produced by the parietal cells in the stomach. The resu lting intrin-
juice that enhances vitamin S.12 absorption. sic factor/vitamin B- 12 complex travels to the terminal portion of the small intestine,
the ileum, where it attaches to special receptor cells on the brush border. Several hours
later, cells within the ileum absorb vitamin B- 12 and transfer it to a specific blood
transport protein, transcobalamin ll. This vitamin-protein complex enrers che portal
vein that drains the small intestine and is taken up by the liver and eventual!) the bone
marrow and red blood cells (Figure 10-8 ).6
It is assumed that 50% of dietary vitamin B- 12 is absorbed by healthy .1dults \\ ith
nom1al GI tract function. Vitamin B-12 is continually secreted into d1e bile, and most
of it is reabsorbed by cnterohepatic circulation. Failure in any of the links found in the
absorptive process reduces absorption to 2% or less of dietary vitamin 13- 12.
••nlnl-12
0 Salivary glands produce

R·protein.
D Food digested in stomach

releases vitamin B-12;
vitamin B· 12/R-protein link
forms in the ocid pH;
parietal cells in stomach
release intrinsic factor.
D Vitamin B· 12/R·protein link

protects vitamin B· 12 from
intestinal bocterio.
IJ Trypsin from pancreas releases

R·protein.
D Vitamin B· 12/lntrinsic factor

link forms in small intestine.
Ii) Vitamin B· 12/lntrinsic factor

complex arrives ot the ileum
where vitamin is absorbed into
the bloodstream ond bound to
transport protein, tronscobolomin II.
Figure 10·8 I Absorption of vitamin B-12. Many factors and si tes in the gastrointestinal tract
participate. Defects arising in the stomoch or small intestine con interfere with vitamin B-12 absorption,
in turn causing pernicious anemia.
Absorption of vitamin B-12 can be disrupted by numerous defects, including the

following: 1•11 •26
• Absence or defective synthesis of R·protein, pancreatic proteases, or inrrinsic factor
• Defective binding of the intrinsic factor/vitamin B-12 complex to receptor cells in
the ileum
• Absence (or surgical removal ) of much or all of the ileum and stomach
• Bacterial overgrowth of the small intestine
• Tapeworm infestation
• Use of certain anti-ulcer medications that significantly reduce acid production by
tl1e parietal cells (e.g., omeprazole [Prilosec])
• Chronic malabsorption syndromes, as can be seen in AIDS
About 50 to 90% of the body's total supply of vitamin B-12 is stored in the liver
(about 2 to 4 mg). In the body, little vitamin B-12 is excreted-just the small amount
that escapes cntcrohepatic circulation of the bile.
Functions of Vitamin B· 12
Vitamin B-12 is associated with cocn.lymcs that move one-carbon groups.6 An exam·
mutase An enzyme that rearranges the pie of an enzyme that uses a vitamin B-12 coenzyme is methylmalonyl CoA mutase.
functional groups on o molecule. This enZ}'ffie requires Yitamin B-12 to com·crc methylmalonyl CoA to succinyl CoA,
an intermediate in the citric acid cycle. This reaction allows ratty acids \\ith an odd
number of carbons (most, but not all, fatty acids have an even number) to be oxidized
for energy. The enzy me methionine synthase requires a vitamin B-12 coenzymc tor the
transfer of a methyl group from mcthyltctrahydrofolatc to homocysteine to form me·
d1ioninc and tctrahydrofolate, as shown on page 356 and in Appendix B.
Vitamin B-12 cocnzymcs also end up helping recycle folate coenzymes. vVhcn fo ·
late coenzymes function, their chemical composition changes as various single-carbon
groups arc added. In a variety of chemical reactions, vitamin B-12 is needed to turn
the folate coenzyme back into the original chemical structure that can resume function
(e.g., free of the added single-carbon group). Vitamin B-12 also plays some roles in
the nervous system, some of which arc not fully understood. 11
Food Sources of Vitamin B· 12 Vitamin B-12 in Foods

Food Item and Amount Vitamin B-12 (µg) Sources of vitamin B-12 include animal products such as meat, poultry, seafood, and
Fried beef liver, 1 oz 31.7 eggs. Especially rich sources of vitamin B-12 (µg/kca l) are organ meats (especially
Baked clams, 1 oz 15.7 liver, kidners, and heart). Another source of vitamin B-12 is dairy products.
Boiled oysters, 2 14.4

Vitamin B· 12 Needs
Brewer's yeast, 2 tbsp 3.0
lobster, 3 oz 2.7 The RDA of vitamin B-12 for adults is 2.4 µg/ day. It is based on maintaining enough
vitamin B-12 in the bod) to adcqu.uely synthesize red blood cells. 11 The Daily Value
Pol roost, 3 oz 2.5
used on food and supplement labels is 6 µg. On average, adult men consume 3 timcl>
Plain yogurt, 1 cup 1.4 the RDA and women consume 2 times the RDA. This high intake provides the aver·
Corn Flakes cereal, age meat-eating person wid1 2 to 3 years' storage of vitamin B-12 in the liver. For men
3/4 cup 1.1 and women 51 years and older, the RDA is also 2.4 µg of vitamin B-12 per day, buc
Shrimp, 3 oz 1.0 this population group is advised to select foods fortified with vitamin B-12 (e.g., rc.1dy-
to-eat breakfust cereals) and/or to rnke a supplemental form. Absorption offoodbornc
1% milk, 1 cup 0.9
vitamin B-12 is hampered by the typical full in gastric acid output seen in aging, called
Soy milk, 1 cup 0.8 achlo rhydria, but the vitamin B-12 thar is added to foods or supplements is not. 1
Soiled egg, 1 0.6 No adverse effects have been observed with excess vitamin B-12 intake from food
Leon ham, 3 oz 0.6 or from supplemcms, so there is no Upper Level for this vitamin. Ll
Beef hot dog, 1 0.5
Hom lunch meat, 2 oz 0.4 Vitamin B· 12-Deficiency Diseases
RDA for adults, 2.4 µg Researchers in mid-nineteenth-century England noted a form of anemia that causl'.s
death within 2 to 5 years of initial diagnosis. They called this disease pernicious
anemia (pernicious literally means "leading to death"). 6 We now know that this ane-
mia is caused by a genetic problem in the production of intrinsic factor thac is needed
achlorhydria A decrease in stomach acid
primarily due to age-associated loss of ocid- for vitamin B- 12 absorption. Clinically, this disease looks like a folace-deficienq anc·
producing gastric cells. mia, because a vitamin B-12 deficiency impairs folace function. For patients with either
a folace or vitamin B-12 deficiency, many megaloblasts (macrOC)'tes) are seen in the
pernicious anemia The anemia that results from blood. As in folate deficiency, the cause of the anemia is an interference with normal
the inability to absorb sufficient vitamin B- l 2; it synthesis of DNA.
is associated with nerve degeneration, which
A vitamin B-12 deficiency also produces nerve degeneration, which can be fatal.
con result in eventual paralysis and death.
The neurological complications produce sensory disturbances in the legs, such ;ii; tin-
poresthesio An abnormal spontaneous gling and numbm:ss (coUl'.ctivcly rdcrrcd to as parestbesia). 21 These unpleasant sen·
sensation such as of burning, prickling, and sarions often are worse in the lower legs. Walking is difficult and "position scme" 1s
numbness. seriously affected. Many mental problems exjst as well, such as loss of concentrntion
and memory, disorientation, .md dementia. As the condition worsens, bowel and blad -
der control is lost. Visual disturbances arc common. There also are numerous GI tract
problems, from a sore tongue to constipation.
Infants who are breastfed by vegetarian or vegan mothers can develop vitamin B-12
deficiency, accompanied by anemia and Jong-term neurological problems such as di-
minished brain growth, degeneration of the spinal cord, and poor imellecnial devel-
opment. The problems may have their origins during pregnancy if the mother is
deficient in vitamin B-12.
Adult vegetarians can also become vitamin B-12 deficienc, though if an adult be-
comes a vegetarian, vitamin B-12 stores in the liver can delay a severe deficiency for a
Jong time (even years). Vegetarians have several options for obtaining vitamin B-12. If
they are not vegans, they can obtai n vitamin B-12 from dairy products. Eggs also con-
tain some vitamin B-12. In addition, vegetarians can take a supplement that contains
vitamin B-12 or cat food products fortified with vitamin B-12 (review Chapter 7 for
further details).
People with malabsorption syndromes of any kind have an increased need for vita-
min B-12. These situations include people who have had their stomach either bypassed
or removed, people who have had their ileum removed, and patients with Crohn's dis- Fish, seafood, and related products are good
ease or any disease involving the ileum. People who are HIV-positive \\ith chronic di- sources of vitamin B-12.
arrhea may develop vitamin B-12 deficiencies. Several other medical conditions, such
as reduced secretions of the pancreas (ch.rank pancreatic disease) and bacterial infoc-
tions of the intestinal tract, reg Llire extra vitamin B-12 because of decreased bioavail-
ability of the vitamin from food. 6
Older people may often have problems with absorbing vitamin B- 12 due to reduced
stomach production of gastric acid, which frees vitamin B-12 from food proteins. This
decrease can lower vitamin .B-12 absorption to the extent that it creates a marginal vi-
t•1min B-12 deficiency. 1 This deficiency is nor severe enough to produce anemia, but it
can cause neurological problems and elevated blood homocysteinc. This degree of im-
paired vitam in B-12 absorption can usually be overcome by a moderate increase of oral
vitamin B-12 intake via fo rtified foods or su pplements.
Three types of therapy are possible for patients diagnosed with a major defect in vi- n the 1920s, researchers found that a
tamin B-12 absorption: monthly injections of vitamin B-12 to bypass the GI tract, use vitamin B-12 deficiency con be cured by con-
of a vitamin B-12 nasal gel (nasal absorption does not reqL1ire the intrinsic facror), or sumption of massive amounts of liver or concen-
weekly ingestion of vitamin B-12 supplements in megadoses ( 300 times the RDA), trated waler extracts of liver. In this case, the
which allow absorption by passive diffusion. Most cases of vitamin B-12 deficiency deficiency was caused by on absorption defect.
among othervvise healthy people in North America result from a defect in vitamin If enough of the vitamin is ingested, it can be
B-12 absorption rather than from inadequate intake. 6 absorbed by simple diffusion, thereby overcom-
ing the defective R-prolein/inlrinsic factor
system.
Concept I Check
Folate is needed for ceU division because it is essential for DNA synthesis. A folate defi-
ciency results in macrocytic anemia as well as diarrhea, inflammation of the tongue, and
poor growth- all signs of inadequate cell division. Folate is found in fresh vegetables and
organ meats. Folate deficiency is most commonly found ia pregnant women, when needs
arc elevated, and in alcoholics, because alcohol interferes \\'ith absorption of folate. Vitamin
B-12 is necessary for folatc metabolism. Without dietary vitamin B-12, folatc deficiency
symptoms, such as macrocytic anemia, develop. In addition, vitamin B-12 is necessary for
maintaining the nervous system; paralysis can develop from a vitamin B-12 deficiency.
Vitamin B-12 is found only in animal foods; meat eaters generally have a 3- to 5-year sup-
ply stored in the liver. However, vitamin B-12 absorption may decline in older persons and
is generally corrected by monthly injections of the vitamin.
Choline
For many years, choline was often included in supplemems as a supposed B-vitamin.
However, most nutrition experrs claimed that c hoLine was not a vitamin at all because Choline
the body makes enough of it to meet its needs. Recent research has contradicted some
of this attitude. Apparently in some cases, the body's production of choline is nor suf:
ficienr to cover requircmcnts. 29 Choline still is nor considered a B-\'itamin. Choline:
does nor have a coenzyme function, and the amount of choline in the body is much
greater than the amount of a typical B·\'itamin.
Absorption, Transport, Storage, and Excretion of Choline

Choline is absorbed from the small intestine by way of transport proteins. Choline i'>
taken up rapidly by the lh·er from the portal vein that drains the small intestine. All tis·
sues contain some stores of choline. Some choline is excreted in the urine, but most of
betaine A product of choline metabolism and a the excess is converted to a n:lated donor of single-carbon groups (bet aine). 29
methyl (CH3) donor in methionine metabolism.
Functions of Choline
Choline functions as a precursor for acetyk holinc, a neurotransmitter associated with
attention, learning and memory, muscle control, and many other fw1crions. Choline il>
a component of phospholipids, such as phosphatidylcholine (lecithin ), a major com·
ponent of the cell membrane and blood lipoprorcins. Liver export ofVLDL is also as
sociared with the action of choline. The methyl (-CH3 ) group of choline can be used
to form methionine from homocysLeine. 29
-CH 3 Methionine
Choline->-> B«''"1"" ~
H omocysteine
Food Sources of Choline Choline in Foods

Food Item and Amount Choline (mg) Choline is widely distributed in foods, mosrly in the form of phosphacidykholine in
Egg, 1 126 membranes. Milk, liver, eggs, and pe.muts arc rich sources. Lecithins often are .llJdcd
to food during processing, so Lhi~ is yet another source. So much choline is J\'aibblc
Cod, 3 oz 70 in ordinary foods th:it a dietary deficiency is unlikely. JO
Chicken, 3 oz 56
Nonfat milk, 1 cup 37
Choline Needs
Beef, 3 oz 36
T he Adequate lntake fo r chol ine !Or adult men is 550 mg/day; for adult women it is
Yogurt, 1 cup 31 425 mg/day. T hese amounts an.: based on the intake of choline required to nuintain
Wheat germ, 2 tbsp 21 liver function as assessed by measuring an enzyme (alanine aminotransferase) concen
Peanut butter, 2 tbsp 20 tration in the blood. 11
Cottage cheese, 1/2 cup 20 Few data exist to assess whether a dietary supply is needed at all life stages. Allhoug.h
Adequate Intakes arc set for choline, iL may be that the choline requirement can be mer
Orange, 1 12 by body synthesis at some or all stages of life. We also consume ample choline from food,
Broccoli, 1/2 cup 7 at least 700 to 1000 mg/ day, so there is no need to supplement a diet with this nuttient. H1
Squash, 1/2 cup 7
Whole-wheat bread, 1 slice 7 Choline-Deficiency Diseases
Apple, 1 7 When humans were fed choline-dcficicnr total parenteral nutrition solutions, they de·
Romaine lettuce, 4 leaves 6 vcloped furry li\'ers and liver damage. Based on these observations, plus laboratory ,\ll ·
White bread, 1 slice 3 inlal studies, choline has been deemed essential, at least in some life stages and health
Adequate Intake for adult men, conditions. 29
550 mg, adult women, 425 mg
Upper Level for Choline
The Upper Level for adults is 3.5 g/day, based on development of a fishy body odor
(arising from a breakdown product) and low blood pressme. Very high doses of choline
have also been associated with vomiting, salivation, sweating, and GI trace effects. 11
w ww.mhhe.com/wardlawpers7 365
Vitamin C 0
II
HO--..._ _..C
Vitamin C, also known as ascorbic acid, is involved in many processes in the human
body, p1imarily as an electron donor. 19 Ascorbic acid is needed by all other life forms, ~ \
but all plants and most animals make ascorbic acid. So ascorbic acid is a vitamin only c I
HO_...- -....... C-H
for humans, plus a few other animals: nonhuman primates, guinea pigs, a few birds,
fruit bats, and some fish. I
The term vitamin C actually refers not only to ascorbic acid but also to its oxidized H-0-C-H
form dehydroascorbic acid. Both forms are found in the foods vve eat. I
CHpH
Absorption, Transport, Storage, and Excretion of Vitamin C

Absorption of vitamin C occurs in the small intestine by means of active transport (for
ascorbic acid ) and by facilitated diffusion (for dehydroascorbic acid). Efficiency of the
absorptive mechanism decreases as intake increases. About 70 to 90% of vitamin C is 0
absorbed at daily intakes between 30 and 200 mg, whereas absorption efficiency de- II
clines substantially with doses exceeding that amoLmt. Excretion by the kidneys in- O~ _...-C
creases as dietary intake increases. 19 c \
The amount of vitamin C varies widely by tissue. High concentrations are found in I o
the pituitary and adrenal glands, white blood cells, eyes, and brain. The Im.vest con- ~c I
0-::;::;-- -.......C -H
centrations are in the blood and saliva. The total amount of vitam in C in the body
varies over a wide range. H-0-C-H
l
I
CH20H
Functions of Vitamin C
Vitamin C performs a variety of important cell functions . lt does so primarily by act- ~.'?e~y~ro~scorbic acid (oxidiz~)
• ---~ -- - - ·-= - ~- - -~
ing as a nonspecific elecu·on donor (reducing agent ).19 As mentioned in conjrn1ction

Ascorbic acid Vitamin C undergoes
\\~th riboflavin and nfacin fimcrions, a reducing agent is a substance that donates elec- reversible oxidation and reduction by loss
trons and, in turn, becomes oxidized (loses electrons) . Ascorbic acid donates electrons or oddition of two hydrogens (red).
as part of hydrogen atoms; however, rnilike the coenzymc function of riboflavin or
niacin, ascorbic acid donates hydrogens in a way that the electrons of the atom go to
reducing agent A compound capable of
different molecules than the rest of the hydrogen. For example, vitamin C C<U1 donate donating electrons (olso hydrogen ions) to
electrons to metal ions, such as iron and copper. In the oxidized state, ferric iron another compound.
(fe3+) can be reduced to ferrous iron (Fe2 +), and the cupric ion (Cu2 +) to the
cuprous ion (Cu+). The metals receive the electrons while the rest of the hydrogen
goes elsewhere (e.g., as H +).
Some vitamin C actions arc associated with enzymes, while others arc not. Even
when enzymes are involved, vitamin C is not considered a coenzyme in die same way
B-vitamins are because the chemistry is different. For example, a riboflavin coenzyme
can modify a compound, whereas a vitamin C may act on a metal in an enzyme.
Collagen Synthesis
Collagen is the fibrous protein that gives strength to conn ective tissue. Collagen collagen The major protein of the material
fibers arc critical to the structure of bone and blood vessels, and they are essential in that holds together the various structures of
wound healing. the body.
A collagen molecule is like a tbree-strru1ded rope. It consists of dJrec-polypcptidc connective tissue Cells and their protein
chains wound toged1er to form a triple helix. To get the three strands in d1c right shape products that hold different structures of the
to form the triple helix, which gives a ropelike structure, vitamin C is needed. In par- body together. Tendons and cartilage ore
ticular, vitamin C helps change the structme of two amino acids, lysine and proline in composed largely of connective tissue.
collagen (Figme 10-9). These arc convened to bydroxylysine and hydroxyproline. The Connective tissue also forms part of bone and
role of vitamin C in the formation of these unusual amino acids is to interact with the nonmuscular structures of arteries and veins.
the enzymes involved in making d1e conversions. These enzymes use iron as part of the
catalytic process. In this process, the iron is converted from Fe2 + to Fe 3 +. For d1e en-
zymes to continue functioning, d1e iron must be recycled to Fe2 +. Vitamin C, as a re·
ducing agent, can provide dectrons for this purpose. 19
Figure 1 0-9. I Vitamin C is needed for the

addition of hydroxyl groups (- OH) to the amino
acid praline in collagen molecules {l-2). Weak
Collagen is unique among body proteins connective
because it contains large amounts of the amino tissue
acid hydroxyproline, which is necessary for the
H H H
t--
formation of stable collagen fibers (3). Without
sufficient vitamin C available to perform this
No vitamin C
H
I \/ o
pre$6nt '-c---c\ II
task, only weak connective tissue is formed (4).
I C-C-OH
Vitami C
presen
~
! -:::::::::-,
Collagen
precursor
molecule
H
c
H,...,-, ---.... N
I
H
/ \H
OH OHoHOH OH
l- 1_l- lJ - oH Hydroxylase
Collagen is
hydroxylated -- , <:Cr r~=-
OH OHoHOH OH ! enzyme,
vitamin C, iron
E Triple helix
formed
! \
Strong connective tissue.
Antioxidant Activity
Li1 vitro (in a test rube), vitamin C can be an anrioxidant by donating e lectrons to free
radicals. Recall that a free radical has an unpaired electron. A vitamin C molecule can
donate electrons ro free radicals so that they become stable. Researchers have proposed
that vitamin C in the body's water-based fluids (e.g., blood) acts just like vitamin E
does in lipid-rich environments. It has also been suggested that vitamin C can recycle
vitamin E and make it ftrnction more effectively.
Although these vitamin C antioxidant actions work well in a test rube, do they work
the same in humans? Despite what you may have read to the contrary, we don't actu·
ally know if vitamin C plays major or minor antioxidant roles in humans. 19 Research
in this area is ongoing. So far, some data suggest that vitamin C does have some im -
portant in vivo antioxidant effects. However, not all the results have been that posi[ive.
In fact, some research suggested that vitamin C can increase oxidative stress, such as in
Orange, limes, lemons, ond kiwi fruit ore all people with diabetes. 18 Dr. Mark Levine and Dr. Sebastian J. Padayarty discuss this role
rich sources of vitamin C. of vitamjn C in more detai l in the Expert Opinion.
Vitamin C is present in high concenrracions in d1e eye, possibly to protect against

photolycically generated free radicals. 19 It is also present in high concentracions in
white blood cells (e.g., Deutrophils}, possibly for protection against the free radjcaJs
produced during immune functions.
Iron Absorption
Vitamin C added to meals modestly facilitates the intestinal absorption of nonhcme
iron (iron that is not in hemoglobin) because of dle conversion of iron in tl1e GI tract
ro ferrous iron (Fe2 +). Vitamin C also counters the action of certain food components
that inhibit iron absorption. 12
Synthesis of Other Vita l Compounds

Carnitine is a transport compound that moves fatty acids from the cyroplasm into the
mitochondria for energy production. Vitamin C participates in two separate steps in Carlos just returned from a local mall and is
carnitinc biosyntl1esis. The biosynthesis of the hormones and neurotransmitters nor- excited because he saw an advertisement
epinephrine and epinephrine depends on vitamin C as an e lectron donor. The conver- claiming that vitamin C will cure ;ust about
sion of the essential amino acid tryptophan to the neurotransmitter scroconin requires everything from colds to heart disease. How
'itamin C. Vitamin C is necessar~· for the biosynthesis of thyroxine (the thyroid hor- would you explain to him vitamin C's main
mone) and many other nen·ous system components. Vitamin C is also invoh·ed in tile functions in the human body?
biosynthcsis of corticosteroids and aldosterone, tile conversion of cholesterol to bile
acids, and tyrosine (an amino acid) metabolism. 12
Immune Function
White blood cells, part of the immune defonses of the body, contain the highest vita-
min C concentration of all body constituenrs. A high co1H:cntn1tion of vitanun C in
white blood cells may provide protection against the oxidative damage associated witll
cellular respiration. 19 Free radicals generated during phagOC)'tosis and neutrophil neutrophil activation A type of white blood cell
activation, though intended to kill bacteria or damaged tissue, can also damage the being prepared for immune response.
body's O\\ n immune cells. Vitamin C may reduce this self-destruction by this ,;tamin's
antiohldam actions. Vitamin C may also have oilier roles in immune fonction. Note,
howe\'cr, that supplemental vitanun C beyond body needs may not necessarily improve Food Sources of Vitamin C
immune function. Food Item and Amount Vitamin C (mg)
Orange, 1 98
Vitamin C in Foods Cooked brussels sprouts,
1 cup 97
All fruits and vegetables contain some vitamin C, but certain fruits and veget:ibles pro-
vide much more than others. Citrus fruits, potatoes, and green vegetables in general Slrawberries, l cup 94
are good sources of \'itamin C. Animal products and grruns are generally not good Grapefruit juice, 1 cup 80
sources. An intake of 5 servings/day of combined frwts and vegetables provides ample Red peppers, 1I4 cup 71
,·itJmin C. The major contributors of vitamin C to North American dices arc oranges
Kiwi fruit, I 57
and or.111ge juice, grapefruit and grapefruit juice, tomatoes and tomato juice, fortified
fruit drinks, tangerines, and potaroes. Vitamin C is easily lost in processing and cook- Green pepper rings, 5 45
ing;. Juices are good foods to fortif)• with vica!1Un C because their acidity reduces vita- Tomato juice, 1 cup 45
min C destruction. Vitanun C is very unstable when in contact wirh heal, iron, copper, Cooked broccoli, 1/2 cup 33
and oxygen.
Kale, 1/2 cup 27
Raw cauliflower, l /2 cup 23
Vitamin C Needs Sweet potato, l 17
The RDA for \'itamin C for adult men is 90 mg/day; for adult \\Omen it is 75 mg/da)'· Baked potato, 1 medium 16
Most of us consume thjs much and more. The RDA is based on near maximal vitamin C Pineapple chunks, 1/2 cup 12
concentrations in neurrophils (a white blood cell) with mi1umal urinary excretion.
Because smoking causes oxidative stress, the needs ofsmokers increases by 35 mg/day. 12 Cooked spinach, 1/2 cup 9
Smokers have a higher turnover of vitamin C, probably because of its anrioxidant ac- RDA for adult men, 90 mg;
riviry. Vitamin C needs are also increased by oral cono·aceptivc use (for reasons that are adult women, 75 mg
not clear). Vitamin C needs can be increased by burns or surgery that removes a lot of
tissue. Such injuries require much collagen production to replace the lost tissue.
However, the medical literature does not agree on how much extra vitamin C is
needed. The Dail}' Value for vitamin C on food and supplement labels is 60 mg.
Vitamin C-Deficiency Diseases

A deficiency of vitamin C prevents the normal synthesis of collagen, thus causing wide·
spread and significant changes in connective tissues rhroughour the body. The first
signs and symptoms of scurvy, the deficiency disease, appear after about 20 to 40 days
on a vitamin C-free diet and include fatigue and pinpoint hemorrhages around hair
follicles on the back of the arms and legs (Figure I 0-10). These hemorrhages arc the
most characteristic sign of scurvy. In addition, there is bleeding in the gums and joints,
a classic sign of connective tissue failure. Other effects of scurvy include impaired
wound healing, bone pain, fractures, and diarrhea. Psychological problems, such as de-
pression, arc common in advanced scurvy. 19
Worldwide, scurvy is associated with poverty. It is especially common in infanrs who
are fed boiJcd miJk (all forms of milk are poor sources ofviramin C) and arc not pro-
vided with a good food source of vitamin Cora supplement.
Figvre 10-10 I Pinpoint hemorrhages of the In North America, vitamin C deficiency is most likely to occur in alcoholics and
skin-on early symptom of scurvy. The spots on those addicted to other drugs, because such people often consume a nutrient-poor
the skin ore caused by slight bleeding into hair diet. Anyone who eats very few fru its and vegetables is also susceptible to vitamin C
follicles. The person also will often show deficiency. Men in general are more at risk of vitamin C deficiency compared with
inadequate wound healing-all signs of women because they are more apr to eat poorly. Finally, people exposed to cigarerte
defective collagen synthesis. smoke generally have lower vitamin C status than nonsmokers.
Vitamin C Intake above the RDA

Some popular authors and speakers advocate conswnption of vitamin C at amount::.
higher than the RDA. Surprisingly, there is not much research comparing different vi·
ta.min C intakes. Note that if vitamin C intake is above about 100 mg/day, much of
the additional vitamin C is excreted in the urine. Some research also indicates that
200 mg/day is the most a person would need to maximize the health benefits of vita-
min C intake. Choosing several vitamin C-1ich foods each day can boost intakes to
!though the development of scurvy in an 200 mg/day. 19
otherwise healthy child is rare, it is possi- One aspect of high vitamin C intake that has drawn a lot of attention is its possible
ble. A 5-year-old boy developed scurvy otter use for prevention or treatment of the common cold. This use is not focused on cor-
eating nothing but Pop-Tarts, cheese pizza, bis- recting vitamin C deficiency. Although such an intake may help with cold severity,
cuits, and water for 5 months. The boy, who was probably by improving immune function, most of the attention has been on a high vi·
growing and maturing normally, started to limp; ta.min C intake by people with no deficiency. At these doses, the vitamin C could exert
his gums became swollen; and small, purple multiple actions, including actions that do nor occur at more typical vitamin C intakes.
spots began to appear on his skin. His baffled The notion that high doses of vitamin C arc useful for preventing and treating colds,
doctors finally diagnosed the boy as having and perhaps some other maladies, has gained a lot of attention. Many of the studies on
scurvy and gave him vitamin C, and his condi- this topic have concluded that high dose vitamin C use (up to about 1000 mg/day)
tion began to improve within a week. may have small effects on cold severity (not incidence) in some people.9
Upper Level for Vitamin C

The Upper Level for viramin C is 2 g/day. Regularly consllming more than that may
cause stomach inflammation and diarrhea. 12 Other purported roxicity symptoms from
vitamin C have been ctiscounted in healthy people, but as noted earl ier a recent srudy
showed an increase in cardiovascular disease deaths in older women with djabetes who
consumed megadose amounts. 18
Figure 1 0-1 1 I Vitamins and related

nutrients (e.g., choline) work together to
maintain health.
C Homocysteine
Vitamin 8·6
Vitamin B· l 2
metabolism
Folote
Thiamin Vitomin K• Vitomin 8·6
RiboAovin Folote
Niocin Vitomin B· 12
Choline (not o true
l
Pontothenic acid
Biotin vitomin, however)
Vitamin B· 12 J RiboAavin (indirect)
Vitamin E
Vitamin A Vitamin C (likelyl
Vitamin D Carotenoids
Vitamin K Lipoic acid (not a true
Vitamin C vitamin, however)
RiboAavin (indirect)
Vitamin 8·6
Vitamin C
Folote
Table 10-1 summarizes much of what is known about the B-vitamins, choline, and
vitamin C.
Figure 10-11 Summarizes the various roles of vitamins in the bod)'. This figure un-
derscores the importance of vitamin nurrirure io maintaining overall health.
Concept I Check eople who wont to experiment with large

Only guinea pigs, monkeys, some birds and fish, and humans need dictan· vitamin C. It is doses of vitamin C should alert their physi·
used mainly in the synthesis of collagen, a major connecti,·e tissue procei1;. A vitamin C de- cion. High doses of vitamin C con change reoc·
ficiency causes scun~·. which is marked by many changes in the skin and gums, such as lions to medical tests for diabetes (urine) or
small hemorrhages, because of reduced collagen synthesis. Vitamin C also modesrl)' im blood in the feces. Vitomin C con interact with
prove!> iron absorption and is involved in the synthesis of certain hormones and neurotrans· the testing procedures because much of o high
mitters. Citrus fruits, green peppers, cauliflo\\'er, broccoli, and strawberries are good dose of vitamin C will not be absorbed, or if ob·
sources of \itamin C. Fresh or lightly cooked foods arc tl1c bcsc sources, because loss of \i· sorbed, will be rapidly excreted. Physicians may
tamin C in cooking can be high. At intakes greater than about 2 g/day, vitamin C can kad misdiagnose conditions when large doses of vi·
to diarrhea and other GT tract problems. tamin C ore consumed without their
knowledge.
Table 10·1 I A Summary of Water-Soluble Vitamins

Vitamin Major Functions Deficiency Symptoms People Most at Risk
Thiomin Coenzyme in energy release Beriberi: anorexia, weight loss, weakness, Alcoholics and people living in poverty
peripheral neuropathy; Wernicke-
Korsokoff syndrome
Riboflavin Coenzyme in numerous oxidation-reduction Ariboflovinosis: inflammation of mouth and People toking certain medications if no
reactions, including those of energy tongue, crocks at corner of mouth dairy products are consumed
release
Niacin Coenzyme in numerous oxidation-reduction Pellagra: diarrhea, dermatitis, dementia Alcoholics and people living in poverty
reactions in energy metabolism, synthesis (death) where corn is the dominant food
and breakdown of fatty acids
Pontothenic Coenzyme in energy metabolism and fatty- Weakness, fatigue, impaired muscle func- None
acid acid synthesis lion, GI tract disturbances
Biotin Cofactor for five corboxylases tha t portici- Dermatitis, conjunctivitis, hair loss, nervous Alcoholics
pate in fatty acid, amino acid, and en- system abnormalities
ergy metabolism
Vitamin B-6 Coenzymes in amino acid metabolism, Dermatitis, anemia, convulsion, depres- Alcoholics
(pyridoxinel heme synthesis, lipid metabolism; homo- sion, confusion
cysteine metabolism
Folote Coenzyme in DNA synthesis, homocysteine Megaloblastic (mocrocytic) anemia, birth Alcoholics, pregnant women, people on
metabolism defects certain medications
Vitamin B- l 2 Coenzymes affecting folote metabolism, Megoloblostic (macrocytic) anemia, pores- Older adults, vegans, HIV-positive patients,
(cobolomin) homocysteine metabolism thesio, pernicious anemia patients with molobsorption syndromes
Vitamin C Collagen synthesis, some antioxidant capa- Scurvy: poor wound healing, pinpoint Alcoholics, individuals who eat few fruits
(ascorbic acid) bility, hormone and neurotransmitter hemorrhages, bleeding gums and vegetables
synthesis
Choline Precursor for ocetylcholine and phospho- No natural deficiency None
lipids; homocysteine metabolism
Table 10-1 I A Summary of Water-Soluble Vitamins (continued)
Dietary Sources RDA or Adequate Intake Toxicity*

Pork and pork products, enriched and whole-grain Men: 1.2 mg/day; None recognized
cereals, nuts and seeds women: 1.1 mg/doy
Milk, mushrooms, spinach, liver, enriched groins Men: l .3 mg/day; None recognized
women: l . l mg/day
Meat, poultry, fish, enriched and whale-grain Men: 16 mg NE/ day; Flushing of skin; Upper level for adults is 35 mg/
breads and cereals; also from tryptophan con- women: 14 mg NE/day day from supplements, based on flushing of skin
version to niacin
Widely distributed in foods Adequate Intake for adults: 5 mg/day None recognized
Widely distributed in foods Adequate Intake for adults: 30 µg/doy Unknown
Animal protein foods, spinach, potatoes, ba- Adults 19-50: l .3 mg/day; men over 50: None from food but excess intake from supple-
nanas, salmon, sunflower seeds 1.4 mg/ day; women over 50: l .3 mg/day ments causes neuropalhy, skin lesions; Upper
level is 100 mg/day, based on nerve
destruction
Green vegetables, liver, enriched cereal products, 400 µg/day of dietary folate equivalents (Note: None; Upper level for adults set at 1000 µg/day
legumes, oranges dietary folate equivalents ore not used for for synthetic folic acid, exclusive of food folate,
women in childbearing years; actual µg folic based on masking vitamin B-12 deficiency
acid is used.)
Animal foods and fortified ready-to-eat breakfast Adults 19-50: 2.4 µg/day; adults 51 and older: None recognized
cereals same, but use of fortified foods or supplements
to meet needs is recommended
Citrus fruits, strawberries, broccoli, greens Men: 90 mg/day; women: 75 mg/day;+ Diarrhea and other Gl tract problems; Upper level
35 mg/day for smokers is 2 g/day, based on development of diarrhea
Widely distributed in foods, plus self-synthesis Adequate Intake for men : 550 mg/day; women: Upper level is 3.5 g/doy, based on development
425 mg/day of fishy body odor and reduced blood pressure
•Toxicily arises only from supplement use.

Expert Opinion :
Vitamin C: Antioxidant and Pro-Oxidant Functions
and the Keystone of Tight Control
Mark Levine, M. D., and Sebastian J. Padayatty, M.R.C.P., Ph.D.
Is vitamin C (ascorbic acid, oscorbote) on antioxidant in humans, as popu- to I 00-fold times that seen in blood. As a result, cells attained their plateau
larly believed? Should vitamin C be obtained from supplements? To answer internal concen trations at even lower doses than tha t seen in the blood.
these questions, this section presents some essential background in basic vi-
tamin C physiology, biology, and chemistry. Gate-Keeper Mechanisms for Regulating
Vitamin C Concentrations
The Physiology of Tight Control of Vitamin C These studies indicate that blood and tissue concentrations of vitamin C are
Researchers know now that the physiology of healthy humans is responsible tightly controlled in relation lo dose. Three gate-keeper mechanisms are re-
for tight control of vitamin C concentrations in blood and tissues and that sponsible for this control: absorption limitations, saturable tissue transporters,
tight control is o function of dose. This knowledge comes from depletion- and excretion by the kidneys, including both filtration and reabsorption.
repletion studies in young healthy men and women on vitamin C- free diets. For oral doses of 15 and 30 mg, bioavailability for vitamin C is about
These subjects were first depleted of vi tamin C and then repleted and al- 90%, but it decreases to less than 50% for a dose of 1250 mg/ day These
lowed enough time to attain o steady blood concentration for each of 7 es- data show that as doses rise, the percent of the dose absorbed Falls, so that
calating doses, from 30 mg lo 2500 mg doily. Between doses of 30 and intestinal absorption is one gatekeeper of tight control.
100 mg, a very A second gate-keeper is tissue transport. With the exception of red blood
sleep increase oc- cells, vitamin C is accumulated into all cells many-fold against its concentration
curred in fasting gradient. Most tissue transport uses sodium-dependent vitamin C transporters,
blood concentra- and these proteins transport vitamin C as such. (In specialized cases, oxidant·
tions. However, the producing cells may transport oxidized ascorbic acid [dehydroascorbic acid)
effect ceased be- via some glucose transporters, followed by immediate intracellular transforma-
yond 200 mg, and tion to the ascorbic acid form.) And as already noted, cells attain their plateau
fasting concen tro· internal concentralions ot even lower doses than that seen in the blood.
lions c~onged little The third mechanism of tight control is the kidney. At doses of less than
as the vitamin C 60 mg daily, no vitamin C appears in the urin e, whereas al a dose of
dose rose higher. 2500 mg/day, all absorbed vitamin C is excreted in the urine. The kidney
Circulating whi te first freely filters vitamin C and then reabsorbs it from the filtrate before ulti-
blood cells and mate excretion until the sodium-dependent transporter saturates. Once satu-
platelets-which ration occurs, excess vitamin C is excreted in urine. Overall, the kidney is o
also provide an esti· key gatekeeper of tight control.
male for body tis-
Reducing Agent? Antioxidant? Pro-Oxidant?
sues in general-
Oranges are a rich source of vitamin C. The many olso accumulated vi- For all its known functions, ascorbic acid has one adion: to donate two elec-
phytochemicols provided are an additional benefit, tamin C in these trons, most likely sequentially. Therefore, as a chemical electron donor, vitamin
and something not found in vitamin C supplements. studies, but 10-fold C is a reducing agent, which is usually synonymous with the term antioxidant.
Is vitamin C on antioxidant in vivo? This is on open question. Using in might foll precipitously, as for those who ore critically ill. An analogous exam-
vitro systems, vitamin C is definitely able to chemically reduce oxidants and ple of excess concentration in relation to need for vitamin C con be seen for co~
to do so better than most other compounds. In vivo, however, the evidence lagen synthesis and scurvy. Vitamin C is essential for several steps in collagen
that vitamin C is on antioxidant by itself is either locking or not compelling. biosynthesis. However, only with advanced deficiency (scurvy) is this need clin-
There ore o number of reasons for this conclusion. ically apparent, suggesting that vitamin C is greatly in excess of its needed con·
Fruits and vegetables ore the primary food sources for vitamin C, and 200 centration for this function and that excess may be a cushion against deficiency.
to 300 mg is usually found in 5 to 9 varied servings of fruits and vegetables. Ironically, emerging evidence indicates that ascorbic acid only in phormo-
Consumption of these foods is associated with health benefits and decreased cologic, not physiologic, concentrations moy hove pro-oxidant, not antioxidant,
disease risk for some cancers and cardiovascular diseases. However, it is un· functions. nght control of blood concentrations normally present in humans, and
known whether benefit is due to the vitamin itself; to vitamin C plus other fruit the gatekeeper functions responsible, con be bypassed transiently by intro·
and vegetable components; to fruit and vegetable components independent venous administration of oscorbote as o drug. In comparison to maximal oral
of vitamin C; to displacement of other harmful foods by fruits and vegetables; dosing, intravenous dosing con produce blood concentrations os much as
or to other lifestyle practices of people who consume fruits and vegetables. 50-fold higher until these concentrations ore cleared by the kidney ofter several
Vitamin C supplements hove been given to subjects who hove diseases be- hours. Ascorbote concentrations produced by intravenous dosing might result in
lieved to be associated with increased oxidant stress, such as diabetes. In most hydrogen peroxide concentrations forming in the extrovasculor space but not in
coses, supplements hove not mode a difference in disease progression or out· blood, with ascorbic acid acting as o prcxfrug for hydrogen peroxide formo·
come. However, these results may be due to properties of vitamin C physiol- lion. Intravenous ascorbote with resulting hydrogen peroxide formation and con-
ogy in humans: tight control. At the beginning of this section we described the sequent pro-oxidant actions may have unexpected and exciting therapeutic
steep dose<oncentrolion relationship for vitamin C doses below JOO mg doily. possibilities in cancer and infection, but this work is only in its infancy.
If the subjects who were enrolled in studies of ascorbic acid and oxidant stress Regardless of potential antioxidant function, vitamin C should be obtained
were initially above the steep portion of the dose<oncentrolion curve before not from supplements but from fruits and vegetables, and 5 to 9 servings
they were given supplements, the supplements would make little difference to should be consumed each day to meet vitamin C needs. This advice hos lhe
resulting concentrations and thus to outcome. To properly address whether vi· strongesl support based on current knowledge of vitamin C.
tomin C supplements affect diseases associated with oxidant stress, the subjects
Dr. Levine received his undergraduate degree from Brandeis
must, at study enrollment, hove low enough initial vitamin C concentrations for
University and his medical training from Harvard Medical School
supplements to substantially increase them. Although undertaking such a study
and the Johns Hopkins Hospital. Dr. Levine is a physician-scientist at
is not impossible, it is certainly not easy. Thus, it remains possible that vitamin
NIDDK and currently Section Chief of Molecular and Clinical
C is a functional antioxidant in vivo but that investigators hove not been able
Nutrition and Senior Staff Physician. Dr. Levine is the author of more
to conduct the proper study to test for this.
than 190 scientific ;ournal articles, chapters, books, and abstracts.
Based on its chemistry, it is likely that vitamin C hos antioxidant functions;
He is recognized internationally for his comprehensive biochemical
whether there is clinical relevance to these functions is the real issue. If ontioxi·
and clinical work on vitamin C.
dont functions ore essential as protective mechanisms, it is predictable that re-
dundant antioxidant protection systems exist in vivo and that vitamin C Dr. Padayatty received his medical degree from St. John's Medical
concentrations are in excess of antioxidant need. Unfortunately, it may be pos- College, Bangalore, Indio. He trained in General Internal Medicine
sible to learn whether there is o functional antioxidant role specifically for vita· and Endocrinology in England and the United States and received
min C only when its concentrations ore extremely low and such function is lost. his Ph.D. from the University of Leeds, England. He is a Clinical
Such low concentra tions may not hove relevance to the healthy population, al- Researcher and Stoff Clinician at the Notional Institute of Diabetes
though there could be relevance to subjects whose vitamin C concentrations and Digestive and Kidney Diseases, Notional Institutes of Health.
1 .._ . -
1
Vitamin-Like Compounds
The various vitamin-like compound~ discussed in

this Nutrition Focus-carnirine, inositol, raurine,
and Lipoic acid-are necessary to maintain normal
metabolism in the body. They all can be synthe-
' r3
CH3 -
'H
Ne-CH2 - CH - CH2 -
wi
C - OH
sized by the body, but their biOS)'nthesis oti:cn oc- I

CH3
curs ar the expense of other nutrients, such as
essential amino acids. The need for these com-
pounds often increases dtLring times of rapid tissue
growth, as in the prcrerm infant.8
Deficiencies of these \~tamin - like compounds
do not exist in the a,·erage healthy adult. But more
research is needed co darif)· ·whether deficiencies is almost absenr from plant foods. Howen'.r, \egc-
might arise in certain disease smes and whether the tarians show normal blood concentrations of c•trni-
compounds should be included in infant formulas tine. Consequently, it is doubtful that carnitinc is
and total parenteral nutrition solutions. Currencly, necessary in the diets of healrhy people. le ma~ be:
manufacturers ofi:en add these \'itJmin-Like com- considered a conditionally essential nucrient in
pounds to infant formulas. times of reco\'ery from disease, serious traunu, kid-
ney dialysis, or preterm birth.
In addition, carnitine has displayed pharmaceu -
Carnitine tical usefulness in the removal of compound\ ch.11
can build to toxic amounts in people with inborn er-
Carnitine is a relativelr simple compound that can rors of metabolism. Dosages approximately l 0 1i111c.s
be synthesized in the li,·er from the amino acids ly- typical dietary intakes lm·e also been shown w im-
sine and methionine. Human needs for carnitine pro,·e the condition of persons with progn.:ssi\l'.
are met from both animal foods and biosymhesis. 8 muscle disease and heart muscle dererior.:ition.
Adults and children who are severely malnourished There have been some sales ofcarnitinc supplements
or on total parenteral nutrition can have lower- to promote weight loss or as an exercise aid; how-
than-normal concentrations of carnitine in their eYer, the research on these uses is still \'ery Limited.
blood. An inadequate supply of protein (e.g., a lack
of the amino acids needed for making carnitine)
leads to abnormal fatty ·acid metabolism. There is Inositol
specuJarion that people with cirrhosis may need
carnitine from the diet to offset inadequate li,·er Of the nine possible isomers of inositol, only one-
nositol in supplement form is production. caUed myo-inositol- has nutritional implications for
promoted as treatment for insomnia. Within the ceU, carnitine transports fatty acids hwnans. The structure of i11ositol is related w chat
There ore a variety of causes for sleep from the cytosol into rhe mitochondria, where the of glucose, from which it is synthesized in the bod\'.
disorders, but probably none ore linked farty acids are then metabolized for energy. Carnirine ~luch of the inositol in body cells occurs 111
to on inositol deficiency. also aids the mitochondria in rcmo1•ing excess or- phosphorylated forms, such a~ inositol triphos·
ganic acids, products of metabolic pathways. phate (IP 3), which is found free in the cell cycosol.8
~lear and dairy products are the main sources of Inosirol is also incorporared into the phospholipids
carnitine. \Ve consume about 100 to 300 mg/ day. located in ceU membranes. These inosirol phospho
Vegetarian diets arc very low in carnirinc because ir lipids are important precursors of the eicosanoids,
374
man) ,·ital functions. It is associated with photore· ne website stoles that many individ·
H H
ceptor acci,;rv in the eve, antioxidant activity in uols ore deficient in L·tourine.
white blood :c11s, the pr~tection of pulmonary tis- Because tourine is found in the central
sue from oxidation, central nervous system func- nervous system, the website claims, it
tion, platelet aggregation, cardiac contraction, controls epileptic seizures, motor tics, and
insulin action, and cell ditlerentiation and growth.a facial twitches. It is also promoted as pre·
Taurine is found only in animal foods. North venting cotorocls and certain forms of
H OH Americans consume about 40 to 400 mg/day. No cordiovosculor disease. Scientific evi·
-
clear cases of caurine deficiencies have been diag- dence for these claims is locking.
Myo-inositol
nosed in \'egans, e\•en though it is not found in
plants, suggesting that synthesis by the body meets
needs. Thus, it appear~ that healthy people need 0
not worry about consuming taurine. II
\\'hi ch have numerous hormonclike actions (review HO-S-CH-NH
Taurinc supplementation may be of benefit ro II 2 2
Chapter 6). Under certain conditions (e.g., the
children with cystic fibrosis. Some of these children
binding of hormones), enzymes in the cell mem- 0
experience increased growth when treated with
brane act on the inositol phospholipids, releasing Tourine
taurine, perhaps because of increased fat absorption
IP 3 . This compound, in turn, mobilizes calcium
from the action of taurinc as part of bile. Preterm
ions (Ca2+) from stores within cells.
infants supplemented with t•rnrinc mav also exhibit
Both free inositol and inositol phospholipids
improved fat absorption. ·
arc presenr in animal foods. Some plant foods (e.g.,
wheat bran) also contain inositol, mostly as part of
phyric acid, a compound that binds minerals. The
Lipoic Acid
:l\'eragc Nonh American diet provides about l g of
Lipoic acid is used in reactions in which a carbon
inositol per d.1y, and another 4 g/day or more are
dioxide molecule is lost from a substrate, as when ome supplement manufacturers claim
S)'nthesized in the kidneys.
pyru\'Jtc is converted into acecyl-CoA. Lipoic acid that the body is unable to monufoc·
The metabolism of inositol is altered bv several
also works with se,·eral antioxidants in the body.8 lure sufficient lipoic acid. They also claim
medical conditions. The hyperglycemia a;sociated
Even though lipoic acid sen·es such beneficial that o deficiency of lipoic acid prevents
with diabetes inhibits inositol transport. Abnormal
functions in the body, it is unnecessary to obtain it antioxidants from working properly to·
inositol metabolism is also noted in multiple scle-
from outside sources. Rich dietary sources are gether. Research hos yet to confirm such
rosis, kidney failure, and certain cancers. Q,•erall, it
meats, liver, and yeast. claims.
appears that inositol is an essential nutrient onl>• in
cercain medical conditions.
Taurine
ol
CH2 - CH2-CH-CH2-CH2- CH2-CH 2 -
II
C-OH
Taurine is synthesized from the sulfur-containing
amino acids methionine and cysteine. Ir is ,\bun- s
I I
s
dant in muscle, platelets, and n~rve tissue. It is also
attached to bile acids. Although its mechanism of
action is not well understood, taurine is in,·oh·cd in
375
' Summary
1. The B vitamins function as coenzymcs. Deficiency symptoms typ- Toxic effects from excess consumption include nerve damage.
ically show up in the skin, GJ tract, brain, and nervous system. 8. Folare in irs many coenzyme forms (tetrahydrofolic acid) accepts
2. Thiamin in irs functional form as TPP serves as a coenzyme in en- one-carbon groups from various donors and domucs one-carbon
ergy release. Typically the only North American population chat groups. The most nocable function performed by folatc is in DNA
could be deficient in thiamin are alcoholics. Pork, pork producrs, synthesis. Tt also participates in homocysteioe metabolism. A di-
and enriched grains are reliable sources of thiamin. etary lack of the vitamin produces mcgaloblastic anemia and in-
3. Riboflavin in fimctional form, FAD and FMN, participates in a creases the risk of spina bifida. Deficiency is common a mong
wide variety of oxidation-reduction reactions including those in alco holics. Folate is found in green vegetables, lcgwnes, liver,
numerous metabolic pathways that produce energy. A specific ri- and fortified cereal grains. Folate is dcscroyed by high cooking
boflavin deficiency is unlikely bur could accompany other B- temperatures.
vitamin deficiencies. Dairy products and enriched grains arc good 9. Vitamin B-12 in coenzyme form transfers one-carbon gro ups.
dietaq sources. Because of its interaction with folate, a deficiency of vitamin B- 12
4. Niacin as NAD and NADP are coenzymes. NAD is important in resnlrs in the same type of megaloblastic anemia as well as excess
oxidation-reduction reactions including reactions that yield en- homocysteine in the blood. Defective absorption of virnmin B-12
ergy. A deficiency of the vitamin produces the disease pellagra. is the cause of the deficiency disease pernicious anemia. In such
Alcoholism can lead to a deficiency. Food sources of niacin are en- cases, injection of the vitamin or another pharmacologic approach
riched cereal grains and protein foods. The body is able to syn- is necessary. Vitamin B-12 is found in animal foods buc not in
thesize the vitamin from the amino acid rryptaphan. Megadoscs of plant foods. Vegans need to look for foods fortified with the \rita·
niacin produce a variety of toxic symptoms. min or take it as part of a multivitamin and mineral supplement.
5. Among its functions, pantothenlc acid in coenzyme form (CoA) 10. Choline is a dietary component that is available from a wide v~u-i
shuttles two carbon fragments from the metabolism of glucose, ery of foods and is synthesized in the body. No natural deficiency
amino acids, faery acids, and alcohol into the citric acid cycle dur- of choline has been reported.
ing energy metabolism. A deficiency of pantothenlc acid is un- 11. Vitamin C functions as an electron donor in many processes, in-
likely, because it is widely disrributed in foods. cluding the synthesis of collagen, a protein in connective tissue. A
6. Biotin functions as a cofactor in five enzymes thac add carbon deficiency of vitamin C causes the disease scurvy. Fresh fruits and
dioxide to a substance. Biotin is \\~dely distribmed ia foods. No vegetables a.re reliable sources of this viramin. Like folarc, \~tamin C
ddicicncy exists in healthy people. Intestinal bacteria also synthe- is dcsrroyed by heat. Among North Americans, alcoholics, smok-
size biotin. ers, and indi,,iduals who don't cat many fruits or vegetables are
7. Vitamin 8-6 in coenzyme form (PLP) participates in amino acid most likely to develop a deficiency.
metabolism, especially the synthesis of nonessential amino acids. It 12. Carnitine, inositol, taLU'ine, and lipoic acid, while participating in
is essential in the S)'nthesis of heme in hemoglobin, the formation many important biochemical reactions in d1e body, are not true\~
of certain neurotransmitters, and the metabolism of homocystcine. ramins because they can be synthesized in the body from readily
Anemia, convulsions, and decreased immune response arc symp- available precursors. Jn some medical circumstances, dietar y imake
toms of a deficien'-)'. Animal protein foods, a few fruirs and vegeta- may be needed to augment cell ular production.
bles, and whole-grain cereals are good sources of this vitamin.
Study Questions
l. Define and explai.n the term coenzyme. 9. Draw MyPyramid and place the various B-vitamins and vitamin C
2. Which vitamins can be synd1esized in the body, and how are they into the food groups in which they are most likely to be found .
syn d1 cs ized? 10. Suppose you read in the newspaper or hear on TV news that a
3. Explain why indi,ridual B-viramin deficiencies are rare in North "new" vitan1in has been discovered. What criteria will have to be
America. Which B-vitamins are added to cereal grains as part of met in order for this substance to be a true vitamin?
the enrichment program?
4. Homocysteine is of some health concern roday. Why?
5. Define Upper Level and explain why certain vitamins have this
designation.
6. Some vitamins have an Adequate Tmake designation rather than
an RDA. Why? BOOST YOUR STUDY
7. Draw a map of the energy-transformation pathways in the celJ and
C heck out the Perspectives in Nutrition: Online Learning
identify rhe biochemical reactions where B-vitamins participate in
Center www.mhhe.com/wardla~.i.r:.I for quizzes, flash
energy metabolism (Hint: re,~ew Figure 10-2).
cards, activities, ond web links designed to further help you leorn
8. Name the vitamins that have been used as pharmacologic agents,
and idemify the medical conditions for which they are used as about the water-soluble vitamins.
therapy.
I. Andres E and others: Food-cobalamin malab- 8. Combs GF: Vicamins. ln Mahan LK Escort 14. Friso S and others: Lo'' pla~ma vitamin B-6
sorption in e lderly patients: Clinical manifcsra· Stu mp S (eds.): Krn11.sc's jilod, 1111t1·ition, a11d concentrations and modul:ition or coronary ar-
tions and trcatmcntS. A 111ericn11 ]onma/ of diet r/Jcmpy. 11th ed. Philadelp hi a: WB tery disease risk. A111ericn11 Jo11r11al of Clmicnl
1vfedici11e 118: 1154, 2005. Saunders, 2004 N11tritio11 79:992, 2004.
Abo111 15% of olde1· nd11/ts s/Jon> dtftcm•e vitn- fa:ccllrnt c/Jnpur 011 Pitnmi11s i11 gmernl. 71lt Loll' plasma co11cmtrntio11S of tilt acrive metnbo·
mi11 B-1211bsorptio11. 111is condit1011 especially 111a11y 1•irnmi11-like compo1111ds arc nlso ret1iewcd. lite of v1tam111 B-6 nre mdtprndemly associntcd
1Jjfects absorption of the vim111i11 B-12fmmd with i11e,.eastd risk for coro11nry nncry diseast
9. Douglas 1\J\.1 and others: Vitamin C for pre-
11nt11mlly i11 foods. Co11s111nprio11 of cr.i•st11tli11c and a1·c i11versely rc/nted to major marllcl"S <If
venting and m:nti ng the commo n cold.
v1tami11 B-12 in co11trasr is 11ot so affected a11d i1lj711111111ntio11.
Coc/Jrn11c Drrrnbnse S)'stemntic Rei•iews 18(4):
was fo11T1d to be a useful form of therapy for tbe CD000980, 2004. 15. Herrmann 1\il and others: Relation between ho-
older adults i11 t/Jis Jt11d_v. mocystcine and biochc:mical bone turno\'cr
After a mrrful rePiew of tilt uiwrific litcrat11rt,
2 Bailey LB .ind others: Folic acid supplements markers and bone mineral density in pcri- and
mcgadosr 1•tt11111111 C thcrnpy wns fo11111t to /Jm•c
and fortificaaon aftect the risk for neural rube po~r-menopausal women. Clmicnl CfJc1111srr_v
110 effect 1111 [ll'c1>c11ri11g t/Jc com1111111 cold for tbc
ddecrs, vascular dibcasc, and cancer. Evolving a11d Lri/Jol"!ltol"yMet/Jods43:1 l 18, 2005.
averngc pc1·so11 b1tr may dee1•c11se m•crity 1111d
science. ]011n1nl of N1ttritio11 l 33:! 96ls, 2003. Elevnttd blood homoc_vstei11c IPflS a modest r1sL·
length ufsuc/J a11 infemon to 11 small degree.
Adeq11riee foltc acid stams btfort and d11ritlg TI}( possible bmtjit is sew p1·i111arily i11 people fnctor for /Javmg low bo11e dmsiry i11 tlJis st11dy.
preg11a11cy reducts the risk of11t11ml tube defects cxpcr1mc111,1f periods of txtTcmc ph)'sicnl c.x£rcise It is r/1111 i111porra11t for older adults co meet
b)· about 70" 11u ability ofJolie acid to red11cc or vrr_1• ((l/rl c/imncric co11dmo1u. t/Jeir 11ttdsfor vitnmi11 B·6,falnre, and vtram111
rhc risk of cn11ur 1Jnd cnrdiovrrswlnr discnsc arc B-12 (11otabZv i11 tbe cry.rtalliuc fonn) i11 order
I 0. Fischer LM and others: Ad libimm choline i11·
intercstiu._11 scic11tific theories tbat need more i·c· to protect /Jo11e /Jealt/J.
senrc/J before dmr reco11mw1dntio11s cn11 bt made. take in hcalrhy individuals meets or exceed~ the
proposed Adequate Intake level. f 011rnnl of 16. Homocystcine Lowering Trialisti.' Coll.1bora
3. Bourgeois C and others: ~iacin. In Shils ME }..'11tntw11 135:826, 2005. tion: Dosc:·dcpc:ndcnt effects of folic acid on
J.nd others (c:ds): Modem 1111rritio11 i11 hen/th blood .:oncentrations ofhomocysreine: A mc:u
1111d d1scnst I 0th cd Philadelphia, PA: Using 11c11• a11d rm:ntly p11b/isbtd darn 011
analysi~ of the randomized trials. A111er1&a11
Lippincotr Williams & Wilkim, 2006. cbolille lc1•c/1 w a large 1111111brr of co111mo11
]01m1al ofC/i11icnl N11tririo11 82:806, 2005.
foods, t/Jr n11thon report t/Jnt /Jenlrll)• mm n11d
C111n11t 1·1a•ic111 11f11inci11 met11bolism. Digestiq11 Co11111111i1i...11 400 µg/day ofJolie ncid contribuu.r
women eo11s11111cd a11101111ts 11f c/Joli1u t/Jnt were
1111d absorption and related issues sucb as phar- to bcnlt/Jy blood i>nilw for lm11ocysui11e.
nt or sl(q/Jtly /Ji_qhcr th1111 t/Jc w1-rmt Adeq11nte
macologie me nrt also covered. bicrtnmig foltc nctd intake to «?00 µg/da_r pro-
flttakc lc1•el, bm some iud1J11d1111/ mbjeci:s, espt·
4 Burterworth RF : Tluamin. In Shils ME and cinl~v womm, comumcd slrg/Jtlv less. 111crcfon 1,idtd a s/ig/Jr~ygreater effttt. 111e a11rl1orr caurio11
others (eds). ,\fodrrn 111Jtrit1011 i11 /Jenlt/J n11d t/Jc w1Trlll Adeq1111te lut11kc /c1•1'1 for choli11c t/Jnt it is 1111porrn11r to also mret 1•irnmi11 B-12
disease. I 0th ed. PhiladelphtJ, PA: Lippincott seems to be ngood approxi111atio11 oft/Jc nctna/ needs wfJm co11m111ing mch d11ses ii/Jolie acid.
Williams & W ilkins, 2006. i11t11kc of r/Jis 1111trient. 17. Kuo HK Jnd orhers: The role of homoq•stcinc
C11rrt11t ,.,l'icll' of tlJirr111i11 11utnbolis111. in multistage age-related problems: A systemattc
11. Food .ind Nutririon Board, Institute of
Digest1011 and nbsorptio11 a11d rdnud i.rmes stub rc,·icw. jo11n111/ of Gcro11tologu11/ n11d Biolo._q1ml
/\ledicinc:: Dutar_Y Rcfi:rrnu Intakes for tfn-
ns r/Jinmm dcjictc11ties sew 111 11/cobolmn are Stimus n11d /tfed1ti11c 60: 1190, 2005.
11111i11, riboj7m•i11, 11iaci11, 1•itn111i11 B-6, folnte,
also co1•rrtd. 111crr isgromi11...1f evide11cc of1111 nss11cinrio11 br-
1•irnmi11 B-12, pnmot/Jmir arid, biotin, and
5 Carmel R: Fobtc. In Shils ME a11d others (eds): r/Joli11,-. W;1shingron, DC: N.itional Academy twee11 dc1•nted blond homoc_v11ci111: and m1111e1"
Modcm 1111tritim1 in '1ca/t/J and disease. I 0th ed. Press, 1991!. 011s /1enltfJ problems nssocinted with aging,
Philadelphia, PA: Lippincorr Williams & i11cludi11g cardiol'flswlnr d1scnst, stroke, dcc/111·
Wilkins, 2006 11Jis rtporr exp/aim holl' 1111nfr111 rccomme11d11-
ing 11w1tnl ftmctio11, a11d bu11t loss. 11Je pro·
tio11s lf'O"t rstnblishcd fart/Jc B 1'itn111i111 n11d
Currm t rc1•irll' Join re mctnb11/is111. D1.!Jesrio11 posed mec/Ja1111m is tbt tmdrnc_v for
choli11c, wir/J specific rcftraur fll IlDA and re-
1111d nbsorpt1011 1J11d rclnred 1ss11rs mcb as genetic IJ011109•ste111e to dnmagc b/tJod 11csse/s nnd 1ur11ts
In ted sta11dnrds. TI1e jlmcrions 11ftnc/J of tbe
muses 1iffol are deficiencies a1·c also copered. a11d to i11/Jibit t/Je e1·oss·littki11g of colttigc11 t/Jnt
B 1•ita111ilis n11d c/Jolinc m·e also c.>;p/nincd.
6 Carmel R: Colbalamin (Vitamin B 12). ln Shi ls is i111p01·ta11r fm' /J1111c sy11t/Jcsis (nnd 1·eryntlmis).
ME and others (eds): Modem 1111tririo11 in 12. Food and Nuuition Board, lnstiu1re of Medi
18. Lee D-11 and others: Docs supplemental \'itJ·
cine: Dutnry llefermce Tntnlus for 1•itami11 C,
/Jen/th 1111d d1stnse. l 0th ed. Philadelphia, PA: min C increase cardiovascular disease r~k m
Lippincon Williams & \Vilkms, 2006. 1•itami11 E, stlmium, n11d cnrormoids. \V.tSh· women \\ith diabetes? Amtrira11 ]011runl of
ingron, DC: National Academy Press, 2000.
C11rre11r rc1•1f11• of1•immi11 B-12 metnbolis111. Ctilliml N111ritio1180:ll94, 2004.
Digestion n11d nbsorptio11 nud rc/ntcd ismcs mcb 171e fimct1om 11f1J11tio),'idn11t 1111triC11ts, bow RDA Vitamin C cn11 nlso be a pro·oxidmu and cn11
as '10111 to pn1pcrly diagnose a 1'ita111i11 B-12 de- nnd rclnted sta11dnrds wc1·c dctcr111i11rd, n11d deft· gl_vcnt( prntei11s. Hig/J vitnwi11 C intake fi·o111
ftciene_v nrc also covered. ciency n11d toxicity symptoms nre rxpllli11ed. 1111$ is supple111t111S is associnted 1v1t/J a11 increased risk
the dcfi111111•c report lry tht pa11d of e..>:ptrts 011 1111· of cardio1•nsmlnr disenst mortality 111 post·
7. Christen WG .ind others. fruit and ,·egerabk
tJ·imt needs for dietar_Y a11t1ox1dn11f1. 111c11opn11snl dinbetic 1vomw.
tnrakc and che nsk of cataract m women.
A111eriem1 Jo11mnl of C/111icnl N11trit1011 13. Forman JP and others: Fol.ire mtakc and the 19. Levine: M and others: Vitamin C. In Shib Ml-.
81:1417, 2005. risk or incident hypertension among u.s. and others (eds): Modern 1111t1·1tion i11 /Jen/th
!11e possible brnejicinl effects offruit a11d 1•eg· women. /011ninl of t/Jc A111t1·icn11 Medical 1rnd disease. lOrh ed. Philade lphia, PA:
cmblcs 011 r/Jr 1·isk of many e/Jromc diseases, in· Association 293:320, 2005. Lipprn.:cm Williams & Wilkins, 2006.
d11di11g catnrna, have a stro11g biologicnl b11Sis Jfeeti11..1f folntt needs was assoriattd n•irh a de· C11rrmt rtJ>mv ofvit11mi11 C 111ctabnlm11, m·
n11d wnrrn11r tbc co11ti1111ed rtcommt11dntio11 to C1"tased risk of i1mdmt h_vprrtcnsio11, partiw· cl11di11g bor/J k11onm n11d proposed roles in tb1·
illcrc11Se total i11rnkcs offruit n11d 1•rgetablcs. lnrly i71 _1'01111._IJer womc11. bod_y. Digmum n11d nbsorptio11 nrc also eol'crcd.
377
20. Macke~ AD and ochers: Vicamin 86. In Shil) disease. !Och cJ. PhiladclphiJ, PA: Lippincon flJis pnpcr rcriews the fimctiom ofji1/nrc a11d B·
ME and others (eds): Modern nucnrion in Williams & Wilkin), 2006 12, bt...11hl(rrbti11g the risks of0Pe1wm11mptiv11
health and disease. lOcb ed. Philadelphia , PA: C11n·mt rn•itll' of ri/Joj1ni•i11 mrtabolism. and 1111rfrrco11mmprio11.
L1ppincorr Williams & Wilkins, 2006. Digestion n11rf nbsorptio11 nr·c also co11ercd. 27. Trumbo TR. l'antothcnic ,1ciu. Jn Shib MF .rnd
C11rrmr l"c:view of vitam in B-6 111ctn/Jolis111. o thers (eds ): Modem n11rruio11 111 bcnftfJ 11nrl
24. M ock DJ',.\: Biorin. In Shi!' M E and othi:rs
D(rrurio11 nurl absorption and related issues mch dismse. J0Lh ed . Philadelphia, PA: I ippincon
(eds): M11dcrn 11111riti1m in bcnltb mid disease.
ns tllf r·isks nssoci11ted n•itb pha,.,,mrologic 11sr William~ & Wilkins, 2006.
10th ed. J'hiladdphia, PA: Lippmcoct Williams
111·c nlso covei·td. Currmt rcl'icw of pa11totbcuir arid 111t·1t1/111!tm1.
& \\"ilkins, 2006
21. Mar~ PW, Zukcrbcrg LR; Case 30-2004: A D(rrcst1011 n11rl nbsorprio11 nn nls11 r11rr1·1·d.
37 ,·c:ir·old woman with pareschc~i~ of chc C11rrmt m•ie1r oj /J1otirt 111ctab11lis111. Digestio11 28. Tucker KL and od1ers: High homoc\',Ccmc .111J
.irms .md legs. T1Jt Xew E11gl1111d ]011r1111I 11f 1111d absorprio11 n11d 1·tlatcrl irsues such ns /Jio· km B l'icanlim predict cognicil'c Jcdinc in
.\frdimu 351( 13):1333, 2004. ri11idnsc dtjiciCll(l.-S nrc nlso corcrerf. agmg men: ll1e \'cccrans Atl:ur. NormaUI.:
A mu of pernicious 1111e111i11 rPir/J 11moi1111111111t 25. Ra1·aglia G and other..: Homcx.•·,rcinc :rnd fo. Aging Snidy. Amcric1111 }011mn/ 1if < lwiml
g11srritis 1111d B-12 deficiency is mcrmf11il.v lace as risk factor; for demenriJ and Alzheimer l\'11tritio11 82:627, 2005.
tl"mrtrl w1r/J pnrwternl trerit111rnrs of disease. A1111·1·1cn11 /1111rnnl of Cli111cnl Ele1•ntcd blood bomoc_vstei11t conffllfl'nt11111; pn--
11lm111111 B-12. Nutrition 82:638, 2005. dictrd mg11iti1•c dcdim i11 tbr 11101 ill Ibis muf.l'.
22. Martinel MA and others: Folatc and colon;ctal ht tbis srurly of 8/6 o/de1· nd11lrs, clcJ1nted blood 'nms it is iwportn11t f ur agiug nr/1111.< 111 mar fl
ncopla)ia: Rcl.1rion between plasma and dicta!'~ bo111ocystci11r 111ns nss11cinll'rl ll'ith almost n dou- 11irn111i11 11enl.s i1111rrlcr 111111ni111ni11 r1trr111ri1•t'
markers or
folacc and adenonu recurrence. b/illg of tb1· 1·isk 1ifdn•dopi11..11 Al::./Jcimcr-'s dis- bcnfr/J.
A11urim11 J01m111/ of Cli11icn/ N11tritio11 79:69 I, tnsc. Low r1111cmrmt1om 11jfoln1r i11 th« 29. Zci)cl 5H, Niculcscu MD: Choline .md phn'
2004 blllorfsrrram we1·,- nprcinl/y pn·dictive of bigb photidakholine. In Shil~ Ml·. and other' (cd,I:
Adcq11ntc fa/ate 1111trit11re 11 nssorinrtd with n blood homoc.vsume 111 rim srurfy, n11d rbcrcforc Modem 1111tntion in bcnlt/J n11d d1m1Sf. I 0th ed.
lower risk of colo11 cnnccr. lnrakts of nbo111 600 low co11cmtrntio11s ojji1/ntt 11cerl to be ni•oidtd Philadelphia, PA: Lippincon \\'illi.1111' &
µg/dn.v s/Jo1J1cd t/Jegmuesr effect. A /Jcnlr/Jy rfm i11 older people. \Vilkms, 2006.
rn11 rnsi(v provide this rw101mt offolau. 26. Scovcr PJ: Phy~iology ol to!Jrc and 1icamin B- (. 11n·wt rcpfr·w of cboliue mc1nb11/ts111. /)IJ/f.fli1111
23. McCormick DB: Ribofla1·in. In Shib 1\ll- anu 12 in healrh JnJ dhca'c N11triti1m RePicrvs n11rf absorpri1111 nnd t/Jc cffrcrs 11f11 drfirirur.v
o ther) (cd~ ): Modern mm-itio>1 "' benltb r111d 62(6):S3, 2004 111/Jc11 mduccd in l111mar1s 11rc nls11 ct11'tTt"d.
Take I Action
I. Spotting Fraudulent Claims on the Internet

Search for vitamins and vitamin-like substances that ore sold
over the Internet. Then write o report concerning any claims
mode on behalf of these products that you consider fraudulent
or misleoding. Are the websites really selling vitamins, or ore
they actually a cover for selling something else? Compare the
price of the vitamins from these sites with the price you would
pay at the local supermarket or drugstore. Do any of these
sites display any disclaimers or warnings about the products?
-.8'
JI
-
• I
Take I Action ,
I
II. Spotting Fraudulent Claims in Popular Books for Sale

at Health-Food Stores and Bookstores
Visit a health-food store in order to examine the books that are for sale.
Haw many books represent sound nutrition, and haw many ore mostly
filled with nutrition quackery? Visit your campus bookstore. Identify the
books (and authors) that represent sound nutrition and the ones that ore
mostly filled with nutrition quackery. Consult lost Sunday's edition of the
New York Times best-seller list. How many books represent sound nutri·
lion, and how many ore nutrition quackery? Write a report comparing
these three sources of nutrition information.
.' -
•
•
-,
WATER AND THE MAJOR MINERALS
CHAPTER ELEVEN
CHAPTER OUTLINE CASE SCENARIO: i

-I
-I
Water
Water in the Body-Intracellular and
Extracellular Fluid • Functions of Water •
Jona, a sophomore in high school, recently gave up drinking milk. She lhought she
could stay slim by avoiding oll lhe calories in milk. Her mother is concerned oboul
,.,:::c
Water in Foods • Water Needs • Woter-
Deficiency Diseases • Water Toxicity
Jana's diel change, especially Jana's fulure risk of osteoporosis. Jona needs an ade- "'--l
"'
quate source of calcium in her diet to allow for continued bane development and I
Minerals m
Absorption, Transport, and Excretion of maintenance of the bone mass she already has. Jana also recently started smoking,
Minerals • Functions of Minerals • Food
<
~
and her only physical activity is proclice for the Women's Glee Club.
Sources of Minerals • North Americans al Risk
for Mineral Deficiencies • Toxicity of Minerals Jana's diet on o recent day consisted of the following items. For breakfast, she
Sodium (Na) hod oatmeal mode wilh water, o banana, and o cup of fruit juice. Al midmorning, z
(./)
Absorption, Transport, Slorage, ond Excretion
of Sodium • Functions of Sodium • Sodium in she bought o snack coke from the vending machine. At lunch, she hod vegetable )>
Foods • Sodium Needs • Sodium-Deficiency pasta, bread with olive oil, o side salad, 1 ounce of mixed nuts, and o soft drink. z
0
Diseases • Upper Level for Sodium
For dinner, she hod o hamburger along wilh mixed vegelobles and another sof1
Polossium (K) ~
of Potassium • Fune/ions of Potassium •
drink. As on evening snack, she hod some cookies and hol tea. zm
What factors place Jona al risk for osteoporosis in the future? Whal changes to
Potassium in Foods • Potassium Needs •
her currenl diet could reduce that risk?
'°
)>
,.....
Potassium-Deficiency Diseases (./)
Chloride (Cl)
of Chloride • Functions of Chloride • Chloride
in Foods • Chloride Needs • Chloride -
Deficiency Diseases • Upper Level for Chloride
Nutrition Focus: Minerals and Hypertension
Expert Opinion: A Close Look at the DASH Diel
Calcium (Ca)
of Calcium • Functions of Calcium • Calcium in
Foods • Calcium Needs • Calcium-Deficiency
Diseases • Upper Level for Calcium
Phosphorus (P)
Absorption, Tronsporl, Storage, and Excretion
of Phosphorus • Fune/ions of Phosphorus
• Phosphorus in Foods • Phosphorus Needs •
Phosphorus·Deficiency Diseases • Upper Level
for Phosphorus
Magnesium (Mg)
of Magnesium • Functions of Magnesium •
Magnesium in Foods • Magnesium Needs
• Magnesium-Deficiency Diseases • Upper
Level For Magnesium
Sulfur (S)
Toke Action
381
W ater-the most versatile medium for a variety of chemical reactions-constitutes the major
portion of human body weight. Without waler, biological processes necessary to life would
cease in o molter of days. We operate on about 3 lo 4 liters (3 to 4 quarts) of water doily and must re-
plenish ii regularly because the body does not store water per se.6 We recognize this constant demand
for water as thirst.2 Many nutrients, including minerals, exist in the
body dissolved in water.21 Because the functioning of minerals is T
related lo the characteristics of water, waler and its roles in the CHAPTER OBJECTIVES CHAPTER 11 IS DESIGNED
body ore explored first in this chapter.
TO ALLOW YOU TO:
Many minerals, like water, ore vital to health. They ore key l. Classify the minerals as major or trace minerals.
participants in body metabolism, muscle movement, body 2. list conditions of the body, dietary factors, and other pertinent
relationships that influence the absorption, retention, and
growth, and waler balance, among other wide-ranging
availability of specific major minerals.
processes.5,6 Some of the minerals found in our bodies-for ex·
3. list and briefly explain the functions of water in the body as well
ample, vanadium and boron-may not be necessary to sustain os typical sources of intakes and losses.
human life. Nevertheless, we know that some mineral deficien· 4. Discuss how body water balance is maintained by the
cies con cause severe health problems.5·6 For this reason, the mechanisms of thirst, absorption, and hormonal regulation.
study of minerals is critical to understanding human nutrition. 5. list key functions of the major minerals.
This chapter focuses on the ma jor minerals, such as calcium and 6. Identify possible deficiency and toxicity symptoms associated
with the major minerals.
magnesium; Chapter 12 focuses on the trace minerals, such as
7. list at least two food sources for each major mineral
iron ond zinc.
8. Describe the processes involving minerals that aid in
maintaining bone health as well as controlling blood pressure

OF WATER AND THE MNOR MINERALS IN CHAPTER 11 , YOU MAY WANT TO REVIEW:
Myfyromid and the 2005 Dietory Guidelines in Chapter 2
The functions of vitomin D ond vitamin K reloted to calcium and bone health In Chapter 9.
The role of vitamin C in collagen synthesis in Chopter 10.
lntrocellulor ond extracellular Auid comportments in Appendix C.
The muscular ond skeletal systems tn Appendix C
Water
To appreciate how miner,1ls operate in the body, it helps to understand the nature and
general chemical properties of water ar. well as specific nutrient-related functions
Water is the largest component of the human body, making up 50 to 70% of the bod) 's
weight (about 10 gallons, or 40 liters). Lean muscle tissue contains about 73% W•ltCI'.
Adipose tissue is about 20% water. 21 T hus, as fat content [ncreases (and the percenr·
A t a molecular level, waler is highly polar,

because the positive charges lend to be
located near the hydrogens and the negative
age of lean tissue decreases) in the bod)', total body water decreases roward 50%.
Depending on bow much fat has been stored, an adult can survi,·e for about
8 weeks without eating food but only several days without drinking water. ln a desert
charges near the oxygen. environment, a person wouldn't survive for more than one day without \\'ater. Tbis dif
s+H H s+
ference in survival time between food and water occurs not because water is more im-
portant than carbohydrate, far, protein, vitamins, or minerals but, rather, because the
"s-o / body has no storage site for water.
\!Yater can dissolve mosc substances, and in doing so, it enables minerals and other
8 d enotes partial charge chemicals to undergo biological reactions in the body (see Appendix A for details).
382
Water in the Body-Intracellular and Extracellular Fluid

Water flows in and out of body cells through ccU membranes. Water inside cells forms
part of the intracellular fluid-fluid within the cells. \Vhcn water is outside cells or in intracellular Auid Fluid contained within a cell
the bloodstream, it is part of the extracellular fl uid-fluid outside cells (Figure 11-1). 21 represents about two-thirds of all body fluid.
Extracellular fluid is further divided into interstitial fl uid-water between cells-and extracellular fluid Fluid present outside the
intravascular fluid-water in the bloodstream and lymph. Interstitial 11uid forms a cells; it includes inlravascular and interstitial
transport link between tissue cells and the blood. fluids; represents about one-third of all body
Because cell membranes are permeable to water, water shifts freely in and out of fluid.
cells. For example, if blood \'Olume decreases, water can move from the areas inside
and around cells to the bloodstream to increase blood volume. interstitial Auid Fluid between cells.
The body controls the amount of water in each compartmenr mainly by controlling intravasculor fluid Fluid within the bloodstream
the electrolyte concentrations in each compartment. 21 In solution, electrolytes such as (that is, in the arteries, veins, capillaries, and
sodium, chloride, and pot.1ssium dissociate into charged particles called ions. Water is lymph vessels); represents about 25% of all
attracted to these electrolytes and other ions. By controlling the mcwements of ions in body fluids.
and out of the cellular compartments, the body maintains the appropriate amo um of electrolytes Compounds that separate into ions
water in each compartment. Where ions go, water follows (Figure 11-2). in water and, in turn, are able to conduct an
electrical current. These include sodium,
Osmosis chloride, and potassium.
1'Iuch of the movement of body water results from ''are r's tendency to mm·e across a
semipermeable membrane so as co equalize tJ1e rota! particle concentration in the com-
partments on each side of the membrane. A semipermeable membrane is one through
which water, but not particles, can pass. In the body, the particles arc primarily electrolytes,
Figure 11 • 1 I Fluid compartments in the

body. Total Auid volume is about 40 liters
(about 10 gallons) .
3 Uters
Blood plasma 40
38
36
34 Extracellular
14 Uters Auid
Fluid between cells 32 (37%)
Lymph 30
Gastrointestinal Auid
Spinal column Auid 28
Fluid in eyes 26
Tears 24
Synovial fluid (in joints) 22 ""Q;
20 :S
18
25 Liters 16
Fluid found inside e:J Intracellular
~of cell, e.g., bl , 14 Au id
one, muscle, adipose 12:r (63%)
10
~i
384 Chapter 11 Water and the Major Minerals
Red blood cell

~/
---
Dilute solution Normal concentration Concentrated solution
(o) A dilute solution with o low ion (b) A normal concentra tion (o (c) A solution wi th o high ion
concentration results in swelling concentration of ions outside the concentration causes
(black arrows) and subsequent cell equal to that inside the cell) shrinkage of the red blood
rupture (puff of red in the lower results in o typically shaped red cell as water moves
left part of the cell) of blood cell. Water moves into and out of the cell and into the
o red blood cell placed into out of the cell in equilibrium concentrated solution (block
the solution. (black arrows), but there is no net arrows).
water movement.
Figure 11 -2 I Red blood cells affected by various ion concentrations. Osmosis causes fluid lo shifl in
and out of the red blood cells depending on the ion concentration in each Rask.
and the membranes arc cell membranes. This passage of water (or other solvcnr), called
osmosis The passage of a solvent (water) osmosis, results in the mm·ement of water from a less concentrated to a more con
through a semipermeable membrane from a centrated solution. 21 The specific concentration is expressed as osmo lality, represent-
less concentrated compartment to a more ing the number of particles per kg of solvent.
concentrated comportment. Figure 11-2 illustrates how osmosis works. When particles in a solution are less con
osmolality A measure of the total concentration ccntrated than those in a closed compartment bounded by a semipermeable mcm
of a solution; the number of particles of solute brane, the comparanent will be forced tO become more dilute. Because particles can't
per kg of solvent. pass easily across the membrane, water moves by diffusion from the relativcl~ dilute so-
lution tO the more concentrated compartment until their particle concentrations be
come identical. The opposite movement would take place if the solution was more
conceno-atcd 1.han the enclosed compartment (review Figw·c 11-2). Besides this effect
on red blood cells, examples of osmosis arc sugar pulling fluid from stra\\ berries and a
salty salad dressing wilting lettuce.
T he term osmotic pressure refers to the

amount of force needed lo prevent dilution
of the comportment containing the higher parti-
Adding water-instead of particles-to a compartment dilutes its particle concentra-
tion, so the compartment tends to donate water by the action of osmosis to more con
centrated compartments nem·by. Th.is happens when you drink water. Some water
cle concentration. absorbed by the body moves from the bloodstream into body cells, which in tmn equal
izes the particle concentration in the cells with that in the various nearby body sites.
Water and Ions in the Body-a Balancing Act

The movement of water across the membrane, depicted in Figure 11 -3, occurs by sim-
ple diffusion. Little of this movement actually occurs across cell membranes because of
their high lipid content. Rather, certain proteins in cell membranes act as channel~
through which water can move. In addition, cell membranes possess an extremely so
phisticated gatckeeping system, which makes them selectively permeable to many elec-
trolytes as well as other compounds. 21 For example, a specific protein located in the
cell membrane can pump potassimn ions into and sodium ions out of a cell. Energy is used
by this sodium potassium pump to move each of these ions against its concentration gra
dient. Cells use such mechanisms in addition to osmotic processes to maintain their intra ·
cellular water volume and electrolyte concentrations wid1in quite narrow ranges.
.,.......--- Phospholipid
bilayer
Extracellular
flu id
Na..,
"}
Cytoplasm
CD Adenosine triphosphate (ATP) and three

sodium ions (Na+) bind to sites on the
cytoplasmic surface of the sodium-potassium
pump (a transmembrane transport protein).
K
"".
;l-i- - - _ _ .
ransport protein Transport protein changes
resumes original shape (requires energy
shape from ATP breakdown)
© This transport protein reverts back to its original @ ATP breaks down into adenosine diphosphate
shape, resulting in the release of the K- ions into (ADP) and phosphate (P), resulting in a release
the cytoplasm. After the K~ ions diffuse away of energy that causes the sodium-potassium
from the sodium-potassium pump, it is ready to pump to change conformation (shape) and
begin the process again. release the Na ions to the extracellular fluid.
p
/
@ As the three Na+ ions diffuse away from the sodium-
potassium pump into the extracellular fluid, two K•
ions from the extracellular fluid bind to sites on the
extracellular surface of lhe sodium-potassium pump.
At the same time, the phosphate produced earlier
by ATP hydrolysis is released into the cytoplasm.
Figure 11 -3 I Sodium-Potassium Pump. A sodium-potassium pump has a lransmembrane

tronsporl protein thal uses energy to transport No+ and K ' ions through lhe membrane from o reg ion al
low concentration lo a region of high concentration. This continuous, active transport process can be
broken down into four steps.
Positive ions (cations), such as sodi um and potassi um, pair with negative ions (an-
ions), such as chlo1ide and phosphate. Intracellular water volume depends primarily on
the imraccllular potassium and phosphate concentratio n. Extracellular water ' 'olume
depends primarily on the cxrracellular sodium and chloride conccntration.2 1
Besides balancing the ion concentrations between the inside and outside of cells,
body cells must also baJancc ion charges. If a negative ion enters a cell, either a posi
rh·e ion muse also enter or another aegati,·e clecnolytt: must lea,·e. 21
Functions of Water
Because of its unique chemical and physical characteristics, water plays several key role!.
in metabolic processes. Water functions in se,·eral ways in the bodr's chemical re.1c
tions: because it is pol:tr, it se1Tes as a solvent for many chemical compounds~ ir pro
vides a medium in which many c hemical reactions occur; and it activdy participaLcs JS
a reactant or becomes a prod uct in some reactions, such as in protein digestion. 1t also
is the transpon medium of the body.6
Water Contributes to Temperature Regulation

Water changes temperatu re slowly because it has a great ability to hold heal. Water has
specific heat The amount of heal required to t his high heat capacity (specific h eat) because water molecules are st rongly attracted
raise the temperature of any substance 1°( to each other. In contrast, the molecules in fat are not strongly attracted to each other,
compared with the heat required to raise the and so fats exhibit lower specific heat ,·aJucs than water.
temperature of the some volume of waler 1°C. As the amount of heat energy contained within the body increases, water in the sur-
Water hos o high specific heat, meaning that o ro unding tissues absorbs any excess heat energy. The body then secretes fluids in the
relatively large amount of heat is required to
form of perspiration, which evaporates thro ugh skin po res. To evaporale water, heat
raise its tempera ture; therefore, it tends to resist
energy is required , so as pcr~piration C\'aporates, heat energy is taken from the skin ,
large temperature fluctuations.
cooling it in the process. This process is the main way in which the bod) cools icselt: 6
Each quart (liter) of perspi ration evaporated represents approximately 600 kcal of en
crgy lost from the skin and surrounding tissues. Note that for this reason feve r in
creases one's need for energy (and fluid).
Recall from Chapter -! that about 60% of the chemical energy in food is turned di -
rectly into body hear. Only about 40% is converted to ATP energy, and almost all of
that energy eventually leaves the body in the fo rm of hcac. If this heat could not be tfo,.
sipated, the body temper.1rure would rise too high and prevent enzyme systems from
fu nctioning effi ciently.
Ho"·e,•er, to cool efficiently, perspiration must be allowed to evaporate. Ir it simph
rolls off the skin or soaks into clothing, perspiration doesn't cool us much. E,·aporation
of perspiration occurs readily when humid ity is low. T his is why we fed more com
forta ble in hot, dry climates Lhan in hot, humid climates.
Water Helps Remove Waste Products

W.ner is an important ,·chicle for ridding the body of waste products. Most unwanted
substances in the body arc water-soluble and can leave the body via the urine. 6 In ad
dition , liver metabolism conver ts some fo r-soluble compounds such as some fat ·
soluble medications and pmential cancer causing substances, into water-soluble com
pounds. In thil> way they, roo, can be excreted in the urine.
he simplest way to determine if water intake A major bod) waste product is w·ea. RecaU from Chapter 4 that this by-product of
is adequate is to observe the color of one's protein metabolism contain!. nitrogen. T he more protei n we cat in exec~ of needs, the
urine, Urine should be clear or pole yellow and more nitrogen we excrete- in d1e form of urea-in the urine. Likewise, the more sodium
hove little odor, whereas concentrated urine is we consume, the more sodium we excrete in the urine. Overall , the amount of mine .1
very dork yellow in color and hos o strong odor. 4 person needs to produce is determined primarily by excess protein and sodium chloride
(salt) intake . B) limiting excess protein and salt intakes, it is possible to limit U1int:
output-a L1!.efl1l practice, for example, in space flights. This type of diet is also used to
u·eat some kidney diseases in which die ability to produce urine output ii> hampered.
A typical urine volume is about 1 liter (l quart) per day, depending mostly on the in ·
take of fluid, protein, and sodium.6 A somewhat greater urine output t han that is fine ,
but less-especially Jess d1an 500 ml (2 cups)-forces the kidneys ro form a very con
centrated urine. The hea'T ion concentration increases the risk of kidney stone formation
in susceptible people, especially among men. Kidney stones arc simply minerals and other
substances dut have precipitated out of the urine and accumulated in kidney tissues.
Other Functions of Water

Water is incompressible, so it helps form the lubricants found in knees and other joints
of the body. It is the basis for saliva, bile, and amn iotic fl uid . Amniotic fluid acts as an amniotic fluid The Ruid contained in a soc
important shock absorber smrounding the growing fetus. Electroh re concentrations within the uterus. This surrounds and protects
,·ary in each t1uid compartment to accommodate specific needs, such :is maintenance the fetus during its development.
ofa specific range in pH. 21
Water in Foods Table 1 1 • 1 I Water Content (by

Water can be found in abundance in fruits and \'egetablcs. Foods that are highest in Weight) of Various Foods
water conrent include fruits and vegetables as well as milk and other beverages, such
Food Water %
as beer. Orher sources rhat fall between 75 and 50% "ater are potacoes, chicken, and
steak. The foods thac are less than 35% \\'atcr include jam, honey, crackers, and various Tomato 95
fats in general (Table 11-1 ). Lettuce 95
Beer 90
Water Needs Milk 89
The Adequ.ue Intake set for coral water imake per day is 3.7 liters ( 15 cups) for adult men Orange 87
and 2.7 liters (11 cups) for adult women. This amount is based p1im.1rily on typical total Apple 86
\\'ater in takes from a combination of fluids <rnd foods. Fluid alone per day corresponds co
Potato 75
abouc 3 liters (13 cups) for men and about 2.2 liters (9 cups) fonrnmen. 6 (The Adequate
Intake does not indicate, ho\\'ever, that onl)' water per sc muse be used to meet fluid Bonano 75
needs.) At minimum, adults need 1 to 3 liters per day orAuid to replace daily water losses. Chicken 64
'vVe consume water in various liquids, such as fruit juice, coffee, tea, soft drinks, and Steak 50
water itself. Note that coffee, rca, and soti: drinks often contain caffeine, "'hich in-
Bread, whole-wheat 38
creases urine output. However, the fluid consumed from these be\'erages is nor com-
pletely lost in urine, so these fluids stiJJ help to meet water needs. Foods also supply Jam 28
warer (Table 11-2). Water as a by-product or metabolism provides approximately 250 Honey 20
to 350 ml (1to1 1/2 cups) of additional water. Butter 16
~luch of the \\'atcr we need is used to produce urine ( 500 to 1000 ml/or more).
Crackers, saltine 4
The rest compensates for typical water losses through the lungs (250 to 350 ml), feces
(100 to 200 ml), and skin (450 to 1900 ml for normal perspiration)6 (figure 11-4). Shortening 0
'Ve are not normally aware of these insensible water losses, as opposed to losses we
more easily notice, called sensible water losses. U1ine output and hea'')' perspiration
insensible water losses Water losses not
full into this latter category. These numbers :ire also just estimates: altimde, caffeine readily perceived, such as water lost with each
intake, alcohol intake, and humidity can :il'fCct these individual losses. When we con- breoth.
sider the large amount of water used to facilitate GI tract function, the loss of onJy
100 to 200 ml of water a day through the feces is remarkable. About 8000 ml of sensible water losses Water losses readily
water enters the GI tract daily via secretions from the mouth, stomach, intestine, pan- perceived, such as urine output and heavy
creas, and orher organs. T he diet supplies an additional 30 to 50% or more. The small perspiration.
intestine reabsorbs most of this water, while the large intestine takes up a lesser-but
srilJ importam-amounc. The kidneys aJso conserve \\'ater, reabsorbing about 97% of
the water filtered from waste products.
Water-Deficiency Diseases
If you don't drink enough water, yolll' body e\'entually lees you k.now by signaling ong airplane Rights ore another situation
llurst. This thirst mechanism is nm always reliable, however, especially dming athletic that demonds extra flu id intake: a traveler
practices and events, in infancy, during illness, and in one's older years.6 For this rea- con lose about 6 cups (1.5 liters) of water dur·
son, athletes should weigh themselves before and alter training sessions co determine ing a 3-hour Hight. The dehumidified air in on
their race of wacer loss and thus their water needs. Replacing at least 75% of this weight airplane is so dry that it induces excessive
loss is advised, especially as weight loss approaches 2%. Abouc 2 1/2 ro 3 cup1> (about insensible perspiration.
3/4 litcr) of water arc recommended per pound (about half a. kilogram) of weight loss
(see Chapter 14 for details on fluid use in athletics). Sick children-especially those
with feyer, ' 'omiting, diarrhea, and increased perspiration-and older persons often
need to be reminded co drink plenty of fluids. As Chapter 17 discusses in further de-
tail, infonrs can easily become dehydrated.
Table 11-2 I Water Content of a Typical Day's Food Intake*
Meal Fluid Oz
Breakfast
1 cup orange juice 7.2
l /2 cup fat-free milk 3.6
l /2 cup strawberries 2.7
l cup Cheerios 0.4
Midmorning Snock
1 cup water 8.0
l banana 3.0
Lunch
2 oz water-pocked tuna 2.2
2 slices whole-wheat bread 0.9
l large tomato 5.0
8 oz low-fat yogurt 6.8
l cup water 8.0
1 kiwi fruit 2.6
Midofternoon Snock
1 cup apple juice 8.0
4 small cookies
Dinner
2 oz baked skinless chicken 1.3
2 cups romaine lettuce 4.0
2 oz sliced red peppers 1.8
l slice bread 1.0
1 baked potato 3.5
1 cup fat-free milk 7.0
l tbsp oil-end-vinegar dressing 0.0
l cup of tea 8.0
Evening Snock
12 A oz diet soft drink 12.0
4 saltine crackers
Total 97 Auid ounces (12 cups)
•Adequote for o womon. A mon should odd 3 more cups ol fluid
Regular intake of Ruid is essential to replace

doily fluid losses. A recent lrend in North
America is lo carry waler and other fluids
with us.
Water Intake Water Output
Fluids: Skin perspiration:

2000 ml (8 cups) 750 ml (3 cups)
+
Lung respiration:
300 ml (1.25 cups)
+
Water content in food:
500 ml (2 cups)
+
Uri ne:
1650 ml (6.75 cups)
+
Water produced
from metabolism:
+
Feces:
300 ml (1.25 cups) 100 ml (0.4 cups)
Total Water Intake Total Water Output

2800 ml 2800 ml
(approximately 10 cups) (opproximotely 10 cups)
Figure 1 1 ·4 I Estimate of woter bolonce-intoke versus output-in a woman. We primarily maintain

our volume of body fluids by adjusting water output to intake. As you con see, most water comes from
the liquids we consume. Some comes from the moisture in more solid foods, and the remainder is
manufactured during metabolism. Water output includes losses from the lungs, urine, skin, and feces. antidiuretic hormone A hormone secreted by
the pituitary gland that acts on the kidneys to
cause a decrease in woter excretion. It is olso
What If the Thirst Message Is Ignored? called arginine vosopressin.
Once the body registers an increase in blood concentration, it increases tluid conser- renin An enzyme formed in the kidneys and
vation. T he pituitary gland releases antidiur etic h ormone to force the kidneys to con- released in response lo low blood pressure; if
serve water (Figure 11-5 ).21 The kidneys respond b)' reducing urine flow. At the same acts on a blood protein called ongiolensinogen
time, as fluid volume decreases in the bloodstream, blood pressme falls. This fall initi- lo produce ongiotensin I.
ates a sequence of events beginning in the kidncrs. Signa led by highly sensitive pres- angiotensin II A compound produced from
sure receptors, the kid neys release an enzyme called renin (Figure 11-6). Ren in, in ongiolensin I that increases blood vessel
rum, activates a circulating blood protein originally produced in the liver called an- constriction and triggers production of the
giotensinogcn to form angiotensin I. Angiorcnsin l is converted to angiotensin II, hormone oldosterone.
which , among other effects, causes blood vessels to constrict and Lriggers the ad renal
390 Chapter 11 Water and the Maior Minerals
Figure 11 · 5 I Antidiuretic hormone is

released in response to on increased In the brain, the hypothalamus
concentration of blood (l ). This hormone acts receives signa ls of increased blood
on the kidney to increase water retention (2); osrnolality from various receptors.
II responds by stimulating the
therefore blood volume and in turn blood posterior pituitary gland.
pressure ore restored to normal values.
I Antidiuretic hormone (ADH)

is released by the
posterior pituitary gland.
EJ Increased
Increased
water retention
by the kidneys blood pressure
lcohol inhibits the action of ontidiuretic
hormone. One reason people feel so weak
the day otter heavy drinking is that they ore very
dehydrated. Even though they may hove con-
sumed o lot of liquid in their drinks, they hove
lost even more liquid because alcohol hos inhib-
ited ontidiurelic hormone. Caffeine also does the
some, and so produces o diuretric effect on the
body.
Decreased blood El Renin (an enzyme)

is released
e
Angiotensin I results
• - - •• from renin action
of a ngiotensinogen
.--------,
Angiotensinogen Conversion
(from liver) takes place
primarily
in the lungs'
II Angiotensin II formed
Figure 11 ·6 I The renin-0ngiolensin system Aldosterone from angiotensin I
is one regulator of blood pressure. A decrease is released
in blood pressure (l) starts the cascade of
reactions (2-7) that act lo restore blood
pressure bock into the normal range. This
system functions with onlidiurelic hormone lo
control blood pressure. Number (5) is listed Adrenal gland
twice since ongiolensin II acts at both the
adrenal gland and blood vessels to help
regulate blood pressure.
~ Blood vessel
*The angiotensin<onverting enzyme (ACE)
inhibitors used to treat hypertension and other
IJ Increased constriction by
ongiotensin II
water retention
disorders act at this site (see the Nutrition Focus by the kidney
for details) . A new class of antihypertensive
medications goes a step further to block the
binding of ongiotensin II to receptors in the Increased
body (e.g., in blood vessels). These are called blood pressure
ongiotensin II receptor blockers (ARBs).
gbnds to release the hormone aldosterone. T his hormone, in mm, signals the kidneys
aldosterone A hormone produced in the
to rerain more sodium and chloride, and therefore more water. Remember chat water adrenal glands that acts on the kidneys,
always follows electrolytes. T hus, low blood pressure, through this roundabout meas- causing them to retain sodium and, therefore,
ure using the kidneys, causes increased water conservation in the body. waler.
However, despite these mechanisms to conserve water, lluid continues to be lost via
the insensible routes- feces, skin , and lungs. T hose losses must be replaced . ln addi-
tion, there is a limit to ho'' concc:nrrated urine can become. E,•enrually, if fluid is not
consumed, the body becomes dehydrated and suffers ill effccts. 6
I Tl.lrl.11,.,
A Closer Look at Dehydration
By rhe time a person loses 1 to 2% of body \\'eight in fl uids, he or she '' ill be thirsty. Stacy has been working in the yard with her
This loss of body weight contributes to fatigue as well as impaired physiological and brother Tom. They have been busy mowing the
performance responses. At a 4% loss of body ''eight, muscles lose significant sn·engrh lawn and pulling weeds since noon. Tom tells
and endurance. By the time body weight is reduced by 10 to 12%, heat rolcrance is de- Stacy that he is feeling weak and hos a
creased and \\'eakness resu lts. At a 20% reduction, coma and death mav soon foUow headache. Stoey is concerned that her brother
(Figure 11-7 ).6 · might be somewhat dehydrated. How can his
symptoms be explained? How could Tom's risk
of dehydration hove been decreased?
Water Toxicity
Too much water- whatever amount the kidnr.:ys are unable to excrete- can also lead
to serious side cftccts, such as headache, blurred vision, cramps, convu lsio ns, and ulti-
mately death. Water intoxication is most likcl) to occur if water intake is not accom-
panied by sufficient dectrolytcs. H owe,·er, an excessive amount \\Ould have to
approach many quarts (liters) each day. 6
Normol weight Figure 11 ·7 I The effects of dehydration

0 range from thirst to death, depending on the
extent of body weight loss.
Thirst
2 Stronger thirst, vague discomfort and sense of oppression, loss of appetite
Increasing hemoconcentrotion
4 less movement
lagging pace, Rushed skin, impatience; in some, weariness and
sleepiness, apathy; nausea, emotional instability
.:E
O>
·~ 6 Tingling in arms, hands, and feeti heat oppression, stumbling, headache;

] heat exhaustion; increases in bOCly temperature, pulse rote, and
·c respiratory rote s bottled water becomes more and more
popular, the industry now generates more
_Q"' Labored breathing, dizziness, cyonosis (bluish color of skin caused by
~ 8
1poor oxygen Row in body)
Indistinct speech
than $3 billion per year. In 1996, FDA instituted
definitions for the various types of bottled water
·~ Increasing weakness, mental confusion on the market; FDA also tests products for micro·
c biol and chemical content. For a list of manufac-
_Q
e 10 Spastic muscles; inability lo balance with eyes closed; general incapacity turers that meet federal guidelines, contact the
]. Delirium and wakefulness; swollen tongue lnternotionol Bottled Water Association at
~ Circulatory insufficiency; marked hemoconcentrotion and decreased blood 1-800-928·371 l or www.nsf.org. Some ex-
volume; foiling kidney !unction
perts recommend that children not be given bot-
~ed water exclusively, because many brands do
Shriveled skin; inability to swallow not contain on adequate fluoride supply to pro·
15 Dim vision tect against dental caries. For adults, battled
Sunken eyes; painful urination water is typically an unnecessary expense, be-
Deafness; numb skin; shriveled tongue
Stiffened eyelids cause it is often very similar to top water.
Crackled skin; cessation of urine formation Chapter 19 reviews issues surrounding the safety
Bare survival limit of our water supply in North America, such as
20
Death possible bacterial and lead contamination.
Very few people are at risk of drinking too much water, but problems do accompany
some disease states and mental disordcrs. 6 In addition, it is also possible for some ath-
letes to drink too much water. Endurance athletes (e~pecially poorly trained indh~du
als and those competing in cold conditions) may not sweat as much as they might have
predicted. Thus, their water losses arc not \'cry high. They must then monitor their
water intake to a,·oid an eventual fall in blood sodium, which is not desirable. Drinking
less fluid so as not to gain weight during the activity can help prevent this problem (see
Chapter 14 for details).
Concept I Check
Because our bodies cannot store water, we can survi\'e only a few days \\ithour it. Water
dissoh·c~ substances, serves as a medium for chemical reactions and as a lubricant, and aids
io temperature regulation. Water accountS for 50 co 70% of body weight and distributes it-
self throughout the bod}' among lean and other tissues (in both incracellular and extracellu-
lar fluids) nnd in urine and other body fluids. The Adequate lntake for total water intake is
2.7 liters (11 cups) for women and 3.7 liters (15 cups) for men. Thirst is the body\ first
sign of dehydration. If this thim mechanism is faulty, as it may be during illnesi. or vigor-
ous exercise, hormonal mechanisms also help consen·e \\'ater by reducing urine output.
Excess tluid intake can be hazardous co a person's health.
Minerals
Minerals arc di' ided into major minerals and trace minerals, depending on the amount
we need per day. Generally speaking, if we require 100 mg (1/50 of a teaspoon) or
major mineral A mineral vital to health that is more per da)' of a mineral, it is considered a m ajo r m in eral, or macr ominera1; other-
required in the diet in amounts greater than wise, it is considered a trace mineral, or micromineral. Using these criteria, calcium
l 00 mg/day; also called a macromineral. and phosphorus are major minerals, and iron and zinc are mice minerals.
trace mineral A mineral vital to health that is The functions and nutritiona l significance of the major minerals are discussed in thil>
required in the diet in amounts less than 100 chapter, and the trace minerals in Chapter 12. But, before examining the properties of
mg/day; also called a micromineral. the indi,~dual major minerals, this chapter considers some topics relevant to all these
mineraJs.
Absorption, Transport, and Excretion of Minerals

A significant factor determining the degree to which a mineral may be absorbed is the
physiological need for that mineral at the time of consumption. Other factors are dis-
cussed in the following paragraphs.
Many minerals ha"e sio-Ular molecular weights and charges (valences). Magnesium,
calcium, iron, and copper can exist in the 2 + valence state. H:n·ing similar ~i~c and the
same charge causes some of these minerals to compete with each other for .:ibsorption
bioavailability The degree to which the amount mechanisms, thereby affecting each other's b ioavaila bility and mctabolism .5 People
of an ingested nutrient is absorbed and is should avoid taking indi~dual mineral supplements unkss a medical condition specil:
availoble to the body. icalJy warranL~ it because an execs~ of one mineral influences the absorprion and me-
tabolism of other minerals. For example, the presence of a large amount of zinc in the
diet decreases copper absorprion.
Some vitamins improve mineral absorption. Vitamin C can improve iron absorption
when the [\VO arc consumed in the same meal. The vitamin D hormone ( 1,25 (OH )1
vitamin D) improves calcium, phosphorus, and magnesium absorprion.!i -
Mineral bion' .lilability can be greatly influenced by nonmineral substances in the diet.
Foods oflcr us a plcntifuJ supply or many minerals, but the body varies in it~ capacity ro
absorb and use .n .:iilable minerals. Although minerals may be present in foods, they are
not bioavailablc unless the body can absorb them. The ability co absorb minerals from
a diet depends on many faccors. The amount of a mineral listed in a food composition
table does not necessarily reflect the amou nt that can be acrualJy absorlx:d.
Components of fiber, especially phytic acid (phytate) in wheat grain fiber, can limit phytic acid (phytate) A constituent of plant
the absorption of some minerals by chemically binding to them and preventing these fibers that binds positive ions to its multiple
from being released during digestion. .A.s noted in Chapter 5, an intake greatly above phosphate groups.
the recommendation of 25 to 38 g/day of fiber can cause problems with mineral sta-
oxalic acid (oxalate) An organic acid found in
tus of the body. However, if grains are leavened witl1 yeast, as they are in bread, en-
spinach, rhubarb, and other leafy green
zymes produced by the yeast can break some of the chemical bonds between phytic vegetables that con depress the absorption of
acid and minerals. This breakdown in some cases reduces the effect ofphytates on min- certain minerals present in the food, such as
eral absorption. The zinc deficiencies found among some Middle Eastern populations calcium.
are attiibuted partly to tl1eir consumption of unleavened breads, resulting in low
bioavailabiliry of dietary zinc. This issue is discussed in detail in Chapter 12.
Oxalic acid (oxalate) is another substance in plants that binds minerals and makes
them less available to the body. Spinach, for example, contains plenty of calcium , but
only about 5% of it can be absorbed because of tl1e vegetable's high concentration of
oxalic acid. On average, about 25% of dietary calcium is absorbed by adults, such as
from milk and milk products. 5
Once absorbed, minerals ti·avel in the blood either in a free form or bOLmd to pro-
teins. For example, calcium ions can be found in tl1e blood as such, as well as bow1d
to the blood protein albumin. Many of tlle trace minerals have specific binding pro-
teins, which transport them in the bloodstream. Trace minerals in tlJeir free form are
often highly reactive and, so, would be toxic if not so bound. Many trace minerals also
are bound by specific cellular proteins once taken up by cells.
MineraJ excretion takes place primarily mrough the urine. When kidney fonction
fails, mineraJ intake must be controlled in order to avoid mineral toxicity, such as with
phosphorus and magnesium. 5 Some minerals, such as copper, arc discharged through
tl1e bile into tlle intestinal tract and then excreted ilirougb tlJe foces .
Spinach is often touted as a rich source of
Functions of Minerals calcium, but little of the calcium present is
bioavoilable, that is, available to the body
The metabolic roles of minerals and the amounts of them in the body vary consider-
ably (Figure 11-8). Some minerals, such as copper and seleniLLin, fimction as cofactors,
enabling enzymes to carry our a chemical reaction. (Recall this term was defined in
- -
1200 Figure 11 ·8 I Approximate amounts of
1200 various minerals present in the overage human
body. Other trace minerals of nutritional
1100 importance not listed include chromium,
Major minerals Some trace minerals
fluoride, molybdenum, selenium, and zinc.
1000
~
"'O
900 --
0
.l:I 800 ..
c
0
E 700
:I
.s:
.5 600
- I
I'
•
"' 500
E f •
..
0
(!) 400 • i -= •
300 I ~ •
200
200
100
0.16 0.12 0.03
~
s~
~
.§
c & .§
.:; b~
.:§'
!'::'
§ § I ~
~
btJ'
~ ~ O' <-3 c,§5 -,,<? ~ ~ § ~
Ci O' q;~ tJ ~ ~ <J
~ .f .f
Minerals
393
Chapter 9.) Minerals also arc components of many body compounds. For example,
iron is a component of hemoglobin in red blood ceUs. Sodium, potassium, and calcium
aid in the transmission of nerve impulses throughout the body. 21 Body growth and de-
velopment also depend on certain minerals, such as calcium and phosphorus. 19 Water
balance requires sodium, potassium, calcium, and phosphorus. At all levels-cellular,
tissue, organ, and whole body-minerals clearly play important roles in maintaining
body functions.
Food Sources of Minerals

i\ilinerals i11 the average North American's diet come from both plant and animal
sources. For some minerals, animal sources are the food sources with the highest
amoLmts and best bioavailabilit:y. For example, dairy products a.re rich sources of
bioavailable calcium, while meat and related foods are rich sources ofbioavailable iron
and zinc. On the other hand, magnesiLm1 and manganese are more plentiful in plant-
based foods than animal food products.
Generally the more refined a plant food~as in the case of white flour-the lower
its mineral content. With regard to minerals, the enrichment process for grains adds
only iron. The seleniw11, zinc, copper, and other minerals lost when grains are refined
are not replaced. This is just one more reason tO consLu11e whole grains on a regular
basis.
North Americans at Risk for Mineral Deficiencies

Typically, the major mineral at risk for being deficient in adult diets is cakium.
Currently, most North Americans do not meet tl1e recommended intake for calcium.
For trace minerals, iron and zinc arc most likel~r to be deficient in diets; these minerals
ru·e discussed in Chapter 12.
Toxicity of Minerals
Excess mineral intake can lead tO toxic results, especially with the n·acc minerals, such
as iron and copper. This potential for toxicity is yet another reason to consider care-
folly the use of minernl supplements. Many trace minerals arc quite toxic at doses not
Some mineral supplements pose a high risk for much above typical needs, which is approximated by the Daily Value on tl1e food or
toxicity. Generally, mineral intake from a supplement label. Thus, doses of mineral supplements should be exa111i11cd carefully,
supplement should not exceed 100% of the especially if inrake will exceed the Upper Level. Such intakes should be taken only
Doily Value unless otherwise specified by a under a physician's supervision because tox.'icity and nutrient interactions are possible
physician. (see the inside cover of tliis text for Upper Levels for minerals).
The potential for taxi.city is not the only reason to carefi.illy consider the t1si.: of min-
eral supplements. Harmful interactions with other nutrients arc possible. Also, contam-
ination of mineral supplements-with lead, for example-is a very real possibility. Use
of brands approved by United States Phannacopeia (USP) lessens this risk. ln summary,
even witl1 the best intentions, people may harm themselves usu1g mineral supplemenrs.
Concept I Check
Minerals are vital for many body processes. Their bioavailability depends on many factors,
including interactions wirh fiber, virnmins, and other minerals. Both animal and plam
sources belp us meet ow· mineral needs. Taking large amounrs of an individual mineral sup-
plement can greatly diminish the absorption and metabolism of other minerals. In addition,
some minerals arc potentially toxic at intakes not much in excess of human needs. These
are rwo good reasons to consider carefully any use of mineral supplements that ext:eed the
Daily Value on the label, especially if the intake is in excess of any Upper Level on a long-
term basis.
Sodium (Na) T he earliest reference to salt is in The Book of

Job written about 300 B.C. At one time, it
was the custom to rub salt on newborn babies
Many health professionals reconunend that North Americans limit intake of
sodium.1 •8,l3,2o Salt contributes almost all the sodiLm1 to our diets. Salt is 40% sodium as a symbol of purity and to ensure their good
health. Salt was once so scarce that it was used
and 60% chlo ride. North Americans typically consume more sodium than is needed.
as money. Caesar's soldiers received part of
Still, as reviewed in the Nutrition FocLJS in this chapter, salt intake is not the major caLJSc
of hypertension in North America (obesity and inactivity are more important).1,lS,!8 their pay in common salt. This part of their pay
was known as their "solarium," and from this
custom came today's word "salary." The expres·
Absorption, Transport, Storage, and Excretion of Sodium sion "not worth his salt" meant that a man did
The human body absorbs aL11ost all sodium consumed because sodium is easily ab- not earn his wages.
sorbed from the GI n·act. The body maintains a large amount of sodium in the blood-
stream for use when needed. Excretion of sodium is via the kidneys inro the urinc. 21
Functions of Sodium
Sodium is the major positive ion (cation) in extracellular fluid and a key factor in re-
taining body fluids. Sodium balance is regulated by the hormone aldosterone. Sodium
also helps regulate the fluid balance of the body both within and outside cl1e cells.21
As both sodium and potassium shift across the cell membrane, cl1ey create an elec-
trical potenrial charge cl1at allows muscles to contract and nerve impulses to be con-
ducted. Sodium also participates in the absorption of other nutrients (e .g., glucose and
amino acids) in the small intestine.
Sodium in Foods
About 80% of the sodium we consume is added during food manufacturing and food
preparation at restaurants (Table 11-3). Sodium added in cooking and at cl1e table pro-
vides about 10% of our intakes, and sodium nanu<lliy present in foods provides the rest,
Table 11 ·3 I Increase in Sod ium Content of Foods duri ng Processing* any commercially prepared condiments,
sauces, and seasonings are high in
Food Category Sodium (mg) sodium. Examples include onion, celery, and
Dairy Products garlic seasonings; sea salt; baking powder;
Fruited yogurt, 3/4 cup 107 salad dressings; pickles; soy, steak, barbecue,
2% milk, I 1/2 cups 182 chili, and Worcestershire sauces; meat tender·
Cheddar cheese, 1 3/4 oz 307 izer; baking soda; salt pork; brine; catsup; mus·
American cheese food, 2 oz 548 lard; bouillon; monosodiurn glutamate (MSG);
Meats and relish.
Beef roost, 1 oz 17
Beef jerky, 2/3 oz 540
Pork loin, 1 oz 22
Bacon, 2 pieces 202
Ham, 1 1/2 oz 564
Vegetables
Fresh peas, 1 cup 5
Frozen peas, 1 cup 139
Frozen peas in cheese sauce, 2/3 cup 205
Conned peas, 1 cup 372
Grain Products
Flour, 1/3 cup 1
Bread, 2 slices 286
Saltine crackers, 12 486
•All exomples in o porticulor group contain rhe some omounr of food energy. Cured meats are very high in sodium.
3 96 Chapte r 11 Water and the Major Minerals
Food Sources of Sodium again about 10%. Almost all unprocessed foods natw-ally contain a little sodium; the
higher amount fow1d in milk (about 120 mg/cup) is one exception.
Food Item Sodium The more processed and restaw-ant food we consume, generally the higher our
and Amount Content (mg)
sodium inrakc is. Conversely, the more home cooking we do, the more sodium coo-
Pepperoni pizza, 2 slices 2045 o·ol we have. 6 Major contributors of sodium in tl1e adult diet are white bread and roll~ ,
Sliced ham, 1 oz 1215 hot dogs and lunch meats, cheese, soups, and foods with tomato sauce, partly because
Chicken noodle soup, these foods are eaten so often. Foods tl1at are especially high in sodium include salted
conned, 1 cup 1106 snack foods, french fries and potato chips, and sauces and gravies.
If we ate only tmprocessed foods and added no salt, we would conSLLme about 500
V8 vegetable juice, 8 oz 620
mg of sod.iwn per day. 6 Comparing 500 mg of sodium from unprocessed food with
Macaroni salad, 1/2 cup 561 the 2300 to 4700 mg or more typically eaten by adults, it is dear that food processing
Hard pretzels, 1 oz 486 and cooking contribute most of our dietary sodium. As discussed in Chapter 2, nutri-
Hamburger with bun, 1 474 tion labels list a food's sodit1m content. When dietary sodium must be severely restricted,
attention to food bbels is of utmost importance. Under FDA food and supplement la-
Green beans, canned,
390 beling rules, tl1e Daily Value ~or sodium is 2400 mg (2.4 g). In addition, various de-
1/2 cup
scriptive terms, such as sodittm-free, salt-free, and low-sodi111n, may appear elsewhere on
Saltine crackers, 6 234 labels (review Table 2-14 in Chapter 2). When sodium must be severely restricted in a
Cheddar cheese, l oz 176 diet, even contributions from tap water (especially from softened water, which contains
Peanut butter, 2 tbsp 156 more sodinm), as well as medicines that contain sodium, must be considered.
fol-free milk, 1 cup 127
7-grain bread, 1 slice 126 Sodjum Needs
Animal crackers, 1 oz 112 The Adequate Inralcc set for sodium for adults under age 51is1500 mg/day. (See the in-
Grape juice, 1 cup 10 side cover for references to m.incral needs for various age groups.) Note tllat 1500 mg/day
is a generous amount. We really need only about 200 mg/day to mainrain physiolog-
Adequate Intake for young
adults, 1500 mg ical functions. Additional sodium was added to the Adequate Intake to allow for a
more varied diet in which not all foods need to be low in sod.ium.6
Adequate Intake for older Should you choose to consume less sodium, you can eventually adapt to a low-
adults, 1200 to 1300 mg
sodium diet, but many typical food choices will need to be eliminated (see the first
Take Action at tile end of this chapter). At first, foods will taste quite flat, but eventu-
ally you will perceive more flavor as tl1e tongue's salt receptors become more sensitive
to tl1e natLU'al salt content of foods . By slowly reducing dietary salt and substituting
garlic, oregano, other herbs, spices, and lemon juice, you can eventually become ac-
customed to a diet containing less sodjum. Many new cookbooks offer tested recipes
for flavorful low-soditl111 foods. Except when baking breads with yeast, omitting salt
from food preparation can still yield many excellent produces .
Sodium-Deficiency Diseases
Only when weight loss from perspiration exceeds about 2% of total body weight (or
o assess the sodium, potassium, chloride,
T mognesium, or phosphorus status of a per-
son, blood concentrations can be measured.
about 5 to 6 lb) should sodium losses be of concern. 21 Even then, merely salting foods
is sufficient to restore body sodium for most people. EndLU'ance athletes, however, may
need to consume sports drinks during competition to avoid depletion of sodium (see
Other methods, which ore often more sensitive,
Chapter 14). Altl10ugh perspiration tastes salty on tl1e skin, sodium is not highly con-
when oppropriole, will be noted in this chapter.
centrated in perspiration. Rather, warer evaporating from tl1e skin just leaves sodium
behind. (Perspiration contains about two-thirds the sodium concentration found in
blood.) Sodium depletion also can occur because of diarrhea or vomiting, especially in
infants. There arc special electrolyte drinks for use in such cases to replace sodium (see
Chapter 17).
Upper Level for Sodium

The Upper Level for sod ium for adults is 2300 mg/day (2.3g). Intakes exceedfog thjs
amount typically increase blood pressure. 6 About 95% of North American adults hn,·e
sodium intakes tl1ar exceed the Upper Level. A sodium intake> 2 g/day also increases
calcium loss in the urine, a probkm for people who consume much salt and little cal-
cimn (and too little potassium). 3 Another health area in whkh salt may be a problem
is kidney stone formation. A high salt intake ma~' contribute to stone formation in cer-
tain people, linked to increased calcium excretion. A very high sodium intake overall, Mrs. Massa has recently seen and heard a lot
can be toxic, especially when the kidneys cannot excrete the excess in the mine. about the amount of salt in foods. She has
Sodium is especialJy toxic when a high intake is accompanied by a lack of water. 6 been surprised by the number of articles that
advise the public lo decrease fhe amount of
Concept I Check salt in their food. If sodium is such a bad thing,
Sodill!n is the major positive ion in the extracellLtlar fluid. It is important for maintaining Mrs. Massa wonders, why do you need lo
fluid balance and conducting nerve impulses. Sodium depletion is unlikely, because the typ- have any al all? How would you explain to her
ical North American's diet has abundant somces of sodium and most of it gets absorbed. this need for some sodium?
Compared to dining out or buying commercially prepared foods, preparation of foods in
the home allows greater control over sodium intake. The Adequate Tntake for sodium for
adults is 1500 mg/day. The average adult consumes 2300 ro 4700 mg or more daily. Some
adults are especiaJly sensitive to sodium. In these people, hypertension can develop as a re-
sult of high-sodium diets. Nutrition experts cmremly suggest that for young adults,
sodium intake should be about 1500 mg (l.5 g), and should not exceed 2300 mg (2 .3 g)
on a regular basis. Sodium in the North American diet is provided predominantly tlu-ough
processed and restaurant foods.
he DASH (Dietary Approaches to Stop

Potassium (K) Hypertension) study showed that when peo-
ple ate 8 to 10 servings of fruits, vegetables,
Like sodium, potassium is a primary dectrolyte in body fluids. Unlike sodium, potas-
and nuts each day (along with low-fat dairy
sium is associated witl1 lower, rather than higher, b lood pressure values.
products)- all sources of potassium-their blood
pressure went down. This trend was especially
Absorption, Transport, Storage, and Excretion of Potassium true for people who had hypertension (see the
Expert Opinion by Dr. Marlene Most).
The body absorbs about 90% of the potassium consumed. Most of this potassiLUn ends
up inside body cells, while some is fuund in the bloodstream. As with sodium, potas-
sium balance is achieved primarily through kidney excretion or retention.21
Functions of Potassium Food Sources of Potassium

Potassium performs many of the same functions as sodium, such as fluid balance and Food Item and Amount Potassium (mg)
nerve-impulse transmission. It also in11uences the conrracti lity of smooth, skeletal, and Kidney beans, 1 cup 715
cardiac muscle. 25 Potassium is the major cation inside the cell. Intracellular fluids con- Winter squash, 3/4 cup 670
tain 95% of the potassium in the body. 2 1
Plain yogurt, 1 cup 570
Orange juice, 1 cup 495
Potassium in Foods
Cantaloupe, l cup 495
Unlike sodium, potassiwn is not generally added to foods. Overall, fresh fruits and Lima beans, l /2 cup 480
vegerables are good sources of potassium. lvlill<, whole grains, dried beans, and meats
are also sources . Major contributors of potassium to the adult diet include milk, pota-
Bonano, 1 medium 470
toes, coffee, tomatoes, and orange juice. Zucchini, l cup 450
Soybeans, 1/2 cup 440
Potassium Needs Artichoke, l medium 425
The Adequate Intake for potassilm1 for adults is 4700 mg (4.7 g) per day.6 The Dai ly
Tomato juice, 3/4 cup 400
Value used on food and supplement labels is 3500 mg. T ypically, North Americans Pinto beans, l /2 cup 400
consLune on average 2000 to 3000 mg/day. Thus many o f us need to increase our Baked potato, l small 385
potassium intakes, preferably by increasing intake of fruits , vegetables, whole-grain Buttermilk, 1 cup 370
breads and cereals, and low-fat and fat-free milk and milk products.6 Information
Sirloin steak, 3 oz 345
about a food's potassium content is required on the Nutrition facts panel only if the
food contains added potassium as a nutrient or if claims :ibom this nutrient appear on Adequate Intake for
rhc label. In all other cases, informacion is voluntary. adults, 4700 mg
Potassium-Deficiency Diseases
Low blood potassium is a life-threatening problem. Symptoms often include a loss of
appetite, muscle cramps, confusion, constipation, and increased urinary calcium excre-
tion . 'Eventually, rhc heart beats irregularly, decreasing its capacity to pump blood.2 1
Some diuretics used ro treat hypertension deplete potassiwn from the body. Peopk
who rake potassium-wasting dimetics need to monitor their potassium intakes care-
fully. A recent study showed an increase in risk of stroke in people on these medica-
tions who did not consume enough potassiL1111. For these people, high-porassium
foods-such as fruirs, fruit juices, and vegetables-are good additioos to rhe diet, and
if recommended by a physician, so are potassium chloride supplements .
A continual deficient food intake, as may be the case in alcoholism, can result in a
sevt:re potassium deficiency. This deficiency also can be evident in people with anorexia
Vegetables are a rich source of potassium, as nervosa and bulimia nervosa, who ba\'e pour eating habits and whose bodies can be
ore fruits. depicted of potassium because of vomiting (sec Chapter 15 ). People o n very low en ·
ergy diets are also at risk, as are athletes who exercise heavily. As covered in Chapters
13 and 14, all these people should compensate for potentially low body potassium by
consrn11ing potassiLL111-rich foods.
Use of potassi um in supplement form to treat a deficiency or poor intake is harm-
less if the kidneys function no rmal ly. T hus no Upper Level has been set.6 However,
taken in excessive amounts, potassium supplements can cause GI tract upset. When the
kidneys fonction poorly, potassium readily builds up in the blood. This buildup inhibits
heart function, causing slowed heartbeat. If untreated, this condition can be fat;1I, be-
cause the heart eventually stops beating. Consequently, in cast:s of reduced kidney
function, close control of potassium intake is criticaJ.21
I Chloride (Cl)
Chlorine is an element, but humans need the chloride io n (Cl-).
Absorption, Transport, Storage, and Excretion of Chloride

Chloride is almost completely absorbed in the small intestine and colon. Much chlo-
270
ride is found in tl1e bloodstream (associated with sodium). Like excretion of sodium
and potassium , excretion of chloride occm s mainly tl1rough the kidneys. 21
250
230 Functions of Chloride

C hloride serves as a.n importaot negative ion in the extracellular fluid. Chloride's neg-
ative charge balances the positive charges of sodium ions and in turn cona-ibutes to
maintenance of electrolyte balance. 21 Chloride contributes to the function of the ner-
vous system. Chloride also is a component of tl1e hydrochloric acid produced in die
stomach, and is used during immu11e responses wben white blood cells arrack foreign
cells. Finally, chloride aids in the transport of carbon dioxide from cells to the lungs as
well as the disposal of c;trbon dioxide by way o~' ex.haled air.
Chloride is likely part of the blood

pressure-raising property of sodium chloride
(salt).
Chloride in Foods
Seaweed, olives, rye, lettuce, a few fruits, and some vegetable!> arc naturally good
sources of chloride. Chlorinated water is also a source. However, \\'e consume most
chloride as s;ilt added to foods. Once we know a food's salt content, we can easily pre-
dict its chloride content; recall that salt is 60% chloride. Natural !)' occurring sodium or
chloride won't significantly affect the prediction.
Chloride Needs
The Adequate Intake for chloride for adults is 2300 mg. This amount is based on the
40:60 ratio of sodiw11 to ch101ide in salt ( 1500 mgs of sodium in a diet is accompanied
by 2 300 mg of chloride). 6 The Daily Value used on food and supplement labels is 3400
mg. An average daily consumption of9 g of salt yields 5.4 g (5400 mg) of chloride.
Chloride-Deficiency Diseases
A chloride deficiency is generally unlikely because our dietary sodium chloride (salt)
intake is so high. Frequent and lengthy bouts of mm.iring- if coupled with a nutrient-
poor diet--can cause a deficiency because stomach secretions contain much chloride. 21
Upper Level for Chloride

As just noted, the average adult typically consLm1es much more rh;in this amount. The
Upper Level for chJ01ide is 3.6 g/day. Th is amount is based on the amount of chloride
that accompanies the Upper Level for sodium (2300 mg/day) .6 Dietary d1loride has been
implicated in the blood pressure- raising ability of sodium chloride. 15 Still, as one lowers
sodium intake as part of hypertension therapy, chloride intake automatically fulls as well.
Concept I Check
Potassium performs functions similar co rhose of sodiwn, except that it is rhe main positive
ion (carion) fow1d inside, nor outside, cells. Potassium is' ital to fluid balance and ner\'e
transmission. A potassium deficiency-caused by an inadequate intake of potassium, persis-
tent vomiting, or use of some diuretics- can lead to loss of appetite, muscle cramps, confu -
sion, and heartbeat irregularities. fruits and vegetables are generally good sources of
pota~sium. Potassium intake can be toxic if a person's kidney~ do not function properly.
Chloride is the major negative ion (anion ) of extracellular fluid. Chloride also fi.mctions in
digestion as pan of hydrochloric acid and in immune and nerrnus system responses.
Deficiencies of chloride arc highly unlikely because we ear so much salt.
Minerals and Hypertension
More than 50 million North American adults have pertensioo with medication w1til the diastolic
hypertension, as docs one our of two adults over blood pressure measures at least 90 mm Hg
age 65. Blood pressure is expressed by two mtm· and/or the systolic blood pressure reaches 140 mm
bers. The higher number repn:scnts systolic blood Hg on three or more occasions. 2
ymptoms of Stroke
pressure, which is the pressure in the arteries when
the heart actively pumps blood. The second value
Individuals experiencing any of the fol· is for diastolic blood pressw·e, which is the artery W hy Control Blood Pressure?
lowing symptoms of stroke should seek pressure when the heart is relaxed. Optimal systolic
immediate treatment because physicians blood pressure is less than 120 mm of mercury Blood pressure needs to be controlled mainlr to
can administer drugs that con reduce the (mm Hg). Optimal diastolic blood pressure is less prevent card iovascular disease, kidney disease,
extent of the damage caused by most than 80 mm Hg. Elevated systolic and diastolic strokes and related declines in brain function , poor
strokes (i.e., ischemic strokes). Currently pressure shows a strong relationship to various dis- blood circulation in r11e legs, problems with \~Sion,
about 700,000 North Americans suffer eases (especially strokes and other cardiovascular and sudden death. All these conditions are much
strokes each year. diseases).2•11 more likely to be found in individuals with hyper-
Sudden disturbances in sight, speech, For adults, hypertension is defined as sustained tension than in people with normal blood pressure.
and steadiness systolic pressure exceeding 140 mm Hg or diastolic Smoking and elevated blood lipoproteins (LDL
Sudden sleepiness or severe headache blood pressure exceeding 90 mm Hg (Table 11-4 ). and VLDL) fi.mher increase disease risk.
Sudden temporary blindness in one Most cases of hypertension (about 95% of cases) Individuals with hypertension need to be diag·
eye or other visual effects have no clear-cur cause and are described as pri- nosed and treated as soon as possible, because rhc
Sudden numbness, weakness, or porol· mary, or essential, i11 nature (e.g., essential hyper· condition generally progresses to a more serious
ysis of on arm, o leg, or on entire side tension). Kidney disease, sleep-disordered stage over rime and even resists r11erap)' if it persi~rs
of the body breathing (sleep apnea), and other causes ofi:en for years.2
lead to the other 5% of cases, known as secondary
Sudden difficulty with speech or the
hypertension. African Americans are more likely
ability lo swallow than Caucasians to develop hypertension and to do Causes of Hypertension
Como or convulsions so earlier in life. As a result, they also suffer more
from hyperrension-related diseases and, so, arc par- Blood pressure usually increases as a person ages.
ticularly advised to have their blood pressure Some increase is caused by atherosclerosis. As
checked regularly and ro have any evidence of hy- plaque builds up in the arteries, the arteries become
pertension treated aggressive!}'· less flexible and c~mnot expand. When vessels re·
Unless blood pressure is measured periodically, main rigid , blood pressure remains high .
the development of hypertension can be easily Eventually, the plaque begins to choke off the
overlooked. Thus, hypertension is described as a blood supply to the kidneys, decreasing their abil-
silent disorder because it usually does not cause ity to control blood volume and, i.11 rurn, blood
symptoms. A physiciru1 usually does not treat hy- pressure. 2
The enzyme renin, which is secreted by the
kidneys and some hormonelike compounds affect
Table 11 ·4 I Latest Classification of Blood blood pressure. Medications are available to reduce
Pressure for Adults Age l 8 Years a nd O lder their effect on the rcnin-angiorensin system. 2•21
in Millimete rs of Mercury (mm Hg) Obesity is often associated with high blood
pressure, especially among women. In fuct, over-
Category Systolic Diastolic weight people have six times greater risk of having
Normal < 120 and < 80 hypertension than do lean people. Overall, obesity
is considered the primary lifestyle factor related to
Prehypertension 120-139 or 80-89 hypertension. 1 The increase in fat mass increases
Hypertension the need for blood circulation. The extra miles of
Regular, moderate physical activity Stage 1 140-159 or 90-99 associated blood vessels increases work by the heart
contributes to better blood pressure and u1creases blood pressure. Elevated blood in·
Stage 2 ~ 160 or ~ 100
control. sulin concentration associated with insulin-resistant
400
. - - - - - - --- '
adipose cells is another reason for this link to obe- if one reduces sodium intake, chloride intake natu·
siry. Insulin increases sodium retention in the body rally falls; the opposite is also true. For the most
and accelerates atherosclerosis. Additionally, an es- part, when nutrition recommendations suggest
timated 65% of people with diabetes also have consuming less ~odium, d1e~ are in essence saying
"consume less salt." Because only some North Regular inloke of fruifs and vegetables
hypertension.
hos been linked lo a decreased risk of
A weight loss of as little as 10 to 15 pounds Americans arc susceptible to increases in blood
bolh hypertension and stroke.
often can decrease the need for hypenension pressure from salt intake, salt intake is only the
drngs, which by themselves may cause headache, fourth leading lifestyle factor related to hyperten-
imporem:c, reduced exercise rolerance, persistent sion. Thus, it is unfortunate that salt intake receives
cough, and other side effects. The sleep apnea the major portion of public attention with regard
linked co h) perrension also typically impro\'CS with
1 to hypertension; obesity, inactivity, and alcohol
weight loss. abuse should be given much more attention, espe-
lnacti\ity is considered the second leading cially for people who arc not sodium sensitivc. 1•18
litestyk factor relaced ro hyperrcnsion. 1 If an obese About half the people with hypertension are not
person can engage in regular physical acti\·iry (at sodium sensiti\'e. Hcmner, many people with hy- reliminory sludies show a link be-
least ti\·e days per week for a rota! of 60 minutes) pertension do not kno\\' whether they arc sodium tween bone lead concenfrofions and
and lose weight, blood pressure often returns to sensiti\·e, and resnng for this sensitivity takes a lot increased risk of hypertension. More in-
normal. of time and is not romincly done. formation is needed, but it is suspected
Excess alcohol intake is responsible ror about that even small amounts of lead stored
10% of all cases ofhypertension, especially in middle- over decodes may damage the kidneys
agcd males and among 1 African Americans in gen- Other Nutrients and and eventually resul! in hypertension. This
eral. It is considered the third leading lifestyle fac- Blood Pressure is jusf one of the deleferious effects of
tor related to hypertension. Hypertension caused lead exposure (see Chapter 19 for more
by excessive alcohol intake is usually reversible. A Recent studies shO\\ that a diet rich in calcium, informofion on lead).
sensible intake for people with hypertension is two potassium, and magnesium (and low in sodium)
or fewer drinks per day for men and one or no may lead to a decrease in blood pressure, especially
drinks per day for women and older adults. (These among African Arncricans. 1 The response is similar
are the same recommendations given to healthy to that seen with typical antiJ1ypertensive medica-
adults.) As discussed in Chapter 8, some studies tions. Dr. Marlene Most discusses this dietary ap-
suggest that such a moderate alcohol intake re- proach t0 lowering blood pressure in detail in the
duces the risk of ischemic srroke. These data, how- Expert Opinion. Other studies also show a reduc-
e\•er, should not be used ro encourage alcohol use tion in stroke risk among people who consume a
in nonconsumers. diet rich in fruits, vegetables, and vitamin C (recall
that fruits and \'egetablcs arc rich sources of potas-
sium).11 Overall, a diet rich in low-fat and fut-free he exod mechanism whereby sodium
Salt and Blood Pressure dairy products, fruits, \'Cgetables, whole grains, and increases blood pressure is not dear.
some nuts can substantially reduce blood pressure Sludies suggesf that a geneficolly inRu-
Excess salt intake tends ro increase blood pressure, and stroke risk for many people. 1·15 enced ability determines the ease of
particularly among African Americans, older per- which the body con excrefe sodium. In
sons, obese persons, and people in general who are salt-sensitive individuals, the kidneys re·
susceptible to developing a problem regulating Prevention of Hypertension quire on elevated blood pressure lo ex-
sodium concentration in the body. This last group crete sodium from the body. Solt-sensitive
is termed "sodium (or salt) sensitive" because they Many of the risk. factors for hypertension and individuals retain more sodium, which
are not good at excreting excess salt \·ia the kidney. stroke are conrrollable, and appropriate lifestyle then leads to Ruid retention. Ultimately,
This excess salt retention d1en has a tendency to in- changes can reduce a person's risk (Table 11-5 ). the Ruid retention leads lo increased
crease blood pressure. 1•15 It is not clear whether fa.-perts typically recommend that people \\~th hy- blood volume and, in furn, the increa~
the sodium ion or the chloride ion is most respon- pertension in the Prchypertension and Stage 1 cat- blood pressure needed lo maintain
sible for the effect. Still, as reviewed in this chapter, egories attempt to lower blood pressure through sodium excretion. 15
401
Table 11-5 I A Nutritional and Related Lifestyle Pion to Minimize Hypertension
and Stroke Risk* l , l l , 20, 25
1. Follow MyPyramid . A person could even consider going beyond this plan to include more fruit,
vegetables, and some nuts, especially if one has hypertension.
2. Make sure to meet nutrient recommendations for calcium, potassium, and magnesium listed in
this chapter.
3. Attain and maintain a healthy body weight.
4 . Incorporate regular physical activity (at least five times per week for a total of 60 minutes).
5. Consume alcoholic beverages in moderation, if at all (two drinks per day maximum for men and
one drink per day maximum fo r women and older adults).
6 . Consume moderate amounts of sodium (salt) and see if any changes in blood pressure occur.
The Upper Level is a reasonable starting point (2300 mg sodium or 6 g salt [l ~ tsp]) per day.
One might even try to lower intake to 1500 mg/day, the Adequate Intake set for sodium .
7. Don't smoke.
8. Maintain blood lipoproleins in the normal range (see Chapter 6 ).
9. Moderate caffeine intake.
10. Find ways lo reduce psychological stress.
•In addition, make sure ta have blood pressure measured on o regular basis (i.e., yearly physical checkupsl.
diet and lifestyle changes before resorting ro blood

pressure medications. Such a focus 0 11 diet and
lifestyle is important because many people discon-
tinue their blood pressure medications because of
expense and side eftects.
Medications to Treat
Hypertension
Potassium-wasting diuretics, such as thiazides
(chlorothi.azidc [Diuril ]), are commonly used for
drug therapy to treat hypertension. People need to
monitor their potassittm intakes carefully while
taking cl1ese drugs. Other rypical medications to
treat hypertension include angiotensin-converting
enzyme (ACE} inhibitors (captopril l Capoten],
angiotensin II receptor blockers (candl.'.sartan
[Atacand] ), beta-blockers (atenolol [Tenormin]),
and calcium channel blockers ( amlodipine
[Norvasc]). A combimtion of two or more drugs
is commonly used. The beta-blockers act to slow
heart rate and cause some vasodilarion, whereas
the calcium channel blockers and ACE-related
medications lead to general vasodilation.2 Older oduhs are particularly at risk of hypertension.
402
I
- - -~~~~~~~~
Expert Opinion
A Close Look at the DASH Diet
Marlene Most, Ph.D., R.D., F.A.D.A.
As individuals ore becoming more aware of the relationship between diet Participants who consumed the DASH diet showed substantial reductions
and their health, they ore searching for dietary means to improve health in blood pressure, especially those who hod hypertension. The magnitude of
by diminishing disease risk factors. We know, for example, that a diet low the effect on blood pressure was similar to that observed with single ontihy·
in soturoted fat will improve blood lipid levels, a major risk factor for car· perlensive drug therapy. Additionally, the diet was particularly effective for
diovasculor health. Similarly, we know that some changes in diet will lower African Americans. Most impressively, the reduction in blood pressure look
blood pressure and in turn minimize the risk of developing hypertension. place rather quickly, occurring within two weeks of the dietary intervention.
These changes include reducing body weight (if overweight or obese}, Although the goal of the DASH study was to find a dietary pattern lo ben·
lowering alcohol intake, and minimizing sodium intake. Other dietary fac- efit blood pressure, certain nutrients were targeted in the diet's design. These
tors, such as potassium, magnesium, calcium, protein, and fiber intake, nutrients specifically included magnesium, potassium, and calcium. The diet
also are implicated in having a beneficial effect on blood pressure. The sci· was also designed to be low in total fat and saturated fat and moderately
entific evidence for these individual factors, however, is inconsistent or high in protein and dietary fiber. Sodium reduction was added in a subse-
inconclusive. quent study-3300 mg/day, 2400 mg/day, and 1500 mg/day groups.
This intervention further lowered blood pressure as sodium intake declined
(called DASH-Sodium).
Why Develop the DASH Diet?
It is plausible that the effects on blood pressure from individual nutrients ore
small and cannot be seen in research studies. Because many of the studies How Do Magnesium, Potassium, Calcium,
hove examined the individual nutrients in supplement form rather than in and Fiber Affect Blood Pressure?
foods, synergistic effects were then considered as well as the possible im-
Clinical and epidemiological studies hod examined the relationship between
portance of a combination of nutrients in foods that may be needed lo re-
blood pressure and magnesium consumption. Some results hove shown on
duce blood pressure. Thus, the National Hearl, lung, and Blood Institute
inverse relationship and a clear effect of magnesium. It hod been shown that
decided in 1992 to fund a study with the goal of examining dietary patterns
magnesium hos a direct effect on reducing the contractile activity of smooth
and blood pressure. The highly successful Dietary Approaches lo Stop
muscle, such as that surrounding blood vessels, which offers a plausible
Hypertension (DASH) diet was the end result.
mechanism for magnesium's con tribution to the regulation of blood pressure.
On the other hand, failures of many magnesium supplementation interven-
tion trials had been reported. Initial magnesium status appears to be impor-
What Actually Is the DASH Diet?
tant. Significant effects tend lo be seen in persons in whom magnesium
The DASH diet is characterized as low in fat ond sodium and rich in fruits, intake or availability initially was compromised.
vegetables, and low·fat dairy products. Here is the actual breakdown: Evidence from clinical studies of dietary or supplemental calcium were
suggestive, but not conclusive, in the role for this mineral in modulating
blood pressure. Benefits were found in persons who hod low calcium intakes
Per day Per week
or metabolic conditions in which calcium availability is affected, such as
6-8 servings of groins and groin 4-5 servings of nuts, seeds, pregnancy. Epidemiological studies also hove provided support for higher
products or legumes calcium intakes and lowered blood pressure.
4-5 servings of fruit 5 servings of sweets and Potassium had the most definitive role of any micronutrienl in the control
added sugars of blood pressure. Potassium intake or urinary potassium is inversely ossoci·
4-5 servings of vegetables ated with blood pressure. Epidemiological and intervention data hove pr<>
2-3 servings of low.fol or fat.free vided support for both phytosterols. Their roles in disease risk reduction ore
dairy products now becoming recognized, as they provide health benefits much beyond the
nutrients present in the foods. It is possible that the biooctive compounds
2 or less servings of meats, poultry,
found in the DASH diet ployed a role in the blood pressure changes ob-
and fish
served in the studies: For example, o probable contributing mechanism for
2-3 servings of fats/oils blood pressure regulation may be through blood vessel relaxation and
403
404 Chapter 11 Water and the Major M inerals
improved potassium intake from foods and supplements in people with nor- rounding blood pressure regula-
mal blood pressure values and mild hypertension. tion. Consequently, the health ben-
High.fiber diets significantly reduce blood pressure in persons with hy- efits of the DASH diet may extend
pertension. Yet in people with normal blood pressure values, fiber supple- beyond blood pressure reduction.
mentation only modestly reduces blood pressure or hos no effect. Positive Look lo the grocery aisles, rather
studies of fiber intake generally utilized vegetarian diets or involved the mo· than the supplement aisles in a
nipulotion of fiber content along with other nutrients. Although suggestive, pharmacy, for the benefits of the
the literature did not unequivocally support a role for fiber alone in the con- DASH diet. Never hos the recom·
trol of blood pressure. mendation for a diet rich in low-fat
and fat.free dairy products, fruits,
vegetables, nuts, and whole-groin
How Does the DASH Diet Benefit One's breads and cereals been so clear.
Total Diet?
Dr. Most is Associate Professor
The failure of many nutrient-specific interventions lo hove significant blood of Research at the Pennington
pressure effects may hove been due to the fact that several aspects of the diet Biomedical Research Center in
must be changed together. The most compelling data for this assertion come Opting for the fruits, vegetables, and Baton Rouge, Louisiana. She is
low-fat foods recommended by the
from studies of vegetarian diets-th ese diets ore strongly associated with re- a registered dietitian and a
DASH diet represents a sound
duced blood pressure when compared lo nonvegelorion diets. Vegetarian charter fellow of the American
approach to nutrition for most people
diets lend to be lower in total fat and higher in fiber, magnesium, and polos· Dietetic Association. She re-
regardless of hypertension risk.
sium. II hod been difficult to tease out which nutrients were responsible for ceived her Ph.D. in Veterinary
the lower blood pressures in vegetarians, suggesting the need for including Medical Sciences, Physiology,
all factors. With this in mind, the combination of nutrients in the DASH di- from Louisiana State University and her M.S . and B.S. in Food
etary pattern led to its success in blood pressure regulation. Science and Nutrition from Colorado State University. Dr. Most has
While certain nutrient targets were achieved in the DASH diet, its focus been principal investigator For feeding studies that examined car-
on fruits, vegetables, ond whole grains also contributed many other com- diovascular benefits of various modified diets and was instrumental
pounds lo the diet. These foods ore abundant in phytochemicols, including in the Dietary Approaches to Stop Hypertension {DASH) studies
polyphenols, corolenoids, and endothelial cell function from the antioxidant funded by the National Heart, Lung, and Blood Institute, NIH.
properties of the polyphenols present in the DASH diet. The actual protective Dr. Most has conducted NIH-funded training workshops For deliver-
mechanisms remain to be determined, and more information will surely being research diets and is the author of several manuscripts and book
come available about the impact of phytochemicols in the processes sur- chapters that describe controlled Feeding study methodologies.
I Calcium (Ca)
All cells need calcium, but more than 99% of the calcium in the body is used as :i struc-
tural component of bones and teeth. This calcium represents 40% of all the minerals
presenr in the body and equals about 2.5 lb (1200 g). As caJcium circulates in the
bloodstream, it suppLles the calcium needs of body cells.5
Absorption, Transport, Storage, and Excretion of Calcium

Ninety-nine percent of calcium in the body is in Unlike sodium , potassium, and chloride, rhe amount of calcium in the body greatly de-
bones. pends on the amount absorbed from the diet (Figure 11-9 ).
Dietary calcium intake 1000 mg Sweat 20 mg Skeletal calcium

500-700 mg
readily exchangeable
Skin
Resorption
Blood calcium
•
Deposition
rit'4IA!!i!@3 and
Digestive juices
disrupted
mucosal cells
150 mg
Filtered
!I Reabsorbed
Kidneys
Feces Urine
850 mg 130 mg
Figure 11 ·9 I Calcium balance in on odult. On on intake of 1000 mg, only about 300 mg ore absorbed by the body, wilh
the remaining 700 mg being excreted in the feces. To maintain calcium balance, 300 mg ore excreted by a combination of lhe
kidneys ( 130 mg). skin (20 mg), and secretions and cell loss into the feces ( 150 mg).
Absorption
Calcium absorption occurs primarily in the upper part of the small intestine because he tooth consists of a hard, yellowish tissue
calcium requires a pH below 6 to stay in solution in an ionic state (Ca2+ ). As the acidic called dentin, which is covered with enamel
stomach contents reach the small intestine, they are partially neutralized by bicarbon- in the crown and cementum in the root. When
ate released rrom the pancreas but are scill slightly acidic, which pro,ides a suitable en- dentin and cementum ore damaged, they con
\'ironment for calcium absorption. Jn addition, calcium absorption within the upper repair themselves. Damaged enamel cannot be
small intestine depends on the active vitamin D hormone ( l ,25 (OH)i vitamin D ). naturally repaired because enamel is a secretion
Because the intestinal concents become more alkaline as they pass down the Gl tract, produced before the tooth erupts, and it does
calcium absorption decreases at the terminal end of the small intestine and colon, al- not hove o blood supply like the other two tis-
though some still occurs Yia passive diffusion. sues. To repair broken or damaged enamel re-
Humans absorb about 25% of the calcium in the foods eacen. 5 However, when tl1e quires the skills of a dentist. In contrast, bone is
body needs extra calcium-such as dw-ing infancy and pregnancy-absorption might well supplied with blood vessels, so a fracture
reach as high as 60%. Young people tend to absorb calcium better than do older people, con be repaired (healed) by the body given
cspecialJy those older than 70. PostmenopausaJ women generally absorb the lca~t calcium. time.
Other fuctors that enhance absorption of cakium include parathyroid hormone; di -
ecary glucose and lactose; and normaJ intestinal motility ( flow).
Factors limiting calcium absorption include large amounts of phytic acid in fiber; ex-
ccssi,·e amounts of dietary phosphorus; polyphenols (tannins) in tea; a ,;tamin D defi-
ciency; and diarrhca.5
Transport, Storage, and Excretion

Each cell has a crucial need for calcium, which is supplied from the bloodstream. This
need is probably the reason humans have such excellent hormonal systems to control
calcium homeostasis in the body (Figure 11-10). Normal blood cakium can be main-
tained despite an inadequate calcium intake, because much is stored in bones. 28 (The
bones, however, pay the price.) This situation makes blood calciu m a poor measure of
calcium status.
Figure 11·1 0 I Regulation of blood

porolhyroid hormone (PTH) and colcitonin ore
EJ Reduces calcium
release from bones
key factors in controlling blood calcium. When to lower blood
blood calcium rises loo high (1), the thyroid calcium liC'll
gland releases calcitonin (2). This hormone ~======'.:...~a:, Thyroid glond Elevated
Ir.I ~ releases calcitanin blood calcium
restores blood calcium lo the normal range
W Reduces calcium
(2-5). When blood calcium foils loo low (6), retention in kidneys
the porothyroid gland releases parathyroid to lower blood
hormone (7). This hormone restores blood calcium
calcium to the normal range (7-11). On o doy-
to-Oay basis, parathyroid hormone is the most
important regulator. Recoil from Figure 9-9 thot .----------4-----t>--------~ 10.8 mg/di
the actions of porothyroid hormone olso involve Blood calcium +
Normal
the active vitamin D hormone (l ,25 (OHb returns to a
normal range. range
vitamin D) in various ways. ;.
' - - - - - - - - - - - - - - - --4-- 1--.L. 8.5 mg/di
Stimulates calcium
release from bones
to increase blood
calcium
fJ Increases calcium
uptake in intestines
la Parathyroid
gland releases
to increase blood parathyroid
calcium' hormone
lfilJ Increases calcium

retention in kidneys
to increase blood
calcium
• Indirectly by increasing 1,25 {OHh vitamin D synthesis by the kidneys
As discussed in Chapter 9, when blood calcium fulls, the parathyroid gland releases
parathyroid hormone. This hormone, working with 1,25 (OH)z vitamin D, iJKreascs
d1c kidneys' retrieval of calcium before it is excreted in the urine. Parathyroid hormone
also helps increase calcium absorption indirectly by increasing the synthesis of 1,25
(OH)i vitamin D. In addition, parathyroid hormone, often working in conjunction
with 1,25 (OH)i vitamin D, causes increased calcium release from bones. In all these
ways, then, parathyroid hormone increases blood calcium.
When blood calcium is too high, the release of parathyroid hormone falls. Then cal-
cium loss from the kidneys increases. Synthesis of 1,25 (OH)i vitamin D also de-
creases; thus, calcium absorption decreases. In addition, die thyroid gland secretes the
hormone calcitonin, which decreases calcium loss from bones. All these metabolic
changes cause blood calcium to remain with.in the normal range.28
Other routes for calciwn excretion arc the skin, as well as d1e feces losses that result
from intestinal secretions into die intestinal lumen. 5
osteoblasts Cells in bone thot secrete mineral Functions of Calcium

ond bone matrix.
Forming and maintaining bones are calcium's major roles in the body.
osteoclasts Bone cells that arise originally from
a lype of whi te blood cell. Osteoclasls secrete
Bone Development and Maintenance
substances that lead to bone erosion. This
erosion can set the stage for subsequent bone Despite its "dead" appearance, bone is very active metabolically. Bone contains two
mineralization. types of cells-osteoblasts and osteoclasts-which are integral to maintaining bones.9
Osteoblasrs secrete a collagen protein matrix that forms the support structure of bone.
They mature to osteocytes and then secrete bone mineral, which causes bone mineral-
ization. This mineral matures and eventually approaches the composition of
Ca 10(P0 4 )6 0H2 , called hydroxyapatitc. 5 In contrast, osteoclam continually break
down bone in areas where bone is not needed. Osteoclast activity is stimulated by
parathyroid hormone, often in conjunction with 1,25 (OH)i vitamin D. These bone
cells arc very active when a diet is deficient in calcium; their action releases calcium
from the bone so it can enter the blood. Remember, a supply of calcium is vital to all
cells, not just co bone cells.
Bone turnover (bone remodeling) represents a cycle of bone breakdown by osteo- bone remodeling A process by which bone is
clasts, followed by bone rebuilding by osteoblasts. In this way, bone is re-formed when first resorbed by osteoclasts and then re-formed
necessary to respond to the physical demands placed on it. Before ne\\ bone can be by osteoblasts. This process allows the body to
built, the old bone in that area must be partially broken down. 9 form bone where needed, such as in areas of
During hw11an growth, total ostcoblast activity exceeds osteoclast activity, so we high mechanical stress.
make more bone than we break down, with more bone being built in areas put under bone moss The total mineral substance (such
high stress. A right-handed tennis player, for example, builds more bone in thar arm as calcium or phosphorus) in a cross section of
than in the left arm. ln older years, osteoclast activity generally becomes more domi - bone, generally expressed as grams per
nant. Most bone is built from infimcy through the late adolescent years. Small increases centimeter of length.
in bone mass continue between 20 and 30 years of age. Genes control up to 80% of
the variation in the peak bone mass ultimately built.9
Bone loss begins in mid-adulthood and increases significantly ar menopause in
women. By age 65 to 70, the rate of bone loss falls to about the same rate as before
menopause. In men, bone loss is slow and steady from around age 30. Overall, this
bone loss in both genders progresses without signs or symptoms. During their life-
times, about one-third to one-half of all women go on to experience fractures associ-
ated with low bone mass, especially women who live beyond age 75. 3 In addition,
some women have much more bone than others. They probably bu ilt more bone when
the}' were young, so they an: able to endure greater bone loss without experiencing frac-
rurcs. Tn sum, many factors are associated with such a higher bone mass (Table 11-6).
Even more factors, however, arc associated with low bone mass: slim figme; family
history of hip fracture or osteoporosis; reduced vitamin D receptor activity in the in-
testine; irregular menstruation; premature menopause; use of certain medications
(such as corticosteroids); exces!> dietary protein and caffeine (\\hich increase calcium
loss in the urine) if sufficient calcium is not conswi1ed; and prolonged bed rest. 3
Visual observation of the cross sections of a bone reveals rwo primary bone structural
type~ in the body: cortical (also called compact) bone and trabccuJar (also called can- cortical bone Dense, compact bone that
ccllous or spongy) bone.9 These two bone types in turn imeracl within each bone to constitutes the outer surface and shafts of bone;
form quire an engineering marvel of strength (Figure 11-11). The entire outer surface olso called compact bone. Cortical bone makes
of all bones is composed of cortical bone, which is very dense. The shafts ofloog bones, up 75 to 80% of total bone mass.
such as those of the arm, are almost entirdy cortical bone. Trabccular bone is found in trobeculor bone The spongy, inner matrix of
the ends of the long bones, inside chc spinal \'ertebrae, and inside the flat bones of the bone found primarily in the spine, pelvis, and
peh-is. Trabecular bone forms an internal scaffolding network for a bone. ft supports the ends of bones; also called concellous bone
outer cortical shell of the bone, especially in hea,·ily stressed areas such as joints. Trobecular bone makes up 20 lo 25% of total
Bone strength especially depends on a person's bone mineral density (bone bone moss.
mass/bone width ). The more densely packed the calcium-rich bone crystals are, the
stronger the bone structures. Another imporrant element of bone strength is the tra-
becu lar bone support network inside a bone.9
Blood Clotting
Calcium ions participate in se\'cral reactions in the cascade that leads to the formation of
fibrin, the main protein component of a blood clot (reYiew Figure 9-13 in Chapter 9).
Transmission of Nerve Impulses to Target Cells

synapse The space between the end of one
\ Vhen a ncr\'e impulse reachc~ its t:trget site-such as a muscle, other ner"e cells, or nerve cell and the beginning of another nerve
a gland-the impulse is transmitted across the junction between the nerve and itS tar- cell.
get cells, called a synapse.2 8 Tn many nerves, the arrival of Lhe impulse at the target
408 Chapter 11 Water and the Ma jor Minerals
Table 11-6 I Diet and Lifestyle Factors Associated with Bone Status3,10,17,19,25
Positive Diet and lifestyle Factors Coll to Action

Adequate diet containing a sufficient amount of • follow MyPyramid with special emphasis on adequate amounts of fruits, vegetables,
protein, calcium, phosphorus, magnesium, and low-fat and fa t-free milk products.
potassium, vilomin A, vitamin B-6, folate, • Consider use of fortified foods (or supplements) lo make up for specific nutrient shortfalls,
vitamin B-12, vitamin C, vitamin D, vitamin K, such as vitamin D, folate, and calcium.
zinc, copper, Auoride, and manganese (and boron?)*
Healthy body weight • Be aware that low body weight (slender figure) increases the risk for low bone mass.
Normal menses • During childbearing years, seek medical advice if menses cease (such as in cases of
anorexia nervoso or extreme athletic training).
• Women at menopause and beyond should consider use of current medical therapies to
reduce bone loss linked lo the fall in estrogen output.
Weight-bearing physical activity • Perform weight-bearing activity because ii contributes to bone maintenance, whereas
bed rest and a sedentary lifestyle lead lo bone loss. Strength training is especially helpful
to bone maintenance.
Genetic background (family history and Black race) • The ability to absorb calcium and regulate bone metabolism are influenced by one's
genetic background.
Negative Diet and lifestyle Factors Coll to Action

Excessive intake of protein, phosphorus, sodium, • Moderate intake of these dietary constituents is recommended. Problems primarily arise
caffeine, wheal bran, and alcohol if adequate calcium is not consumed.
• Excessive soft drink consumption is especially discouraged.
Smoking • Because smoking lowers estrogen output in women, smoking cessation is advised.
Use of certain medications, such as corticosteroids • Corticosteroid medications lead to bone loss, so medical therapy to counteract the bone
loss should be instituted if use is long term.
Celioc disease • Malabsorption of nutrients due to this intestinal disease leads to poor bone maintenance.
•Vitamin B-6, folote, and vitamin S.12 ore listed because elevated blood homocysteine is o risk factor for low bone density.
corticosteroid A steroid hormone produced by

the adrenal gland, an example of which is
cortisol.
Blood
vessel
Figure 1 1 • 1 1 I Cortical and trabeculor

bone. Cortical bone forms the shafts of bones
and the outer mineral covering. Trabecular
bone supports the outer shell of cortical bone in
- - -- - - - - Morrow
various bones of the body, as in the bone
cavity
pictured.
Figure 1 1 • 1 2 I The release of a

neurotransmitter. Nerve impulses, by opening
Ca2+ channels (1 J, stimulate the fusion of
synoptic vesicles containing neurotransmitters
with the cell membrane of the nerve terminals
(2). This leads lo exocytosis and the release of
Ca 2• a neurotransmitter (3). The neurotransmitters
f· 0
~---- Presynaplic
terminal
will bind to and stimulate the postsynaptic
membrane of nearby cells.
Neurotransmitter llf!§i~~Postsynaptic
00 o0 membrane
Oo 0
site stimuJates an inOux of calcium ions inro the nen·e from the extraceUuJar medium.
The rise in intracellular calcium ions then triggers the release of neurotransmitters from
synaptic vesicles, which are responsible for storing the neurOLransmitter until needed.
The released neurotransm itter then carries the impuJse across the synapse co the target
cells (Figure 11-12).
ln an entirely differenr process, nerve impulses develop spontaneously if insufficient
calcium is a\'ailable, leading to what is called hypocalcemic tetany. This condicion is tetany A body condition marked by sharp
characterized by muscle spasms, because die muscles recci\'e continual ner\'e stimula- contraction of muscles and failure lo relax
tion. Inadequate parathyroid hormone release or action is d1e typical cause of aherward; usually caused by abnormal calcium
hypocalcemia. 28 metabolism.
hypocalcemia Low blood calcium, typically

arising from inadequate parathyroid hormone
Muscle Contraction release or action.
The critical role of calcium in muscle conrraction is most easily understood in the con-
text of skeletal muscles, but oilier types of muscles use calcium in a similar fashion.
When a skeletal muscle is stimulated by a nerve impuJse from the brain, calcium ions
are released from intracellular stores wichin the muscle cells. The resulting increase in
the concentration of calcium ions in a muscle cell is one factor, along with ATP, that
permits the contractile proteins to slide along each omcr. 28 This movement leads to
muscle contraction. Then, to aLIO\\ for subsequent rel.l\,ltion, the caJcium ions are re-
LUrncd to intracellular stores, and d1c contractile proteins slide apart (see Figure C--l
in Appendix C).
Cell Metabolism
Calcium ions help regulate metabolism in the cell by parricip.uing in the calmodulin calmodulin A cell protein that binds calcium
system. When calcium enters a cell (often because of hormone action ) and binds to the ions. The resulting calmodulin-Ca2+ complex
protein caJmodulin, the resulting protcin-cakium complc\ can regulate d1e acti\~ty of inAuences the activity of some enzymes in the
,·arious enzymes, including one d1at breaks down glycogen to many units or
glucose cell.
1-phosphate (Fig1.1rc 11 -13).28
410 Chapter 11 Waler and the Maier Minerals
Other Possible Health Benefits of Calcium

Researchers have been examining links between calcium intake and risks for a wide
array of diseases. An adequate calcimn intal<e can reduce the risk of colon cancer, es-
Ca2+ is released from pecially in people who consume a high-fut diet. A decreased risk of some forms of kid-
endoplasmic reticulum ney stones and reduced lead absorption are other possible benefits when calcium is part
in response to hormones
or neurotransmitters of a meal. Calcium intal<es of 800 to 1200 mg/day may also decrease blood pressure,
compared with i.mal<es of 400 mg/day or less. As covered in Chapter 6, calcium in-
takes of 1200 mg/ day in combi nation with a low-fat, low-cholesterol diet can help
people with elevated LDL improve their blood lipid profiles.
A link between a low calcium intal<c and overweight/obesity is also under study.
Although the true benefit in this regard is not clear, an adequate calcium intake (compared
to a very low intake [e.g., 400 mg/day]), coupled \\~th a low energy intal<e, may promote
G colmodulin·
2
$ even more weight loss than the low energy diet alone. Focusing on dairy sources of c.:al-
ciLun is recommended because other components of dairy foods, such as some of the spe-
f j 'a + compl~
cific dairy proteins present, contribute to this potential weight-loss benefit.
For women, an adequate calcium intake might also reduce the risk of premenstrual
EJ lncreosed intracellular syndrome and high blood pressure that can develop during pregnancy. Overall, the
benefits of a diet providing adequate calcium extend beyond bone health. 5
Ca2• concentration
favors formation of a
calmodulin-Ca2+ complex
Calcium in Foods
Dairy products, such as milk and cheese, provide about 70% of che calcium in North
American diets. The exception is cottage cheese, because most calcium is lost during
production. White bread, rolls, crackers, and other foods made \Vith milk products arc
secondary contribut0rs. Leafy greens (such as spinach), broccoli, sardines, and canned
salmon are also sources. However, much of the calcillln in some leafy green vegetables,
notably spinach, is not absorbed because of the presence of oxalic acid. This effect is not
as significant, however, in kale, collard, nirnip, and mustard greens. The calcium-tOrri.fied
versions of orange juice, cranberry jLtice, and other beverages as well as calcium-
fortified cottage cheese, ~·ogurr, breakfust cereals, breillast bars, bread, chocolate can-
dies, and snacks also provide much calcium. Another source of calcium is soybean curd
(tofu), if il is made with calcium carbonate (check the label ). Note that it is the bones
present in canned fish, such as salmon and sardines, that supply the calcium.
Information about calcium is mandatory on food labels.
Glycogen
Calcium Supplements
Colmodulin·Ca2• complex
is on essential component Calciw11 supplements can be used by people who do not like milk or who cannot in-
of many Ca 2+ -dependent corporate enough calcium-containing foods into their diets. Calcium carbonate, the
enzymes, such as form found in calcium-based antacid tablets, is the most common supplement used .
phosphorylose b kinase
People should talcc this supplemcnr with or just after meals in doses of about 500 mg
so thac stomach acid produced during digestion can aid with absorption of this min-
Figure 11·1 3 I Calmodulin mediates many eral. On the other hand, a supplement containing calciLtm citrate, which is acidic itself,
of the effects of intracellular calcium-in this can be taken between or with meals, or at bedtime.28
case (1-3), the regulation of the breakdown of Herc is how to determine the calcium content of typical supplements based on the per-
glycogen to many units of glucose 1-phosphate. cent of calcium per wlit of weight and form of calcium, as listed on the supplement label.
Note that a kinase is an enzyme that adds a
phosphorus group to another molecule. • Calcium carbonate: 40%
• Calcium phosphate (tribasic): 38%
• Calcium citrate: 21%
• Calcium lactate: 13%
• Calcium gluconate: 9%
5 ome calcium supplements are poorly di-

gested because they do not readily dissolve.
To test for solubility, put a supplement in 6 oz of
To calculate the arnOLU1t of calcium in a supplement, simply multiply the weight of the
capsule by the percentage just listed. For example, if one tablet of calcium citrate
weighs 500 mg, it contains 105 mg of calcium.
cider vinegar. Stir every 5 minutes. It should dis·
solve within 30 minutes. 500 mg X 0.21 = 105 mg
www.mhhe.com/ w ardlaw pers7 411
With calcium supplements, interactions with other minerals are a valid concern.
Food Sources of Calcium
Perhaps most importantly, there is some evidence that calcium supplements may de-
crease zinc absorption. Therefore, calcium supplements should not be taken with meals Food Item and Amount Calcium (mg)
rich in zinc. An effect of calcium suppkmenr~1tion on iron and magnesium absorption Plain yogurt, 1 cup 450
is possible; however, this effect appears to be small over the long term. To be safe, peo- Parmesan cheese, 1 oz 390
ple using ~1 calcium supplement on a regular basis should notify their physician of t he
Fortified orange juice, 1 cup 350
practice.
Some calcium supplemenrs conrain lead. Chapter 19 points out that lead produces Romano cheese, 1 oz 300
an array of deleterious effects on the body. Currently, FDA has no standards for lead 1% milk, 1 cup 300
content in food supplements. It b especially important to avoid supplements made Buttermilk, 1 cup 285
from bonemeal, the worst offender when it comes to lead. Tablet or liquid calcium Swiss cheese, I oz 275
supplements with the USP seal of approval arc less likely tlun others to contain hjgh
concena·ations of contaminants. Typically, taking 1000 mg of calcium daily in divided
Spinach, 1 cup 250
doses of 500 mg each in the form of calcium carbonate or calcium citrate is safe. Salmon (with bones), 3 oz 210
Cheddar cheese, 1 oz 200
Calcium Needs Total Raisin Bran cereal, 3/4 cup 180
The Adequate Intake set for calcium for adults ranges from 1000 to 1200 mg/day. For Sardines (with bones), 2 oz 170
adolescents between the ages of 9 and 18, the Adequate Intake is set higher, at Chocolate pudding, 1/2 cup 160
1300 mg. The Adequate Intake for adults is based on the amount of calcium needed Tofu, 1/2 cup 140
each day to oftSet calcium losses in urine, teces, and other rourcs. 5 The Adequate Adequate Intake for adults,
Intake for young people includes an additional amount to allow for increases in bone 1000 mg;
mass during growth and development. The Daily Value for calcium used on food and
Adequate Intake for adults
supplement labels is 1000 mg.
over 50, 1200 mg
[n North America, average calcium intakes range from approximately 600 co 800 mg/
day for women and 800 to 1000 mg/day fo r mc::o. About 25% of women consw11e
only abour 300 mg/day. Thus, dietary intakes of calcium by many women, especially
young women, arc well below the Adequate Intake amount, whercas intakes by most
men ,\re roughly eqw,·alent to it. It is important for Ycgans to focus on earing good
plant sources of calcium as well as on the total amount of calcium ingested.
Calcium-Deficiency Diseases
The most common calcium-related deficiency disease is osteoporosis, but calcium is
not the only nutrient needed to maintain bone health (rcvic\\ Table 11 -6) . 10 To pre·
\'ent low blood calcium, the body withdraws ca1citm1 from bone. This action preserves
indispensable functions of calci um, such as those tllat keep the heart and muscles work·
ing. There is also some evidence that a low calcium intake mar increase blood pressure
and the risk of certain cancers, such as colon cancer, by aftecting cell turnover. Some
recent research is indicating that low calcium intake is also ,1ssociated with low bone
mass development in growing children.3 Manuela is o vegan. She stopped eating meal
Although it is assumed that calcium intake is a factor in most cases of bone loss, the and dairy products when she was 12 years
exact contribution of calcium intake versus other factors is hard to quantif)1• Bone loss old and is now in her mid-twenties. She wants
is not due co a calcium deficiency in the same way that SClJI\')' is due to a vitamin C de- lo start a family but is concerned about
ficiency. In the latter case, low vitamin C intake is typically the onl)' factor, whereas whether she can obtain enough calcium from
multiple factors likely contribute to most cases of bone loss. It is d ifficu lt to pinpoint her diet to ensure her baby's health. How can
the extent to which various factors contribute to bone health, because bone-related she consume enough calcium to meet her own
disease can take decades to develop. Studies have to look back at what happened over and her baby's needs?
a long period of time or look forn ard to what could happen.
Failure co maintain adequate bone mass in the body throughout lite firsr leads to a
state of osteopenia. Osteopenia can be caused by the ,·itamin D deficiency disease os· osteopenia Decreased bone moss caused by
tcomalacia, the use of certain medications, cancer, and other conditions. The diagno- cancer, hyperthyroidism, or other reasons
sis of osteoporosis generally is made when the bone loss becomes marked and/or a
fracture occurs and there is no obvious medically related cause (Figure 11-14).3
Typically bod1 cortical and trabecular portions ofd1e bone arc affected, particularly d1e
u·abccular portion. People who develop more bone by early adulthood can sustain
412 Chapter 11 Water and the Ma jor Minera ls
T o estimate your calcium intake, use the rule

of 300s. Give yourself 300 mg for calcium
provided by a typical diet of moderate energy
intake. Add to that another 300 mg for every
8 oz of milk or yogurt or 1.5 ounces of cheese
you consume. If you eat a lot of tofu, almonds,
or sardines or drink calcium-fortified beverages,
use the second Toke Action or food composition
tables to obtain a more accurate estimate of
your calcium intake.
Normal trabecular bone Osteoporotic trabecular bone

Figure 11·14 I Normal and osteoporotic trabeculor bone. Note in the picture on the right how
there is much less trobeculor bone. It is especially critical for the horizontal frobecu loe lo extend
continuously- without breaks-between the areas of vertical lrobeculoe. Any break in either the
horizontal or more verticol trobeculor beams weakens the support system of a bone and increases the
risk for bone fracture. And, once these beams ore broken, there is currently no way lo rebuild them. This
is why it is so important lo limit bone loss as people age.
greater age-related bone loss with Jess fracture risk than those who have buiJr Jess bone.
Thus, osteoporosis is considered to be a pedjatric disease with geriatric consequences
(Pigure 11-15).
Osteoporosis currently leads to approximately 2 million rracmres per year, rcsulring
in over $16 biJlion in rurect health-care costs. 16 Many o lder women i.n North America
show low values for bone mass and are therefore at risk for these fractures.
Diagnosis of Osteoporosis
Dual energy X·ray absorptiometry (DEXA) bone A simple and very accurate test to idencify osteoporosis is dual energy X-ray a bsor p-
scan Method to measure bone density that tio metry (D BXA) bone scan .22 A DEXA scan measures bone mass and bone density
uses small amounts of X-ray radiation. The in the spine, hip, and total body using a small amount of X-ray radiation. For this rest,
ability of a bone to block the path of the a person lies down on his or her back on a padded table while a movable imaging arm
radiation is used as a measure of bone density glides over the length of the body (see Figure 13-12 i.n Chapter 13). The procedure usu-
at that bone site. ally talces about 10 to 20 minutes. The ability of a bone to block the patl1 of radiation i&
used as a measure of bone mass and bone density at that bone site. A very low dose of ra-
diation is used for rhe DEXA-about one-rentl1 oftl1c exposure from a chest X-ray.
From the DEXA measurement of bone density, a statisrical analysis called a T score
is generated, which compares the observed bone density to tl1at of a person at peak
bone densi r:y. T scores may be interpreted as follows:
0 to - 1 Normal
- 1 to -2.4 Osteopenio
- 2.5 or lower Osteoporosis
Peripheral DEXA and ultrasound are adrutional ways to measme the bone density
of one part of tl1e body, such as tl1e wrist or heel. Even though peripheral methods are
fuster than DEXA, they a.re not as accurate because the density of one part of the body
may not reflect the density of other areas susceptible to fractures , such as tl1e spine.
Osteoporosis Prevention and Trea tment

As women mature, different strategies for preventing osteoporosis arc needed , based
on tl1e risk factors present.3,2 3 Young women should meet calcium, vitamin D , and
other nutrient needs and should see a physician with any sign of i.rregula.r menstrua-
Healthy bone mineral density

Low bone mineral density
Osteoporosis
~
.iii
c
GI
"ti
lGI
c
·e
GI
c
0
111:1
10 20
Age of Women (years)
figure 11 • 1 5 I The relationship between peak bone moss and the ultimate risk of developing
osteoporosis and related bone fractures. Woman A developed o high peak bone moss by age 30. Her Milk is o rich as well as convenient source of
bone loss was slow and steady between ages 30 and 50 and sped up somewhat offer age 50 calcium.
because of the effects of menopause. Still, by oge 75 the woman hod o healthy bone mineral density
value and did not show evidence of osteoporosis. Woman B developed on overage peak bone moss
and experienced the some rote of bone loss os woman A. By age 65, woman B hod low bone mineral
density and evidence of osteoporosis. She wos now at risk of related fractures. Woman C achieved o
low peak bone moss, ond by following the typical pattern for bone loss, she already showed evidence
of low bone mineral density ond osteoporosis ot oge 50. Given the low calcium intakes that ore
common among young women today, line C is a sobering reality. Ideally, by following o diet ond
lifestyle pattern that contributes to maximal bone mineral density, more women will follow line A and in
turn significantly reduce their risk of developing osteoporosis.
tion. Ln young women, regular menstruation is a main contributor to bone mainte-

nance, as evidenced by low bone mass in some no1u11enstruating fcm~1le ath letes and
other "·omen with irregular menstruation (e.g., those with anorexia ncrvosa). An ac-
ti\ e lifestyle that includes weight-bearing physical acti\ icy is also important (to build
and maintain muscle mass). 12 Greater muscle mass linked 10 physical activity is associ-
ated with greater bone mass, because m uscle keeps tension on bone:~ Stil l, physical ac-
tiviry cannot prevent rhc bone loss associated with irregular menstruation. Thus,
1Cma1e athletes with irregul,1r menstruation should be closely monitored by a physician.
Smoking and excessi,·e alcohol intake decrease bone mass .u any age. Smoking lo\\"ers
the estrogen concentration in the blood in women, increasing bone loss. Alcohol is toxic
to bone cells, and alcoholism is probably a major undiagnosed and unrecognized cause of
osteoporosis. L\ loderation in phosphorus, caffeine, sodium, and protein intake is also ad-
\ised. Exccssin: intakes arc especially problematic when insufficient calcium is consumed. 3
At menopause, women should discuss appro,•ed osteoporosis-related therapies with
J physician. They also need co accurately Lrack their height. A decrea~e of more than
1 1/2 inches from premenopausal values is a sign that significant bone loss is taking
place (Figure l l -16 ). Currently, five medical therapies can be used to slow bone loss bisphosphonotes Compounds primarily
at menopause in women. Some can even be used in men who develop lo\\ bone mass. composed of carbon and phosphorus that bind
The approved drugs a.re estrogen (\·arious forms are '" .1il.1ble ); bisphosphonates (al - lo bone mineral and in turn reduce bone
cndronate f Fosamax ], risedronate [Acton cl J, and ibandronate [ Boni\'a ]); selective es- breakdown.
[rogen recepcor modulators (SERMs) (raloxifcnc [Evista]); calcitonin (nasal form is
Figure 11 -1 6 I A loss of height and a

distorted body shape are common signs of
osteoporosis. Monitor your adult height 72
changes to detect early osteoporosis. All
women 65 years and older should be screened 64 64
for this disease. Medicare covers the cost of the
needed DEXA scan. Younger women are
advised to have the some test al menopause ii 56 Wedged
they have associated risk factors or if the results upper
of the screening would help them decide what vertebrae
treatment plan is appropriate at menopause.
48
Crushed
.,, lower
Q) vertebrae
32 32-5
-=
24 24
16 16
8 8
0 0
Young Older
woman woman
Miacakin ); and a form of parathyroid hormone called teriparatide (Forteo ). btrogcn

and SER.t\Is blunt bone turno,·er by binding co receptors on bone; bisphosphon.uc~
blunt bone resorption by binding to bone mineral; calcitonin inhibits osrcodaH .Kti\
ity and, so, bone resorption; and teriparatide stimulates new bone gro\\ th.3·23
All these medications have side effecrs, so use needs to be tailored co J person'!> cur-
rent health status. The latest thinking is that estrogen replacement is most useful for
treating menopaus.11 symptoms such as hot flashes, whereas the bisphosphonates .rn:
most usefu l for preventing bone loss. 3,2 3,2 6 The recent trend to use bisphosphonates a&
the major form of medical tht"rapy for osteoporosis rather than estrogen rcpbccmcnr
stems from the observation that greater than 5 years of estrogen use increases the ri1,k for
breast and some other forms of cancer, such as in the ovaries. If a woman at mcnopau~t'
begins estrogen therapy to relie\'C related menopausal symptoms, ex'Perrs suggest <,he
should consider switching ro another form of osteoporosis therapy as soon a~ possiblc.r
Older men and women need to stay ph)•sically actiYe-including doing some
weight-bearing and resistance activities-and they should at least meet the Adequ,l(c
Intakes for calcium and vitamin D set for their particular age. This combination ot
physical activity and cakium and vitamin D intake!> is most likely co limit bone loss 111
some areas ofrhc body, such as the hip. 12•28 Still, this fo rm of therapy docs not replace
the need for medical therapy in high-risk individ uals. O lder people also need to mini-
mize the risk for falls, especially by limiting their use of medications and alcohol,\\ hich
might disrurb coordination, and d1ey should take corrective measures if visual function
is impaired. (Hip protective garments arc also available to reduce hip fracrurc ri'>k. )
Women with osteoporosis typically develop Upper Level for Calcium

abnormal curvature of the upper spine. This
results from fractures of the weakened The Upper LcYcl for calcium is 2500 mg/day, based on the risk of developing kidne\'
vertebrae. Osteoporosis con lead to both stones.5 Normally, rhc small intestine prevents excess calcium from being absorbed.
physical and emotional pain. However, if this level of conrrol breaks down, the calcium concentration in the blood
mJy tise and lead to calcification of che kidneys and other orgJns, irric.1bility, headache, o find out more about osteoporosis, check
kidney failure, kidney stones in some people, and decreased absorption of other min- out the website of the Notional Osteoporosis
erals. Ordinarily, calcium in food and usual doses of calcium supplements do not pose Foundation lwww.nof.org) or coll
a hec1ld1 d1reat because it is presenc in relatively modest :i.moums. 800·464-6700. Another helpful website
is that of the Notional Dairy Council
(www. notionoldo irycouncil.org).
Jona is increasing her chances of developing osteoporosis later in life because of

her current high.risk lifestyle. Factors contributing to her potential risk include a
poor dietary intake of colcium. Jona needs lo find some reliable sources of cal- o form of natural calcium, such as coral
cium. These could include calcium.fortified juices, colcium-forlified bread and snack bars, and calcium, is superior to typical supplement
calcium-fortified chewable chocolate candies. Tofu (mode with calcium) is another potential forms. People making such claims of superiority
source, os is calcium-fortified soy milk. Meeting the Adequate Intake of 1000 mg/doy for her hove even been prosecuted by the U.S. Federal
oge would not be that hard if she were to make o conscious effort to use these colcium·rich Trade Commission for false advertising.
foods and/or incorporate other rich sources (which include calcium supplements). She also
should rethink her rationale for avoiding milk. Fat-free milk is very low in energy content and
provides much calcium. Dairy products such os milk do not lead to weight gain per se.
Concept I Check
About 99% of calcium in the body is found in the bones. Calcium requires J slightly acid
pH and the ,·icamin D hormone for efficient absorption. Factors that reduce calcium ab-
sorption include large amounts of fiber, decreased estrogen production, and a great excess
of phosphorus in the diet. Blood calcium is n.:gulated primarily by hormones .111d docs not
closely rctlect daily intake. Aside from its critical role in bone, calcium also functions in
blood clotting, muscle contraction, nen·e-impulse transmission, and cell metabolism. A per·
son can decrease risk for osteoporosis by consuming adequate calcium and' itam111 D; en-
gaging in \\'eight-bearing exercise; considering bisphosphonares or otber medications that
decrease bone loss (postmcnopausal temalc); and moderating sodium, alcohol, and caffeine
intake. Dairy products arc rich food sources or calcium. Certain cakium-fonilicd foods,
such as some be,·erages, are rich sources as well. Supplemental forms, such JS calcium car-
bonate, are "'ell absorbed b} most people. ~lcgadose supplementation can result in the de·
1·elopment of kidney scones and other health problems among some people.
eople who hove experienced extreme

Phosphorus (P) weight loss and long·slonding poor nutrient
intake ore ot risk of low blood phosphorus and
Efficient absorption plus the wide aYailability in food makes phosphorus a much less
o related condition called refeeding syndrome. If
important major mineral than calcium in diet planning.
these individuals ore aggressively refed, such os
in o hospital or in o famine relief setting (in the
Absorption, Transport, Storage, and Excretion of Phosphorus developing world), much of the small amount of
phosphorus in the bloodstream will shift into cells
The bod) absorbs phosphorus quite efficiently, up to about 70% of dierary intake in
in order to participate in essential metabolic
adults, by passi\'e diffusion in the GI tract. The active vitamin D hormone 1,25 (OH)z
pathways. This shift con cause blood phosphorus
vicamin D also enhances phosphorus absorption. As pointed out in the next section,
to be so low that respiratory failure and other
much phosphorus is stored in bones. Excretion of phosphorus is achic\'cd by the k.id-
critical health conditions may result. To ovoid this
nc\'s. The degree of excretion is the primary mechanism by which blood phosphorus
problem, clinicians generally check blood phos·
is regulatcd. 1-1 This mechanism differs from that of calcium, in which changes in ab-
phorus before feeding such o person to correct o
sorption arc a more significant factor.
phosphorus deficiency ii present. Under such cir·
cumstonces, people then ore gradually refed
Functions of Phosphorus ond blood phosphorus is monitored lo make
sure ii remains within o normal range. 14
Approximately 80% is found in bones and teeth as calcium phosphate. The remainder
of phosphate is found in C\'ery cell in the body and in the extracellular fluid as P0 2 4.
Phosphorus is a component of man) enzyme systems, adcnosinc triphosphate (ATP),
416 Chapter 11 Water and the Major Minera ls
DNA and RNA, and the phospholipids in cell membranes. It also participates in acid-
Food Sources of Phosphorus
base balance.21
Food /fem and Amount Phosphorus (mg)
Plain yogurt, l cup 350
Phosphorus in Foods
Swiss cheese, 2 oz 345
Mille, cheese, yogurt, bakery products, and meat provide most of the phosphorus in
Almonds, l /2 cup 340
the adult diet. Cereals, bran, eggs, nuts, and fish are also sources. About 20 to 30% of
Sunflower seeds, l oz 330 dietary phosphorus comes from food additives, especially in baked goods, cheeses,
l % milk, l cup 235 processed meats, and many soft drinks (about 75 mg per 12-oz [1/3 liter] serving of
Cheddar cheese, 1.5 oz 220 soft drinks).
Salmon, 3 oz 220
Sirloin steak, 3 oz 210 Phosphorus Needs
Raisin Bran cereal, l cup 215 The RDA is 700 mg/day. Phosphorus needs are based on the amount that maintaim
Egg, 2 hard-boiled 200 an adequate blood concentration. 5 Adults consume about 1000 to 1600 mg or more
of phosphorus per day. Thus, a phosphorus deficiency is unlikely in healthy adults, es-
Chicken breast, 3 oz 180
pecially because it is so efficiently absorbed. The Daily Value for phosphorus used on
Roasted turkey, 3 oz 180 food and supplement labels is 1000 mg.
Pot roost, 3 oz 170
Lean ham, 3 oz 165 Phosphorus-Deficiency Diseases
American cheese, l slice 155
A chronic deficiency of phosphorus can contribute to bone loss, decreased growth, and
RDA for adults, 700 mg poor tootl1 development. Symptoms of rickets may occur in phosphorus-deficienr chil-
dren. Fu rtl1ermore, symptoms of a deficiency include anorexia, weight loss, weakness,
irritability, stiff joints, and bone pain. Marginal phosphorus status can be found in
preterm infants, alcoholics, older people on nutrient-poor diets, people experiencing
long-term bouts of diarrhea and weight loss, and people who daily use aluminwn-
containing antacids, which in the small intestine bind phosphorus.14
Upper Level for Phosphorus

The Upper Level for phosphorus in adulmood is 3 to 4 g/day, based on d1e risk of de-
veloping impaired kidney function. 5 High blood concentrations of phosphorus can
cause calcium-phosphorus precipitates to form in body tissues as well as contribute to
bone loss by inducing the release of parath)rroid hormone (review Chapter 9 ).
A chronic in1balance in tlie calciwn-to-phosphorus ratio in the djet, resulting from
a high phosphorus intake coupled witl1 a low calcium intake, can also contribute tO
bone loss. 3 This situation most likely aiises when calcium needs are not met, as can
occur when adolescents and adults regularly substitute sofi: drinks for miU< or other-
wise underconsume calcium. 28
Magnesium (Mg)
Meats are rich in phosphorus. MagnesiL1m, like calcium, is a divalent cation. Because magnesium is fo1u1d in chloro-
phyll, green leafy vegetables are rich sources.
Absorption, Transport, Storage, and Excretion of Magnesium

We normally absorb about 40 to 60% of tl1e magnesium in our diets, but absorption
efficiency can increase up to about 80% if intakes are low. Both passive and active ab-
sorption in the sma ll intestine is used. The active vitamin D hormone 1,25 (OH)i ' 'i-
tamio D enhances magnesium absorption to a lin1ited extent. Some magnesium is
www.mhhe.com/wardlawpe rs7 4 17
stored in bones; a small amount is stored in other tissues, such as muscles. Thc kidneys Food Sources of Magnesium
primarily regulate blood concentrations of magnesium and arc able to reduce magne-
sium loss into the urine when blood magnesium is lo\\. 24
Food Item and Amount Magnesium (mg}
Spinach, 1 cup 157
Functions of Magnesium Squash, l cup 105

Wheat germ, I/4 cup 90
Magnesium has a vital role in a varying range of biochemical and physiological
processes. More than 300 enzymes that utilize ATP require magnesium. Magnesium Raisin Bron cereal, 1 cup 90
ions bind to ATP ro form active ATP. One of the magnesium dependent enzyme sys- Novy beans, 1/2 cup 54
tems pumps sodium out of cells and potassium into cells. This process seems especially Peanut butter, 2 tbsp 51
sensitive to magnesium deficicnqr. Magnesium also contributes to DNA and RNA syn- 46
Black-eyed peas, 1/2 cup
thesis. Its role in calcium metabolism contributes to bone strm:ture. Magnesium is also
important for nerve and heart function as well as insulin release from the pancreas and Plain yogurt, 1 cup 43
ultimate insulin action on cells. Other possible benefits of magnesium include de- Kidney beans, I/2 cup 43
creasing blood pressure by dilation of arteries and preYenting heart rhythm abnormal- Sunflower seeds, 1/4 cup 41
ities. 24 Because of its ability to lower blood pressure, magnesium is used to treat 37
Broccoli, 1 cup
hypertension that arises during pregnancy (see Chapter 16).
Bonano, 1 medium 34
1% milk, I cup 34
Magnesium in Foods Watermelon, 1 slice 32
The richest sources of magnesium arc plant products, such as whole grains, broccoli, Oatmeal, 1/2 cup 28
squash, green leafy vegetables, beans, nuts, seeds, and chocolate. Animal products, Whole-wheat bread, 1 slice 25
such as milk and meats, supply some magnesium, although less than the foods just
RDA for adult men 400 mg
listed. Another source of magnesiw11 is hard tap water, which contains a high mineral
RDA For adult women 310 mg
content (hard water also contains calcium). About 45% of dietary magnesium comes
from vegetables, fruirs, grains, and nuts, whereas abom 30% comes from milk, meat,
and eggs. Refined foods generally arc low in magnesium.
Magnesium Needs
The RDA for magnesium is 400 mg/day for men 19 to 30 years of age and 310 mg/
day for women 19 to 30 years of age. Magnesium needs increase slightly (an additional
I 0 mg/day) beyond this age for adult men and women. Magnesium needs arc based
on a daily intake that equals daily losses. 5 The Daily V:ilue for nugnesium used on food
and supplement labels is 400 mg.
Adult men consume an average of 325 mg/ day, whereas women consume closer to
225 mg/day. \Vomcn particularly should find some good food sources of magnesium
that they like and cat them rcgularly.7 Note that the form or magnesium in multivita-
mim. and mineral supplements (magnesium oxide) is not well absorbed but can con-
tribute to meeting magnesium needs.
Magnesium-Deficiency Diseases
Animals deficient in magnesium become very irritable and, with severe deficiency,
eventually suffer convulsions and often die. In humans .1 magnesium ddicienc) causes
an irregular heartbeat, sometimes accompanied by weakness, muscle spasms, disorien-
tation, nausea and vomiting, and seizures. These symptoms may be related to abnor-
mal ncrYe cell function due to impairment of sodium and potassium pumping. A fall
in blood calcium is also seen in magnesium deficiency as well as rc:;istance to 1,25
(OH)i vitamin D. It is possible that a ch ronically dclicient intake of magnesium then
may increase the risk of osteoporosis. Nore that a magnesium deficiency develops very
slowly because our bodies store it readily. 24 Nuts ore a rich source of magnesium.
Poor magnesium st;ltus is cspcciaUy found among users of ccnain diuretic~, "hich
increase m.lgncsium excretion in the urine. In addirion, heavy perspiration for \\eeks
in hot climates and bout~ oflong-standing di.irrhca or vomiting cause signific.111r mag-
nesium loi.s. Alcoholism also increases the risk of a deficiency because dietary intake
may be poor and became alcohol 111creasei. magnesium excretion in the urine. The dis-
orientation and weakness associated \\ir.h akoholism closely resemble the bdunor of
people with low blood magnesium. People" ith diabetes .rnd some other he.11th prob-
lems may have highc.:r magnesium needs, which makes them vulnerable ro 11urgin.u
magnesium deficicnC) .
Upper Level for Magnesium

The Upper Le\ cl of 350 mg/ dny for magnesium only rdcrs co supplement and other
nonfood sources onl}, such as certain laxatives and ant.Kids {e.g., Milk of i\fogncsi.1 ).
Lntakes above this .unount from these sourci.:s cin lead to diarrhca. 5 T'oxicity also C•lll
be seen in k.idne) failure because the kidney'> primaril) regulate blood magnesium . In
this case, high blood m.1gnesium leads to wcaki1ess, nausea, slowed brc.lthing, e\·cmual
malaise, coma, and death. Older people in general arc Jt p.1rticular risk of m.1gnesium
toxicity, bcc.u1sc kidney li.1nction may be compromised.
Sulfur (S)
fhe minerals discussed so far function in the body primarily in the form of durg.ed
ions. In contr.tsr, much of the sulti.ir in the body occurs in nonionic forms •I!> an ince-
gral component or organic comp0Lu1ds, such as the vitamins biotin and thi.1111in.
Because the amino .tcids methionine and L)'Steine both contain sulli.ir, it also is present
in proteins Disulfide bridges form "hen the sulti.tr atoms 111 two cystcine residues bmd
to each orhcr; these bridges stabilize the structure of nuny protein molecules (redew
Chaprcr 7). For example, this stabi lization is necessary for the for111.uio11 of coll.1g.c11,
the prOLein found in connective tissue, and for keratin, which is found in nails, skin,
and hair. Ionic forms of sulfur, such as sulfate (SO/-), participate in the acid-base bal-
ance in the body, arc present in many substances found in the exa-accllular flmd, .rnd
p lJy an important role in some drug-detoxifying pathways in the body. 6
We actually do not need to consume sulli.ir as such in our diets because proteins
supply che sulfur we need. Sulli.ir compounds are also used to prescr\'e food'> ('>cc
Chapter L9).
Table 11-7 provides .1 summary of the 111;1jor minerals.
Protein-rich foods supply sulfur in the diet.

Concept I Check
i\lagncs1um is a mineral fow1d mostly in plant foods . It is important for ncn•c and hc.m
or
function and as an •ICli\'.llOr many cnzrmcs. Whole gr.tins (bran portion), vegt.:t.ibb,
nuts, seeds, milk, .md meats arc good food sources. Sulfur is incorporated inro certain \llJ-
mins and .1mino acid\. lts abilir} ro bond with other sulfur aroms enabb n to !>tab1h1e pm~
rein structun:.
Table 11-7 I A Summary of the Major Minerals
RDA or
Adequate Deficiency Toxicity
Mineral Major Functions Intake Dietary Sources Symptoms Symptoms
Sodium • Major positive ion Age 19-50 years: • Tobie salt • Muscle cramps • Contributes lo
of the extracellular 1500 mg • Processed foods hypertension in
fluid Ages 51-70 years: • Condiments susceptible individuals
• Aids nerve impulse 1300 mg • Sauces • Increases calcium loss
transmission Age 71 years or more • Soups in urine
• Water balance 1200 mg • Chips • Upper level is
2300 mg
Potassium • Major positive ion 4700 mg • Spinach • Irregular heartbeat • Slowing of the
of intracellular fluid • Squash • loss of appetite heartbeat, as is seen
• Aids nerve impulse • Bananas • Muscle cramps in kidney failure
transmission • Orange juice
• Water balance • Milk and milk products
• Meat
• Legumes
• Whole grains
Chloride • Major negative ion 2300 mg • Table salt • Convulsions in • Linked lo hypertension
of extracellular fluid • Some vegetables infants in susceptible people
• Participates in acid • Processed foods when combined with
production in stomach sodium
• Aids nerve impulse • Upper Level is
transmission 3600 mg
• Water balance
Calcium • Bone and tooth Age greater than • Milk and milk products • Increased risk of • May cause kidney
structure 18 years: • Conned fish osteoporosis stones and other
• Blood dotting 1000-1200 mg • Leafy vegetables problems in
• Aids in nerve impulse Age 9-18 years: • Tofu susceptible people.
transmission 1300 mg • Fortified orange • Upper level is
• Muscle contractions juice (and other 2500 mg
• Other cell functions fortified foods)
Phosphorus • Major ion of Age greater than • Milk and milk products • Possibility of poor • Impairs bone health
intracellular Auid 18 years: • Processed foods bone maintenance in people wi th kidney
• Bone and tooth 700 mg • Fish failure
strength Age 9-18 years: • Soft drinks • Poor bone
• Part of various 1250 mg • Bakery products mineralization if
metabolic compounds • Meats calcium intakes are
• Acid/base balance low
• Upper Level is
3-4 g
Magnesium • Bone for malion Men: • Wheat bran • Weakness • Causes diarrhea and
• Aids enzyme function 400-420 mg • Green vegetables • Muscle pain weakness in people
• Aids nerve and Women: • Nuts • Poor heart function with kidney failure
heart function 310-320 mg • Chocolate • Upper Level of
• legumes 350 mg, but refers
to nonfood sources
{e.g., supplements)
only
Sulfur • Port of vitamins None • Protein foods • None observed • None likely
and amino acids
• Aids in drug
detoxifica tion
• Acid/base balance
Summary
I. Warcr consrirutes 50 to 70% of the human body. Its unique chcm- hydrochloric add and in immune and nen·e fi.rnccions. Table s.1Jt
ic:U propenics enable ir to dissolve substances as well as serve as a supplies most of 1.he chloride in our diets.
medium for cht:mical rcacriom, temperarn re regulation, and lu - 5. Calcium furms a vi tal part of bone su-ucture and is very imporram in
brication. Water also helps regulate the acid-base balance in 1.hc blood clotting, musck: concracrion, nerve cransmission, and cell me
body. For .ldults, daily fluid needs as such arc estimated .IC 9 cups tabolism. Calcium absorption is enhanced by stomach acid and rhc .K
(wome n ) to 13 cups (men). ci\·c \fol.min D hormone. Milk and milk product' .U"e rich calcium
2. tllany minerals arc vital for sustaining life. I-or humans, animal sources. Women arc particularly ar risk for nor meeting calcium ncctk
products :ire the most bioavailablc sources of most 111inera11.. They arc also typically at risk of developing ostc<>poros1s as they .1gc.
Supplemcnrs of minerals exceeding the Daily Value, and espcciaJly Numerous litCsrylc and medical options help reduce this risk.
the Upper Le\ cl, should be taken only under :i physician's ~uper 6. Phosphorus aids function of some enzymes and f(>rms pan of kc\
,·ision bcc.lu1.c tox.icit} and nutrient inceracrions are po1>Siblc. mct.lbolic compounds, cell membranes, and bone. Jr is e!licicncl~
3. Sodium, rhe major positi,·c ion (cation) found outside cclb, is \ital .1bsorbed, and deficiencies arc rare. Typical food :.ourcc:. arc d.1in
in fluid b.dancc and nerve impulse transmission. The North products, bakery products, and 1ncari>.
American diet prO\·idcs abumfanr sodium through processed foods 7. Mag nesium , a mineral found mostly in plants, is impormm for
and table salt. ncrYe and heart function and as an activator for m.rny enzyme'
4. Potassium, the major positi\'e ion (cation) found inside cells, has \Vholc grains (br.m portion), \'egcrables, nu~. '>Ccds, milk, and
functions similar ro rhose of sodium. Milk, fTuits, and \'egcrables meats are rypical food sources. Sulfi.ir is incorpor.ncd 11Ho ccrram
arc good source!.. Chloride is rhe major ncgarive ion (.111ion ) Yitamins and amino acids. !rs ability to bond with ocher :.ulfur
found outside cells. Ir is important in digestion as pan gastric or atoms enables it 1.0 stabilize protein strucnirc.
Study Questions
J. Approximately how much water does a person need each day to 8. What might you 1.ell a 12-year-old child abou1. the importance of
sray healthy? Idemit)r at le.1st two situations that increase rhc need co11sumj11g sufficient calcium?
for water. Then list three sources of,Yatcr in Ll1e average person', 9 . ln terms of coral amow1rs in rhc body, calcium and phosphoru~ arc
diet. the first and ~ccond most abundam minerals, rc~pccli,·el). Name
2. Whr arc most minerals present in higher concentrations in ammal mo ways in \\'hi ch phosphoru~ and calcium arc alike .rnd two '' .1y'
foods than in plant foods? in which they diftcr.
3. How is water eliminated from the body> What physiologic.-il forces 10. Describe tl1e rc l.irionship bcrwcen magnesium ;ind 1hc function/
regulate this output? hcalt:h of d1c heart.
4. \Vhat is rhe main physiological difference between recrh and
bones?
5. ldcntit) four factors that influence rhc bi<>availabili1y of minerals
from food. BOOST YOUR STUDY
6. What is the rcbtionship between sodium :rnd \\'atcr balance, .ind
how is tl1.1t relationship monitored as well ~ maintain<:d in Ll1c Check out the Perspectives in Nutrition: Online Learning
body? Center www.mnh• .com/wardlawpers7 for quizzes, Aosh
7. Wirhin what physiological ~ystem do sodium, potassium, and c.ll- cards, activities, and web links designed to Further help you learn
cium incer,1ct? What arc the indh·idual roles of these minc r.1b in about water and the mojor minerals.
1.his system?
1. Appel LJ and others: Dictar) approaches to high blood pressure. ]011runl oft/Jc Amcrimu fllld tfisca.rc. I 0th ed. Philadclph1a, l'A: Lipp1nco1t
prc\·em an treat brpertcnsion: A ~kntific stare- .\fctfiml ksorintw11 289:2560, 2003. Williams & Wilkins, 2006.
mcm from the American Heart association. 11Jis arrul.- is a ro111prd1mm•t look at tlu l'flri- C11rrem r(J•1e11• of osuopororis dia.11noris and
ff.vpertmrio11 47:296, 2006. 011s lifm.vlc n11d mcdiml i11rer1•cnti1111s to pre- trtntmwt, flS well as wrrwt 11udical tl1crapia
Lfltest fldl'ict fmm t/Jt Amencn 11 Hmn vent rr.11d trmt l~vpcne11sio11. Kr.v /1festyle frr.ctors for the disonfrr.
Associrrrio11 1111 diet mul J~1·11e1·1c11sio11. Key Pl'I'· cmphrrsizc1{ nrc weight red11ctio11, rcgulnt; p/Jysi· 4. Fiske I-I: Measuring water'& benefits and opti
1>c11ti11c ffl.-ton n 1·c to flvoitf ol'cr111c(flbt rr11tf 111- ml nctil•i~l', 1·ducrio11 ill mlt intake, modem· mal im.1kc recommendation~. Todn.v's Diu1 -
flctivity, fllltf modcmu alcohol fllltf salt illmkc rio11 ill fllcohol mc, fllld fol/011'111g fl /Jealtl~1· diet, tin11, p. 22, January 2003.
2. Chob.inian A\' and ochers: The SC\'enth report mcb flS tbe DASH ditt. One n>fl.V to make sure 111c stfl_r ll'dl IJJdraud is to
of the joint n.ioon.il commim:c on the preven- 3. Dawson-I tughc~ B: Osteopor!.b In Shils ~IF alll'nys bfll'f 110 more rhn11 fl pfllc _wllow 111"111r.
aon, dctecrion, c1·aluation, .md treatment of and others (eds): Modem 1111tritim1 in henltb For 111n11.v of 11s bydrntio11 is uot n clmllcn,flc br·
must 0111" t/11rsr 111i:dm11is111s c11co11mgt 11S tu ncss, and blood lipids in c.1rh pmuncnopall'·'' 18. Mirka J\.I: Dash ofdis~cnr on .,,1lr intake ad\'Kc
drink fluid w/Je11 needed. Alljlu1ds cu1111r, el'rn mtcopc1m: women: Result\ ot rhe Erlangcn Jo11n111/ uf r!Jc A111crict111 Mcdun/ JUs11Cint1011
rbost n•irh mf)i"i11c nnd nlco/Jol (bur 1111r quite ns Fimcss Osrcopormi' Prc1·tm1on Stud) 291:1686, 2004
11111ch ns 11'fltcr mdj). (1::.FOPS). rlrchil•cs of lllumnl .\icdici11c li111•-s11diu111 dim rspuin/~\' bdp so111e peoplt- r1111·
5 Food and Nmririon Board, ln~titutc of Medi- 164: 1084, 2004. tr11/ b/o11d pressure, b11t some ocfi<Tts rn11te11ri
cine: Dictnry ll~fcrwce btmlm jiw cnlci11111, A /f&1w·11l·purposc exercise pro.1.1m111 has n posi· thnt rcco1m11mdi11..rr such n dicr to 11ll 11d11/rs d11cs
p/Jo.rphor11s, 111ng11esi11111, J>itn111i11 D, n11d flzw- til'c iwpncr 1111 11'11111m 11'/Jo nr,· i11 rbr mrZv .Ycm·s 11ot hnPr stnm.fl scimtijic mpprwt. 171e1·e is 1111
ridc. W.i~hingron, DC: N.rnonal .-\cadcm1• of mmopnmc Suc/J n progrnm rn11 nlso imprm•r comptllrng n•1dwu ro shull' time /ow-sodium
Press, 1997. srr·e11g1/J n11d md111"1111ce. ffd11cc bnck pnill, n11d diets bnr111 ndu/rs i11 gwcrn/, 11'/Jich hns led
Dier11r:1• 1tn11d111·ds fo1· 111n11_v 111n;1w 111i11crnls nn: i111prm•c lipid /C1•ds. ot/Jer cxpcns w ri·commc11d rn11ri11c nd11ptio11 1~/"
disC11ssed. 771t· mr11111a/c used rn scr RDA or n loll'·sodiu111 dtrr.
13. Kha\\ K r ~ml others: Blood prc\Slll'C and uri
Adtquntc bitn~·a n11rl Upper L1·1'dsjiw time 19. Nieves J\V: Osteoporosis: The role of nucronu
nary sodium in mcn and \\Olllcn: T he Norfolk
1111rriC11rs is disC11sscd i11 dctnil. triem>. Amrricnu Jottrna/ 1tf Cli11icnl N11t1·1t11111
Cohorc of the European P1w.pcc:1ivc L1WC\ti·
6 Food and Numrion Boa.rd, lru.mutc of ~ledicine: 81:12325, 2005.
gacion 11110 Cancer ( EPIC-:-.orfolk). Amcricn11
Dirmr_r Rcji·rmu /llmkts for wnrcr, pomssi11111, /ournnl of Cl111icn/ X11trit11111 80 1397, 2004 77Jc cjft"cts l)fcnlc111111n11d1'itt1111111 D 011 bo11c
sodw111, c/J/nridc, 1111d mlfnu. \Va,hington, DC: cn111101 bt' co11!idcrcd 111 1solrrtin11 ji-lm1 rbc 11rho·
Wirhm rb<" 1w111/ m11gc jiJu11d 111 11 fra·li1•i11.rr
Nariona.1 Acadcn1\ Prc~s, 200-l. co111po11mrs of the diet. 77Jc 11r/Jn· 111icm1111n·irn1s
pop11lnrit111, btnlm· nnzamw of 111"i11m:v surli11111, uccdcd jiw 11pti111izi11g bo11c bcnlrh i11d1trlc 11111..rr·
Dicrar~v st1111rlnrrls for n•nta, pornssi11111, sodium,
1111 i11dimrnr 1fdict111:v sod111111111tnkc,111·c nsso- 11esi11111, p11rnssi11111, 11it11111i11 C, n11d Pit11111ill K.
1111d chloride nrt' dimmed. T71t mri1111nlt used t11 cinced ll'ith 111m:nscs ill blood prcsstir( ofclmim/
dcrit•c tbt Adcq1111tt: Intakes, ns ll'Cll ns tht 771esc needs cn11 be mer n•1t/J 11 l1tnltl~v rliet rlmr
nnd pub/if hmlth rdcm11a n1.- jilldi11gs rein· is /Jig/1 iu fr11irs 1111d l'C!fctnblcs (2: 5 scrl'mfls
Upper lcrds, nn· presenrcd a/011.fl ll'llh illfon1111· force rcco111111e11dn1io11s to lower n1•crn.11r sudi11111
rio11 011 fi111ct1<111, 111rakc, n11d d1ftciwc.v. per rlny).
i11tnkcs i11 1h.-.11mcrnl pop11llllii111.
7 Ford ES, i\lokad AH: Diet.111 magncsillm in· 20. Now~on ( t\: Blood pn:ssurc rc.,poiu.e LO di
14. Knoc:hcl JP· Phmphorus. Jn Shils t- lE and 01.h - erary modifications in lrce living individual~.
rake in a nJn onal sample of U.S. ad ults.
ers (cd~ ): :\fodcm uutnriou 111 /1cn/tlJ n11d dis· foumnl of N11rritio11 134:2322, 2004.
]0111w1/ of Nutrition 133:2879, 2003.
cnsc. I 0th ed. Philadelph1.1, l'A'. Lippincoll A pup11/nrio11·11'idc red11ctio11 i11 dicrnr_v sod111111,
Jlir11.1· ndults rnrrmt(1· do uor meet their 11111g11c· mlli;um & Wilkins, 2006.
si11111 11uds 011 11 rt-g11/nr b111is, p11nirnlnrZ1· spccijirnl~r b.1· red11ci11g tbc sodium ro11te11t 1tf
women 11'/Jo do 11ot rnkc n m11/tii•1t11111111 n11d C111Tt11t 1·n·frn· 1~/'p'1ospbrwus mrtnbolism. smplc food irrms, togcr/m· w11/J n11 i11crmu in
111i11errr/ supplc111mt nllfi Aji·icn11·A111erirn11.< iii Digesrio11 1111d nlmirption n11rl rdnted issues such p11mssi11111 111tnkt' (tbrtm!fb i110·,·nscd frnit, l'C..11"
gmcmL Grcm 1•c.trctnblcs, 1111ts, .reeds, dried ns ctimcnl stntcs tb11t pose n risk jiw a rlcficic11c.v ctnb/e, n11d 111bole-grni11 ccrcn/ iittnl1c), 11•011/d
be1111s, whole .rrrnim, dni1:r producrs, 1111d meats use rr1·c nls11 (Ol'rrcii. comribuu to rbe 111ni11tm1111ce of 11pt1mnl bill11d
11reg1Jod 111ng11rs111111 sources for n diu. 15. KotchenTt\, Kotchcn Ji\1 :--:ucmion, diet and prcrmra ill rbr populnriou.
It Ha,·as S and ochers: Reducing rhc public health h~·pc:rtell\ion. In Shils ~ll::. .md othc;rs (eds): 21 Oh i\lS, UribJrri J: Ekctrolnc~. "acer, and
burden from clc' a red blood pre'>'> Ure lc,·els in M11dcrn 11ut1·1111111 itt /Jrnlt/J nnd durnsc. 10th ed. acid·bJsc balance. In Shih Ml- and others
rhc C11itcd St.He' by lowering i11t.1kc of dieL.11) Philadc;lph1J, PA: Lipp1ncoll William~ & (eds): Modem 111rtritw11 i11 /Jmlrb 1111d dismsc.
~odium. A111tTim11 Jmmrnl 11[ Public Hcnlr/J Wilkin~, 2006. 10th ed. Philadelphia. PA: Lippincott \Villi.11m
94:19. 2004. Cun·ellf rcl'irn• uf t111tritim1. 1/irr n11d /~1'jlcl'tm· & Wilkim, 2006.
77Jt Amcrun11 public comumcs fnr more sodium sio11, i11c/11di11..n n da111lt-d disws.rio11 of the wn.n
t/J1111 is 11udcd. ,\Ion of r/Jis sodium is ndded ns C111·ro1t l't"l'ltll' offt'nrcr n11d dutruZYtc manbn·
i11 11'/Jic/J mlt illfnkr ro11rrib11w tu r/J, prob/mt. fism, nmf rbr t'})'ccrs 1ifbot/J dcjicm1c_1· trnd roxu·
.m/c byfood 111n111ifnct11n:rs 1111d rcn1111m11ts.
16. Kllehn Bt-1: Bcrccr osteoporo''' m.magemem .1 i~1· nn ro jiir ll'lllrr n11d Ml"i1111s durr11~1·tcs.
9 Hcanc) RP: Bone biolog} in he.11th .md disc.1~c. priori!)·: lrnp.ict pn::dictcd en 'o~r with aging
In ShiJs M !:: .111d orhers (eds): .\lodem 1111triri1111 22. Ra~z LG: ~crccning for o~teoporo,is. 171t .\'ell'
popuiJtion. /11111·11nl of tlH A 111a1t1111 ll,/cdicnl
i11 /Jcnlt/J n111i dismsc. 10th ed. Phil.1dclphia, P.-\; Associ11tio11 293(20):2453, 2005 E11gln11d jo1mial of .\fcdici11t 353: l 64, 2005
l.1ppmcon \\'ilhJms & \\'ilklm, 2006.
,\Jore th1111 2 1111//i1111 i11dii•1d1111/s i11 rfu U11itt'd i\fr11mrm1mr l)fbonr 111i11cr11/ rlmsity at tbc
C11n-c11t 1·f1•irn• l)f bo11c bioli?fl.\' i11 bmlt/J a11d
Stnrcs ll'ill ,·xprncurr ostmpm-mis·r·dnrcd frnc· /11111lJ11r spmc n11d prox111111/ .fcmm· by dual·
dism.rr. Durnn•fncton suc/J ns J1111·ii111s Pitnm111s
rm·cs t/Jis ym1·, r1·s1ilriu.ff in t'srt 11111trrl mrdirnl Cllct~fl.'' X·m.Y nbsorptio111rtry bo11r .rrnm is n rdt·
1111d 111i11cm.ls r/Jnt nffict bone /Jm/1/J 111·,· 11/so
costs~(' 111111'<' tlm11S16.1) bill11111. Ry 2025, tfJL' nblc rr11d snfc ll'll)' to nsscss //Jt risk 11[fmctun· iu
c011t·rcd.
1111r11lJO" ujji·nctul't"s and till' llSY11ci11ti·d costs ftrt' posm10111pn11snl 11'0111e11. Holl'l'l'CT; 111m1y otlJLT
10. Hoolihan L: Beyond ca.kium. N11tritio11 Todny cxprcud tu 1·ut' b_1· .JS••• D.-sp1u r/111 dn1111ti11g fncmrr wflumu fmcturc risk, surh 111 goutit
39(2):69, 2004 r/111//mg1", r/Jr nnwnl of tools to irlmrif:r. pn· bnckgrormd n11d race, 1111d shrwld be comidtrcd
.\frcri11g 011c '.( 1ucds for rnlci11111 11Slll!f riall".I' l'Ott, m· trmt 11.ruuporosis /111.<.111·1111'11 c1msidcmb/\o i11 mnkiu.rr 1-un111111mdnrio11s r·r..r111rdi11.11 b111u
p1·nri11crs 11111y propidr hen/th bcucjirs b<:ro11d m•ff rbr pnsr 10 1·cn1·s. Prop<'I' rlur n11d i:.xr:1·c1st' dcmit11111crry n11d tbcrnp_v.
rlJOse nrrribulrd r11 t/Jc cnlci11111m11rmr11/011c. tlm111gbour /(fr 11r1· l'CC11!J11iztd ns tbc mosr cjfcc· 23 Rmcn CJ: Postmcnopausal osrcoporo~i ~. !71.-
/11c11rpornti11.rr milk 1111d milk pl'llducts iuro n ttl'C mmmrc.1 t11 111m11ta111 /J11m· /Jrnltb. 1\Tcll' 1:.11g/1111d Jo1mrnl of Jfrrl1w1c 353:595,
diet is a ~rrood /Jnb1t co d.-11clop. 2005.
l"' Lic:bm.m B· Brc:akmg up: Strong bones need
11 How to prc:,·enr strokes. Ci111s11111<"r Reports 1111 more than cakmm. X11trir11m Auio11 Hmlt/J A rc1•inl' oft/Jc ding11osis 1111d nwt111c11t of os·
Hcnltb 16(9):1, 2004. Lmcd2(3):3, 2005. tcoporosis, 111c/11rli11g ctn-tY:11t mrrlimrinm. 17JL'
17Jis 111·ticlc prm•ides dcrnilcd m•iell' 1tfrl1t Good, bt1Szc 111'1'l"l'frw ~f lnt,.sr rt'!rnn/J for pr... 11ur/J11r 1·1·co111111mds bip/Josp/Jor111rcs ns tbc mosr
/Jcnlt/J l'isks pomf /Jy strokes ns ll'dl 11s n look nt 1•wti11g bou.- lt!s.< n11d 11111i11tni11i11g bone hcnlr/J. nppropl'inr.- 111cdicnrio11 1111d 11/s11 1uo111111mtfs
c1wrcnt t1·cnt11101ts. P1·evc11ti11c mmmrcs i11cl11ric T7J,· 111·t1clc 111cl11ries spccijir rcct11111umd11ri1111s meeti11..11 cnlcium n11d l'ira111111 D needs.
11ot s111oki11..fl, 111uri11g nutriwr 11uds, rt·duci11g for dai(r t'.Wl"Clft" n11d for mrnku 1~(cnlm1111, 24. Rude RK, Sh1ls ~lE: ,\lagnc'>ium In Shib ,\IE
stress. 1111d co11rrnllillg d111bctcs zf prawr. 1•irnmi11 A, 1•irnmi11 D. 1•1tn111i11 K, protein, and others (eds): .\lodcm 11u1ruio11 i11 bmlt/J
12 . Kemmler W and others: Benelib of 2 year> of n11d pornssium n11d for ji·uits n11d Prganb/u 1111d diunsr. 10th ed. Philadelphia, I\-\:
1mense exercise on bone dcns11y. physical lit- iu gencrnl. Lippincott Williams & \Vilk.111~. 2006.
422 Chapter 11 Water and the Major M inerals
C11rrt111 rt:l'it1v of mn.1111Csi11111 mttnboliJm. 26. Stronger bones witl1ouc che h\-pe. Co11mmcr womm. A11.v ntch mt sho11/d be s/Jorr urm, mch rrs
Dwm11111 n11d nbsorprio11 nnd rdnud i111us mc/J Reporrso11Hcnlt/J16(5).l. 200-1. for NWtll(.IJ t/Jc itminl symptoms of111mopn11sc,
ns 111111w·11m cli11irnl t'.\'/r111ples where rr dcfi- TJ1e rrl'firlc /lrOl'idts drtrrilcd n11sl1'ers to rypicnl T71e A111ericn11 College of Obstetrics n11d
czmc_y 111igbr dePclop nrc rrlso coJ1acd. qucstilms nbo11t b11111· ht·nlt/J. A 1·evien• of the np- Gy11ccohigy, tl1c Amerirn11 Hen rt A5socin11011, t/Jc
prol'ed osteoporosis mrdirnrions is rrlso pro111ded. North A 111cncrr11 Jfe11opn11sc Society, n11d r/;c
25. Sch.irdc D: Potas~1um: Bone~. stones, and Ca11ndirr11 fnsk Force 011 Prn•wrirr Hcnlrh Crrrr
27. U.S. Prc\·cnm·e Semcc~ Task Force Recom-
stroke~ on chc line. X11rritio11 Att1011 Htnlrh 111nke nmi/111· recommmdntions.
Lcttt'r, p. 8, December 2004. mendarion Sr.1ccmcnt. Hormone therapy for
the prc1 ention of chronic cond irion ~ 111 posc- 28. Weaver C M, Heaney RP: Calci um . In Shils ME
Potrrssi11111 is rhe Stl'tllfh most ple11tijiil 111i11trnl menopama l women. A111erirn11 Fnmily and others (eds): Modem 11urririo11 in /Jen/th
1111 mrth, but iris 1111u/J too scaru i11 t/Jr Pl~1'Sicirr11 72(2):311, 2005. nnd disenu 10th cd Philadclph1J, PA.
A111tritn11 diet. Co11m111111l1 more pornss111111 17Je USPS IF 1uommmdI ngninst ro11r111r use of Lippincon William~ & Wilkms, 2006.
would hdp prorea 11s rr_r1ni11st bigh b/011d prcs- co111bi11cd mrogm rr11d pnigcstin far t/Jt' prcpen- C111-re11r rci•icw of crrlciu 111 111ctnbolis111.
Slll'r, str11/1a, kid11cy sro11cs, rmd bo11c loss. rio11 of r/Jro11ic co11dirio11s ill posmm1opn11snl Digestion rr11d rr.bsotjitio11 11re nlso col'cffil.
Take I Action
I. How High Is Your Sodium Intake?

Complete this questionnaire lo evoluote your sodium habits with respect to typically nch sources.
How Often Do You ••• Ro rely Occasionolly Often Regularly (Daily)

1. Eot cured or processed meats, such os horn, bacon, sausage,
frankfurters, and other luncheon meats? 0 0 0 0
2. Choose conned or frozen vegetables with sauce? 0 0 0 0
3. Use commercially prepared meals, moin dishes, or conned or 0 0 0 0
dehydrated soups?
4. Eat cheese, especially processed cheese? 0 0 0 0
5. Eat salted nuts, popcorn, pretzels, corn chips, or potato chips? 0 0 0 0
6. Add salt to cooking water for vegetables, rice. or posta? 0 0 0 D
7. Add solt, seosonrng mixes, solod dressings, or condiments-such as 0 0 0 0
soy sauce, steak sauce, cotsup, and mustard-to foods during
preporotion or ot the table?
8. Solt your food before tasting it? 0 0 0 0
9. Ignore labels for sodium content when buying foods? 0 0 0 0
10. When dining out, choose foods with sauces or foods that ore 0 0 0 0
obviously salty?
The more checks you put in the "often" or "regularly" columns, the higher your dietary sodium intake is. However, not oil the habits in
the table con tribute the some amount of sodium. For example, mony natural cheeses such as cheddar ore relatively moderate in
sodium, whereas processed cheeses ond cottage cheese ore much higher. To moderate sodium intake, choose lower-sodium foods from
eoch food group more often and bolonce high-sodium food choices with low-sodium ones.
Adopted from USDA Home and Garden Bulletin No. 232-6, April 1986.
II . Working for Denser Bones

Osteoporosis and related low bone moss offed mony adults in North America, especially older women. In foci, one-third of all women
experience fractures because of this disease, amounting to about 2 million bone fractures per year.
Osteoporosis is o disease you con do something about. Some risk factors can't be changed, but others, such os o poor calcium in·
toke, con. Is this true for you? To find out, complete this tool for estimating your current calcium intake. For all the following foods, write
the number of servings you eot in o doy. Total the number of servings rn eoch category and then multiply the total number of servings
by the amount of calcium for each ca tegory. Finally, odd lhe total amount for each food category to estimate your calcium intake for
thot doy.
Does your intake meet your Al set for calcium?

Take I Action
Food Serving Size Number of Servings Calcium (mgl Total Calcium (mg)
Plain low-fat yogurt 1 cup
Fat-free dry milk powder 1/2 cup
Total servings x 400 mg
Conned sardines (with bones) 3 ounces
Fruit-Rovored yogurt 1 cup
Milk: fat-free, reduced-fat, whole, chocolate, 1 cup
buttermilk
Calcium-fortified soy milk (e.g., Silk) 1 cup
Parmesan cheese (grated) 1/4 cup
Swiss cheese 1 ounce
Cheese (all other hard cheese) 1 ounce
Pancakes 3
Conned pink salmon 3 ounces
Tofu (processed with calcium) 4 ounces
Collards or turnip greens, cooked 1/2 cup
Ice cream or ice milk 1/2 cup
Almonds 1 ounce
Chord, cooked 1/2 cup
Cottage cheese 1/2 cup
Corn tortilla 1 medium
Orange l medium
Kidney, limo, or navy beans, cooked 1/2 cup
Broccoli 1/2 cup
Carrol, row 1 medium
Dotes or raisins 1/4 cup
Egg 1 large
Whole-wheat bread l slice
Peanut butter 2 tablespoons
Calcium-fortified orange juice 6 ounces
Calcium-fortified snack bars 1 each
Calcium-fortified breakfast bors 1/2 bar
Calcium-fortified chocolate candies I each
Calcium supplements* leach x 500 mg
Total calcium intake mg
Other calcium sources lo consider include many breakfast cereals (100 lo 250 mg per cupl, ond some vitamin/mineral supplements
(200 to 500 mg or more per tablet).
•Amount varies, so check the label for the amount in o specific product orid then od1ust the cokulotion os needed
Reprinted with permission from Topio in Clinical Nutrition, ' Putting Calcium inlo Perspective for Your Clienb." G. Wordlow and N Wce-.e, 11 1, p. 29 © 1995 Aspen Publishe" Inc
TRACE MINERALS
ER TWELVE
~
Troce Minerals-An Introduction Al o recent family reunion, Gino learned thot on ount wos currently undergoing
...::z:=
Research on Troce Minerals treatment for colon cancer. Her grandmother olso explained thot two other family
'"=
Difficulties in Studying Trace Minerals • Trace
Minero/ Needs • Food Sources of Trace members hod died of the disease before Gino wos born. Aker the reunion Gino de-
-l
Minerals cided to leorn more obout colon cancer ond how her family history of the disease I
Iron (Fe) m
could affect her. Gino's research uncovered thot 150,000 Americans ore diagnosed
Absorption, Transport, Storage, and Excretion <
~
of Iron • Functions of Iron • Iron in Foods • with colon cancer each yeor ond that her family history increased her chances of
Iron Needs • Iron-Deficiency Diseases• Upper developing the disease. While searching online she come across o site thot recom·
Level for Iron
Expert Opinion: Iron Overload: Too Much of o mended 200 µg/doy of the trace mineral selenium os o woy to prevent the disease. z
(/)
Good Thing She then went to her locol supermarket ond found thot 100 selenium tablets contain· )>
Zinc (Zn) ing 200 µg eoch only cost $7.50 o bottle. Gino figured this supplement wos cheop z
Absorption, Transport, Storage, and Excretion 0
Hinsuronce" ogoinsl developing the disease and so begon toking 200 µg of sele-
of line • Functions of Zinc • Zinc in Foods • ~
line Needs • Zinc-Deficiency Diseases • Upper
Level for line
nium o doy. Is Gino's practice harmful? Should we oll follow her example? Are there zm
other nutritional practices she should consider to help protect her from developing :;o
Copper (Cu) )>
Absorption, Transport, Storage, and Excretion colon cancer? ,...--
(/)
of Copper • Functions of Copper • Copper in
Foods • Copper Needs • Copper-Deficiency
Diseases • Upper Level for Copper
Selenium (Se)
of Selenium • Functions of Selenium • Selenium
in Foods • Selenium Needs • Selenium·
Deficiency Diseases • Upper Level for Selenium
Iodide (I)
of Iodide • Functions of Iodide • Iodide in
Foods • Iodide Needs • Iodide-Deficiency
Diseases• Upper Level for Iodide
Fluoride (F)
of Fluoride • Functions of Fluoride • Fluoride in
Foods • Fluoride Needs • Upper Level for
Fluoride
Chromium (Cr)
of Chromium • Functions of Chromium •
Chromium in Foods • Chromium Needs •
Chromium.Oeficiency Diseases
Mongonese (Mn)
Molybdenum (Mo)
Ultrotroce Minerals
Boron {B) • Nickel {Ni) • Silicon {Si) • Arsenic
(As) • Vanadium (VJ
Nutrition Focus: Nutrition ond Cancer
Toke Action
425
T race minerals make up less than 1% of oil minerals in the body, but their functions ore absolutely
9
essential for life. •10,ll A trace mineral is defined as a mineral for which our doily nutritional need
is less than 100 mg. Grouping them together this way, however, is too simplistic because the functions,
mechanisms of absorption, transport in the body, and metabolism of the various trace minerals vary con-
siderably. For example, the body carefully regulates the absorption and transport of iron and copper
but not selenium and iodide. This difference makes these lotter trace minerals potentially toxic al intakes
not much above our needs The trace minerals ore also very in-
teractive; the abundance of one mineral in the diet and in the
body con affect the absorption and metabolism of several other
minerals.10
TO ALLOW YOU TO:
Information about trace minerals is one of the most rapidly
1. list conditions of the body, dietary factors, and other pertinent
expanding areas of nutrition science. Wi th the exception of iron
influences that determine the absorption, retention, and
and iodide, the importance of trace minerals to humans has availability of specific trace minerals.
been recognized only within the last 50 years. This chapter will 2. List key functions of the trace minerals.
examine some of these new findings as well as the role played 3. Identify possible deficiency and toxicity symptoms associated
with the trace minerals.
by various nutrients in cancer development and prevention.
4. List al least two food sources for each trace mineral.

OF TRACE MINERALS IN CHAPTER 12, YOU MAY WANT TO REVIEW:
Digestion oncl absorption processes in Chapter 3.
• The process of oxidation ond reduction ond the electron lronsport chain in Chopler 4.
• Vitamins in Chapters 9 ond l 0.
• Calcium in Chopter l L
Chemistry terms such os valence ond free radicals in Appendix A
Respiration, the muscular and skeletal systems, cell structure and function, immunity, and the endocrine system in
Appendix C
I Trace Minerals-An Introduction

The terms trncc miucm/ •ll1d micromi111:ra/ Jre somewhat imprecise bccJusi: scwral
definitions of these terms ha\'C evolved O\'Cr time. Originally the terms were u~cd w
describe minerals that were not easily quantified by existing analytical methods, bm
today we have precise techniques for determining the concentration of \'Cr) small
amounrs of minerals in tissues and 111 fomh. Thus, the definition used in this textbook
relates to "a daily nutritional need oflc.,s than 100 mg_" Trace m.inerab an.: dietaty cs
sentials in that the) h.1,·e specified biologic•ll functions and a dietar) deficicnC\ pro-
duces physiological or structural abnormalities.9·'0,t t
Discovering the import.1nce of the~c trace minerals to humans has a fairly rcccnc his
tory, although the use of diet.1ry iron to treat the effects of blood loss can be traced
back to ancient ci' ilizations. In l 96 1, scientists linked dwarfism among villagers in the
Middle:: East to a zinc dcticicncr- Other researchers later recognized that an obscure
form of heart deterioration in an isolated area of China was linked to a selenium de ti
cicncy_ In the United States, deficiencies of some trace minerals were first obsen ed in
the late 1960s tO early 1970s \\hen these nutrients Were omitted in the prcpJraLion of
synthetic formulas used fo r rot;1J pnrenternl nlllrition. T his "accident" also led w prool
rhnr some trace minernls we re essential pnrts or
a hum:ui diet.
426
I Research on Trace Minerals

Not only are trace minerals needed in much smaller amounts than the major minerals,
but the actual need for some trace minerals is also still debatable. Table 1-3 in Chapter 1
listed nine essential trace minerals but some other possible entries also were listed.
Demonstrating the essential nature of this latter group of nutrients is hampered by dif-
ficulty in measuring the small amounrs needed by the body and by not knowing all the
functions in the body that may be associated with the trace mineral. Before presenting
each trace mineral, this chapter looks at why research in this area is so complex.
Difficulties in Studying Trace Minerals

Rigorous protocols often are required to p roduce a trace mineral deficiency in ;u1imals.
(All animal research referred to in this discussion was conducted with farm and/or lab-
oratory animals. ) The animals may need to be raised in ultraclean environments and
have their diets carefully formulated from individual essential nutrients to ensure that
no trace mineral contamination occurs. Stainless steel and plastic cages may also be
needed so that the animals do not obtain any trace minerals, such as zinc, from chew-
ing on the cages. Trace minerals must sometimes even be filtered from the air, and the
water must be as free of trace minerals as possible. ln addition, glassware used for
chemical analysis may need to be rinsed repeatedly in acid tO eliminate tr~lce mineral Seafood, such as scallops, is a good source of
conramination; sometimes only plastic bottles are appropriate. many trace minerals.
Despite tl1e difficulties encow1tered in experimentally producing most trace mineral de-
ficiencies in laboratory animals, overt h uman deficiencies still do occur. In addition, some
evidence suggests that marginal dietary intakes of certain trace minerals (e.g., iron, zinc, esearch on trace minerals in humans still
copper, and chromium) also occur, leading to mild, undetected deficiencies in hu - has a long way to go because our current
mans.9JO,ll The lack of precise tests t0 pinpoint these deficiencies is one reason rllere is understanding of trace mineral metabolism relies
concern but not hard evidence. Most of these tests involve blood san1ples. However, for heavily on the knowledge gained from studies
many n-ace minerals, rile blood tests most commonly used aren't sensitive measw·es of with farm and laboratory animals.
small changes in o-ace mineral status. Moreover, die values for many of these blood tests
are influenced by factors not related to the trace mineral status, such as ongoing infections.
A good example of these various difficulties is the a·ace mineral copper. A copper
deficiency is often assessed by the amount of copper, or the protein thar contains most
of the copper ( caUed ceruloplasmin) in the blood .16 However, based on work with ceruloplosmin A blue copper-containing
laboratory rats, these values don't fall as readily dming a mild copper deficiency as do protein in the blood that can remove an
some orl1er copper-related parameters in various tissues. ln addition, both laboratory electron from Fe 2+ (the ferrous form) to yield
animal and human smdies have shown that copper or ceruloplasmin readings in the Feh (the ferric form). The Fe3 "" form of iron
can then bind with iron transport and storage
blood are affected by factors such as inflammation, pregnancy, fluctuating esu·ogen
proteins, such as tronsferrin.
levels, and oral contraceptive use. For reasons like this, diagnosing marginal trace min-
eral deficiencies can be seen as an art that only a few researchers can reliably perform.
Another reason why marginal trace mineral deficiencies often go Ltndetected is that
the effects may be subde and may involve interactions with od1er fuctors. For example,
a marginal trace mineral deficiency might produce a change in cardiovascular disease
risk factors or immune function. However, rllese changes are not obvious to the per-
son affected. Even the person's physician mighr not recognize that tl1ese effects involve
trace minerals because many other factors are involved in cardiovascLLlar or immune
fimction. T herefore, it is important that research with trace minerals conrinues.
Meanwhile, you would do weU to eat a balanced diet and pay attention to situations
that may cause low trace mineral intakes or lead to high trace mineral needs. Many of
these siniatioos a.re discussed in this chapter.
he difficulty in measuring trace mineral nu-

Trace Mineral Needs
trition in humans makes setting specific
The pLimary metl1od used to set trace mine.ral nutrient needs is rile balance snidy. This human needs problematic. Some trace minerals
is the same basic technique that is used for nitrogen balance studies (re\iew Chapter 7). have only an Adequate Intake (Al), not a more
Researchers try to determine the lowest trace mineral intalze that compensates for all precise RDA
428 Chapter 12 Trace Minerals
trace mineral losses from urine, feces, hair, skin, perspiration, menses, and so on. These
srudies are ver~ expensive to perform. In addition, a balance study tells only the
amount of dietar)' intake needed co maintain a specific pool of the trace mineral in the
body, bur this pool does not necessarily represent the amount needed to maintain all
body functions or ensure good health.
Another complication is that trace minerals inccract with each other. For example,
an O\'erabundancc of iron in the digesti\'e tract can interfere with the absorption of
other minerals, such as zinc. Thus, to set human dietary needs for zinc, nutrition sci
entisrs must estimate the amount of iron that will be consumed to predict hem much
zinc the body \\ill actually .1bsorb. to Overall, quite a lot of scientific judgment must go
into setti11g appropriate intake!> for trace minerals.
Sources of Trace Minerals

Trace m inerals arc found in both plane and animal foods. However, the bioavailability
of trace minerals is an importnnt issue LO consider, especially when planning diets. E\'tn
if a food is high i11 a p;uticular tr.Kc mineral, it will not supply much to the body un
less the trace mineral is absorbed well. M.my factors found in foods inhibir trace min
eral absorption. i\lineral absorption from some sources can amount to only l to 6% of
the rota! present, with the lo\\ est percentages typically seen in plant sources.
By eating a \'ariery of foods, ) ou can obtain nutrients from plants grown in a \'ari-
cty of soils and, thus, maximize your chances of consuming adequate amouncs of trace
minerals. In addition, for most trace minerals, it is best co consume as many minimaJI~
processed foods as possible; general!), rhe more refined a food, the lower its comenr
of trace minerals. for example, during chc refining of whole wheat inco white tlour,
The trace mineral content of plant foods much of the trace miner.11 content of iron, selenium, zinc, and copper is lost. The en-
depends on the soil in which they were grown. richment of \\'hite !lour restores iron but not the other trace minerals.
I Iron (Fe)
Tron is found in every living cell; toral body content is about 5 g (about 1 tsp ). The
importance of iron for 1.hc maintenance of health has been recognized for cenrnries. In
4000 B.C., the Persian physician Mel.m1pus gave iron supplements to sailors to com-
pensate for tbe iron lost from bleeding during battles. Today, iron deficiency and re-
lated cases of anemia are common worldwid<.:, affecting an estimated 1 billion or more
people in developing and devclop<.:u countri<.:s. l n most developing nations, about 1wo-
thirds of all children nnd women or chi ldb<.:ari ng age experience iron deficiency. t 8
hemoglobin The iron<ontoining protein in red
blood cells that transports oxygen to the body
tissues ond some carbon dioxide owoy from Absorption, Transport, Storage, and Excretion of Iron
the tissues. It is also responsible for the red
color of blood. The body uses ,1 rnriety or mechanisms co .1bsorb iron and distribute it in the bod~.
These \'aiious mechanisms m,nimizc iron function and minimize iron toxicit). Although
myoglobin The iron<ontoining protein thot this system doesn't work perfectly if body iron is \'Cry low or \'ery high, it still works wdl
controls the rote of diffusion of oxygen (02) most of the time. The body's handling of iron is affected by a number of facror~, but
from red blood cells to muscle cells. the most intluential factor is bod) iron stores. If stores arc low, the small intestine be
heme iron Iron provided from onimol tissues comes more efficient at iron absorption. Diet composition also plays a major role. Thc5e
primarily as o component of hemoglobin and and other facrors that affect iron absorption are summarized in Table 12-1.
myoglobin. Approximately 40% of the iron in Iron occms in foods in various forms. In meat, fish, and poultry, some of the iron
meat is heme iron; ii is readily absorbed. is present as hemoglobin and myoglobin, which collectively are called h eme iron.
nonheme iron Iron provided from plant sources The rest of the iron present in these foods, as well as alJ the iron in vegetables, grains,
and elemental iron components of animal and supplements, is nonh eme iron . Heme iron is absorbed more readily than non -
tissues. Nonheme iron is less efficiently heme iron (generally 30% versui. 2 to l 0%, respccti,•ely). 10 This is one reason meat
absorbed than heme iron, and absorption is products arc an efficicm way tO obtain iron from foods. The amount of iron in meat
also more closely dependent on body needs. is also higher than the nmounl naturally occurring in plant foods . (This discussion ,
however, does not discount the value of iron in plant foods. Those sources still help
Table 12-1 I Factors That Affect Iron Absorptio n

Increase Absorption Decrease Absorption
Gastric acid Phytic acid (in fiber)
Heme iron in food Oxalic acid in leafy vegetables
High body demand for red blood cells Polyphenols in tea, coffee, red wine, and other
!blood loss, high altitude, physical foods
training, pregnancy)
Full body stores of iron
Low body stores of iron Excessive intakes of other minerals (Zn, Mn)*
Meat protein factor (MPF) Reduced gastric acid output
Vitamin C intakes Calcium-containing supplements and antacids
(small effect in the long run} Minimally-processed foods should be the focus
'Especiolly when token os supplements for your doily intake of trace minerals.
meet iron needs.) Another reason that meat is advantageous is that it helps us absorb
the nonheme iron from other foods, although d1e exact mechanisms aren't well un-
derstood. A meat protein fuctor (MPF) may explain part of this effect.
Organic acids, such as vitamin C, in the foods we eat also increase non heme iron
absorption by adding an electron to Fe 3 + {the ferric form ), yielding Fe2+ (the ferrous
form ). Vitamin C then forms a complex, called a chelate, with Fc2+ , d1ereby enhanc- chelates Complexes formed between metal
ing absorption. For vegetarians or people who limit intake of animal flesh, combining ions and substances with polar groups, such as
vi ta.min C-rich foods with plant foods containing iron is a useful strategy. proteins. The polar groups form two or more
Ferrous iron (Fe 2 +) is absorbed better than ferric iron (Fe 3+ ) because it crosses the attachments with the metal ions, forming a
mucous laver of the small intestine more readily to reach d1c brush border of intestinal ringed structure. The metal ion is then firmly
bound and sequestered.
absorptive. cells. There, Fe2 + must then have a~ elecu·on removed, oxidizing it to Fc 3 + ,
before it enters me absorpti\'e cells. At me cell membrane of the brush border, Fc 3 +
binds to a receptor protein, called a membrane iron-binding protein, which finally
u·ansfcrs iron into the absorptive cell.
Although no iron absorption occurs in the sromach, gastric acid plays an important I 1'1nL i.r:g
role in nonheme iron absorption by promoting the conversion ofFe3+ to Fe2+ and by
solubiJizing the iron. The decreased production of gastric acid experienced by many Annie, Tom's friend, is toking a nutrition class
older people can lower both their iron absorption and Liltimately their body stores of al her university. She suggested that he con·
iron. Once acted on by acid in the stomach, absorption of the iron then occms pri- sume some extra vitamin C-rich foods every
marily in the small intestine. day. Tom is confused by this advice, because
Heme iron follows a different absorptive process. lt is likely absorbed directly into his doctor told him that lo help treat his low
the absorptive cells after the globin (protci n) fraction has been removed. Once inside blood iron, Tom should increase the amount of
the absorptive cells, the iron is released from the heme portion. iron in his diet but not the amount of vitamin C.
Several d ietary factors interfere with ow· abiJicy to absorb iron. Phytic acid and oilier How can Annie explain her recommendation to
factors in grain fibers and oxalic acid in vegetables can aJJ bind iron, reducing its ab- him?
sorption. For this reason, spinach is not a good iron source despite containing rela-
tively high amounts of iron for a plant food. Polyphenols, such as tannins found in tea
and related substances found in coffee, also reduce iron absorptioo. 10 People trying to
rebuild iron srores arc advised to reduce coffee and tea consumption, particularly at
meal times. Finally, several studies have shown that calcium interferes with dietary iron
absorption, but the effect is mild at best. Still, experrs on calcium and iron interactions
recommend that indjviduals with high iron requiremenrs avoid taking calcium supple-
ments at meals that contain most of d1e dietary iron. They coli.Id also consider taking
calcium supplements between meals or at bedtime to avoid this potential interaction.
Because iron is essential but high intalces can be quite toxic, the body has an elabo-
rate system to try to place iron where it belongs and inhibit iron toxicity (a few high- ferritin A protein compound that serves os the
lights of mis iron processing are noted in Figure 12-1 ). First, cells of the smaJl intestine storage form of iron in the blood and tissues.
make an iron-binding protein called ferritiu in proportion to body iron stores. If
j
Figure 12· 1 I Iron absorption and
Myoglobin
distribution. Iron binds with a protein called Iron
-
apoferritin to form ferriti n when stored in cells ingested
(1 }. If the intestinal absorptive cells are in food .... \ Bone
sloughed before iron is absorbed from them,
the iron is not absorbed into the blood (2). This
\Iron
Intestinal
mucosal cells
marrow
allows the body to control the absorption of

iron. The mechanism for resisting absorption of
EJ 1!ron
excess iron, primarily that in the nonheme form,
is termed a mucosol block. Iron tha t enters the
bloodstream binds to transferrin (3) and is then
distributed lo various cells in the body (4).
Some iron is also recycled for further use in the le]
body./5) Liver and
spleen break
down RBCs;
• most iron is
recycled
Iron lost os
GI tract cells
ore sloughed off
{mucosal blockl Blood loss leads
to iron loss, os
m menses
he copper·containing blood protein cerulo· stores are low, little ferritin is made . This condition elevates iron absorption because
plasmin removes an electron from f e2+, ferritin is a barrier to iron reaching the bloodstream. If iron stores arc high , much fer·
yielding fe3 -, the form bound by transferrin. ritin is made, which binds iro n as it enters these intestinal cells. Much of this iron is
Thus, copper metabolism and iron metabolism kept from ever entering the bloodstream because after just a few days, inrcsrinal cells
are closely linked. arc sloughed off. Any iron bound to ferritin goes back to the intestinal lumen \Yith
tl1e cells. The process is termed a mucosa.I block, because this process is in effect
blocking iron absorption. LO This response of ferritin to an increase in iron stores can
be fairly rapid.
After iron is absorbed from the small inrestine, it can be srorcd in the liver. Like
in the intestine , ferritin is the primary iron-binder in the liver. Iron can be trans·
ported ou t of the liver to other body sites using a step that involves a copper en-
zyme mentioned in the section that described the difficulties in smd~ring tr~\l:C
minerals ( ceruloplasmin). In the blood, iron is carried to these sites via a transport
transferrin A protein that transports iron in the protein called t ransferrin. This protein t hen binds ro receptors on cells, which take
blood. up the whole transferrin protein by a process called endocytosis, described in
Chapter 3. T he transferrin then finds its way to a cell organelle called the lysosomc
where acid re leases the iron from transforrin. The released iron can then become
part of various iron-containing molecules, such as certain enzymes, hemoglobin (if
a red blood cell is being made), myoglobin (a protein that u·aps oxygen in tissues),
and ferritin (which stores iron and helps prevent toxiciry). In states of iron over-
hemosiderin An insoluble iron-protein load, another protein, called h emosiderin, is made to bind up much of the excess
compound in the liver. Hemosiderin stores iron iron. This protein also helps reduce iron toxicity, but it does not prevent it. Overall ,
when the amount of iron in the body exceeds the main defense against iron toxicity is ferritin in the smal l intestine. If a lot of iron
the storage capacity of ferritin. manages to get by this defense, then the other mechanisms become an important
consideration.
Much of the iron in tl1e body is inserted into hemoglobin, which transports oxygen
in red blood cells (Figure 12-2 ). The iron in hemoglobin is what actually binds the
OJqrgen. These red blood cells do eventually die, but most of the iron from hemoglo-
bin is conserved by the body. The same is u·ue for iron used for other purposes.
Noneilieless, some iron is lost each day via the GI tract, urine, and skin. Women who
are menstruating also lose iron as part of tl1at blood loss. IO
Functions of Iron s a red blood cell matures, its nucleus is

expelled along with its DNA. Such a cell
Iron plays an importanr role in many parts of the body, including immune fimcnon, cog-
cannot replace itself. The red blood cell goes on
nitfre de\'dopmenr, tcmperanire regulation, energy mecabolism, and work pcrformance.18
to hove a life span of about 120 days.
Iron is •l component of two proteins that arc im·oh·ed in the cramport and meLab-
olism of oxygen. In hemoglob111, iron is the oxygen carrier of the blood , which Lr•ms-
porrs oxvgen from the lungs to aU tissues and assists in the transport ot some carbon
dioxide back co the lungs for expiration. When the owgcn-carrring capacity of 1he
blood begins co decline, the kidneys produce the hormone crythropoictin, which Lar- erythropoietin A hormone secreted mostly by
gets the bone marro\\ co produce more red blood cells. the kidneys that enhances red blood cell
As p,1rt of myoglobin, iron provides oxygen to skeletal am! heart muscle cells. synthesis and stimulates red blood cell release
Within the mitochondri.1, the electron transport chain uses iron as ,1 component of from bone morrow.
cyrochromes that carry electrons from NADH + H + and fADl:-J 2 Lo molecular m;y-
gen. The flrst step in chc citric acid cycle, the conversion of citrate ro isocitrate, re-
quires an iron-contain ing Cl1Z)'llle. The limitation of these thn:c processes in iron
deficiency helps explain why this condition readily leads to fatigue upon physical ex-
ertion. Iron found in cn7ymcs in the endoplasmic reticulum conrrihuLes LO many
processes, such as alcohol metabolism, drug detoxification, and carcinogen cx.:rcl ion,
especially in the liver.
Iron in peroxidase enzymes helps break do\\ n toxic oxygen species, such as hydro
gen pcrox.idc (H 20 2 ). Peroxidase en1-ymes are fow1d in" hite blood cclb and platelets
(clotting factors in the blood ). Iron also functions as a cofacmr for some other en-
zymes, including rhosc im olvcd in the synthesis of coUagen, various ncurotransmiuers
(e.g., dopamine, epinephrine, norcpmcphrine, and seroronin ), and eicosanoids.
\Vhcn iron IUnctiom in cytochromes of the electron transport chain .111d in iron-
requiring cnzymcs; ic can exist stab!) in two different \"aknccs (2 and 3 ). Within q -
tochromes .111d enz\'mes, iron will switch between these two \ alcnccs, which catalyzes
the mm·cmenr of dectrom either along the electron transport chain or .1s part of .m
enzyme reaction. Thi!. fi:anire of iron is ,-er) useful "hen the iron is confined within
these systems, but this ,1bility to readily change \'alences also makes iron \ 'Cf\ cox1c if
the iron ro.1ms rrcc. r11 the latter case, iron can catalyze dcstructi\'e reactions, includ
ing the formation of free radicals.
(a )
Figure 1 2-2 I (a) Red blood cells. (b) Most iron in the body is present in the hemoglobin molecules
of the red blood cells. (c) Iron gives hemoglobin the ability to carry oxygen.
Food Sources of Iron Iron in Foods

Food Item and Amount, Bcc:.mse much of the iron in animal foods is heme iron, the most bioavailablc form ,
with Bioavailabilily (in meaes are ehe richest sources of iron. The major iron sources in North American dices
parentheses} Iron (mg) are animal foods, such as beef steaks, roasts, and hamburger. The next greatest sources
Oat bran cereal, l cup 15.0 (low) are bakery produces, including white breads, rolJs, and crackers. Most of the iron u1
Baked clams, 3 oz 14.0 (high) thcse products is elcmeatal forms of iron added to refined flour as pare of the enrich-
ment process. For some cereal products, iron is added in higher amotu1ts than used for
Spinach, l cup 6.4 (low)
enrichment, which makes the product a fortified product. About 5% of the iron added
Kidney beans, l cup 5.3 (low) to grain products is absorbed. Overal l, the North American diet contains about 5 to 7
Pot roast, 4 oz 3.9 (high) mg of iron per 1000 kcal. 10 The bioavailability of the iron present in a meal depends
Sirloin steak, 4 oz 3.8 (highl on its form and the presence or absence of factors that influence absorption. The
body's need for iron then ultimately determines how much iron actually is absorbcd in
Fried beef liver, 2 oz 3.6 (high) the small intestine. 18
Shrimp, 3 oz 2.7 (high) A common cause of iron deficiency anemia in children is an overrcliancc on milk, a
Brounschweiger sausage, very poor SOlll'Ce of iron, and too little meat in their diets. In the United Stares, a major
l piece 2.7 (high) contributor to decreasing rates of iron deficiency anemia in preschool children has been
Flour tortilla, 1 2.4 (low} the use of iron-fortified formulas and cereals in the Special Supplemental Nutrition
Program for Women, Infants, and Children (WIC program) (see Chapters 16 and 20).
Garbanzo beans, l /2 cup 2.4 (low}
Another somce of iron is cooking utensils. When acidic foods, such as tomato sauce,
Novy beans, 1/2 cup 2.3 (low} are cooked in iron cookware, some iron from the pan is taken up by the food.
Baked potato, l 1.7 (low) Vegetarians can especially benefit from this interaction. The replacement of iron cook-
Artichoke, l 1.6 (low) warc with stainless steel and aluminum cookware in recent times likely has decreased
the amount of iron in the diet.
Whole-wheat bread, l slice 1.0 (low)
RDA for adult men, 8 mg;
RDA for adult women, l 8 mg
Iron Needs
Because a major source of iron loss can be due tO menstrual blood loss, the iron RDA
varies greatly with age and gender. For adult women, the RDA is 18 mg/day, while it
is 8 rng/da)' for adult men. The RDA for teenage girls, 15 mg/day, is slightly lower
than that for adulr women. The RDA for teenage boys, 11 mg/day, is slightly higher
than that for adulr men because of the need to support more lean tissue growth dur-
ing the teenage years. Al l these values are based on the need to balance iron intake with
iron losses. It is also assumed that 18% of dietary iron will be absorbed .lo The Daily
Value for iron used on food and supplement labels is 18 mg. The average daily intake
for North American women is 12 mg, whereas among men it is about 17 mg.
Iron-Deficiency Diseases
Iron deficiency is the most common trace mineral deficiency in North America. In severe
iron deficiency, there is not enough iron to produce all the hemoglobin needed, which
rcsulrs in iron deficiency anemia. Anemia represents any impairment in transporting oxy-
Red meal is o major source of iron in the North
gen in the blood; iron deficiency anemia is the most common form of anemia. When this
American diet. As noted in Chapter 7, a
moderate serving about two times a week or anemia occtll'S, red blood cells viewed under a microscope appear small and show less
less is o typical recommendation for red meat color, resultil1g i11 the diagnosis of a microcytic, hypochromic anemia (Figure 12-3). lron
intake. deficiency anemia can be detected by a blood measmement called h ematocrit, which is
the percent of blood volume occupied by the red blood celJs. A value below 34 to 37%
microcytic Describing red blood cells that are indicates iron deficiency anemia. An even more accurate measure is blood hemoglobin.
smaller than normal; literally, "small cell." A value less than l 0 to 11 g/dJ also indicates iron deficiency anemia.18
Anemia in any form impairs energy because aerobic respiration cannot occur without
hypochromic Describing pole red blood cells oxygen. Obvious signs of anemia include fatigue upon exertion and difficu lties in men-
locking sufficient hemoglobin as o result of iron tal concentration. However, aerobic respiration is also important to many tu1Scen body
deficiency. Hypochromic cells hove o reduced proccsses, including those that contribute to organ system development during growth.
oxygen-carrying ability.
Energy impairments due to iron deficiency anemia are also made worse by other effects
hematocrit The percentage of total blood of iron deficiency. Because iron functions in the electron transport chain and in the cit-
volume occupied by red blood cells. ric acid cycle, impairments in those functions impair aerobic respiration . In addition to
effects on energy metabolism, iron deficiency also compromises immune function.
(o) (b)
Figure 1 2·3 I Iron deficiency anemia. lo) Normal cells-both cell size and color ore normal.
(b) Iron-deficient cells-both cell size and color ore decreased. The loss of color stems from the lower
amount of the pigment hemoglobin. The stages of iron depletion in the body progress from Il) low
ferritin in the blood to (2) low tronsferrin saturation in the blood to 13) microcytic hypochromic anemia.
It is \'ery important to note chat some people can ha\'e a marginal iron deficiency char
docs not produce ancmia. 18 In chis state, aerobic respiration is still impaired to some ex-
tent. However, this impairment occurs not because of anemia, but rather because of iron's
ocher roles in aerobic respiration. In addition, immune function can be impaired. Because
marginal deficiency does not involve anemia, a hemoglobin or hematocrit measurement
will not detect marginal iron ddiciency. For this reason, if a physician or a registered die-
titian is seeing a diem who shows signs of fatigue upon exertion and concentration prob-
lems, a hemoglobin or hematocrit measurement cannot be the sole means of ntling out
an iron concern. Fortunately, unlike for marginal deficiencies of some other trace miner-
als, many clinical laboratories can perform other tests for iron status. The most common
method used has been scrum ft:rritin, but another blood measure, such as a rise in trans-
fcrrin receptors in the blood, may soon become more widely used.
Many different groups are at risk for iron deficiency. ln fuct, it may be simpler to say
who tends not to be at risk than list everyone at risk. 18 One group that rends not to
be at high risk arc adult males who consume meat regularly. On the other hand, young
adult women, as well as teenage girls, arc often at risk for iron deficiency due to blood
iron losses and lower than average meat consumption. 19 vVomen with heavy menstrual
blood losses arc especially prone to iron deficiency. Pregnant women don't have to
conrend with menstrual blood losses, but iron is still a concern. During pregnancy,
much of the bod)1's iron is used to expand the blood supply and for ocher physical
changes. As a person ages, iron can become a problem for both genders because food
imake ofi.cn declines. In addition, body iron absorption and distribution can become
less efficient. At the opposite end of the age spectrum, just after birth, prcterm infants
(born before 37 weeks after conception) can have iron problems. During tl1c first six
months to one )'Car of age, iron stores present at birth should be able to meet much
of the infant's needs. Because these iron stores are built mostly during the last weeks
of pregnancy, a prctcrm birth cuts short che time to build iron stores.
Two other groups of people prone to iron deficiency are children who arc pick)'
eaters (these children typically avoid iron-rich foods) and vegetarians. The lauer group
has a challenge to get enough iron because, as noted earlier, meat provides relatively Pregnancy greatly increases iron needs, as
\veil -absorbed dietary heme iron, plus meat promotes iron absorption from other does growth in childhood.
onsumption of dirt and similar nonfood sub- foods. Moreover, the high O\alic acid content of man)' ,·cgetarian dices can farther de
stances may lead lo iron deficiency anemia press iron absorption On the other hand, vegcta1ian diets u!>ually are rich in \'itamin ( .
because these substances con bind much of the Vegetarians should consume \it.101in (' rich foods sin1ultancously with rhe few non::m
iron in the GI tract. The practice of eating non· imal foods that contain .1pprcciablc .101ouncs of iron. Use of an iron-fortified ready-to-
food items, termed pico, is discussed in eat breakfast cereal can be useful for Ycgctarians, even though this iron is not as wdl
Chapter 16. Blood loss caused by intestinal absorbed as heme iron. Another option b a multi,itamin and mineral supplement th.11
or bloodbome parasite infections is another contains iron.
common cause of anemia around the world. Finally, the donation of 1 pint (0.5 L) of blood represents a loss of 200 to 250 mg
of iron. It generally take~ Sc\ eral months to replace this iron. Most healthy people can
donate blood two to four times a )'Car without harmful conscqucnccs; gcncrall),
women need a longer interval between donarions to rebuild their iron stores. As .1 pre
caution, blood banks first screen potential donors' blood for evidence of anemia.
Upper Level for Iron

Although iron dcfkicncy is a major public health concern, iron also poses a risk for tox
icity. The Upper Level for iron is 45 mg/day. Higher amounts can lead to stomach ir·
ritation. 10 Iron's ability to alternate between t\\.·o valences (2+ vs. 3 +) is functional
when confined to cytochromes and enzvmcs, but is toxic when nor. One reason for the
toxicity is chat changes in iron \'alcnccs can cac~1lyze the formation of free radicals. Two
hemochromotosis A disorder of iron prominent causes of significant mm toxicity arc the genetic condition hemochro·
metabolism characterized by increased matosis and repeated blood transfusions. The iron absorption section in this chapter
absorption of iron, saturation of iron-binding described the mm:osal block th.u protects the body from oral iron. Jn hcmochro-
proteins, and deposition of hemosiderin in the matosis this mucosa! block works less cfticicnrly. 12 The iron introduced into the both
liver tissue. through repeated blood transfusions abo bypasses the protecth·e system and can result
in dangerously high iron stores in the bod). Ill
Because of the bod) 's protective system, it is generally not easy to produce sen:re
toxicity due to oral iron consumption. One e\ception ro this general rule invol\'es the
susceptibility of children to iron tO\icit'). Children are more rnJncrablc w oral iron poi
soning chan adults because their protective system cannot respond as rapidl} as ,111
adult's. The prime source of iron overload in chi ldren is the consumption of ncess
esting is available to determine the presence
T of the genes that ore responsible for he·
mochromotosis. The cost is usually about $150.
chewable iron -cont.tining supplements. FDA has recently ruled that all iron supple
ments must carry a warning about toxicity, and those with 30 mg of iron or more pn
tablet must be indi' idually wrapped.
Treatment of iron toxiciry depends on the situation. For hcmochromarosis, a nor-
mal treaw1cnt is periodic blood removal (the same removal process as when blood ii.
donated to blood banks). Another approach that is used in some siULations is admin
istracion ofa drug that binds iron in the bloodstream and enhances its excretion. ~lore
C hopler 9 noted that if men, in general, and
older women toke o multivitamin and min·
erol supplement, it should be low in iron or iron·
can be fonnd on iron O\'erload in the Jccompanying Expert Opinion by Dr. lhrb.u;1
Bowman and Dr. Giuseppin.1 Imperatore. Final!)', besides overt toxicity, there is wme
free because of their increased risk for iron (but conflicting) e\ idcm:e that mild iron toxicity contributes to health probll'ms such
toxicity. as cardiovascular disease .md arthritis.
Concept I Check
Iron absorption depends mostly on m form and the body's need fur it. Absorption is hin ·
dered b) a muwsal block, but e\ce~s iron intake can O\'erride the system, leading to to\ic-
ity. Iron absorption incre.1ses in the presence of \'icamin C and decreases in the presence of
large amounts of O\alates .md some components of grains, such as phytic acid. Iron 1s most
H emosiderosis is the storage of excess iron
in the form of hemosiderin. This form of
excess iron is not associated with the organ
important in synthesizing hemoglobin .md myoglobin, in supporting immune function,
and in energy metabolism. Iron deficiency can cause a form of anemia. It is particular!) im -
portant for women of child bearing age to consume adequate iron, prim:lrily co replace th<H
damage of hemochromolosis, because excess
lost in menstrual blood. Sources include red meat, pork, liver, enriched grains and o:rc.ll~,
iron is stored in areas of normal storage. In he·
and oysters. Iron toxicity usuall)• resu lts from a genetic disorder called hcmochrom,Hosi~.
mochromolosis, the iron accumulates in body or·
This disease causes the ovcrnbsorption and accumulation of iron, which can rc11ult 111 se\'er1:
gons outside normal oreos, such os in the liver
liver .tnd heart damage.
and heart, and causes organ deterioration.
Zinc (Zn)
Although zinc has been recognized as an essential nutrient in animals since the early
1900s, zinc deficie ncy was first recognized in humans in the early 1960s in Egypt and
Iran . The deficiency was determined to be the cause of growth restriction and inade-
quate sexual development in humans. 1 3 Curiously, the dietary zinc concent was not
that low. The key factor was that t he customary diet contained almost exclusively un-
leavened bread and little animal protein. Unleavened bread is very high in phytic acid
and other factors that decrease zinc bioavailability. Yeast fermentation in the prepara-
tion of bread dough reduces the effect of phytic acid by tenfold. In addition, parasite
infrstation and the practice of eating dirt also contributed to t hese cases of seYere zinc
deficiencv observed in humans.
ln North America, zinc deficiencies were first observed in the early 1970s in hospi-
talized patienrs receiving total parenteral nutrition. Originally, zinc was not added ro
the intravenous solutions, but the protein source in the solutions was based on milk
protein or blood fibrin, which contain zinc. vVben the solutions were later changed to
include mostly isolated amino acids as the protein source, zinc-deficiency symptoms
quickly developed. The isolated amino acids source of prorcin is very low in zinc.
Minimal intakes of energy, protein, and zinc

Absorption, Transport, Storage, and Excretion of Zinc limit the growth of people worldwide.
Zinc is absorbed throughour the small intestine. Factors rhar affect the absorption of
zinc include the body's need for zinc (especially important) and the composition of the
meal in which zinc is consumed . These factors arc summarized in Table 12-2. T he ab-
sorption and transport of zinc utilizes a two-step process. The first step is the uptake
or membrane binding at the mucosa] surface. The second step is the n·ansport of zinc
across rhe mucosa! cell and the release into the bloodstream, bul the process is not
com pletely understood. After entt:ring the blood, zinc binds to blood proteins, such as
albumin, for transport to the liver. T he liver releases zinc into genera l circularion
bound ro proteins, such as globulins. 1OThere is no storage site per sc for zinc in rhc
body. Zinc status is primarily maintained d uring low intakes by conser\'ing (e.g., recy-
cling) what zinc is availablc. 13
When zinc is absorbed into intestinal cells, it induces the synrhesis of m etalloth - metallothionein A protein that binds and
ionein, a protein tl1at binds zinc in much rhe same way chat tcrritin binds iron. regulates the release of zinc and copper in
Homeostatic regulation of zinc absorption may partly be due tO the synthesis of met- intestinal and liver cells.
allothionein, becaust it hinders the movement of zinc from intestinal cel ls. If zinc is
not trwsfcrred to the blood from the intestinal cells with in their short lifetime, it is
sloughed off along with d1e cell and excreted . Thus, a mucosa! block works against
the overabsorption of zinc and iron, but much more so in t he case of iron. Large
doses of zinc override tl1e mucosa! block. Luckily for overconsumcrs, zinc is also read-
ily excreted \'ia the pancreas into the intestinal tract and then leaves the body by way
of the feces. It is also excreted in small amounts in urine and swear.
Like iron absorption, zinc absorption is influenced by the t)rpes of food ingested.
Absorption is more likely when animal protein sources are consumed, when tl1e body's
zinc needs are elevated, or when smaU amounts are consumt:d. 10, 13
Table 12·2 I Factors That Affect Zinc Absorptio n
Increase Absorption Decrease Absorption

Moderate zinc intake Phytic acid and calcium supplements
Body deficiency Excessive zinc intake
Animal protein Oxide form in supplements
Expert Opinion 1
Iron Overload: Too Much of a Good Thing

Barbara A. Bowman, Ph.D., and Giuseppina Imperatore, M.D., Ph.D.
Nutritionists consider iron to be the gold standard of micronutrients, because major mutations hove been identified. The Fundamental defect involves the reg·
we know more about the dietary intake, metabolism, and nutritional re- ulotion of iron absorption. In hereditary hemochromotosis, iron absorption is ex·
quirements of iron than any other trace element. Despite this extensive knowl- cessive, and iron absorption is not reduced when iron status is normal. The
edge and the array of sophisticated techniques for evaluating iron nutrition, human body does not hove a mechanism for eliminating excess iron. Therefore,
however, more than 1 billion people suffer from iron deficiency, which is the ofter many years of absorbing too much iron, excessive amounls of iron con OC·
most prevalent micronutrient deficiency in lhe world. cumulate in the body, leading to iron overload and ti ssue injury. If undetected
Iron deficiency is also a significant health problem in the United Stoles, and untreated for many years, iron levels con build up in the liver, heart, pan·
especially in young children and women of childbearing age, particularly creos, joints, and pituitary gland and con eventually lead to liver disease, heart
pregnant women. Iron deficiency is a special concern for women and chil· disease, diabetes, arthritis, and hypopituitorism with hypogonodism. People at
dren because one of its major consequences is anemia. Anemia, defined as o late stage of iron overload moy hove skin that turns bronze or gray The dis-
a low concentration of hemoglobin in blood, leads lo decreased work ca- eases caused by iron overload usually appear by age 40 to 60, although some
pacity in adults, developmental delays and behavioral disturbances in chil· people ore affected earlier and others never become ill. With early detection
dren, increased susceptibility to infection, and increased mortality in both and treatment, argon damage con be prevented. However, without lifelong
children and adults. In the United States, about 3.3 million women of child· treatment, organ damage may be permanent and life-threatening.
bearing age and 240,000 children age 1 to 2 years hove iron deficiency Up to 1 million Americans, mostly people of European descent, hove the
anemia, the most severe form of iron deficiency. mutation for hemochromotosis. However, for fewer actually develop iron
Iron overload lies at the opposite end of the spectrum of iron status. If un· overload. Some people hove the mutati on but never get iron overload, prob-
treated, iron overload disease, like iron deficiency, con lead to illness and ably because clinical expression of iron overload depends on additional foe·
even death. This section examines iron overload in more detail. tors, including the severity of the metabolic defect, the amount and type of
iron in the diet, other dietary factors that enhance or inhibit iron absorption,
environmental factors, and blood loss (menstruation, for example)
Etiology of Iron Overload
What causes iron overload? The major cause of iron overload in the United
Diagnosis and Treatment of Iron Overload
Stoles is hereditary hemochromotosis, a genetic condition that affects about one
person out of every 200 to 500 in the United States. Iron overload con also Early detection and lifelong treatment con prevent the complications of he-
occur in chronic liver disease due to alcohol abuse, viral infections, and chronic mochromotosis. The ma jor approach to diagnosis is a series of blood tests
anemias requiring frequent blood transfusions (e.g., tholossemio). The specific to measure the amount of iron in the blood, such as the extent to which trons-
genetic lesion in hereditary hemochromotosis was identified in 1996, and two ferrin is saturated with iron and the amount of ferritin in the blood. The some
Functions of Zinc
lnl..i '1Q
It is hard to name a body process or body strucwrc that isn't affected either directly
Zinc lozenges hove received much attention as or indirectly by zinc. Some zinc fonctions involve enzymes in which zinc is either part
a treatment far the common cold. You tell o of t11e catalytic reaction or it stabi lizes the enzyme strucn1re. T he exact number of
classmate that you do not feel that the evi- known zinc-dependent <.:nZ)'mes depends on classification (i.e., two similar enzymes
dence is convincing enough to recommend this can be called two different e112ymes or a single c111yme witl1 different forms). Suffice
practice to the general public. Your friend it to say that over 50 (and as many as 200 or more) enzrmes need zinc to funccion .
would like to know what ii would toke lo con· These functions contribute to DNA and RNA synthesis, alcohol metabolism, protein
vince you that zinc is o reasonable treatment metabolism and related growth and development of the body, antioxidant defenses
for the common cold. (see the functions of copper for details), immune function, and acid/base balance in
the body. 13 In addition to enzyme-related functions , zinc also stabilizes the structure~
of cell membrane proteins, certain hormones, and gene transcription factors (called
zinc fingers). The cell membrane function has very broad effects because cell mem-
brane stability influences the mem brane receptors, which conu·ol actions in cells.
blood tests are used during treatment to monitor cause heme iron is more readily absorbed.
the amount of iron in the body and the response Most people with hereditary hemochromato-
to treatment. Genetic testing is also being studied. sis ore not aware that they have a predispo-
However, not everyone with the mutation develops sition to accumulating excessive amounts of
iron overload. Because of concern about the need iron. If such a person were lo decide to use
for privacy and possible discrimination in employ- iron supplements to increase his or her energy
ment and insurance, genetic screening for heredi- or to combat fatigue, for example, iron accu-
tary hemochromatosis is not recommended. mulation and tissue damage could be accel-
People who hove been diagnosed with hereditary erated and enhanced, increasing the risk of
hemochromotosis should tell their family members chronic disease. For this reason, iron supple-
and urge them to get tested, too. ments should not be used indiscriminately but
Treatment of iron overload is straightfor- should be used only when iron deficiency has
ward, safe, and effective. After they hove been been diagnosed by a health professional and
diagnosed, people with iron overload have Regular donation of blood is the main intervention iron therapy is prescribed.
blood removed regularly, usually o unit or pint for treating iron overload in the body. As you can see, with iron more than per-
of blood, to remove the excess iron that has ac· haps any other nutrient, ii is critical to meet
cumulated. The procedure, which is called phle- doily requirements for the proper nutrient in-
botomy, is exactly the same as when blood is donated. The frequency of take- not too little, not too much, but just the right amount. Different indi-
phlebotomy depends on how much iron has built up. When iron overload is viduals have different needs. People who don't consume enough iron to
first diagnosed, phlebotomy may be needed every week or lwo. W hen ac- meet their needs can develop iron deficiency and eventually anemia. On
cumulated iron has been reduced to a safe amount, phlebotomy may be the other hand, for some people, consuming too much iron every day can
needed only a few times a year, but it must be continued. Health-care lead to serious illness, including death. Hereditary hemochromatosis is one
providers use blood testing to determine when phlebotomy trea tment is of the first examples of how a gene interacts with nutrition (iron intake) to
needed. affect risk of disease. As the public and health professionals become more
People with hemochromatosis must be sure to follow their doctor's ad- aware of hereditary hemochromotosis, iron overload can be detected ear-
vice and get tested regularly to prevent complications from developing. For lier, treated more effectively, and ultimately prevented.
most, periodic phlebotomy will be needed for the rest of their lives. It is also
important for people with hemochromotosis to ovoid alcohol and row shell- Ors. Imperatore and Bowman ore epidemiologists ot the Centers for
fish, which can damage the liver. Dietary supplements that contain iron must Disease Control and Prevention in At/onto, Go. Dr. Imperatore is o
not be used, and foods highly fortified with iron should be avoided. The genetic epidemiologist and Dr. Bowman is Chief of the Chronic
same advice may be given as well for vitamin C supplements. Foods con- Disease Nutrition Branch. Both ore especially interested in the dis-
taining heme iron pose more of a risk than foods with nonheme iron be- ease hemochromotosis.
Zinc in Foods
In general, protein-rich diets are also rich in zinc. North Americans get about 70% of
their dietary zinc from animal foods. Lean meats-especially beef, other red meats, and
shellfish- are among the besr zinc sources. Plant sources of zinc, such as nuts, beans,
and whole grains, can also deliver substantial amounts of zinc to body cells. Zinc is not
part of the enrichment process so refined flours are not a good source.
Zinc Needs
The RDA for zinc of 11 mg/day for adult males and 8 mg/day for adult females is
based on replacing daily losses via feces, skin , and urine. The RDA assumes that 40%
of dietary zinc will be absorbed. 10 The Daily Value used on food and supplement la-
bels for zinc is 15 mg. Average adult i.ntakes in North America are 9 to 13 mg/day,
with men showing the higher value. 19 Peanuts are a plant source of zinc.
Food Sources of Zinc

One key issue in understanding zinc needs is body adaptation via conservation tO
different intakes, as mentioned in the opening section. Some research suggests that
Food Item and Amount Zinc {mg) people change their zinc absorption and excretion rates to allow them to tolerate lower
Steamed oysters, 6 49.9 intakes than what is seen among people who eat rclativclr high amounts of zinc. 13
Sirloin steok, 4 oz 7.4
Peanuts, 1 cup 4.8
Zinc-Deficiency Diseases
Pot roost, 3 oz 4.6
Special Kcereol, 1 cup 3.8 In a zinc deficiency, not all zinc functions decrease at the same rates. Some arc im-
paired even in mild zinc deficienC}', whereas others do not show a major impairment
Wheat germ, 1/4 cup 3.5 unless the deficiem.)' become~ severe. 13 Cell membrane functions may be the most sen-
lamb chops, 3 oz 2.7 sitive change to a mild zinc deficiency. Still other zinc-requiring functions manage to
Block-eyed peas, 1 cup 2.2 use zinc so effectively that they operate fairly well even in a pronounced zinc deficiency.
Plain yogurt, 1 cup 2.2 T hus, the symptoms ofzinc deficiency depend a lot on its severity. The symptoms seem
also to depend on what else is taking place in the body at the same time, such that
Lean ham, 3 oz 1.9 some zinc fimctions are affected ma inly w hen a zinc deficiency is combined with cer-
Swiss cheese, 1.5 oz 1.7 tain other factors (e.g., the pn:scnce of another disease or a period of rapid growth).
Ricotta cheese, I/2 cup 1.7 Linking poor health with zinc dcficier1C}' can be challenging because zinc affects so
Sunflower seeds, I oz 1.5 many molecular processes and functions, either directly or indirectly. For example, a
severe zinc deficiency can affect bone growth. There are many possible reasons for this
Cheddar cheese, 1.5 oz 1.3 effect on bone, including a number of zinc-dependent enzymes and hormones.
Enriched white rice, 1/2 cup 1.1 As noted at the beginning of the zinc section, se,•ere deficiency in humans was first
RDA for adult men, 11 mg; reported in areas of the Middle East. Symptoms included severely srumed growth,
RDA for adult women, 8 mg poor taste sensitivity, and impaired sexual maturation in the males (Figure 12-4).
In certain parts of the world, where poverty limits food choices, the effects of zinc
deficiency can be clearly seen in children. Symptoms include se,·ere, even futa1 diarrhea,
ocrodermotitis enteropothico A rare inherited poor growth, impaired 'itamin A function, and high risk of pneumonia (presumably
childhood disorder that results in the inability to due to impaired immune function). Tn these same parts of the world, zinc deficienc)
absorb adequate amounts of zinc from the diet. in pregnant women may contribute to increased infant mortality and birtl1 defects. 13
Symptoms include skin lesions, hair loss, and Besides dietary causes of severe zinc deficiency, this state can aJso be produced by a
diarrhea. If untreated, the condition con result generic condition in which zinc absorption is impaired. This disease, acrodermatitis
in death during infancy or early childhood. entero pathica, is recognizable by a skin condition that develops in infancy. The con -
Management of this condition is with zinc dition can be treated with supplemental zinc. Preterm infants can also show signs of
supplements.
zinc deficiency for the same general reason described for iron and pretenn infants.
Marginal zinc deficiency may occur in many people, though there are still many
questions to be answered. The classic example of documented marginal zinc deficiency
involves a study of a group of children in the Denver, CoJorado, area. The study re-
ported that marginal zinc deficiency was responsible for impaired growtl1 in a number
of children. Other groups that may be prone to marginal zinc deficiencies are Crohn's
disease patien ts, people on kidney dialysis, diabetic individuals, older adults, sickk-celJ
anemia patients, alcoholics, and children with Down's syndrome. Vegetarians may also
be \'Ulnerable to marginal zinc status. However, there is some evidence that ,·egetari-
ans adapt to low imake by reducing zinc excretion while increasing zinc absorption. 13
Upper Level for Zinc

The Upper Level set for zinc is 40 mg/day, based on the ability of zinc to interfere with
copper status as measured by a faJJ in the acci\'ity of copper-containing enzymes. 10 Zinc
supplements at approximately 5 to 20 times the RDA can reduce HDL-cholesterol ,
perhaps by interfering with copper absorption. Again, this finding shows why mineral
supplements shouJd not be consumed in excess of the Upper Level on a chronic basis
Figure 1 2·4 I An example of zinc unJess under close scrutiny of a physician. This caution includes use of zinc lozenges
deficiency. An Egyptian form boy, age 16 to treat cold symptoms for more than a week or so. (Note that these lozenges have a
years and 49 inches toll, with dwarfism and minor effect, if any, on cold symptoms.) Zinc intakes over 100 mg/day also result in
inadequate sexual development associated with diarrhea, cramps, nausea, vomiting, and depressed immune system function, especially
a zinc deficiency. if intake exceeds 2 g/day.
ne study hos shown that megodose zinc

Copper (Cu) supplements (80 mg/day of zinc oxide)
reduces the progression of moculor degenero·
Like iron, copper can catah•zc certain reactions by alternating between two \alcnccs
(Cu+ and Cul-+). Also as \\ith iron, this property is \'cry useful when copper is con- lion by 25% in people who hod a moderate
case of the disease. The zinc supplements
tained within enzymes or orher protcms, but dangerous when not. Thus, specific chap-
worked even better when provided in combino·
erone proteins arc used to distribute copper around the body. Copper enzymes
lion with 400 IU of vitamin E, 500 mg of vitamin
perform a number of different functions and are quite impaired by se,·cre copper dcfi-
C, and 15 mg of beta-carotene. (Copper oxide
ciency.16 In addition, some research suggests chat moderate copper deficiem:y may im-
[2 mg) was also included because zinc de·
pair copper function enough co have subtle, but important, long-term cftccti. on health.
creases copper absorption.) Although the study
hod some Rows, some experts suggest that
adults who have evidence of moderate moculor
Absorption, Transport, Storage, and Excretion of Copper degeneration talk lo their physicians and eye-
Copper is absorbed mostly in the small intestine, with a percent .1bsorption that can core specialists oboul the possibility of following
vary widdy (12 to 70%). 10 The factors affecting copper absorption have not been stud- such a protocol. 2
ied as well as the factors afkcting iron or zinc. However, one major fuctor in copper
absorption can be zinc supplementation. High-dose zinc supplementation can impair
copper absorption to the point of causing a severe copper deficiency. This impairment
probably involves some competition between copper and zinc for a common intestinal
receptor.
After intestinal .1bsorption, copper moves rapidly into the liver and kidney, the main
sites of storage. rollowing chis initial distribution, copper transport i~ ,·cry conrrollcd.
Copper moves from the liver ro other tissues tightly bound to the protein ceruloplas-
min, which also has an enzyme function (see the functions section). Ccruloplasmin
then releases copper to cells via a specific receptor. Excess copper is excreted primaril}
in the bile. Jn a generic disorder called Wilson's disease, this excretion is impaired,
which can produce copper toxicity (sec the section on Upper Level for copper).
Functions of Copper
Copper functions in cn;,ymes as a caralyst that alternates between mo different va-
Seafood is a good source of copper.
lcnces.16 One or these Cnlymes, ceruloplasmin (and possibly some other copper en
zymcs) arc needed to transport iron from the Liver to various Functional sires,
including where iron is inserted into hemoglobin. Ceruloplasmin m.1y also have an
antioxid.rnt ru11ctio11 by inhibiting iron-catalyzed formation of free radicals. An even
better characterized ~lntioxid.rnt runction for copper is its role in t\V() or the three
members of a family of enzymes known as superoxide dismutase (also called SOD). superoxide dismutase An enzyme thot con
This family of enzyme~ eliminates one parricular free radical known as superoxide quench (deactivate} o superoxide negative free
(0 2 · -). Copper is needed for function of the SOD enzyme found in the cytosol of radical (02 -1. This con contain the trace
cells (partners with 1inc) and for anocher SOD enzyme found outside or cells (again minerals copper, zinc, and manganese.
partners with zinc). (A third SOD enzvmc is found in mitochondria, but it contains
onl~ manganese.)
Copper is a.lso part of a number of other cnzymes. 16 One of these enzymes is cy
tochrome C O\idase, \\ hich catalyzes the last step of the electron tr.msport chain. In
this step of the chain, o\ygen enters and water leaves. Another copper enzyme form!>
norcpinephrine, which 1s tmporranc both as a hormone and a ncurotr.rnsmirter. Still
another copper en.t:yme, lysyl oxidasc, is very important in connecti\·e ris!>ue formation.
Lysyl oxida.se cross-links the \trands within two strucrw·al proteins chat give rcnsile
strength to connecth·c tissues. Connective tissue comprises a large portion of struc
tures such as blood vessels, lungs, skin, and the protein portion or bone. ·1 he two
structural proteins th.n arc cross-linked by lysyl oxidase arc elastin and collagen. The opper is also essential to optimal immune
latter is the same protein whose structure is affected by vitamin C (review Chapter 10). function, though the exact reasons ore still
Vitamin C is needed to put collagen in the right shape for the three individual strands unclear. Possibly, copper ontioxidonl functions
ro curl around each other. Lysyl oxidasc completes the process by cross-linking the help protect immune cells, which ore o~en under
strands together. a lot of oxidative stress.
Food Sources of Copper Copper in Foods

Food Item and Amount Copper (µg) Good food sources of copper include liver, shellfish, nuts, seeds, soy produces, avoca-
Fried beef liver, 3 oz 3800 does, and dark chocolate. Legumes, whole-grain products, and often tap water are also
Power bar, l 700 important sources. Meat is a marginal source of copper. Nonetheless, the copper pres-
cnc can contribute at lease part of one's copper needs. ln addition, meat may promote
Walnuts, l /2 cup 600
copper absorption from other foods, jusr as it does with iron. Cow's milk is not a good
Kidney beans, 1 cup 500 copper source. Unlike somc trace mineraJs, copper is not typically added to ready-to-
Lobster, 3 oz 400 eat breakfast cereals in high amounts because cereal fats can be oxidized by the copper
Molasses, 3 tbsp 300 complexes most often used for food fortification.
Sunflower seeds, 2 tbsp 300
Shrimp, 3 oz 300 Copper Needs
Raisin Bran cereal, l cup 300 The adu lt RDA for copper is 900 µg/day for adults, based on the need for normal ac-
Great Grains cereal, l cup 300 tivity of copper-containing enzymes (e.g., SOD) and proteins (e.g., ceruJoplasmin) in
the body. LO The Daily Value on food and supplement labels for copper is 2 mg. The
Semi-sweet chocolate, l oz 210 average adu lt intake in North America is about 1 tu 1.6 mg/day. Women generally
Black-eyed peas, l /2 cup consume the smaller amount.
cooked 200
Wheat germ 1/4 cup 200
Copper-Deficiency Diseases
Milk chocolate, l oz 110
The most common cause of severe copper deficiency is high-dose zinc supplementa-
Whole-wheal bread, l slice 80
tion, which inhibits copper absorption. Prominent symptoms include iron deficicncy-
RDA for adults, 900 µg like anemia and a low count for one type of white blood cells. 16 Some medical
situations, such as recovery from burns or kidney dialysis, may also kad to a copper de-
ficiency. Preterm i.nfunts are aJso prone to copper deficiency during the first few days
of life and then again during the catch-up growth period of the first year. The reason
for this deficiency is the same as that noted for iron and zinc.
For a number of years, copper researchers have been interested in marginal copper
n inherited copper-related disease called deficiency. Two concerns have spmred this interest. First, many health problems, es-
A Wilson's disease results in the accumula-
tion of copper in the liver, brain, kidneys, and
pecially those invohring inflammation, such as rheumatoid arth ritis, may raise copper
needs. Second, the types of symptoms observed in experimental animals with copper
cornea of the eye. People with this disease can't deficiency (sometimes with just a marginal deficiency) resemble common human
incorporate copper into ceruloplasmin and also health problems (elevated blood cholesterol, suboptimal immune function , and poor
have a decreased ability to excrete copper in the resistance to oxidative stress). Future research wiU likely determine how much we
bile. Some of the wide range of symptoms in- should be concerned about marginal copper deficiency.
clude liver, nervous system, and psychiatric dis-
orders as well as kidney abnormalities. If caught
Upper Level for Copper
early in life, treatment with agents that bind cop-
per, such as penicillomine, or use of high The Upper Level for copper is l 0 mg/day, based on the risk of liver damage. 10
dosages of zinc to block copper absorption, can Generally, copper toxicity in humans is not very common because intakes are usually
prevent tissue damage and reduce the mental not very high and because our bodies can regulate copper storage through excretion
degeneration commonly seen in Wilson's via the bile. At single supplemental doses of 10 to 15 mg, though, copper provided in
disease. aqueous forms tends to cause vomiting.
Concept I Check
As with iron absorption, zinc absorption is partly regu lated by a mucosa! block. Animal
protein souJces, increased body needs, and small intakes lead to increased zinc absorption.
Zinc funclions as a cofucror for many enzymes and is important for growth and develop·
ment and for immune function. Beef, seafood, and whole grains arc rich food sources of
zinc. Copper functions mainly as part of enzymes and other compounds involved in iron
metabolism, cross-linking of collagen, and neurotransmitter synthesis. A copper deficient)'
can rcsuJt in a form of anemia and impaired immune fi.mction. Food sources of copper are
liver, seafood, legumes, nuts, and whole grains.
I Selenium (Se) ou hove now seen that the absence of

many nutrients from the diet con lead lo
Selenium deficiency and toxicity have occu rred in livestock in areas where the soil is anemia:
very low or very high in selenium, respectively. The same is true in humans, though • Vitamin E deficiency con lead to hemolytic
the number of docLLinented cases is fewer in humans. Selenium functions in certain en- anemia (see Chapter 9).
zymes and has drawn interest for its roles in antioxidant defense and thyroid hormone • Vitamin Kdeficiency, especially coupled with
production as well as possible applications in cancer prevention. use of certain antibiotics, can lead to blood
loss and thus to hemorrhagic anemia (see
Chapter 9).
• Vitamin B-6 deficiency con lead to microcytic
Absorption, Transport, Storage, and Excretion of Selenium anemia and sideroblostic anemia (see
Selenium enters the body in many ionic forms. Most selenium in foods is bound to de- Chapter IO).
rivatives of the amino acids methionine and cysteine. Because these substances are • Folote deficiency con lead to megoloblostic
readily absorbed, the bioavaiJabiLity of selenitun is considerably higher than that of iron anemia (see Chapter 10).
and zinc. About 50 to 100% of dietary selenium intake is absorbed, and it is not af- • Vitamin B· 12 molobsorption con lead to
fected by one's selenium status. Because no physiological mechanism appears to con- megoloblostic anemia (see Chapter 10).
trol selenium absorption, selenium has a definite potential for toxicity.ll • An iron deficiency con lead lo microcytic
Not much is known abour the transport of selenium. What is known is that sele- hypochromic anemia.
nium is made available for use when the particular amino acid it is bound to is catab- • A copper deficiency con lead, although
o lized. The selenium can then be incorporated into macromolecules, transported to rarely, to iron deficiency anemia because
various organs, or excreted. Homeostasis of selenium in the body is achieved through copper aids in iron metabolism.
excretion, mainly via the urine and feces . Urinary excretion of selenium increases as di-
etary intake increases. Selenium is stored primarily boLU1d to the amino acid methio-
nine and as part of gl urathione peroxide enzyme. Both are found tlu·oughout the body.
Functions of Selenium ome interesting research hos suggested that

a moderately high·dose supplement of sele·
Selenium is incorporated into certain enzymes as part of an amino acid known as se-
nium (i.e., 200 µg/doy) may lower the risk of
lenocysteine (i.e" selenitun bound to the amino acid L)'SteiJ1c). 3 Normally, the amino
certain cancers, such as in the prostate gland.
acid cysteine contains sulfu r, but in selenocysteine, the sulfur is replaced by selenium.
(A current trial using 200 µg/ day, with mego-
The best understood enzymatic fi.rnctioo of selenium occurs as part of two enzymes,
dose vitamin E supplementation [400 mg/day]
each nan1ed glutathione peroxidase (one is inside cells, whereas the other is outside
as well, is testing that hypothesis in older men
cells including in the blood). Glutathione peroxidase is part of the body's antioxidant
with enlarged prostate glands.)
defense network described in the vitamin E section of Chapter 9. Some of this network
is shown in Figure 12-5. Glutathionc peroxidase eliminates peroxides, inclucli11g hy-
drogen peroxide. These peroxides occur in the body as a by-product of certain body
reactions and can also arise in other ways. Peroxide accumulation is a concern because
peroxides can easily form free radicals. Another antioxidant system that uses selenium
is the newly described th ioredoxin family of enzymes. 3 thioredoxin A fami ly of three selenium-
Selenium also fonctions in an enzyme that is part of the process that makes thyroid dependent enzymes that hove on ontioxidonl
hormones. Thyroid hormones arc very important in stimulating energy input to vari- role and other roles in the body.
ous body processes needed for growth or maintenance. A few other proteins in the
body have been found to contain selenium, but their fi.mction is not yet known.
Selenium in Foods Tammy read on article about antioxidants and

Animal products are good sources of selenium, though some are better than others. their role in preventing free radical damage to
Grain products and nuts arc also good sources. Whole-grain products generally have celfs. When Tammy went to the drugstore to
more selenium than those made with white flour, though the latter can also provide toke a closer look at such supplements, she
selenium. Tht.: exact amount of selenium in grain products depends on the selenjum sow that selenium was one of the antioxidants
content of the soil in which the grains arc grown. For example, in the United States, in the supplements. Why does selenium de-
pasta tends to be high in selenium because tbc durum wheat that is used tends to come se!Ve consideration as on antioxidant?
from high-selenium soils in the Dakotas.
Figure 12·5 I Selenium is port of the

glutothione peroxidase system (l ), which Various peroxides
D Glutathione
Various alcohols
peroxidase
breaks down peroxides, such as H20 2 to water
(H 20), before they con form free radicals (2) +
and lead to cell damage (3). This breakdown
of peroxides in turn, spores some people of the
need for vitamin E, which is a major free
radical scavenger (4). ' I Vitamin E I
Stabilized (quenched)
[B Free radicals free radicals
Domoged cellular
membrane or
Cellular cell structures
damage
Food Sources of Selenium Selenium Needs

Food Item and Amount Selenium (µ.g) The RDA for seleniwn is 55 µg/day for adult men and women, 11 based on the
Tuna, 3 oz 68 amount of selenium needed ro maximize glutathione peroxidase activiry in blood. ln
North America avernge intakes arc about 105 µg/da)' from food. The Daily Value used
Leon ham, 3 oz 42
on food and supplement labels for selenium is 70 µ,g.
Clams, 3 oz 41
Salmon, 3 oz 40
Selenium-Deficiency Diseases
Egg noodles, 1 cup 35
The signs and symptoms of a selenium deficiency in animals and humans include mus-
Sirloin steak, 3 oz 28
cle pain, muscle wasting, and cardiomyopatby, which is a form ofheru·t muscle damagc.3
Chicken breast, 3 oz 20 These same signs and symptoms arc noted when there is insufficient selenium in total
Special Kcereal, l cup 17 parenteral nutrition solutions. Fru·m animals in areas wirh low soil concentrations of se-
Oat bran cereal, l cup 14 lenium (e.g., New Ze<tland and Finland) and humans in some areas of China develop
characteristic heart muscle disorders associated with an inadequate selenium intake.
Whole-wheat bread, l slice 10
Keshan disease, a dcficienC}' state that results in varying degrees of heart deteriora-
Cooked oatmeal, l /2 cup 10 tion in children, is associated with inadequate selenium intake. Viral infections also seem
White bread, 1 slice 9 to play a role in the disease. This disease was first observed in the Keshan pro\'ince of
Raisin Bron cereal, l cup 4 China but since has been found elsewhere, inclmfo1g Finland and New Zealand.
Regardless of geography, Kcshan disease occurs when the soil is almost devoid of sele -
RDA for adults, 55 µg
nium. Note that although selenium is protective against development of' the disease, se-
lenium cannot correct the heart disorders once they have occwTed. A selenium
deficiency can also result in an accumulation of fatty acid peroxides in Lhe bean, lead-
ing to an increased risk of blood dot formation. Additional studies have associated lo\\
blood selenium with both the incidence of myocardial infurctions and an increased
dead1 rate from cardiovascular disease. Studies have also reported a relationship between
kidney disease and depressed selcniwn stanis. Further srndies will be identifying the ef-
fects of supplementation and its application in the prevcmion of ccrtai n clu·onic diseases.
Upper Level fo.r Selenium

The Upper Level is 400 µg/day for adults, based on overt signs of selenium toxicity,
such as hair loss and high blood concentrations. 11 Daily intakes as low as 1 to 3 mg
can cause toxicity symptoms if taken for many months. These signs and symptoms, be-
sides hair loss, include a garlicky odor of the breath, nausea, diarrhea, fatigue, and
changes in fingernails and toenails. Rashes and cirrhosis of the liver may also develop.
Gino's supplement dose of 200 µg/doy, plus o typical dietary intake of 105
µg/day is below the Upper Level of 400 µg/day. Therefore, her practice is prob-
ably safe . Whether ii will be helpful in reducing colon cancer risk awaits further
research. Thus, widespread use of such a high dose of selenium is not currently recommended.
Pasta made from North American wheat is
generally a good source of selenium, as is any
meat in the accompanying sauce.
Iodide (I)
Iodine (12 ), present in food as iodide (I-) and other nonelemental forms, was linked
to the presence of goiter, an enlarged thyroid gland, during World War I. Men drafted goiter An enlargement of the thyroid gland that
from areas such as the Great Lakes region of the United States had a much higher rate can be caused by a lack of iodide in the diet.
of goiter than men from some other areas of the country. The soil in these areas is very
low in iodide. During the 1920s, researchers in Ohio found that goiter could be pre-
vented in children by feeding them low doses of iodide for an extended period.
Following the lead of the Swiss, American companies began adding iodide to table salt.
Use of iodized salt is the major method for correcting iodide deficiencies.
Absorption, Transport, Storage, and Excretion of Iodide

odine (1 2), which is quite poisonous, can be
Iodide is efficiently absorbed along tl1e gastrointestinal tract in its inorganic form, d1e
most common form of dietary iodine. 10 Iodide is also easiJy absorbed in other forms,
I used in a water solution as o topical anti·
infective agent. The iodide ion (I- ) is the form of
such as the iodate (10 3 - ) form that is added to bread. After iodide is absorbed into this trace mineral that is an essential nutrient.
the bloodstream, it is transported as free ions and bound to proteins, including The term iodine is sometimes used in nutrition
thyroid-binding globulin and albumin. The transported iodide is then distributed instead of iodide; however, to avoid confusion
throughout the body's extracellular compartments. with this poisonous form, the term iodide will be
About three-quarters of the iodide fo und in the adult human body is located in d1e used exclusively in this textbook.
d1yroid gland. The thyroid gland actively accumulates and traps iodide from the blood-
stream to support myroid hormone synd1esis. The d1yroid hormones thyroxine (T4 )
and triiodothyronine (T3 ) are synthesized from the amino acid tyrosine and iodide. If
a person's iodide intake is too low, me thyroid gland enlarges as it attempts to take up
more iodide from the blood.
H I H
CJ ~ J HH0
HO-C
II - \
c-o-c
/1 - \ I I I
c-c-c-C-OH
\=cl \==cl I I
I I I I H NH2
I' H H
Structure of thyroxine (T4 ). Note that triiodothyronine (T3 ) lacks
one iodide (1), indicoted in this figure with a red asterisk.
Food Sources of Iodide The kidneys are the principal route for iodide excretion. The amount of iodide
Food /fem and Amount Iodide (µg ) found in w·ine is an adequate measurement of the status of iodide intake, along with
current blood concentration of iodide.
Table salt, l /2 tsp 195
Plain yogurt, l cup 87
Functions of Iodide
Buttermilk, l cup 60
l % milk, 1 cup 59 The major function of iodide is the synthesis of the thyroid hormone thyroxine (T4 ). 10
Almost all organs in the body are targets for T 4 , but T 4 is actually considered a prc-
Luna bar, 1 38 hormonc. Within the target cell, T 4 is converted to T 3 , the active form of the bot'-
Soy protein bar, l 38 mone. T 3 controls the rate of cell metabolism.
Egg, l large 35 T 3 binds to DNA receptors and stimulates mRNA and protein synthesis in a way sim-
l % cottage cheese, J/2 cup 28
ilar to that of vitamin A and vitamin D (review Figw·e 9-3). This action is especially im-
portant for development of the central nervous system. During periods of rapid growth
Mozzarella cheese, 1 oz 10 (the first 6 months in utero), T 3 is cmcial for normal brain development. Under nor-
RDA for adults, 150 µ.g mal circumstances, T 3 also increases glucose utilization and protein synthesis.
todide in Foods
Saltwater fish, seafood, iod ized salt, molasses, and some plants contain various forms
of iodide, especially t:he leaves of plants grown near the sea. Sea salt found in health-
food stores, hmvever, is not a good source because the iodide is lost during process-
ing. A half teaspoon (about 2 g) of iodide-fortified salt supplies the adult RDA for
iodide. The actual amount of fortification in th e United States is 76 µ,g of iodide per
gram of salt. This fortification is voluntary, however, so check the label. (ln Canada
sucb fortification is mandatory.)
The bioavailability of iodide in the diet is associated with the consumption of
goitrogens Substances in food and water that goitro gens, which arc found in raw vegetables such as turnips, cabbage, brussels
interfere with thyroid gland metabolism and sprouts, cauliflower, broccoli, rutabagas, and cassava as well as other plants and even
thus may cause goiter if consumed in large water. Goitrogens inhibit iodide metabolism by the thyroid gland and, in mm, inhibit
amounts. thyroid hormone synthesis. However, goitrogens are not that important in developed
countries because they are destroyed by cooking, and the foods they are found in do
not play a cenu·al role in our eating patterns. They arc, however, important to consider
in less-developed parts of the world .
Iodide Needs
The RDA for iodide for adults is 150 µg/day. 10 This amount of iodide is needed to
maintain adequate iodide uptake and turnover by the thyroid gland . The Daily Value
used on food and supplement labels for iodide is also 150 µg/day. Most North
Americans consume much more iodide than the RDA. Consumption is estimated ro
be about 190 to 300 µg/day (not including the iodide contributed by the use of
iodized salt at the table), with men consuming the higher amounts.
Such intakes are typical because iodide is used as a sterilizing agent in dairies and
restaunnts, as a dough conditioner in bakeries, in food colorants, and in iodized sale.
Iodide-Deficiency Diseases
Some areas of Europe, such as northern ltaly, have very low iodide concemrations in
the soil but have yet to adopt the practice of fortifying salt with iodide. People in these
areas, especially women, still suffer from goiter, as do people in areas of Latin America,
the Indian subcontinent, Southeast Asia, and Africa. About 2 billion people worldwide
are at risk of iodide deficiency, and nearly 700 million of t:hese people have suffered the
widespread effects of such a deficiency. Eradication of iodide deficiency is a goal of
ma11y health-related organizations worldwide. 20
A small amount of iodized salt in one's diet ln an iodide deficiency, insufficient T 4 is produced. An adaptive response causes
helps meet iodide needs. continuaJ growth of the thyroid gland, evenrually producing a goiter. A fall in meta-
bolic rare and an increase in blood cholesterol are rwo other symptoms of thyroid hor-
mone deficiency. 10
Simple goiter is a painless condition, bur if uncorrected it can lead to pressure on
the crachea (windpipe), which may cause difficulty in breathing. In addition, other se-
rious metabolic problems can result from low T 4 levels. Treatment with iodide can re-
sult in a slow reducrion in the size of the thyroid gland, although surgical removal of
pare of the gland may be required in seYere cases.
An iodide-deficient diet poses a major threat to pregnant women and the forus, es-
pecially during the latter two-thirds of prcgnancv. Some of chc harmful documented
effects include stillbirth, low birth weight, increased infant mortality, goiter, impaired
mental fimction, and restricted development. Increasing the mother's intake of iodide
prior to the fourth month of pregnancy, but preferably sooner, can prevent these ab-
normalities. Iodide deficiency is the major preventable cause of mental retardation
worldwide. 2 0 The World Health Org<mization estimates that at least 50 million people
in the world suffer from varying degrees of preventable brain damage d ue to the effc<.:rs
of iodide deficiency on fotal brain development. The resulting restriction of body
growth and mental dcvdopment is referred to as cretinism . C retinism was common in cretinism The stunting of body growth and
certain areas of the United States before the program to fortify salt with iodide. Today, mental development during fetal and later
cretinism still appears in parts of Europe, Africa, Latin America, and Asia (Figure 12-6 ). development that results from inadequate
Some of these areas arc attempting to decrease iodide deficiency by providing iodinated maternal intake of iodide during pregnancy.
vegetabk oil orally or by injection in addition to the fortification of sale with iodide.
Upper Level for Iodide

When very high amounts of iodide arc consumed, thyroid hormone synthesis is inhib-
ited, as in a deficiency. The Upper Level of 1.1 mg/day is based on such .m effect. This
eftect can appear in people who cat a lot of seaweed, which is rich in iodide.
I
/'\\
I I
I
: \ \ I
~ \ I t
:
I
\.I :I
I I
} ( Goiter
~" ~,I
' ...,...... ,....... ____,,.,,. ....-'
Trachea
Figure 1 2·6 I Goiter and cretinism in Bolivia. The mother on the left is goitrous but otherwise
normal. The daughter is goitrous, mentally retarded, deaf, and mute. Bath mother and daughter exhibit
characteristics typical of iodide deficiency.
Illustration by William Ober.
446 Chapter 12 Troce Minerols
ike chlorine, fluorine (F 2) is a poisonous gos.

The fluoride ion (F- ) is the form of this trace
I Fluoride (F)
mineral thot contributes to human health.
Fluoride may not be an essential nutrient per sc because all basic body functions may
proceed \\'ithout it. However, fluoride docs have some health-promoting attributes.
Dentists in the early 1900s noticed a lower incidence of dental caries in cl1c soll[h-
western United States, where the water naturally contained high concentrations of flu-
oride. Many people in these areas had small spots on the teeth, called mottling (or
enamel fluorosis ), due co deposits of fluoride. Although discolored, these mottled
teeth were virtually free of dental caries. After experiments showed that fluoride in the
w~tter does indeed decrease the rate of dental caries, the controlled fluorida tion of
mottling The discoloration or marking of the water in parts of the United States began in 1945 (review Chapter 5 concerning the
surfaces of teeth From exposure to excessive development of dental caries).
amounts of fluoride (also called enamel People who have grown up drinking fluoridated water generally have 40 to 60%
fluorosis). fewer dental caries than people who did not chink flu oridated water as children.
Dentists can prO\"ide fluoride rrcaL111ents and schools can provide tluoriclc tablets, buL
it is mw.:h less e:..pensive and more reliable to simply add fluoride to the communiLy's
drinking water. However, not all public or private water sources coma.in c:nough fluo-
ride. vVhen in doubt, contact your local water planr or have die water in your home
analyzed for fluoride content. If the water doesn't contain the recommended
amoum-1 part per million parts of water ( 1 ppm, or 1 mg/L)-talk to your dentist
about r.he best means for obtaining sufficient fluoride. And although the most impor-
tant clinic<tl aspect of fluoride is its benefits in the prevention of dental caries, fluoride
has also been shown to protect against the demineralization of other calcified tissues. I
Absorption, Transport, Storage, and Excretion of Fluoride

The absorption of fluoride occurs very rapidly. A significant proportion of dietary fluo-
ride is absorbed in the stomach. Absorption continues to ta.kc place throughout the GI
tract by passive diffusion. Overall, about 80 co 90% is absorbed. Fluoride is then a·a.ns-
ported throughout the body via the bloodstream in the ionic form. 9
Calcified tissue deposition and renal excretion a.re the two major mechanisms b)
which flurnide is removed from circulation . An estimated 50% of the fluoride absorbed
each day is deposited in cl1e bones and teeth. The am0Lu1t of fluo1ide deposited de-
pends on the stage of development of cl1e bone, with the developing stages being the
most significant. The major path for the excretion of fluoride from the body occurs via
Example of mottling in a tooth caused by
overexposure to fluoride.
the urine.
Functions of Fluoride
Although an essential function has not been described for fluoride, it is still recognized
as a trace mineral with the beneficial property of protecting against the demineraliza-
tion of calcified tissues.9 The action of fluoride on the erupted teeth of children and
adults is due to its effects on the metabolism of bacteria in dental plaque. It also works
to reduce dental caries by
fluoropotite A fluoride<ontaining, ocid- • Reducing the acid solubili ty of enamel by fo rming fluorapatite crystals rather than
resislant crystalline substance that is produced the typical hydroxyapatite crystals
during bone and tooth development. Its • Promoting the remineraJization of enamel lesions
presence in teeth helps prevent dental caries. • Increasing the deposition of minerals that rcsuict the development of caries
• Reducing the net rate of transport of minerals from the enamel slU'fuce
Fluoride present in bones is constantly released into the blood, and more so if the
bone fluoride content is high. This blood fluoride combines with daily fluoride expo-
sure from fluoridated water (if available) and toothpaste (if used ). Blood fluoride then
contributes to fluoride in the saliva, which in turn bathes the teeth to provide daily flu-
oride protection. Overall, lifelong fluoride exposure on a daily basis is the most bene-
ficial way to receive tbe dental caries-preventive function of fluoride.
Fluoride in foods ecouse of its ability to increase bone moss,

In North America, the major source of dietary tluoride is drinking water (bur not bot-
B high doses of fluoride (>20 mg/day) ore
being used experimentally in adults to treat se·
tled water). Typical fluoridated water contains about 0.2 mg/cup. Tea, seafood (cspe-
vere osteoporosis, especially that seen in the
ciilly marine fish that arc consumed with their bones), and seaweed are among rhc
spine. Fluoride con stimulate osteoblasts (bone-
richest dietary sources of fluoride. Estimating fluoride content in food can be difficult
forming cells) to increase the production of
because water somces can vary in amount. Toothpaste, mouth rinses, and fluoride
proteins that ultimately undergo rapid mineral-
treatments performed by dentists a.re other sources of fluoride.
ization to form new bone. Such high
fluoride dosages can cause significant side ef·
Fluoride Needs feels, such as stomach upset and bone pain.
Ongoing research is attempting to establish on
The Adequate intake for fluoride is 3.1 mg/day for women and 3.8 mg/day for men.9
effective dose and duration of treatment.
For in£'lnts up to 6 months of age, the Adequate Intake is 0.01 mg/day and increases
to 0 .5 mg/day through age l. For children and adolescents, the fluoride Adequate
Lnrake ranges from 0.7 to 3.2 mg/day. This range of intake provides the benefits of
resistance to dental caries without causing mottling of the teeth, which is the basis for
setting the Adequate [make.
N ote that high Auoride intake in adults does
not cause mottling of teeth.
Upper Level for Fluoride
The Upper Level set for children over 9 years of age and adulcs is 10 mg/day, based
on the risk of skeletal fluorosis.9 A fluoride intake greater than 6 mg/day is a con- skeletal ff uorosis A condition caused by a
cern in childhood because this amount can mottle and weaken teeth during their de- greatly excessive fluoride intake, characterized
velopmentaJ sragt:. Children who swallow large amounts of fluoridated toothpaste as by weakened skeletal structure.
part of daily tooth care arc at greatest risk. Limiting the amount ust:d to "pea" size is
the best way to prevent this problem.
Concept I Check
Selenium is imporrant for the activity of glucathione peroxidase, an enzyme chat reduces
the concentration of peroxides, thus lessening the free radicaJ load in the body. In this way,
selenium spares some of the need for vitamin E. A deficiency results in muscle and heart
disorders. Organ meats, eggs, fish, and grains arc good selenium sources; however, the sele-
nium content in grains depends on the selenium concentration in the soil. A high selenium
intake is potentially toxic. Iodide is vital in Lhe synthesis of thyroid hormones. A prolonged
insufficient intake will cause the thyroid gland to t:nlargc, resulting in goiter. Insufficient
intake in pregnancy can lead to mental retardation in the offspring. The use of iodized salt
has virtually eliminated this condition in North America. Fluoride incorporated into teeth
dLu'ing development makes them resistant to acid and bacterial attack, in turn reducing de-
velopment of dental caries. Regular Auoride exposure also aids in the remineralization of
tcclh once decay begins. Most of us receive adequate amounts of fluoride from that added
to drinking water and toothpaste. A high Auoride intake during tooth development can
lead to spotted, or mottled, teeth.
Chromium (Cr)
The import:.mce or chromium in human diets has been recognized only in the past 40
years. Ahhough not much is understood about this mineraJ, many studies suggest that
chromium plays an important role in maintaining proper carbohydrate and lipid me-
tabolism, which may help alleviate type 2 diabetes for some individuals. Fluoridated water is responsible for much of the
decrease in dental caries throughout North
America in recent years.
Absorption, Transport, Storage, and Excretion of Chromium
OnJy about 0.5 to 2% of chromium from food is absorbed. However, the bioavailabil-
ity of chromium in humans is difficwt to assess becau1>e the conct:ntrations in human
tissues are very low. Chromium is transported in the bloodstream primari ly by the
iron-bindjng protein transferrin, and it appears to be a bone-seeking trace mineral.

Chromium accurnuJates as weU in the spleen, liver, and kidneys. The excretion of
chromium occms via the feces. 1O
Functions of Chromium
The most studied function of chromium is the maintenance of glucose uptake into
cells, but the actual mechanism is still under debate. One proposal is that chromium's
ability to enhance insulin action occurs when a chromium-binding protein binds to in-
sulin receptors on the cell membrane and then boosts receptor activity. 1O
Chromium in Foods
Mushrooms ore a good source of chromium.
Information regarding the chromium content of various foods is scant, and most food
composition tables do not include values for this trace mineral. Processed meats, organ
meats (liver), whole-grain products, egg yolks, mushrooms, broccoli, nuts, some
hromium supplements hove been touted to
legumes (such as dried beans), and beer are the most reliable sources. Yeast is also a
help with weight loss and exercise-induced
source. Generally speaking, whole grains and cereals contain higher concentrations of
increases in muscle moss, linked to its effect on chrnmium than do fruits and vegetables. The amount of chromitun in foods is closely
insulin function. Most research, however, does tied to the local soil content of chromium. To provide yow-self with an adequate
not support this assertion. In addition, any bene· chromium intake, regularly choose whole grains in preference to refined grains.
fit would be negligible compared to regular oer·
obic physical activity and some strength training.
Chromium Needs
The Adequate fntake for chromium is 35 µg/day for men and 25 µ..g/day for
women, IO based on the amount typically found in well-balanced ruets. The average di-
etary intake for adults in North America generally meets the Adequate Intake stan-
hromium in foods (Cr3+) hos not shown any dards. The Dai ly Value used on food and supplement labels for chromium is 120 µg.
toxicity, so no Upper Level hos been set.
Chromium toxicity hos been reported in people
exposed lo chromium in industrial settings Chromium-Deficiency Diseases
(specifically Cr6+). Chromium poisoning dam· A clu·omium deficiency is characterized by impaired glucose tolerance and elevated
ages the lungs and causes allergic responses in blood cholesterol and triglycerides. The mechanism by which chromium influences
the skin. In addition, the most popular form of cholesterol metabolism is not known but may involve enzymes that control cholesterol
chromium in dietary supplements, chromium pi- synthesis. Clu·omium deficiency appears in people maintained on total parenteral nu-
colinote, appears lo be absorbed in o fashion trition not supplemented with chromium as well as in children suffering from under-
different from dietary chromium and con lead lo nutiition.10 Ln addition, some adults may become chromium-deficient as they age, and
the production of harmful free radicals. this deficiency may cono-ibute to the increased risk for the development of type 2 dia-
betes. A recent study observed that when yeast chromium was fed to older persons,
there was in1provement in glucose tolerance. Because sensitive measures of chromium
status are not available, marginal chromium deficiencies may go undetected.
Manganese (Mn)
It is easy to confuse the mineral manganese (Mn) with magnesium (Mg). Their names
are similar, and in a few metabolic patb\.vays they can substitute for each other. Borh
these minerals form bridges between ATP or ADP and enzymes. In some cases, these
enzymes can use either magnesium or manganese, but in many other cases, magnesium
seems to be the preferred mjneral. On the other hand, some enzymes prefer man-
ganese, including an enzyme involved in glucose production and a fumily of enzymes
that put together protein-carbohydrate complexes in the protein portion of bone.
Besides bridge-forming activities, manganese is an actual part of some enzymes, mucb
like copper, zinc, and iron. Manganese-containing enzymes include mitochond1ial su-
peroxide dismutase. Manganese enzymes also participate in the urea cycle and in car-
Nuts ore a good source of manganese. bohydrate metabolism. LO
Based on balance studies of incakes and losses, an Adequate Intake for manganese
is set at 2.3 mg/day for men and 1.8 mg/day for women. 10 It has been generally as-
sumed that almost C\'eryone consumes plenty of manganese, but a fe" studies have
raised the possibility th.u this assumption may not always be true. Unfortunately, \'Cry
Linle manganese research has been done in humans. The Daily Value used for man-
ganese on food .md supplement labels is 2 mg.
Foods that contain the most manganese include nuts, legumes, tea, and whole
grains, but little is known about how \\'ell manganese is absorbed from ,·arious foods.
Animal products generally conrribute little manganese to the diet.
A concern has been raii.cd for m:inganese roxicity due to some high-dose supple-
ments. The Upper Level for manganese is 11 mg/day based on the development of
nerve damage. 10
Molybdenum (Mo)
Molybdenum is notable for its interactions with iron and copper. In particu lar, high in-
takes of molybdenum inhibit copper absorption.
Several enzymes-including xanthine dehydrogcnase and a related form, xanthinc xanthine dehydrogenase An enzyme
oxidase-requirc molybdenum. The oxidase form of the enzyme is produced from the containing molybdenum and iron that functions
dehydrogenase form during tissue injury. No molybdenum deficiency has been observed in the formation of uric acid and the
in people consuming ,, normal diet, although deficiency signs and symptoms have ap- mobilization of iron from liver ferritin stores.
peared in people on total parenteral nurricion. 10 These ~111ptoms include increased heart
and respiration rares, night blindness, mental confusion, edema, weakne~•.md coma.
Good food sources of molybdenum include milk and milk products, beans, li\er,
"·hole grains, .111d nurs. The RDA for molybdenum is 45 µg/ da)' for adults, 10 based
on the amount needed ro balance daily losses. The Daily Value used on fr>od and sup-
plement labels for molybdenum is 75 µg. Typical North American int.lkes arc 75 to
110 µg/day, with the higher inrakes seen in men. When laboratory animals consume
high dosages of molybdenum, they develop evidence of toxicity, including anemia,
weight loss, and decreased growth. The Upper Level of 2 mg/da) is based on de-
creased growth and reproduction in laboratory animals. 10
Table 12-3 re,iews the minerals discussed so fur i11 this chapter. Figure 12 7 sum-
marizes the roles of major minerals and trace minerals in the body.
Ultratrace Minerals
Many elements of the periodic Lablc occur in microgram/gram amounts in body tis
sues (Table 12 4 ).8 Ulrimarcly, some may be elevated Lo the :.tatu1. of essential nulri
ents, but at this rime clements such as aluminum, cadmium, bromine, germanium,
lead, rubidium, and tin ha,·e nor been shown ro ha,·e any beneficial enccts in humans.
In fact, lead is a danger to roung children, as evidenced b) toxicity to those children
li,·ing in older homes contaminated with peeling lead-based paint (see Chapr1:r 19 for
more details on lead).
What follows is a discussion ofli"e ultratrace minerals that may ha\'e a role in hum.111
nutrition. Because these minerals ha\'e not yet been derermirn:d to be essential trace
minerals, no R.DAs or Adequate Intakes have been set. Howe,·er, because these ulLra-
rrace minerals, like a.II minerals, C•ll1 be toxic, in some cases an Upper Le\'cl ha~ been
established.
Boron (B)
Boron has long been known as an important growth factor for plantl>. 111 humans,
boron may be involved in the metabol ism of steroid (chokslcrol-containing) hor
manes, such as the active vi tami n D hormone and the estrogens.~ There appears co be Fruits are a source of boron.
Table 12-3 I A Summary of Key Trace Minerals
Major Deficiency People RDA or Good Results of

Mineral Functions Symptoms Most at Risk Adequate lntoke Dietary Sources Toxicity
Iron Functional component fatigue upon exer· Infants, pre- Men: 8 mg Meals, seafood, Gostroinlestinol upset; toxi-
of hemoglobin and lion; small, pole red school children, Women: 18 mg enriched city especially seen when
other key compounds blood cells; low women in child- breads, fortified children consume many
used in respiration; blood hemoglobin bearing years cereals, iron pills; toxicity also
immune function; cog· values; poor im- molasses seen in people with he-
nitive development mune function mochromolosis; Upper
Level is 45 mg/day
based on gastric irritation
Zinc Required for many Skin rash, diorrheo, Vegetarians, Men. 11 mg Seafoods, Supplement use con re-
enzymes such as decreased appetite elderly people, Women. 8 mg meals, whole duce copper absorption;
those that porticipote and sense of taste, people with ol- groins con cause diarrhea,
in antioxidant protec· hair loss, poor coholism, mol- cramps, depressed im-
lion; stabilizes cell growth and nourished mune function; Upper
membranes and other development populations level is 40 mg/day,
body molecules based on interaction with
copper
Copper Aids in iron metobo- Anemia, low white Overzealous 900 µg Liver, cocoa, Excessive supplement use
lism; works in antioxi- blood cell count, supplementation beans, nuts, can cause vomiting;
dont enzymes and poor growth of zinc whole groins, nervous system and liver
those involved in con- shellfish disorders; Upper Level is
nective tissue metobo- 8- 10 mg/day, based on
lism and hormone liver damage
synthesis
Selenium Port of an antioxidant Muscle poin, muscle Known only in 55 µg Meats, eggs, Excessive supplement use
system weakness, form of areas of the fish, seafoods, con cause nausea, vomit-
heart disease world with low whole groins ing, hair loss, weakness,
selenium content liver disease; Upper level
in the soil is 400 mg/day, based on
hair loss
Iodide Component of thyroid Goiter; mental retor· Major problem 150 µg Iodized salt, Inhibition of function of the
hormones dotion, poor growth in most ports of white bread, thyroid gland; Upper level
in infancy when the world saltwater fish, is 1. I mg/day, based on
mother is iodide de- dairy products decreased T4 synthesis
ficienl during
pregnancy
Fluoride Increases resistance Although not o true Areas where Men: 3.8 mg Fluoridated Stomach upset; mottling
of tooth enamel lo deficiency symptom, water is not Women: 3.1 mg water, tooth- (staining) of teeth during
dental caries dental caries is a Auoridoted paste, dental development, bone deteri-
risk treatments, tea, oration; Upper Level is I 0
seaweed mg/day, based on bone
problems
Chromium Enhances insulin High blood glucose People on intra- 25-35 µg Egg yolks, Caused by industrial con-
action ofter eating venous nutrition, whole groins, lamination, not dietary ex-
perhaps elderly pork, nuts, cess; no Upper Level set
people with mushrooms
type 2 diabetes
Manganese Cofactor of some en· None in humans Unknown 1.8-2.3 mg Nuts, oats, Nervous system disorders;
zymes, such os those beans, tea Upper level is l I mg/
involved in carbohy- day, based on nerve
drote metabolism and damage
antioxidant protection
Molybdenum Aids action of some None in healthy Unsupplernented 45 µg Beans, grains, Poor growth in laboratory
enzymes humans total parenteral nuts animals; Upper Level is
nutrition support 2 mg/day, based on poor
growth in laboratory
animals
Figure 12·7 I Minerals contribute to many

functions in the body. Mineral deficiencies
therefore lead too variety of health problems.
Ion balance Calcium
in cells Phosphorus
Magnesium
Calcium
Zinc
Phosphorus
Sodium Chromium
Iron
Potossium Iodide
Zinc
Chloride
Phosphorus Copper
Fluoride
Manganese
Selenium Calcium
Zinc Phosphorus
Copper Zinc
Manganese
Sodium Iron
Potassium Copper
Chloride Calcium
Calcium
Table 1 2·4 I A Summary of Ultrotrace Minerals for Which Human Needs Hove
Not Been Definitely Established
Estimates of
Mineral Proposed Functions Doily Human Needs Dietary Sources
Boron Cell membrane function l- 13 mg Fruits, leafy vegetables, nuts,
(ion transport), steroid beans
hormone metabolism ne possibility lo consider is that many ul-
trotroce minerals present in tissues ore
Nickel Amino odd ond fotty acid 25-35 µg Chocolate, nuts, beans, whole
there by occident, and although they don't pro-
metabolism groins
vide ony health benefits, neither do they repre-
Silicon Bone formation 25-30 mg Root vegetables, whole groins
sent a threat. Most of the current knowledge
Arsenic Amino acid metabolism, about the ultrotroce elements hos come from oni-
DNA function 12-25 µ.g Fish, groins, cereal products mol studies, which may suggest possible benefits
Vanadium Mimicry of insulin action 10 µ.g Shellfish, mushrooms, block for humans, but the evidence is tentative at best.
pepper
Deficiency symploms hove been produced mostly in experimental animals. Nv:Jny trace minerals pose a high risk for toxicity. Any
supplemenl use should not exceed the estimotes al human needs listed in rhis table
a close interrelation among boron, calcium , and magnesium, but more information is
needed to understand how each mineral affects the absorption of the others. Boron
acts as a regulator in cell membrane function, such as membrane stability, or acts as the
regulator of the movement of cations and anions through the cell membrane. Sources
of boron are peanuts, fruits (especially raisins), legumes, potatoes, vegetables, and
wine. Coffee and milk, which are low in boron, are other contributers because of the
amounts typically consumed. Adults consume about 0.75 to 1.35 mg of boron per day.
The Upper Level for boron is 20 mg/day, based on developmental abnormalities in
laboratory animals. 10
Nickel (Ni)
No biochemical function has been clearly defined for nickel for humans, but a variety
of deficiency signs have been reported for farm animals and rats. Nickel may function
as a cofactor with a variety of enzymes, such as those involved in the breakdown of
branched-chain amino acids and odd-chain-length fatty acids. 8 It also may be involved
in the metabolism of vitamin B-12 and folic acid during the synthesis of methjonine
from homOC)'Steine. Nickel is fow1d in chocolate, nuts, legumes, and grains. North
Americans have an intake of 69 to 162 µg/day. The Upper Level is 1 mg/day, based
on poor weight gain in laborarory animals. 10
Silicon (Si)
Next to m.·ygen, silicon is the most abundant element in the earth's crust. If that sur-
prises )' Ou , realize that quartz is made of silicon and sand is made of quartz. With all
this silicon around, it is obvious that some should find its way into plants, animals, and
humans. What is nor so obvious is whether people actually need silicon. Studies with
laboratory rats and chickens suggest that the answer may be yes. In these animals, sil-
icon has shown some relationship to the formation of connective tissue, espcci<illy in
die protein portion of bone. 1OThere has been some speculative research on silicon and
human bone structure, but nod1ing definitive is known. Silicon can be found in food s
such as high-fiber grain products and root vegetables, but knowledge about silicon ab-
sorption from foods is limited.
Arsenic (As)
Most people recognize arsenic as a potentially very toxic mineral. Depending on the
form of arsenic consumed, absorption varies from 20 to 90%. It is rapidly excreted in
d1e urine and via the bile. Although not clearly established, arsenic is probably biolog-
ically active in the metabolism of the amino acid methionine and methyl groups.
Another possible role is in the regulation of gene expression to produce certain pro-
teins.8 Also, arsenic seems to enhance DNA synthesis in whfre blood cells. For this rea-
son arsenic is being used in some cancer chemotherapy regimens. North Americans
Legumes (beans) are a good source of some consume about 30 µ,g/day. Fish, grains, and cereal produces contribute the most ar-
ultralrace minerals. senic to the diet. 10
Vanadium (V)
Vanadium shows pharmacological activity that mimics the actions of insulin, prevent-
ing the symptoms of diabetes in diabetic rats; thus, vanadium may have a role in treat-
ing human diabetes. Clinical studies with the trace mineral in both lypc l and type 2
diabetes showed some improvement in glucose utilization. 8 Type 2 diabetes patienrs
displayed improved insulin sensitivity. Vanadium is poorly absorbed and is excreted in
the mine and bile. Other than vanadium's possible pharmacologic properties in dia-
betes treatment, a defined biochemical function for humans has not been described. In
laboratoq• animals, it also seems co stimulate the mineralization of bones and teeth and
has a variety of other actions. A \'anadium deficiency has not been identified in humans.
Human diets supply about 6 to 18 µg per day. Vanadium is found in shellfish, mush-
rooms, parsley, dill, and some prepared foods. The Upper Level is 1.8 mg/day, based
on dc\clopment of kidney damage.10
Concept I Check
Chrommm mar increase the action of the hormone insulin. The amount of chromium
found in food depends on soil conrcnr. Whole grains, egg yolks, and meat .ire some of the
berrer sources of chromium. i\langanesc is a component of bone and man~ enz~ mes, in-
cluding those in\'Oh·ed in glucose production. Because our need for it is lo", deficiencies
are rare. Good food sources of manganese are nuts, oats, tea, and beans. i\ Iolybdcnum is a
componcm of some enzymes. Deficiencies have appeared only \\ith rotal parenteral nutri-
tion. Beans, milk and milk products, grains, and nuts arc sources of molybdenum. Boron
comributcs to ion transport across cell membranes, nickel contributes to amino acid mctab·
olism, and silicon contributes to bone metabolism. The roles for some other tr.1cc miner-
als-including arsenic and \'anadium-ha\'e not been fully established in humans. These
minerals arc required in such small amounts that diets including a \'<lrictY of foods and con-
taining some plant protein and whole grain~ most likely suppl~· adcqu.ue amounts.
Nutrition and Cancer
Cancer is currently the second leading cause of cerous. A mmor is spontaneous new tissue growth
death for North American adults. Lung, prostate, that serves no physiological purpose. Twnors can
benign Noncancerous; describes tumors breast, and colorectal cancers account for slightly be benign, such as a wart tl1at doesn't spread, or
that do not spread. over half of all cancers in North America and are the malignant, such as lung cancer that spreads co sur-
malignant Essentially, malicious; in leading cause of cancer death for every racial and roLU1ding tissues and organs. A malignant neo-
reference to a tumor, the property of ethnic group. 15 The good news is that new cancer plasm means the same thing as a malignant mmor.
spreading locally and to distant sites. cases and cancer deaths for all cancers (except lung Most cancers fall into one of three groups: car-
cancer in women) have declined in recent years. cinomas, sarcomas, and leukemias and lymphomas.
neoplasm A new and abnormal growth
Carcinomas comprise 80 to 90% of all cancer.
of tissues, which may be benign or
cancerous.
They develop from cells that cover the body and af-
What Is Cancer? fect secretory organs, sucb as the breast. Sarcomas
carcinoma An invasive malignant tumor are cancers of connective tissues, such as in bone.
derived from the epithelial tissues that Cancer is not a single disease but exists in at least Leukemias are malignant neoplasms of the blood-
cover the body. 100 different forms (Figure 12-8). Some of the fac- forming tissues, the bone marrow. Lymphomas
sarcoma A malignant tumor arising tors tl1at cause skin cancer may be different from are various malignant tumors that are in the lymph
from connective tissues. those leading to breast cancer, and treatments for nodes or lymphoid tissues.
the different varieties of cancer vary with the type Benign tumors are enclosed in a membrane
leukemia A malignant neoplasm of of cancer itself. Essentially, cancer is abnormal and that prevents them from spreading. They are dan-
blood.forming tissues, the bone marrow.
Lmcontrollable cell division. If untreatable or not gerous only if dley interfere wid1 normal function .
lymphoma A malignant tumor arising treated, it leads to death. Most cancers take the For instance, a benign brain tumor can cause illness
from lymph nodes or other lymph tissues. form of tumors, altl1ough not au tumors are can- and death if it blocks blood flow in the brain.
Estimated % of Cancer Deaths for 2004
Male Female
<1% Brain 2%
4% Esophagus and stomach <1%
32% Lung 25%
Breast 15%
3% liver <1%
5% Pancreas 6%
9% Leukemia and lymphomas 9%
10% Colon and rectum 10%
6% Urinary
Ovary 6%
10% Prostate
Uterus and cervix 3%
All others
25% (e.g., oral and skin)
(e.g., oral, skin, and bladder) 24%
Figure 1 2·8 I Cancer is actually many diseases. Numerous types of cells and organs ore its target. Note that about one-third
of all cancers arise from smoking (primarily lung cancer) .
4 54
-- - - - - - - - - - -
- - - -
Chemicals, radiation,
ond viruses con
OIJ Normal cell
(melonocyte)
oltercell DNA
(in this cose, rodiotion
from the sun is the
E ICell DNA oltered

likely couse)
Alcohol, estrogen, Altered cell-this

ond dietory fol con grow into
encouroge cell o cancer
division in certain
cells.
EJ lncreosed cell
division-this 1s
needed lo promote
the cancer process
;.r:~.,-------- Cancerous tumor

(molignonl melonomo)
lymphatic - - - - - -·rn
vessel
Blood vessel
Figure 12·9 I Progression from o normal skin cell (1 l to skin cancer through the initiation (2),
promotion (3). and progression (4) stages The boll of cells is a developing tumor. As the moss of cells
grows, ii con invade surrounding tissues, eventually penetrating into both lymph and blood vessels (5).
These vessels carry spreading (metastatic) cancer cells throughout the body, where they con form new
cancer sites.
i\t.1lignam mmors, on rhe other hand, arc capable Mechanisms of Carcinogenesis

of invading surroundmg strucrure!>, induJi ng
blood \'esscls, the lymph sysrem, and nerw msuc. .\!mt cells exist in a homcmt.uic \t,ue; there 1s a metastasize The spreading of disease
Thcv can metastasize ro disc;mt sites \i,l the blood balance bet ween rhc rurning-on .111d ntrning-off of from one port of the body to another,
or lymph, dlcreby producmg im asi\'l' cumors Ill .11 - cellular n:pltcauon. Regulation of the cell cycle ex even to ports of the body that ore remote
mmc ,my part of the body (rigure 12-9). ists bcmeen the grnc products th.H spur replication from lhe site of the original tumor.
Because lcukcmi.1, •l cam:er found in white and gene produLts that deter replit:auon. Cancer cells con spread via blood
blood cells (lcukoq•ccs), docs nor produce .1 m.1!>s, vessels, the lymphatic system, or direct
Oncogenes and Other Genes growth of the tumor.
ll isn't d.issified as .1 tumor; howe\·cr, it C\htbits the
ti.ind.l111cncal property of rapid and inappropriate licnc!> that produce product~ th.tr cause .1 rcsung protooncogenes Genes that cause a
grmnh. Leukenu.l i!> still malignant and therefore cell ro di\'idc uc rclerrc:d to .1~ protooncogencs, resting cell to divide.
represents a form of cJncer. and genes that produce product' that prevent cclb
455
tumor suppressor genes Genes that from dividing are known as tumor suppressor cancer initiation. Subsequently, it is followed by
prevent cells from dividing. genes. Cancer often results from a lack of suppres- cancer promotion and finally cancer progression
sor genes or too much action by the protoonco- (review Figure 12-9). Initiation can develop spon-
oncogene A protooncogene out of
control. genes. The cancer gene, or oncogene, is the taneously or can be induced by agents known as
protooncogcne out of control; it is making dozens genotoxic carcinogens. Tbe affected cells can then
p53 gene A tumor-suppressor gene that or hundreds of copies of itself, and there are no dictate their own rate of division. Agents tl1at arc
can prevent inappropriate cell division. mechanisms to overcome the process. Ultimately, responsible for carcinogenesis include tobacco, al-
telomeres Cops ot the end of all cancer is genetic, in that defects in specific genes cohol, radiation, occupational toxins, infections,
chromosomes. lead to the proliferative growth. diet, and drugs (Table 12-5).
The tumor suppressor genes are the braking A mechanism that can prevent cancer initiation
telomerose An enzyme that maintains
mechanisms within a cell, preventing uncontrolled is a fumi.ly of enzymes in cells that can dctoxil)• and
length ond completeness of
growth . When something goes wrong with these speed up excretion of cancer-producing chemicals.
chromosomes.
tumor suppressor genes, the oncogenes arc free to These enzymes arc sometimes called phase 2 en-
cancer initiation The stage in the promote rapid cell growth. One tumor suppressor zymes. Some dietary phytochemicals increase the
process of cancer development that gene, known as p53, can prevent the abnormal arnolll1t of tl1ese enzymes in the body. The p53
begins with olterolions in DNA, the growth associated with nimors. Alteration in tl1is gene, already identified as a tumor suppressor gene,
genetic material in a cell. These gene has been discovered to cause cancers of the is another way to prevent abnormal growtl1 as~oci
alterations may cause the cell to no ated with tumors, because it can postpone cell di,·i-
ovary, breast, lung, and colon.
longer respond lo normal physiological
There are repair mechanisms within a cell that sion, which allows time for damage repair.
controls.
constantly look for errors in DNA replication and Enzymes can travel up and down the DNA double
cancer promotion The stage in the make corrections. Sometimes the repair mecha- helix, repai1ing broken components and correcting
cancer process during which cell nisms fa.i i, which results in an inherited defect for defects. Abour 99% of tbe t:irne, the repair enzymes
division increases, in turn decreasing the cancer, such as hereditary colon cancer. Early de- find the damage and correct it before the i.:dl di-
time available for repair enzymes to act tc:cts in DNA replication tlrnt arcn 't caught and re- vides again and thus undergoes mutation.
on altered DNA and encouraging cells The initiation stage of carcinogenesis, during
paired are likely to predispose the cell to even more
with altered DNA to develop and grow.
errors, elms leading to cancer. which time DNA is altered, is relatively ~hort, rang-
cancer progression The final stage in Otl1er agents tl1at play a part in the cell replica- ing from minutes to days. The promotion state
the cancer process, during which the tion process are telomeres, caps at tbe ends of cliro- may last for months or years. During this period,
cancer cells proliferate, forming a mass mosomes. An enzyme called telomerasc maintains the damage is locked into tl1e genetic material in
lorge enough to significantly affect body d1eir length <md completeness. This enzyme is active cells. Compounds that increase cell division arc
functions. when we are young and tapers off as we age. Each called promoters or epigenetic carcinogens. These
genotoxic carcinogen A compound that time an adult cell divides, tl1e telomeres or the daugh- compounds are thoughc to promote cancer either
directly alters DNA or is converted in ter cells arc slightly shorter. At some point, tclomcres by decreasing the time available for repair enzymes
cells to metabolites that alter DNA, become so short that the genes at tl1e ends of the to act or by encouraging cells with altered DNA to
thereby providing the potential for chromosome can no longer function, and the (:CU develop and grow. Some probable promoters .ll'e
cancer lo develop. dies. ln malignant tumor cells, me tdomerase activity estrogen, alcohol, and possibly a high intake of di-
increases, and the length of tl1e telomere is main- etary for. Bacterial infections in the stomach arc
mutation A change in the chemistry of o
gene that is perpetuated in subsequent
tained, resulting in a cell that can live indefinitely. also suspected agents. For example, infection with
divisions of the cell in which it occurred; There seems to be a difference in relomerase activity Helicobacter pylori, which cause ulcers, may ulti-
a change in the sequence of the DNA between normal tissue and cancer tissue. Much more mately promote stomach cancer.
base pairs. remains to be learned about conditions that promote The final stage in carcinogenesis, cancer pro-
abnormal telomerasc activity and whether d1is en- gression, begins with tl1e appearance or cells tlm
zyme can become a target in cancer therapy. grow autonomously (out of conu-ol). During the
progression phase, tliese malign:.inc cells proliferate,
Cancer Initiation, Promotion, invade surrounding tissue, and metastasize to otht:r
and Progression sires. Early in tl1is stage, tl1e imrn unc system ma}
Carcinogenesis, the development of cancer in a find the altered cells and destroy them. Alternately,
body, is a multiplc-sLep event. It starts with tl1e ex- the ca.ncer cells may be so ddcctivc thar their own
posure of a cell to a carcinogen, in turn rriggcring DNA limits their ability to grow, and they die. If
456
- 1 ;
- - - -
Taltle 12·5 I The Cancer Development Process
Cancer Initiation
Process: DNA alteration occurs in this relatively short phase (minutes to days)
Causes:
Radiation: e.g., sun overexposure
Cross-links double strands of DNA or breaks them into fragments
Chemicals: e.g., aflatoxin (mold from peanuts and cereal grains), benzo(a)pyrene (smoke from charbroiled
meat fat). These agents are transformed to highly reactive cancer initiators by cytochrome P4SO, an cytochrome P450 A set of enzymes in
enzyme system that alters foreign compounds in the body. These metabolites ore then able to cause cells that act on compounds foreign lo
mutations in DNA, RNA, and proteins. the body. This action oids in their
Biological agents: e.g., viruses excretion, but also creates short-lived,
Promote uncontrolled growth of cells by inserting viral DNA or RNA into normal cells, which alters the highly reactive forms.
cell's genes
Cancer Promotion
Process: DNA alterations ore "locked" into the genetic material of cells over a period of months to more than
10 years.
Causes:
Long-term excess estrogen exposure
Excess alcohol
Excess dietary fat (controversial)
Bacterial infections: e.g., Helicobacter pylori
Cancer Progression
Process: Cells that con grow autonomously appear. These cells spread to surrounding tissue and other sites.
Causes:
Excess energy intake
lock of early detection
Development of blood supply to the tumor
The tumor uses newly formed capillaries to grow and spread cancer cells to remote sites in the body.
Anything thot increases the role of cell division decreoies the chance thol the repair enzymes will find the altered port of the ONA in tome lo do
their work. Once o cell multopfies ond incorporates its newly altered ONA into its genetic instructions, the repoor enzymes con no longer detect the
changes in ONA.
nothing impede~ cancer cell gro\1 th, one or more Diet and Cancer
rumors eventually develop that arc large enough to
affect body functions, and the signs and symptoms
Oxidative damage to DNA is likely to caui.e muta·
of cancer appea1· (review Table 12·5 ).
tions. This damage can be enhanced by some di·
etary factors or, in contrast, reduced by enzymes
Is Cancer Environmental such as those that incorporate the trace mineral se-
or Hereditary? lenium. There is evidence that intake of selenium
above the RDA has .m anticancer eflcct in humans,
Inherited mutations cannot account for the dra· but there aren't enough data at this time to make a
matic ditforences in cancer rates around the world. ln recommendation as co the extra amount needed.
poorer countries, cancers of the scomach, liYer, mouth, Excessi\'t: energy intakes mcrease the risk of
esophagui., and uterus are m~t common, whereas in human cancer. L1bor.uory animal i.rudies have
aftluem countries, cancen. of the lung, colon-rectum, shown that energy restriction during periods of
breast, and prostate gland predominate. rapid growth is protecti\·e against cancer. No doubt
The e1wironmencal factors shared by a family obesity increases the risk of cancers of rhe uterus,
can include human papillonmirus infection for breast, kidney, and possibl}' the prostate gland, eople who meet their vitamin C
ccn"ic:u cancer, smoking (passi,·e and active) for colon, and gallbladder. faces~ body fat may affect needs may hove o lower risk of can-
lung cancer, diet for colon cancer, and Hclicobnctcr sex hormone and insulin production, which in· cer of the oral cavity, esophagus, stom·
PJlori for stomach cancer. Heritable factors are seen creases cancer risk, or cancer cells may grow more ach, and breost. Whether this benefit is
primarily for colorectal, breast, and prostate cancer. easily when energy is plentili.11. 6 due to vitamin C itself or because these
Still, the impact of heredity on cancer risk is small; No link has been found between a low-fat dier people eat a lot of fruits and vegetables,
inherited genetic foctors :m:ounl for only 1 to 15% and the dcvclopmcm or bn:.m cancer, but excess which provide many other nutrients, is
of all the cancers. body weight i111.:reases the risk. Perhaps cenain fatty still unknown.
457
<Kids, such as monouns.uurated and polyuns.nu ci.lll\' wlon cancer. It may be that c.1kium bind'
raced fan:y acids in fish and canola oil, .ire bencticial. frl.'.e fact) acid and bile acids in Lhc colon so th.lt
High intakes of \'egetabb and fruirs ha\'e been the~ arc bs likely to interact with certain rypcs of
associated \\"ich lower risks of man~ c:mccr,. 4.5 14 intestinal cells, which in turn become cancer
The constituents that arc protccti\'e ag:iinsc cancer The hormone.: form of\'itamin D-1.25 (0H h
have not been identified, but evidence supports the \'itamin D-has been shown to inhibit rhc progrcs
B·viramin folate as one of the factors. Studies of sion of human colorectal cells from rnncerm"
colorectal cancer show an inverse rel.11ionship be· polyps. Vitamin D also has been shown to inhibit
rwecn folatt: status and the rate or cancer. An inad · rapid colon/rectal cell growth in people with 11\les
equate intakt: offol.1tc could also intlucnce the risk 1i11.1l in0.1mmarory diseases. These combined d.ll.1
of mutation. sugge\l .1 chemoprevenrh·e action or vitamm D
High intakes of meat and protein products against colon neoplasms. This action m.l) be thl.'.
h,we been associated ll'ith an increased risk of beneficial effect of \itamin D-fortified dain' foods
prostate ca1Ker. This association might be rcl.ucd B.1sed on our currenr knowledge of diet and
to d1e sarurated fat content of the tood. In addi cancer risk, che follo"ing guidelines arc .1hout all
rion, meat cooked at high temperatures m·cr .m that c,111 be recommended at this nmc: remain
open tlame, such as in charcoal broiling, produce!. ph)·sic.1lly .Ktin:; a\'oid obesity; cngagi: in regular
polyaromanc hydrocarbom, one being bcnzo· physical .1cti\ iry that promotes chc formation of
[.1 Jpyrene. Bcnzo·[ a lpyn:m: binds to D~A .md lean muscle; consume an abundJJlce of fruit\, \'q!.·
produces tumors, such as m the colon. 1- ctabks, and whole grains; consume plenty of low·
bcess alcohol consumption increases che risks fat and far-free dairy products; amid a high inrakl.'.
of upper GI tract cancers. £,en moderate.: alcohol of red meat, processed (rnred) meats, and animal
intake sc.:ems to increase the risk of cancers of chc.: fat; .md arnid excessive use of alcohol (fable\ 12-6
brc.ist and colon. and 12 -7). 4 ·~· 14 .1 7
Cruciferous vegetobles such os cabbage Nitrosamincs arc carcinogenic Nit rmammcs
and couliAower ore rich in concer- arc formed from nittite, "lm:h c.:mts in ';rnous
preventing phylochemicols.
food' and is produced cndogl·nous[\· from nitr.ue American Institute for Cancer
in \'egcrablcs. Nitrosamine compounds .in: f(>und
Research Diet and Health
in bacon, sausage, hot dogs, beer, cl1cesc, and some
nitritc· prcser\'cd foods. Guidel ines for Cancer
1\.lycotoxins arc toxins produced b~ fungi. Prevention
Among the many examples is ,111,uO\in B1, .1 com·
ponent of many moldy foods, such .is moldv grain 1. Choose a dier rich in J variety of plam ba~cd
and peanuts. It is classified .1s a human urcinogcn foods.
and is thought to cause lin:r cancer Drought con· 2. bt plenty ofvegetables and fruics.
ditions in Asian and African coumnes haw resulted 3. ~l.11ntain .1 healthy weight and be phys1c.1lly
in the widespread conr.1mination of foods b\' .1tl.1 active.
toxins. faen in rhe l'nited Scates, corn lus been 4- Drink alcohol only in moderation, if at all .
found wich increased car1..-inogen Inds trom atb· 5. Sclecc foods low in for and salr.
toxin B1 because of changing weather conditions, 6. Prep.1rc and store food safely.
bur grain ele\·aror operators and rDA monimr And nlll'trvs r1·111e111bt:r . ..
gr.uns for unsafe amounts Current studies arc fo . Oo noc use tobacco in any form.
cusing on nrious annoxidanrs rh.u m.1y protect us
fi-om em"ironmental carcinogens such as all.uoxms.
Another recem disco\·en n:sul11ng from .n· Cancer Warning Signs
tempts to find dietary solutions to the prncntion
of c.tnccr suggests that c.1kium .md '1tami11 D (or Rcme111ba also that if a cancer is left untreated, 1l
mode rare sun expos me) ma) be pan of th1.. ans\\'cr. can spread quickly throughout che bod\'. When this
C.1kium intake is ul\'er~cl) rcl.lted to c.111ccr, cspe happens, the cancer will much more likely lead w
458
Tllltle 12·6 I Some Food Constituents Suspected of Having a Role in Cancer
Constituent Dietary Sources Action
Possibly Protective•
Vitamin A liver, fortified milk, fruits, vegetables Encourages normal cell development.
Vitamin D Fortified milk Increases production of o protein that suppresses cell growth, such
as in the colon.
Vitamin E Whole groins: vegetable oils: green, leafy vegetables Prevents formation of nitrosomines and hos general antioxidant
properties.
Vitamin C Fruits, vegetables Con block conversion of nitrites and nitrates to potent carcinogens
and likely hos general antioxidant properties.
Fol ate Fruits, vegetables, whole groins Encourages normal cell development; especially reduces the risk of
colon cancer.
Selenium Meats, whole groins Port of antioxidant system that inhibits tumor growth and kills devel-
oping cancer cells.
Corotenoids, such as Fruits, vegetables Likely act as antioxidants; some of these possibly influence cell me-
lycopene tabolism. Lycopene in particular may reduce the risk of prostate
cancer.
lndoles, phenols, and Vegetables, especially cabbage, cauliflower, broccoli, Moy reduce cancer in the stomach and other organs.
other phytochemicol brussels sprouts; garlic; onions; tea
substances
Calcium Dairy products, green vegetables Slows cell division in the colon, binds bile acids and free fatty
acids, thus reducing colon cancer risk.
Omego-3 fatty acids Cold-water fish, such as salmon and tuna Moy inhibit tumor growth.
Soy products Tofu, soy milk, tempeh, soy nuts Phytic acid present possibly binds carcinogens in the intestinal
tract; the genistein component possibly reduces growth and metos·
Iasis of malignant cells.
Conjugated linoleic acid Dairy products, meats Moy inhibit tumor development and act as on antioxidant.
Fiber-rich foods Fruits, vegetables, whole-groin breads and cereals, Colon and rectal cancer risk may be decreased by accelerating in-
beans, nuts testinal transit and excretion of carcinogens.
Possibly Carcinoge nic
Excessive energy intake All mocronutrients con contribute. Excess fat moss leading to obesity; linked to increased synthesis of
estrogen and other sex hormones; which in excess may themselves
increase the risk for cancer. Resulting excess insulin output from cre-
ation of on insulin-resistant state is also implicated .
Total fat Meats, high-fat milk and milk products, animal fats The strongest evidence is for excessive saturated and polyunsatu-
and vegetable oils rated fat intake. Saturated fat is linked to on increased risk of
prostate cancer.
High glycemic load Cookies, cokes, sugared soft drinks, candy Insulin surges associated with these foods may increase tumor
carbohydrates growth, such as in the colon.
Alcohol Beer, wine, liquor Contributes to cancers of the throat, liver, bladder, breast, and
colon (especially if the person does not consume enough folote).
Nitrites, nitrates Cured meats, especially horn, bacon, and sausages Under very high temperatures will bind to amino acid derivatives to
form nitrosomines, which ore potent carcinogens.
Aflotoxins Formed when mold is present on peanuts or groins Moy alter DNA structure and inhibit its ability to properly respond to
physiologic controls; oflotoxin in particular is linked to liver cancer.
Benzo(o)pyrene and other Chorcoo~broiled foods, especially meats Linked to stomach and colon cancer. To limit this ri sk, trim fat from
heterocyclic amines meat before cooking, cut barbecuing time by partially cooking
meat (such as in a microwave oven), and don't consume blackened
ports of meats.
•Many of the octions tisted for these pouibly protedive ogenb ore specutotive ond hove been verified only by experimentot onimot studies. The best evidence supports obtaining these nutrients ond
other food constituents From foods Recently the U.S. Preventive Service Tosk Force IUSPSTF} supported this s10temen1, noting it.ere is no clear evidence lhot nutrient supplements provide lhe some benelias
4 59
Tallle 12·7 I Example of a Diet Intended to Limit the Risk for Cancer-low in Fat and
High in Fruits and Vegetables with Plenty of Calcium
Breakfast
6 oz calcium-fortified orange juice
l cup ready-to-eat whole-groin breakfast cereal
l cup 1% milk
1 banana
l slice whole-wheat toast, jelly, soft margarine
Hot lea
Lunch
Sandwich:
1/2 cup chicken salad served on l /2 of a bagel or 1 slice of whole-wheat bread
Assorted row vegetables: carrots, celery, broccoli, chopped lettuce
1 cup 1% milk
Fresh fruit: strawberries, melon, gropes, apple
2 fig cookies
Dinner
3 oz baked fish (e.g., cod, salmon}
Baked potato lopped with shredded mozzarella cheese (1/3 cup)
Roosted corn on the cob, soft margarine
Fresh garden salad with low-Fat llolion dressing
1 whole-wheal dinner roll
l scoop lemon ice or orange sherbet
Hot tea
Snack
12-oz con diet cola or apple juice
2 cups popcorn
1/4 cup mixed nuts
Nutrient Breakdown:
2300 kcal
% energy from fat: 25%
death. Thus, early detection is critical. Aids ro early tions for middle-age and older adults, PSA
detection include the following warning signs (the (prostate-specific antigen) tests for men over age
acronym is CAUTION): 50, Papanicolaou rests (Pap smears) and regular
• Change in bowel or bladder habits breast examinations (and mammograms starting
• A sore that does not heal
abour age 40 to 50) for women and regular self
• Unusual bleeding or discharge examination of testicles for men.7 Finally, to learn
• Thickening or lump in the breast or elsewhere still more about cancer, review these sources of
• I ndigestion or difficulty in swallowing credible cancer information on the Internet:
• Ob,fous change in a wart or mole
• Nagging cough or hoarseness
\\\\"\\.cancer.Orf. American Cancer Society
There are still other ways to detect cancer early. \\'\\ w.icic.nci.nsh.g.ov ConcerNet
Some recommendations .ire colonoscopy examina- www.c.mccr.mcd.11penn .edu O ncolink
460
I
- - --
Summary
l. Six of the trace minerals (iron, zinc, copper, molybde1mm, iodide, as part of antioxidant enzymes. A copper deficiency can result in a
and selenium ) have an RDA. An Adequate Intake has been set for secondary iron deficienC). Copper is found in lin~r. cocoa,
three trace minerals (manganese, chromium, and fluoride ). legumes, and whole grains.
2. Some trace minerals are difficult co detect in humans, and it is 10. Selenium acts as a cofacror for the enzyme glutath1onme peroxi-
often hard co determine the exact amount of a trace mineral in dase, which protects cells against destruction br hrdrogen perox-
food. Deficiencies were first observed in small, geographically iso- ide and free radicals. In some instances, selenium can rep lace some
lated groups (e.g., selenitun deficiency in an area of China) or in of the need for vitamin E. Human deficiency is rare in North
people nourished exclusively by t0tal parenteral nutririon that did America. The selenium content of the soil in which a plant is
not contain sufficient trace minerals. grown greatly affects the selenium content of the plant food .
3. Iron is a critical component of hemoglobin, 1m·oglobin, and cy· Where the soil is selenium-poor, the inhabitants may experience
tochromes. Iron acts as a cofactor for several enzyme \)"Stems. selenium deficiency. Meat, eggs, fish, and shellfish .1rc sources of
Two-thirds of the body's iron is found in hemoglobin in red blood selenium. Plant sources include grains and seeds.
cells, where its job is co transport oxygen from the lungs to the tis- 11. Iodide forms part of the thyroid hormones, one being thyroxine
sues. A prolonged low incake of iron can lead t0 decreased pro· T.i· A l:ick of dietary iodide causes an enlarged thyroid gland,
duction of red blood cells and a lack of oxygen being delivered to known as goiter. The iodide contcnc of th<.' soil in "hi ch .1 plant is
the tissues. This condition is called iron deficiency anemia, which grown great!~· affects the iodide content of the planr food. Today,
results in fatigue upon exertion and apathy as well as decreased iodide deficiency in North America is \irrually unknown because
learning ability in children. of the fortification of table s.11t with iodide, but deficiency 1s still a
4 . The absorption of iron depends on the body's need for the min- major problem in most pam of the world.
eral and on rhe form of iron in food. The body cmnot rc.1dily ex- 12. fluoride cll.posure makes the moth crystal resist.mt to dental
crete excess iron, bur the body has a mucosal block rlu1 limits caries, and Jluoride in saliva aids in t he remincrali.-:.uion of dam-
O\'crabsorption. Heme iron from animal foods is better absorbed aged tooth surfaces. Most North Americans receive fh1oridt: from
than nonhemc iron obtained from pl.111t sources. The bes1 sou1u:s fluoridated drinking water and tootl1paste.
of dietary iron arc animal protein, including beef and other dark 13. Chromium contriburei. to the action of in~ulm . Chromium i\
meats, oysters, and lh·er. found in meats and whole grJins.
5. Girls and women ha,·e a higher RDA for iron than men bt:causc of 1-1. Mang.111e~e functions in ~e,·eral important enzrme systems, in-
menstrual blood losl>. Even in North America infants and d1ildren cluding one that p.1rticipatcs in amioxidant protection .
.1re often iron deficient. Deficiency is rare. Whole grains, legumes, tea, and nuts are food
6. Iron toxicity can occur because of a genetic disorder c.1llcd hc- sources.
mochromarosis, "hich causes the overabsorption of iron. Iron l;>. Molybdenum is found in several enzyme sysrems. Deficiency is
poisoning and death can occur when toddlers and young children rare. i\ lolybdenum is found in plant foods such as legumes and
swallow a large number of iron pills. whole grains.
7. Zmc functions as a cofucror for many cnl\·mc systems and .1lso sta· 16. Boron contributes co ion transport in cell membranes. l-ruits, leal)•
bilizes membranes and other bod)' molecules. Among the vcget.1blc~, nuts, and beans arc sources.
processes affected b)' zinc are growth, antioxidant protection, sex- 17. Nickel likel)' participates in amino acid metabolism. Nickel 1s
ual development, immm1c function, and taste. A zinc deficiency found in nuts, beans, :ind whole grains.
can result in growth failure, loss of .1ppetire, inadequate mental 18. Silicon is involved in bone formation. Root vegetables and whole
function, a persistent rash, and decreased immune fi.mction. grnins are sources.
8. Like iron, the best dietary sources of zinc arc found in animal 19. Arsenic likel)• participates in amino acid and D>:A metabolism.
foods. Need drives absorption. And like with iron, a mucosa! block Fish, grains, and cereal produces are sources.
in the intestinal cells regulates the amount of zinc rhar can be ab- 20. Vanadium like)~· has insulin like actions in the body. Shellfish and
sorbed. Calcium and iron in supplement form can interfere with mushrooms are sotu·ccs.
zinc absorption. The richest source of zinc is oysters. Other ani- 21. Cancer develops in a multistep fashion in the body. Numerous di-
mal proteins arc excellent sources. Plam somces are whole grains, etary factors affect the various steps in this process. A diet rich in
peanuts, and legumes. low-fa1 and fat-free dairy products, fruits, vegetables, and whole
9. Copper aids in iron mobilization from body srores. Copper is re- grains likely lessens cancer dc\'clopment in some body tissues.
sponsible for d1c cross-linking in collagen formation and also acts Regular physical acti,·ity adds further benefit.
Study Questions
J. What is a balance stud~·. and why is it only a limited rool in evalu- 4. 'vVh.u factors increase the abwrption of dietaq iron?
ating rhe need for rrace minerals? 5. What arc ~ome tests used m access iron deficiency anemia? mea·
2. What is anemia? How does a deficiency of,itamins E, K, B-6, fo- sure iron status? \Vhac exactly do these tesrs measure?
lacc, and B· l2 and the trace minerals iron and copper c.1me .me- 6. Wh~ doc~ zfoc affect so many body processes?
mia? Desciibe the specific type of such anemias. 7. The tluoridation of drinking \\,\ter began in rhe United State~ in
3. Explain three ke~' fi.1nctions of iron in the human body. 1945. How else do humans obtJin fluoride?
462 Chapter 12 Trace M inerals
8. Describe ci1c c hief fimction of fluoride , copper, chromium, man-

ganese, boron, nickel, and silicon in the body. BOOST YOUR STUDY
9 Why are animal foods a better source of iron, 1.inc, and selenium Check out the Perspective s in Nutrition: Online Learning
than foods of plant origin? Center "VWW.mhlw .com/ wardlawpers7 for quizzes, flash
I0. Prior to rhe 1920s, wh~r was goiter such a hc.ihh problem for pco· cords, activities, and web links designed to further help you learn
pie living in rhc Great Lakes region of the United Stares? How wa~
about Issues surrounding the trace minerals.
chis dcficicncv d isease eventually conrro lJed?
I. ADA Reporcs: Position of rhe American ,\fa11_v foodJ, pnrtimlar~v pln11t·bnscd foods, 10. Food and Nuuitio11 Board, lnstirute of
Dietetic Associarion: The impact offluo1idc on migbt bclp /01111'1" th<" ri.<11 of rcrtni11 rn11cen. Medicine: Dietar.v Rcfermce Iurnkes fiw 1•it11
hcllth. /011runl of the A111erirn11 Dietetic U11/ikc i11dh•1d11nl mpplmw1ts,fi111ds offer n 111i11 A, 1>itnmi11 K, m·srnic, bm·1111, clJ1'0111i11111.
Alsocmtio11 I 05: 1620, 2005. unique mi:.: 11f 1•itnmi11s n11d 111i11trnls, multiple copper, iodmc, iron, ma11gn11ru, 1110£vbdm11111,
T71e Amtric1111 l)uutic Associ11tio11 rtnf]irms p/Jytochemuals, Jibcr, and-1101 least of nll-tlu 11ickcl, silicnn, rn11nd111111. n11d ::-111r.
rbnr fl11oridc is n11 important demon for nil plenmrc of cnri11..n. Washington, DC. ::\'ational ·\c.1Jcmr Pre),,
mi1urnlized 1issucs in t/Je body. Approprinre flu· 6. Cornng:i N: Ooc,1cy, physic.ii ,1cu111)', and c.111- 2001.
oridc inrnkc is bmcftcinl to bo11r a11d toot/J i:cr risk. Today's Dirriti1111, p. 14, Ocrober 2002. Dictm·y sta11dm·dsfor mn.11y tnrr1· mincrn/i nff
/Jen Ith. Key factors Jin· rt'dttcing cm1ca risk nre mai11- cove1·ed. 11JC rntin11nle wed to s,·1 RDA or
2 Age-Related Eve Disease Stud>' Research milli11g n /JmltbJ bod_v 111ei._nlH n11d pcrfon11i11g Adeq11nu l11tnkcs n11d Upper l.nitls }ii,. these
Group: A r.1n<lomized, pl.icebo-conrroUed, re._1111lnr pl~mcnl nmrit)'. A1•01dm..11 n>cig/Jt~qai11 1111trirnts 11 diswsscd ill dernil
clinical tri.11 of high-dose supplementation with i11 ndulthood IS opainl~v 1mponn11t
11. Food Jnd N umt1on BoJrd, lmtiunc of
l'imnim ( and E ,tnd bcra-carnrcnc for agc- 7. Coughl in J.: American Cancer '>ocierr rdca~c~ 1'.ledicinc: [)frm1:v Refcrma l111nkcs fol' l'itn·
rdarcd ca1a1-.1c1 .111d \'ision lo>>. Arc/Jipe.r of ~n nu al gu1dch nc' for the c.1 rl y dc1cction of ca11 111i11 C, 1•i111nw1 E. sdc11i11m, nud mn11,•1111id>.
Opbt/Jn/1110/i{!J)' I J9: L439-1452, 200 I. i:cr. A11m·icn11 Fnmi~v P/J_vsici1111 7 1( 11 ):2202, Wa~h i ngwn, DC: N.ttio1u l r\odcmy ol
Megados( ::-i11c mpplcmrnts (80 111...11/dn.v of zinc 2005. Sciences, 2000.
oxide) comb11ud with 2 mg/dn_1· of copper re· 17u Amrricn11 Cnu<cr Socitf)· 1·u1m1111rnds rlJflt
d11ccd p1·0~111·tssw11 of mnrnlar de_qmtrntion in 111e fimct1011s of a11tioxidn11t 1111trimrs; bow
brcnsr cancer scru11ing sbo11/d be_qm w/Jm
RDA n11d rr/nud sr1111dm·ds wrn· drtowi11rrf:
proplc rrbo .c/Jnwtd e1>idcncc of t/1c d1senu. T71e womeu m·c 20 )'t'lll·s old, ll'itb di11icnl brmst ex·
::-me mpptwmw n•orked ei•rn better 111/Jm pro- n11d deficiency mui toxicity sy111ptm11s nt'~
nminntillw n•cry 3 .venrs 1111til tbr ngc of39. explni11ed.
l'tdcd i11 combinntio11 n•ith 400 JU of1•itami11 TJJe1·enfte>~ wumm n.t average risk s/1011/rf hn1•c
E, 500 mg ofl'1rnmi11 C, n11d LS mg of bem- n11n111111nl111nmmograp1Jy Ccr1•1cnl cn1uer 12. Franchini M, Veneri D: Hcredic.uv hemochm·
cnrou11e. 11JC am/Jors S11.!l..1TCJt t/Jnt nd11lrs 111/Jo scrcm11w .<l11mld be._qm 3 .venrs njta 1/Jc onset nf matoMs. Hc111arolog,r 10( 2 )· l 45, 2005.
bnre evidrnu of mncular degtllcrarto11 tnlk to Mgiiin/ 111Tffco11rsr bur 110 Inter t/Jf111 21 .vcnrs Hcred1rar_v l1tmoc/J1·0111ntosis 11 n duord,.,. 1if mm
tlmr pl~11iciam n/Jo11t possibly fo/1011>ing mc/J n ufngc. Adults !It ni>emgt nsk of d1wlopi11g col- 111etnbolis111 c/Jnrnc;rei·iud V)' pr11.wrssi1•e ris..-111'
protocol. orcctnl ca11rcr sl1011lrf bcgi11 scrc&11i11g nt 50 .Ytnrs il-011 ovc1·/ond t/Jar lcndst11 irre1>rni/Jlt Qrgn11
3. l~urk RF, Lca,·andcr OA: Selenium. In Shils of ngc. Mm nt IJ(11/1 ,.isk fi1,. pnJS/ntc cn11eei· damage 1/11or rreared in time. 11m1sftrri11 sntu·
Ml:. and other~ (eds): 1\lodem nutrition 111 s/Jo11ld b(/1111 trstmg ar the n..ne of -15. rntio11 n11d serum ftrriri11 nrc still tbt mosr ,.d1-
/Jmlt/J nnd diJtfl!f I 0th ed. Phil.1delphia, PA: 8 Eck.hen CD: Olhcr tr.ice clcmcnr~ In Shils Ml-. nble tests for r/Je dercmo11 ofpeople n'llh
Ltppmcorc Williams & Wilkins, 2006. and ocher.. (c<l)): ,\ lodem 1111rr1tio11 i11 /Jen/th /Jerdirnr)' bcmoc/Jromntosis. n1crnpr11ric p/Jlr-
Se/eni11111 bas bor/J k11ow11 and less ll'tll·knonm a11d disease. I 0Lh ed. Philadc:lphia, PA. boto111.1• is tbe 11111insray of t,.cntmmr. If p/Jle-
j/111ctio11s, mr/J ns for t/Jioredoxiu, n recently de- Lippmcott Wi lliams & Wilkins, 2006. botom.r is stnned befo1·c tbe omct of wm1cmblc
scribed set of nmiuxirfn11i en::-ymcs tl1nt co11tni11 OllJflll rfamngc, tbc lift c.-.:pcctflll(Y of time pn
At least 18 demmrs could be co11s1dt1·<'d ultra·
stlmi11111. ill some cnses, modcrnrcl.v bigb sele- trace 111i11ernls: nlm11i1111111, n1·srnic, boron, ttents is s1milnr to rlmt of r/g 11ominl pop11lnt11111.
11i11m intakes mny bdp prermr ccrrni11 disrrues, bromillt, tt1d111i11111, cbrom111111,fl11oride,gcr- 13. King JC. Cousins, RJ: Zinc. In Shib .'olE and
mcb as cn11ur. 111n11i11111, 1od11u, lend, lirlm1111, 111of.1'bdem1111, ochers (cd\): :0-lodem 1111rrmo11 111 brnlrb n11d
4. Bvcrs T and other>: American Cancer Sociccy nickel, r11b1rfi11111, 1rlcni11111, silicou, ri11, n11d disease. J01h ed. Philadclph1.1, PA. Lippin.:on
guidelines on nurririon and physical activity for vnnndi1tm. 'nJC role of eacb m b11111n11 mui lnbo- WilJiams & Wi lkins, 2006.
cancer pre,·cntion: Reducing the ri5k of cancer rntory 1mi11111/ pb_vsiologicnl systems is rci1iemerf T/Jis rhnptcl" presents 1•nrio11s rnbjccts rdt:Pnur tu
\\;th health\• lood choices and physical acti,·il)•. i11 tins c/Japtcr t/Jis millcrnl. Zinc is espccia/(v 1111porrnnt to alls
CA: Cmict1· /011r11al fur Cl1111cin11s 52:92, 9. Food amt Nutrition Bo.ird, Institute of r/Jnt bnl't 11 ht11b t1tmo1•tr, mc/J ns 11111111mr er/ls.
2002. J.ledicine: l)ictnr.1· Reference lnrnkcs for ca/- 14. Liu RH : Polcntial synergy ofph\IO~hcmkal' in
A diet loll' i11 red n11d p,.ocessrd wen rs n11d rich ci11111, pbosplJ11r11s, 11tfljJ1ltsi11111, 1•1Tn111i11 D, n11rf cancer prevention: Mechanism of acurn1.
111 fn1its, 1•(1)ttn/1/es, nud w/Jolegrni11.r is nd110- flu oride. Wa~hmgron , DC: Nauonal Acadenw ]01mrnl of N11triti1111 134:347$, 2004.
cnterf as a srrnf(fT.Y Jiw 1·ed11ciug cnuccl' risk. Press, 1997. No si11g/c n111ioxidn11t cn11 n·plnrr r/J1· .-ombm11·
Reg11lnr plJ.vsicnl acril>ir.1· is n/so i111portn1it to Dittar.1· sr1111dm·ds for 111n11.v mnjol' mmtrnls m·c riou of11arurnl plr;toc/Jemicnls 111 Ji-lms n11d
ndd. co11ercd. 11" rntio11nle med to sff RDA or l'egcra/Jlcs to ac/1icrc the limltb lmujits.
5 <...tncer-fighting foods. .\Inyo Clill ic Hen/th Adeq11nrc fornkn n11rf Upper Le1•ds for rhcse A11tioxidn11rs 01· /nonetn•c co111po1111ds nrt best
Lmer 22( I 2 ): I, 2004 1111trimts i1 dimmi·d in drtnil. acquired tlm111.qb wliolefonrf mm11111pt1011, 1111t
17. Willcrr WC: Diet .md cJno:r: An crnhing pi..:- 1999-2000. AdM1m D11t11 '134: I, 2003
fr11111 dictnr.v mpplo11ow. C:1111m111ptit111of5 t11
JO stTl'i11..11s d.1if.1· ti/ n w1d,· l'nrWJ ofjh1its n11d nin:. /011m11/ uf t/Jr A111crfrn11 .llcdicnl (April 17 '·
1••:wrnblcs is n11 11pp1·11print•· srmu..11.v }ill' si__rp1ifi· Associnritm 293· 2 );233. 200S. l\i1111m i11 _qrncml fnil to 111ut im11 11uds. /II
mmf.v rt'd11cillg ""risk of dm111ic dismSt's mc/J 17ic rd11ri1111 brtir•'t'll rt'n mmr mnm111ptio11 nnd c1111rr11sr, ::.me intakes appmr ndrq11nte 110'0$$ tllf
ns ca11"r n111l to mat 1111triwt r.-q11iro110/fs fur rulorcrrnl canur 11111y 1wt b,· ru11d11m·e, /1111 pr11· 11d11/r pop11Jntfo11.
opti11111111 bt.·1/1/J. de11u 11'011/d Sltf[flt'.<t tlmt r.·d mmt, 1111d 20 ZnnmcrmJn ~IB: :\~c~ng icl<iinc \!Jlll' .iml
15. Patel ID .111d other.: Lun~ c.mccr in LS proass.·d 111mt1 i11 pnrtu11"11; 1l11lltld br <'ntm momroring pro!o-'TCS> of iodized 'alt progrJlll\.
women /0111'1/nl ti}' tl1t· A11urun11 ,\frdicnl spnrittrrl_v to 111111i1111:x risk. l\'bm tlm ndl'irr u /mmml of~'11ttitim1 134:1673, 2004.
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Take I Action j :
I. Analyze Iron and Zinc Intake in a Sample Vegan Diet

Steve hos been a vegan for 2 months. He chose thi s diet pattern for health reasons, but is his diet really that healthy? His food and
beverage intake yesterday was as follows:
Breakfast
Soy milk, 1 cup
Raisin Bron cereal, 1 cup
Bonano, 1
Block coffee, 12 oz
Lunch
Sandwich:
Whole-wheal bread, 2 slices
Tomato, 1 small
Bean sprouts, 1/4 cup
Mayonnaise, 2 tbsp
Granola bar, 1
Orange, 1
Water, 12 oz
Snock
Oatmeal cookies, 3 small
Apple juice, 12 oz
Dinner
Salad:
Romaine lettuce, 1-1/2 cups
Carrol, 1 (shredded!
Cucumber, 1/2 sliced
Mushrooms, 1/3 cup
French dressing, 3 tbsp
White bean soup, 2 cups
Whole-wheat crackers, 8
Soy cheese, 1 oz
Hot tea, 12 oz
Snock
Popcorn, 3 cups
Root beer, l 2 oz
Start by analyzing Steve's iron and zinc intake using Appendix N or the NutritionColc Plus software. What is your conclusion? Does
Steve's diet appear to be o healthy way to eat? What other nutrients may be of concern? Check the analysis for those nutriel)IS also
...
~ 11 ..:eSec~.Out Vo~r!Municipal 1 Water SuppJy
-
• •
Heollhy People 2010 set a goal that 75% of people in the United States will be served by community waler systems that odd sufficient
Auoride. Today only about 60% of Americans hove access to naturally or artificially Auoridoted water. Is your hometown (or ~allege
town) water supply Auoridoted? To find the answer, check with your local water deportment. What amount of fluoride is odoeo to
drinking water, and how long hos this procedure been in operation? You con also check with your family dentist; he or she will know
how much Auoride is added to the water in your hometown. If the water supply is not fluoridated, what procedures does your dentist
i ecommend For obtaining sufficient fluoride?
ENERGY BALANCE AND
CHAPTER THIRTEEN WEIGHT CONTROL

Energy Balance Chris hos o hectic schedule. He works full-time at on industrial plonl. Three nights o
Positive and Negative Energy Balance • Energy
Intake • Energy Output • Basal Metabolism week he attends class ot the local community college in pursuit of certification. On
Determination of Energy Use by the Body weekends he tries to squeeze in studying and time for his family ond friends. He hos
Direct and Indirect Colorimetry • Estimates of m
Energy Needs
little time lo think about what he eats-convenience rules. Unfortunately, over the zm
Why Am I Hungry? post few years Chris's weight hos been climbing, especially around his waist. ~
Hypothalamus: Key Satiety Regulator • Satiety Watching television o few nights ago, he sow on infomercial for a product that GJ
Regulation of Other Body Sites • Control of ~
Feeding through Body Composition • promises he con eat large portions of tasty foods but not gain weight. Celebrities c:o
)>
Hormones Thal Affect Satiety • Nutrients in the support the claim that this product allows one to eat at will ond not gain weight.
Blood Thal Affect Satiety • Does Appetite );::
Regulate Whal We Eat? • Hunger and Appetite This claim-that by toking this product he con eat whatever he wonts and never z
()
In Perspective gain weight-is tempting lo Chris. What do you think he should do? What advice m
Estimation of a Healthy Weight con you offer Chris for evaluating weight-loss programs? )>
Using Body Mass Index (BM/) lo Set Healthy
Weight • Putting Healthy Weight info
z
0
Perspective
Expert Opinion: Sorting Out Satiety and Weight ~
c:o
Regula tion: Hormones and Dietary )>
Macronutrients );::
Energy Imbalance z
()
Estimating Body Fat Content and Diagnosing m
Obesity • Using Body Mass Index lo Define
Obesity • Using Body Fat Distribution fo Further
Evoluafe Obesity
Why Some People Are Obese-Nature Versus
Nurture
How Does Nature Contribute lo Obesity? •
Does the Body Have a Set Point for Weight? •
Does Nurture Have a Role? • Nature and
Nurture Together
Treatment of Overweight and Obesity
What lo Look for in a Sound Weight-Loss Plan
• Wishful Shrinking-Why Can'/ Quick Weight
loss Be Mostly Fat? • Weight Cycling ls All Too
Common • Weight loss in Perspective
Control of Energy Intake: The Main Key lo
Weight Loss and Weight Maintenance
Regular Physical Activity: A Second Key to
Weight Loss and Especially Important for
Loter Weight Maintenance
Behavior Modification: A Third Strategy for
Weight loss
Nutrition Focus: Popular Diets-Why All the
Commotion?
Professional Help for Weight loss
Medications for Weight loss • Treatment of
Severe Obesity
Treatment of Underweight
Toke Action
465
I n North America, 29% of men and 44% of women ore trying to lose weight. Still, despite all their ef-
forts, the ranks of the obese in North America and worldwide ore growing. 9 Recall from Chapter 1
that it is estimated that about 1 billion people in the world ore overweight. This problem is increasing not
only in the United Stoles but also among affluent people in Brazil, Chino, Indio, Russia, the United
Kingdom, Germany, and many other countries. Excess weight increases the likelihood of many health
problems, such os cardiovascular disease, cancer, hypertension, strokes, certain bone and joint disor·
ders, and type 2 diobetes. 1l ,19 To some extent regular physical activity con prevent or reduce the risk of
these health problems, but lifelong weight control is still an impor-
tant focus. 10
For most people, weight-reduction efforts fizzle before people CHAPTER OBJECTIVES CHAPTER 13 IS DESIGNED
TO ALLOW YOU TO:
achieve o healthy weight range Typical popular ("fad ") diets
are generally monotonous, ineffective, and confusing. They may 1. Describe the uses of energy by the body and what constitutes
energy balance.
even endanger some populations, such as children, teenagers,
2. Characterize the terms hunger, appetite, and satiety and outline
pregnant women, and people with various health disorders. Yet the internal and external forces involved in satiety regulation.
a more logical approach to weight loss is actually very straight- 3. Describe how to establish o healthy weight for o person.
forward· ( 1) Eat less; (2) increase physical activity; and 4. Describe various ways to diagnose overweight and obesity
(3) change problematic eating behoviors.19 5. Outline the risks to health posed by overweight and obesity.
Experts are colling for a notional commitment lo address the 6. List and discuss factors affecting energy balance and describe
growing weight problem in North America. They suspect that the the concept of set point.
current trends will not be reversed without a notional commitment 7. Describe why and how reduced energy intake, behavior
to weight maintenance and effective new approaches lo making modification, and increased physical activity fit into a weigh;.
loss pion.
our social environment more favorable to maintaining o healthy
8. Evaluate popular weight.reduction diets and determine which
weight.2 Chopter 13 discusses these recommendations to help ore unsafe, doomed to foil, or both.
you understand obesity's causes, consequences, and potential 9. Outline the benefits and hazards of various weight-loss methods
treatments. Note that Chapter 17 does the same for child and for severe obesity.
adolescent obesity. 10. Describe possible reasons and treatments for underweight
status.

OF ENERGY BALANCE AND WEIGHT CONTROL IN CHAPTER 13,
YOU MAY WANT TO REVIEW:
The concept of energy density ond oppropriote single serving sizes for foods in Chapler 2
• The causes and consequences of ketosis in Chapter 4
The fat content of various foods in Chapter 6
The lon9·term risks of high-protein diets, especially for some people, in Chapter 7
Energy Balance
Thil> chapter b egins with som e good news Jnd some bad news. The good nc\\'S is thar
ir ~ro u stay at a hcalLhy body weig ht, you increase your chances o f living .1 long and
healthy life. T he bad news is that currently 65% or
all North AmcriC•lll adults art: over-
weight, signjfic:mtl\ more than JS n:ccntly JS the 1980s. Qf those, about 45% ( 3()% of
the total popul.uion ) are obese. There is a good dunce thJt any o f us could b1.:..:omc
pan of those statistics if we do not pJ\ .utcnrion to prnenting significant \\eight g.1in
in ,1 dulthood.4 Gaining more than L0 lb or 2 inches in waist circumforencc .1rc sigmls
that a reevaluation o f diet and lifostylc is in o rde r.
466
There is no quick cure for overweight, despite wh at advertisements and in- y ~ =·· '
·The Growing OverweightI
fomercials claim. Any success comes from hard work and commitment. Currently,
Obesity Problem
a combination of decrease in energy intake, increase in physical acti\'ity, and behavior
modification is the most reliable plan for the problem of O\'erwcight. And withour a Adults 20 to 74 who are overweight
doubt, pre\'enting the problem in the first place is the most successful approach of aJl.9 or obese:
1960-1962 45%
Positive and Negative Energy Balance 1971-1974 47%
Many of us would benefit from paying more attention to the important concept of 1976-1 980 47%
energy balance. Think of energy balance as an equation:
1988-1994 56%
Energy Input = Energy Output 1999-today 64.5%
(food incake ) (metabolism; digestion, absorption, and
transport of nutrients; physical activity)
The relative size (measured in kcals) of the rwo sides of this equation can infl uence
energy stores, especially the amount of trigl)rceride stored in adipose tissue (Figure 13-1 ).9
energy balance The state in which energy
When energy input is greater than energy output, the result is positive energy bal- intake, in the form of food and beverages,
ance. The excess energy consumed is stored, resulting in weight gain. There arc some matches energy expended, primarily through
situations in which positi,·e energy balance is necessary. During pregnancy, a surplus of basal metabolism and physical activity.
energy is needed to support tl1e de\'doping terns. Infants and children require a posi-
ri,·e energy balance for growth and de\ c.:lopment. In adults, however, eYen a small pos- positive energy balance The state in which
energy intake is greater than energy expended,
itive energy bahu1ce over rime can cause body weight to climb.
generally resulting in weight gain.
On the otl1er hand, if energy input is less than energy ourput, there is an energy
deficit, and negative energy balance results. Weight losl> occurs because the person is negative energy balance The stole in which
in a state of negati\'e energy balance. And e\'cn tl1ough we think of extra bod) weight energy intake is less than energy expended,
as "far," this \\'eight loss always invoh·es a reduction in both lean and adipose.: tissuc- resulting in weight loss.
jusr the relati,·e mix differs.
As nored in the introduction, maintaining energy balance- matching energy intake
to energy output over the long term- substantially contribmes to health and well-
being in adults by min imizing the risk of developing many common health problems. 19
Adulthood is often a rime of subtle increases in weight gain, which e\'entually turns
into obesity if left unchecked. The process of aging itself docs not cause weight gain;
rather, weight gain stems from a pattern or excess food intake coupled with limited
physical acti\'ity and slower metabolism. 9 The following sections look in derail ar the
factors tl1at affect the energy balance equation.
Energy Intake
Energy needs are met by food intake, represented b\• the kcaJs eaten each day.
Determining the appropriate amount and type of food to march energy needs O\ er the
Today we demand food that is immediately
long run is a challenge for many of us. Our desire to consume food and ability lO use available, tastes great, requires little or no
it efficiently are evolutionary survival mechanisms. However, because of modern preparation, and is served in generous
North American food supplies and accessibili ty, many or us arc now too successful in quantities. Of these characteristics, the
obtaining food energy. The refrigerator has essentially replaced the need to store body generous quantities are the most troublesome
fat-food is always at hand. 19 And given the wide availability of food in vending ma- for many of us. As noted in Chapter l , a
chines, drive-up "indows, social gatherings, and fast-food restaurants-combined with response to serving large quantities might be to
larger and larger portions-it is no \\'Onder that the an:ragc adult is 8 lb hea,·ier tl1an share your meal with another person.
just 10 years ago. You might say "food hunts man" today. In response to this cultural
trend of wide food availability, "defensive eating" (i.e., making careti.u and conscious
food choices, especially in regard to portion size) on a cominual basis is important for
many of us. s, l 5
How much food energy is contained in a meal? A bomb calorimeter can be used LO bomb calorimeter An instrument used to
determine the amount of energy in a food. The process is described in Figure 13-2. The determine the energy content of a food.
bomb calorimeter measures the kcals th.u can be dcri\•ed from carbohydrate, far, pro-
tein, and alcohol. Recall that carbohydrates yield about 4 kc.ll/g, proreins yield about
4 kcal/g, fats yield about 9 kcal/g, and alcohol yields 7 kc:11/g. These energy fi gures
468 Chapte r 13 Energy Balance and Weight Control
T
Intake 'Output Weight Chang~
- - - -- - - --~
Energy balance
(equilibrium)
3000 kcal 3000 kcal
.....
,,
Positive energy
~ balance
"... _....;( .
.•
: . 1
..
4000 kcal 2000 kcal Increase
N egative energy
balance
2000 kcal 3000 kcal Decrease
Figure 13· 1 I A model for energy balance-input vs. output. This figure depicts energy balance in
practical terms.
have been adjusted for ( 1) digestibility and (2) substances in food, such as fibrous plane
A 26-year-old classmate of yours hos been parts that burn in the bomb calorimeter but are unusable by the human body for rn -
thinking aboul rhe process of aging. One of crgy needs. The figures are then rounded to whole numbers. Note, however, that
lhe things she fears most as she gets older is today it is more common to determine the energy content of a food bv simply quan
gommg weight. How would you explain en- tifying its carbohydrate, protein, and fat (and possibly akohol) comenr. Then the
ergy balance to her? kcal/g factors arc used to calculate the total energy content. ( Recall that Chapter l
showed how to do this calculation.)
Figure 13·2 I Cross-section of o bomb

colorimeter. A dried portion of food is burned
inside a chamber charged with oxygen and
surrounded by woter to determine energy
Thermometer content. As the food is burned, it gives off heat,
which increases the temperature of the water
surrounding the chamber. The increase in water
temperature indicates the number of kcal
contained in the food, because 1 kcal equals
the amount of heat needed lo roise the
temperature of 1 kg of water by 1°C.
_,....~--- Chamber
Insulation-----
around chamber for food
Energy Output
The other side of the energy balance equation is energy outpur. The body uses energy
for three general purposes: basal metabolism; physical activity; and digestion, absorp-
tion, and processing of ingested nutrients. A fourth minor form of energy output,
known as thermogenesis, refers t0 energy expended during fidgeting or shivering in re-
sponse to cold (Figure 13-3).9
Basal Metabolism
As co,·ered in Chapter 12, basal m etabolism (expressed as basal metabolic rat e basal metabolism The minimal amount of
[BMR]) represents the minimum amount of energy expended in a fasting state energy the body uses lo supporl itself in o
( 12 hours or more) to keep a resting, awake body alive in a warm, quiet environment. fosling stole when resting and awoke in o
For a sedentary person, basal metabolism accounts for about 60 to 70% of total energy worm, quiet environment. II amounts to roughly
use by the body. Some of the processes involved include the bearing of the heart, res· 1 kcal/kg per hour for men and 0.9 kcal/kg
per hour for women.
piration by the lungs, and the activity of other organs such as the lfrer, brain, and kid·
ney. 9 It does not include energy used for physical activity or digestion, absorption, and basal metabolic rate (BMRl The rote of energy
processing of nutrients recently consumed. If the person is not fasting or completely use (e.g., kcal/min) by the body when ot rest
rested, the term resting m eta bolism is used (expressed as resting metabolic rate and awoke in a worm, quiet environment.
[1Uv1R] ). An individual's RMR is typically 6% higher than his or her BMR. resting metabolism The amount of energy the
To see how basal metabolism contributes to energy needs, consider a 130-lb woman. body uses when the person hos not eaten in
First, knowing that there are 2.2 lb for every kg, convert her weight into metric units: 4 hours and is resting (e.g., 15 to 30 minutes)
130 -:- 2.2 = 59 kg and awoke in a worm, quiet environment. It is
roughly 6% higher than basal metabolism due
Then, using a rough estimate of basal metabolic rate of 0.9 kcal/kg per hour for an to the less strict criteria for the lest; often
a\'erage female (1.0 kcal/kg per hom is used for an average male), calculate her basal referred to as resting metabolic rate (RMR).
metabolic rate:
59 X 0.9 = 53 kcal/hour
470 Chapter 13 Energy Balance and Weight Control
Figure 1 3·3 I The components of energy Basal Thermic effect

intake and expenditure. This figure incorporates metabolism of food (TEF)
lhe moior variables lhol influence energy
balance. Remember tho! alcohol is on Physical
activity
oddilionol source of energy for some of us (but
is not depicted). The size of each component
shows the relative contribution of !hot
component lo energy balance.
hile a person is resting, the percentage Finally, use this hourly basal metabolic rate to find her basal metabolic r.w: for an
W of total energy use and corresponding
energy use by various organs is approximately
entire day:
as follows:
53 X 24 = 1272 kcal
T hese calcul:uions give only an estimate of acrual basal metabolism, bec:rnsc it can
Brain 19% 265 kcal/ doy
vary 25 to 30% among individuals. Factors that increase basal metabolism include:
Skeletal muscle 18% 250 kcal/day
Liver 27% 380 kcal/ doy • Greater lean body mass
Kidney 10% 140 kcal/ day • Larger body surface area
Heart 7% 100 kcal/day • Male gender (q pically more lean body mass compared to fema les)
1
Olher 19% 265 kcal/ day • Body temperaLure (fever or cold environmental conditions)
• Thyroid hormones
• Aspects of nervous system activity (release of n01·epinephrine)
• Pregnancy
lean body mass Body weight oher subtracting • Caffeine and tobacco use (Still, using smoking to control body weight is not rec-
fat storage weight. lean body moss includes ommended because too many health risks are increased.)
organs such as the brain, muscles, ond liver os
well os blood and other body fluids. Of those factors, the amow1t oflean body mass a person has is the most important one.
In contrast to fuctors that increase basal metabolism, a low-energy intake decreases
basal metabolism by about 10 co 20% (about 150 to 300 kcal/day) as the body senses
starvation and shifts into a conservation mode. This shift is a barrier to sustained
weight loss during dieting that im·olves an exrremely lo'' food intake. 19 In addition,
the effects of aging make weight maintenance a challenge. As lean body mass slowly
and steadjly decreases, basal metabolism declines 1 to 2% for each decade past the age
of 30. However, because physical activity aids in maintaining Jean body mass, remain·
ing active as we age helps to preserve a high basal metabolism and, in turn, aids in
weight conrrol. 10
Energy for Physical Activity

Physical activity increases energy expenditure above and beyond basal energy needs by
as much as 25 to 40%. In choosing to be active or inactive, we determine nmch of ow·
total energy expenditure for a da). Energy expenditure from physical ac1friry in rum
varies widely among people.
Classwork leads to mental stress but puts little Climbing stairs rather than riding the eb•ator, walking rather than driving to the
physical stress on the body. Hence, energy store, and standing in a bus rather than sitting increase physical activity and, hence, en-
needs ore only about 1.5 kcal per minute. ergy use. T he alarming rate of and recent increase in obesity in North America are
caused in parr by our inactivity. 10 Jobs demanJ less phy'>ical acti\'it), .rnd leisure time is
often spent slouched before a tcle\'ision or computer.
Thermic Effect of Food (TEF)

ln addition to basal metabolism and physical acti\'ity, the body use~ energy to digest, ab-
sorb, and further process the nmrients receml~· consumed. Energy used for these tasks thermic effect of food ITEF) The increase in
metabolism that occurs during the digestion,
is referred to as the t h erm ic effect of food (TBF). TEr i~ analogous to a sales tax-it
absorption, and metabolism of energy·yielding,
is like being charged about 5 to l 0% for the tot.11 amount of energy we eat to cover the
nutrients. TEF represents 5 to 10% of energy
cost of processing the food eaten. (\Ve ma) recognize this increase in metabolism as a consumed.
\\arming of the bod) during and right .tfter <l meal.) For every 100 kcal needed for basal
metabolism and physical acti' ity, we must eat between I 05 and 110 kcal. ff our daily
energy intake was 3000 kcal, TEF would account for 150 to 300 kc.11. As with other
component!> ofenerg) output, the total amount can \'ar~ somewhat among indhiduals.9
Food composition influences TEF. For example, the TEF \•alul' for a protein -rich he TEF value for alcohol is 20%.
meal (20 to 30% of the energy consumed) is higher than that of .1 carbohydr;ltc- rich
( 5 ro I 0%) or fut-rich (0 to 3%) meal because it takes more energy to metabolize amino
acids into fat than to com·en glucose into glycogen or tr:mstcr absorbed fat into adi -
pose stores. ln addition, large meals result in higher TEF \alucs than the same amount
of food e<HCn over many hours.9
Thermogenesi s
T herm ogenesis represents the increase in non\'oluntary physical activity triggered by thermogenesis The ability of humans to
mid conditions or O\creating. Some examples of nonvolunrary activities include fid- regulate body temperature within narrow limits
gering, shi,·cring \\hen cold, maintenance or muscle tone, and upholding body posture (thermoregulotion). Two visible examples of
when noc lying down. 9 Studies h<l\e shown rhat son1e people arc .1blc t<> resist weight thermogenesis are fidgeting ond shivering
when cold. Other terms used to describe
gain from oYerfeeding by inducing thermogcncsis, "hilc others .1re not able to do so
thermogenesis ore adoptive thermogenesis and
ro a great extent. Note also that thcrmogcncsis goes by other names: thermorcgula-
nonexercise activity thermogenesis (NEAT).
cion, ad.1ptivc thermogcnesis, and nonexercise .Ktivity rhermogcnesi~ (NE.l\T).
B rown a dipose tissue is a specialized form of adipose tissue that participates in brown adipose tissue A specialized form of
thermogencsis. It i:-. found in small ,1moums in infants. The brown appearance results adipose tissue that produces large amounts of
from its rich blood flow. Brown adipose tissue conu-ibutcs to rhermogcncsis by releas- heat by metabolizing energy-yielding nutrients
ing much of the cncrg~ from energy-yielding nuu-ients into the emironmem as heat. without synthesizing much useful energy for the
body. The unused energy is released as heat.
le contaim protcim that uncouple ener~ release with ATP production. Adults have
n:ry link bro\\11 adipose tissue, and its role in adulthood is unkt10\\n. It is thought to
mostly be important for thermoregulation in infants, in whom brown adipose tissue
contributes as much as 5% of body wcighL Hibernating animals also make use of
brown adipose tissue so they can generate hear to withstand a long "inter.
The contribution of thermogencsis to o,·erall energy expenditure is fairly small. The
combination of basal metabolism and TEF accounts for 70 to 80% of e nergy used by
a sedentary person. The remaining 20 to 30% is used mostly for physical acti\'ity, with
a small amount used for thermogcnesis. 9
Concept I Check
Enerro balance invohes matchmg energy intake with encrgv output. cnerro· content of
too<l 1~ expressed in kcals and can be determined using J bomb calorimeter This anal)rsis
yield~ the .}-9-4-7 estimates for kcab in a gram of carbohydr:irc, fat, protein, and akohol.
The body uses energy for four main purposes:
l. B.tsal metabolism (60 to 70%of cotal energy output) represent~ the minimal
amount of enl'rfil needed to maintain the body ac resc. Primary determinants of
b.1sal metabolic rJte include quantiry of lean body m.m, amount of hody surface,
and thyroid hormone concentrations in the bloodmeam.
2. Phvskal actiYit) expenditure (20 to 30% of total energy output) represents cnerro•
u~e for total bmh cdl metabolism aboYe ''hat is n1:eded during rest .
472 Chapte r 13 Energy Balance and Weight Control
3. Thermic cffecL of food (5 to I 0%of total energy output) represents the energy
needed to digest, absorb, and process recentl)r consumed nutrients.
4 . Thermogenesis (small, \':triable percentage of total enerb'Y output) includes nonvol-
untan, heat-producing actiYitie~ . such as fidgeting and shivering when cold.
Determination of Energy Use by the Body

T he amounc of energy a bod) uses cm be measu red by borh direct and indirect
calorimetry or can be estimated based on height, weight, degree of physicaJ acti,iry,
and age.
Direct and Indirect Calorimetry

Direct calo rimetry measures the amount of body heat released by a person. The sub-
jcct is put into an insulated chamber, often the size of a small bedroom, and body hear
released increases the tempcrarure of a layer of water surrounding the chamber. A kcal,
as you recall, is related ro the amount of heat required to raise the temperature of
Figure 1 3.4 I Indirect colorimetry. The water. By measuring the water temperature in the direcL calorimeter before and after
method of measuring oxygen use and carbon the body releases heat, scien tists can d etermine the e nergy expended.
dioxide output can determine energy use D irect calorimetry works because almost all the energy used by the body evenrually
during daily activities. leaves as hear. r lowe,·er, te" swdies use direct calorimetry, mosrly because of its ex-
pense and complexity.
The most commonly used method of indirect calo rimetry measures the amount of
oxygen a person consumes (Figure l 3-4). A predictable relationship exists between the
direct calorimetry A method of determining a
body's use or energy and oxygen. For example, when metabolizing a mi xed diet of car·
body's energy use by measuring heat that is
released from the body, usually using an
bohydrate, fat, and protein-a l)1pical blend of energy-yielding nutrients- the human
insulated chamber. body needs l liter of oxygen m yield abou t 4.85 kcal or energy.
Tnstrnments LO measure oxygen consumption for indirect caJorimctry arc wide!~
indirect colorimetry A method to measure used. They can be mounted on carts and rolled to a hospital bed or carried in back-
energy use by the body by measuring oxygen packs \\ hilc a person plays tennis or jogs. There arc even newly developed handhdd in-
uptake. Formulas are then used to convert this
struments (nude by Body Gem). Tables showing energy costs of various forms of
gas exchange value into energy use.
nercises rely o n information gained fro m indirect calo ri metr y studies.
stable isotope A specific nonradioactive form Ano the r app roach to indj rect calo rim etr y uses s table isoto pes of oxygen and h)'-
of a chemical element. II differs from atoms of drogen. In this method, a person d rinks isotopically labeled water (2 H 2 0 and
other forms (isotopes) of the same element in H/80). Analysis of urine and blood samples provide data o n 2H and 18 0 excretion.
the number of neutrons in its nucleus. Stable The labeled oxygen is eliminated from the body as water and carbon dioxide,
means that the isotope is not radioactive, in whereas the hydrogen is eliminated only as water. Subrracting rJ1e hydrogen losses
contrast to some other types of isotopes.
from the:: oxygen losses provides a measure of carbon dioxide o utp ut. Th is ulcimace
estimate of C0 2 output is t hen L1sed co calcula te energy expenditure, just as is done
with oxygen use in indirect calorimetry. 2H and 18 0 arc stable isoto pes or h ydrogen
and oxygen (therefore, they arc nonradioacti,·c); special instrume n rs can measure
i.hem in body fluids . This stable isotope method is quite accurate but also very ex-
pensi\"e. It is the basis for determining estimated energy requireme n ts for humans
(see the next section ).
Estimates of Energy Needs

The Food and Nutrition Board has published a number of formulas called Estimated
Energy Requirements (EER), to cstim,ltc energy needs. Listed here are the formulas
for adults (remember to do multiplication and di\'ision before addition and subtrac-
tion). ( Formula~ for childr en, tei.:nagers, p regnant women, and lactating women are
listed in C hapters 16 and 17.)
www.mhhe .co m/wa rd la wpers7 473
Men 19 years and older he Harris-Benedict Equation can be used lo

determine resting energy expenditure (REE).
EER = 662 - (9.53 x AGE) + PA x (15.91 x WT + 539.6 x HT)
Men
Women 19 .i•cnrs and older REE = 66.5 + (13.8 x WT) + (5 x HT)
- (6.8 x AGE)
BER= 354 - (6.91 x AGE) +PA x (9.36 x WT+ 726 x HT)
Women
The \'ariablcs in the formulas correspond ro the folio\\ ing: REE = 655.1 + (9.6 x WT)+ (1.9 x
EER Estimated Energy Requirement HT) - (4.7 x AGE)
AGE = age in years The variables in the formulas correspond lo the
PA Physical Activity Estimate (sec the accompanying tabk ) following:
WT = weight in kg ( lb + 2.2)
REE Resting Energy Expenditure
HT = height in meters (inches + 39.4) WT weight in kg (lb + 2.2)
HT height in cm (inches X 2.54)
Physical Activity IPA) Estimates AGE = age in years
Activity Level PA (Men) PA (Women)
Sedentary (e.g., no exercise) 1.00 1.00
Rough guidelines for energy needs (in kcals)
low activity (e.g., walks the equivalent of 2 miles per day al 3 to 4 mph) 1.11 1.12 from MyPyramid ore os follows:
Active (e.g., walks the equivalent of 7 miles per day ot 3 lo 4 mph} 1.25 1.27 Children Sedentary ~ Active
Very active (e.g., walks the equivalent of 17 miles per day at 3 to 4 mph) 1.48 1.45
2-3 years 1000 )J 1400
Practice using the formula for EER. Consider a man "ho is 25 years old, 5 feet,
9 inches ( 1.75 meters), 154 lb (70 kg), :md has an active lifestyle. His EER is: Females Sedentary ~ Active
EER = 662 - (9.53 x 25) + 1.25 x (15.91 X 70 + 539.6 X 1.75) = 2997 4-8 yeors 1200 1800
You have determined this man's EER to be about 3000 kcal/day. Remember that 9-13 1600 2200
rhis is only an estimate; many other factors, ~uch as generics and hormones, can aftcct 14-18 1800 2400
actual energy needs. 19-30 2000 2400
A simple method of tracking your energy expenditure, and thus your energy needs, 31-50 1800 2200
is to use the tC>rms in Appendix G. Begin by taking an entire 24-hour period and list· 51+ 1600 2200
ing all acti' ities performed, including sleep. Record the number of minutes spent in
each acth·icy; the total should equal 1440 minutes (24 hours). Ncxr, record the energy
Moles Sedentary ~ Active
cost for each activity in kcal per minute following the directions in Appendix G.
Multiply the energy cost by rhe minutes. This figure is the energy expended for each 4-8 years 1200 --)J• 2000
activity. Total all the kcal values. This figure is your estimated encrg~· expenditure for 9-13 1800 ---i)J~ 2600
the dav. 14-18
19-30
2200
2400
--·~ 3200
--·· 3000
Concept I Check 31-50 2200 ---i)J~ 3000
51 + 2000 _ ......... 2800
Energy use by the body can be measured by direct calorimcLry as heat given off and by in·
direct calorimetry as oxygen used. A person's Estimated Energy Requirement can be csti·
mated based on the following characteristics: gender, height, weight, age, .md amount of
physical acri,·iry.
hunger The primarily physiological (internal)

drive to find and eat food, mostly regulated by
innate cues lo eating.
Why Am I Hungry?
appetite The primarily psychological (external}
Two drh cs influence our desire to eat and thus cake in food energy: h u n ger and ap- inAuences that encourage us to find and eat
petite. These diftcr dramatically (Figure 13-5 ). Hunger, our primarily physiological food, often in the absence of obvious hunger.
drive to cat, is controlled by internal body mechanisms. Organs such .ls the liver and neuroendocrine linked to the combined action
brain interact with hormones, hormonelike (neuroendocrine) factors, the nervous sys- of the endocrine glands and the nervous
tem, and ocher aspects of body physiology to influence lccding bcha,ior (T.1ble 13- 1).I8 system. Examples include substances released
ror example, carbohydrate intake induces in the GI tract the release of the hor from glands in response to nerve stimulation .
monclike compound glucagon-like pc.:pLidc- l (GLP- 1 ). This rele.1sc then reduces
47 4 Chapter 13 Energy Balance and Weight Control
Central Nervous System
Peripheral Body Systems Hypothalamus

Stomach distention Vogus nerve
Liver, adipose tissue
Hormones; insulin,
growth hormone,
sex hormones, ond
glucogon
Hunger Disease States

"How soon con I eot?" ~
Obesity ~
/
Anorexia nervosa
Psychopathologies ~
Emotional Factors
m
Mood
nvironmental Emotional Influences

actors
Temperature
Humidity
Metabolic Influences
Energy needs
Specific' Appetites ~\ Neurotransmi tter levels
Va rious hormones
Solt @!
~\
/~
"Sweet tooth"
j Appelite Disease Influences
~
~T
Learned Preferences
and Aversions 1/ t
"What do I wont to eot?"
umor pr
od t
uc s
Ak~I I\
Medication Influences
Pleasurable Factors Anorectics

Sedatives
Palatability Social Influences
Toste
Texture ~: Religion
Odor ~'"'R Culture
~
Figure 13·5 I Factors that inAuence satiety. Although some factors hove on impocl on both hunger and appetite, internal factors ore primarily responsible
for hunger, whereas external factors primarily influence appetite. These factors combine to ploy a role in the complex and interrelated processes that help
determine when, what, and how much we eat.
Table 13·1 I Hormones, Neuroendocrine Substances, Medications, and Other

Factors That Affect Feeding Behaviort
Increase Food Intake Decrease Food Intake
Neurotransmitters
Norepinephrine Serotonin
Growth hormone releasing hormone Dopamine
Neuropeptides and Hormones

Opioids Cholecystokinin
Galonin Enterostotin
Neuropeptide Y Tumor necrosis factor
Agouti-related protein Glucogon-like peptide-1 (GLP-1)
Orexin·A Corticotropin releasing hormone
Melonin<oncentroting hormone POMC
Ghrelin Melanocyte-stimuloting hormone
Gastric inhibitory peptide Melanocortin
Peptide YY3.36
Amyl in vagus nerves Nerves arising from the brain
Adipsin that branch off lo other organs and ore
Leplin* essential for control of speech, swallowing, and
gastrointestinal function.
Medications
satiety Stale in which there is no longer a
Corticosteroids Sibutramine desire to eat; a feeling of satisfaction.
Some tranquilizers Amphetamines
Progestins hypothalamus A region at the base of the
Some antidepressants brain that contains cells that ploy o role in the
regulation of hunger, respiration, body
tSome of these body hormones moy olso be used os medicotions in 1he future, Mony of the neuropeplides ore olso found in the temperature, and other body functions.
gostrointestinol troct (see Chopler 3)
•tn conjunction with the honnone insulin when both ore present in the broin sympathetic nervous system Port of the
nervous system that regulates involuntary vital
functions, including the activity of the heart
further food intake. Dr. Peter J. Havel discusses this process in greater detail in the muscle, smooth muscle, and adrenal glands.
fa.-pert Opinion. Then as macronutrients are absorbed, the liver and surrounding or-
gans communicate with the brain through the rwo vagus nerves. This communication
changes subsequent food choices by sending information about the rate of digestion
and en~rgy metabolism from the GI tract and the liver to the brnin. I 8
Appetite, our primarily psychological drive to eat, is affected by exrernal food choice
mechanisms, sucb as seeing a tempting dessert. Fulfilling either or both drives by eat-
ing sufficient food normally brings a state of satiety, temporarily halting our desire to
continue eating.
Hypothalamus: Key Satiety Regulator

Out bodies have many internal signals to encourage or reduce food intake. The h ypothal-
amus, a portion of the brain, is the key integration site for this regulation (Figure 13-6).
When stimulated, cells in the feeding centers of the hypothalamus signal us to cat. Then,
as we eat, hunger decreases. Evcnn1ally, we stop eating as cells in the satiety centers of the
hypothalamus are stimulated. Various cues to eat come from other sources, such as groups
of cells near the hypothalamus, macronua1ents such as glucose in the bloodstream, various
hormones and other substances, and sympathetic n ervous system acti,icy. Overall, as sym-
pathetic nervous system acti,ity decreases, food intake increases. The opposite is also true.
Thus, many internaJ signals both inhibit and encourage food intake. LS
Chemicals, surgery, and some cancers can destroy the feeding and satiety centers in
the hypothalamus. Without satiety-center acci,·i1y, laboratory animals (and humans) eat Figure 1 3·6 I The hypothalamus. This site in
their way to obesity. 'Vithout feeding-center activity, animals eat little and C\ entually the brain does most of the processing of signals
lose weight. 18 regarding food intake.
Satiety Regulation at Other Body Sites

As just mentioned, satiety is controlled by a network of mechanisms spread through-
out the body. Satiety is maintained first by the sensory stimulation that food elicits,
coupled with the knowledge that a meal was eaten. Second, the effects of nutrient di-
gestion, absorption, and metabolism are felt. The satiety and feeding centers in the hy-
pothalamus communicate and internet with other decision points in the brain, small
intestine, and liver. Overall, the process of satiety is very complcx.18
Dr. Barbara Rolls, an expert in this fie ld, has found that meal-to-meal satiety is in-
fluenced by the energy density of foods. Lower-energy-density foods result in the
greatest effect. As discussed in Chapter 2, energy density is linked to the total weight
of such foods (i.e., water content) and fiber content. Other factors that influence sati-
ety are dietary \'ariety, food particle size, viscosity, glycemic load, palatability, and ,·isual
clues such as size and shape. Still, Dr. Rolls suggests that in the long run our eyes might
be the most important factor. Thus the practice of recognizing appropriate serving sizes
of foods shown in Chapter 2 and training oneself to expect d1at amount can help con-
trol energy intake in the long run. 5 People who have trouble controlling body weight
should try to train d1c eye to expect less food by slowly decreasing serving sizes. Food
intake will be reduced as one expects Jess food but still experiences saricty. 5
Control of Feeding through Body Composition

Feeding behavior also changes in response to the amount of body fat. When body fat
is surgically removed from animals, their food consumption increases. Based on work
with genetic forms of obesity in animals, researchers have identified a group of sub-
stances that circulate in the blood and communicate the degree of body fatness to the
central 11en·ous system. The gene for one such substance in mice and humans has been
isolated (called the ob gene). The produce produced by the gene has been named
leptin A hormone (167 amino acids) mode ~ lcptin. Work with one strain of mice suggests that lcptin pardy decreases the .icci\'iry
adipose tissue that influences long-term of neuro peptid c Y and od1er small proteins present in the brain (review Table 13-1 ).ls
regulation of fat moss. Leplin also influences This decrcal.e then reduces food intake. Some people exhibit leptin resistance, in d1at
reproductive functions as well as other it doesn't rcadil)' bind to its receptors in die brain. This situation then leads to greater
physiological processes such as insulin release. hunger than is seen in people who don't ha,·e d1is problem. Only a fi.~,, people han:
been found to be tntl~· leptin deficient.
neuropeptide Y A small protein (36 amino
acids} that increases food intake and reduces Theoretically, when adipose tissue scores are increasing, lepcin (and/or related sub-
energy expenditure when in jected into the stances) causes satiety. Conversely, when adipose tissue stores are decreasing, nor as
brains of experimental animals. much leptin (and/or related substances) is released into tht: bloodsu·cam, and the de-
sire to eat is enhanced. The main runction of leptin is probably energy conser\'ation
during periods of inadequate food supply. Low leptin output leads to decreased thy-
roid gland acti\'ity and, thus, a fall in basal metabolism. Lcptin-deficicnt animals also
show decreased spontaneous activity, suggesting that they arc consen•ing body energy.
Experts suggest that leptin actually may be more important for lessening the effects of
starvation than for preventing obesity. Thus, leptin is not there primari ly to protecr
against obesity but, instead, to serve as a signal fo r lmv body fat stores. 18
Because Jeptin is a protein, it must be injected into the body. Inrcrei.tingly, not all
people treated with lt:ptin ha\'e lost significant amounts of weight; some people ha\'e
even gained weight during the therapy. Currently, the initial excitement O\'Cr tl1e use of
leptin to curb hunger and so contribute to weight loss is waning because clinical trials
have not supported its general usefulness. The current hope is d1at leptin injections will
help people limit weight regain after weight loss. T here is some evidence that such use
of leptin is helpful. (Note that lcptin is not available for commercial use at this time. )
endorphins Natural body tranquilizers that
may be involved in the feeding response and
function in poin reduction. Hormones That Affect Satiety
ghrelin A hormone mode by the stomach that E ndorphins, the body's natural opioid painkillers, and hormones, such as high
increases food intake. amounts of cortisol, can prod us to eat. The same is true for ghrelin, a hormone made
by the stomach. On the other hand, other hormones, hormonclikc compounds, and
still other chemical factors in the body can contribute to the foe ling of satiety. With eat-
ing, blood concentrations of some digestive hormones, such as cholecystokinin
(CCK), increase. This increase, also combined with gastrointestinal distention, helps gastrointestinal distention Expansion of the
shut off hunger. wall of the stomach or intestines due to pressure
Certain p<uts of the nervous system also contribute to satiety, in part linked to the caused by the presence of gases, food, drink,
release of the neurotransmitter histamine. Increased production of serotonin, another or other factors. This expansion contributes to a
feeling of satiety brought on by food intake.
brain neurotransmitter, has also been linked to intake of various nutrients, especially
carbohydrates. High seroconin concentrations in the brain can be calming, induce serotonin A neurotransmitter synthesized from
sleepiness, and reduce food imake. 1S For t.his reason, medications that prolong sero- the amino acid tryptophon that affects mood
tonin action in the brain are used to treat certain eating disorders (see Chapter 15). (sense of calmness), behavior, and appetite,
Following the Likely influence of gastroinrestinal distemion, nutrient receptors in and induces sleep.
the small intestine are believed to take over in promoting satiety after a meal. This con- nutrient receptors Proposed sites in the small
cept is supported by experiments in which subjects felt satiated when futs or carbohy- intestine that contribute signals to the brain that
drates were infused directly into tl1e small intestine. This effect was not reported, in turn elicit a feeling of satiety. These receptors
however, when the same fats or carbohydrates were infused directly into tl1e blood- ore stimulated by nutrient exposure in the lumen
stream. of the small intestine.
Nutrients in the Blood That Affect Satiety

Accumulating evidence from botl1 human and animal studies on the regulation of
hunger suggests tl1at an underlying hunger for food is never actually absent. After a
meal, blood concentrations of macronutrients increase, the brain registers satiety, and
hunger is temporarily relieved. IS Studies suggest that an apolipoprotein on the chy-
lomicrons (apolipoprotein A-IV) also signals satiety to the brain as chylo111icrons build
Early Flavor of food
up in the blood after a meal. sensations
Several hours after eating, when concentrations of macronutricnts in tl1e blood
begin to fall, the body must start using energy fow1d in body stores; hunger tl1en re- ~
Knowing a meal was just eaten
turns because S<ltiety is no longer registered by tl1e metabolism of energy-yielding com-
pounds tl1ar have been eaten. In other words, feeding signals begin to dominate
again. 18
~
lnffuence of stomach and intestinal
expansion and activity as well as
receptors in the intestinal trod
Does Appetite Regulate What We Eat?
Yarious feeding and satiety messages from body cells do not single-handedly determine ~
''hat we cat. Almost e\'eryonc has encountered a mouthwatering dessert and devom·ed lnAuence of nutrient use in
it, even on a fu ll stomach. We have an im1aLc taste for sweet and acquire a taste for fut. Late the liver and related
Appetite can be affected by a variety of external forces, such as environmental and psy- sensations communication with the
hypothalamus and other
chological factors as well as social customs (review Figme 13-5). regions of the brain by
We often cat because food confronts us. Ir smells good, tastes good, and looks hormones
good. \Ve might eat because ic is die right time of day, we are celebrating, or we are
trying to overcome the blues. Appetite may not be a biological process, but it does in-
fluence food intake. After a meal, memories of pleasant tastes and feelings reinforce ap-
petite. If stress or depression sends you co the refrigerator, you are mostly seeking
comfort, not food energy.
Hunger and Appetite in Perspective

Internal and external signals that drive hunger and appetite generally operate simulta-
neously and lead us to decide whether to reject or eat a food item. For example, visual
5 ociol customs, peers, and authority figures
con inRuence the desire to eat. Concern
about appearance when on a dote con inRuence
and taste stimulation can cause sometlling called cepbalic pbnse 1·espomes by tl1e body. the food choices mode. A woman concerned
Saliva flows and digestive hormones and insulin are released in response to seeing, about looking "petite" in company may choose
smelling, and initially tasting food, such as a hamburger. The physiological responses a smaller portion of food than when alone. We
prepare the body for the meal. These internal forces arc elicited by external cues, again are also likely lo eat more at a meal when with
showing the degree to which internal and external forces are intertwined. 1S a large group of people than when with a few
The next time you pick up a candy bar or ask for second helpings, remember tl1e people or alone, or when someone else is "pick-
physiological intluences on eating behavior. Rody cells ( brain, stomach, intestine, liver, ing up the check."
and other organs), hormones (such as CCK and ghrclin), neurological components
(such as serotonin), and social customs all influence food intake. Where food is ample,
appetite-not hunger-mostly n·iggcrs eating. Keep track of what triggers your eating
for a tew days. ls it primarily hunger or appetite? Note as \\'Cll that this system is noc
perfect; your bod) weight can increase (or decrease ) o,·er ti.me if you arc nm careful to
balance cnerg) intake with enerro oucpur.
Concept I Check
Hunger is the primarily physiological or internal desire to find and eat food. Appeasing it
leads ro saLicl'1°- 110 further desire to cal exists in rhac moment. Satiety is influenced by
hunger-related (um:rnal ) forct:s in the brain, gastrointestinal rract, adipose tissue, liver, and
other organs. \'.mous honnont:s and neuroendocrinc compounds participate. Food intake is
also affected b~ appetite-relatt:d (psychological and external ) forces such as social custom,
time of day, palatability, and presence of others. North Americans probably respond more
ro exrcrnal, appCLite-related forces than to hunger-related ones in choosing when and what
to cal.
Estimation of a Healthy Weight

Numerous methods are used to est.lblish whar body weight should be, typically called
hen/thy wcigbt. Several tables exist, generally based on weight-for-height. These table~
a1ise from studies oflarge population groups. When applied to a popul.ltion, the~ pm·
vide good esumatcs of \\'eight associated with health and longe\·iry. Howner, the~ do
not necessaril) indicate tbe ht:J.lthicsL body weight for each incfo·idual. Athletes with .1
large, lean bod) mass and little body far are a prime example.
Ideal ly, famil)' history of wcight-rcl.lted disease and cunent health conditions, in ad-
dition to wcight-for-hcighr, should be considered when establishing a healthy weight for
an individunl. Consideration of the following weighr-rcl:lled conditions is important: 19
• Hypertension
• Elevated LDL-choksrerol
• Family history of obesity, cnrdiovascular djsease, or certain forms of cancer (e.g.,
uterus, colon )
• Pattern of fat distribution in the body
• Elevated blood glucose
• Elevated blood triglycerides
On a more practical note, ocher questions can be pertinent: Whar is the least one has
weighed as an adult for at least a year? What is the largest size clothing one would be
happy with? What weight has one been able co maintain during previous diets without
feel ing constantly hungry? Overall, the individual, under a physician's and/or registert:d
dietitian's guidance, should establish a "personal" healthy weight (or need for weight
reduction) based on weight history, fat distribution patterns, family history of weight-
related disease, and current health status. Thjs assessment points out how \\'ell cbe per-
son is tolerating any ex.isting excess weight. Thus, current height/weight standards arc
onl)' a rough guide. Furthermore, a healthy lifestyle may make a more important con-
tribution to a person's health status than the number on cbe scale. Fit and overweight
are not necessarily mutually exclusive (aJthough nor often seen rogether), and nor is thin
synonymous wirh being healthy if the person is not also physically active.
Using Body Mass Index (BMI) to Set Healthy Weight

Q\'er the p.lsr 50 years, use of \\eight-for-height tables issued by the Metropolitan Lite
Insurance Company ha\'e been the typical \\'ay healthy weight was established. These
tables considered gender and frame size, predicting the weight range at a specific
I Expert Opinion
Sorting Out Satiety and Weight Regulation : Hormones
and Dietary Macronutrients
Peter J. Havel, D.V.M., Ph.D.
Satiety and Short-Term Regulation ghrelin (ond possibly peptide YY3-3 6) from the GI tract. These long-term sig-
of Food Intake nals act in concert with the short-term signals in the coordinated regulation
of energy intake and body odiposity. It hos been proposed that the long-term
Satiety is a condition of satisfaction or gratification with no desire to ingest
signals determine the sensitivity of the central nervous system to the satiety·
additional food; it is the stole that directly leads to the termination of o meal inducing effects of the short-term signals. Experimental evidence for this hy-
and determines o meal's size and duration. What triggers the feelings of full- pothesis indicates that both insulin and leptin increase the sensitivity to CCK,
ness associated with satiety? First, physical and chemical qualities of the food
and so its ability to limit meal size in animals. This integration serves to con-
activate mechan~ (stretch) ond chem~receptors in the stomach and upper
trol energy intake ta match energy expenditure so that body weight is re-
small intestine. Second, o number of peptide hormones ore released in re-
markably stable over time in both humans and other animals. For example,
sponse to the presence of food in the gastrointestinal (GI) trod. Neural signals
o person who gains 20 lb (- 9 kg) of body fat between 20 and 40 years of
from stretch receptors, chem~eceplors, and peptide hormone receptors in the age is consuming only about 11 kcal/day in excess of energy expenditure
liver and GI tract are transmitted to broinstem nuclei via the vogus nerve. (less than a 0.5% mismatch of energy balance). However, larger mismatches
Among many GI tract hormones that are known to decrease hunger and
of energy intake and expenditure can and do lead lo much larger degrees
inhibit food intake, cholecystokinin (CCK) and glucagon-like peptide-1 (GLP-1)
of weight gain ond profound obesity.
are the most likely to have a physiological role in satiety. These hormones
relay neural signals to the central nervous system. They also can influence Insulin
satiety indirectly by inhibiting gastric emptying. Together these neural and Pancreatic beta cells immediately secrete insulin in response lo glucose and
hormonal signals regulate food intake in the short term, but by themselves amino acids. Insulin concentrations in the bloodstream are inversely related
they are not sufficient to regulate to insulin sensitivity; because increased body fat is a major contributor to in-
body weight and body odiposity. sulin resistance, circulating insulin levels are higher in obese people. In ad-
For example, in o study in which dition, insulin levels decrease independently of body weight during fasting.
CCK was repeatedly administered Thus, overall circulating insulin levels and insulin exposure to the brain ore
to rots over a period of several proporfonal to both fat stores and recent energy balance. Insulin is trans-
weeks, the size of each meal de- ported to the hypothalamus where it regulates the production of neur~
creased, but meal frequency in- peptides, such as neuropeptide-Y ond melanocorlins. Insulin also hos an
creased, so overall food intake and important indirect role in long-term energy balance: it regulates leptin pr~
body weight were only minimally duction and ghrelin secretion (see the following sections)
affected. This finding suggests that
the effects of short-term signals, leptin
such as GI stretch receptors and The hormone leptin, produced by adipose cells, works in the brain to inhibit
CCK, on energy intake are coun- food intake ond increase thermogenesis. It also regulates other endocrine
terbalanced by reduced input from systems (reproductive, thyroid, etc.) involved in adaptation to negative en-
long-term hormonal regulators of ergy balance. Leptin's effects in the central nervous system to inhibit food in-
energy balance. take are dependent on a signal pathway that is shared with insulin. like
insulin, leplin production and circulating leptin concentrations are related to
both body fat stores and recent energy intake. leptin levels ore proportional
Long·Term to body fat, but leptin levels decrease acutely during fasting or restricted en-
"I can't eat another slice.• Have you Regulation of
ergy intake and increase after refeeding, even if the amount of body fat does
ever considered the physiological Energy Balance not change. These odiposity-independent changes in leptin production pri-
processes involved in feeling full?
What role does satiety play in the Long-term energy balance 1s regu- marily relate to changes in insulin.dependent glucose metabolism in adipose
amount of food you eat, and how lated by several endocrine signals: cells The decrease of leptin in times of decreased energy intake helps en-
does that affect long-term body insulin from the pancreas, leptin sure that when food is scarce, hunger, food-seeking behavior, and an adop-
weight regulation? produced by adipose cells, and tive decrease in energy expenditure ore triggered well before body energy
stores become compromised. This appears to be the primary function of lep- number of studies hove demonstrated thol consumption of low-fat, high-
tin in energy balance. corbohydrote diets results in weight loss in the majority of people, even when
Leptin exists in the body to help monoge the threat of starvation, but con portions ore not restricted. In contrast, increasing the fat content of the diet
it olso manage the threat of obesity? Genetic leptin deficiency leads to ex· almost invariably results in increased energy intake and weight gain in hu-
treme hunger and massive obesity that ore reversed by leptin odmin1strotion. mans and animals
The leptin deficit induced by dieting suggests that leptin replacement in diet- Circulating leptin concentrations exhibit o nocturnal peak that is largely
ing subjects might help prevent weight regain dependent on insulin responses lo meals consumed during the day. High-
corbohydrole meals induce larger increases of leptin 4 lo 6 hours ofter the
Ghrelin meal than do high-fat meals containing the some amount of energy. The
Endocrine cells in the stomach and upper GI tract produce ghrelin. In con- height of the nocturnol leptin peak is reduced when subjecls consume high-
trast to the satiating effects of other GI peptides, ghrelin stimulates food in- fat meals. This reduction in leptin output may be an important signal to the
take. Chronic administration of ghrelin also inhibits fat utilization and CNS in body weight regulation because the amount of leptin released cor-
induces weight gain in animals, suggesting a role in long-term body weight relates with body weight and body fat loss when a low-fol diet is consumed
regulation. Circulating ghrelin levels decrease within 30 minutes ofter a meal However, not all dietary carbohydrates hove the same effect. For example
and remain low for up to 3 hours. It is likely that insulin, glucose, and other although consuming glucose-sweetened beverages with a meal stimulates in-
GI hormones contribute lo the inhibition of ghrelin secretion ofter a meal. sulin and leptin production and induces ghrelin suppression ofter the meal,
Circulating ghrelin levels ore lower in obese people compared lo people of these effecls are significantly less ofter consumption of the some meals with
normal weight, and increase substantially in people who have lost weight fructose-sweetened beverages. The lock of effects of fat and fructose on these
through dieting, on effect that predisposes them lo future weight regain. endocrine signals of energy balance (insulin, leptin, and ghrelin) suggests on
Circulating ghrelin levels remain low in patients who hove lost weight ofter endocrine mechanism by which prolonged consumption of diets high in fat
Roux-en·Y gastric bypass surgery (discussed later in the chapter), suggesting and/or fructose contribute to weight gain and obesity.
that lock of on increase in ghrelin levels may contribute to weight loss and
weight maintenance ofter this type of surgery.
Conclusions
Peptide YY3-36 Signals from 1he GI tract, including activation of stretch receptors and the GI
Endocrine cells in the colon produce PYY3_36 and release ii into the blood- hormones CCK and GLP-1, promote sensations of satiety and fullness in
stream in response to eating. PYY3-36 administration decreases food intake order to limit meal size and thereby regulate short-term energy intake. These
in laboratory animals and humans. Because a relatively short-term (90 short-term signals ore not sufficient by themselves to regulate energy balance
minute) infusion of PYY3_36 results in a 12-hour reduction of appetite and over more prolonged periods of time and therefore ore not involved in the
food intake in humans, it is possible that, unlike most GI peptides that inhibit long-lerm control of body weight. The long-term signals-insulin, leptin, ghre-
food intake (e.g., CCK), PYY 3_36 moy function as o medium- to long-term reg- lin, and possibly PYY 3-36-ore produced and circulate in proportion lo re-
ulator of energy intake. Because PYY3-3 6 levels ore reduced in obese indi- cent energy intake and body odiposity. These long- and short-term signals
viduals and PYY3-36 inhibits food intake in both obese and lean subjects, ii ore integrated such that the long-term signals appear to set the sensitivity of
hos been proposed that treatment with PYY 3-36 may be on effective medical the cenlrol nervous system to the satiety-producing effects of the short-term
therapy for obesity. signals. A better understanding of the mechanisms regulating satiety and
long-term energy balance will lead lo new approaches for managing obesity
and its many comorbidities, including diabetes, hypertension, and coronary
Macronutrients, Sat~ety, and Energy Balance
heart disease.
There ore important differences in the effects of major dietary mocronutnents
on short-term satiety ond long-term energy balance. Dietary fat is energy- Dr. Havel is Associate Endocrinologist in the Department of Nutrition
dense (9 kcol/g) and so con be overconsumed in the short term. However, at the University of California, Davis. Dr. Havel earned a bachelor of
fat ingestion also induces greater feelings of fullness due to its effects to delay science degree from the University of Washington and doc/oral de-
gastric emptying. Energy consumed in the form of beverages con olso be grees in Veterinary Medicine and Endocrinology, both from
consumed in large quantities, in port because gastric emptying of fluids is University of California, Davis. Dr. Hovel's research focuses on the
rapid. The long-term influence of mocronutrients on energy balance and physiology of body weight regulation, carbohydrate and lipid me-
body weight also appears lo involve the endocrine signals just discussed A tabolism, and the palhophysiology of obesity and diabetes.
. --- - - - - - -- '
height that was associated with the greatest longevity. The latest table (issued in 1983)
and methods for determining frame size can be found in Appendix I.
Currently, body mass index (BMI) is the preferred weight-for-height standard
(Figure 13-7).9 Research has shown that body mass index is the weight-for-height
standard that is most closely related to body fat content.
Body mass index is caJcuJatcd as
body weight (in kg) ne BMI unit = 6-7 lb.

hcight2 (in meters)
An alternate method for calculating BMI is
weight (lb) X 703

height2 (inches)
Table 13-2 lists the BMI for various heights and weights. Health risks from excess
weight may begin when the BMI is 25 or more. A heaJthy weight-for-height is a BMI
18.5 to 24.9. What is your BMI? How much would your weight need to change to Women Men
yield a BMI of25? 30? These arc general cut-off values for the presence of overweight
and obesity, respectively.
The concept of body mass index is convenient to use because Lhc values apply to
both men and women. However, any weight-for-height standard is actually a crude
measure. Keep in mind, also, that a BMI of 25 to 29 .9 is a marker of overweight (com-
pared to a standard population) and not necessarily a marker of overfat. Many men (es-
pecially athletes) have a BMI greater than 25 because of extra muscle tissue. Also, very
short adults (under 5 feet tall) may have high BMis that may not reflect overweight or
fatness. For this reason, BMI alone should nor be used to diagnose overweight or
obesity.
StiU, overfat and overweight condjtions generally appear together. The focus is on
BMI in clinical settings mainJy because BMI is easier to measure than total body fat.
A shortcut method for roughly estimating healthy body weight is the pounds per
inch of height method. For women, start with 100 lb for the first 5 feet, then add 5 lb
for every inch thereafter. To estimate a man's healthy body weight, start with l 06 lb
for the first 5 feet and then add 6 lb for each inch thereafter. The estimate of weight
is then given a ± 10% range. Based on this system, a 6-foot-taJl man should weigh
about 178 ± 18 lb (106 + [12 X 6 = 178]).
Putting Healthy Weight into Perspective

One current school of thought is to let nature take its course with regard to body
weight. According to this proposal, after weight is lost in order to fall \vithin a specific
(often unrealistic) height/weight range, people often regain their original weight plus
more. In contrast, listening to the body for hunger cues, regularly eating a healthy diet,
and remaining physically active (not to be overlooked) eventually helps one maintain
an appropriate height/weight valuc. 19 This concept will be further addressed in the
upcoming discussion on treatment for obesity. (It is a cornerstone of the current "size
acceptance" movement.) The clearest idea regarding a healthy weight is that it is per-
sonal. Weight has to be considered in terms of health, not simply a mathematical
cakulation.
Concept I Check
Healthy body weight is generally determined in a clirucaJ setting using a body mass index
or another weight-for-height standard. Family history and the presence of existing weight- BMl30
related disease should be considered in determining health}' body weighc. Total health and
Figure 13-7 1Estimates of body shapes at
a healthy lifestyle shouJd be the major considerations when determining healthy weight.
different BMI values.
Table 13·2 I Body Weight in Pounds According to Height and Body Moss Index IBMIJ
Healthy BMI Overweight BMI Obese BMI
19 20 21 22 23 24 25 26 27 28 29 30 35 40
Height (Inches) Body weight (lb)
58 91 96 100 105 110 115 119 124 129 134 138 143 167 191
59 94 99 104 109 114 119 124 128 133 138 143 148 173 198
60 97 102 107 112 118 123 128 133 138 143 148 153 179 204
61 100 106 111 116 122 127 132 137 143 148 153 158 185 211
62 104 109 115 120 126 131 136 142 147 153 158 164 191 218
63 107 113 118 124 130 135 141 146 152 158 163 169 197 225
64 110 116 122 128 134 140 145 151 157 163 169 174 204 232
65 114 120 126 132 138 144 150 156 162 168 174 180 210 240
66 118 124 130 136 142 148 155 161 167 173 179 186 216 247
67 121 127 134 140 146 153 159 166 172 178 185 191 223 255
68 125 131 138 144 151 158 164 171 177 184 190 197 230 262
69 128 135 142 149 155 162 169 176 182 189 196 203 236 270
70 132 139 146 153 160 167 174 181 188 195 202 207 243 278
71 136 143 150 157 165 172 179 186 193 200 208 215 250 286
72 140 147 154 162 169 177 184 191 199 206 213 221 258 294
73 144 151 159 166 174 182 189 197 204 212 219 227 265 302
74 148 155 163 171 179 186 194 202 210 218 225 233 272 311
75 152 160 168 176 184 192 200 208 216 224 232 240 279 319
76 156 164 172 180 189 197 205 213 221 230 238 246 287 328
Eoch entry gives !he body weigh! in pounds for o person of o given height ond BMI (kg/m 2). Pounds hove been rounded off To use the table, find the oppropriote height in the for lefl column . Move
OCJOss the row lo o weight. The number ol the lop of the column is the RMI for the height and weight.
ealthy weight is currently the preFerred

H term to use for weight recommendations.
Older terms, such os ideal weight ond desirable
I Energy Imbalance
If enerro mtake exceeJi. output o\'er time, O\'erweight (and often obesity) is a likely re
weight, ore no longer used in medicol literoture.
i.ulc. Otten, health problems eventually folio\\ (Tabk 13-3). In this contexc, rnedti:,\l
However, you still may hear these terms in dini·
.md nutrition experts recommend that .m individual's cutoff value for obesity should
col practice.
not be based primarily on body weight but, rather, on the total a mount of fat 111 the
body, the location of body fat, and the presence or .1bsencc of weight-related medic.11
problems. 19
Estimating Body Fat Content and Diagnosing Obesity

Body far can range from 2 to 70% of body weight. Desirable a.moums or body far .uc
about 8 co 24°;., of bod~ weight for men and 21 to 35% for women. In th ts regard, men
"ith mer 24'\ body fat .md women ''1th mer about 35% body fat arc cons1tic.:red
obese. \Vomen need more body fat bec.1use some "sex-specific" far is .1ssociatcd \\1th
underwater weighing A method of estimating reproductive functions. This fat is norm:tl and factored into cakul:ttions.
total body fat by weighing the individual on a To measun: body fat content accurately using rypicil methods, both body weight
standard scale and then weighing him or her and body volume of the person must be known. Body weight is easy to mc,\sure. 01
again submerged in water. The difference thc typical methods used co estimate body \Olume, underwat er weigh ing is the most
between the two weights is used to estimate .u:euratc. nm. technique determines body volume using the loss of weight when phti:ed
total body volume unden\ater, the rclaLi,·e densities of fat tissue and le;111 tissue, and <l specific mathe
matical formulJ . This procedure requires that a subject be totally submerged in :i t•mk
Table 13·3 I Health Problems Associated with Excess Body Fat
Health Problem Partially Attributable To

Surgical risk Increased anesthesia needs as well as greater risk of wound infections (linked to a decrease in immune
function)
Pulmonary disease and sleep disorders Excess weight compresses lungs and pharynx
Type 2 diabetes Enlarged adipose cells, which poorly bind insulin and poorly respond to the message insulin sends to
the cell; increased synthesis of factors (e.g., immune system-related) by enlarged adipose cells that
lead to insulin resistance; less synthesis of factors that improve insulin action (e.g., odiponectin) by en·
lorged adipose cells
Hypertension Increased miles of blood vessels found in the adipose tissue, increased blood volume, increased
sodium retention, and increased resistance to blood Row related lo hormones mode by adipose cells
Cardiovascular disease (e.g., coronary Increases in LDL-cholesterol and triglyceride values, low HDL-<:holesterol, decreased physical activity,
heart disease and stroke) and increased synthesis of blood clotting and inflammatory factors by adipose cells, especially those
that ore large in size; greater risk for heart failure is also seen, in port due to on altered heart rhythm
Bone and joint disorders (including gout) Excess pressure put on knee, ankle, and hip joints
Gallstones Increased cholesterol content of bile
Skin disorders Trapping of moisture and microorganisms in tissue folds
Various cancers, such as in the kidney, Estrogen production by adipose cells, animal studies suggest excess energy intake encourages tumor
gallbladder, colon and rectum, and uterus development
(women) and prostate gland (men)
Shorter stature (in some coses of obesity) Earlier onset of puberty
Pregnancy ri sks More difficult delivery, increased risk of gestational diabetes, and increased needs for anesthesia
Reduced physical agility and increased risk Excess weight that impairs movement
of accidents and falls
Menstrual irregularities and infertility Hormones produced by adipose cells, such as estrogen
Vision problems Cataracts and other eye disorders ore more often present
Premature death A variety of risk factors for disease listed in this table
Infections Reduced immune system activity
Liver damage and eventual failure Excess Fat accumulation in the liver
Erectile dysfunction in men low-grade inflammation caused by excess fat moss and reduced function of the cells lining the blood
vessels associated wi th being overweight
The greoter lhe degree of obesity, the more likely ond the more serious these heolth problems generolly become. They ore much more likely to oppeor among people who hove excess upper-body fot
distribution ond/or ore greoter than twice heollhy bocly weight
of water, and a trained technician needs to direct the procedure (Figure 13-8 ). Air dis- air displacement A method for estimating body
placement is another method of determining body volume. Body volume is quantified composition that makes use of the volume of
b~ measuring the space a person takes up inside a measurement chamber, such as the space token up by a body inside o small
BodPod (Figure 13-9 ). A further method to measure body rnlwm: is to simply sub- chamber.
merge a person in a tank and obserYe the level of the water before and afi:er submer-
sion. The volume of the displaced water is then calcu lated.
Once body volume is known, it can be used along with body weight to calculate
body density. Then, using body density, body far content finally can be determined.
One formula used is:
. body weigh L ven ogreed·upon weight standards for BMI

Bocv
j dens1ty •
· body volume ore not for everyone. Adult BMls should not
be applied lo children and adolescents, frail
% bod~· fat= (495 + body density) - 450
older people, pregnant and lactating women,
For example, assume that the subject in the undt:rwa.ter weighing tank in Figme 13-8 and highly muscular individuals. Children and
has a. body density of 1.06. T he units arc g/cm 3 . The second formula is used to cal- pregnant women hove unique BMI standards
culate r.hat he has 17% body fat ([495 + 1.06] - 450 = 17). (see Chapters 16 ond 17).
Figure 13·8 I Underwater weighing. In this technique the subject exhales Figure 13·9 I BodPod. This device determines body volume based on the
os much air as possible and then holds his or her breath and bends over ot volume of displaced air, measured as o person sits in o sealed chamber for o
the waist. Once the subject is totally submerged, the underwater weight is few minutes.
recorded. Using this value, body volume con be calculated.
Skinfold rhickness is a common anthropomerric method to estimate tOtJI body fat

content, alrhough there arc some hmits ro its accuracr. Clinicians use calipers to mea-
sure the fat layer directly under the skin at multiple sites and then plug these 'alw:s
into a mathematical fornmb (Figure 13-10).
bioefectricof impedance A method to estimate Bioelectrical impedance also can be used to estimate body fat content. T he in-
total body fat that uses o low-energy electrical stniment sends a painless, low-energy electrica l current to and from the body via wires
current. The more fat storage o person hos, the and electrode patches to estimate body fat. Researchers surmise that adipot.e tissue re-
more impedance (resistance) to electrical flow sists electrical flow more than lean tissue does because adipose tissue has a lower elec-
will be exhibited. trolyte and water concent than lean tissue and so more adipose tissue proportionately
means greater electrical resistance. Within a few minutes, bioelecn·icaJ impedance ana-
lyzers co1wert body electrical resistance into an approximate estimate of t0tal body far,
as lo ng as body hydration status is normal (Figure 13-1 1).
dual energy X-ray absorptiometry (DEXA) A Dual energy X-ray absorp tiometry (D EXA) is considered the most accurate way
highly accurate method of measuring body t0 determine body fat, but the equipment is very expcnsi,•e and not widely available
composition and bone moss and density using for this use. This X-ray system allows the clinician to divide body weight into three sep-
multiple low-energy Xrays. arate components: fat, fat-free soft tissue, and bone mineral. The usual whole-bod~
scan requires about 5 to 20 minutes and the dose of radiation is less than a chest X ray.
Obesity, osteoporosis, and other aspects of nutritional health can be investigated using
this metl1od (Figure 13-12).
nother method to assess body fat is to

measure total-body electrical conductance Using Body Mass Index to Define Obesity
when placed in on electromagnetic field
(TOBEC). Still another method, near-infrared re- BMI offers another way ro define obesity (Figure L3- l 3).9
octonce, exposes the bicep muscle to a beam of
near-infrared light. The measuring instrument as- 30-39.9 Obese Increased health risk
sesses the interactions of the light beam with fat
40 or greater Severely obese Major health risk. Note that the number of North
and lean tissues in the upper arm. After on~ Americans falling into this category is increasing
2 seconds, this Roshlight-size device con give on rapidly.
estimate of body composition. Although conven-
ient and inexpensive, this method is not very
accurate.
/Skin
Figure 13· 1 O I Skinfold measurements. W ith proper technique and calibrated equipment, skinfold measurements around the body con be used to predict
body fat content in about 10 minutes.
Figure 13-12 I Dual energy X-ray obsorptiomelry (DEXA). This method

measures body fat by releasing small doses of radiation through the body
that a detector then quantifies as fat, lean tissue, or bone. The scanner arm
Figure 13·11 I Bioelectricol impedance. This method con estimate total moves from head to toe and in doing so con determine body fat as well as
body fat in less than 5 minutes and is based on the principle that fat in the bone density. DEXA is currently considered the mos! accurate method for
body resists the flow of electricity since it is low in water ond electrolytes. determining body fat as long as the person is not loo obese to fit on the
The degree of resistance to electrical flow is used to estimate body fatness. table and/or under the arm of the instrument. The radiation dose is minimal.
Figure 13· I 3 I Height/weight table Height•

bosed on BMI; the upper ends of the healthy 6' 6#
weight ranges correspond to a body mass 6' 5· ·• - ' - - -·
index of 25. 6' 4• -
6' 3"
6' 2"
6' 1"
./ f ·-
6' O"
5' 11 " · ~
~
ff
·
r
5' 10· •
5' 9• I I
s a· - J' ~
5·r
5' 6" ~--:_~ I ,ri·
L
I
__.___
5' 5•
5' 4"
.. 0 Ip
I
5' 3" ,_ -·
J
5' 2· - 1' T
..
I
5' ,. - I
5' o· - - I -·
I
4 ' 11 · - I I
4 ' 10·
I I I
50 75 100 125 150 175 200 225 250

PoundsI
• Without shoes.
t Without clothes. The higher weights apply to people with
more muscle and bone, such as many men.
Using Body fat Distribution to further Evaluate Obesity

\Vhere we store fat, as well as how much, can predict health risks, ljkcly even more Lhan
a person's BMI can. Some people store fut in upper-body areas. Others hold fat lower
on the body. Excess fut in either place generally spells trouble, but each storage space
upper·body obesity The type of obesity in also has its unique risks. Upper-body (an d roid) o besity is more often related co car-
which fat is stored primarily in the abdominal diovascular disease, hypertension, and type 2 diabetes. 13 vVhereas other adipose cells
area; defined as a waist circumference more empty fat dfrectly into general circulation, the fat released from abdominal adipose
than 40 inches (l 02 centimeters) in men and cells goes straight Lo the liver by way of the portal vein found there. This process likdy
more than 35 inches 188 centimeters) in interferes with the liver's ability to clear insulin and alters lipoprotein metabolism by
women; closely associated with a high risk for the liver. These adipose cells also make substances that increase inflammation in the
cardiovascular disease, hypertension, and type
body as well as ini.:rease insulin resistance, blood clotting, and blood 'csscl consuic·
2 diabetes.
tion. All these changes can lead to long-term health problems.
High blood testosterone (primarily a male hormone) lc\•els apparently encourage
upper-body obesity, as does a ruer with a high glycemic load, alcohol intake, and smok·
ing. Th.is characteristic male pattern of fat storage appears in an apple shape (large ab-
domen [pot bdly I and thinner buttocks and thighs). Upper body obesity is assessed by
simply measuring the waist at the widest point just above the hips when relaxed. A
waist circumfrrencc more than 40 inches ( 102 cm) in men and more than 35 inches
(88 cm) in women indicates such a shape (Figure 13-14). 9
Estrogen and progesterone (prin1arily female hormones) encourage lowcr· body fat
lower·body obesity The type of obesity in storage and lowe1·-body (gynecoid or gynoid) o besity. The small abdomen and
which fat storage is primarily located in the much larger burcocks and thighs give a pear-like appearance. After menopause, blood
bullocks and thigh area. estrogen falls, encouraging upper-body fat distribution in women.
Figure 1 3· 1 4 I Body fat distribution,

showing upper-body and lower-body locolions.
The upper-body (android) form brings higher
risks for ill heollh associated with obesity.
The woman hos a waist circumference of
32 inches. The man hos a woisl circumference
of 44 inches. Thus, the man hos upper-body fat
distribution but the womon does not, based on
a cutoff of 40 inches for men and 35 inches for
women.
Lower-body fat distribution Upper-body fat distribution

(gynoid: pear shape) (android apple shape}
Concept I Check I Thinking

O\'en\'eighr and obes1t\ t\'pically arc associJreJ ,,;th cxc.:cssi\'e boJ~· fat scora).!.C. The risk of Based on what you now know, how would you
health problems related to being O\'erwcight especially incrcJses under the following define the term healthy body weight?
conditions:
• A m.111 's percentage or body fat cxc.:eeds 25%; .1 woman's exceeds about 35%.
• Excess fat is primaril) stored in the upper-bod~ region
• Bod) mass index (BMl) is 30 or more (calculated as weight in kg divided by
height squared in meters).
Howewr, these are merely guidelines. A more iodiv1dualized approach to .1sscssmcnc is
warranted as long as a person is following a health)' litcstyk ;md has no existing health
problems.
Bod} fat c.:onccnt co.Ill be estimated using a \'aricry of methods such JS underwater wt>igh-
ing, .iir displ.tc.:cment, skmlold thic.:kneSl., b10ckcrric.:al impedance, J11d DEX:\. rat storage
distribution forrher specifics an obese state .1s either upper body or lower body. Obesity
leads to an increased risk for c1rdiovast:ul<lf dise<1Sc, sonH.: rvpc5 of cancer, hvpcrtcnsion,
type 2 diabetes, certain bone and joint disorders, and some: digestive disorders. rJ1c risk tor
some of these conditions 1~ grcarcr with upper body fac stor.1ge.
Why Some People Are Obese-Nature Versus

Nurture
Both genetic and environmental facrors c.111 increase tht risk for obcsitr. Experts in the
fiel d arc at odds over the relative import<111Cc or nature versus nurture.
How Does Nature Contribute to Obesity?

iclenticol twins Two offspring that develop from Studies in pairs of identical twins give us some insight into the contribution of nature
a single ovum and sperm and, consequently, to obesity. Even when identical twins arc raised apart, they tend co show similar weight
hove the some genetic makeup. gain patterns, both in overall weight and body fat distribution. Nurture-earing habits
and nutrition, which varies between twins who are raised apart-seems co have less to
do with obesity than nature does. 9 rn fact, research suggests that genes account for up
to 40 to 70% of weight differences bct:ween people.
We also inherit specific body types. Tall, thin people appear co have an inherenrly
easier time maintaining healthy body weight. Basal metabolism increases as body sur·
face increases, and rl1ereforc taller people use more energy than shorter people, even
at rest.
Some rats and mice can have a genetic predisposition to obesity if they inherit a
"rllrifty metabolism"- one that uses energy frugally. This metabolism enables Lhem to
score fat more readily rl1an the typical animal. Many of us probably have inherited a
thrifty metabolism as well, so that we require less energy metabolism to get through
the day. lo earlier times, when food supplies were scarce, a thrifty metabolism would
have been a built-in safoguard against starvation. Now, with a general abundance of
food, people operating in Lhis low gear require much physical activity and wise food
choices to prevent obesity. If you think you are prone to weight gain, you likely have
inherited a ilirifty metabolism.
A child with no obese parent has only a l 0% chance of becoming obese. When a
child has one obese parent (common in our society), that risk advances up to 40%, and
with two obese p:irents, it soars co 80%. Our genes help determine metabolic rate, fuel
use, and differences in brain chemistry-all of which affect body weight.
Does the Body Have a Set Point for Weight?

set point Oken refers lo the close regulation of The set-point theory of weight maintenance proposes that humans have a generically
body weight. It is not known what cells control predetermined body weight or body fat coment, which the body closely regulates.
this set point or how it actually functions in Some research suggests chat the hypothalamus monitors the amount of body fat in
weight regulation. There is evidence, however, humans and tries LO keep that amount constant over time. Recall from earlier in the
that mechanisms exist that help regulate weight. chapter that the hormone leptin forms a communication link between adipose cells and
the brain, which allows for some weight regulation. 18
What evidence supports the set-point theory? In human studies, volunteers who had
lost weight through starvation tended to eat in such a way to regain their original
weight. In addition, studies in the 1960s using prisoners with no history of obesity
Does the difference in body fat between the

grandfathers and the grandsons arise from
nature or nurture or both?
found it was hard for some men to gain weight. Also, after an illness is resolved, a per-
son generaJly regains lost weight.
PhysiologicaJ measurements also endorse the set-point theory. for example, when
energy intake is reduced, the blood concentration of thyroid honnones fulls, which
slows basal metabolism. In addition, as weight is lost, the energy cost of weight-bearing
activity decreases, so that an activity that burned 100 kcal before weight loss may onJy
burn 80 kcal after weight loss. Furthermore, with weight loss, the bod} becomes more
efficient at storing fut by increasing the activity of the enzyme lipoprotei11 lipase, which
takes fat into cells. All these changes protect the body from losing weight.
If a person overeats, basal metabolism tends to increase in the short run, which
causes some resistance to weight gain. However, in the Jong run, resisrance LO weight
gain is much less than resistance to weight loss. When a person gains weight and stays
at that weight for a while, the body tends to establish a new set point.
Opponents of the set-point theory argue that weight docs not remain constant Student life is often full of physical activity. This
throughout adulthood-the average person gains weight slowly, at least until old age. is not necessarily true for a person's later
Also, if an individual is placed in a different social, emotional, or physical environment, working life; hence, weight gain is o strong
weight can be altered and maintained markedly higher or lower. These arguments sug· possibility.
gest that humans, rather than having a set point determined by genetics or the num
ber of adipose cells, actually settle into a particuJar stable weight based on their
circumstances, often referred to as a "settling point."
Overall, the set point is weaker in preventing weight gain than in prevcming weight
loss. 9 Even with a set point helping us, the odds are in favor of cvcnrual weight gain
unJcss we devote effort to a healthy lifestyle.
Does Nurture Have a Role?

Some researchers would argue that body weight similarities between family members
stem more from learned behaviors than from genetic similarities. Even couples (who
generally have no genetic link) may behave similarly toward food and eventually as-
sume similar degrees of leanness or fatness. Proponents of nurture pose that environ -
mental factors, such as high-fat diets and inactivity, literally shape us.9 Consider that
our gene pool has not changed much in the past 50 years, but the ranks of obese peo·
pie have grown in what the U.S. Centers for Disease Concrol and Prevention describe
as epidemic proportions over the last 15 years.
Is poverty associated with obesity? Ironically, the answer is ofLcn yes. North
Americans of lower socioeconomic status, especially females, arc more likely Lo be
obese than those in upper socioeconomic groups. Arc cuJtural cxpcctalions or socio-
economic stress (e.g., food insecurity) the cause of this increase in obesity in lower food insecurity A condition of anxiety
socioeconomic classes? regarding running out of either food or money
Adult obesity among women is often rooted in childhood obesity. In addition, rel- to buy more food.
ative inactivity, periods of stress or boredom, and excess weight gain during pregnancy
contribute to female obesity. (Chapter 16 notes that breastfeeding one's infant con·
tributes to loss of some of the excess fat associated with pregnan<..-y. ) These patterns
suggest both social and genetic links. Male obesity, however, is not strongly linked to
childhood obesity and, instead, tends to appear after age 30. This powerful and preva-
lent pattern suggests a primary role of nurture in obesity, \Vith less genetic influence.
Nature and Nurture Together

Overall, both nature and nurture influence the tendency toward obesity (Table 13-4).
The eventual location of fat storage is strongly influenced by genetics. Consider the
possibility that obesity is nurture allowing nature to express itself. Some obese people
begin life with a slower basal metabolism, maintain an inactive lifostylc, and consume
highly refined, energy dense diets. These people in turn arc nurnircd into gaining
weight, promoting their natural tendency toward obesity.9
Table 13·4 I What Encourages Excess Body Fat Stores and Obesity?
Factor How Fat Storage Is Affected

Age Excess body fat is more common among adults and middle-aged individuals.
Menopause Increase in abdominal fat deposition is favored.
Gender Females generally have more fat.
Positive energy balance Over a long period, positive energy balance promotes storage of fat.
Composition of diet Excess energy Intake from o high-fat intake, generous alcohol intake, and preference for energy-dense (sugary,
fat-rich) foods ore likely to contribute to obesity.
Physical activity low or decreasing amount of physical activity ("couch potato") affects energy balance and body fat stares.
Basal metabolism A low value is linked lo weight gain.
Thermic effect of food This is low for some obesity coses.
Increased hunger sensations Some people especially hove trouble resisting the wide food availability typical of modern life, likely linked to
the activity of various brain chemicals.
Ratio of fat to lean tissue A high ratio of fat moss to lean body mass is correlated with weight gain.
Fat uptake by adipose tissue This is high in some obese individuals and remains high (perhaps even increases) with weight loss.
Variety of social and behavioral factors Obesity is associated with socioeconomic status; familial conditions; network of friends; busy lifestyles that dis-
courage balanced meals; binge eating; easy availability of inexpensive, "super sized" high-fat fast food; pat-
tern of leisure activities; television time; smoking cessation; excessive alcohol intake; lack of adequate sleep;
and number of meals eaten away from home.
Undetermined genetic characteristics These affect energy balance, particularly via the energy expenditure components, the deposition of the energy
surplus as adipose tissue or as lean tissue, and the relative proportion of fat and carbohydrate used by the
body.
Race In some ethnic groups, higher body weight may be more socially acceptable.
Certain medications Food intake increases.
Childbearing Women may not lose all weight gained in pregnancy, leading lo increased weight gain.
Notional region Regional differences, such as high-fat diets and sedentary lifestyles in the Midwest and areas of the South, lead
to different roles of obesity in different places.
Still , genes do not fully control destiny. With increased physical activity and de-
creased food consumption, even those people with a genetic tendency coward obi:sity
can attain a healthier body weight. 20
he total cost attributable lo weight-related

I Treatment of Overweight and Obesity
disease is about $90 billion annually in the
United States. Half of this cost is borne by the
Tn.:atmenl of overweight and obesity should be considered similar to treatment for an)
taxpayers through Medicare and Medicaid.
chronic disease: it requires long-term lifestyle changes. 19 Too often, ho\.vever, peopk
vkw a "diet" as something they go on temporai;Jy, only to resume prior {typicallr
poor) habit-s once satisfactory results have been achieved. ft is mostly for this reason
that so many pi:opk ri:gain Inst weight. Instead, overweight and obese (and as well un-
derweight) people should emphasize healthy, active lifestyles with lifolong dietary
modifications (Figure 13-15). 20 The following sections explore why obesity muse be
regarded as a chronic disease and treated appropriately.
What to Look for in a Sound Weight-Loss Plan

A dieter can tr)' ro devise a plan of action by seeking advice from a health protessional,
such as a registered dietitian, or by consulting cmrent literatw-e. Either way, a sound
weight-loss program should especially include these components:6,8,IO
Rate of Loss .
0 Slow and steady weight loss, rather than rapid weight loss, is encouraged
0 Goal is 1 lb of fat loss per week.
0 A period of weight maintenance for o Few months ofter 10% of body weight is lost.
0 Evaluation of need for further dieting before more weight loss begins.
'llffinM
0 Ability to participate in normal activities (e.g., parties, restaurants).
0 Adaptations to individual habits and tastes.
Fruit is o great snack- high nutrient density and
low energy density.
0 Nutritional needs ore met (except for energy needs).

0 Common foods ore included, with no certain foods being promoted as magical.
0 Use of o Fortified ready-to·eat breakfast cereal or balanced multivitamin/mineral supplement
is recommended, especially when consuming less than 1600 kcal per day.
0 Use MyPyromid as o pattern for food choices.
Behavior Modification
0 Maintenance of healthy lifestyle (and weight) is o key concern; there is o lifetime focus.
0 Changes ore reasonable a nd con be maintained.
0 Social support is encouraged.
0 Plans for relapse so one does not quit ofter a setback.
;.· . .
Overall Health
D Screening by a physician is required for people with existing health problems, those over 40
(men) to 50 (womenl years of age who pion to substantially increase physical activity, and
those who pion to lose weight rapidly.
0 Regular physical activity, proper rest, stress reduction, and other healthy changes in lifestyle
ore encouraged.
0 Underlying psychological weight issues ore addressed, such as depression or marital stress.
Figure 13·1 5 I Characteristics of a sound weight-loss diet. How many t2I are part of the diet plan
that you may be considering? As noted in the discussion on set point, the body makes numerous
physiological adjustments during times of underfeeding or overfeeding that resist weight change. This
compensation is most pronounced during times of underfeeding and is why slow, steady weight loss is
advocated.a
l. Control of energy intake. One recommendation is to decrease energy intake by

I 00 kcal/day (and increase physical activity by 100 kcal/day). This change should
eight-Control Objectives from
allow for slow and steady weight loss.
Healthy People 2010
2. Increased physical acti\'ity.
• Increase by 40% the proportion of adults who
3. Acknowledgment that maintenance of a healthy weight requires lifelong changes
are at a healthy weight (body moss index be·
in habits, not simply a short-term weight-loss period.
tween 18.5 and 251
A one-sided approach that focuses only on restricting cnerro intake is a difficult plan • Reduce by 50% the proportion of adults who
of action. Instead, adding physical activity and an appropriate psychological compo- ore obese (body moss index of 30 or more)
nent \\'ill cono·ibute to success in weight loss and eventual weight maintenance • Reduce by 50% the proportion of children
(Figure 13-16). and adolescents who ore overweight or obese
Figure 13· 16 I Weight-loss triad. The key

to weight loss and maintenance can be thought
al as a triangle in which the three corners
consist al ( 1) controlling energy intake,
(2) performing regular physical activity, and
(3) controlling problem behaviors. The three
corners al the triangle support each other in
that without one corner the triangle becomes
incomplete. In the same way, without one of the
three keys to weight loss, weight loss and loter
maintenance become unlikely.
Control energy intake
Perform regular physical activity Control problem behaviors
s you read brochures, articl es, or research Wishful Shrinking-Why Can't Quick Weight Loss
reports about specific diet plans, look be- Be Mostly Fat?
yond the weight loss promoted by the diet's ad-
Rapid weight loss cannot consist primarily of fat loss because a high energy deficit is
vocate to see if the reported weight loss was
needed to lose a large amount of adipose tissue. Adipose tissue, which is mostly fat,
maintained. If the weight maintenance aspect
contains about 3500 kcal/lb. Weight loss as fa t includes adipose tissue plus support-
was missing, then the program was not
ing lean tissues and represents approximately 3300 kcal/lb (about 7.2 kcaJ/g).
successful.
T herefore, to lose 1 lb of adipose tissue per week, energy intake must be decreased b~·
approximately 500 kcal/day, or physical activity must be increased by 500 kcal/day.
Alternately, a combination of both strategies can be used.9 Diets that promise 10 to
15 lb of weight loss per week cannot ensure that the weight loss is from adipose tissue
stores alone. Subtracting enough energy from one's daily intake to lose that amount
of ad ipose tissue si mply is not possible. Lean tissue and water, rather than adipose tis-
sue, account for tbe major part of the weight lost d uring these dramatic weight-loss
programs.
Weight Cycling Is All Too Common

Only about 5% of people who follow commercial diet programs actually lose weight
and then remain close to that weight. Typically, one-third of the weight lost during di-
eting is regained within 1 year of the end of dietary restriction, and almost all weight
lost is regained within 3 to 5 years. Some programs have higher success rates than 5%,
as do some people who simply lose weight on their own without enro lling in any su-
pervised plan. Overall, however, the statistics are grim. Currently, only the suxgicaJ ap-
proaches to obesity treatment show routine success in maintaining the weight loss in
most people .
Negative health consequences associated with this weight cycling are an increased
risk for upper-body fat deposition, profound discouragement and erosion of sclt:
esteem, and possibly a fall in HDL-cholesterol and immune system actinty.

Nevertheless, experts still encourage obese people co attempt \\'eight loss, with a strong
focus on maintaining that lower weight. Still, dieters need to be a\\'are of the trap of
today's crash diet, which too often leads to the next month's weight gain. Weight-loss
programs that claim you can lose weight and keep it off without changing food intake
or increasing physical activity arc selling a fantasy. A weight-loss program should be
considered successful only when the subjects involved in the process remain at or close
to their lower weights.
Weight Loss in Perspective or more information on weight control, obe·

sity, ond nutrition, visit the Weight-Control
All these principles point to the importance of preventing obesit:y. This concept has Information Network (WIN) al
"·ide support because conquering the disorder is so difficult.8 Public health strategies www.ntddk.nih.gov/ health/ nutrit/ win.htm or
to address the current obesity problem must speak to all age groups. There is a partic- coll 800.WIN-8098. Complete guidelines for
ular need to focus on children and adolescents because patterns of excess weight and weight monogement ore ovoiloble al
sedentary lifestyle developed during youth may form the basis for a lifetime ofweight- www.nhlbi.nih.govI guidelines/ index .htm.
relared illness and increased mortality. Tn the adult population, attention should be di- Other websites include www.coloriecontrol.org,
rected coward weight maintenance and increased physical activity. www.weight.com,www.obesity.org, and
www.cyberdiet.com.
Concept I Check
Obesity 1s a chronic disease that necessitates litelong treatment. Emphasis ~hould be placed
especially on prc\'enting obesity, because m·ercoming this disorder i~ \'Cry difficult.
Appropriate weight-loss programs h.wc the following characterisrics in common: ( l ) They
meet nutritional needs (except for energy needs); (2) the~· can adjust ro Jccommodate
habit~ and tastes; (3) they emphasize readily obtainable foods; (4) they promote changing
habits thar discourage overeating; (5) they encourage regular physical activity; and (6) they
help change obesity-promoting beliefs and rally healthy soci.11support.
Control of Energy Intake: The Main Key to Weight

Loss and Weight Maintenance
A goal of losing l lb or so of stored far per week may require limiting energy intake to
1200 kcal/day for ,,·omen and 1500 kcal/day for men. The energy .1llowance could
also be higher for very active people. Keep in mind that in o ur very ~edentar y society,
decreasing energy intake is vital because it is difficult to burn much energy without
ample physical activity. With n:gard to consuming less energy, some experts suggest
consuming less fat (especially saturated fat and tranr fat ), whi le others suggest con-
suming less carbohydrate, especially refined (high glyccmic load ) carbohrdrate sources.
Protein intakes in excess of what is typically needed by adults arc also recehfog atten-
tion as a weight-loss strategy (especially plant protein sources ).7 Using all these ap-
proaches simultaneously is also fine. At this time the lo\\ -fat, high-fiber approaches
have been the most successful i11 long-term studies. There is no long-term evidence tor
the effectiveness of the other approaches. 16 Finding what works for an individual is a
process of trial and error. In addition, as shown by Dr. Andrea Buchholz and Dr. Dale
Schoeller in their Expert Opinion in C hapter 4, the notion th.-it .-iny type of diet has a
"metabolic advantage" (i.e., promotes greater energy use by the body) is nonsense, de-
spite the marketing clain1s for low-carbohydrate diets.
One way for a dieter to monitor energy im.-ikc at the stare of a weight-loss program
is by reading labels. Label reading is important because man~ foods are more energy
dense than people suppose (Figure 13-17). Another method is co \Hice do\\'n food in -
take for 24 hollrs and then calcul.ue energy intake from the food table in Appendix N
or by using diet analysis software, adjusting futtu·e food choices as needed. Because
people often underestimate portion Si.le when recording food intake, measuring cups Slow, steady weight loss is one of lhe
and a food weighing scale can help. characteristics of a sound weight-loss program.
Serving Size: 1/2 cup (106g)

Servings Per Container. 4
Saturated Fat 1g Saturated Fat 11 g

Ttilnslat Og Ttilnslal Og
Cholesterol 1Omg Cholesterol 120mg
Sodlum 30mg Sodtum 85mg
Total Carbohydrates 17g Total Carbohydrates 20g
Dietary Fiber Og Dietary Fiber Og
Protein 3g Protein 5g
• Vitamin C 0% • Vitamin C 0%
Figure 13· 17 I Reading labels helps you choose foods with less energy content. Which ol these
frozen desserts is the best choice, per 1/2 cup serving, for o person on o weight-loss diet? The % Doily
Values ore based on o 2000 kcal diet.
Table 13-5 shows hm\ to start reducing energy incake. It is best to consider hc.ilthy
caring a lifosrylc change rather than simply a "eight-loss plan. Nore also that ltqu1d\
desen·e attention because liquid calorics do nor stimulate satiety mechanism~ to the
same extent as solid food'\. The corresponding advice from experrs is w use beverages
that have ljrclc or no energy content and limit sugar-sweetened beverages.
Regular Physical Activity: A Second Key to Weight

Loss and Especially Important for Later Weight
Maintenance
ote that spot-reducing by using diet and ReguJar physical .Krivit) is n:ry important for C\'cryone, especially people \\'ho arc tr~ ·
physical activity is not possible. #Problem" ing to lose weight or maintain a lower body weight. 10 Energy use is enlunced.
local fat deposits con be reduced in size, how· Therefore, it greatly complements a reduction in energy intake for wcighr loss ( but
ever, using suction lipeclomy. Lipectomy means does not substirute for it). Many people rarely do more than sir, stand, ,rnd slccp.
surgical removal of fat. A pencil-thin tube is in· Obviously, more energy is used during physical activity than at rest. Even cxpending
serted into on incision in the skin, and the fat tis· only 100 to 300 cxtra kcal/day above and beyond normal daily activity, whi le con·
sue, such as that in the buttocks and thigh area, crolling energy int.1kc, C;'ln lead to a steady weight loss. Furthermore, physical .11.:rivity
is suctioned This procedure carries some risks, has so many other bcnetits, including a boosc for mcrall self-esteem.
such as infection; lasting depressions in the skin; Adding any ofche acti,ities in Table 13-6 to one's lifr:sryle can increase enerffi out·
and blood dots, which con lead to kidney failure put. Duration and regular performance, rather than intensity, are the keys to success
and sometimes death. The procedure is designed with this approach co weight loss. One should search for acti,·irics that can be conrin·
to help o person lose about 4 to 8 lb per treat· ucd over rime. In this regard, waJkjng ,·igorously 3 miles/day can be as helpful .1s aer·
ment. Cost is about $1600 per site; total costs obic dancing or jogging, if it is maintained. Moreover, acri,ities of lighter intensity .m:
range as high as $2600 to $9000. less likely to lend to injuries. Snme resistance exercises such as weighc training also
Table 13-5 I Saving Kcal: Ideas to Help Get Started
Instead of Try Number of Kcal Saved

3 oz well-marbled meat (prime rib) 3 oz lean meat (eye of round) 140
1/2 chicken breast, batter-fried 1/2 chicken breast, broiled with lemon 175
1/2 cup beef strogonoff 3 oz lean roost beef (or use a fat-reduced recipe) 210
1/2 cup home-fried potatoes 1 medium baked potato 65
1/2 cup green bean-mushroom casserole 1/2 cup cooked green beans 50
1/2 cup potato salad 1 cup row vegetable salad 140
1/2 cup pineapple chunks in heavy syrup 1/2 cup pineapple chunks conned in juice 25
2 tbsp bottled French dressing 2 tbsp low<alorie French dressing 150
1/8 9-inch apple pie I baked apple, unsweetened 308
l /2 cup ice cream 1/2 cup fat-free ice cream 45
1 danish pastry 1/2 English muffin 150
1 cup sugor<ooted corn flakes 1 cup plain corn flakes 60
1 cup whole milk 1 cup 1% low-fat milk 45
7 oz gin and tonic 6 oz wine cooler mode with sparkling water 150
1-oz bog potato chips 1 cup plain popcorn 120
1/12 8-inch white layer coke with chocolate frosting 1/12 angel food cake; 10-inch tube 185
12 oz regular beer 12 oz light beer 40
should be added to increase lean body mass and, in turn, fat use (see Chapter 14). And
as lean muscle mass increases, so will one's overall metabolic rate. An added benefit of
including exercise in a weight-redm:tion program is maintenance of' bone health.
Unfornmately, opportunities to expend energy in our daily lives arc diminishing as
technology systematically eliminates almost every reason to move our nmsclcs. 2 The
easiest way to increase physical activity is to make it an enjoyable part of a daily rou-
tine. To start, one might pack a pair of sneakers and walk around the parking lot be- pedometer is a device that monitors activ-
fore coming home after school or work. every day. There are also plenry of other simple ity as steps. Cost is minimal. An often-
ways to increase activity of daily living, such as avoiding elevators in favor of stairs, stated goal for activity is lo toke at least 10,000
parking t11e car further away from the shopping mall, or getting up to change the chm1- steps/day-typically we toke half that many or
nels on the television. less. A pedometer tracks this activity.
Behavior Modification: A Third Strategy

for Weight Loss
Controlling energy intake, so important to weight loss, also means modifying problem
behaviors. 6 Only the dieter can decide whar behaviors keep him or her from reaching
for the wrong foods at t11e wrong times for the wrong reasons.
What events start (or stop) the action of eating? What factors influence food
choices? Psychologists ofi:en use terms such as chrrin-brealzing, stimulus control, CO/fni-
ti11c rcrtruct11ri11g, contingrncy management, and sc~fmonitorin._q when discussing be-
havior modification (Table 13-7). 19 These factors help place the problem in
perspective and organize the intervention strategy into manageable steps.
Chain-breaking separates behaviors that tend to occur rogcthcr-for example, chain-breaking Breaking the link between two
snacking on chips while watching television. Although these activities do not haw co or more behaviors that encourage overeating,
occur together, they often do. Dieters may need to break the chain re;.11.:tion (see the such os snacking while watching television.
Take Action at the end of this chapter fur more details).
Table 13·6 I Approximate Energy Costs of Various Activities, and Specific

Energy Costs Projected for a 150-lb (68 kg) Person
Kcal/kg Total Kcal/kg Total

Activity per Hour kcal/hour Activity per Hour kcal/hour
Aerobics-heavy 8.0 544 Horseback riding 5.1 346
Aerobics-medium 5.0 340 Jogging-medium 9.0 612
Aerobics-light 3.0 204 Ice skating (l 0 MPH) 5.8 394
Backpacking 9.0 612 Jogging- slow 7.0 476
Basketball- vigorous 10.0 680 lying-at ease l.3 89
Cycling (5.5 MPH) 3.0 204 Racquetball-social 8.0 544
Bowling 3.9 265 Roller skating 5.1 346
Calisthenics-heavy 8.0 544 Running or jogging (10 MPH) 13.2 897
Calisthenics-light 4.0 272 Downhill skiing (10 MPH) 8.8 598
Canoeing (2.5 MPH) 3.3 224 Sleeping 1.2 80
Cleaning (female) 3.7 253 Swimming (.25 MPHI 4.4 299
Cleaning (mole) 3.5 236 Tennis 6.1 414
Cooking 2.8 190 Volleyball 5.1 346
Cycling (13 MPH) 9.7 659 Walking (2.5 MPH) 3.0 204
Dressing/showering 1.6 106 Walking (3.75 MPH) 4.4 299
Driving 1.7 117 Water skiing 7.0 476
Eating (sitting) 1.4 93 Weight lihing-heavy 9.0 612
Physical activity complements any diet plan. Food shopping 3.6 245 Weight lihing-light 4.0 272
Football-touch 7.0 476 Window cleaning 3.5 240
Golf 3.6 244 Writing (sitting) 1.7 118
The values refer to totol energy expenditure, including that needed lo perform the physicol activity plus that needed for basal metob-
olism, the thermic effect of food, and thermogenesis. Use your diet analysis software for your personal estimate.
Stimulus control puts one in charge of temptations. Options include pushing

tempting food to the back of the refrigerator, removing fut-laden snacks fi-om the
kitchen counter, and avoiding the path by the vending machines. Provide a positive
stimulus control Altering the environment to stimulus by keeping low-fat snacks available to satisfy hunger/appetite. Note that al-
minimize the stimuli for eating- for example, cohol and foods offer quick, easy stress relief. Plan healthful alternatives.
removing foods from sight and storing them in Cognitive restructuring changes one's frame of mind. For example, after a hard
kitchen cabinets.
day, respond with a walk or satisfying talk with a friend instead of a binge. Replace eat-
cognitive restructuring Changing one's frame ing reactions to stress with healthful, relaxing alternatives.
of mind regarding eating-for example, Labeling some foods as "off limits" sets up an internal struggle to resist the urge
instead of using a difficult day as on excuse to to eat t hat food. This hopeless battle can keep one feeling deprived and defeated.
overeat, substituting other pleasures or Managing food choices with the principle of moderation is best. If a favorite food be-
rewords, such as a relaxing walk with o friend. comes troublesome, place it off limits only temporarily, until it can be enjoyed in
contingency management Forming a pion of moderation.
action to respond to a situation in which Contingency management prepares one for potential pitfalls and high-risk situa-
overeating is likely, such as when snacks ore tions. Rehearse in advance some appropriate responses to pressures-such as food
within arm's reach al a party. being passed around at a party.
A self-monitoring record can reveal patterns- such as unconscious overeating-
self-monitoring Tracking foods eaten and
conditions affecting eating; actions ore usually
tl1at may explain problem eating habits. This record can encourage new habits to coun-
recorded in a diary, along with location, lime, teract unwanted behaviors. Obesity experts note that self-monitoring is the key
and stole of mind. This is a tool to help people behavioral tool to use in any weight-loss program.
understand more about their eating habits. Overall, it's important to address specific problems, sucl1 as snacking, compulsive
eating, and mealtime overeating. Behavior modification principles end up as critical
Table 13-7 I Behavior Modification Principles for Weight loss
Shopping
1. Shop for food ofter eating-buy nutritious foods.
2. Shop from a list; limit purchases of irresistible "problem" foods. It helps to shop First for fresh
foods around the perimeter of the store.
3. Avoid ready-to-eat foods .
4. Put off food shopping until absolutely necessary.
Plans
1. Pion to limit food intake as needed.
2. Substitute periods of physical activity for snacking.
3. Eat meals and snacks at scheduled limes; don't skip meals.
Activities We ore faced with many opportunities to
overeat. It takes much perseverance to eat
1. Store food out of sight, preferably in the freezer, to discourage impulsive eating. sensibly.
2. Eat all food in a "dining" area.
3. Keep serving dishes off the table, especially dishes of sauces and gravies.
4. Use smaller dishes and utensils.
Holidays and Parties
1. Drink fewer alcoholic beverages. uccessful weight losers and maintainers
2. Pion eating behavior before parties. from the Notional Weight Control Registry
3. Eat a low<olorie snack before parties. engage in the following aclions:20
4. Practice polite ways to decline food.
5. Don't get discouraged by on occasional setback. • Eat a low-fut, high-carbohydrate diet (on av·
erage 25% of energy intake as fat).
Eating Behavior • Eat breakfast almost every day.
1. Put fork down between mouthfuls. • Self.monitor by regularly weighing themselves
2. Chew thoroughly before toking the next bite. and keep a Food journal.
3. Leave some food on the plate. • Exercise for a total of about l hour/day.
4. Pause in the middle of the meal. • Eat al restaurants only once or twice per
5. Do nothing else while eating (For example, reading, watching television). week.
Reward Other recent studies support this approach,
1. Pion specific rewords For specific behavior (behavioral contracts). especially the lost four characteristics.
2. Solicit help from Family and friends and suggest how they can help you. Encourage family and
friends to provide this help in the Form of praise and material rewords.
3. Use self-monitoring records as basis for rewords.
Self·Monitoring
1. Note the time and place of eating.
2. list the type and amount of food eaten.
3. Record who is present and how you feel.
4. Use the diet diary lo identify problem areas.
Cognitive Restructuring
1. Avoid setting unreasonable gaols.
2. Think about progress, not shortcomings.
3. Avoid imperatives such as always and never.
4. Counter negative thoughts with positive restatements.
Portion Control
l . Make substitutions, such as a regular hamburger instead of a "quarter pounder" or cucumbers
instead of croutons in salads.
2. Think small. Order the entree and shore it with another person. Order a cup of soup instead of
a bowl or an appetizer in place of an entree.
3. Use a to-go container (doggie bog). Ask your server to put half the entree in a to-go container
before bringing ii to the table.
Mony of us need to become •defensive eolers." Know when to refuse food oher sotiety registers, and reduce portion sizes.
components or weighL reduction and maintenance. Withour behavior modification, it

is difficult to make the lifelong changes needed to meer weight-control goals.
Relapse Prevention Is Important

A dieter can tolerate an occasional lapse but needs to plan for them. 6 The key is nor to
overreact, but take charge immediately. Change responses such as "I ate th.u cookie;
I'm a fuilure'' to "late that cookie, bul I did well to stop after 0111)• one!" An occasional
cookie is fine; a bag of cookies in one afternoon deserves serious attention. When di-
eters lapse from their diet plan, newly learned food habits should steer Lhem back ro-
ward the plan. Dieters need ro learn to avoid the lapse-relapse-collapse trap. Without a
relapse prevention A series of strategies used strong behaYioral program for relapse prevention in place, a lapse frequenLI) rums into
to help prevent and cope with weight-control a relapse. Once a pattern of poor food choices begins, dieters may foci that the) h.m:
lapses, such os recognizing high-risk situations fuilcd and stray farther rrom the plan. As the relapse lengthens, the diet pl.m collapses,
and deciding beforehand on appropriate and dieters full short of their weight-loss goal Even \\ ith a good behavioral pbn, a per-
responses. son may fail at a diet. Losing weight is difficult. Over.111, maintenance of weight loss is
fostered by the "3 Ml': motivation, movement, and monitoring. 19
Social Support Aids Behavioral Change

Hcald1y social support is helpful in weight control. Helping others understand how
they can be supportive can make wcighL control easier. Family and friends can pro\'idc
With regard lo readiness lo lose weight, what praise and encouragement. A registered dietitian or other weight-control prolcssionaJ
would you say lo a young woman who has can keep dieters accountable and help them learn from difficult situations. Long-term
just had a baby, needs lo find a new job, and contact with a pro~essional can be quiLc helpfuJ for I.leer weight mainten.1ncc. Groups
recently has gone back to school porl-lime? of indiYiduals anempting to lose weight or maintain losses can pro\'ide empathetic
support. 19
Concept I Check
Increasing physical activity in daily lilc should be part of any weight-loss plan . Dail~ .11.:tivity,
such as walking Jnd stair climbing, is recommended. Beha\'ior modification can improw
conditions for losing weight. One key step is to break behanor chains that cncourJge
O\'ereating, such as snacking while watching tebision. Another tactic is to modi~ the cn\'i-
ronment to reduce temptation; for e\amplc, put foods into cupboards to keep them out of
sighr. Tn additit>n, rethinking attitudes about eating-for example, substituting plc.1surcs
other than food as a reward for coping wiLh a stressful day-can be important l(ir altering
undesirable behavior. Advanced planning to prevent and deal with lapses is vital; .1~ is r.illy-
T he motivation to lose weight and keep it off

generally comes with o proverbial #Rip of
the switch," in which the desire to lose weight fi-
ing healthy social support. Finally, earetiJl observation and recording of eating habits can
rc\'eal subtle cues that lead to O\'ereJting. Q,·craU, weight loss and maintenance Jre fostered
by controlling energy intake, performing regular physical activity, and modi~•ing problem
nally becomes more important thon the desire to behaviors.
overeat.
Popular Diets-Why All the Commotion?
i\fany on:rweight people try ro help themsd\'es by initial weight loss primarily results from \\ Jter
using the latest popular (:ilso called fud) diet book. loss and lean muscle mass depletion. well-known example of the effec-
Bm a\ you will see, most of these diets do not help, 2. They limit food selections and dictate specific tiveness of monotony contributing to
and some can actually harm those who follow them nruals, such .is eating only fruit for breakfast weight loss is the experience of Jared
(Table 13-8). or cabbage soup c1·ery day. Fogle. He ate primarily Subway sand-
Recently, weight-loss experrs came together at 3. They use te~timomab from famous people and wiches for 11 months and lost 245 lb.
the request of USDA to evaluate weight-loss dices. tie the diet to well-known cities, such as He notes, however, that this is not o mira-
Their conclusion was to forget fads when it comes Bel"crl) Hills :'Ind Ne11 York. cle diet-it tokes o lot of hard work to
to dieting. Most of the popular diets arc nutrition- 4. The)' bill the1meh·es as cure-alls. These diets lead to the success he experienced.
all\' inadequate and include certain foods that peo- claim ro work for everyone, whatever the type
ple would not normally choose to consume in large of obcsit) or the person's specific srrcngths
amounts The experts stated that eating less of cer- and weaknesses.
tain foods and becoming more physicall\' acti\'e can o. The) often recommend expensi\'e supplements.
be much more eflect:iYe "·hen trying co implement 6. ~o arrempcs are made to change eating habits
a weight loss diet. People need a plan chat they can permanently. Dieter~ follow the diet until the
lin: with in the long run because the best predictor desired weight is reached and then rc\'crt to
of dieting success is Jong-term adherence to a Jo,, - old eating habits. They are told, for example,
caloric diet. ro cat rice for a monrh, lose weight, and then
The goal should be weight control 01·er a li fe - return to old habits.
time, not immediate weight loss. Every popular diet 7. They .ire generally critical and skeptical of the
le.lds ro \omc immediate weight loss simply because scienti fic community. The fact tl1at the med-
daih energy intake is monitored and monotonous ical ,rnd dietetic..~ professions cannot pro\'ide a
food choices are typically pan of the plan. On:rall, quick Ii\ for m·crweight has led some people
a rraditioml moderate diet coupled with regular co seek Jd\ ice from those who appear to ha1·c
ph\'sical .lCti\ity is .1dequate for weight lcm. 19 the amwer.
You nuy wonder why popular diet book\ exist
.u .ill. Why doesn't the go\'ernmenr put .i stop to Probabl) the cruelest characteristic of these
rhem? i\lany contain blatant misinformation. diets is tlw they cssenti,illy guarantee failure for the
Hnwe1·er, FDA concerns itself only when products dieter. The dietlt .ire not designed for pernunent
,U"e suspected of doing serious harm, a~ in the case weight loss. Habi t~ .m: not changed, and the tC>0d
of e.irlier fi.Jrms of liquid protein dim. Classic ad- selection is so limited that the person cannot follow
\ ice is still l"alid: "Let the buyer beware." the diet in the long run. Although dieters am1me
Responsibility rests \\itl1 the authors and publish- they Im c lost fat, 1hey ha\'e actuall~ lost mostly
ers, who \\'ant to sell books and earn money. muscle and other lean tissue mass. As soon a!> they
~ 1.ikmg outrageous claims sells more books tlun begin caring normally again, much of the lost tis-
writing, "Eat less and walk more." sue is replaced. In .i matter of weeks, most of the
lost weight is back. The dieter appears co ha1·c
failed, 11 hen .ictually the diet has failed. The gain
How to Recognize a Dubious and loss c~1ek is C<llled weight cycling, or yo-yo di·
c:ting. This whole scemrio can lead co blame and
Popular Diet guilt, challenging the sdf-worth of the dieter. l t
can also come with some health costs, such ai. in-
This ch,1pter has already discussed the criteria for
creased upper-body fut deposition. If someone eol replacement formulas to re·
e1·aJu.1ting weight-loss programs ,,;th regard to tl1eir
needs help losing \\c1ghr, professional help is ad place o meal or snack ore appro·
sati:ry Jnd effectil"eness. In contrast, dubious popular
l"iscd. 19 It is unfortunate that current trends sug- priote to use one to two times per day, if
dii:cs t\'Pic.tll) share some common ch.iracteristics:
gest that people arc spending more time and one desires. These ore not o magic bullet
I . The1· promote quick \\'eight loss which is the monq on quick fixes rather than on such profes- for weight loss, but hove been shown to
primary temptation chat dicccrs foll for. This sional help. help some people lose weight.
499
~ Table I 3·8 I A Summary of Popular Diet Approaches to Weight Control
0
Approach Examples Characteristics Outcomes
Moderate energy The Set-Point Diet lose the last l 0 Pounds Generally 1200 to l 800 Acceptable if a balanced multi-
restriction Slim Chance in a Fat World Dieting with the Duchess kcal/day, with moderate fat vitamin and mineral supple-
Weight Watcher's Diet Dieting for Dummies intake ment is used and if physician
Mary Ellen's Help Yourself Diet The Wedding Dress Diet Reasonable balance of approval is obtained
Plan Dr. Shapiro's Picture Perfect macronutrients
The Beyond Diet Diet Encourage exercise
Staying Thin French Women Don't Get Fat Moy use behavioral approach
The Calloway Diel No Fad Diel: A Personal Plan
Living without Dieting for Healthy Weight
Volumelrics
Restricted carbohydrate Dr. Atkins New Diet Revolution Four Day Wonder Diel Generally less than 100 g of Ketosis; reduced exercise ca-
Calories Don't Count Endocrine Control Diet carbohydrate per day pacity due lo poor glycogen
Miracle Diet for Fast Weight Enter the Zone stores in the muscles; exces-
loss Protein Power sive animal fa t and choles-
Woman Doctor's Diet for The Five-Doy Miracle Diet terol intake; constipation,
Women Healthy for life headaches, halitosis (bad
The Doctor's Quick Weight Loss Carbohydrate Addicts Diet breath), and muscle cramps
Diet Sugar Busters
The Complete Scarsdale South Beach Diel (especially
Medical Diet initial phases)
Low fat The Rice Diet Report The Maximum Metabolism Diet Generally less than 20% of Flatulence; possibly poor min-
The Macrobiotic Diet (some The Posto Diet energy intake from fat eral absorption from excess
versions) The McDougall Pion Limited (or elimination on ani· fiber; limited food choices
The Pritikin Diet Ultrofit Diet mol protein sources; also lim· sometimes leads to
Eat More, Weigh Less Stop the Insanity ited fats, nuts, seeds deprivation
The 35+ Diet G-lndex Diet Not necessarily to be avoided,
20/ 30 Fat and Fiber Outsmarting the Female but certain aspects of many
Fat to Muscle Diet fat Cell of the plans possibly
T-Factor Diet Foods That Cause You lo unacceptable
Fit or Fat lose Weight
Two-Day Diet Leon Bodies
Turn Off the Fol Genes
Novelty diets Dr. Abrovenel's Body Type and Eat lo Succeed Promotes certain nutrients, Malnutrition, no change in
lifetime Nutrition Pion (or his The Underburner's Diet foods, or combinations of habits, which leads to re-
other books) Eat to Win foods as having unique, magi- lapse; unrealistic food choices
Dr. Berger's Immune Power Diel Paris Diet cal, or previously undiscov- lead to possible bingeing
Fit for Life Cabbage-Soup Diet ered qualities
The New Hilton Head Eat Great, Lose Weight
Metabolism Diet Eat Smart Think Smart
The Beverly Hills Diet Scenlsolional Weight Loss
Dr. Debetz Champagne Diet Eat Right 4 Your Type
Sun Sign Diet The Greenwich Diet
F-Plan Diel 3 Season Diet
Fat Attack Plan Metabolize
Autohypnosis Diet God's Diet
The Princeton Diet The Weigh Down Diet
The Diel Bible
notable are the Pritikin Diet and the Dr. Dean eople on diets often foll within a
Types of Popular Diets
Ornish "Eat More, Weigh Less" diet plans. This non-overweight BMI of 18.5 lo 25.
approach is not harmful for health~, adults, but it is Rather than worrying about weight loss,
low- or Restricted-Carbohydrate
difficult to follow. People get bored wiili this type thes.e individuals should be focusing on a
Approaches
of diet very quickly because they cannot eat many heolthy lifeslyle that allows for weight
The low-carbohydrate diet is currently the most of their favorite foods. These dieters cat primarily maintenance. Incorporating necessary
common of the popular diers. Low-carbohydrate grains, fruits, and vegetables, which most people lifestyle changes and learning lo accept
intake leads to less glycogen synthesis :md therefore cannot do for very long. Eventually, the person one's particular body characteristics
less water in the body (about 3 g of water arc stored wants some fr>ods higher in fat or protein. These should be the overriding goals. Dieting
per gram of glycogen). As discussed in Chapter 4, a diets are just too different from the typical North mania con be viewed as mostly a social
very-low-carbohydrate intake also forces the liver to American diet for many adults to follow consis· problem stemming from unrealistic weight
produce needed glucose. The source of carbons for tently, but may be acceptable for some people. expectations (especially for women) and
this glucose is mostly tissue proteins. (Recall also lock of appreciation for the natural vori·
from Chapter -! that typical f.my acids can't form ety in body shape and weight. Not every
glucose. ) Thus, a low-carbohydrate diet results in Novelty Diets
woman con look like o fashion model,
protein tissue loss (whkh is about 72% water) as A ,·aricty of dices are built on gimmicks. Some nO\'· nor con every man look like a Greek
well as urinary loss of essential ions such as poras· elty diets emphasize one food or food group and god, but all of us con strive for good
sium. Bt.'.cause protein tissue is mostly water, Lhe di· exclude almost all others. A rice diet was designed health and, if physically possible, on cc·
eter loses weight very rapidl~·· When a normal diet in the 1940s to lower blood pressure; now it has live lifestyle.
is resumed, the protein tissue is rebuilt and the resurfaced as a weight-loss diet. The first phase
weight is regained. consists of eating only rice and fruit. Another nov-
Low-carbohydrate diets primarily work in the elty diet is the egg diet, on which you eat all the
short run because they limit total food intake. And eggs you want. On the Be\•erly Hills Diet, you cat
in long-term studies these diets ha\'c nor shown a mostly fruit.
distinct ad\'antage compared ro diers that simply The rationale behind these diets is that you can
limn energy intake in general. eat only eggs, fruit, or rice for just so long before
Diet plans that use a low-carbohydrate ap· becoming bored and, in tl1eory, reducing your en·
proach .1rc the Dr. Atkins' New Diet Revolution, ergy intake. However, chances arc that you \\~II
the Scarsdale Dier, and the Four· Day Wonder Diec. abandon the diet entirely before losing much
i\lori.'. moderate approaches are found in the vari · weight.
ou:; Zone diets (40% of energy intake as carbohy· The most qucscionable of the no,·elty diets pro-
dratc), Sugar Busters diet, and tl1e South Beach pose that "food gets stuck in your body." Fit for
diet (especially initial phases). When you see a new Life, the Beverly Hills Diet, and Eat Great, Lose
diet ad\'ertisement, look first to see ho'' much car· Weight are examples. The supposition is that food
bohydratc it contains. If breads, cereals, fruits, and gees sruck in Lhe intestine, putrefies, and creates
,·egerables are extremely limited, you are probably toxins tint invade the blood and cause disease. In
looking at a low· or restricted-carbohydrate diet. response, recommendations are to not consume
The popularity of low-carbohydrate diets has meat with potatoes, or consume fruits only after
already reached its peak. Recent studies show these noon. These recommendations make no physiolog·
diers provide no long rerm advantage over other ical sense, nor do recommendations for eating ac·
diet plans. 3 In addition, comp.rnies producing cording to one's blood type.
foods for these diets ha\'e been going bankrupt, as
ha\'e srores specializing in low-carbohydrate foods.
Quackery Is Characteristic of
Low-Fat Approaches
Many Popular Diets In time, the very-low-carbohydrate, high-
protein diets typically leave o person
The 'cry-low-fat diet rums out to be a \cry-high- Many popular diets fall under the category of wonting more variety in meals, and so
carbohydrare diet. These diets contain approxi· quackery-people caking advantage of otl1ers. They the diets ore abandoned. Dropout rotes
mately 5 to 10% of energy intake as fat. The most usually i11\'olve :i produce or service tl1at costs a ore very high on these diets.
501
I
" -- - -- - - - - - -- - - - - ·--- - - - - - - -- -
considerable amounr of money. Often, those offer-
R ecently a woman developed liver
failure otter using a so-coiled
weight-loss aid called usnic acid. Her
ing the product or service don't realize that they
are promoting quackery because they were victims
futw·e an important aid for weight loss is discovered,
you can foci confident that major jow-nals, such as
the Journal ofthe American Dietetic Association, d1e
purchase was via the Internet. Today themselves. For example, they tried the product Jo11r11al ofthe American Medical Association, or 11Je
more than ever, let the buyer beware con- and by pure coincidence it worked for them, so Ne111 England journal of Medicine, will report it. You
cerning any purported weight-loss aid not they wish to sell it to all their friends and relatives. don't need to rely on paperback books, infomercials,
prescribed by a physician. Numerous other gimmicks for weight loss have billboards, or newspaper advertisements for informa-
come and gone and are likely to resurface. 17 If in the tion about weight loss.
- As you hove probably surmised, Chris will just be wasting his money if he buys the
product seen in the infomercial. Unfortunately, regulation of the supplement industry
currently is woefully lacking. In the future, if there is a meaningful breakthrough in
weight loss and weight control, authorities such as the Surgeon General's Office or the National
Institutes of Health will make North Americans aware of that fact. At this time, Chris would be
better off simply paying more attention to what he is eating and trying to find time for doily
physical activity.
I Professional Help for Weight Loss

The first professional to see for advice about a weight-loss program is one's family
N orth Americans are willing to try almost
anything to shed unwanted pounds.
Operation Waistline is a program designed by
physician. Doctors are best eq uipped to assess overall health and the appropriateness
of weight Joss. The physician may then recommend a registered dietitian for a specific
the U.S. Federal Trade Commission to terminate weight-loss plan and answers to diet-related questions. Registered dietitians are
fraudulent claims being made by weight-loss uniquely qualified to help design a weight-loss plan because they understand both food
charlatans with regard to diet products. The pro- composition and the psychological importance of food. Exercise physiologists can pro-
gram hopes to put on end to the $6 billion spent vide advice about programs tO increase physical activity. The expense for such profes-
annually in the United States on counterfeit sional interventions is tax deductible in the United States in some cases (see a tax
products. Recently the Enforma Natural Products advisor) and often covered by health insurance plans if prescribed by a physician.
Corporation had to pay $10 million in response Many communities have a variety of weight-loss organizations. These include selt: help
to false claims for its "Fat Trapper" product. groups, such as Weight Watchers and Take Off Pounds Sensibly. Other programs, such as
Jenny Craig and Medifust, are less desirable for the average dieter. Often, the employees
are not registered dietitians or other appropLiately trained health professionals. These pro-
grams also tend to be expensive because of their requirements for intense counseling or
mandatory diet foods and supplements. In addition, the Federal Trade Commission has
charged these and other commercial diet-program companies with misleading consumers
through tmsubstantiated weight-loss claims and deceptive testimonials.
Medications for Weight Loss

People who are candidates for medications for obesity include those with a BMl of 30
or more, or a BMT of27 ro 29.9 with weight-related (i.e., comorbid) conditions, such
as type 2 diabetes, cardiovascular disease, hypertension , or excess waist circumference;
502
those with no contraindications co use of the medication; :rnd those n:.id)' to under·
rake litestyle change. Success wich medications has been shown only in those w ho also
modi!)· their heha,ior, decre.1se energy inrake, and increase physical activicy. 19 Drug
cherap} alone has not been found co be successful. In addition, if a person has not losr
.it le.isr 4.4 lb (2 kg) after 4 weeks, it is nor likely that the person will benefit from fur-
ther use of the medication .
Currenrh three main classes of medications are used. 12 An amphetamine-like med- amphetamine A group of medications thol
ic.ition ( ph~nte1-.u11ine [ bsan or Ionamin ]) prolongs the activity of epinephrine and stimulate the central nervous system and hove
norepinephrinc in the bram. This therapy is eftcctive for some people in the shorr run other effects in the body. Abuse is linked lo
bur has not yet been proven effective in the long run. Most state medical boards cur- physical and psychological dependence.
rently limn use co 12 weeks unless the person is participating in a medical stud)' usi ng
the product. The mcdic.:arion should not be used by pregnant or nursing women o r
those under 18 years of age.
Sibutraminc (Mcridia) is a second class of medicatio n that has been approved by
FDA for weight loss. It enhances both norepinephrine an d scrotonin activity in the
brain by reducing reuptakc of these neurotran smitte rs by nerve cells. T he ne urotrans·
mittcrs then remain active in tht: brain for a longer period of time and so prolo ng a
sense of reduced hunger. The most common side effects arc comtipation, dry mouth ,
insomni.1, .rnd a mild increase in blood pressure in some people. T hus, sibutramine
should be used \\1th caution in people with a history of hypertension (or cardiovasc.:u·
lar disease). Studies ha\·c sh(m n that it is etleccive in helping some people who alread y
eat health) diets, bur 1usr ear coo much. 19 The main effect is to moderately reduce ap·
petite so tlut people car less. Siburr:unine is safe and effecti\'e only when combined
with a c.:omprchensi,·e weight-conrrol program and when supervised b)' .i physician.
The third class of' medication approved by FDA for weight loss is orlistar (Xcnical).
This medication inhibits lipase enz) me action in the small intestine, reducing far di-
gestion by about 30%. Orlistat reduces .ibsorption of dietary fat b>' one-third for abou t
2 hours when taken along with a meal comaining fut. This malabsorhcd fat simply is
deposited in the tCc.:es. Frit i11rn.lu- /Jns ro be co11tro!lcrf, however, because large amounts he only two weight-loss medications op·
of fat in the ICccs cause numerous side effects, such as gas, bloating, and o ily discharge. proved by FDA for long-term use ore sibu-
lnrcrestingly, orhscat use can actually remind the person to follow a fat -controlled dicr, tromine (Meridio) and orlislol (Xenicol). Drug
because the svmproms resulting from consuming a high-fat meal arc unpleasant and companies ore working on many other types of
quic.:kly develop. Orlistar is taken with each meal conraining fat. medications (e.g., rimonobont) and hove high
Because the malabsorbed fat also carries fat-soluble vitamins into the lcccs, the person hopes that some of these will prove to be safe
taking orlistat must take a multivitamin and mineraJ supplcmcnt at bedtime. In this way, and effective for weight loss. In addition, physi·
any mic.:ronutricnLs not absorbed duri ng the day can be rcplacl!d ; fat malabsorption fro m cions may prescribe medications that ore not
the dinner meal will not greatly influence micronutricnt absorption in the late evening. approved for weight loss per se but con hove
Overall, in skilled hands, pn:scriprion medications can aid weigh t loss in some in weight loss as a side effect. Certain antidepres-
sranc.:es. However, they do not replace the need for reducing energy intake, modi fying sants (e.g., bupropion [Wellbutrin]) ore on ex-
problem beha\ iors, ,rnd increasing physical activity, both during and a~lcr thcrapy. 14 omple.14 Such on application is termed
And more often than not, any weight loss during drug creatment can be auributcd off.lobe/, because the product label does not in·
mostly to the incfo·idual's hard work at balancing energy intake with outpur. 19 elude weight loss as on FDA-approved use.
Treatment of Severe Obesity

$e\'crc ( morbid ) obesity-\\ eighing ar least l 00 lb over health} bod) weight (or twice
one's health\ body \\'eighr)-requircs professional treatment. Because of the serious
health implications of se\'crc obesit), drastic measures may be necessary. Such treat-
ments are recommended only when tradirionaJ diets fail. Drastic weight-loss procc·
dures arc not without side clfocts, both physical and psychological, making carcfi.tl
monitoring by a physician necessary.
very-low-calorie diet (VlCD) Diel that a llows a
person 400 to 800 kcal per day, often in liquid
Very-Low-Calori e Diets form. Of this, 120 to 480 kcal is carbohydrate,
If more tradiuonal dice changes have failed, treating severe obesity with a very-low· and the rest is mostly high<juolity protein. Also
calorie d iet (VLCD) is possible, especially if the person h~1s obesity-related diseases known os protein-sporing modified fast (PSMF).
that arc not well controlled (e.g., hypertension , type 2 d iabetcs). 19 Some researchers
believe that people with body weight greater than 30% above their healthy weight arc
appropriate candidates. Optifast is one such commercial program. In general , the diet
allows a person to consume 400 to 800 kcal/day, often in liquid form. (These die~
were previously known as protein-sparing modified fasts.) Of this amount, about I 00
to 120 g ( 400 to 480 kcal) is carbohydrate. The rest is high-quality protein, in the
amount of about 70 to 100 g/day (280 to 400 kcal). This low carbohydrate intake
often causes ketosis, which ma)' decrease hunger. However, the main reasons for
weight loss arc the minimal energy consumption and the absence of food choice.
About 3 to 4 lb can be lost per week; men tend to lose at a faster rate than women.
When physical activity and resistance training augment this diet, a greater loss of adi-
pose tissue occurs. Careful monitoring by a physician is crucial throughout this very re-
strictive form of weight loss. Major healLh risks include heart problems and gallscones.
Weight regain remains a nagging problem, especially without a behavioral and phys-
ical activity component. lf behavioral therapy and physical activity supplement a long-
term support program, maintenance of the weight loss is more likely but still difficult.
Any program under consideration should include a maintenance plan. Today, antiobc
sity medications also may be included in this phase of the program.
Ga strop la sty
Gastroplasty (gastric bypass surgery, also called stomach stapling) is the primary surgi -
cal procedure used today for treating severe obesity. 1 About $1 billion is spent each
year for this procedure. The most common and effective surgical approach in the long
run is the Roux-en-Y gastric bypass procedure. It works by reducing the stomach ca-
pacity to about 30 ml (the volume of one egg or shot glass) and bypassing a short seg-
ment of the upper small intestine (Figure 13-18). Weight loss is promoted mainly
because overeating of solid foods is now less likely because of reduced ghrelin output
and discomfort or vomiting with overeating. It is also necessary to eliminate simple
carbohydrates (sugar) from the diet of people who have undergone gastroplasty Lo
avoid dmnping syndrome. Dumping syndrome is characterized by severe diarrhea,
which begins almost immediately following Lhe ingestion of concentrated sugar, such
as regular soft drinks, Jell -o, candy, cookies, and other high-sugar foods.
About 75% of people with severe obesity eventually lose 50% or more of excess bo<ly
weight with this method. In addition, the surgery's success at long-term maintenance
often leads to dramatic health improvements, such as reduced blood pressure and elim
ination of type 2 diabetes. Risk of death from the surgery itself is about 2%, especially
if the surgeon bas performed less than 20 of the procedures. Risks of this very de-
manding surgery include bleeding, blood clots, hernias, and severe infections. In the
long run, nutrient deficiencies can develop if the person is not adequately treated in
the years following the surgery (chewable multivitamin and mineral supplements arc
often used). Anemia and bone loss might then be the result.
Current patient selection criteria for Roux-en-Y gasrroplasty include the following:
• BMI should be greater than 40.
• BMI between 35 and 40 is considered when there are serious obesity-related health
concerns.
• Obesity must be present for a minimum or 5 years, with several nonsurgical at ·
tempts ro lose weight.
• There shouJd be no history of alcoholism or major psychiatric disorders.
The person also must consider that the surgery is costly ($12,000 to $40,000 or
more) and may not be covered by medical insurance. In addition, follow-up surgery is
often needed after weight loss to correct stretched skin that was previously lilied with
fat. Furthermore, the surgery necessitates major lifestyle changes, such as the need to
plan frequent, small meals. Therefore, the dieter who has chosen this drastic approach
to weight loss faces months of difficult adjustments.
Other surgical approaches arc vcrLical-bandcd gastroplasty, gastric banding proce-
dure, and biliopancrcatic diversion. Jn the vertical -banded gasrroplasty, a vertical sta-
www.mhhe.com/w ardlawpers7 505
Stomach Figure 1 3-1 8 I Three of the most common

forms of gastroplasty for treatment of severe
obesity. The Roux-en-Y procedure (b) is the most
effective method but is more technically
I....~~~"'..;..;..+++- Staple
Unused portion line demanding for the surgeon than gastric
of stomach banding (c) or vertical-banded gastroplasty (d).
Small In vertical-banded gastroplasty, the band
intestine prevents expansion of the outlet for the stomach
pouch.
Small
(a) Normal stomach (b) Roux·en·Y gastric bypass
Esophagus Unused
portion of
Small stomach stomach
pouch
Gastric bond-__..,,..,,,
~~~~ch
portion
~
1 Small
intestine
Port for injecting

saline solution
(c) Gastric banding (d) Vertical-banded gastroplasty
(e.g., LAP-BAND® procedure)
pie line is made down the length of the stomach to create a small stomach pouch. At
the outlet of the pouch, a band is placed to keep the opening from stretching (review
Figure 13- 18 ). With gastric banding, a band is placed around the upper portion of the
stomach, creating a small stomach pouch (review Figure 13-18). A salt solution can be
injected into the band through a port to adjust the size of the pouch over time. In the
biliopancreatic diversion (often called duodenal switch), stomach volume is reduced
surgically by 75%, and much of the intestinal tract is bypassed. This combination leads
to less food consumption and significant nutrient mafabsorption. Because of the latter
factor, this procedure has yet to gain much acceptance by surgeons for weight loss,
whereas the other two procedures are common.
Concept I Check
Severely obese people who have f.iiled to lose weight with conservative weight-loss strate-
gies may consider other options. Their doctors may recommend that they uodergo surgery
such as reducing the volume of the stomach to approximately 30 ml or following a very-
low-calorie diet plan containing 400 to 800 kcal per day. Careful monitoriog by a physician
is crucial in both cases.
Treatment of Underweight
underweight A body mass index below 18.5.
We frequently hear about the risks of obesity but seldom of underweight. In our cul- The cutoff is less precise than for obesity
ture, being underweight is much more socially acceptable than being obese. because this condition has been less studied.
Underweight can be caused by a variety of factors, such as cancer, infectious disease
(e.g., tuberculosis), digestive o-acr disorders (e.g., du·onic inflammatory bowel dis-
ease), and excessive physical activity. Genetic background may also lead to a higher
resting metabolic rate, a lean or petite body frame, or both. Significant underweight is
also associated with increased death rates, especially when combined with cigarcue
smoking. Health problems associated with underweight include the loss of menstrual
function, low bone mass, complications with pregnancy and surgery, and slow recov-
ery after illness.
Sometimes being underweight requires medical intervention. A physician should be
consulted first to rule out hormonal imbalances, depression, cancer, infectious disease,
digestive tract disorders, excessive physical activity, and other hidden disease, sud1 as a
serious eating disorder (see Chapter 15 for a dcrniled discussion of eating disorders).
The causes of w1derweight are not altogether different from the causes of obesity.
Internal and enernal satiety-signal irregularities, the race of mernbolism, hereditary
tendencies, and psychological traits can all contribute to underweight.
In growing children, the demand for energy to support physical activity and growth
can cause underweight. During growth spurts in adolescence, active children may not
take the time to consume enough energy to support their needs. Moreover, gaining
weight can be a formidable task for an underweight person. An extra 500 kcal per day
may be required to gain weight, even at a slow pace, in part because of the increased
expenditure of energy from thermogenesis. In contrast to the weight loser, the weight
gainer may need to increase portion sizes.
When underweight requires a speci£c intervention, one approacb for treating adults
is to gradually increase their consu mprion of energy-dense foods, especiaUy d1ose high
in vegetable fat. Italian cheeses, nuts, and granola can be good choices because they
are low in saturated fat. Dried fruit and bananas are good fniit cboiccs. If eaten at the
end of a meal, they don't cause early satiety. The same advice applies ro sal:ids :ind
soups. Underweight people should replace such foods as diet soft drinks with health~
energy sources, such as fruit juices and smoothies.
Encouraging a reguhtr meal and snack schedule also aids in weight g<t.in .rnd mam-
tenance. Sometimes people who arc tmderweight have experienced stress at work or
have been too busy to eat. Making regular meals a priority may not only hdp them at-
tain an appropriate weight but also help with digestive disorders, such as constipation,
that arc sometimes associated wid1 irregular eating times.
Excessively physically active people can reduce activity. 1f d1eir weight remains low,
they can add muscle mass through a resistance training (weight-lifting) program, bur
they must increase their energy intake ro support that physical activity. Otherwise,
weight gain will be hindered.
Summary
l. Energy balance considers energy intake and energy output. person, abour 70 ro 80% of energy u~c is acrnumed for hy ba~al
Negative energy balance occw-s when energy ourpm surpasses en- meLabolism and the therm it: effect of food.
ergy intake, resulting in weight loss. Positive energy balance occurs 3. Energy use by the body can be measured directly rre>m heal ouL-
when energy inrake is greater than output, resulting in weight gain. pm or indirectly from oxygen uptake, carbon dioxide outpur, or
2. Basal metabolism, the thermic effect of food, physical activity, and both. An Estimated Energy Requircmem can be calcul.uc:d using
rhcrmogenesis accow1C for total energy use by the body. Basal me- ~ormulas based on various combination..c; of bod~ height and
tabolism, whic h represents the minimum amounr of energy use<l weight with degree of physical activity and age.
to keep the resting, awake body alive, is primarily affected by lean 4. Groups of cell~ in the hyporhalamus and othc:r regions in rhc brain
body mass, surface area, and thyroid hormone concentrarions. aftccr hunger, the primaiily internal desire to tind .ind cat lixid.
Physical activity is energy use above tl1at which is expended at rest. These cells monitor macronuc.ricnts and other subscancc~ in Lht•
The thennic effect of food describes tl1e increase in metabolism blood <md read low amounts as a signal co promote freding.
that facilitates digestion, :ibsorption, and processing of nutrients 5. A rnriecy of external (appctitc:-rd:ited) forces, such as food av.1il-
recently consumed. Thcrmogenesis is heat production caused by abiliry, aftect satiety. Hungc.:r cues combine with appetitt· mes to
shivering when cold, fidgeting, and other stinmli. In a sedentary promorc tccding.
6. In North America, the major detern1inants of food intake are exceeds intake by about 500 kcal per da~', a pound of adipose tis-
probably appetite-driven forces because food is so readily avail- sue can be lost per week.
able. The physiological influences affecting food consumption are 12. Physical activity as part of a weight-loss program should be fo.
often suppressed or igno red. cused on duration rather than inrensiry. Ideally, vigorous activiry
7. A person of healthy weight generally shows good health and per- for 60 to 90 minutes shotLld be part of each day.
forms daily activities without weight-related problems. A body 13. Behavior modification is a vita.I part of a weight-loss program be-
mass index (weight in kilograms .;- height2 in meters) of 18.5 co cause the dieter may have many habits that discourage weight
2 5 is one measure of healthy weight, although weight in excess of maintenance. Specific behavior modification techniques, such as
this value may nor lead to ill health. A healthy weight is best de- stimulus control and self-monitoring, can be used to help change
termined in conjunction with a thorough health evaluation by a problem behavior.
physician. 14. Medications to blunt appetite, such as phenrera.mine (Fastin) and
8. A body mass index of25 to 29.9 represents overweight. Obesiry sibutramine (.Meridia), can aid weight-reduction strategies.
is defined as a total body fat percentage over 25% ( men ) or 35% Orlistat (Xenical) reduces ratabsorption when taken with the
(women), or a bod~· mass index of 30 or more. meal. '\;\/eight-loss drugs are reserved for those who are obese or
9. Fat distiibution greatly determines health risks from obesity. have weight-related problems, and they must be administered
Upper-body far storage, as measured by a waist circumference under close physician supervision.
greater than 40 inches (102 cm) (men) or 35 inches (88 cm) 15. The treatment of severe obesiry may include surgery to reduce
(women), increases the risks of hypertension, cardiovascular dis- stomach volume to approximately 30 ml ( 1 oz) or very-low-
ease, and type 2 diabetes more than does lower-body fut storage. calorie diets containing 400 to 800 kca.J/day. Boch of these meas-
10. A sound weight-loss program emphasizes a wide variety of low· ures should be reserved for people who have failed at more con-
calorie bulky foods; adapts co che dieter's habits; consists of read- servative approaches to weight loss. They also require close
ily obtainable foods; strives tO change poor eat ing habits; sti·esses medical supervision .
regular physical activity; and stipulates the participation of a physi· 16. Underweight can be caused by a varicry of factors, such as exces-
cian if weight is to be lost rapidly or if the person is over the age sive physical activity and genetic background. Sometimes being
of 40 (men ) or 50 (women) and plans co perform substantially underweight requires medical attention. A physician should be
greater physical activity than usual. consulted first to rule out underlying disease. The Lmderweighr
11. A pound of adipose tissue contains abom 3500 kcal. Loss or gain person may need to increase portion sizes and learn to like energy·
of a pound of adipose rissue-rhe fat itself plus lean supporr tis- dense foods. In addition, encouraging a regular meal and snack
sue-represents approximately 3300 kcal. Thus, if energy output schedule aids in weight gain as well as weight maintenance.
Study Questions
1. After re-examining the internal and external forces associated with
9. Define the term beh(lvior modification. Relate it to tl1e terms stim·
hunger, satiety, and food choices, propose rwo hypotheses for tl1e
ulus control, self-monitoring, chain-breaking, relapse prevention,
de\'elopmenr of obesity.
and cognitii>e restrnctnring. Give examples of each.
2. Propose rwo hypotheses for the deve lopment of obesity based on
10. Why should the t1·eat111ent of obesity be viewed as a lifelong com·
the four contributors to energy expenditure.
3. Define a healthy weight in a way that makes the most sense to you. micment rather than just a shorr episode of weight loss?
4. Describe a practical method to define obesity in a clinical setting.
5. vVhat are tl1e two most convincing pieces of evidence chat both ge·
netic and environmental faccors play significant roles in the devel-
opmenr of obesity? BOOST YOUR STUDY
6. Lise three health problems that obese people typically face. Check out the Perspectives in Nutrition: Online Learning
Describe a possible reason why each problem arises. Center www.mhhe.com/ wardlawpers7 for quizzes, flash
7. vVhen searching for a sound weight-loss program, what th ree key
cords, activities, ond we b li nks designed to further help you learn
characteristics would you look for?
about energy balance and weight control.
8. Why is tl1e claim for qllick, effortless weight loss by any method
always misleading?
1. Blackburn GL: Solutions in weight control: 1·isk of pre111nt11re death, a1f({ impnme q11nlity of 2. Booth KM and others: Obesity and the built
Lessons from gastric surgery. A111e1·icrm lift i11 n lmoe p1·oporti1111 of 11besc i11dh1id11als. environment. Jo11mnf of the American Dietetic
jorwnal of Cliuical Nutrition 82:248S, 2005. Roux·m· Y gastric bypass, t/Je most widely per· Associatio11 105:Sll0, 2005.
Sm;.qery is Ct11'1'C11f~)' rl1e only pr<il'Cll 1J1ay r.o formed pl'llccdttn- in r/Jc United Smtes, ac/Jici>es Obesity is linked rvitb many fan tu res of the
achicl'c .fig11ificant long-term weig/Jt lo.rs, im· sig11iflca11r wcighr loss i11 11un·e rlm11 90% ofcnses "b11ilt '11vi1·om11e11t»: nside11cc, 11eighbor/Jood,
pnJVc obesit_v·1·eltircd comorbiditics, red11cc tbc ofscrere obcsi ty. rcsnttl'ccs, television, malknbility, land use, and
spmml. LoJPer sociouonomic status neighbor- tbe slow 1veig/Jr gai11 that wrPrnrly chamcterizes m1icwed i11 the 1Trtic/c. E11ide11ce fiw11 din ical
hoods are a prima1·y concern, as residents in t/Je fa.te 1~f 111ost North Americn.11 1Td11lts. n·in/s i11dicates thnt 111cigJ1t loss resulti11g fro 111 the
these areas may h1111e less access to reet·en.tional 9. H ill JO and others: Obcsicy: Eriology. ln Shits 11sc of mauy of these off-lnbcl pbn.1"1111Tcc11tic1TI
facilities or food stores with healthfnl, affordable ME and oth ers (eds): ModeY11 11utrition in ageuts i.r 11111dest, lmt still mfficienr ro rli111inisb
options. In the futt~re, neighborhoods should be hen.Ith a11rl disease. I 0th ed. Philadelphia, PA: cardiovasc11lar risk fa ctors. Medicati1111s 11/011e,
designed i11 1vays that promote pJ~ysical acrivity. Llppincorr Williams & Wilkins, 2006. 111ithout bebavior modification, arc not ejJectivt;
3. Dansinger ML and others: Comparison of the Ctwrent review of the causes of obesity in 011r so· people 111/Jo respond to mcdicntio11 rypim/~\' rt(.q1Ti11
Atkins, Ornish, Weigh t Watchers, and Zone ciety. The article points out that obesity is uot a 111eight whcri the medication is disconti1111cd.
diets for weight loss and heart disease risk re· siniple discn.se to 1mde1·sta.11r/ because mrrn;Yfac- 15. Periera MA and others: T he fast· food track w
duction: A randomjzed trial. ]01mml of the tors co1m·ibuu to irs etiology. obcsicy and insulin resistance. La11cet 365: 36 ,
American Medical Association 293:43, 2005. 2005.
10. Jakicic JM and Otco AD: Physical activiry con-
All fo11r popular diets (Atkins, Omish, Weight siderations for the treatment and prevention of Pa1·ticipnnts in t/Jis study JVho reported 11111rc
Watcher.r, Zone) are eq11ally effective far helping obesity American Jonrnnl of Clinical than 2 fast-food visits eacb 111eek gainer/ sig11ifi·
adults lose 1Peight and reduce cardiac risk fac- Ntttritio11 82:226$, 2005. cnntl)• mo1·c weigJ1t a11d hatf n t11111fold i11rra1sr
tors. Because mccess in this study direct~y corre- in i11mli11 1·esistance, compared ivitb pm·rici-
Physical activity is an important component of
lated with adherence to tbe diet, it makes sense pnnts 111/Jo reporter/ ft1ve1· than 1 weck~v f 11.frfo orl
long·term weight co11t1·ol, 1111d therefore adequate
to help patients choose tbe diet that is easiest for i•isit. TJms, the growing 11sc ofjiut food rcm111-
levels of nctivity .rho11lrl be prescribed to combat
tbem to follow, rn.ther than p1·eftrmtially en- ra11ts needs to be reexami11ed by many of 11s.
the obesity epidemic. AlthougJJ there is e11idmce
couraging one diet 011er rmy other. that 30 minutes of modcmte-immsir.y ph;~ical 16. O rn ish D : Was Dr Arkins righr? j o11m1Tl 1f the
4. Davison KK, Birch LL: Lean and weighr stable: acrii•ity may improve healrh outcomes, a gro1vi11g American Dietetic A.rsocia.ti1m 104: 537, 2004.
Behavioral prediccors and ps)'chological corre- body of scic11tiftc literntttre StllJ!lests t/Jnt at lenrt The author Sl'll!JCSts tlmt t}Je mfen Jllay to lo.re
lates. Obesity Research 12:l 085, 2004. 60 uii1mtes of1m1demte-intemity physica.t activ- 111eight iii the long ru 11 is to Joens 011 1·cd11ci11g
Being ar IT bealth.)' weight and m>oiding large ity mny be 11ece.rsm·y to mnximizc weight loss and fn.t and refined cm·bohydi·ate i11mke. IV/Joie
ivcigbt fl11mmtions dttring ndnlthood arc linked prevent sig11ifica11 t n>eight ngain. foods nnd complex cn.1•bo'1_vdm1es .rbo11/d iust(ar/
with patterns of hcnlthy eating and n1g11lar physi- 11. Klein Sand others: Clinical implications of obe- be cmph11Sized.
cal activity, lower dietm·y restrni11t, rmd less re- sicy with specific focus on cardiovascular dis- 17. Pitt.lcr MH, Ernst E: Dietary supplemcms for
liance on dieting attempts. These lifestyle be- ease. Cirrul1Ttio11 ll0:2952, 2004. bod)'-Weighr reduction: A systematic review.
havioml pattem.r may emerge during childhood; Ame1·ica11 Jo11m1TI of Clinicnl N 11tritio11
Obesity ad11ersely 1Tffects cnrdinc jimction, in-
int<'YJ>c11tio11 effertr should focu.s on this age period. crell.fes the i·i.sk flTctors f01· corolllll")' heart disease, 79:529, 2004
5. Ello-Marrin JA and others: The influence of a11d is an i11depc11rlmt risk fnctt!r for canl.iov1Ts- Evidmcc for most diernry mpple111mts ITS nids in
food portion size and energy density on energy c11fllr disease. The risk l}f de1•elopit!.!J C01·01111.ry reduciug body weighr i; uot cr1111•i11ciug. No11c of
intake: lmplicarions for weight ma nagement. hm1"t disensc is dircct~y related to obesity-related tlJC rcPiewcd dieta1·y mpplc111e11ts i11 the nrtich-,
American }011mal of Clinical Nut1·iti1m risli factm·s. In colltrnst, modest wcigbr loss ca11 mch 11s chromium mzd cbitosa11, en 11 be ruom -
82:236S, 2005. nffcct the entfre cluster of cardio1mscular disease 111e11ded f01· ovcr-th1•-co1mter 11s«.
Pro1•iding older c/Jild1w and adults ivirh lar,ger risk facton si11111lt1TJtcom~y. 18. Smith GP: Control of food intake. ln Shit~ /\IE
and lm;ge1· food portions e1m lead ro significant 12. Li Z and ochers: Mera-analysis: Pharmacologic and others (eds}: Modem 1mtriri1111 i11 /Jmlrb
increases in wergy intake. One strateg.i• to tirl- rreacmenL of obesity. A1111a/.s of l11teri1al and disease. 10th ed. Philadelp hia, PA:
dress this effect ofportio11 size is decreasing the Medicine 142(7):532, 2005. Lippincon Williams & Wilkins, 2006.
ene1;gy density offoods. En ting satisfying por- Sib11tmmi11&, ol"lirtlTt, 1111d p!Jentermi11c, 1T11d The 111a11y nrnrotmmmittcn 1T11d hom1011 cs tllllr
tions of loiv-encrgy-rleme foods maintains satiery
p1·obnbly dict/J_vlpropion, b11p1·opi11111 and topi- i11fl11e11ce food inta.kr arc 1"cvic1vcd by the IT ur/Joi:
while ,·educing m er,gy intake. m111cte proml}tc wei.ght loss whm gi1•c11 nlo11g Tbe WITJS these compo1111d.r intcra&r with the
6. Foster GD and others: Behavioral treatment of 111itb i·ecommcndn tio11.r fm· diet ( n11d ot/Jcr be- brain and GI tract to i11:fl11ence body w,;ig/Jt
obesi[y. Ame1·ium joun1al of Clinical havioral and exercise intervwtious). The co11 trot are highlighted.
Nutrition 82:2305, 2005. n.11101mt of extra weight loss attrilmrabLe to these 19. Wadden TA an d others: Obesity: i\lanagcmcnt.
The behavior change process is facilitated thmugh medicatiom is modest, bttt still ma)' be clinically In Shils ME and others (eds): Modem 1111triti1111
the me ofself-mo11itrm11g, goal-setting, and prob- significant. Use of caclJ of these 111edicatio11s is i1I health and dise1Tsc. !Orn ed. Philadelphia, l't\:
lem solving. Behavior thempy can help individuals reviewed in detail. Lippincott WiUiams & Wilkins, 2006.
develop a set ofskills (such as eating n low-ene1;gy, 13. Lofgren I and others: Waist circwnference is a The J>ariow tools available to clinicin.11s to bclp
loivfat diet) to 11Chieve a hca/thie1· weight. better predictor than body mass index of coro- people lose weight arc presented b.v the ITtttbor.r.
7. Hu FB: Protein, body weigh t, and cardiovascu- nary heart disease risk in overweight pre- Concern is also expressed that the effectiveness 11f
lar health. American Journal of Clinical menopausal women. ]011r11at of N1tt1"ition tbese tools, mc/J n_r reco111111mdntio11s to coumme
Nutrition 82:2425, 2005. 134:1071, 2004. le.rs enet;gy, arc being C11mp1·11111iscd by 0 1w c111·-
It may be beneficial to partially replace refined Altho11g/J 11either BMI 1101· wnist cit-c111nftre11ce re11t socinl 1:1111irom11c11t, and so tbe lnttcr 11ecds
carbohydrates with p1·otein sottrces low in snt11- provides n complete pict11re ofovcrall rislt, the to be addressed ns well.
rated fat. Plant sources of protein and fat, mch waist circumftmtee classiftcarion of the subjects 20. Wing RR, Phelan S: Long-term weighc loss
as 11 uts, l~gmnes, soy, and i>egetabM oils, may from the p1·eseni study m•c1Tled stro11ger associa- mai mcnancc. A111c1·icar1 Jo11rnnl of Cli11ic11/
pro11ide evm greare1· health bcnefitJ in place of tions wit/J multiple 1·isk facrm·s fm· chronic disense. Nutritio11 82:222S, 2005.
refined carbohydrates rmd rmimal products. This fi11di11g StllJ!lCsts that ivnist ci1"c11111fereuce Natio111T/ Weight Cmm·o/ R.cgistry 111e111ber.r pn1-
8. H ill TO and others: Obesity and the: cnviron- sbo11./d br used to screen the g eneml p11p11Lnti1m.
vide evidence that /011g·tcrm wcig/Jt loss 111ai11tc-
mem: Where do we go from here? Science 299: 14. MO)' CfS SB: Medications as .1djw1cr therapy for 11a11ce is possible m11I help idemijj• tbc specific
853, 2003. weigh[ loss: Approved and oft:label agenrs in approac/Jes associrtted wirb lfmg-tel'llt sttccrss. 11Jt
A moderate decrease in mer,gy intake (1 00 kcal) use. Jonrnnl of t/Je Americ1111 Dietetic article re11iews t/Je b1Tbirs of t/Jesc participn11ts,
n11dgreater physiml acti11ity (100 kcal) are ad· Associatim 105:948. 2005. such ITS reg11/ar~y eating b1"cnkfasr1sdf-mo111tor-
vocaurl b_v these authors to a.chieve tbegoal of Some ctinicinns prescribe medicatio11s not ap- i11g weight, rrnd meeting tbc[fOll/ o.f 60 111i1111w
slow weight loss. There is a11 urgent 11eed t11 stop prolled for weight loss. 71;ese 111edic11tiom tit't: ofphysical nctii•ity.
Take I Action
I. A C lose Look at Your Weight Status

Determine the following two indices of your body status: body moss index and waist circumference.
Body Mass Index (BMI)

Record your weight in pounds: lb
Divide your weight in pounds by 2.2 to determine your weight in kilograms: kg
Record your height in inches: in
Divide your height in inches by 39.3 lo determine your height in meters: m
Calculate your BMI using the following formula:
BMI = kg/ m2 = _ __
Waist Circumference
Use a lope measure lo measure the circumference of your waist (ot the novel with stomach muscles relaxed). Circum ference of
waist= in
Interpretation
l . When BMI is greater than 25, health risks from overweight may begin. It is especially advisable lo consider weight loss if your
BMI exceeds 30. Does yours exceed 25 (or 30)?
Yes No _ __
2. When o person hos o BMI greater than 25 and o waist circum ference of more than 40 inches (l 02 cm) in men or 35 inches
(88 cm) in women, there is on increased risk of cardiovascular disease, hypertension, and type 2 diabetes. Does your waist cir-
cumference exceed the standard for your gender?
Yes No _ __
3. Do you feel you need to pursue o program of weight loss?

Yes No _ __
Application
From what you've learned in Chapter 13, what habits con you change in patterns of eating and physical activity to lose weight and
help ensure maintenance of any loss?
.
l
I
1
11 . ~n A~tion Plan to Change or Maintain Weight Stc;;tus
Now that you have assessed your current weight status, do you feel tha t you would like to make some changes? Following is o step-by-
slep guide to behavioral change. This process can be useful even for people who ore satisfied with their current weight, because ii con
be applied to cho11ging exercise habits, self-esteem, and o variety of other behaviors (Figure 13-19).
Becoming Aware of Jbe Problem

By calculating your current weight status, you have already become aware of the problem, if one exists. From here, ii is important to
find out more information about the cause of the problem and whether it is worth working toward o change.
Take I Action
Develop a receptive
framework for learning
Become Gather baseline
Changes become aware
port of lifestyle of the information
problem
Set
goals
Original
status quo
Chart a
pion of
Unable or action
unwilling to
commit to
changes
Practice the plan
Figure 1 3· 1 9 A model for behavior change. It starts with awareness of the problem and ends with
the incorporation of new behaviors intended lo address the problem.
1. look back ot the food diary you completed in Chapter 1. What ore the factors that most influence your eating habits? Do you eat
out of stress, boredom, or depression? Is volume of food your problem, or do you eat mainly the wrong foods for you? Take some
time lo assess the root causes of your eating habits.
2. Once you have more information about your specific eating practices, you must decide if it is worth changing these practices. A
benefits and costs analysis con be o useful tool in evaluating whether it is worth your effort lo make life changes. Use Figure 13-20
os o guide for listing benefits and costs pertinent to your own situation.
Setting Goals
Whal can you accomplish, and how long will ii toke? Setting a realistic, achievable goal and allowing o reasonable amount of time to
pursue ii increase the likelihood of success.
1. Begin by determining the final outcome you would like to achieve. If you are trying to change your eating behaviors to be more
healthy, list your reasons for doing so (e.g., overall health, weight loss, self-esteem).
Overall goal:
Reasons to pursue goal: •
i .. 'If
www.mhhe.com/ wardlawpers 7 511
Take I Action
Benefits and Costs Analysis
1 Benefits of changing eating

habits?
What do you expect to get. now or What do you get to do that you
later, that you want? enjoy doing?
What may you avoid that would be What do you avoid having to do?
unpleasant?
µJetter ;4ereall, 111rl
ffJICMl~ea.4
looi kttu-
What do you have to do that you What unpleasant or undesirable

don't want to do? effects are you likely t o experience
What do you have to stop doing now or in the future?
that you would rather continue What are you likely to lose?
doing?
tak t/Me Cd;kr KU& 111ri.fhQf Cl'UfJl"trj "1eijJ.tj<V°'r
K«Kt~ ¥ ,f(JJl(eriMkre "'"' ~df-M/:eur Md/DD/' ka/(J,
Figure 13·20 I Benefits and costs analysis applied to changing eating habits. This process
helps put behavior change into the context of total lifestyle.
2 Now list several steps thot will be necessary to achieve your goal. Keep in mind, however, that ii is generally best to change only
a few specific behaviors al first-walking briskly for 60 minutes each day, reducing fat intake, using more whole-groin products,
and not eating ofter 7 P.M. Attempting small and perhaps easier dietary changes first reduces the scope of the problem and in-
creases the likelihood of success.
Steps toward achieving goal:
1. - - -- - --------::_____ _ _ _ _ _ _ _
... ~
., 1 r
2 ~~~~---:-..,.-~---:---:-~-=-=~~~~~-:-:-:,--~~~~~~~~~~~~~-:-~~~~-
,.. .... •
'
Note l~ol if you ore having trouble dec~hering the steps needed to achieve your goal, health professionals ore on excellent resource
for aic In planning.
Take I Action I
Measuring Commitment
Now that you hove collected information and know what is required to reach your goal, you must ask yourself, "Con I do this?"
Commitment is on essential component in the success of behavioral change. Be honest with yourself. Permanent change is not quick or
easy. Once you hove decided that you hove the commitment required to see this through, continue on to the followi ng sections.
Making It Official with a Contract

Drawing up a behavioral contract often odds incentive lo follow through with a pion. The contract could list goal behaviors and objec-
tives, milestones for measuring progress, and regular rewords for meeting the terms of the contract. After finishing a contract, you
should sign ii in the presence of some friends. This formality encourages commitment.
Initially, plans should reword positive behaviors, and then they should focus on positive results. Positive behaviors, such as regular
physical activity, eventually lead to positive outcomes, such as increased stamina.
Figure 13-2 l is a sample contract for increasing physical activity. Keep in mind that this sample contract is only a suggestion; you
con odd your own ideas as well.
Psyching Yourself Up
Once your contract is in place, you need to psych yourself up. Discouragement from peers and your own temptations to stray from
your pion need to be anticipated. Psyching yourself up con enable you to progress toward your goals in spite of others' attitudes and
opinions. Everyone benefits from assertiveness when it comes to changing behaviors. The following ore a few suggestions. Con you
think of any others?
• No one's feelings should be hurt if you soy, "No, thank you," firmly and repeatedly when others try to dissuade you from a pion.
Tell them you hove new diet behavior and your needs ore important.
• You don't hove to eat a lot to accommodate anyone-your mother, business clients, or the chef. For example, at a party with
friends, you may feel you hove to eat a lot to participate, but you don't. Another trap is ordering a lot just because someone else is
paying for the meal.
• Learn ways to handle put-downs-inadvertent or conscious. An effective response con be lo communicate feelings honestly, without
hostility. Tell criticizers that they hove annoyed or offended you, that you ore working lo change your habits and would really like
understanding and support from them.
Practicing the Plan

Once you've set up a pion, the next step is lo implement it. Start with a trial of al least 6 lo 8 weeks. Thinking of a lifetime commitment
con be overwhelming. Aim for a total duration of 6 months of new activities before giving up. We may hove to persuade ourselves
more than once of the value of continuing the program. The following ore some suggestions lo help keep a pion on track:
• Focus on reducing, but not necessarily extinguishing, undesirable b.ehaviors. For example, it's usually unrealistic to soy, "I'll never
eat a certain food again." It's better lo soy, "I won't eat that problem food as often as before."
• Monitor progress. Note your progress in a diary and reward yourself according lo your contract. W hile conquering some habits
. . and seeing improvement, you may find yourself quite encouraged, even enthusiastic, about your pion of action. That con give you
the impetus to move ahead with the program.
• Control environments. In the early phases of behavioral change, try to avoid problem situations, such as parties, coffee breaks, and
favorite restaurants. Once new habits ore firm ly established, you con probably more successfully resist the temptations of these
environments.
www.mhhe.com/wardlawpers7 S 13
Take I Action
Name .i?kn Young

Goal
la9reeto_r
"--'-1Cl.
=...t:~~t??-'-'-'¥P-~~~¥~e~r'--=c~1~S~e.._~6~tuit~c::--~~~~~~~~~~~~~~~-
(specify behavio r)
under the following circumstances .eo,. .SO /'1?1nv~s. 'f= &mes ae:c week
. (specify where, when, how much, etc.)
In the. even10g
Substitute behavior and/ or reinforcement schedule I tu/!/ c<:UzAzcce au1set£
1'1' .Ive. och1(we<i m</ goalol'/ic a mantlz with o wee.i'enc/ afl'
(!o,,.,pu6 with 11'7'1 ,..-0Qtnn7ofc .
Environmental planning
In o rder to help me do this, I om going to ( 1) a rrange my physical an d social environment
by Oul/'Of! o aew pacfq.!/e. CD ,WO<ft:c
and (2) control my internal environment (thoughts, images) by t:«2C!:ltnatrn~ cktmg

z»c /1crst Tl/. wordtm :r a'4 vi the: eveaiq
The. 61.kc:; 1L11'i1z 9
Reinforcements
Reinforcements provide d by me doily o r weekly (if contract is kept):
..IA»"!( (zq'fmft'•1G/£ Q Of/!W p1i:.cr: o£ c4tfl1ay roe
a£-I' Carnpu r
Reinforcements provided by others doily or weekly (if contract is ke pt):

4t"rik e.ml rtf a aumtA if ..1vi: cam.p1cli:eft?U(gaal ~ ,aacca.t~ &»i/
6u¥ mt'! Q ~mc.ss clu6 mtU>?kc.Sh~a ..<:u 4110 rec.
Social support
Behavior change is more likely to take place when other people support you. During the
quarter/semester please meet with the other person ot least three times to discuss your
progress.
The nome of my "significant helper" is: /ilr. 4'ul ,Airs. Y,,unJ
This contract should include:

1. Baseline doto (one week)
2. Well-defined gaol
3. Simple method for charting progress (diary, counter, charts, etc.)
"
--
4.
5.
Reinforcements (immediate ond long-te rm)
Evaluation method (summary of experie nces, success, and/ or new learnings about self ).
Figure I 3 - 21 I Alon's behavior contract. Completing such o contract con help generate commit·
ment to behavior change. What would your contract look like?
..
-.
5 14 Chapter 13 Energy Balance and Weight Control
Take I Action 1
Reevaluating and Preventing Relapse

After practicing a program for several weeks to months, it is important to reassess the original plan. In addition, you may now be able
to pinpoint other problem areas for which you need to plan appropriately.
1. Begin by taking a close and critical look at your original plan. Does it actually lead to the goals you set? Are there any new steps
toward your goal that you feel capable of adding to your contract? Do you need new reinforcements? It may even be necessary
to make a new contract. For permanent change, it is worth this time of reassessment.
2. In practicing your plan over the past weeks or months, you have likely experienced relapses. What triggered th ese relapses? To
prevent a total retreat to your old habits, it is important to set up a pion for such relapses. Do this by identifying high-risk situa-
tions, rehearsing a response, and remembering your goals.
You may have noticed o behavior chain in some of your relapses. That is, the relapse may stem from o series of interconnected habit·
uol activities. The way to break the chain is to first identify the activities, pinpoint the weak links, break those links, and substitute other
behaviors. Figure 13-22 illustrates o sample behavior chain and a substitute activities list. Consider compiling your own list based on
your behavior chains.
Epilogue
If you hove used the activities in this section, you ore well on your way to permanent behavioral change. Recall that this exercise can
be used for a variety of desired changes, including quitting smoking, increasing physical activity, and improving study habits. It is by
no means an easy process, but the results can be well worth the effort. Overall, the keys to success ore motivation (keeping the prob-
lem in the forefron t of your mind), having a plan of action, securing the resources and skills needed for success, and looking for help
from fam ily, friends, or a group.
Beginning finishing an
behavior ample dinner arguing
with entering
Feeling
sitting in watching spouse the kitchen
sleepy getting out
a favorite a lousy of the easy
easy chair TY show chair
openirg the
refrigerator
eating
wanting Feeling cheesecake
Terminal more guilty
behavior cheesecake
Figure 1 3·22 I Identifying behavior chains. This is a good tool for understanding more about your habits and pinpointing ways to o'longe
wanted habits. The earlier in the chain you substitute a nonfood link, the easier it is to intervene. Four types of behaviors con be substituled in •
ongoing behavior chain: 1. Fun activities (toking a walk, reading o book); 2. Necessary activities (cleaning o room, balancing your che:kbool
3. Incompatible activities (toking a shower); 4. Urge-Oelaying activities (setting a kitchen timer for 20 minutes before allowing yourself to eat).
Overall, using activities to interrupt behavior patterns that lead to inappropriate eating (or inactivity) con be a powerful means of chonghg hal
..
I
•
NUTRITION: FITNESS AND SPORTS
CHAPTER FOURTEEN

The Close Relotionship between Nutrition ond Marcello is training for a 1OK run coming up in 3 weeks. She hos read a lot about
Fitness
sports nutrition, especially about the importance of eating a high-carbohydrate diet
Designing a Fitness Program
Phase 1: GeHing Started Means Getting Going while in training. She also hos been struggling to keep her weight in a range that
m
• Phase 2: Achieving and Maintaining Even
Greater Physical Fitness
she feels contributes to better speed and endurance. Consequently, she is trying to z
m
eat as little fat as possible. Unfortunately, over the post week her workouts in the af- :;:itJ
Energy Sources for Muscle Use
Adenosine Triphosphote (ATPJ-lmmediately ternoon have not met her expectations. Her run times ore slower, and she shows G>
~
Usable Energy • Phosphacreotine: The Initial signs of fatigue after just 20 minutes into her training program.
Resupply of Muscle ATP • Glucose: Moior Fuel CP
)>
for Sharl-Term, High-Intensity and Medium-Term
Exercise • Fat: The Main Fuel far Prolonged
Her breakfast yesterday was a large bagel, a small amount of cream cheese,
s;:
Low-Intensity Exercise • Protein: A Minor Fuel
and orange juice. For lunch, she hod a small salad with fat-free dressing, a large z(")
Source, Primarily far Endurance Exercise plate of pasta with tomato marinara sauce and broccoli, and a diet soft drink. For m
The Body's Response to Physical Activity dinner, she hod a small broiled chicken breast, a cup of rice, some carrots, and )>
Specialized Functions of Skeletal Muscle Fiber
Types • Adaptation of Muscles and Body iced tea. Loter, she snacked on fat-free pretzels.
z0
Physiology to Exercise What advice would you give Marcello regarding her training diet? Note current
Power Food: Dietary Advice for Athletes
~
strengths and weaknesses. Is her diet likely contributing to her recent fatigue during CP
Energy Needs • Carbohydrate Needs • Fol )>
Needs • Protein Needs • Vitamin and Mineral workouts? s;:
Needs z(")
Expert Opinion: Does Increased Physical Activity
Necessitate Antioxidant Supplementation?
m
A Focus on Fluid Needs
Fluid Replacement Strategies • Use of Sports
Drinks
Specialized Dietary Advice for before, during,
and ofter Endurance Exercise
Replenishing Fuel during Endurance Exercise •
Carbohydrate Intake during Recovery from
Prolonged Exercise
Nutrition Focus: Evaluating Ergogenic Aids to
Enhance Athletic Performance
Toke Action
SIS
A hletes invest o lot of time ond effort in training . Because
hey often seek ways to enhance their diets to improve
performance, athletes make eosy targets for purveyors of nulri·
TO ALLOW YOU TO:
lion misinformation. Most athletes don't wont to miss out on ony
1. List five positive health-related outcomes of a physically active
odvontoge, whether real or perceived, !hot might give them the lifestyle.
winning edge. 2. Design o fitness regimen.
Although good eating habits can't substitute for physical 3. Describe when and how glycogen, blood glucose, fat, and
training ond genetic endowment, proper food ond beverage protein ore used to meet energy needs during different types of
physical activity.
choices ore crucial for top-notch performance, contributing to en·
4. Differentiate between anaerobic ond aerobic use of glucose,
durance ond helping to speed the repair of injured tissues. 19 ond identify advantages and disadvantages of each.
Looking at our population in general, experts might disagree 5. Show how muscles ond related organs adapt to an increase in
on how much carbohydrate, protein, and fat we should con· physical activity.
sume, but there is no argument over the health benefits of regu· 6. Outline how to estimate an athlete's energy needs and discuss
the general principles for meeting overall nutrient requirements
lar physical activity. It is even beneficial for overweight people
in the training diet.
who remain ot that excess weight. 4
7. Examine problems ossocioted with rapid weight loss by
In Chapter 14, you will discover how physical fitness bene- dehydration and outline the importance of water and/or sports
fits the entire body ond how nutrition relates to fitness and sports drinks during exercise.
performance. 8. Understand the importance of slaying well nourished with

vitamins ond minerals during training.
9. List several ergogenic aids ond describe their effects, if ony, on
an athlete's performance.

OF NUTRITION FOR FITNESS AND SPORTS IN CHAPTER
14, YOU MAY WANT TO REVIEW:
The current trend of consuming energy bors in Chopter 1.
The concept of glycemic load in Chapter 5.
The various food sources of carbohydrates, proteins, and lipids in Chapters 5 through 7.
Food sources of calcium in Chapter 11 and iron in Chapter 12.
The components of the cell and functions of various organelles in Appendix C.
I The Close Relationship between Nutrition

and Fitness
The abil ity to engage routinely in vigorous physical activity requires good health. Peak
performance for physical activity (and exercise) also depends on a diet that supplies all
the oeeded nutrients.19
Once muscles have nutrients available to them, what determi11es the type of Fuel
they will use? Athletes have a say in that decision, depending on how physically fit they
are and how hard they perform. This physical fitness- defined as the ability to perform
moderate to vigorous activity without undue fatigue-especially affects fat use by the
ecoil from Chapter 1 how the terms body. As one's level of ph)rsical fitness improves, so does one's abifay to mobilize fat
Rphysical activity and exercise ore related.
Exercise is physical activity done with the intent
stores for energy needs-especially during activities that last for 20 minutes or more.
Beyond affecting fuel use, the benefits of regular physical activity include enhance·
to gain health ond fi tness benefits, whereas ment of several aspects of hearr function, less inju ry, better sleep habits, and improve-
physical activity is simply part of day·to·day ment in body composition (less body fat, more muscle mass). Physical acti,·ity also can
activities. reduce stress and positively affect blood pressme, blood cholesterol, blood glucose
5 16
www.mhhe.com/wardlawpers7 S 17
Figure 1 4· 1 I Exercise is medicine. Here

Reduces ore the benefits of regular, moderate physical
blood pressure
aclivily and exercise. There is also evidence
lhal such activily slows the aging process.
Increases cordiovosculor
l! improves blood
glucose regulation fu nction ond improves
blood lipid profile
Reduces stress ond Aids in weight

improves self.image loss/weight control
~creases flexibility
L ond bolonce
Increases muscl:l
moss ond sire~
Improves immune Improves GI

function troct peristalsis
Reduces risk of colon

cancer, prostate cancer,
Improves sleep ~
(if activity is done in
ond likely breast concer the morning or
afternoon)
___J
regulation, and immune function. In addition, physical acti,iry aids in \\eight control,
both by raising resting energy expenditure for a short period or time after exercise and
by increasing overall energy expenditure. 3 •9 ,I 4.1 6 ,2 0 See Figure 14-1 for a further look
at these and other benefits of a physically active lifestyle.
Unfortu nately, as noted in Chapter 13, many North Ame rican adu lts lead sedentary
lives. Most adults do not practice moderate to vigorous physical activity on a regular
basis, and about half of all adults quit an exercise progr.1111 within 3 months. Does this
discussion moth·ate you to assess your activity patterns and imprcl\'e them as needed?
Hcnlt/Jy People 2010 has set a number of specific objecti,·cs for U.S .•1dults related to
physical activity and exercise:
• Reduce by 50% che proportion of adults engaging in no leisure-time physical acth•-
iry (currently 27% of adults).
• Double the proportion of adults engaging regularly, preferably daily, in moderate
exercise for at least 30 minutes per day (currently 45% of adulrs).
• lncn:ase by 50% the proportion of adults who perform exercises that enhance and
maintain muscular strength and t:ndurance (cu rremly 19% of adu lts).
The 2005 Dietm:v Guidelim·s for Americans recommends three different time goals
for physical acti\'ity ( re,·iew Chapter 2 ).
• 30 minutes/day of moderate-intensity physical activity, in addition to usual activity,
for individuals trying to reduce their risk of chronic disca5C in adulthood. Doing
more than 30 minutes or increasing the intensiry of the workout could lead to e"cn
greater benefits.
• 60 minutes/day of moderate- to vigorous-intensity physical acti\'iry ro help adults Whal is the best exercise? One you want lo
manage body weight and prevent grad ual weight g<1in. conti nue to do.
518 Chapter 14 Nutrition: Fitness and Sports
• 90 minutes/day of moderate-intensity physical activity may be needed for some

adults to sustain weight loss; at the same time, these individuals also need to mon ·
itor their energy intakes.
Designing a Fitness Program

ne day in December 2000, Joe Decker: For healthy people, a gradual increase to a goal of regular physical activity is recom-
mended. Men 40 years of age or older and women 50 years of age or older who have
bicycled 100 miles, been inactive for many years or who have an existing health problem should discuss
ran l 0 miles, hiked 10 miles, their fitness goals with their physician before increasing activity. Health problems that
power-walked 5 miles, require medical evaluation prior to an exercise program are obesity, cardjovascular dis-
kayaked 6 miles, ease (or fami ly history of it), hypertension, diabetes (or family history), shormess of
skied on a NordicTrack 10 miles, breath after mild exertion, and arthritis.
rowed l 0 miles, swam 2 miles,
did 3000 abdominal crunches,
did 1100 jumping jacks, Phase 1: Getting Started Means Getting Going
did l 000 leg lifts, did 1100 push-ups. During the first phase of a fimess program to promote health, you should begin to in -
And he lifted weights for a cumulative total corporate short periods of physical activity into your dai ly routine sucb as walking, tak-
of 278,540 lb. ing the stairs instead of the elevator, house cleaning, gardening, and other activities
For his efforts (and pains), he earned a place in that cause you to huff and puff a bit. The goal is a rotal of 30 m inutes ot· this moder-
the Guinness Book of World Records as the ate physical activity on most (and preferably all ) days. lf necessary, these activities can
fittest man alive. be broken up into increments lasting at least 10 minutes. Experts suggest starting with
short intervals and build up ro a total of 30 minutes of activity incorporated imo each
day's rasks. 4 If there is not much time for activity, you can even go for more intensity
in the activities over shorter periods to get the same benefits.
T h e easiest way to increase physical activity is to make it part of a daily routine, sim -
ilar to other regular activities, such as eating. 11 You do not need to join a gym or at-
tend aerobic classes. Daily activities can meet the Phase l goal. Mai1y people find that
the best time to exercise is when they need an energy pick-me-up or a break from
work. Rather than abandoning an exercise program entirely when obstacles get in the
way, strive to use any small periods of available time, such as bre<tks between classes or
coffee breaks at work. Once you reap the benefits of exercise, you will tend to spend
more time at it.
C learly, many activities recommended for Phase I are not very vigorous. Although
Phase 1 is recommended for people starting an exercise program, fitness experts have
not given up on the value of more vigorous physical activity. They're just making con·
cessions to human nature. Still, most of the possible health benefits from pl~vsical activi(v
lire seen if t/1is P/Jnse 1 goal is met.
Phase 2: Achieving and Maintaining Even Greater

Physical Fitness
Once you can perform physical activity for 30 minutes per day, tum your arrention to
more specific exercise activities, such as increasing muscle mass and su-engrh, to reap
even more bencfits. 18.19
Warm-up
Begin by doing activities that move the whole torso for 5 to 10 minutes. Starr with
smaller muscle groups (arms) and work toward larger muscle groups (legs and
abdomen ).
Do 5 to 10 more minutes oflow-intcnsity exercises, such as walking, slow jogging,
term that hos been coined recently is or any slow version of anticipated activity. This warms up your muscles so that muscle
sedenfary death syndrome (SeDSJ. The fi laments slide over one another more easily to increase range of motion and decrease
term describes the hazards of being inactive. the risk of injury.
Aerobic Workout o help yourself stay with on exercise pro·

gram, experts recommend the following:
Daily aerobic acth~ty is recommended. To start, an aerobic workout prescription con-
siders mode, duration, frequency, intensity, and progression. • Start slowly.
• Vary your activities; make it fun.
Mode: The mode of exercise is the type of exercise prescribed. LL must be one that uses • Include friends and others.
large muscle groups in a rhythmic fashion, such as brisk walking, running, lap swim- • Set specific attainable goals and monitor
ming, or cycling. progress.
• Set aside a specific time each day for exer·
cise; build it info your routine, but make it
Duration: Duration is the amount of time spent in an exercise session. It should gen-
convenient.
erally last at least 20 to 30 minutes, depending on intensity, nor counting time for
• Reword yourself for being successful in keep-
warm-up and cooldown. Ideally, this exercise should be continuous (without stop-
ing up with your goals.
ping), but multiple 10-minute bouts with rest periods in bet\\een arc also acceptable.
• Don't worry about occasional setbacks; focus
on the long-term benefits to your health.
Frequency: The frequency of the exercise describes the number oC times thar the ac-
tivit)' is performed. The frequency of exercise should be at least live rimes per week.
Daily exercising will lead ro even funhcr benefirs related to physical firness.
Intensity: Intensity is defined as the level of exertion that imfo:atcs d1e degree of en-
erro expcndirure required to sustain the acti,·it:y. In other words, intensity is used to
describe how hard you are working and to what extent you can maintain that intensity
over time. Health benefits beyond Phase l are especially seen \\hen you can achieve a
moderate lcYcl of intensity of exercise.
There arc a few ways to determine the intensity of exercise. A popular and simple
method is to use a percentage of your age-predicted maximum heart rmc. To find max-
imum heart rare, subtract your age from 220. Multiplying maximum hcan rate by 0.60
and 0 .90 will resLLit in a range of heart rates, sometimes called the tnrgct zone. For a
20-ycar-old person beginning an exercise program, maximum hearc rate equals 200
beats per minute (220 - 20 = 200). Then, (200 X 0.6 ) and (200 X 0.9 ) yields a tar-
get zone of l 20 to 180 beats per minute. ~leasuring heart rate (pulse) is eas)': Stop
and count your pulse rate for 10 seconds and then multiply that number by 6 to de-
termiJ1c your heart rate for one minute. There are also watches available that contain
heart rate monitors.
At the initiation of an exercise program, aim for the lower end of the target zone.
As you progress and become more physically fit, you can work up LO a higher heart
rate. As with many of d1e prediction formulas, cakLLlation of maximum heart rate is
just an estimate. Medications, such as those for hypertension and other health condi-
tions, may impact heart rate. If you have health concerns, a physician can help to per-
sonalize the t<trget zone.
Another way of determining the intensity of exercise is the Rating of Perceived
Exertion scale (RJ>E). One version includes a range of 1 to 10, \\ ith each number cor-
responding to a subjective feeling of exertion. For example, the number 0 is " nothing
at all" (sining at a table ) and the number 10 is considered close to maximal effort or
"very, very strong" (all-out sprint) (Figure 14-2).
'Nhcn using the RPE scale, the goal is to aim for the number 4, which corresponds
co the beginning of "somewhat strong." At this point }' OU begin to see significant fit-
ness results. You should be working hard but still be able to talk to an exercise partner Toking your pulse determines if your exercise
(somccimcs called the "talk test" ). output is in the target zone.
Progression: Progression, the final component, describes how the frequency, intensity,
and duration of exercise haYe increased over a period of time. The first 3 to 6 weeks of
your new exercise program are the initiation, or "getting started," phase. This phase
corresponds to the ti.me it takes for your body to adapt to rhc exercise program. The
next 5 or 6 months of training arc the improvement stage, in which the intensity and
duration increase to a point of tapering off. In other words, you notice no further ap-
preciable gains in fitness. T his plateau marks the beginning of your maintenance stage.
Rating of Personal Exertion Scale
Nothing Very Somewhat Very Very, very

al all weak Weak Moderate strong Strong strong strong
/ / !I I
0 2 3 4 5 6 7 8 9 10
Figure 14·2 I A Rating of Perceived Exertion scale (RPE). This version includes a range of 1 to 10,
with each number corresponding to a subjective feeling of exertion. An RPE beyond 10 is considered
maximal.
At this stage, you evaluate your goals, bur need to make no cha nges to your exercise
program in order to maintai11 the gains already achieved.
Strength-Training Workout
Strength training should be done at least 2, and preferably 3, days per week. To start,
a group of 8 tO 10 exercises should be performed in a circuit (during the same exer-
cise session) to condition major muscle groups of the upper and lower body. When se-
lecting the proper weight to use, make sure that che weight allows you co perform one
or more secs of at least 8 repetitions, but no more than 12. (However, 10 to 15 repe-
titions is fine for older adults using lighter weights.) Proper form during these exer-
cises is importanr m avoid injuries. Generally, if more than 12 repetitions can be
performed with relative ease, the weight can be increased in moderate increments.
Cooldown
During cooldown, follow a reverse pattern of the warm-up: 5 tO 10 minutes of low-
intensity activity, and add 5 to 10 minutes of stretching. The sao1e exercises performed
du1·ing warm-up are appropriate. The cooldown is essential tO the prevention of injury
and soreness.
Further Considerations
Including several rypes of enjoyable physical activities in a fitness program may also be
A totol fitness plan includes resistance training helpful. For example, jogging one day might be followed by swimming the next day.
and stretching after exercise. Adding vaiiety to a program not only keeps you mentally fresh, but also strengthens
different muscle groups and reduces risk of injury. An exercise partner may offer addi-
tional motivation.
Vigorous programs for obese people should be non-weight-bearing activities, such
as swimmjng, water aerobics, and bicycling. Note also that even if weight loss does nor
readily occur, obese people still benefit from regular physical activity.4
Whatever activities you choose to include in your fitness program , they should be
enjoyable. This way they can become routine. Consider convenience, cost, and op-
tions for bad weather so that when motivation wanes, you are not adding further ob-
stacles. Overall, do what you enjoy, but start out small, committing to keeping on
track and maintaining reasonable expectations. Positive results may take a month or
so to be noticeable.
trength-training athletes otten use creotine

I Energy Sources for Muscle Use supplements to try lo increase muscle moss
(see the Nutrition Focus ot the end of this chap-
As you learned in Chapter 4, cells can't directly use the energy released from breaking
ter for details).
down glucose or triglycerides. Rarher, to utilize the chemical energy in foods, body
cells must first convert the energy to adenosine triphosphate (ATP).
Adenosine Triphosphate (ATP)-lmmediately Usable Energy

The partial breakdown of ATP by cells to yield ADP and P 1 (the abbreviation for in-
organic phosphate) releases usable energy for cell functions, including muscle contrac-
tions required for locomotion. A resting muscle cell, however, contains just a small
amount of ATP, enough to keep the muscle working maximally !Or about 2 to 4 sec-
onds. To produce more ATP for muscle contraction over extended periods, the body
uses phosph ocreatine (PCr), a high-energy compound that is formed and stored in phosphocreatine (PCr) A high-energy
muscle cells from the amino acid derivative creatine (the amino acids glycine, arginine, compound lhat can be used to re-form ATP from
and methionine participate in its synthesis). 8 Dietary carbohydrates, fats, and proteins ADP.
are also used as energy sources (Figure 14-3). The breakdo" n of all these compounds creatine An organic molecule in muscle cells
releases enough energy to make more ATP (Table 14-1 ). that serves as a part of the high-energy
compound creatine phosphate or
phosphocreotine.
Phosphocreatine: The Initial Resupply of Muscle ATP
During periods ofrelaxation, muscles synthesize PCr from ATP and creatine and then
store this in small amounts. As soon as ADP from the breakdown of ATP begins to ac-
cumulate in a contracting muscle, an enzyme is activated that transfers a high-energy
P 1 from PCr to ADP, thus reforming ATP (Figme 14-4):
PCr +ADP~ ATP+ Cr
lf no other system for resupplying ATP were available, PCr could probably main-
tain maximal muscle contractions for about 10 seconds. 19 However, because the en-
ergy released from the metabolism of glucose and fatty acids also begins to contribute
ATP and thus spares some PCr use, this results in PCr functioning as the major source
of energy for all events lasting up to about 1 minute (review Table 14-1 ).
The main ad\•anrage of PCr is that it can be activated instantly and can replenish
ATP at rates fast enough to meet the energy demands of the fastest and most power-
ful sports events, including jumping, lirring, throwing, and sprinting actions. The cLis- Bursts of muscle octivily use o voriely of energy
advantage of PCr is that nor enough is made and stored in the muscles to sustain a sources, including PCr and ATP.
high rate of ATP resupply for more than a few minutes.
Figure 1 4·3 I Energy sources for muscular

Muscle glycogen
Fatty acids, activity. Different fuels ore used for ATP
amino acids, -~Lactate synlhesis. As shown, ATP con also be
muscle glycogen,
blood glucose synthesized rapidly using phosphocreotine.
Muscle
contraction
Table 14· 1 I Energy Sources Used by Resting and Working Muscle Cells
Source/System• When in Use Activity
ATP At all times All types
Phosphocreotine All exercise initially; short bursts of Shotput, high jump, bench press
(PCr) exercise thereafter
Corbohydrote High·intensity exercise, especially 200-yord (about 200-meter) sprinl
(anaerobic) lasting 30 seconds to 2 minutes
Carbohydrate Exercise lasting 2 minutes to 3 hours Bosketboll, swimming, jogging
(aerobic) or more; the higher the intensity
(for example, running o 6-minute
mile), the greater the use
Fot Exercise lasting more thon o few Long-distance running, long-distance
(aerobic) minutes; greater amounts ore used cycling; much of the fuel used in o
ot lower exercise intensities brisk 30-minute walk is fat
Protein Low quantity during oll exercise; long-distance running
(aerobic) moderate quantity in endurance
exercise, especially when carbohy-
drate fuel is locking
•At ony given time, on systems 0te operating ot the some time-just rhe relative omount of use differs during vorious ocflvohes
Figure 14·4 I Quick energy for muscle use

includes o supply of phosphocreotine (PCr).
This con rapidly replenish ATP stores os oclivity
begins. Phosphocreotine con be almost
depleled in moximolly contracting human
forearm muscles in less thon 60 seconds. It
tokes 4 minutes of resl to replenish half the PCr
ond 7 minutes to replenish 95% of the PCr.
Similarly, it tokes about 7 minutes of rest to
replenish 95% of the PCr depleted with
repeated knee extensions against resistance. I PCr + ADP -ATP t Cr
PCr concentration is PCr concentration falls as much of it is used to

about five time greater restore ATP concentration from the ADP that
than ATP concentration. builds up The PCr concentration does not fall
lo zero because some resynthesis occurs even
in active muscles.
Muscle at rest Active muscle
Glucose: Maior Fuel for Short· Term, High-Intensity,

and Medium-Term Exercise
Recall from Chapter 4 that glucose breaks down during glycolysis, producing the
three-carbon compound pyru\'ate. Glycolysis docs not require oxygen, bur it onl)
yields a small amount of ATP. If oxygen is prcsenr, the pyruvate is metabolized fi.trthcr,
yield ing much addirion.11 ATP.
Figure 14- 5 I ATP yield from oerobic versus

anaerobic glucose utilization. If the anaerobic
glycolysis pathway uses glycogen os the starting
material, 3 ATP are produced. This is because
the first ATP-requiring step in glycolysis when
starting with glucose is bypassed.
ATP ADP+ Pi
(glucose '>., 4 glucose-6-phosphate)
Loctote T
Anaerobic Pathway
When the oxygen supply in muscle is limited (anaerobic state ) or when the physical ac-
tiviry is intense (e.g., running 400 meters or swimming 100 meters), pyruvate result-
ing from glycolysis accwnulares in the muscle and is converted to lactate (Figure 14-5 ).
Because the breakdown of 1 glucose to 2 pyruvates yields 2 ATP, glycolysis can resup-
ply some ATP depleted i.n muscle activity. 8 Carbohydrntc is the only ji1el that can be ttsed
fo1· this process. The advantage of the anaerobic pathway is that, other than PCr break-
down, it is the fastest way to resupply ATP in muscle. 19
Glycolysis provides mosr of the energy for physical activity from about 30 seconds ecol! from Chapter 4 that when acids lose
to 2 minmcs after it has started. As you 'ti see shortly, far utilization simply can't occur o hydrogen ion, os typically happens at the
fast enough to meet the ATP demands of short-duration, high-intensity physical ac- pH of the body, they are given the ending ·o/e.
tivity.19 If fat were the only available fuel, we would be unable to carry out physical ac- Thus, pyruvic acid is called pyruvofe and lactic
tivity more intense than a fast walk or jog. acid is called locfofe when in the context of body
The anaerobic pathwa~r has tlu·ee major disadvantages: metabolism.
• It can't sustain ATP production for long.
• Only about 5% of the energy avai lable from glucose is released during glycolysis.
• The rapid accumulation of lactate from anaerobic glycolysis greatly increases the
acidity of muscle cells.
Because high acidity inhibits tl1e activity of key enzymes in glycolysis, anaerobic ATP
production soon slows and fatigue sets in. The acidity also leads to a net potassium loss
from muscle cells, providing another cause of fatigue.8 We learn by trial and error an
exercise pace that controls muscle lactate concentrations from anaerobic glycolysis.
Most of the lactate tl1at accumulates in active muscle cells is eventually released into
tl1e bloodstream. The liver (and to some extent the kidneys) takes up some of the lac-
tate from tl1e blood and resyntl1esizes it into glucose, an energy-requiring process. This
glucose then can reenter tl1e bloodstream, where it is available for ceU uptake and
breal<.down. The heart can also use lactate directly for its energy needs, as can Jess ac-
tive muscle cells situated near active ones.
Aerobic Pathway
If there is plenty of ox.·ygen available in muscle (aerobic state) and the physical activity
is of moderate to low intensity (e.g., jogging or distance swimming), tl1e bulk of the
pyruvare produced by glycolysis in the cytoplasm is shuttled to the mitochondria and
further metabolized into carbon dioxide and water in a series of oxygen-requiring re-
actions. About 95% of the ATP produced from the complete metaboUsm of glucose is
formed aerobically in mitochondria (Figure 14-6).
Although the aerobic pathway supplies ATP more slowly than does the anaerobic
pathway, it releases more energy. Furtl1ermore, ATP production via tl1c aerobic path-
wav can be sustained for hours. Accordingly, tl1is patl1way of glucose metabolism
Dietary Dietary Dietary

protein carbohydrate fot
Protein used Amino acids Blooo Fatty acids ond

Glucose stored Fat stored in
to form in the glucose as glycogen triglycerides in
body cells bloodstreom body cells
the bloodstream
J
ATP
Lacta te
ATP
Aerobic
metabolism in ATP
mitochondria
Figure 14· 6 I Simplified view of ATP formation from carbohydrate, fat, and protein. Along with
phosphocreatine (PCr), all three mocronutrients may be used for ATP synthesis, but glucose and fotty
acids ore primary sources. Glucose may be broken down anaerobically or may undergo complete
aerobic metabolism. The products of fatty acid breakdown are channeled into aerobic metabolism (the
glycerol that is released as part of the triglyceride is not depicted). Although limited, products of amino
acid breakdown also are channeled into the aerobic pathway. Recall from Chapters 10 through 12 that
many vitamins and minerals participate in these metabolic pathways.
makes an important energy contribution to sports events lasting from about 2 minutes
through 3 or more hours (Figure 14-7). 19
Glycogen versus Blood G lucose as Muscle Fuel

Glycogen is rhe temporary srorage form of glucose in the liver (about 100 g) and mus-
cles (about 300 gin scdcnrary people). It is broken down to a form of glucose that in
turn can be merabolized by bod1 the anaerobic and aerobic pathways. Glycogen is, in
fact, the primary source of glucose for ATP production in muscle cells du1ing fairly in-
tense activities that last for less than about 2 homs. In such activities, the depletion of
glycogen in the liver leads to a fall in blood glucose, whereas the depletion of glyco-
Figure 14-7 I Rough estimates of fuel use

Percent of energy
use met by fuel source L Carbohydrate Fa t
during various forms of exercise. With regard
lo the weight lifting session, carbohydrate use
100 could be somewhat greater and fat use
somewhat less if the session is intense and fast·
90 poced (e.g., circuit training). Fat use generally
is higher since much of the time spent weight
80 lifting is for rest periods.
70
60
50
40
30
20
10
W eigh t lifting 200-meter Championship Hord cycl ing 2-hour

session hurdles basketball for l hour marathon
gen in the musd es contributes to fa tigue.8 Once these glycogen stores arc ex hausted,
an athlete can continue working at only abo ut 50% of maximal capacity. Athletes call
this point of glycogen depiction "hittillg the wall," because further exertion is ham
pered. T hus, when their event will require them ro meet or exceed 70% or maximal ex·
ertion fo r more than an hour or so, athletes (e.g., Jong-distance runners or cyclists)
shou ld consider increasing the amount of carbohydrate stored in their muscles. Diets
high in carbohydrate can be used to increase muscle glycogen stores- up to double the
typical amounts-in advance of competition, thereby forestalling fatigue and improv-
ing endurance. A later section in this chapter on carbohydrate needs discusses how co
plan such a diet.
As exercise duration increases beyond about 20 to 30 minutes, the maintenance of
blood glucose becomes an increasingly important consideration. This can spare the use
of muscle glycogen, saving it in the muscle for sudden bursts of effort that may be re
quired, such as a sprinr to the finish in a marathon race. A carbohydrate intake of
0.7 g/kg/hour (abour 30-60 g/hour) during strenuous endurance exercise, such as
cycling that lasts about 1 hour or more, can help maintain adequate blood glucose con-
centrations, which in turn results in delay of fatigue. 5 A later section on sports drinks
discusses [his process in more detail.
Without the maintenance of blood glucose during endurance activities, a decline in
mental functio n may also occur (cyclists call this "bonking"). Note however that the
fall in blood glucose is related to depletion of liver glycogen, nor m uscle glycogen,
since liver glycogen is used to maintain blood glucose.
Carbohydrate intake is not as important for the muscles in shorter events (e.g., 30
minutes or so) because d1e muscles do not take up much blood glucose during shorr-
term exercise, relying instead primarily on glycogen stores for carbohydrate fuel. The
action of insulin co increase glucose uptake by m uscles is blunted by od1er hormones,
such as epinephrine and glucagon, which increase initially during exercise.19
Concept I Check
ATP is the main form of energy that cells use. Carbohydrate metabolism to form ATP be-
gins as glucose becomes available from the bloodstream or from glycogen breakdown.
Carbohydrate feeding during exercise can also supply glucose. In a muscle cell, each glu -
cose is broken down through a series of steps to yield either lactate or carbon dioxide
(C0 2 ) plus water (H 20). The breakdown of glucose to carbon dioxide and water is called
the aerobic pathway because it requires oxygen. The conversion of glucose to lactate is
called the <tnacrobic pathwly because no oxygen is used. This latter process allows the cell
to quickly re-form ATP and supports the demand for energy during intense physical activ-
ity, as docs phosphocreatine (PCr). The aerobic pathway takes longer co suppl~r ATP but
provides more energy in the end. This pathway is used more by endurance activities.
Fat: The Main Fuel for Prolonged Low-Intensity Exercise

The majority of stored energy in the body is found in the fatty acids of scored triglyc-
erides. Most of this energy resides in adipose tissue depots, aJthough some is stored in
d1e muscle itself. That stored in muscles is especially used as activity increases from a
low to a moderate pace. When fut stores in various adipose tissue depots begin m be
broken down for energy, one triglyceride molecule first yields three fatty acids and one
glycerol. The free fatty acids are then released into d1c bloodstream and travel to the
muscles. Once fatty acids enter muscle cells, they join with any of those released from
intramuscular triglyceride storage. 8 All these fatty acids d1en move into the mitochon-
dria, using a shuttle system that uses carnitine. Then t hey are broken down inro car-
bon dioxide and water, using in part the oxygcn-requiril1g electron mrnsporr chain that
yields much ATP. The rate at which muscles use fatty acids depends on a number of
factors:
he fatty acids con come from all over the • The mnre trained a muscle, thegnater its abiti~J' to use fat as a fuel. After a period of
T body, not necessarily from depots near the
active muscles. This is why spot reducing does
aerobic training, muscle cells contain more and larger mitochondria. These and
od1er changes enable muscle cells to produce more ATP via oxygen -requiring path-
not work. Exercise con tone the muscles underly- ways, including the pathwav used to burn fat for fuel (Table 14-2).
ing adipose tissue but does not preferentially use • The rtuwc fatty acids t/Jat rwe released from adipose tiSSTJ.e stores in to the bloodstrcn.111, the
those stores. If it did, we would all hove lean moi·e fat J11ill be used by the muscles. Some ath letes have arrempred to raise their blood
cheeks and necks, because muscles in that vicin- corn:ena-ations of fatty acids by constmting caffeinated beverages. This practice ac-
ity are regularly used. tually can increase fatty-acid release from adipose tissue and can be helpful co some
athletes (sec tl1e Nutrition Focus at the end of this chapter).
• As exercise becomes increasirtgly prolmtged, fat use predominates, especially when ex-
ercise remains at a low or moderate (aerobic) rate. When energy is needed for long-
duration exercise or physical labor, there is almost ahvays plenty of fat that can be
16-carbon called on. In comparison, carbohydrate stores are quite limited.
fatty acid
The advantage of fat over other sources of energy is d1at it provides more "bang for
the buck." That is, for a given weight of fuel, fat supplies more than nvice as much en -
about I 08 ATP ergy as carbohydrate. The aerobic breakdown of a 6-carbon glucose molecule yields 30
for cell use to 32 ATP (ratio of about 5 ATP to 1 carbon), whereas a 16-carbon fatty acid mole-
CLtle produces 108 ATP (ratio of about 6.8 ATP to 1 carbon).
However, carbohydrate is more efficient than fat in one very important way: the
C0 2 + H20
amount of ATP produced per unit of oxygen consumed. It tal<es 6 0 2 molecules to
ATP yield from aerobic fatty acid utilization. produce 30 to 32 ATP molecules during the aerobic breakdown of a molecule of glu-
Table 1 4-2 I Adaptations to Endurance Exercise in Skeletal Muscle

Changes Advantage
Increased ability of muscle to store glycogen More glycogen fuel available for the final
(high<orbohydrate diet increases this even minutes of on event
further)
Increased triglyceride storage in muscle Conserves glycogen by allowing for increased
fat use
Increased mitochondrial size and number Conserves glycogen by allowing for increased
fat use (even of high exercise outputs)
Increased myoglobin content Increased oxygen delivery to muscles and
increased ability to use fat for fuel
Overall, training allows on athlete lo use lot for fuel more readily, which allows the athlete to conserve glycogen for when 11 Is really
needed-such os for o burst of speed at the end of o race.
cose (ratio of about 5 ATP to I 0 2 ), whereas 23 0 2 molecules arc needed to produce

108 ATP molecules from a 16-carbon fatty acid (ratio of about 4.5 ATP ro I 0 2 ).
When an athlete's maximal performance would be limited by the activity of oxygen-
requiring pathways (as in competitive endurance exercise), muscle cells also use carbo- The energy lo perform comes fram
hydrate as an energy ~ourcc as long as the carbohydrate supply (especially muscle carbohydrate, fat, and protein. The relative
glycogen) lasrs. 19 mix depends on the pace.
During ,·cry lengthy activities, such as a triathlon, ultramarathon, manual labor in a
foundry, or C\'en work ar a desk for 8 hours a day, far supplies about 50 to 90% of the
energy rcquired. 19 Q,·erall, keep in mind that the only fuel source we cat that can sup-
port incense (anaerobic) acti\'ity is carbohydrate. In contrast, slow and steady (aerobic)
acti,·ity uses primarily fat and carbohydrate.
Protein: A Minor Fuel Source, Primarily for Endurance Exercise

Although amino acids derived from protein can be used to fud muscles, their 1:oncri-
bution is relatively small compared with that of carbohydrate and As a rough guide, rat.
only about 5% of the body's general energy needs, as well as the typical energy needs
of exercising muscles, is supplied by amino acid metabolism.s
However, proteins can contribute significantly to energy needs in endurance exer-
cise, perhaps as much as 15%, especially as glycogen stores in the muscle arc ex-
hausted.8 Most of the energy supplied from protein comes from metabolism of rhe
branched-chain amino acids-leucine, isoleucine, and valine. Because a normal diet
provides enough protein to supply ample branched-chain amino acids, prorein or
amino acid supplcmenrs arc not needed. In contrast, protein is used for fuel less in re-
sistance exercise (e.g., weight lifting) than for endurance exercise (e.g., running) ( rc-
\'iew Figure 14-7). The primary muscle fuels for weight lifting arc phosphocrearinc
(PCr) and carbohydrate, with far pro\'idjng fuel during the resting st.1ges. Despite this
fact, high-protein product:. such as Pro-Complex, Amino Fuel 2000, High Voltage
Protein Drink, and Instant Egg Protein are marketed specifically for weight litters and
bodybuilders and sold in nearly every health-food and fitness store. Instead of con -
suming supplements like these, consuming high-carbohydrate, moderate-protein foods
immediately after a wcighr-rraining workout would enhance the anabolic efti.:ct cf the
activity, most likely by increasing the concentrations of insulin and growth hormone in
the blood and contributing to protein synthesis. 19 It is impossible to increase muscle
mass simply by eating protein, however. Putting physical strain on muscle through
strength training or other physical activity is needed.
Concept I Check
Fat is a key aerobic fuel for muscle cells, especially at low to moderate exercise intensities.
Training enhances the ability to use fat for fuel, in turn conserving glycogen stores. At rest,
muscles burn primarily fat for energy needs. On the other hand, little protein is used to fuel
muscles. It supplies roughly 5% of energy needs under most conditions, and perhaps IO to
LS% of energy needs during endurance exercise when glycogen stores have essentially been
exhausted.
The Body's Response to Physical Activity

The previous section discussed how muscle cells o btain the ATP energy needed to do
work. This section focuses on how muscles and related organs adapt to an increased
workload.
Specialized Functions of Skeletal Muscle Fiber Types

The body contains th1·ee main types of muscle tissue: skeletal muscle, the type involved
in locomotion; smooth muscle, the type found in internal organs except the heart; and
cardiac (heart) muscle. Skeletal muscle is composed of three main types of muscle
fibers, which exhibit distinct functional characteristics:8
• Type I (slow twitch-oxidative): Fueled by aerobic metabolism of fat; also called red
fibers because of their higb myoglobin content.
• Type IIA (fast twitch-oxidative, glycolytic): Fueled by glycolysis using glucose
(anaerobic) plus aerobic metabolism of both fat and glucose.
• Type IIX (fast twitch-glycolytic): Fueled by glycolysis using glucose (anaerobic);
also called white fibers (in rodents Type IlX fibers arc called Type IIB ).
Prolonged low-intensity exercise, such as a slow jog, mainly involves use of type I
muscle fibers, so the predominant fuel is fat. As exercise intensity increases, type IIA
and type IIX fibers are gradually recruited; in tmn the contribution of glucose as a fud
increases. Type TIA and type IIX fibers also are important for rapid movements, such
as a jump shot in basketball.
The quick, powerful movements of the gymnast The relative proportions of die three fiber types throughou t the muscles of the body
rely primarily on type llA and type llX muscle vary from person to person and are constant throughout each person's life. The indi-
fibers. What sort of physiological changes vidual differences in fiber-type distribution are partially responsible for producing elite
would you expect to occur in a gymnast who marathon nmners who couJd never compete at the same level as sprinters, or elite gym-
has trained diligently for many years? nasts who could never be competitive as long-distance swimmers. AJd1ough the pro-
portion of muscle fiber types is largely determined by genetics, appropriate training can
develop muscles within limits. For example, aerobic u-aining enhances the capaciry of
rype IJA muscle fibers to produce ATP and may bring about a relative change in size.
Overall, great athletes are born, but their genetic potential then must be nurtmed by
training. 8
muscle fiber Essentially a single muscle cell.
This is an elongated cell with contractile Adaptation of Muscles and Body Physiology to Exercise
properties tha t forms the muscles of the body.
With training, m uscle strength becomes matched to the muscles' variable work de-
hypertrophy An increase in tissue or organ mands. Muscles enhu·ge after being made to work repeatedly, a response called hyper-
size. trophy. Certain cells in the muscles gain bulk and improve their ability to work.
Conversely, after several days without activity, muscles diminish in size and lose
atrophy A wasting away of tissues or organs.
strength, a response called atrophy. Both hypertrophy and atrophy are forms of adap-
tation to the load applied. Thus, many marathon runners have well-developed Leg mus-
cles but little arm or chest muscle development.
Repeated aerobic exercise produces beneficial changes in the heart ai1d blood ves-
sels tl1at are responsible for delivering oxygen to the mitochondria of the muscle cells.
Because the body needs more oxygen dw-ing exercise, it responds to training by pro- TP (energy) needs dictate the amount of
ducing more red blood cells and expanding total blood volume. Training also leads to
an increase in the number of capillaries in muscle tissue; as a result, oxygen can be de-
A oxygen used by cells: 1.5 or 2.5 ATP mol·
ecules ore produced from each molecule of
livered more easily to muscle cells. Finally, training causes the heart, a muscle itself, to oxygen.
strengthen. Theo each contraction empties the heart's chamber more efficiently, so
more blood is pumped \\'ith each beat. As exercise increases the heart's efficiency, its
rare of beating ar rest and dming submaxin1al exercise decreases. 19
0:-..)'gen consumption indicates how hard a person is exercising. The more physically
fit a person is, the more work the muscles and body can do and the more o:-..)'gen the
person can conswne. A o-ead.mill test is commonly used to detennine a person's
V0 2 max> which is the maximum amount of m..-ygen that can be conswned in a unit of V0 2mox The maximum volume of oxygen that
time (ml/min). In this test, oxygen consw11ption is measured as the treadmill speed con be consumed per unit of time.
and/or grade is gradually increased until the subject can no longer increase OA)'gen use
as workload increases. The mc)'gen consumption measmed at this point is V02 max·
Most people can improve their V0 2 max by 15 to 20% or more with training.8
Because of individual differences in V0 2 max> it is generally best to express exercise
intensity as a percentage ofV0 2 max· The percentage ofV0 2 max required for exercise
of various intensity is as follows:
• Low intensity (e.g. , fast walk)-30 to 50% ofV0 2 max Relative Distribu~on of Muscle Fiber Types
• Moderate intensit:y (e.g., fastjog)-50 to 65% ofV02 nm Type 1: Type IIA + Type llX
• High intensity (e.g., 3-hour marathon pace)-70 to 80% ofV0 2 max Sedentary person 45-50% : 50-55%
• Very high intensity (e.g., sprints)-85 to 150% ofV0 2 max
Sprinter 20-35% : 65-85%
In very-high-intensity activities, the ATP equivalent to the "extra" 50% above 100% Marathoner 80%: 20%
ofV02 max is produced anaerobically from PCr and glycolysis. In terms of fuel sources
for muscle cells, fat use peaks as exercise intensity increases (Table 14-3). Carbohydrate
use then becomes more important for meeting energy needs.
Exercise output is sometimes expressed in units called metabolic equivalents
(METs). One MET is the expenditure of 1 kcal/kg/hr or, on average, 3.5 ml 'fh: .,, i El
0 2/kg/min. This approximates resting energy expenditure. A brisk walk represents
about 4.5 METs of energy n"µendintre. Exercise prescriptions given to people recov- Marty started going to the gym about 8 weeks
ering from a heart arrack are often given in MET units. 19 ago. At first, he noticed that he began huffing
and puffing about 7 minutes into his aerobic
workout. Now, however, he can work out for
Power Food: Dietary Advice for Athletes about 25 minutes without tiring. What is a pos·
sible explanation for his ability to work out
Athletic training and genetic makeup are two very important determinants of athletic longer?
performance. A good diet won't substitute for either factor, but eating well can help
enl1ance and rnaximjze an athlete's potential. On the other hand, poor food choices
can seriously reduce performance.
Energy Needs
Athletes need varying amow1ts of food energy, depending on each athlete's body size,
body composition, and the type of training or competition being considered. A small
person m~ay need only 1700 kcal/day to sustain normal daily activities without losing
Table 14·3 I Fuel Use Estimate Based on Percent of V0 2 mo.x Typical V0 2 mox Values ml O/kg/min
Muscle Muscle Blood Free Fatty Acids in Sedentary elderly person 15
V02max Glyogen Triglycerides Glucose the Bloodstream Typical middle-aged adult 35-45
25% 20% 10% 70% Elite athlete 65-75
65% 40% 25% 10% 25%
85% 55% 15% 15% 15%
body \\'eight; a tall, muscular man may need 4000 kcal/day. These rough estimates can
be \'iewed as starting points that need to be individualized by triaJ and error for each
athlete.
An estimate of the energy required to sustain moderate activity is 5 to 8 kcal/min.
The energy required for sports training or competition then has to be added co the en
ergy used just to car•"}' on normal acti\·ities. For example, an hour of bowling requires
litde energy in addition to that required to su!>tain normal daily living. At the other ex-
treme, a 12-hour endurance bicycle race over mountains can require an additional
4000 kcal/day. Therefore, some athletes may need as much as 7000 kcal/day or more
just to maintain body weight while training, whereas others may need 1700 kcaljda)
or less. If an adilete experiences daily fatigue, the first consideration should be whether
that person is consuming enough food. Up to six meals per day may be needed, in
el uding one before each workout.
How can we know if an .uh lcte is getting enough energy? Estimating daily intake
from a food diary kept by the athlete is one wny. Another step is to estimate the ath -
lete's body fat percentage via skinfold measurements, bioelectrical impedance, or llll -
derwater weighing (review Chapter 13 ). Body fat shoLtld be the typical a.mount fouml
fo r athJetes for die specific sport practiced: 5 to 18% for most male athletes and 17 to
Athletes ohen expend much energy. In such 28% for most female athletes. The next step is to monitor body weight changes on .l
coses, their resulting increased food and daily or weekly basis. If body weight starts to fall, energy intake should be increased; if
beverage intake should easily provide ample weight rises because or increases in body fat, die athlete should car lcss. 19
carbohydrate, protein, and other nutrients to If dle body composition rest shows that an athlae has too much body fut, the .uh
support activity. letc should lower food intake by about 200 to 500 kcal/day while maintaining a reg-
ular exercise program until the desirable fat percentage is achieved. Reducing fat intake
is the best nutrient-related .tpproach. On the other hand, if an athlete needs to gain
eview Tobie 13-6 in Chapter 13, which weight, increasing food intake b) 500 to 700 kcal/day ""ill eventually lead m the
listed the energy costs of typical forms of needed weight gain. A mix of carbohydrate, fat, and protein is advised, coupled with
physical activity. exercise co make sure this gain is mostly in the form of lean tissue and not fat stores.
Note that wrestlers, boxers, judoisrs, jockeys, and rowers often rry to lose weight
before a competition so that they can be certified to compete in a lower weight class.
This maneuver helps them gain a mechanical ndvantage OYer an opponent of smaller
stature. They usually lose diis weight before stepping on the scale for weighc certifi-
cation. Athletes can lose up to 22 lb (10 kg) of body weight as water in 1 day by sit-
ting in a sauna, exercising in a plastic sweat suit, or taking d iuretic drugs, which
speed water loss from the kidneys. Losing as liulc as 2% of body weig h t by dehydra-
tion, however, can adversely affect end urance performnnce, especia lly in hot weather.
A pattern of repeated weigh t loss or gain of more dlan 5% of body weight by dehy-
dration carries risk of kidne)' 111alfi.1nction and heat-related illness. Death is also ,1
possibility.
To prevent future deaths from such wcighr loss in acliletes, the National Collegiate
Athletic Association and many states have authorized physicians or adlletic trainer!> to
set safe weight and body fat content minimums (e.g., 7% or more of total body weight)
for male athletes in weight-class sports ( 12% or more for females). Under ne\\ guide-
lines, athletes are assigned to weight classes at die beginning of the season and arc not
allowed to "cut weight" to gain a competirh·e ad,·amage. (Weight gain in the day-; after
a competition [reflecting regain of body water l can now be no greater than 2 lb.) Lf
athletes, such as wrestlers, wish to compete in a lower weight class and have enough
extra fut stores, they should begin a gradu.11, sustained reduction in enerm intake long
before the competitive season starts.
Carbohydrate Needs
Anyone who exercises \'igorou~ly, especially for more than I hour per day on a rcgul.1r
basis, needs to consume a diet that includes moderate to high amounts of carboh)'-
High-carbohydrate foods should form the basis drates. The diet should rrovide a variety of foods, such as those recommended by
of the athlete's diet. MyPyramid. Numerous servings of gr;1ins, stnrchy vegetables, and fruits provide
enough carbohydrate to maintain adequate liver and muscle glycogen stores, especially
for replacing glycogen losses from workours on the previous day. Relatively low- I Thi'1' 'n!J
carbohydrate/high-protein diets, such as The Zone Diet, are not recommended. RecaU Joe is a wrestler who qua/iFied for the 125-lb
that Chapter 13 discussed die Zone Diet. The carbohydrate content ofthis diet is only weight clossificofion in the annual stale high
40% of energy intake, rather than the 60% or more that is typically recommended for school competition. After a few matches, Joe
athlctes. 3 began lo feel dizzy and fainl. He was disquali-
Carbohydrate intake should be at least 5 g/kg of body weight. People engaged in fied because he was unable to continue the
aerobic training and endurance activities (duration 60 minutes or more per day) may match. Later, the coach found out that Joe had
need as much as 7 g/kg of body weight. When exercise duration approaches several spent 2 hours in the sauna before weighing in,
hours per day, the carbohydrate recommendation increases to up to 10 g/kg of body which had made him dehydrated. What are
weight. 2 In other words, triatbletes and marathon runners should consider eating close the consequences of dehydration? What can
ro 500 to 600 g of carbohydrates daily. Even more may be necessary to (l) prevent you suggest as a safer alternative for weight
du·onic fatigue and (2) load the muscles and liver with glycogen. Attention to carbo- loss?
hydrate intalce is especially important when performing multiple training bouts in a
day, such as swim practices, or heavy training on successive days, as in cross-country
running. Depletion of carbohydrate ranks just behind depletion of fluid and elec-
trolytes as a major cause of fatigue.
Table 14-4 shows sample menus for diets providing food energy ranging from 1500 ppropriate Activities for
to 5000 kcal/day. In addition, the Exchange System described in Appendix Eis a very
useful tool for planning all types of diets, including high-carbohydrate diets for athletes.
A Carbohydrate Loading
Marathons
Athletes should obtain at least 60% of total energy needs from carbohydrates (rather long-distance swimming
than the 50% typical of most North Aim:rican diets), especially if exercise duration is Cross-country skiing
expected to exceed 2 homs and total energy intake is about 3000 kcal per day or less. 30-kilometer runs
Diets providing 4000 to 5000 kcaljday can yield as little as 50% of energy content Triathlons
coming from carbohydrate and still provide sufficient carbohydrate (e.g., 500 to 600 g Tournament-play basketball
or so per day). 2 Soccer
Note that athletes do not have to give i1p any specific food when planning a bigh- Cycling lime trials
carbohydrate diet. The focus is to include more high -carbohydrate foods while mod- Long-distance canoe racing
erating concentrated fat sources. Sports nutritionists emphasize the difference between
nappropriate Activities for
a high-carbohydrate meal and a high-carbohydrate/high-fat meal. Before endurance
Carbohydrate Loading
evenrs such as marathons or triathlons, some atl1letes seek to increase their carbohy-
American football games
cirate reserves by eating foods such as potato chips, french fries, banana cream pie, and
l 0-kilometer or shorter runs
pastries. Although such foods provide carbohydrate, they also contain a lot of fat.
Walking and hiking
Better high-carbohydrate food choices include pasta, rice, potatoes, bread, fruit and
Most swimming events
fruit juices, and man)' breakfast cereals (check the label for carbohydrate content)
Single basketball games
(Table 14-5 ). Sports drinks appropriate for carbohydrate loading, such as Gator Lode
Weight lifting
and Ultra.Fuel, can also help. Consuming a moderate rather than a high amount of
Most track and field events
fiber during the final day of training is a good precaution to reduce the chances of
bloating and intestinal gas during the ne.Kt day's event.
for atl1letes who compete in continuous, intense aerobic events lasting more than
60 to 90 minutes (or in shorter events taking place more than once within a 24-hom·
period), a carbohydrate-lo ading regimen can help maximize the amount of energy carbohydrate loading A process in which a
stored in the form of muscle glycogen for the cvent. 19 (Note, however, tliat this very high carbohydrate intake is consumed for
aniount of activity applies to fow athletes.) In one possible regimen, dming the week 6 days before an athletic event while tapering
prior to the event, the athlete graduaUy reduces the i.11tensiry and duration of exercise exercise duration in an attempt to increase
("tapering") while simultaneously increasing the percentage of total energy intake sup- muscle glycogen stores.
plied by carbohydrate.
For example, consider the carbohydrate-loading schedule of a 25-year-old man
preparing for a maratl1on. His typical energy needs are abom 3500 kcal/day. Six days
before competition, he completes a final hard workout of 60 minutes. On tlrnt day, car-
bohydrates contribute 45 to 50% of his total energy intake. As he goes thrOL1gh the rest
of tl1e week, the duration of his workouts decreases to 40 minutes and tl1en to about
20 minutes by the end of the week. Meanwhile, he increases the amount of carbohy-
drate in his diet to reach 70 ro 80% of total energy int~1ke as the week continues. Total
energy intake should decrease as exercise time decreases throughout the week. On tl1e
final day before competition, he rests while maintaining the high-carbohydrate intake.
53 2 Chapter 14 Nutrition: Fitness and Sports
Table 14·4 I Sample Doily Menus Based on MyPyromid That Provide Various Total Energy Intakes
1500 kcal Diet 2000 kcal Diet 3000 kcal Diet 4000 kcal Diet 5000 kcal Diet
Breakfast Breakfast Breakfast Breakfast Breakfast
Fat-free milk, 1 cup Fat-free milk, 1 cup Fat-free milk, 1 cup Fat-free milk, 1 cup Fat-reduced milk, 1 cup
Cheerios, 1/2 cup Cheerios, 1 cup Cheerios, 2 cups Cheerios, 2 cups Cheerios, 2 cups
Bagel, 1/2 Bagel, 1/2 Bagel, 1 Orange, 1 Bron muffins, 2
Cherry iam, 2 tsp Cherry jam, 1 tbsp Cherry jam, 2 tsp Bran muffins, 2 Orange, 1
Margarine, 1 tsp Margarine, 1 tsp Margarine, 1 tsp
Oat bran muffins, 2 Snock Snack
lunch lunch Chopped dates, 3/4 cup low-fat yogurt, 1 cup
Chicken breast (roasted), Chicken breast (roasted), Lunch Chopped dotes, 1 cup
2 oz Chicken breast (roosted), lunch
2 oz Romaine lettuce, 1 cup lunch
Figs, 1 Wheat bread, 2 slices 2 oz
Mayonnaise, 1 tsp Wheat bread, 2 slices Garbanzo beans, 1 cup Apple juice, 1 cup
Fat-free milk, 1/2 cup Grated carrots, 1/2 cup Chicken enchilada, 1
Bonano, 1 Raisins, 1I4 cup Provolone cheese, 1 oz
Cranberry juice, Mayonnaise, 1 tsp French dressing, 2 tbsp Romaine lettuce, 1 cup
Snack l 1/2 cups Raisins, l /3 cup Macaroni and cheese, Garbanzo beans, 1 cup
Oatmeal-raisin cookie, 1 Bonano, 1 Cranberry juice, 3 cups Shredded carrots, 3/4 cup
low-fat fruit yogurt, l cup l 1/2 cups Apple juice, l cup Chopped celery, 1/2 cup
Snock low-fat fruit yogurt, 1 cup Seasoned croutons, 1 oz
Dinner Oatmeal-raisin cookies, 3 Snack French dressing, 2 tbsp
Spaghetti w/meatballs, low-fat fru it yogurt, 1 cup Snack Wheat bread, 2 slices Wheat bread, 2 slices
1 cup Bonano, 1 Margarine, 1 tsp Margarine, 1 tbsp
Romaine lettuce, 1 cup Dinner Oatmeal-raisin cookies, 3 Jorn, 2 tbsp
Italian dressing, 2 tsp Broiled beef sirloin, 3 oz Snack
Romaine lettuce, 1 cup Dinner Dinner Bonano, 1
Green beans, 1/2 cup Skinless turkey breast, 2 oz
Cranberry juice, l 1/2 cups Italian dressing, 2 tsp Broiled beef sirloin, 3 oz Bagel, 1
Green beans, 1 cup Romaine lettuce, 1 cup Mashed potatoes, 2 cups Cream cheese, 1 tbsp
Fat-free milk, 1/2 cup Garbanzo beans, 1 cup Peas and onions, 1 cup
18% protein (68 g) Banana, 1 Dinner
64% carbohydrate (240 g)
Italian dressing, 2 tsp
17% protein (85 g) Spinach pasta noodles, Fat-free milk, 1 cup Fat-reduced milk, 1 cup
19% fat (32 g) Beef sirloin, 5 oz
63% carbohydrate (315 g) l l/2 cups Snock
20% fat (44 g) Margarine, 1 tsp Mashed potatoes, 2 cups
Pasta, 1 cup cooked Spinach pasta noodles,
Green beans, l cup Margarine, 2 tsp
Fat-free milk, 1/2 cup 1 1/2 cups
Parmesan cheese, 2 tbsp Grated parmeson cheese,
Cranberry juice, 1 cup 2 tbsp
17% protein (128 g)
62% carbohydrate (465 g) Green beans, 1 cup
14% protein (140 g) Oatmeal-raisin cookies, 3
21% fat (70 g} 61 % carbohydrate (610 g)
26% fat (116 g) Snack
Cranberry juice, 2 cups
Air-popped popcorn,
4 cups
Raisins, 1/3 cup
14% protein (175 g)
63% carbohydrate (813 g)
24% fat (136 g)
Carbohydrate Loading Regimen

Days before Competition 6 5 4 3 2
Exercise time (minutes) 60 40 40 20 20 Rest
Carbohydrate (grams) 450 450 450 600 600 600
Tllis carbohydrnte-loading technique usually increases muscle glycogen stores by 50
to 85% over cypicaJ conditions (that is, when dietary carbohydrate consrirutes only
about 50% of total energy intake).
A potential disadvantage of carbohydrate loading is that additional water (about 3 g)
is incorporated into the muscles along with each gram of glycogen. Although this
water aids in maintaining brdration , for some individuals this additional water weight
Table 14·5 I Grams of Carbohydrate Based on Serving Size of Typical

Carbohydrate-Rich Foods
Starches-15 g Carbohydrate per Serving (80 kcal)

One Serving
dry breakfast cereal*, l /2-3/ 4 cup baked potato, 1I4 large
cooked breakfast cereal, 1/2 cup bagel, 1I4 (4 oz)
cooked grits, 1/2 cup English muffin, 1/2
cooked rice, l /3 cup bread, l slice
cooked pasta, l /3 cup pretzels, 3/4 oz
baked beans, l /3 cup saltine crackers, 6
cooked corn, l /2 cup pancake, 4 inches in diameter, 1
cooked/dry beans, 1/2 cup taco shells, 2 (odd 45 kcal)
Vegetables-5 g Carbohydrate per Serving (25 kcal)
One Serving
cooked vegetables, 1/2 cup
row vegetables, 1 cup
vegetable juice, l /2 cup
Examples: carrots, green beans, broccoli, cauliflower, onions, spinach, tomatoes, vegetable juice
Fruits-15 g Carbohydrate per Serving (60 kcal)
One Serving
conned fruit or berries, 1/2 cup gropes (small), 17
fruit juice, 1/2 cup grapefruit, l /2
figs (dried), 1 1/2 dotes, 3
apple or orange, l small peach, l
apricots (dried), 8 watermelon cubes, 1 1I4 cups
banana, 1 small
Milk-12 g Carbohydrate per Serving
One Serving
milk, 1 cup soymilk, 1 cup
plain low-fat yogurt, 2/3 cup
Sweets-15 g Carbohydrate per Serving (variable kcal)
One Serving
coke, 2-inch square ice cream, 1/2 cup
cookies, 2 small sherbet, 1/2 cup
Modified from Exchange Lists for Meal Planning by !he Americon Diabetes Association and Americon Dietetic Association, 2003,
Chicago. American Dietetic Association.
•Nole that the corbohydrole content of dry cereal varies widely. Check !he labels of the ones you choose and adjust !he serving
size accordingly.
and related muscle stiffoess can detract from their sports performance, making carbo·
hydrate loading inappropriate. Athletes considering a carbohydrate-loading regimen
should try it during training (and long befure an im portant competition ) to experience
its effects on performance. They can then determine wht:ther carbohydrate loading
works for them. Note also that consuming carbohydrate during a competition provides
abollt the same advantage as carbohydrate loading prior to the event. In fact, expert
advice is currently shifting away from carbohydrate loading and more toward this sec-
ond method, coupled with a daily diet high in carbohydrate. 19 In addition, remember
tl1e imporcance of the "training effect" discussed on pages 528-529.
Fat Needs
A diet containing up to 35% of energy intake from fat is generally recommended for
athlcres. Rich sources of monounsaturated fat, such as canola oil, should be empha-
sized, and saturated fat and tram fat intake should be limited. 2
Protein Needs
Typical recommendatio ns for protein intake in the sports nutrition literature for most
athletes range from 1.0 to 1.6 g of protein/kg of body weight. 2 This amOlmt is con·
siderably higher than the RDA of0.8 g/kg of body weight recommended by the Food
and N utrition Board for all adults, including athletes (Table 14-6).
For athletes beginning a sn-ength-training program, some experts recommend up to
1.7 g of protein per kg of body weig ht. L7 T hat amount is more than twice the RDA
for protein. To date, the value of such an excessive protcLn intake during the initial
High-protein products, which are often phases of strength training has not been supported by sufficient research. Li addition,
marketed to athletes, ore unnecessary in most protein intakes above this amo unt simply result in an increased use of amino acids for
coses. The some holds true for high-protein energy needs; no further increase in muscle protein synthesis is seen . Note also that en -
bars. ergy needs for sn·ength training itself arc not the reason fo r the high protein recom-
mendation, because the fuel used in this activity is primarily phosphocreatine and
carbohydrate. The extra protein, theoretically, is required for the synthesis of new mus-
cle tissue brought on by the loading effect of strength n·ai.ning. Once the desired mus-
cle mass is achieved, protein intake need not exceed l.2 g/kg of body weight.
Table 14-6 summarizes recommended ranges of protein intakes for various rypes of
C onsuming excessive amounts of protein hos
drawbacks. A; noted in Chapter 7, it in·
activity. Any athlete not specifically on a low-calorie regimen can easily meet these pro-
tein recommendations si mply by eating a va1icty of foods (review Table l4-4). To il-
creases calcium lo;s somewhat in the urine. It
lustrate, a 123-Jb (53-kg) woman who is performing endurance activity can consume
also leads to increased urine production, possi·
64 g of protein ( 5 3 X 1.2 ) during a single day by including 3 oz of chicken (one
bly compromising body hydration. It also may
chicken breast), 3 oz of beef (a small, lean hamburger), and two glasses of 1nilk in her
lead to kidney stones in people with a history of
diet. Similarly, a 180-lb (77-kg) man who aims to gain muscle mass through strength
this or other kidney problems. Finally, enough
training needs tO consume only 6 oz of chicken (a large chicken breast), 1/2 cup or
carbohydrate fuel may not be consumed on such
cooked beans, a 6-oz can of tuna, and d1ree glasses of milk to achieve an intake or 130 g
a diet, leading lo fatigue.
of protein (77 X l.7) in a day. And for botb athletes, these calculations do not even
include the protein present in grains or vegetables they will also eat. As you can see,
simply by meeting their energy needs, many athletes consume much more protein than
is required. Despite marketing claims, protein supplements are an expensive and tU1-
necessary part of a fitness plan.
Athletes who either feel they must significantly lin1it their energy intake or are veg-
etarians should specifically determine bow much protein they eat. They should make
sme to follow a diet rhat provides at least 1.2 g of protein per kg or body weight per
day, the upper recommendation for most athletes.
Vitamin and Mineral Needs

Vitamin and mineral needs are the same or slightly hig her for athletes compan::d with
those of sedentary adu lts. Still , because athletes usually have such high energy intakes,
they tend to consume plenty of vitamins and minerals. An exception is adtletes con-
Table 14·6 I Current Recom mendations for Protein Intake Based on kg Body
Weight*
Activity Group g/kg Amount for a 70·kg Person lg)

Sedentary 0.8 56
Strength trained, maintenance 1.0-1.2 70-84
Strength trained, gain muscle moss 1.5- 1.7 105- 119
Moderate-intensity endurance activities 1.2 84
High-intensity endurance training 1.6 112
Weight-restricted athletes especially should
make sure they ore consuming enough protein •colculote kilogroms by dividing pounds by 2.2.
as well as other essential nutrients. Source: Burke l, Deakin V: Clinical Sport; Nutrition, McGrow·Hill, Roseville NSW2069, Austrolio, 2000.
suming low-calorie diets (about 1200 kcal or less), such as some female athletes par- ecall from Chapter 9 that supplement use
ticipating in events in which maintaining a low body weight is crucial. These diets may should not exceed any Upper Levels over
not meet B-vitamin and other micronutriem oeeds. 10 Vegetarian athletes are also a the long term. Also, men should be cautious
concern. Such athletes should consume fortified foods such as ready-to-eat breakfast about any use of supplements containing iron.
cereals o r a balanced multivitamin and mineral supplement.
Athletes' needs fur vitamin E and vitamin C may be somewhat greater because of
the potential antioxidant protection these nutrients provide; this effect could be espe-
cially important in the face of high oxygen use by muscles. Still, as noted by
Dr. Priscilla Clarkson in the Expert Opinion, the use of large doses of vitamin E and
vitamin C requires more study and is not currently an accepted part of tl1e dietary
guidance for atl1letes. It is more important to follow a diet containing foods rich in an-
tioxidants, such as fruits, vegetables, whole-grain breads and cereals, and vegetable oils.
In addition, there is evidence that antioxidant systems in the body increase in activity
as exercise training progresses. Oxidative stress produced during exercise might also
have benefits, such as for muscle adaptation to exercise, and so rrying to block this
process may not be advantagcous. 12. l 3
Iron Deficiency Impairs Performance

Because iron is invoked in red blood cell production, oxygen transport, and energy
production, a deficiency of mis mineral can noticeably detra<.:t from optimal atl1letic
performancc. 15 The potential <.:<1uses for iron deficiency in atl1letcs ,·ary. As in the gen-
eral population, female atltletes are most susceptible to low iron status due to montl1ly
mensLrual losses. Special diets followed by athletes, such as low-energy and vegetarian
(especially vegan) diets, are likely to be low in iron. Distance runners shou ld pay special
attention to iron intake, because their incense workouts may lead to gastrointestinal
bleeding. Another concern is spo1·ts n11cmi11, which occurs because exercise causes blood
plasma volu me to expand, particular!)' at the stan of a u·aining regimen before tlte syn-
tllesis of red blood cells increases. This expansion results in dilution of the blood. In
sports anemia, even if iron stores ate adequate, blood iron tests may appear low.
Spores anemia is not detrimental to performance, but it is hard to differentiate be- t one time in his career, long-distance run·
tween spores anemia and true anemia. If iron status is low and not replenished, iron- ner Alberto Solazar experienced problems
defi<.:iency anemia and markedly impaired endurance performan<.:c cm eventually result. sleeping and performed poorly because of low
True anemia (noted as a reduced blood hemoglobin level) has been found among ath- iron intake and related iron-deficiency anemia.
letes Ill some studies (possibly up to about l 5% of males Jnd 30% of females), so it is
a good idea, especially for adult women ath letes, to have meir iron status checked at
the beginning of a training season and at least once during midseason, and to monitor
dietary iron intake.
Any blood test indicating IO\\ iron Starns-sports anemia or not-is cause for
follow-up. For some atl1letcs the use of iron supplements may be advisable. However,
indiscriminate use of iron supplements is not ad,ised be<.:ause to\1c effects are possible.
It is important that physicians i1wcstigatc the cause of me ddicicnC\ because iron de-
fkiency can be caused by blood loss. If caught early, some serious medical conditions
can be treated or prevented.
Some studies ha,·e suggested thar iron deficiency without anemia may also have a
neg<nive effect on physi<.:al activity and pcrformance. 15 Also, on<.:c depicted, iron stores
can take months to replenish. for this reason, athletes must be especially careful to
meet iron needs.
Calcium Intake Deserves Attention, Especially For Women

Athletes, especially women trying to lme weight b)' restricting their intake of milk and
milk products, can have marginal or lo" dietary intakes of cakium. This practice com-
promises optimal bone healtl1. Of still greater concern are women athletes who have
stopped menstruating because Lheir arduous exercise training and lo" body fat content
interferes with the normal secretion of reproductive hormones. Disturbing reports
536 Chapter 14 Nutrition : Fitness and Sports
Expert Opinion !
Does Increased Physical Activity Necessitate
Antioxidant Supplementation?
Priscilla M. Clarkson, Ph.D.
Adenosine triphosphote (ATP) is the primary fuel that skeletal muscle uses to Various markers in muscle, blood, and urine hove been used to determine
generate force. A large portion of this ATP is produced in muscle cell mito- oxidative stress in response to exercise. The most common measurements to
chondria, specifically the electron transport system. The process of produc- indicate oxidative stress are by-products of lipid peroxidotion that appear in
ing ATP in this manner is termed aerobic metabolism, where molecular the blood. Changes in status of antioxidant compounds such as glutathione,
oxygen is reduced (loses two electrons) and combines with hydrogen ions to protein and DNA oxidation products, and antioxidant enzyme activities
farm metabolic water. About 5% of the oxygen is not fully reduced, resulting have also been used. Techniques to directly measure free radicals, used pre-
in free radicals and reactive oxygen species (ROS), chemicals with unpaired dominantly in in vitro studies, have recently been used with some success to
electrons in their outer shell, such as superoxide, hydrogen peroxide, and hy- detect free radicals in blood. Of the many studies that used these measures
droxyl radicals. to examine whether exercise increases oxidative stress, most have found in-
When left unchecked, ROS con wreak havoc by attacking cellular com- creases in oxidative stress in response to intense exercise. However, results
ponents, especially lipids. The attack on lipids initiates o chain reaction from these studies ore not consistent in the amount of oxidative stress gener-
called lipid peroxidation, leading to a generation of more radicals. These ated, and some studies found no increase. These equivocal results are likely
processes can result in damage lo membranes, proteins, and nucleic acids due to the different levels of training among the subjects, the different exer-
(e.g., DNA). To neutralize ROS, the body has an elaborate defense system cises and intensities used, and the various measures of oxidative stress em-
consisting of enzymes such as catalase, superoxide dismutase, and glu- ployed. The physical outcomes of increased oxidative stress to the person
tathione peroxidase as well as numerous nonenzymatic antioxidants, includ- during exercise are unknown, but recent evidence suggests that oxidative
ing beta-carotene, vitamin E, vitamin C, glutothione, ubiquinone (coenzyme stress may contribute to muscle fatigue.
Q. J0), and flovonoids. All these non enzymatic antioxidants con be obtained The findings tha t physical activity increases oxidative stress have led to
from foods, and some ore also synthesized by cells. the concern that regular, strenuous exercise may cause harm to muscles. This
Increased physical activity requires muscle to produce more ATP, which in idea led to numerous investigations of antioxidant supplementation to reduce
turn requires more oxygen to be used and generates more ROS. Exercise also oxidative stress in an attempt to determine possible benefits of antioxidant
increases ROS through other means such as increased epinephrine and re- supplements for people who exercise regularly. Early studies that examined
lated compounds as well as production of lactate. In this manner, exercise can whether antioxidant vitamin supplements (mostly vitamins C and/or E) would
produce a temporary imbalance between ROS generation and the ability of enhance athletic performance generally concluded tha t performance was not
antioxidants to counteract them. This imbalance is known as oxidative stress. improved unless there was a preexisting vitamin deficiency. Loter research
show that female athletes who do not mensn·uate regularly have fur less dense spi nal
bones than both nonathletes and female athletes who menstruate regularly. These fe-
male athletes are at increased risk for bone fractures during training and competition
and for osteoporosis in later life.7 This combination of risks outweighs the benefits of
weight-bearing exercise on bone density. This topic is discussed furd1er in Chapter 15
with respect to the female athlete nfad and in Chapter 11, where osteoporosis was re-
viewed in detai l.
Research has clearly documented the importance of regular m.enstruacion to main·
tain bone mineral density. A woma11 ru ru1er who does not mensa·uate regularly may
stress fracture A fracture tha t occurs from also have a higher risk for the development of a stress fracture. Thus, fema le ad1letes
repeated jarring of a bone. Common sites whose menstrual cycles become irregular should consult a physician to determine the
include bones of the foot. cause. Decreasing the amount of training o r increasing energy intake and body wcighr
often restores regular menstrual cycles. 20 If irregular mensn-ual cycles persist, sc,·crc
bone loss (much ofwhicb is not reversible) and osteoporosis can result.7 Ex'1:ra calcium
in die diet does not necessarily compensate for the effects of menstrual irregularities,
but inadequate dietary calcium can make matters worse.
focused on the independent effects of vitamin processes. Perhaps the body produces ROS for a reason, that on increase in
C or vitamin E supplementation on immune re- ROS is not o mistake of metabolism.
«<,I, .~
sponse to exercise or on countering exercise- The body's natural defense system works to prevent harmful effects of ox-
induced muscle damage. These study results idative stress, but some oxidative stress may be necessary to promote training
were not consistent in that some studies re- adaptations. It is not known whether strenuous exercise will produce o level
ported o benefit and other studies reported of oxidative stress at which the potential risks oulweigh the benefits, thus im-
no effect of antioxidant supplementation. pairing performance and the ability to train effectively. If so, athletes would
Vitamin C and vitamin E also have been used : r
'
I '"
' require antioxidant supplements to restore the balance. Until this information
.. ·'r1•
in combination to determine the effects in re- is ovoiloble, massive interventions with supplements to prevent ROS should be
ducing muscle damage related to exercise, viewed wi th cau tion. The antioxidant defense system is o complex interaction
but here too, the results of studies ore equivo- and balance of endogenous and exogenous antioxidants. Dramatically in-
- ..
cal. Supplementation effects of other dietary • ·~J
creasing selected dietary antioxidants could disrupt this equilibrium and neg-
antioxidants, or combinations of these with vi- atively impact the system. A prudent recommendation for athletes in strenuous
tamin E and vitamin C, hove not produced Athletes should be cautious training is to consume o diet rich in antioxidants and possibly take o balanced
consistent results. It is difficult to make com- about claims for mega- multivitamin and mineral supplement (containing no more than the Doily
dose antioxidant
parisons between the various studies because Values listed on the label) to make up for specific diet shortfalls rather than
supplements. These
the type of supplement, dosage, timing of the toking supplements that provide high doses of antioxidants.
supplements actually cause
supplement, intensity of the exercise, and out-
more harm than good.
come measures differed. Dr. Clarkson is Professor of Exercise Science ond Associate Deon for
Although exercise can result in oxidative Research in the School of Public Health ond Health Sciences of the
stress, increased oxidative stress is not necessarily harmful. It seems counter· University of Massachusetts- Amherst. She hos served os president of
intuitive to think that the body's response to exercise, a function essential to the Notional ACSM and related organizations. She is the 1997 re-
life and important for health, would be in jurious. In fact, physical training ap- cipient of the Notional ACSM Citation Award, the 2001 Excellence
pears to boost the body's natural antioxidant defense system. Several stud- in Education Award from the Gatorade Sport Science Institute, the
ies hove found that training results in increased antioxidant capacity, Notional ACSM Honor Award in 2005, and the University of
reduced production of oxidants when at rest, and reduced generation of Massachusetts Chancellor's Medal, among other awards.
ROS in the mitochondria, which would increase resistance to subsequent ox- Dr. Clarkson hos published over 150 scientific research articles on
idative stress. Moreover, cells hove on enhanced repair system related to ex· topics such as how human skeletal muscle responds to environmental
ercise training. Thus, ROS may serve as signals that stimulate adoptive challenges.
A Focus on Fluid Needs

heat exhaustion The first stage of heat-related
illness that occurs because of depletion of
fluid needs for an average adult are about 9 cups per day for women and 13 cups per
blood volume from flu id loss by the body. This
day for men. Athletes need th is amount and generally even more to maintain the
depletion increases body temperature and con
body's ability to regulate internal temperature and to keep cool. 5 Most energy released lead to headache, dizziness, muscle weakness,
during metabolism appears immediately as heat. Furthermore, heat production in and visual disturbances, among other effects.
contracting muscles can rise 15 to 20 tin1es above that of resting muscles. Unless this
heat is quickly dissipared, heat exhaustion, heat cramps, and deadly heatstroke may heat cramps A frequent complication of heat
ensue (Figure 14-8).6 In fact, typically three co five athletes die each year of heatstroke. exhaustion. They usually occur in individuals
who hove experienced large sweat losses from
In 2001 , coUege football players and a professional football player died this way.
exercising for several hours in a hot climate
Heat exhaustion occw-s when heat stress causes loss of body fluid and then depic-
and hove consumed a large volume of water.
tion of blood volume. Maintaining adequate body fluid is important. As environmen- The cramps occur in skeletal muscles and
tal temperature rises above 95°F (35°C ), virtually all body hear is lost through the consist of contractions for l to 3 minutes at o
evaporation of S\veat from the skin. Sweat rates dw-ing prolonged exercise range from time.
3 to 8 cups (750 to 2000 ml) per hour. However, as the humidity rises, especially
heatstroke A condition in which the internal Heat Index

body temperature reaches 104°F. Sweating
100 72!' 80° 91° 108°
generally ceases if left untreated, and blood
circulation is greatly reduced. Nervous system 90 71° 79° 88° 102° 122°
damage may ensue, and death is likely. Often ~ 80 71° 78° 86° 97• 113°
the skin of individuals who suffer heatstroke is L 70
~ 70° 77• 85° 93° 106° 124°
hot and dry.
:a 60
·e 69° 76° 82° 90° 100° 114°
:I
:c 50 70° 75° 81° as· 96° 107° 120°
40
·i
"i
Ill:
30
68°
67°
93°
90°
101°
96°
110°
104° 113° 123°
20 66° 87° 93° 99° 105° 112°
10 65° 85° 90° 95° ioo· 105°
0 64° 69° 73° 78° 830 87° 91° 95° 99°
70° 75° 80° 85° 90° 95° 100· 105° 1100
Air Temperature (°F)
Heat index Heat disorders possible with prolonged exposure and/ or physical activity
80°- 89° Fatigue
90°-104° Sunstroke, heat cramps, and heat exhaustion
ios·- 129° Sunstroke, heat cramps, or heat exhaustion likely and heatstroke possible
- -
,_
-· ..,. er Heatstroke/sunstroke highly likely
NOTE: Direct sunshine increases the heat index by up to l 5°f
Figure 1 4-8 I Heat index chart showing associated heat disorders.
above 75%, evaporation slows and sweating becomes a.n inefficient way to cool the
body. The result is rapid fatigue, increased work for the heart, and difficulty with pro-
longed exertion. Clearly, the combination of high heat m1d humidity (e.g., 95°F and
90% humidity) can be as dangerous as exrreme cold.
Increased body temperature associated witb dehydration is evident when the amount
of water loss only exceeds 2% of body weight, especially in hot weather. This dehydra-
tion then leads to a decline in endurance, strength, and overall performance. Wearing
football equipment in hot weather can lead to a loss of 2% of body weight in 30 min-
utes. Marathon runners have been shown to losc 6 ro 10% of body weight during a race.
Common symptoms of heat exhaustion include profuse sweating, headache, dizzi-
Dehydration, which con lead to illness and ness, nausea, vomiting, muscle weakness, visual disturbances, and Ausbing of the skin.
death, must be avoided during physical activity. A person with heat exhaustion should be taken to a cool environment immediately, and
excess clothing should be removed. The body should be sponged with tap water. Fluid
replacement, as tolerated, then should suffice to correct the condirion. 6
Heat cramps a.re a frequent complication of heat exhaustion, but they may appear
without other symptoms of dehydration. Cramps usually occur in individuals wbo have
experienced significant sweating from exercising for several houxs in a hot climate and
wbo have coosumed a large volume of water without replacing sodium losses. It is im-
portant not to confuse heat cramps with other forms of muscle cramps, such as those
caused by GI tract upset. Heat cramps occur in skelet..-U muscles, including those of the ab-
domen and exrremities. They consist of a contraction lasting l to 3 minutes at a time. The
cramp moves down the muscle and is associated with excruciating pain. The best way ro
prevenr heat cramps is to exercise moderately at first a.nd to have adequate salt intake be-
fore engaging in long, strenuous activity in the heat, and to nor become dehydrared. 6
Heatstroke can occur when the internal body temperature reaches 104°F or more.
Related symptoms include nausea, con.fusion, irritability, poor coordination, seizures, and
coma. Exertional heatstroke resuJts from higb blood flow to exercising muscles, wh.ich
oYerloads d1e body's cooling capacity. Swearing generally ceases, and me body tempera-
ture may become dangerously high. If left untreated, circulatory collapse, nervous system
damage, and death are likely. The death rate from heat stroke is high, approximately 10%. 6
Many individuals faint during hcatsrsoke, and their skin becomes hot and dry.
Cooling rhe skin \vld1 ice packs or cold water is the usual recommended immediate
treatment until medical help can be summoned. To decrease the risk of developing heat-
stroke, athletes should watch for rapid changes in body (2% or more ), replace lost flu-
ids, and avoid exercising tmder extremely hot, humid conditions.
Athletes must avoid becoming dehydrated because dehydration during exercise sets
the stage for heat exhaustion, heat cramps, and potentially fatal heatsn·oke. Fluid in-
take during exercise, when possible, should be adequate to minimize loss in body
weight; follo\\ing this practice is a good idea even when sweating can go unnoticed,
such as \\'hen swimming or during the winter. 5
The recommended fluid status go.11is a loss of no more tlun 2% of body weight dur-
ing exercise, especially in hot weather. Athletes should first calculate 2% of their body
weight and then by trial and error determine how much flu.id they must drink to avoid
losing more than this amount of weight during exercise. This determination will be
most acwrate if an athlete is weighed before and after a typical workout. For every
1 lb ( l / 2 kg) losr, 2 1/2 to 3 cups (about 0.75 liters ) of \\'ater should be coasw11ed
during exercise or immediately ati:ern ard. Experts now recommend a total of2 1/2 to
3 cups (0.75 lirers) of water per pound lost, rad1er than the pre,ious recommendation
of 2 cups per pound, because some of the fluid replacemcm "ill quickly be lost from
increased sweating after exercise and increased urine output. Much of this fluid re-
placement will haYe to take place alter exercise because it is difficult to consume
enough fluid during exercise to prevent weight loss. If weight change can't be moni-
tored, urine color is another measure of hydration status. Urine color should be no
more yellow than that of lemonade.19
Thirst is a late sign of dehrdration and so is nor a reliable indicator of an athlete's
need to replace tluid during exercise. An athlete who drinks only when thirsty is likely
to take 48 hours to replenish fluid loss. After se,·eral da}'S of training, an ad1lete rely-
ing on thirst as an indicator can build up a thud debt that will impair performance.
fluid Replacement Strategies

The lollowing fluid replacement approach can meet athletes' fluid needs in most cases: 2
• Freely drink beverages (e.g., water, diluted fruit juice, sports drinks) during the Fluid intake during exercise is important.
24-hour period before an event, even if not particulad)' thirsty.
• Drink l 1/2 to 2 1/2 cups of tluid (400 ro 600 ml) 2 to 3 hours before exercise.
This allows time for both adequate hydration and excretion of excess flu.id.
• During c\•ents lasting more than 30 minutes, consume ,\bout 1/ 2 to l 1/2 cups
( 150 to 350 ml ) of fluid e\'ery 15 to 20 minutes beginning at the start of the exer-
cise. Consuming more than 1 quart ( 1 liter) per bow· can cause discomfort. On hot
days, cold drinks are preferable ro help cool the body. Again, athletes should not
wait unti l they feel thirsty. In many cases, athletes, especially children and teenagers,
need to be rem.inded to drink.
• Within 4 to 6 hours after exercise, about 2 1/2 to 3 cups of fluid should be con-
sumed for every pound lost. 1t is also important that weight be restored before the
next exercise petiod. Skipping 11uids before or during events will almost certainly
impair performance. Note also d1at because caffeine has a dehydrating eftCct on the
body, fluids comaining it should not be part of any hydration plan before, during,
or after exercise. Alcoholic be,·erages also ha,·e a diuretic effect.
Use of Sports Drinks

A question d1at often arises is whether athletes should drink water or a sports-type
carbohydrace-elecn-olyte drink (e.g., All Sport, Exceed Enerb'Y Drink, Gatorade,
PowcrAdc, or Amino Force) during competition (Figure 14-9). For sports that require
less than 60 minutes of exertion or when total weight loss is less than 5 to 6 lb, the
primary concern is replacing the water lost in sweat because losses of carbohydrate
stores and elecnolytes (sodium , chlo1ide, potassium, and other minerals) are not usu-
ally very great. Although elecu·olytes are lost in sweat, the quantities lost in brief to
moderate duration exercise can be easi ly replaced later by consuming normal foods
such as orange juice, potatoes, and tomato juice. Keep in mind that sweat is about 99%
water and only 1% electrolytes and other subst;rnces.
When exercise extends beyond 60 minutes, electrolyte (especially sodium ) and car-
bohydrate replacement becomes increasingly importam. 5 Use of sports drinks during
these longer boms of exercise-even more so in hot weather-can offer several distinct
advantages over water alone.
Water by itself, as you have learned, increases blood volume to allow for efficient
cooling and transport of potential cellular fuels and waste products. The add_ition of
Nutrition Facts carbohydrate to a sports drink supplies glucose to muscles as they become depleted of
Serving Size 8 noz (240m1)
Servings Per Container 4 glycogen and thus can enhance performance when admi11istered during endurance ac-
Amount Per Setv'lng tivities (see the later section on carbohydrate replacement). The electrolytes i11 sports
Calories 50
% Dally Value•
drinks help maintain blood volume, enhance the absorption of water and carbohydr<ltc
Total Fat Og 0% from the intestine, and stimulate thirst. For these reasons, some experts prefer sports
Trans Fat 0% ..
drinks over water for all athletes.
Sodium 110mg 5%
Potassium 30mg 1% Overall, the decision to use a sports drink hinges primarily on the dw-ation of the
Total Carbohydrates 14g 5% activity. As the projected dmation of continuo us activity approaches 60 minutes or
longer, the advantages of a sports drink over plain water clearly emerge. However, ath-
letes should first experiment with sporrs drinks dming practice instead of trying them
for the fu-st time during competition.19
It is also possible for some athletes to d1·ink too much water. Endurance athletes (es-
peciall)' poorly trained individuals) may compete at relatively low exercise intensities for
prolonged periods of time and therefore may not sweat as much as they think they wi ll.
Thus, water losses arc not very high. In addition, some of these ath letes use one-half
su·ength Coca-Cola as their fluid-replacement beverage, which is relatively low in
sodium, and they drink this at every rest stop. This combination leads to an eventual
Figure 14· 9 I Sports drinks for fluid and fall in blood sodium, which is not desirable (note that a fall in blood sodium can occur
electrolyte replacement typically contain simple in both hot and cold weather). Drinking Jess fluid, choosing a sports drink containing
carbohydrates plus sodium and potassium. The sodiLLtn ( usually in the form of sodium chloride), and not gaining weight during the
various sugars in this product total 14 g/cup activity can help prevent this problcm. l
(240 ml) serving. In percentage terms based on
weight, the sugar content is about 6% ([14 g
sugar per serving 7 240 g per serving] X 100
= 5.8%). Sports drinks typically con tain about Specialized Dietary Advice for before, during,
6 to 8% sugar. This provides ample glucose
and other monosaccharides to aid in fueling
and after Endurance Exercise
working muscles, and it is well tolerated. Drinks
with a sugar content above 10%, such as soh A light meal supplying up to 1000 kcal shou ld be eaten about 2 to 4 hoLLrs before an
drinks or fruit juices, may cause stomach endurance event to top off muscle and liver glycogen stores, prevent htmger during the
distress and so are not recommended. event, and provide exu·a fluid. The longer the period before an event, the larger the
meal can be, because there will be more time available for digestion. A pre-event meal
should consist primarily of carbohydrate (about 200 g), have little fat or fiber, and in-
clude a moderate amount of protein (Table 14-7). A meal eaten 1 hour or so before
an event should be blended or Liquid to promote rapid stomach emptying. Exampks
are low-fat smoothies, juices, and sports drinks. 19
Good food choices for a pre-event meal include spaghetti, muffins, bagels, pancakes
with fresh fruit topping, oatmeal with fruit, baked potato topped with yogurt or a small
amount of sour cream, toasted bread with jam , bananas, apples, oranges, pears, plums,
nuts, and low-sugar breakfast cereals with reduced-fat or fat-free milk. Liquid meal-
replaccment formulas, such as Carnation Instant Breakfast, also can be used. Foods espe-
cially rich in fiber should be eaten the previous day to help empty the colon before an
event, but they should not be eaten the night before or in the morning before d1e event.
Foods to avoid are those that are fatty or fried, such as sausage, bacon, sauces, and gra,~es.
Table 14·7 I Convenient Pre-event Meals Rule of Thumb for Approximate

Pre·event Carbohydrate Intake
Breakfast Grams per For a
Cheerios, 3/4 cup 450 kcal Hours kilogram 70-kg
Reduced-fat milk, 1 cup 82% carbohydrate Before Body Weight Person
Blueberry muffin, l (92 g) l 70
Orange juice, 4 oz 2 2 140
or
low-fat fruit yogurt, 1 cup 482 kcal 3 3 210
Plain bagel, l /2 68% carbohydrate 4 4 280
Apple juice, 4 oz (84 g)
Peanut butter (for bagel), 1 tbsp
or
Whole-wheal toast, 1 slice 507 kcal
Jam, 1 tsp 73% carbohydrate
Apple, 1 large (98 g)
Reduced-fat milk, 1 cup
Oatmeal, 1/2 cup (with reduced-fat milk, 1/2 cup)
Lunch or Dinner
Chili; with beans, 8 oz 900 kcal
Baked potato with sour cream and chives 65% carbohydrate
Chocolate milk shake (150g)
or
Spaghetti noodles, 2 cups 76 l kcal
Spaghetti sauce, 1 cup 66% carbohydrate
Reduced-fat milk, 1 1/2 cups (129 g)
Green beans, l cup
or
Orange, 1 large 829 kcal
Reduced-fat milk, 1 l /2 cups 70% carbohydrate
Chicken noodle soup, 1 cup (160 g)
Saltine crackers, 12
Buttered beans, l cup
Corn, 1 cup
Angel food coke, l slice
The rule of thumb when liming preocttv1ty meols is to allow 4 hours for o big meol (oboul 1200 kcoll, 3 hours for a moderole meol
(about 800 to 900 kcal), 2 hours for o light meol loboul 400 to 600 kcol), end on hour or less for a snack {about 300 kcoll .
Replenishing Fuel during Endurance Exercise

For sporting e\·cnts that are longer than 60 minute!>, consumption of carbohydrate
during acti\'ity can impro\'e ath letic performance because prolonged exercise depkrcs
muscle glycogen stores and low levels or blood glucose lead to fatigue, both physical
.ind mental. 5 Recall that when the supply of energy from carbohydrates runs low, ath·
le res often complain of "hitting the wall," the point ar \\ hich maintaining a competi-
tive pace seems impossible. One way to overcome this obstacle is tO m3intain normal
blood glucose concentrations by carbohydrate feed ings. A general guideline for en-
durance events is to consume 30 to 60 g of carbohydrate per hour; however, an ath-
lete should experiment during training sessions to establish the b·el that leads to
optimal performance. 5
In the previous section on fluid needs, you learned that sports drinks are a good
source of carbohydrates for endurance events. They supply the necessary fluid, elec-
trolytes, and carbohydrate to keep athletes performing at their best. As an alternative
to sports drinks, some athletes have begun ro use carbohydrate gels (e.g., PowerGcl
and ClifShot) and energy bars (e.g., PowcrBar). Check the label on these products to Carbohydrate intake during endurance
gauge the amount of gel or bar that provides 30 to 60 g of carbohydrate per hour. Gels exercise helps maintain this source of energy
contain about 25 g of carbohydrate per serving, and depending on the type, popular for the body.
Table 14-8 I Energy and Macronutrient Contents of Popular Energy Bars

and Gels
Product Energy (kcal) Carbohydrates (g} Protein (g) Fat (g)

PowerBar Performance
(chocolate) 230 45 10 2
PowerBar ProteinPlus
(cookies & cream) 230 38 24 5
PowerBar PowerGel
(lemon lime) 110 28 0 0
Luna Bar (cherry<overed
chocolate) 180 28 10 4
Clif Bar (chocolate chip) 250 45 10 5
Clif Shot (viva vanilla) 100 24 0 0
Balance Bar (chocolate) 200 22 14 6
Balance Sotisfoction
(chocolate crisp) 280 47 12 6
Boulder Bar (chocolate) 210 42 10 4
Choosing energy bars is J)feferoble lo choosing candy bars and packaged cokes. When used in spo<I$ situations. energy bars con
be handy. Better yet, however, is lo eat a variety al wholesome foods; these offer more health-protective compounds They are also
Elite athletes such as Olympic beach volleyball a less expensive choice, especially for day-te>doy snacking
gold medal winner Kerri Walsh are well oware
that modifying their diet and training regimen
to match up with the specific needs of their
sport is key to optimum performance. energy bars range from 2 to 45 g of carbohyd rate per serving (Table 14-8). Sport!>
Replenishing carbohydrate ond fluids is drinks, by comparison, contain about 14 g of carbohydrate per 8-oz serving. T he \\'ide
especially important when training. range of carbohydrate content in energy bars is due to a varie ty of marketing trends in
the sports supplement industry.
Q,·erall, choosing a bar with about -10 g of carbohydrate and no more than I 0 g of
protein, 4 g of fat, and 5 g of fiber is recommended. The bars are also typicall\' forti
fied with vitamins and minerals, often to 100% of the Daily Values. As such, these bar-.
can be seen as a convenient, although somewhat expensi,·e, source of maricnu•.
If the ath lete prefers solid sources of carbohydrate, fig cookies, Gummy Bears, wd
jellybeans yie ld a quick source of glucose.: with a much lower cost. However, anr
carbohydrate-containing food, including energy bars and gels, must be accomp.rnied
by fluid to ensure adequate hydratioo. 19
Carbohydrate Intake during Recovery from Prolonged Exercise

hen regularly consuming energy bars,
be aware of your overall micronulrient Carbohydrate-rich foods pro,iding l to 2 g of carbohydrate per kg of bod~ weight
intake. Many energy bars ore fortified with should be consumed within 2 hours after extended (endurance) exercise, the sooner
amounts of micronutrients such os vitamin A and the better (Table l 4 9). lmmediately after exercise is when glycogen synthesis is gre.lt·
iron that could be toxic if several bars are con· est, because the muscles are ver}' insulin-sensitive •lt tnis poinr. 19 This process should
sumed in o day. then be repeated over tJ1e next 2-hour interval. Athletes who are training hard can con
sumc a simple sugar cJndy, sugared soft drink, fruit or fruit juice, or a sports· type car-
bohydrate supplement right after training as they attempt to reload their muscles with
glycogen. Later, bread, mashed potatoes, and rice can contribute to additional carbo-
hydrate consumption. AU these high-glycemic-load carbohydrates especially contribute
to glycogen synthesis (recall tJ1at Table 5-4 shO\\S the glycemic load ofvaiious foods).
Adding some rich protein sources may also be considered, "ith carbohydrate to pro·
tein in about a 3: l ratio. This inclusion is especially useful if the greater food choices
allowed help the athlete meet overall energy needs. For a 154-lb (70-kg) athkce, thi~
ratio corresponds co about 70 g of carbohydrate and 25 g of protein in each 2-hour
interval. In summary, the following are key factors for acl1ieYing the most rapid re·
plenishment of muscle glycogen after exercise: ( 1) availability of adequate carbe>h)
ny nutrition strategies should be tested dur·

Table 1 4·9 I Sample Postexercise Meals for Rapid Muscle Glycogen
ing practice and trial runs before being
Replacement
used in a meet or key event. An athlete should
Option 1 never try o new food or beverage on the day of
bagel, 1 regular competition. Some food items and beverages
peanut butter, smooth, 2 tbsp may not be well tolerated, and the day of com·
Fat-free milk, 8 oz petition is not the time to find this out.
banana, 1 medium
562 kcal, 77 g carbohydrate, 23 g protein, 18 g lot
Option 2
Carnation Instant Breakfast, 1 pocket
fat.free milk, 8 oz
bonono, 1 medium
peanut butter, 1 tbsp
Blend until smooth
438 kcal, 70 g carbohydrate, 17 g protein, 10 g fat
Option 3
GatorPro, 1.5 cons (11 Aoz per con)
559 kcal, 89 g carbohydrate, 26 g protein, 11 g fa t
drate, (2) ingestion of carbohydrate as soon as possible ati:er completion of exercise,

and ( 3) selection of high·glycemic-load carbohydrates.
Fluid and elecu·olyte intake is also an esscntiaJ component of an athlete's recovery hy hasn't fat been mentioned as a way
dier. 2 Replenishing body fluids as quickly as possible is especially important if two to improve athletic performance during
workout:. a day arc performed or if the en\'ironmcnt is hot and humid. If food and fluid on endurance event? Although it is true that fat
intake is sufficient ro restore weight loss, it generally will also supply enough elec- is used along with carbohydrate as fuel during
trolytes to meet needs during recovery from endurance activities. prolonged aerobic activity, the processes of di·
gestion, absorption, and metabolism of fat are
relatively slow. Therefore, consumption of fat
during activity is not likely to translate into better
Concept I Check
AU athletes would do well to follow a wdl-balanced diet. 1-ligh·carbohydrate foods should athletic performance.
be emphasized and should dominate in pre-event meals. Protein intake abo,·c 1.7 g/kg of
body weight is nor supported by scientific e\'idence. Most athletes easily consume enough
protein from typical food choices. ff nutrient supplements are used, dosages generally should
not exceed the Upper Level for each nutrient. Fluid should be consumed as liberally as pos-
sible before, during, and after .m event. Carbohydrate and electrolytes in the fluid help delay
fatigue and maintain electrolyte balance when exercise duration exceeds 60 minutes.
Marcella is correct in following a high<orbohydrate diet. However, in her effort to or more information on sports nutrition, visit
minimize her fat intake, she is probably not consuming enough energy, protein, the Gatorade Sport Science institute web
iron, or calcium lo support her training routine. She hos fallen into the bagel, pasta, page (www.gssiweb.com). For more informo·
and pretzel routine that sports nutritionists worn is not conducive lo peak performance. lion on sports medicine, visit
Marcella's performance would improve if she also had o high-protein food al each meal. She www.physsportsmed.com. This home page of
could include milk with breakfast and possibly some low-fat yogurt or low-fat cheese al lunch. The Physician and Sportsmedicine journal details
She should have a carbohydrate/protein snack before her workout, such as half a sandwich current issues in sports medicine, including in-
with fruit and some water. The sandwich and fruit will help provide her with fuel lo support her jury prevention, nutrition, and exercise. Also
vigorous training. During her workouts, she could consume a sports drink lo meet Auid needs helpful ore the web poges of the American
and supply some carbohydrate, or she could consume water a long with a few lig cookies or College of Sports Medicine (www.ocsm.org),
other high<arbohydrote food. In the evenings, she could substitute cheese and crackers for the Centers for Disease Control and Prevention
pretzels to improve protein intake. Overall, it is important for Marcello lo fuel her body before, (www.cdc.gov/nccdphp/dnpo), and the
during, and ofter workouts. American Council on Exercise
(www.ocefitness.org).
Evaluating Ergogenic Aids to Enhance
Athletic Performance
Extreme diet manipulation to improve athletic per- view Chapter l ), and the manufacturing processes
formance is not a recent innovation. Thirty years for dietary supplements arc not as tightly regulated
ago, American footba ll players were encouraged on by FDA as they arc for prescription drugs. Some
hor practice days to "toughen up" for competition supplements may contain substances that will cause
by liberall)' consuming salt rablets before and dur- achlete~ to test positive for various banned sub-
ing practice and by nor drinking ".uer. Now it is stances. This problem was demonstrated 111 the
widely recognized chat this practice can be fatal. 2002 Winter Olympics. Recent studies abo haw
Today's achletes are as likelr as their predecessors to caJlcd inro question che quality control associated
experiment with artichoke he.1rts, bee pollen, dried with che manufacturing of dietary supplements.
adrenaJ glands from cattle, seaweed, freeze-dried Many do not contain che substance and/or tl1c
liver !lakes, gelatin, and ginseng. These are just amount listed on the label. These results add ycr
some of the ineffective substances used by athletes another worry for tl1e athlete.
ergogenic Work-producing. An erin hopes of gaining an ergogcnic (work-producing) The NCAA's Committee on Competiti\'c
gogenic aid is a mechanical, nutritional, edge. Safeguards and Medical Aspects of Spores has de-
psychological, pharmacological, or Today's athletes can benefit from recent scien- veloped lists of supplements chat are pcrmi!>~ibk
physiological substance or treatment that tific evidence documenting the crgogenic proper- and nonpermissible for achletic departmcnr~ ro db·
is intended to directly improve exercise ties of a few dietary substances. These ergogenic pense. Following are key examples:
performance. aids include sutlicient water and electrolytes, lots of
carbohydrates, and a balanced and varied diet. 19 Permissible Nonpermissible
Protein and amino acid supplements are not
Vitamins and minerals Amino acids
among those aids because athletes can easily meet
protein needs from foods, as Table 14-4 demon- Energy bars (if no more than Creatine
strated. The use of nutrient supplements should be 30% protein) Glycerol
designed to meet a specific dietary shortcoming, Sports drinks HMS
such as an inadequate iron intake. These and ocher Meal replocement drinks such L-cornitine
How would you odvise someone who aids, which often ha,·e dubious benefits and may as Ensure Plus or Boost Protein powders
was planning to buy a purported pose health risks, must be given close scrutiny be-
"muscle-building# protein supplement? fore use. The risk-benefit ratio of any ergogenic aid Even appro,·ed substances chat ha,·c been sup-
What risks are important lo point out? merits carefuJ evaluation.19 ported by systematic sciemific studies should be
As SLm1marized in Table 14-10, no scientific ev- used with caution, because the testing conditions
idence supports che effectiveness of many sub- may not match those of che tntended use. finally,
stances touted as performance-en hancing aids. rather than waiting for a magic bullet to cnh.1nce
Many are useless; some arc dangerous. Athletes performance, athletes are advised ro concentrate
should be skeptical of any substance until its er- their efforts on improving their training routines
gogcnic effect is scientifically verified. FDA has a and sport techniques while consuming well ·
limited ability to regulate dictar>' \upplements (re- balanced diets as described throughout thi~ book.
Table 14· 10 I An Evaluation of Ergogenic Aids Currently in the Limelight

Substance/Practice Rationale Reality
Useful in Some Circumstances
Crealine Increase phosphocreatine Use of 20 g per day for 5 to 6 days and then a maintenance dose of 2 g per day may im-
(PCr) in muscles to keep prove performance in athletes who undertake repeated bursts of activity, such os in sprint-
ATP concentration high ing ond weigh! lihing. Vegetarian athletes may especially show benefits because creatine is
low or nonexistent in their diets. Some of the muscle weight gain noted with use results
from water contained in muscles. Endurance athletes do not benefit from use. Little is
known about lhe safety of long-term creatine use. Continual use of high doses has led to
kidney damage in a few cases (lwo to dote). Cost: $25 to $65 per month.
Sodium Bicarbonate Counter lactic acid buildup Partially effective in some circumstances in which lactate is rapidly produced such as
{baking soda) wrestling, bul induces nausea and diarrhea. The dose used is 300 mgs/kg, given 1 lo
3 hours before exercise. Cost: nil.
544
Taltle 14· 1 0 I An Evaluation of Ergogenic Aids Currently in the Limelight (continued}
Substance/Practice Rationale Reality
Useful in Some Circumstances
Caffeine Increase use of fatty acids Drinking two to three 5-ounce cups of coffee (equivalent to 3 to 9 milligrams of caffeine per
to fuel muscles, promote kilogram of body weight) about 1 hour before events lasting about 5 minutes or longer is
psychological effects useful for some athletes; benefits ore less apparent in those who hove ample stores of
glycogen, ore highly trained, or habitually consume caffeine; intake of more than about
600 milligrams (six to eight cups of coffee) elicits a urine concentration illegal under
NCAA rules (greater than 15 micrograms per milliliter) . A possible side effect is reduced
body hydration and shakiness. Cost: $0.08 per 300 mg.
Possibly Useful, Still Under Study
Beto-hydroxy-beta Decrease protein cotabo- Research in livestock and humans suggests that supplementation with this substance may in·
methylbutyric acid (HMB) lism, causing o net crease muscle moss. Still, safety and effectiveness of long-term HMB use in humans is un·
growth-promoting effect known. Cost: Sl 00 per month.
Glutomine (on amino acid) Enhance immune function, Some preliminary studies show decreased occurrence of upper respiratory tract infections in
preserve lean body moss athletes with use. It also may promote muscle growth, but long-term studies are locking.
Protein foods are a rich source of glutamine. Cost: $ l 0 to $20 per month for 1 to 2 g
per day.
Branched-chain amino Important energy source, Supplementation of BCAA (10 to 30 g/doy) during exercise can increase BCAA in the
acids (BCAA) (leucine, especially when carbohy- blood when levels ore low due to exercise but there is no consistent evidence of improved
isoleucine, volineJ drate stores ore depleted performance. Carbohydrate feeding, by delaying use of BCAA as fuel, may negate the
need for BCAA supplementation. Preliminary studies show that BCAA use increases muscle
moss more than does carbohydrate supplementation alone in swimmers, but there ore no
studies regarding resistance training. Protein-rich foods (especially dairy proteins) ore rich
in BCAA. Cost: $20 per month.
Glucose mine Aid in repair of joint Most of the positive evidence is for repair of knee damage in older people, but o recent
damage large scale trial showed no clear benefit for such use. Moy be of use to athletes experienc-
ing knee damage, but again reliable evidence is locking. Cost: $30 per month .
Dangerous or Illegal Substances/ Practices

Anabolic steroids Increase muscle moss and Although effective for increasing protein synthesis, anabolic steroids ore illegal in the United
(and reloted substances, strength States unless prescribed by o physician. They hove numerous potential side effects such os
such as androstenedione premature closure of growth plates in bones (possibly limiting potential height of o teenage
and tetrohydrogestrinone athlete), bloody cysts in the liver, increased risk of cardiovascular disease, increased blood
[THG]) pressure, and reproductive dysfunction. Possible psychological consequences include in-
creased aggressiveness, drug dependence (addiction), withdrawal symptoms (such as de-
pression), sleep disturbances, and mood swings (known as Nroid rage"). Use of needles for
injectable forms odds further health risk. Banned by the International Olympic Committee
and many professional sports organizations.
Growth hormone Increase muscle moss Moy increase height; ot critical ages may also cause uncontrolled growth of the heart and
other internal organs and even death; potentially dangerous; requires careful monitoring by
a physician. Use of needles for injections odds further health risk. Banned by the
International Olympic Committee.
Blood doping To enhance aerobic capac- Moy offer aerobic benefit, very serious health consequences ore possible, including thicken-
ity by injecting red blood ing of the blood, which puts extra strain on the heart, is an illegal practice under Olympic
cells harvested previously guidelines.
from the athlete, or alter-
nately the athlete may
use the hormone eryth ro-
poietin (Epogen) to in-
crease red blood cell
number
Gamma hydroxybutyric Promoted as o steroid FDA has never approved it for sole as a medical product; is illegal to produce or sell GHB in
acid (GHB) alternative for body- the United States. GHB-reloted symptoms include vomiting, dizziness, tremors, and
building seizures. Many victims hove required hospitalization, and some hove died. Clandestine
laboratories produced virtually all the chemical accounting for GHB abuse. FDA is working
with the U.S. Attorney's office to arrest, indict, and convict individuals responsible for the i~
legal operations.
Substances that ore promoted to athletes but hove yet to show ony clear ergogenic effects include pyruvic acid lpyruvotel, glycerol, ribose, chromium, coenzyme Q-10, medium chain triglyc-
erides, l<ornitine, conjugated linoleic acid ICLAI, bovine colostrum, insulin, and amino acids not already mentioned in this section. Any use of these products is not recommended at this lime.
Note that some of these substances ore defined in the glossory 545
Summary
I. A gradual increase in regular physical activity is recommended for carbohydrate is used increasingly as activity inrensific~. Little pro-
all healrhy persons. A minimum plan includes 30 minures of phys- tein is used to fuel muscles.
ical acti\icy on most (or all) days; 60 to 90 minures per day pro- 5. V0 2 ml'< is a measure of the maximum \'Olume of o:.ygcn one c:an
,·ides e\'Cn more benefit, especially if weight concrol is an issue. An consume per unit of time. Oxygen consumption is me.1sured br
intense program should begin with warm-up exercises to increase exercising the subject at :m increasing pace and workload until fu -
blood Aow and warm rhe muscles and sho uld end with cooldown tiguc occurs. The amount of oxygen consumed ri g ht before total
exercises. Regular resistance activities .ind stretching add fi.1nher cxh,rnstio n is V0 2 max· The value of V0 2 n1.1x varies among indi-
benefits. viduals but usually improves with exercise training.
2. Hwnan metabolic pathways extract chemical energy from food 6. Anyone who exercises regularly should consume ,, dicr chat mecb.
and transform it inro ATP, the compound that prmides enerm· for energy needs, is moderate to high in carbohydrates and fluid, and
body functions. is adequate in other nutrients such as iron and cakium.
3. [n glycolysis, glucose is broken down inro the rhree-carbon com- 7. Arhletes should conSLLme enough tluid to both minimize loss of
pound pyrm'ic acid, yielding some ATP. T his compound is metabo- body weight and ultimately restore preexercise weight. Sports
lized forther via the aerobic pathway tO form carbon dioxide (C0 2 ) drinks help replace fluid , electrolyte, and carbohydr.1te replace-
and water (H20) or \'ia the anaerobic pathway to form lactic acid. mcm. Their use is especially appropriate when conrinuous acrh·iry
4. At rest, muscle cells mainly use fat for fuel. For intense exercise of lasts beyond 60 minutes.
shore duration, muscles mostly use phosphocrcatine (PCr) for en- 8. Plenty of carbohydrates should be in tl1c pre-evenr meal, cspcciall)
ergy. During more sustained intense activity, muscle glycogen tor endurance athletes. High-gl)•cemic-load carbohydrates should
breaks down to lactic acid, providing a small amoun t of ATP. For be consumed by an athlete within 2 hours after a workout to beg.in
endurance exercise, both fat and carbohyd rate arc used as li.1cls; resror.uion of muscle glycogen stores.
Study Q uestion s
I . How does grearcr physical fitness conrribute to greater m·erall 9. What advice would you give your neighbor, who is plJnning to
health? Explain the process. run a 5-kilomctcr (km) race, concerning tluid int.lke before .rnd
2. ATP storage in muscle is rapidly depicted once muscle contraction during the event?
begins. For physical activity to continue, ATP must be resupplied 10. One of your friends, a competitive athlete, asks your opinion
immediately. Describe how resupply occurs after initiation of ex- abour an ami no acid supplement sold in a local >porting-goods
ercise and at various times thereafter. store. She has read d1ar such supplements can help impro\·e arn-
3. What is the difference between anaerobic and aerobic exercise? lecic performance. What would )'OU tell her about the general cf
Explain wh)' aerobic mccabolism is increased by a regular cxcrc:ise feccivcncss of such products?
routine.
4. What is glycogen? How is it used during exercise?
5. Is fur from adipose tissue used as an energy source during exercise?
If so, whe n?
6. What are some rypic.li measures used to assess whether an athlete's BOOST YOUR STUDY
energy intake is adequate?
Check out the Perspectives in Nutrition: Online Learning
7 . List five specific nuLricnrs char athletes need and the appropriate
food sources from which d1ese nutrients c;m be obtained. Center -I ' 1/ . ' luwpu·s7 for quizzes, Rash
8. What conditio ns mig ht contribute co rhc inability ro get all re- cards, activities, and web links designed to further help you learn
quired nutrie nts from food, thus requiring use of a multivitamin about nutrition as it relates lo fi tness and sports.
and mineral supplement?
I. Almond CSD .md OLhcrs: H yponat rcm1:i ners i11 ro111pnriw11 t11 elite nthlctrs. A 11y JT!lid 171e 111/J/cte iv/Jo iv11111:s m 11pri111i::.· exe1·cist· pc1·-
.unong runners in the Bost0n MaraLhon. 171c rtplnccmwr 11ct·ds tlJ be crm:ji1/ly 111011ito1·ed to ji11wn11cc 11ceds to fa/111111good 1111rririo11 mu/ /J_v-
Nrw E11gln11d ]011rnnl of Medicine 352: 1550, n Poid ll'cig/Jr ,11n 111 d 11ri11g pro/011..11cd p/JyficnI drntio11 prncticcs, use mpplc111mts nllff t'llJ"._l]mir
2005. nctiviry. nids cm·cfi11/)', minimize m•crr ll'rl,_ 11/Jr-loJS prnc-
Low blood sodium (udmicn/~y en/led hypo11n- 2 . American Collcg<: ofSport:S llled1cinc and oth - trces, n11d cat n variety ofjimds 111 ndcq11nrt
rrm1ia) ii a pormrinl prob/rm if r111111ers dri11k ers: Num11011 and arhleric performJncc. a11101111rs. 171c vnru111s ruo111111mdntiom fo r cnr-
too 11111ch wnter d11rm._11 a prolonged rau. This Medicim· rmd ~cimu i11 Sports nnd liwrcisc bobydr11u, protei11,far, 11itn1111111, 11111m·nfs, n11d
pr11ble111 is cspuinll_v scc11 i11 poorly rmi11rd r11w 32:2 130, 2000. fluids i11 C/Japter 14 iverc 111km fr11111 rim m·tick.
www.mhhe.com/ wardlaw pe rs7 547
3. B3con SL .md ochers: Effi:ccs of exercise, diet, Reg11/11r p/Jysicnl aetii>ity cn11 m.bsta11tirrll_v re- 15. Sinclair Li\!, Hinton PS: Prt:\·.ilcncc of mm de-
and wcigh1 loss on high blood pressure. Spo,.ts d11cc the risk ~frfel'Clop111.11 l')'Pe 2 diabetes 111 ficiency wi1h and \\ichout .rncmia in rccrc.rnon-
Mcdicilir 34:307, 2004. high-risk i11di11id1111ls. Proplc who i11cre11sed rbeir allr active men and women. Jo11n111/ 1>f tbc
rrctivity fiw11 moderate tll 1i._q1w011.r 1111101111t.r 1·e-
1 American Dittetic Associ111i1111 I 05:975, 2005.
E1•e11 when people 1J1ith h_vpenewio11 jo//011• cur-
rent diet ruo111111wdntio11s fo1· thnr co11dirilm, ducc c/Jrir risk 1ifdt-vclop11i..n type 2 d111beus {J_Y Both malt 1111d ftmn/c atlJ/'1cs arc at risi• tlf ex·
nddi11g physical acti1•itJ prol'idcs a fi1nl!lr drop 65% cu111p111·rd to people ll'ho 1-e111ni11ed 11111ai1•c. lnbitmg poor 11'011stores1111d r1•m iro11 dtft·
i11 blood prumre. 11m·c is nlso cJ>idwa ji·om this El'm l')'ptrrrl /ow-i11tc11s1ty nctil'itics, mrh ns rimc_1 nmmin, n•irb fc11111/u brmg at muc/J
1
m1d.1• r/Jnt 1111111cro11s otbcr i111pmve111c11ts i11 cnr- wnlki11g, co11fr1-red s-imilm· bmcfits 111 this m11f_v. /Jigber 1·i.rk. 771r a11tbon rcrrm1111e11d t/J111 111/J/etcs
dioMswltir hen.Ith rcmlr 111hc11 bypcrtwsiJ>e peo- I 0. Luka~ki I IC: Vitamin .rnd minera l status: be screcw:d fl11· iron deficimcy rr 11emia and rrlso
ple follow a program of 1·rg11/nr p/Jysicnl acti1•ity. Effcctl> on physicJ.i performance. N1m·itio11 hm•c their wrrmr state 11f 1ro11 storage tcstfd
20:632, 2004. Poor iro11 .rtnflls rn11 lmd 111 poor n•orlt pcrji1r·
4 . Bl;ur SN, Church TS The fimess, obesity, and
/>/Jysicn/~11 nct11•c pcoplcgmrmll_v comu111c s11ffi- 111111icc mid tberrfore .1'1011/d bt al'oided.
health equation. jo11mnl of t/Jr A111rric1111
Medical Associntio11292:1232, 2004. cic11t 11ito111i11s rr11d 111i1umls ro mpporr such ac- 16. Thompson PD and ocher~: Exercise and phy~i ·
tivity. 11Jt" dcrrrest i11dicotio11far11St of 1•it11111i11 .:al actfrity in Lhc prevention .md trc.ument of
.\,£ost of tlu /Jca/t/J bmefits from pl~1-sicnl nctiJ>ity athcrosclerotic cardiovai.cul.ir disease. <u-rnl11-
nnrf mi11cml s11pple111wts by nthlues is to rrcar
come ll'ir/J 011~1· 30 11111111tcs at n modemu pact tio11 107:3109, 2003.
txisti11g 1111tritio11 defirimcirs or ro brir{qe ,11nps
performed at least 5 tin.vs per week. 17me rem/rs
m 1111tru11r 111tnkc vcrrns 11utrie11t needs. Use of 17Je A mericnn Hearr Ass11cinrio11 suppons rbc
are tmc for both lca11 1111d 01>crivci._11bt 111di1>id11-
l'itn111i11 1111d 111i11eml supplements docs 1111t im· rt·c11111r11e11dnti1111 frnm t/Je Cc11te1·; fin· /Jiscnsc
a/s. B1·islt 11'11lki11g, swi111111i11g, biC)•di11..11, oi·
provr mcnmrcs ofpc1·f11r111a11u in pcoplt co11- Conrro/ 1111d />rcvemio11 (CDC) a11d the
dn1Z1 nrm1ities mcb as.1111rdmi11g and house
mmillg 11drq11au diets. Americnn Co//r._qe of Sports Jletfici11r (A ( ·\.If)
work comribmc to mutmg tlJtS goal.
l l. blakc the most of your cxt:rcbc n11nutcs. that i11di1•1d1111/s s/Jo11/d e1i..11a.11e in 30 11111111u.< or
5 Coyle Ef-: Fluid and fud intake during exercise. Consumer Hcpurts 011 Hmlt/J, p. 1, November more of111odrrnte-i11tenrit.v physical actn•i1_1•
}01m111I 1>f Sports Seim cc 22:39, 2004. 2003. (such ns brisk J11nlki11g) 011 11111s1 (prtfcrnblv 111/)
Regular fluid n11d carbohydrate i11t11ke nre cm· Ke.Y co11sidcmtio11S ll'hw drsi..1111illg 1111 o:t1-cisc tin.vs of the nwk. S11c/J act1 vit_Y is bmcjinal 111
cinl to 11111111t11i11 perfon11anct d11ri11g prolonged progrn 111 n1·r to i11cl11dc nl1t:m11ti11g bo11ts of l''!J- bnr/J the prrl'mtion a11d rrmt111c11r of cnrd101•11s-
ph_mcn/ ner11•1ty. Jn t/Jc postrecover.v period, oro11s a11d cnsier cxtrcisr 111 .flll't mmdu n c11/nr disease.
j711id, cnr/10'1ydrate, 1111d prorciii mmltc duci·ve cha11cr ro 1·crm•c1-; 11!tcmrrti11..11 nmo11g exercises to 17. T ipton KD, Wolfe JUl: l'rmein and amino a.:idi.
tile most nttrntio11 i11 dier planning. 17JC m·ticle work dijfcrmt 111mc!cs; 1111d ft11di11g wrr.Ys ro for athlete~. }011r1111l of Sp11rrs Scic1w· 22:65,
pro1•1dcs tbc scientific support far mc/J nd1•ice. makr 011c 's whole dn.v 11111rc plrysicn/~y nctn•r. ·n,e 2004.
6. Glazc:r JL: t\lanagcmcnr of heat stroke and heat articlegors 011 ro prol'idc 11111r/Jgu1drmce 1111·- A 11>ell·ba/a11ud diet c1111 cnsi/.y meet rhr p1·11u111
exhau~uon. A111trua11 Fa111i~11 />bysici1111 ro1111di1w cxrrt:isc pr11toc11ls 11cedJ of nt/Jlctrs. 17JCrc ts 1111 11red t11 c1111S111111•
7l :2133, 2005. 12. Nicnrnn l)(' and mhcrs: Vitamin E .tnd immu - 11101·e t/Jn112~fJ11fprotei11 pc1· k..IJ 11f body ll'<"{lfht,
Hent cxl11111stio11 n11d brntm·okc are com111011 nity .ifler 1hc Kon.1 Triathlon World tl'ai fur strC1tfftb·traini11g nth/etcs. In fiur, 1111
and prcvmtnble co11ditio1u thnt nffut 11f1Jletes Championship. Mcdici11r 1111d St:imcc i11 ,\ports mrnkc of more r/J1111 1. -.!J of protem per k..11 11f
(a11d other 111divid11als mcb ns older nd11/ts). n11d Excmse 36:1328, 2004. bod_v ive(qht j11sr rem/rs i11 the cxtm prott'lll
Trentmmt of bent exhr111srio11 i11voh•cs putting Athletes i11 t/Ji..r stud_y iv/Jo wrrr p1-nl'idrd 800 IV being used tll meet mC'lJJ 11ad.r.
tbr jltTJOll inn cool, .rlmdy w1•iro11111e11T and e11- of11it1i111111 E per dayjiw 1wo 111011t/Js bcjo1·c their 18. \t\lhy everyone needs \ lre ngth Lr.ti ning, UC
mrill..n 11dcq11atc hydration. Trenti11..n /Jmtsrroke trintlJllJ11 er•wr .<holl'cd n gi·mtei- degra 11f whole Berkelc_v 1Vtll1ws Letter, p. 4, May 2004
is 11111clJ 1111,,.r complicnud, ns is 1mtli11cd ill the bod_v ox1d1111t dnmnge compnrtd to nt/Jleus 11'/Jo ~trwgt/J trn111iu11 is a11 m1ponn11t part 1Jj a11
arttrle. did 11ot co11m111c the mpplcmwt. 11JC n11r/Jors or•rrn// 11ct111r lifestyle. One rn tbrcc sets 11f N 111
7. Harber VJ: Energy balance and reproductive cn11ti1111 t/Jnt megndosc 11u 1if Pitn111i11 E Sllflf!le· IS 1·cpttitwm is mfficmll Ji,,. rr specific r.wffisc.
funcuon in active women. Cn1111di1111 }011mrr/ of mcnrs /~\' 111/Jlucs pm111ores lipid oxidnti1m rrud 19. William~ t-1H: N1m·iti1111 Ji1r hmlth,flturn. n11d
Applied l'bysiology 29:48. 2004. i11fln11111111ti1111 d11ri11g r.wrrise, n11d so s/Jo11/d ;port. 7ch ed. l\osron: t\lc(jr.1\\ -Htll, 2005
11ot bt• 1-uu11111u11dcd.
It 1s 1·crv 1111ponn11t for female ntiJlcrcs t•i..nn9cd ·n,;s uxtlJ11ok 1s c.-.;cc/lmt for r1>v1tll'iit111111rr1011
i11 1-i.._norn11s rrni11iiig pr11..111·1111is to mur their m- 13. Power.. ')Kam.I others: Dietary antioxidJnts and needs of atblurs n.1 IJ!ell ns lrrrmi11g more 11bo11t
"ll.l' 11uds. !f 11ot, t/Jc rc.wlti11g ne._qnth1r c11cr.gy exercise ]111w11nl o_(Spons ~cw1ces 22:81, 2004. tlJ10gc11ic aids; it 11/so prn1>idcs n danilcd !011k 111
bnlnucc will likely lend rv rr l'aricty of 111e11strunl ilftn· cnnjltl rericll' 11/tbt scimtifte litcmt11rc, 111et11bolis111 iu exercise.
c_yclc dis:wrb1wces t/Jnt rn11 cnmc ot/Jer hcnltlJ the 0111/Jon co11/d ft11d little rv1dt11cc for tlu cF 20. Zankcr CL, Cooke CB: l:.ncrgy baLm<"e, hone
problems. 171e article diswsscs this issue 111 derail ftctit'mrrs of11nrioxidn11t mpplcmmrs 111 prr- rnrnon:r, and skeletal heahh in physicalh Jcm·e
a11d pr111•idrs rrtntmmr stmtcgiu for problems rc111i11g rxc1·C1sc-rclarcd 11111srle dnmngc. individual~. Medicine a11d Sriwcc i11 Sp11rts rrnd
tbrr r 11111_-v dcvdop. 17m·cfo1'1:, t/Jry find t/Jnt a11tiuxid1111t supp!t-- faercisc 36: I 372, 2004.
8. Hunter GR: Physic.ii activity, timcss, and 111c11ts c111111ot be 1·cco111111cndL'd at t/Jis ti111t for
A pl~'Sicnl(1· 11ct1ve liftnyle co11trib11tcs t1111111i11·
health. In Shils ME and others (eds): Modem nrhlcus.
twn11u of bone benlt/J; /Joll't1•t1; skdctnl prob-
1111tntio11 i11 /Jrnlt/J 1111d discnsc. 101h ed. 14 Ross R .ind others: Exew,c-induced reduction lems cnn 1·es11/t i11 1111dtr111q11/Jr 11•011101 11•1!11 1111
Ph1l.idclphia, PA: Lipp111corL Willrnms & in obe~11y .111d insulin rcsi\tance in W<>mcn: A lo119cr bnl'r 111m.rrr11nl periods. 17JC nurluws mus
Wilkin~, 2006. randomized control tri:il. Obesity Rcscnrc/J the i111pona11cr for womm t11 meet ent"l~lf.l' 11crrts
This chnpttr pro1•idcs n sy11t/Jesis of r/Jc p/Jysiolog_v 12:789, 2004. dm·ing c.wrris.- i11 order 111111•111d tins pr11ble111.
1111d rtlnttd hen Ith nd1•1111rnge1 of rtgulnr p/J_vsi- Folioll'mg n rtgular c.>.:Lrrise progrrrm for J.l weeks 17Jcrc is cl'm su111c cvidmu t/Jnr tile snmr pr11b-
cnl nct11•1ty. rrs11/rcd i11 n rrd11rrio11 111 111t11/ and abdo111i11nl lc111 c1111 /Jappen i11 111c11 11'/Jn do 11or mut CllC'lf_Y
9. La3kl.oncn DE and others: Physical activiry in obesity i11 tbis study. Add111..11 cnloric rcstncrio11 to 11ci:ds, b111 ir is 11ot specijlrrr!Zy li11ked ton .<tx
the prevention of rype 2 diabetes: The Finn ish r/Jc cxerti.rc Jlrl1£T'"fllll ll'llS ns.rocinted 111ir/J Cl'Clt /Jom11111e deficimc.v, as it is i11 1110111&11. 'nms, t/Jc
Di3betcs Pre,'cnricm Srudy. Diabaes 54:158, more s11bsraminl dccrms.: in those pnrnmtTLn ns kq fncror i11 tl1c rfist111"ba11ee ofsfrkml /Jen/th is
2005 ll'CI/ /IS 11 dtCl'CllSC 111 lllJll/111 rtSISTllllCC. a dietnr_Y Wtr.!J.'' deficit.
Take I Action
I. Meeting the Protein Needs of an Athlete-A Case Study

Mork is a college student who hos been liking weights at the student recreation center. The trainer at the center recommended a pro-
tein drink to help Mork build muscle moss. Answer the questions below about Mark's current food intake and determine whether a pro-
tein drink is needed lo supplement Mark's diet.
The following is a lolly of yesterday's intake. Use Appendix N or NutrilionColc Plus software to calculate Mark's protein intake.
Breakfast Frosted Mini-Wheats cereal, 2 oz

l % milk, 11 /2 cups
Orange juice, chilled, 6 oz
Glazed yeast doughnut, 1
Brewed coffee, 1 cup
Lunch Double hamburger with condiments, 1
French fries, 30
Colo, 12 oz
Medium apple, 1
Dinner frozen lasagna w/meat, 2 pieces
1% milk, 1 cup
Looseleaf lettuce, chopped, 1 cup
Creamy Italian salad dressing, 2 tsp
Medium tomato, 1/2
Whole carrot, row, 1
Evening snack Vanilla ice milk, 1 cup
Hot fudge chocolate topping, 2 tsp
Sofi chocolate chip cookies, 2
1. Mark's weight hos been stable at 70 kg (154 lb). Determine his protein needs based on the RDA (0.8 g/kg).
a. Mark's estimated protein R D A : - - - - - - - - - - - - - - - - - - - - -- - -- - - - - - -

b. What ore the maximum recommendations for protein intake for athletes (see p. 534)? - -- - - - - -- - - - -
c. Calculate the maximum protein recommendation for Mork.--- - - - -- - - - -- - - - -- - - - -
2. An analysis of the total energy and protein content of Mark's current diet is 3470 kcal, 125 g of protein (14% of total energy in-
take supplied by protein) . This diet is representative of the food choices and amounts of food that Mork chooses on a regular
basis.
a. What is the difference between Mark's estimated protein needs as on athlete (from question 1) and the amount of protein that
~scurre~d~t~o~de~---------------------------------
b. Is his current protein intake inadequate, adequate, or excessive? - - - - - - - - - - - - - - - - - - - -
3. Mark tokes his trainer's advice and goes to the supermarket to purchase a protein drink to odd to his diet. Four products ore
available; they contain the following label information.
Joe Weider's Joe Weider's Victory

Sugar-free Dynamic Super Mega
Amino Fuel 90% Plus Protein Muscle Builder Mass 2000
Serving size 3 tbsp 3 tbsp 3 tbsp 1/4 scoop
Kcal 104 110 103 l04
Protein (g) 15 24 10 5
Take I Action
The trainer recommends that Mork odd the supplement to his diet two times a day. Mork chooses Joe Weider's Dynamic Muscle
Builder.
a. How much protein would be added to Mark's diet doily from two servings of the supplement alone (pri or to mixing ii with a
beverage)?
b. Mork mixes the powder with the milk he already consumes at breokfosl and dinner. How much protein total would Mork now
consume in 1 day? (Add the protein amount from the nutrilio11 analysis lo the value from question 3o.)
c. What is the difference between Mark's estimated protein needs as on athlete and this total value?
4. What is your conclusion-does Mork need the protein supplement?
Answers to Calculations
1a. Mark's estimated protein RDA: 70 kg X 0.8 g/kg = 56 g.
I b. Maximum recommendation for protein intake for athletes = 1.7 g/kg.
I c. Applied to Mork: 1.7 X 70 = 119 g.
2a. Difference between Mark's diet and the maximum amount recf mmended for athletes; 125 11 9 = 6 g.
2b. Mark's current diet is adequate.
3o. Two servings of protein supplement alone = 20 g of protein.
3b. Mark's total protein consumption: 125 g + 20 g = 145 g protein.
3c. Difference between Mark's estimated maximum protein needs as on athlete and total value (from 3b): 145 g - 119 g = 26 g
of protein.
550 Chapter 14 Nutrition: fitness and Sports
'
Take I Action l
II. How Physically Fit Are You?

The fitness assessments presented here are easy to do and require little equipment. Also included ore charts to compare your results to
those typical of your peers.
Cardiovascular Fitness: One-Mile Walk

Measure a mile on a running track (usually four lops) or on o little-trafficked neighborhood street (use o car's odometer to get the right
distance). With a stopwatch or watch with o second hand, walk the mile as fast as you con. Note the time it took.
Strength: Push-ups
Men: Get up on your toes and hands. Keep your bock straight, with hands flat on the floor directly below your shoulders.
Women: Some position, but you con support your body on your knees if necessary.
Lower your body, bending your elbows, until your chin grazes the floor. Push bock up until your arms ore straight. Continue until
you can't do any more push·ups (you con rest when in the up position).
Strength: Curl-ups
Lie on the floor on your bock with your knees bent, feel flat. Your hands should rest on your thighs. Now squeeze your stomach mus·
cles, push your bock flat, and raise your upper body high enough for your hands to touch the lops of your knees. Don't pull with your
neck or head, and keep your lower bock on the floor. Count how many curl-ups you con do in one minute.
Flexibility: Sit-and-Reach
Ploce o yardstick on the floor and apply a two-foot piece of lope on the floor perpendicular to the yardstick, crossing at the 15-inch
mark. Sit on the floor with your legs extended and the soles of your feel touching the lope al the 15-inch mark, the zero-inch focmg
you. Your feel should be about 12 inches oporl. Put one hand on the other, exhale, and very slowly reach forward as far as you con
along the yardstick, lowering your head between your arms. Don't bounce! Note the farthest inch mark you reach. Don't hurt yourself
by reaching farther than your body wonts to. Relax, and then repeal two more times.
Now check your results. Wont to improve? You know the answer:
• Do aerobic exercise that makes you breathe hard for at least half on hour on almost or all days of the week.
• LiA weights that challenge you two lo three times per week.
• Stretch ofter activity at least a couple of times per week.
• Wolk more.
Cardiovascular: One-mile walk (time, in minutes)

Under 40 Over40
Men Women Men Women

Excellent 13:00 or less 13 :30 or less 14:00 or less 14:30 or less
Good 13:01-15:30 13:31-16:00 14:01-16:30 14:31 - 17:00
Average 15:31-18:00 16:01-18:30 16:31-19:00 17:01 - 19:30
Below overage 18:01-19:30 18:31-20:00 19:01-21:30 19:31 - 22:00
Poor 19:31 or more 20:0 l or more 21 :31 or more 22:0 l or more
Take I Action ,
Strength: Push-ups (number completed without rest)

Men
Age 17-19 20-29 30-39 40-49 50-59 60-05
Excellent >56 >47 >41 >34 >31 >30
Good 47-56 39-47 34-41 28-34 25-31 24-30
Above overage 35-46 30-39 25-33 21 - 28 18-24 17-23
Average 19-34 17-29 13-24 11-20 9-17 6-!6
Below overage 11- 18 10-16 8-12 6-10 5-8 3-5
Poor 4-10 4-9 2-7 1-5 1-4 1-2
Very poor <4 <4 <2 0 0 0
Women
Age 17-19 20-29 30-39 40-49 50-59 60-65
Excellent >35 >36 >37 >31 >25 >23
Good 27-35 30-36 30-37 25-31 21-25 19-23
Above overage 21-27 23-29 22-30 18-24 15-20 13-1 8
Average 11-20 12-22 10-21 8- 17 7-14 5-12
Below overage 6-10 7-1 1 5-9 4-7 3-6 2-4
Poor 2-5 2-6 1-4 1- 3 1-2 1
Very poor 0-1 0-1 0 0 0 0
Source: topendsports.com
Strength: Curl-ups (number completed in 60 seconds)
Men
Age 18-25 26-35 36-45 46-55 56-65 65 ~
Excellent >49 >45 >41 >35 >31 >28

Good 44-49 40-45 35-41 29-35 25-3 1 22-28
Above overage 39-43 35-39 30-34 25-28 21-24 19-21
Average 35-38 31-34 27-29 22-24 17-20 15-18
Below overage 31-34 29-30 23-26 18-21 13-16 11- 14
Poor 25-30 22-28 17-22 13-17 9-12 7-10
Very poor <25 <22 < 17 <9 <9 <7
.,
•Ill •
- I . ..
Take I Action
Strength: C url-ups (number completed in 60 seconds) (can't)

Women
Age 18-25 26-35 36-45 46-55 56-65 65

Excellent >43 >39 > 33 >27 >24 > 23
Good 37-43 33-39 27-33 22-27 18-24 17-23
Above overage 33-36 29-32 23-26 18-21 13-17 14-16
Average 29-32 25-28 19-22 14-17 10-12 11-13
Below overage 25-28 21-24 15-18 10-13 7- 9 5-10
Poor 18-24 13-20 7-14 5-9 3-6 2-4
Very poor < 18 <20 <7 <5 <3 <2
Source: 1opendsporls.com
Flexibility: Sit-and-reach (in inches)
Men Women
Super > +27 > +30
Excellent +17-+27 +21-+30
Good +6-+ 16 + 11-+20
Average 0-+5 + l-+10
Fair -8-- 1 - 7-0
Poor - 19-- 9 -14-- 8
Very poor < -20 < - 15
Source: topendsports.com
These charts ore typical charts used by health and fitness experts. For a more thorough assessment of fitness or for development of on
exercise pion appropriate for your fitness level, consult a certified personal trainer or other fitness professional.
EATING DISORDERS: ANOREXIA
NERVOSA, BULIMIA NERVOSA,
BINGE-EATING DISORDER, AND
OfHE ONOITI

From Ordered to Disordered Eating Habits At age 16, Sarah suddenly became selkonscious about her body when her friends
Food: More Thon Just a Source of Nutrients •
OveNiew of Anorexia NeNosa and Bulimia teased her about being overweight. She began exercising to on aerobics video for
NeNosa • Is There a Genetic Connection lo an hour each day and found that she hod success in losing weight; this was just the
Eating Disorders? m
Nutrition Focus: The Personal Side of Eating
beginning of her obsession to be thin. Next, Sarah turned to eating less food to lose z
m
Disorders even more weight and began eliminating certain foods from her diet, such os candy
Anorexia Nervoso and meat. She increased her water and vegetable intake and chewed sugarless
'°
G)
~
Profile of the Typical Person with Anorexia
gum to curb her appetite. Once she began dieting, stopping was impossible. She OJ
NeNosa • Early Warning Signs • Physical )>
Effects of Anorexia NeNosa • Treatment of
Anorexia NeNosa
really enjoyed having a high degree of self-control over her body. She was literally
s;:
obsessed with food and stored at others while they were eating a meal. She occa· z
sionolly cooked large meals and then refused to eat all but a few bites. By the time n
m
Bulimia Nervoso
Typical Behavior in Bulimia NeNosa • Health Sarah was 19 years old and 5 feel 6 inches tall, her weight had dropped from )>
Problems Stemming from Bulimia NeNosa • 150 lb to 85 lb in 20 months. Her family was concerned about her weight status,
z
Treatment of Bulimia NeNosa CJ
and demanded that she go to a physician for an evaluation. Sarah was not happy
Eating Disorders Not Otherwise Specified ~
(EDNOS) about this idea but believed that her family would stop pestering her if she just went. OJ
)>
Binge-Eating Disorder • Other Examples of
Disordered Eating
Sarah did not think she hod a problem; she truly thought she was still grotesquely s;:
Expert Opinion: The Female Athlete Triad overweight. She did notice, however, that she was intolerant of cold temperatures zn
Prevention of Eating Disorders and was concerned that she hod not menstruated in a year. m
Organizations to Help You Understand More Does Sarah meet the qualifications to be diagnosed with on eating disorder? What
about Eating Disorders
types of therapy do you ihink the physician will suggest for Sarah? Where could she go
Take Action
for such therapy? What 1s the likelihood that she will fully recover from her condition?
553
A !though obesity is the most common eating disorder in our society, the eating disorders explored
in this chapter involve much more severe distortions of the eating process. The eating disorders
discussed here ore just os serious ond con develop into life-
threotening conditions if left untreoted.20 What's most alarming
obout these disorders-such os onorexio nervoso, bulimia ner- CHAPTER OBJECTIVES CHAPTER 15 IS DESIGNED
TO ALLOW YOU TO:
voso, and binge-eating disorder-is the increasing number of
coses reported each year. 2 1. Contrast health attitudes toward uses of food with behavior
patterns that could lead to unhealthy uses of food.
Some people ore more susceptible to these disorders than
2. Outline the causes of, effects of, typical persons affected by,
others-for genetic, psychological, and physical reasons. and treatment for anorexia nervoso.
Successful treatment of eating disorders, therefore, is complex 3. Outline the causes of, effects of, typical persons affected by,
and must go beyond nutritional theropy.5 And keep in mind also and treatment for bulimia nervoso.
tha t eating disorders ore not restricted to any socioeconomic 4. Outline the causes of, effects of, typical persons affected by,
and treatment for binge-eating disorder.
class or ethnicity. They con occur ot any oge in both females and
moles. This chapter examines the causes and treatments of eat-
5. Relate the presence of eating disorders to current social trends.
6. Describe methods to reduce the development of eating
ing disorders in detail, because they touch many of our lives.
disorders, including the use of warning signs to identify early
coses.

OF EATING DISORDERS, SUCH AS ANOREXIA NER-
VOSA AND BULIMIA NERVOSA, IN CHAPTER 15, YOU MAY WANT TO REVIEW:
The role of genetic risk in diseose susceptibility in Chapter 1
The effects and treatment al osteoporosis in Chapter 11
The effects and treatment of iron deficiency anemia in Chapter 12.
The distinction between hunger and appetite in Chapter 13
Calculation of BMt in Chapter 13.
The effects of neurotransmitters on food intake in Chapter 13
orly in life, we develop images of #accept·

able- ond "unacceptable# body types. Of
From Ordered to Disordered Eating Habits
all the attributes that constitute attracfiveness,
Eating- a completely instinctive behavio r for animaJs-~erves an extrao rdin:iry num-
many people view body weight as the most im·
ber of psycho logical, social , and cultural purposes fo r humans. Eating pracrices may
portent, por~y because we can control our
take on religious meanings; signify bonds within famil ies and edmic groups; and be a
weight somewhat. Fatness is the most dreaded
means to express hostility, affection, prestige, or class values. Within t he fam ily, pro-
deviation from our cultural ideals of body
\'iding, preparing, and distriburing food may be :i means of expressing love, control, or
image, the one most derided and shunned, even
even power.1
among schoolchildren.
We are bombarded daily with images of society's "ideal" body. Television programs,
billboard advertisemenrs, magazint: pictures, movies, an<l newspapers imply thJt an ul-
traslim body will bring happiness, love, and ultimately, success. This fantasy notion is
especiaJly i1·onic given the fact that much of society is becoming fatter. In response,
some of us take an extreme approach- the patho logical pursuit of wcig hc control or
weight loss.
Given the multiple relationships between normal eating and the media's bombard-
ment of the ideal body image, it is n<>t surprising that some people progress from nor-
mal eating patterns, to obsessive weight loss behaviors, and then to a full -blown e:iting
disorder.5
554
www.mhhe.com/ wardlawpers7 SSS
Food: More Than Just a Source of Nutrients rogression from Ordered to

Disordered Eating
From birth, we link food with personal and emotional experiences. As infants, we as- Attention to hunger and satiety signals; limitation
sociate milk with security and warmth so the breast or bottle becomes a source of com- of energy intake lo restore weight to a healthful
fort as wel l as food. As noted in Chapter 1, most people conrinue to derive comfort level
and great pleasure from food. This comfort is both a biologica l and a psychological .J,
phenomenon. Food can be a symbol of comfort, but eating can also stimulate the re- Some disordered eating habits begin as weight
lease of certain neurotransmitters (e.g., serotonin ) and natural opioid~ (including en- loss is attempted, such as very restricted eating
dorphins), which produce a sense of calm and euphoria in the human body. Thus, in J,
times of great stress some people nirn to food for a druglike, calming et1ect. Clinically evident eating disorder recognized
Food is also used as a reward or a bribe. Haven't you heard or i.poken somcthjng
similar ro the following comments?
You can have your dessert if you ear five more bites of your vegetables.
You can't play until you clean your plate.
I'll cat the broccoli if you let me watch TV.
lf you love me, you'll eat your dinner.
On the sw·fuce, using food as a reward or bribe seems harmless enough. EventuaUy,
however, this practice encourages both caregivers and children ro use food to achieve
goals other thm satis~'ing hunger and nutrient needs. Food mar then become much
more chan a source of nutriencs. Regularly using food as a bargaining chip can con-
tribute w ,1bnormal eating patterns. Carried to the extreme, rhese patterns can lead to
disordered eating.2 disordered eating Mild and short-term changes
Disordered eating can be defined as mild and short-term changes in eating patterns that in eating patterns that occur in relation to a
occm in response to a stressful evenc, an ill ness, or a desire to modify the diet for a variety stressful event, an illness, or a desire to modify
of health and personal appearance reasons. The problem may be no more Lhan a bad habit, one's diet for a variety of health and personal
a style of eating adapted from friends or f:"Unily members, or an aspccL or prepaiing for ath- appearance reasons.
leck competition. While rusordered eating can lead to weight loss or weight gain and to eating disorder Severe alterations in eating
certain nuttiLional problems, it rarely requires in-depth profession.11 attention. If, however, patterns linked to physiological changes. The
disordered caring becomes sustained, distressing, or stai·cs to imertcre with everyday ac- alterations are associated with food restricting,
tivities due to physiological changes, professional inten·ention ma) be necessary. 1 binge eating, purging, and Auctuotions in
weight. They also involve a number of
emotional and cognitive changes that affect the
Overview of Anorexia Nervosa and Bulimia Nervosa way a person perceives and experiences his or
her body.
Given the common practice of dieting in North America, it is not obvious when dis-
ordered eating stops and an eating disorder begins. Indeed, many eating disorders anorexia nervosa An eating disorder involving
a psychological loss or denial of appetite
start wiLh a simple diet. Eating disorders then go on to involve physiological changes
followed by self-starvation; related in port to a
associated with food restricting, binge eating, purging, and fluctuations in weight.
distorted body image and to various social
They also invoh·e a number of emotional and cognitive changes that affect the way a pressures commonly associated with puberty.
person perceives and experiences his or her body, such as feelings of distress or c:...'trcmc
concern about body shape or weighr. 20 Eating disorders arc noc due co a failure of will bulimia nervoso An eating disorder in which
or behavior; rather, they are real, treacable medical illnesses in "hich certain maladap- large quantities of food are eaten al one time
ti,·e patterns of eating cake on a lite of their own. 18 (binge eating) and then purged from the body
by vomiting or by misuse of laxatives, diuretics,
The main types of eating disorders are anorexia nervosa and bulimia nervosa. A
or enemas. Alternate means to counteract the
third type, binge-eating w sorder, has been recognized by the psychiatric community
excess energy intake are fasting and excessive
since 1994. Currently, scientists arc researching whether binge-caring disorder should exercise.
be included as a diagnosable disease alongside anorexia ncrvosa and bulimia ncrvosa. 3
l\1orc than 5 million people in North America have one of these disorders; females out- binge-eating disorder An eating disorder
number males 5 to 1. Eating disorders de\'elop 85% of t11e rime during adolescence or characterized by recurrent binge eating and
early adulthood, but some reporcs indicate that their onset can occur during childhood feelings of loss of control over eating that have
lasted at least 6 months. Binge episodes can be
or later in adulthood. Eating disorders frequently co-occur with other psychological
triggered by frustration, onger, depression,
djsordcrs such as depression, subscance .1buse, and anriery disorders. 20 People who suF
anxiety, permission to eat forbidden foods, and
je1· from en ting disorders, especially nnorexin. nerPosa mu( b11li111in 11erJ1osn, ca 11 experi- excessive hunger.
mce n wide range ofphysical benltb complications, including m·io11s /Jenn conditions and
kidney failure, which may CllCIJ lend to dcat/J. Recognition or eating disorders as impor-
canr and treatable ruseases, therefore, is critical. 5
556 Chapter 15 Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, Binge-Ealing Disorder, and Other Conditions
C urrently, up to 5% of women in Nortl1 America develop some form of anorexia

nervosa o r bulimia nervosa in the ir lifetimes. 3 This section provides a brief description
of the characteristics and diagnoses of these 1wo disorders. Detailed discussion of these
and related disorders, including treatment, then foUows.
Anorexia nenos:i is characterized by extreme weight loss, a distorted bod~ image,
and an irrational, almost morbid, fear of obesity and weight gain. Anorexic patients ir-
rationally believe they are fat, even though otl1ers constantly comment on their thin
physique. Some anorexics realize they are thin but continue co be haunted by certain
areas of their bodies tl1at they believe to be fat (such as thighs, buttocks, a nd stomach ).
The discrepancy between actual and perceived body shape is an important gauge of the
severity of the disease.
Common Lo born eating disorders, the term 11erJ>osa refers to disgu<>t \\ith one\
body. The term nnorcxia implies a loss of appetite; however, a denial of appetite more
accurately describes the behavior of people with anorexia nervosa. Estim.lting tl1c
prevalence or eating disorders is difTicult because or underrepo rting, but approximate!)
1 in 200 (0.5%) 20 adolescent girls in North Am erica evenLuaUy develo ps anorexia ncr-
\'OSa. This relatively high number may be due to girls' tendency to blame themseh cs
for weight gain associated with puben:y. It happens less commonly .1mong adult
women and African-American women. Men account for approximately 10% of cases of
anorexia ncrvOS<l, partly because the ideal image con\'eycd for men is big and muscu-
lar. Among men, :uhletes are most prone to develop anorexia nervosa, especially those
who participate in sports thar req uire weight classes, such as boxers, \\'restlcrs, and
The media and the fashion world bombard us jockeys. Other activities that may fos ter eating disorders in me n include swimming,
with body images thot are unrealistic for most dancing, and modeling.3
people. Bulimia nen os.1 (bulimia means "grear [ox] hunger") is characteri:ted b~ episodes
of binge eating followed by attempts to purge me excess energy taken up b) 1he bod)
by vomiting or misuse of laxati\'es, diuretics, or enemas. Some people use exccssi\'C
exercise (hypergymnasia) to try to burn off a binge's hig h energy intake. People; with
bulimia nervosa may be di[flcult ro identify because they keep their binge p~irgc be-
hypergymnosio Exercising more than is havio rs seer-cl, <llld their symptoms arc not obvious. Up to 4% of adolescent and
required for good physical fitness or maximal college-age women suffer from bulimia nervosa. Abom 10% of the cases occur in
performance in a sport; excessive exercise. men. 3
The Din~11nostic am/ Statistical Mn1111t1L of Mcutnl Disorders lists specific c1ircria for di-
agnosing eating disorders (Table 15- 1). People may exhibit some symptoms of Jn caring
disorder but not enough to enable a medical worker to diagnose the diseal>c. Th..:se peo-
ple may full under the category E::1 ting Disorders Not Otl1erwise Specified (ED NOS).
One of tl1e calegorics falling under EDNOS is binge-eating disorder (Table 15-2). 3
Note that Table 15-1 shows two subcategories for .morexia nervosa: restricting type
and binge-eating/purging type. Up to 60% of individuals diagnosed with anorexia ner-
\ 'OSa develop a binge and purge pattern. Despite this, their diagnosis is ~till anorexia
nervosa. Bulimia nervosa is a separate condition with distinct criteria.
Over one-third of individuals initially diagnosed with anorexia nervosa m:ty cros!>
over to bulimia nervosa, although the o pposite crossover from bulimia nervosa to
anorexia nervosa is much less likely. Typically, the crossover between eating disorders
occurs within the first five )'Cars of the iUness. Anorexic persons who percei\'e their par-
ents as being highly critical arc most likely to cross over to bulimia nervosa. In con-
ur passion for thinness moy hove its roots trast, bulimic imfoiduals who struggle \\'ith alcohol abuse are most likely to cross m ·er
in the Victorian era of the nineteenth cen- to anorexia nen·osa.
tury, which specialized in denying "unpleasant" Until recently, most researchers have reported mat eating disorders primarily affect
physical realities, such as appetite and sexual middle- and upper-class white women. Now, stud ies show greater similarities in tl1e
desire. Flappers of the 1920s cemented the rates of body dissatisfaction and disordered eating behaviors across ethnic and culmral
twentieth century trend for thinness. Since 1922, groups. Perhaps minorities with eating disorders have been less likely to ~eek help in
the BMI values of Miss America winners hos the past because of shame, stigma, lack of resources, or language barriers. Also, healm-
steadily decreased; during the lost three care workers arc less likely co diagnose nonwhites \\ith eating disorder!>. Alrhough
decodes, most winners hod a BMI in the under- some nonwhite cultures may be more accepting of larger body shapes, mainstream
weight range (less than 18.5). pressures for thinness influence o ur society as a whole.
Table 15·1 I Diagnostic Criteria for Anorexia Nervosa and Bulimia Nervosa
Anorexia Nervosa
A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight
less than 85% of that expected; or failure to make expected weight gain during periods of growth, leading lo body weight less than 85% of that
expected)
B. Intense fear of gaining weight or becoming fat, even though underweight
C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of
the seriousness of the current low body weight
D. In postmenarcheal females, amenorrheo-i.e., the absence of at least three consecutive menstrual cycles IA woman is considered to have
amenorrhea if her periods occur only following hormone [e.g., estrogen) administration.)
Specify Type
Restricting type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (such as self-
induced vomiting and the misuse of laxatives, diuretics, or enemas).
Binge-eating/purging type: During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior !such
as self-induced vomiting and the misuse of laxatives, diuretics, or enemas).
Bulimia Nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by bath of the following:
1. Eating, in a discrete period of time (e.g., within ony 2-hour period), on amount of food that is definitely larger than most people would eat during a
similar period of lime and under similar circumstances
2. A sense of lack of control over eating during the episode !e.g., a feeling that one cannot stop eating or control what or how much one is eating)
B. Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other
medications; fasting; or excessive exercise
C. The binge eating and inappropriate compensatory behaviors both occur, on average, al least twice a week for 3 months.
D. Self-evaluation is unduly influenced by both body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Specify Type
Purging type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives,
diuretics, or enemas.
Nonpurging type: During the curren t episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or
excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
Eating Disorder Not Otherwise Specified (EONOS)

This category is for disorders of eating that do not meet criteria for any specific eating disorder-for example:
1. For females, all of the criteria for anorexia nervosa ore met except that the individual has regular menses.
2. All of the criteria for anorexia nervosa are met except that, despite significant weight loss, the individual's current weight is in the normal range.
3. All of the criteria for bulimia nervosa ore met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less
than twice a week or for a duration of less than 3 months.
4. The regular use of inappropriate compensatory behavior by an individual of normal body weight ofter eating small amounts of food
5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food
6. Binge-eating disorder (BED): Recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors
characteristic of bulimia nervoso
Reprinred with permission from rhe Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition !Text Revision! (DSMN·TR™l . Copyright 2000 American Psychiatric Association.
This toble will help you understand the characteristics of anorexia nervoso, bulimia nervosa, and binge-tialing disorder. [Tobie 15·2 on page 55B provides more details on bing&<loling disorder.I
However, please do nol attempt lo diagnose these disorders yourself. Instead, use this information lo determine whether professional help is needed. Note also that for both anorexia nervoso and bu·
limio nervoso, all chorocteristics (A-D or A-E, respectivetyl must be present lo make the diagnosis.
Table 15-3 lists some characteristics of people with anorexia nervosa and bulimia
nervosa. Do you know someone who is at tisk for these eati ng djsorders? If so, suggest
that the person seek a professional evaluation because the sooner treatment begins, the
better the chances a.re for recovery. 19 However, do not try ro diagnose eating disor-
ders in your friends or family members. Only a professional can exclude other possible
diseases and correctly evaluate the diagnostic criteria required to make a d iagnosis of
anorexia nervosa or bulimia nervosa. Once an eating disorder is diagnosed, immediate
treatment is advisable. As a friend, the best you can do is ro encourage an affected
558 Chapter 15 Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder, ond Other Conditions
Table 1 5·2 I Research Criteria for Binge-Eating Disorder

A. Recurrent episodes of binge eating, an episode being characterized by both of the following
1. Eating, in a discrete period of time [e.g., wi thin any 2-hour period), on amount of food that
is definitely larger than most people would eat during a similar period of time in similar
circumstances
2. A sense of lack of control during the episodes [e.g., a feeling that one can' t stop eating or
control what or how much one is eating)
B. During most binge episodes, at least three of the following occur:
l . Eating much more rapidly than usual
2. Eating until feeling uncomfortably full
3. Eating large amounts of food when not feeling physically hungry
4. Eating alone because of being embarrassed by how much one is eating
Self-image is an important part of adolescence. 5. Feeling disgusted with oneself, depressed, or very guilty after overeating
For people with eating disorders, the difference
C. Marked distress regarding binge eating
D. The binge eating occurs, on overage, ot least 2 days o week for 6 months.
between the real and desired body images may
be too difficult to accept. See the website E. The behavior does not occur only during the course of bulimia nervosa or anorexia nervoso.
www.4women .gov/bodyimage/i ndex.htm. Reprinted by permission from the Diognoslic ond Stotisticol Manuol of Mento/ Disorders, Fourth Edition (Text Revision} (DSM-IV-TRI
Americon Psychiatric Association, Woshington DC, 2000.
Table 15·3 I Typical Characteristics of Anorexic and Bulimic Persons
Anorexia Nervoso Bulimia Nervosa

• Rigid dieting causing dramatic weight loss, • Secretive binge eating; generally not
generally to less than 85% of what would overeating in front of others
be expected for one's age (or BMI of 17.5 • Eating when depressed or under stress
or less) • Bingeing on a large amount of food,
• Folse body perception-thinking "I'm too fat," followed by fasting, laxative or diuretic
even when extremely underweight; relentless abuse, self-induced vomiting, or excessive
pursuit of control exercise [at least twice o week for
• Rituals involving food, excessive exercise, 3 months)
and other aspects of life • Shame, embarrassment, deceit, and
• Maintenance of rigid control in lifestyle; depression; low self-esteem and guilt
security found in control and order {especially after o binge)
• Feeling of panic ofter o small weight gain; • Fluctua ting weight (:!: I 0 lb or 5 kg)
intense fear of gaining weight resulting from alternate bingeing and
• Feelings of purity, power, and superiority fasting
through maintenance of strict discipline and • Loss of control; fear of not being able to
self-denial stop eating
• Preoccupation with food, its preparation, and • Perfectionism, "people pleaser"; food os
observing another person eat the only comfort/escape in an otherwise
• Helplessness in the presence of food carefully controlled and regulated life
• Lock of menstrual periods ofter what should • Erosion of teeth, swollen glands
be the age of puberty for ot least 3 months • Purchase of syrup of ipecac, a compound
• Possible presence of bingeing and purging sold in pharmacies that induces vomiting
practices
People who exhibit only one or o few of these characteristics moy be al risk but probobly do nol have either disorder. They should,
however, reffeci on their eoting habits and reloted concerns and take appropriate action such os seeking a coreful evofuotian by a
physicion.
person to seek professional help. Note that such help is commonly available at student
health centers and student guidance/counseling facilities on college campuses.
T here are no si mple causes of eating disorders, and there arc no simple treatments.
Stress may have an especiall}' strong role in the development of eating disorders. Drug
Eating disorders are commonly seen in people abuse also is a factor to consider.6 An underlying commonality seems to be the lack of
who must maintain low body weight, such as appropriate coping mechanisms as individuals approach adolescence and young adult-
ballet dancers. hood, coupled with dysfunctional family relationships.
Is There a Genetic Connection to Eating Disorders?

Both anorexia nervosa and bu limia nervosa tend to duster in families, suggesting that
these two eating disorders share common causes. A few research studies have investi-
gated the possible link between genetic factors and the development of eating d.isor-
ders. These studies have involved a comparison of identical twins with fraternal twins
and the incidence of eating disorders. In general, these snidics have shown that iden-
tical twins have a higher likelihood of developing shared eating disorders than do fra-
ternal twins. 20 This finding indicates that genetics may play a strong role in
development of such disorders, because identical twins share the same DNA. However,
these smdies have not ruled out the impact of the environmental influences in eating
disorder development. Identifying genes that cause eating disorders could eventually
help in tailoring prevention efforts to those at risk, but affected individuals would still
need the same counseling that is pan of therapy today.
I Anorexia Nervosa
Anorexia nervosa evolves from a dangerous mental state to an often life-threatening disturbing trend is the attempt to promote
physical condition. People suffering from this disorder think they are fat and intensely eating disorders as a way of life. Some
fear obesity and weight gain. They lose much more weight than is healthful. Although anorexic individuals hove personified their ill·
food is entwined in this disease, it stems more from psychological conflict. ness into o role model named "Ano" who tells
Depression is commonly fow1d in conjunction vvith an eating disorder. ln fact, a them what to eat and mocks them when they
sn1dy done in the 1940s at the University of Minnesota found that depression and ob- don't lose weight. Ano websites reject the seri-
sessional behaviors developed in the subjects dming a 6-month period of restricted en- ous health risks of anorexic behaviors and in-
ergy intake. These abnormal behaviors did not reverse immediately after refeeding but, stead dispense unsafe "thinspiration" to
rather, took many weeks to return to normal (see Chapter 20 for details). vulnerable individuals.
About 3 to 10% of people with anorexia evennially die from the disease-from sui-
cide, heart ailments, and infections. 15 ,20 Anorexia nervosa can worsen d1e effects of di-
abetes on the body, especially if too Little insulin is injected as a means of increasing
glucose excretion in the urine. 1 8 About one quarter of people with anorexia nervosa
recover witl-tin 6 years, whereas the rest simply exist with the disease or go on to de-
velop another form of disordered eating or bulim.ia nervosa. The longer son1eone suf-
fers from this eating disorder, the poorer the chances arc for complete recovery.
Prompt and vigorous treatment with close follow-up improves the chances for success.
Anorexia nervosa may begin as a simple attempt to lose weight. A comment from a
well-meaning friend, relative, or coach suggesting that the person seems to be gaining
weight or is too fat may be all that is needed. The stress of having to maintain a cer-
tain weight to look attractive or competent on a job can also lead to disordered eating.
Physical ch;rnges associated with puberty, the stress of leaving childhood, or the loss of
a friend may serve as another trigger. Leaving home for boarding school or college or
starting a job can reinforce the desire to appear more "socially acceptable." Still, look-
ing "good" does not necessarily help people deal wit11 anger, depression, low self-
estet:m, or past experien~es with sexual abuse. If these issues are behind the disorder
and are not resolved as weight is lost, the individual may intensify efforts to lose weight
"ro look even better," rad1er than work through unresolved psychological concerns.
The resulting extreme d ieting represents a hallmark of anorexia nervosa.18
Adolescence is a period of turbulent sexual and social tensions. As teenagers seek to
establish separate and independent Lives, they often react intensely to how they d1ink
others perceive them. At the same time, their bod ies are changing, and much of t11e
change is beyond their control. In response to an adolescent's Jack of control in life or
poor coping mechanisms, dieting may start and t11en lead to a failure to gain appro-
priate weight-for-height. This situation may not be readily identified as a problem be-
cause the chi.Id has not actually lost any weight. Srunting (fuilure to grow in height) Concern over self-image begins early in life; o
may also occur with a severe decrease in energy intake during a period of growth. 1f focus on good health with regard to body
anorexia develops before puberty, sexual maturation and menstruation may be delayed. weight should olso begin at this lime.
The Personal Side of Eating Disorders
Thoughts of an Anorexic Also at this time, I started running, an<l m}

friend Laura became my running partner. She \\.15
Woman getting in shape for the next season of field hocke\'.
After school, we met in the locker room, changed
It was the spring of my freshman year or high out of our school clothes, and our we went. I had
school, and I had just turned 15. T wanted to get a never been much of an athlete-I thought that
leading role in the upcoming high school musical, being part of a team, whether in sports or academ-
West Side Sto~y. I thought l should lose some ics, diluted the exceUence I could achieve on my
weight to look more attractive to the student di- own. Running, however, could just be me and the
rector Shawn, so I decided to give up junk food. road- no mediocrity there.
The next day my friend Sandra looked at my lunch, Cheese and butter had made it to the "no" list
spread out neatly on a napkin before me, and by the time 1 was 16 and down to 105 lb. Fat-free
squawked, "Dill pickles?! Who brings dill pickles was my mantra. In fuct, for my 16th birthday, my
for lunch in a Ziploc plastic bag?" The other girls friends threw a little surprise party for me. Nora,
at the table fell into a fit of hysterics. "Casting for knowing I would put up a .fight, made me a cake.
West Side Story is coming up," I said, "and I gave " It's your birthday! You can have a piece of cake!"
up junk food to try to lose a few pounds." One of I politely said no, that I would cut it for everyone
my friends thought it would be funny to give me an else, but I really didn't want any. They pestered me
M&M candr-just to smell. Ha, ha. l put it in a lit· and Nora started to feel offended, so .finally I took
de Tuppcnvare container and kept it for days in my a fe" bites so she wouldn't burst into tears. It had
backpack as a reminder. been so long since I'd had so much sugar. I felt
Every once in a while, 1 did smell it. bloated and sick. I ate nothing for the rest of the
For the next few weeks there were times when day, and only 6 saltines, 1 apple, and 2 stalks of eel
I would find myself cracking open the refrigerator cry the next day. Those foods were on the "'yes" list.
door and just staring down what I knew to be a de- Salads also were okay, but only lettuce with salt and
liciously crunchy, crisp, and cold Kit Kat bar in the vinegar. I told my parents that the dissections in bi-
dairy bin. I didn't eat it though. At the mall with ology class had given me a distaste for meat, but re
my friends (since at 15, d1at's about all my parents ally, r just didn't want all those calories. For a while,
allowed me to do), Bridgette and Nora wanted ro 1 craved food day and night, but I was getting bet
stop and get a Cinnabon. They chided me, but I Ler and better at holding my ground.
didn't budge. The Cirmabons smelled so good. By my senior year, I was skipping lunches alLO·
But as I sat opposite them in the food court and gether, opting instead to hang ouL in the library
watched them overdramatize its ooey·gooey good- and read over my AP Bio text. "Where were you .ll
ness, T folt a sense of pride that l could make a de- lunch today?" Bridgette would ask later. "Oh, l
cision and stick with it. l could sec that they were had some reading to do. The AP exam is going to
jealous of my willpower. be rough." At 100 lb, l was getting closer co find -
When Easter came around, I took a look at the ing out what "tough" really meant.
contents of d1e Easter basket m}' mom insisted on E\'Cn though Laura moved out of state, [ di<ln 't
The psychological disease anorexia preparing and turned up my nose at it. I had gi,'c up on exercising. Now, the stair 5teppcr in d1e
nervoso con lead to numerous physical pro' en to myself tl1at T could resist temptation ... ID'm was my fuvoritc. I'd take my microbiolog')
problems. why stop now? notes, prop them up in front of me, and stcp-step-
I was eventually offered only a minor pan in stcp until r had burned 400 kcal. MuJtitasking tch M'l
d1e musical, but I wasn't that disappointed. I was efficient. Sometimes I'd go on the stair stepper twice
looking so much better as the pounds kept coming a day. As senior year wore on, d1ough, it got harder
off faery morning, just after going to the bath· and harder ro get up in d1e morning and put on my
room and before getting any breakf.lst, I would cennis shoes. And d1en one morning, in the ~bower,
pop onto d1e scale in my mom\ bathroom. One I just collapsed under the stream of bot water.
hundred and fifteen pounds and still going. At 5 Tended up in this hospital bed with an TV tube
feet 7 inches, that wasn't too ba<l . in my arm. At 92 lb, my body was starving. As it
560
. -~~~-
turns out, if you don't give your bod)' any fuel, you don't want to stay the same! I want to be thinner!
start to cannibalize yourself, in a sense. My body I look into the mirror. I think my thighs are ugly
had been so hungry, m}' muscles had been wasting and deformed looking. I sec a lumpy, clumsy, pear-
away, and the episode in the shower was due to a shaped wimp. There is always something wrong
problem with my heart. It's a problem r have cre- \\~th what I sec. I feel frustrated, trapped in this
ated ... not my parents or my distant group of body, and I don't know what to do about it.
mends ... just me. My mom was there, next to me, l fioat to the rctiigerator knowing exactly what
caressing the arm with the IV tube, putting her is t11crc. I begin with last night's brownies. I always
whole life on hold because of me. Tsn't this what I'd begin wit11 the sweets. At first I try to make it look
or
wanted-to be in control my own destiny? like nothing is missing, but my appetite is huge and
Where do r go from here? I resolve to make another batch of brownies. l know
there is half of a bag of cookies in the bathroom,
thrown out t11e night before, and I polish them off
Thoughts of a Bulimic Woman
inunediately. I take some milk so my vomiting will
I am wide awake and immediately out of bed. I think be smoother. I like the full feeling 1 get after down-
back co the night before, when I made a new list of ing a big glass. I get out six pieces of bread and toast
what I wanted to get done and how I wanted to be. one side of each in the broiler, turn them over and
My husband is not Far behind me on his way into the load them \\id1 pats of butter, and put them under
bathroom to get ready for work. Maybe I can sneak the broiler again until they are bubbling. I take all six
onto the scale to sec what I weigh this morning be- pieces on a plate to the television and go back for a
fore he notices me. I am already in my private world. bowl of cereal and a banana co have along with
I feel overjoyed when the scale says that I stayed the them. Before the last piece of toast is finished, I am
same weight as I was the night before, and I can fed already preparing the next batch of six more pieces.
that slightly hungry feeling. Maybe it will stop today; Maybe another brownie or five, and a couple oflarge
ma}•bc today everything will change. What were the bowls full of ice cream, yogurt, or conagc cheese.
projects Twas going to get done? My stomach is stretched into a huge ball below
We eat the same breakfast, except that I take no my rib cage. r know I'll have to go into the bath-
butter on my toast, no cream in my coffee, and room soon, but I want to postpone it. r am in
never take seconds (until Doug gets out the door). never-never land. I am waiting, feeling tl1e pres-
Today I am going to be real ly good, and that sure, pacing the floor in and out of the rooms.
means eating certain predetermined portions of Time is passing. Time is passing. It is getting to be
food and not taking one more bite than l think I time. I wander aimlessly through each of the rooms
am allowed. I am very careful to sec that I don't again, tidying, making the whole house neat and
take more than Doug. I judge myself by his body. put back together. I finally make the turn into the
I can feel the tension building. I wish Doug would bad1room. 1 brace my feet, pull my hair back and
hurry up and leave so I can get going! stick my finger down my throat, moking twice,
As soon as he shuts the door, l try to get in- and get up a huge pile of food. Three times, four Bulimia nervoso may hove on innocent
rnlved with one of chc myriad responsibilities on my times, and another pile of food. I can see every- beginning, but con lead to tragic
list. I hate them .111! I just want to crawl into a hole. thing come back. I am so glad to sec chose brown- consequences.
I don't want to do anrthing. I'd rather cat. I am ies because the}' are so fattening. The rhythm of the
alone; I am ncr,ous; I am no good; I always do emptying is broken and my head is beginning to
everything wrong anyway; I am nor in control; I hurt. I stand up feeling dizzy, empty, and weak.
can't make it through the day, I know it. It has The whole episode ha~ taken about an hour.
been the same for so long. I remember the starchy
cereal r ate for breakfust. I am into the bathroom From Hall L, Cohn L: Bulimitr-A Guide to
and onro the scale. It measures the same, buL I Recovery. Gurze Book~: Carbb:td, CA, 1992.
561
562 Chapter 15 Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder, and Other Conditions
B y severely limiting energy intake for long

periods, odolescent girls and young adult
women greatly compromise their nutritional sta·
Teens with chronic illnesses, such as type 1 diabetes or asthma, are at even greater
risk for disordered eating. 1 Any evidence of poor weight gain/maintenance or exces-
sive exercise among these individuals is a possible sign of disordered eating.
!us, impair tlieir reproductive systems, and re· Extreme dieting is the most import<rnt predictor of an eating disorder. (Adolescents
strict growth. 10 The harm produced by milder, expressing concern about their weight sho uld be advised to focus o n exercise, which
shorter periods of diet restriction is not dear. does not appear to impart a risk for subsequent problems.) Once dieting begins, a per-
Evidence, however, suggests that even moderate son developing anorexia nervosa does not stop. The result is a Jong period of rigidly
diet restriction, if continued, contributes to the self-enforced semistarvation, practiced almost with a vengeance, in a relentless pursuit
risks for various anemias, permanently reduced of control. For example, recently, a 19-year-old woman was admitted to the Ohio State
bone mass, later pregnancy complications, and University Hospitals witl1 a body weight of 60 lb. She had lost 55 lb in the previous
delivery of a low-birth-weight infant.12 6 montl1s and \Vas at great 1isk of impending deatl1. Upon interview, she said she
started dieting and could not stop.
Anorexia nervosa may eventually lead to bingeing on large amounts of food in a
short time, tben purging. Purging occurs primarily through vomiting, bur laxatives, di-
uretics, and enemas are also used. Thus, a person with anorexia nervosa may exist in :i
state of semistarvation or may alternate periods of starvation with periods of bingeing
and purging. 3,i 6
Profile of the Typical Person with Anorexia Nervosa

A person with anorexia nervosa refuses to eat enough food to maintain an acceptable
weight. This refusal is a common finding of the disease, whether or not other practices,
such as binge-purge cycles, appear. T he most typical anorexic person is a white female
from the middle or upper socioeconomic class. Perhaps her mother also bas distorted
views of desirable body shape and acceptable food habits. The girl is often described
by parents and teachers as responsible, meticulous, and obedient.
The girl is often competitive and often obsessive. 18 At home, she may nor allow
clutter in her bedroom. Physicians note that after a physical examination, she may fold
her examination gown very carefully and clean up the examination room before leav-
ing. Even though such behavior may seem obvious, only a skilled professional can tell
Even well-intentioned parents may place the difference between anorexia nervosa and otl1er adolescent complaints, such as de-
expectations on their children that compound
layed puberty, fatigue, and depression.
the anxiety often experienced during years of
difficult emotional and physiological changes. A common thread underlying many-but not all--cases of anorexia nervosa is con-
In response, adolescents and young adults may flict within the fami ly structure, typically manifested by an overbearing mother and an
find comfort in exerting control over their emotionally absent father. When family expectations are too high-including those re-
environment through the restrictive behaviors garding body weight-frustration leads to fighting. Overinvolvemenr, rigidity, over-
associoted with eating disorders. protection, and denial arc typical daily transactions of such famiLies.
Issues of control are central to the development of anorexia nervosa. The eating
disorder can allow an anorexjc person to exercise control over an otherwise powerless
existence. 5 Losing weight may be tl1e first independent success the person has had.
People with anorexia evaluate their self-worth almost entirely in terms of self-control.
Some sexually abused children develop anorexia nervosa, believing that if tl1ey control
their appetite for food, they wiJ I feel in control of and can thereby eliminate their
shameful feelings. Moreover, food restriction, which arrests development and shuts
down sexual impulses, may be a strategy to prevent future victimization and guilt feel -
P arents may not consider a teenager mature
enough lo make decisions. If the teen dis·
ogrees and the situation is very tense, she may
ings. Often anorexic persons feel hopeless about human relationships and socially iso-
lated because of their dysfunctional families. They focus on food, eating, and weighl
turn to purging or starving as a way lo show her instead of human relationships.
power: "You may try to control my life, but I can
do anything I want with my body."
Early Warning Signs
In the words of one young woman, "I couldn't
get angry, because it would be like destroying A person developing anorexia nervosa exhibits important warning signs. At fust, dit.:t-
someone else, like my mother. It felt like she ing becomes the lite focus. The person may think, "The only thing I am good ar is di -
would hate me forever. I got angry through eting. I can't do anything e lse." This innocent beginning often leads to very abnorm;1I
anorexia nervoso. It was my last hope. It's my self-perceptions and eating habits, such as cutting a pea in half before eating it. Other
own body and this was my last-ditch effort." habits include hiding and storing food and or spreading food aroirnd a place to make
1t look as if a lot has been eaten. An anorexic person may cook a large meal and wacch
ochers cat it while refusing to eat anything. Anorexics may also exercise to the point of
obsession, such as doing squats while brushing teeth.
As rhe disorder progresses, the variety of foods eaten may narrow and be rigidly di-
vided into safe and unsafe ones, with the list of safe foods becoming progressively
shorter. For people developing anorexia nervosa, these practices say, "I am in control."
These people may be hungry, but they deny it, driven by the belief that good things
will happen by just becoming thin enough. For an anorexic person, success is a matter
of wiUpower.
Soon people with anorexia become irritable and hostile and begin to withdraw from
famil) and friends. School performance generally crumbles. They refuse to eat out with
family and friends, thinking, "I won't be able to have the foods I want to eat," or "I
won't be able to throw up afterward."
Anorexic persons see themselves as rational and others as irrational. They also tend
to be excessively critical of themselves and others. Nothing is good enough. Because it
cannot be perfect, Life appea1·s meaningless and hopeless. A scnse of joylessness per- Jennifer is an attractive 13-year-old. However,
\•ades everything. she's very compulsive. Everything has to be
As stress increases in the person's life, sleep disturbances and depression are com- perfect-her hair, her clothes, even her room.
mon. Many of the psychological and physical problems associated with anorexia ner- Since her body is beginning lo mature, she's
\OSa arise from insufficient energy intake as well as deficiencies of nutrients, such as quite obsessed with having perfect physical
°
thiamin and \'itamin B-6. 2 For a female, the combination of problems-coupled with features as well. Her parents ore worried
lower and lower body weight and fut stores--<:auses menstrual periods to cease. 13 This about her behavior. The school counselor told
sign of the disease may be the first one that a parent notices and represents an addi- them to look for certain signs that could indi-
tional hallmark of tl1e disease. cate an eating disorder. What might those
Ultimately, an anorexic person eats very little food; 300 to 600 kcal daily is not un- signs be?
usual. In place of food, the person may consume up to 20 cans of diet soft drinks and
chew many pieces of sugarless gum each day.
Physical Effects of Anorexia Nervosa

Rooted in the emotional state of the victim, anorexia nervosa produces profound phys-
ical effects.8 The anorexic person often appears to be skin and bones. Body weight less
than 85% of chat e>..'Pected is one clinical indicator of anorexia nervosa. 18 This per-
centage can be calculated using the Metropolitan Life fosurance tables (see Appendix
I ), but it is important to notc that body build and weight history should also be used
when estimating an appropriate weight. B.NU is a more rel iable indicator of the degree
of malnourishment; generally, a BMJ of 17.5 or less indicates a severe case (review
Chapter 13 for more on BMI). For child ren under age 18, growth charts should be
used to assess weight status (sec Chapter 17).
This state of semistarvation forces the body to consenre as much energy as possible
and results in most of the phrsical cftecrs of anorexia nervosa (Figure 15-1 ). Thus,
many complications can be ended by returning to a heal thy weight, provided the du-
ration of anorexia nervosa has not been too long. Following arc predictable effects
caused by hormonal responses to and nutrient deficiencies rrom semistarvation:3,5,12,20
Lowered body temperature and cold intolerance caused by loss of insulating fat
layer.
Slower metabolic rate caused by decreased synthesis o~· thyroid hormones.
Decreased heart rate as metabolism slows, leading to easy fatigue, fainting, and an
overwhelming need for sleep. Otl1er changes in heart function may also occur,
including loss of heart tissue itself and poor heart rhythm.
Iron deficiency anemia, wbjch leads co further weakness.
Rough, dry, scaly, and cold skin from a deficient nutrient intake, "hich may also
show multiple bruises because of d1c loss of protection from the fut layer nor-
mally present under the skin.
Lo\\ white blood cell count, which increases the risk of infection and potentially Anorexia nervoso occurs much more frequently
death. in young women than in young men.
564 Chapter 1 S Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder, and Other Conditions
Symptoms of
Bulimia Nervosa
Hair loss Blood potassium Swollen salivary

imbalance glands
Fainting/fatigue Dental decoy Irritation of the
esophagus
Loss of heart tissue/ Iron-deficiency
decreased heart rote anemia
Lonugo Low white blood Stomach ulcers

cell count/decline
Little subcutaneous in immune
fat function
Loss of menstrual Constipation

periods
Low bone moss
Muscle tears/ stress

fractures
Low body
temperature
Bruising
Low metabolic rote/
cold intolerance
Figure 1 5· 1 I Signs and symptoms of eating disorders. A vast array of physical effects ore
associated with anorexia nervoso and bulimia nervoso. This figure contains many potential
consequences but is not on exhaustive list. These physical effects con also serve as warning signs that o
problem exists. Professional evaluation is then indicated.
Abnormal feeling of fu llness or bloating, which can last for several hours after eating.
Loss of hair.
lanugo Downlike hair tha t appears ofter o Appearance of lanugo- downy hairs on the body that trap air, reducing heat loss
person hos lost much body fat through that occurs with the loss of far tissue.
semistorvotion. The hair stands erect and traps Constipation from semistarvation and laxative abuse.
air, acting os insulation for the body to Lo•..v blood potassium caused by a deficient nutrient intake, loss of potassium from
compensate for the relative lock of body fat, vomiting, and use of some types of d iuretics. Low blood potassium increases
which usually functions os insulation. the risk of heart rhythm d ismrbances, another leading cause of death in
anorexic people.
Loss of menstrual periods because of low body weight, low body far conrenr, and
the stress of the disease. Accompanying hormonal changes cause a loss of bone
mass and increase the risk of osteoporosis later in life.
Changes in nemotransmitter function in the brain, leading to depression.
Evenmal Joss of teeth caused by acid erosion if freqLtent vomiting occurs. Until
vomiting ceases, one way to reduce this effect on teeth is to rinse the mouth
with water right away and brush the teeth as soon as possible. Loss of teeth
E riko Goodmon, o former dancer with the
Jeffrey Ballet, is now in her fi fties and is
crippled from osteoporosis resulting from years
(along with low bone mass) can be lasting signs of the disease, even if the other
physical and mentaJ problems arc resolved.
Musde tears and stress fractmes in athletes because of decreased bone and muscle
of restricting food intake to maintain a low body
mass.
weight. Her food restriction led to irregular or
absent menstrual periods for many years. A person with this disorder is psychologically and physically ill and needs help. 13
Concept I Check
Anorexia nervosa is an eating disorder characterized by semistarvation. It is found prima-
rily-but not exclusi,·ely-in adolescent girls, starting at or around puberty. People with
anorexia nen·osa dwindle essentially co skin and bones but still bclic\•e they are fat.
Scmistarvation produces hormonal changes and nutrient deficiencies that lower body rem-
perature, slo" the heart rate, decrease immune response, stop menstrual periods, and con-
rribute to hair, muscle, and bone loss. Anorexia nervosa is a very serious disease that often
produce..s fatal or lifelong consequences.
Treatment of Anorexia Nervosa

People with anorexia often sink into shells of isolation and tear. They deny that a prob-
Jennifer continues her pursuit of the perfect thin
lem cxists.9 Frequently, their friends and family members meet with them to confront
body info her late teens. She ignores the ad·
rhe problem in a lo\'ing way, called an intcn•cntion. They present evidence of the prob-
vice of her parents and the counselor. As o 19-
lem Jnd encourage immediate treatment. Treatment then requires a multidisciplinary
yeor-old entering college, she is finally
ream of experienced physicians, registered dietitians, psychologists, and other health
beginning lo realize that her anorexic behavior
profossionals working rogether. 20 An ideal sening is an eating disorders clinic in a med-
might hove serious consequences. She hos
ic.ll center. Outpatient therapy generally begins first and may be extended to 3 to 5
been fluctuating 15 lo 20% below her healthy
days pi:r week. Day hospitalization (6- 12 hours) is another option, as is total hospital-
body weight and hos been omenorrheic for o
ization. Hospitalization is necessary once n person falls bdow 75% of expected weight,
few years. She would like to marry someday
experiences acute medical problems, and/or exhibits severe psychological problems or
and hove o Family. Whal ore some of the
suicidal risk. 20 Still, r.:,·en in the most skilled hands at the finest facilities, dforts may
health consequences for o person with
fail. The prevention of anorexia nervosa is of utmost importance.
anorexia nervoso, such as Jennifer?
Once a medical team has gained thr.: cooperation and trust of an anorexic patir.:nt,
the team attempts to work together to resrorc a sense of b:ilancc, pu11')ose, and future
possibilities. As previously stated, anorexia nervosa is usually rooted in psychological
conflict. However, the ano rexic person who has been barely existing in a state of semi-
srnrvation cannot focus on much besides food. Dreams and even morbid thoughts
.lbout food wiU imerfore with therapy until sufficient weight is regained.
Nutrition Therapy
The first goal of nutrition therapy is to gain the patient's cooperation and trust in order
to increase oral food intake. Ideally, weight gain must be enough to raise the metabolic ome anorexic people use cigarette smoking,
rate to normal and reverse as many physical signs of the dise:ise as possible. Food in-
take is designed fin.t ro minimize or stop any further weight loss. Then the focus shifts
5 which increases metabolic role, as a way to
resist weight gain during nutrition therapy.
to restoring appropriate food habits. After this, the expectation can be switched t<> slow
weight gain. A range of 2 to 3 lb/week is appropriate. Tube feeding and/or coral par-
enteral nun-ition support is used only if immediate renourishrnenr is required, because
this drastic measure can cause the patient to distrust medical staff.
Energy needs begin at 1000 to 1600 kcal/day in multiple, small meals, and this al-
location is increased in 100- to 200-kcal increments every few days as possible until an
appropriate rate of weight gain is achie\'ed. This appropriate weight is one in which
normal menstruation is restored. An energy distribution of about 50 to 55% carbohy-
drate, 15 to 20% protein, and 25 to 30% fat is appropriate. This nutrition therapy may
ultimately require a daily intake of 3000 to 4000 kcal to attain a goal weight, because
the increase in body metabolism and anxiety associated with feeding needs to be ac- young woman in a self-help group for
counted for. 17 A mu ltivitamin and mineral supplement will be added, as well as enough
calcium to raise intake to about 1500 mg/day. As noted before, nutrient deficiencies
A those with anorexia nervoso explained her
feelings to the other group members: •1 hove lost
are commonly seen in anorexic persons.20 a specialness that I thought it gave me. I was dif·
Patients need considerable reassurance dw-ing the refecding process because of un- ferent from everyone else. Now I know that I'm
comfortable effects, such as bloating, increase in body heat, and increase in body fat. somebody who's overcome it, which not every-
This process is frightening because these changes can lead to the patient feeling out of body does.·
control. Monitoring for rapid changes in electrolytes and minerals in the blood, espe-
cially potassium, phosphorus, and magnesium, is critically important as more food is
included in the diet. 5
In addition to belping patients reach and maintain adequate nutritional stanis, the
registered dietitian on the medical team also provides accurate nutrition information
tlu·m1ghout treatment, promotes a healthy attitude toward food, and helps the patient
learn co eat based on natural hunger and satiety cues. Nutrition tl1erapy with anorexic
persons can be frustrating for a dietitian because many anorexic persons are very
knowledgeable regarding the energy and fat gram content of most food products. The
focus should be on helping these patients identify healthy and adequate food choices
that promote weight gain ro achieve and maintain a clinically estimated goal wt'.ight
(e.g., BMl of20 or more).1 The medical team also should assure patients that they will
not be abandoned after gaining weight.
Because excessive energy expenditure prevents weight gain, professionals must work
with anorexic patients tO help them moderate their activity. At many treatment centers,
patienrs are placed on moderate bed rest in the early stages of u-eatment to help pro-
mote weight gain.
Experienced professional help is the key. An anorexic patient may be on the verge
of suicide and near starvation. fn addition, anorexic people are often very clever and
A history of anorexia nervoso con harm resistant. They may try to hide weight loss by wearing many layers of clothes, putting
physical os well as mental health. coins in their pockets or underwear, and drinking numerous glasses of water before
stepping on a scale.
Psychological and Related Therapy

Once rhe physical problems of anorexic patients are addressed, the treatment focus
shifts to the w1derlying emotional problems of the disorder. To heal , these patients
must reject the sense of accomplishment they associate with an emaciated body and
begin to accept tbemselves at a health)' body weight. If therapists can discover reasons
for the disorder, they can develop psychological strategies for n::storing normal weight
and eating habits. Education about the medical consequences of semistar vation is also
helpful. A key aspect of psychological treatment is showing affected indjviduals how ro
regain control of other facets of their lives and cope with tough situations. As eating
evolves into a normal routine, tl1ey can n1rn to previously neglected activities.
Therapists may use cognitive behavior therapy, which involves helping the person
cognitive behavior therapy Psychological
confront and change irrational beliefs about body image, eating, relationships, and
therapy in which the person's assumptions
about dieting, body weight, ond related issues weight. 5 Underl.)~ng issues d1at may be the cause for the disease, such as sexual abuse, must
ore challenged. New ways of thinking ore be identified and addressed by the d1erapist. Interpersonal tberapy is another psychologi·
explored and then practiced by the person. In cal approach used in anorexia nervosa. Rad1er than focusing on the patient's eating habits
this way, the person con learn new ways lo and assumptions about weight and shape, interpersonal d1erapy formulates the problem in
control disordered eating behaviors ond related terms of the interpersonal context, usually in one or more of four areas: grief, interpersonal
life stress. problems (e.g., difliculry forming or maintaining close relationships), interpersonal dis-
putes (e.g., unresolved conflict regarding d1e expectations of significant others in the per-
son's life), or role transitions (e.g., fear of independence due to lack of self-confidence).
Treatment focuses on assisting d1c patient to change in one or more of these areas.
Family therapy often is important in treating anorexia nervosa, especially for yoLmger
patients who still live at home. Family therapy focuses on the role of tl1e illness among
family members, the reactions of individual fumily members, and ways in which their
°
subconscious behavior might contiibute to d1e abnormal eating patterns.2 Frequendy,
a therapist finds family struggles at the heart of the problem. As the disorder resolves,
patients must relate to famiJy members i11 new ways to gain the attention that was
needed and previously tied to the disease. For example, tbe family may need to help the
young person ease into aduld1ood and accept its responsibilities as well as its advantages.
Self-help groups for anorexic people, as well as their fami lies and friends, represem
nonthreaten ing first steps into treatment. People can also attend to get a sense of
vvhether they really do have an eating disorder.
Medications are generally not eftective in treating the primary symptoms ofanorexia
°
nervosa. 2 Fluoxetine (Prozac) and other rel:ued antidepressant medications called se-
lective serotonin reupcake inhibitors (SSRis) may stabilize recovery in patiems with
anorexia who have attained 85% of their expected body weight. SSRis work by pro-
longing serotonin ,\ctiviry in the brain, which in rum rcgubtes mood and feelings of
satiety. A variety of other types of pharmacologic agent~ may have some role in treat-
ing mood changes, anxiety, or psychotic symptoms associated with anorexia nervosa
(e.g., olanzapirn: [Zyprexa]) bur have limited value in patients unless weight gain is
also achieved. 5
With professional help, many people with anorexia nervosa can lead normal lives.
Although they may not be totally cured, they do not have to depend on unusual eat-
ing habits to cope with daily problems. They recover a sense of normality in their lives.
No universal approach exists because each case is unique. fatablishing a strong rela-
tionship with either a therapist or another supportive person is an especially important
key to recovery. Once anorexic patients feel understood .rnd accepted by another per-
son, they can begin to build a sense of self and exercise some autonomy. As the)' learn
alternative coping mech~misms, recovering patients can leave behind their dyslirnc-
tional relationships with food and instead develop healthy personal relarionships. 20
Early treatment for on eating disorder such as

anorexia nervoso improves chances of success.
Sarah does hove the characteristics to be diagnosed with anorexia nervoso be-
cause she refuses to maintain o healthy weight-for-height ratio, is ot o weight below
----~ 85% of that expecled, hos o distorted view of her appearance, and hos hod no
menstrual periods For over 3 consecutive months.
Sarah would need to be hospitalized initially because of her low BMI of 13.8. While in the
hospital, her treatment most likely would consist of moderate bed rest to promote weight gain,
and on intake of 1000 to 1600 kcal initially, which is then increased by increments of about
100 to 200 kcal every few days until on acceptable rote of weight gain is achieved.
The goal is for Sarah to achieve o body weight that is at least 90% of on expected weight
for her age, such as o BMI of of least 19. This weight goal should also allow for resumption of
menstrual periods. The physician would likely prescribe o multivitamin ond mineral supplement
along with additional supplements of calcium to ensure on intake of about 1500 mg/day. These
supplements will correct vitamin and mineral deficiencies that exist, and the calcium will con-
tribute to bone maintenance. A learn of health professionals, most likely consisting of o physi-
cian, registered dietitian, and psychologist, would provide therapy. Sarah's cooperation would
be the most important element for therapy to be successful. She needs to realize she hos o prob-
lem and that she needs help. The team, especially the psychologist, may use cognitive behavior
therapy lo help Sarah improve her self-image. inger Koren Carpenter's death from compli-
Otherwise, Sarah's outlook for recovery is not good. Even if she is willing to accept the ther- cations of anorexia nervoso in 1983 in-
apy and counseling, relapse is likely to occur. Only about 50% of anorexia nervoso patients creased awareness of the serious nature of this
hove been found to fully recover from the disease. Because Sarah's disordered eating habits disease. Currently, the overage time for recovery
hove been in place For about 6 years, her problem is deep-rooted. The chances of recovery ore from anorexia nervoso is 7 years; many insur-
greater if a vigorous treatment program is reinforced with close follow-up. ance companies cover only a fracfon of the esti-
mated $150,000 cost of treatment.
Concept I Check
To relieve the semistarved condition of most anorexic patients, the initial treatmem focuses
on moderately increased food intake and slow weight gain. Once these goals arc accom-
plished, psychotherapy can begin to uncover the causes of the disease and help patients de-
\ clop skills to return ro a healthy life. Family therapy can be an important tool in
treatment, whercai. medications have a limited role.
568 Chapter 15 Eating Disorders: Anorexia Nervosa, Bulimia Nervoso, Binge-Eating Disorder, and Other Conditions
Bulimia Nervosa
ingeing and purging (via vomiting) in Bulimia nervosa involves episodes of binge eating followed by various means LO purge
B group settings were practiced in pre-
Christion Romon times. Singeing ond purging
the food. This eating disorder was first described in the medical literature in 1979 and
classified as a clinical psychiatric disorder in 1980. It is most common among young
associated with bulimia nervoso ore generally adults of college age, although some high school students are also at risk. Susceptible
practiced in private. people often have genetic factors and lifestyle patterns that predispose them to be-
coming overweight, and many try frequent weight-reduction diets as teenagers. Like
people with anorexia nervosa, those with bulimia nervosa are usually female and suc-
cessful. Unlike anorexics, however, they arc usually at or slightly abo,·e a normal
weight. 11 Females witl1 bulimia oervosa are also more likely co be sexually accivc than
those with anorexia nervosa.
The person with bulimia nervosa may think of food constantly. Unlike the anorexic
person, who turns away from food when raced with problems, the bulimic person turns
toward food in critical situations.4 Also, Lrnlike those with anorexia ncrvosa, people with
bulimia nervosa recognize their behavior as abnormaJ. 18 These people often have very
low self-esteem and arc depressed. Approximately half the people with bulimia nervosa
B ulimio nervoso is rare in developing coun-

tries, which suggests that our culture is on
important causal factor.
have major depression. Lingering effects of child abuse may be one reason for these feel -
ings. Many bulimic persons report that they have been sexuall) abused. The \\'Orld secs
their competence, while inside they feel out of control, ashamed, and fruscraced.
Bulimic people tend to be impulsive, which may be expressed as thievery, increased
sexual activity, drug or alcohol abuse, self-mutilation, or attempted suicide. Some ex-
perts have suggested that part of the problem may actually arise from bulimic individ-
uals' inability to control responses to impulse and desire. Some studies have
demonstrated that bulimic people tend ro come from disengaged fami lies-ones t hat
are loosely organized. In these famil ies, roles for family members are not clearly de-
fined. Rules arc very loose and a great deal of connict exists. In comparison anorexic
people tend to have families so actively engaged that roles may be too well dcfined.3
Typical Behavior in Bulimia Nervosa

Many people with bulimic behavior are probably never diagnosed. The strict diagnos-
tic criteria specify that to be classified as having bulimia nervosa, a person must binge
and purge at least twice a week for 3 months.3 People with bulimia ncrvosa lead secret
lives, hiding their abnormal eating habits. Moreover, it is impossible to recognize peo-
ple with bulim ia ncrvosa simply from their appearance. Because most diagnoses of bu-
limia nervosa arc based on self-reports, current estimates of the number of cases arc
probably low. The disorder, especially in its milder forms, may be much more wide-
spread than commonly thought.
For intake to qualif)• as a binge, an atypicall)' large amount of food must be con-
sumed in a short time, and the person must exhibit a lack of control over his or her
behavior. 11 Bingeing often alternates with attempts to rigidly restrict food intake.
Elaborate food ru les arc common, such as avoiding all sweets. Thus, eating just one
cookie or doughnut may cause bulimic persons to feel they h::ive broken a rule. Feeling
like a £wurc, the bulimic person may then proceed to binge. Usually, this action leads
to significant overeating, partly because it is easier to regurgitate a large amount of
food than a small amount.
Binge-pw-ge cycles may be practiced daily, weekly, or at longer intervab. A ~pccial
time is often set aside. Most binge eating occurs at night, when other people arc less
likely to interrupt, and usually lasts from 1/2 to 2 hours. A binge can be triggered b~
a combination of hunger from recent dieting, stress, boredom, lonc\incss, and dcprcs
sion. Bingeing often follows a period of strict dieting and thus can be linked to intense
hunger. The binge is not Jl all like normal eating; once begun, it seems to propel it-
The binge-purge cycle con lead to o sense of self. The person not only loses control but generally doesn't even taste or enjoy the
helplessness. food that is ea ten during a binge. This separates the practice from simple overeating.
Most commonly, bulimic people consume cakes, cookies, ice cream, and similar
high-carbohydrate convenience foods during binges because these foods can be
purged relatively easi ly and comfortably by vomiting. In a single binge, foods supply-
ing up to 3000 kcal or more may be eaten. 5 Purging follows in hopes that no weight
will be gained. However, even when vomiting follows the binge, 33 to 75% of the food
energy taken in is still absorbed, which causes some weight gain. When laxatives or en-
emas arc used, about 90% of the energy is absorbed, because these products act in the
large intestine, beyond the point of most nutrient absorption. Clearly, the belief of bu-
limic persons that purging soon after bingeing w ill prevent excessive energy absorption
and weight gain is a misconception.
Early in the onset of bulimia nervosa, sufferers often induce vomiting by placing
their fingers (or other objects) deep into the throat. In the case of fingers, they may
inadvertently bite down on these fingers, such that the resulting bite marks around the
knuckles become a characteristic sign of this disorder. Once the disease is established,
however, a person can often vomit simply by contracting the abdominal muscles.
Vomiting may also occur spontaneously.
Another way bulimic people attempt to compensate for a binge is by engaging in
excessi,•e exercise to expend a large amount of energy. Some bulimic people try to es-
timate the amount of energy eaten in a binge and then exercise to counteract this en-
ergy intake. This practice, referred to as "debting," represents an effort to control their
wcight. 11
People with bulimia nervosa are not proud of their behavior. After a binge, they
usually feel guilty and depressed.18 Over time, they experience low self-esteem and feel
Excessive exercising con be one component of
hopeless about their situation (Figure 15-2). Compulsive lying, shoplifting co obtain bulimia if it is used as o way to offset the
food, and drug abuse can further intensify these feelings. Bulimic people caught in the energy intake from o binge. Exercise is
act of bingeing by a friend or family member may order the intruder to "get out" and considered excessive when it is done at
"go away." Sufferers gradually distance themselves from others, spending more and inappropriate times or settings, or when o
more time preoccupied by and engaging in bingeing and purging. person does ii despite injury or other medical
complications.
Figure 1 5·2 I Bulimia nervosa's vicious

cycle of obsession.
Health Problems Stemming from Bulimia Nervosa

The vomiting associated with bulimia nervosa is a physically destructive method of
pmging. lndccd, the m.tjority of health problems associated with bulimia ncrvosa tlut
are listed here arise from vomiting:3,7,1l
Repeated exposure of teeth tO the acid in vomit causes demineralization, making
the ccerh painful and sensitive to heat, cold, and acids. Eventually, the teeth
may decay severely, erode away from fillings, and finally fall out (Figure 15-3).
Dental professionals arc sometimes the first health professionals to notice signs
of bulimia ncrvosa. It is in1portant to rinse the mouth with water after any
vomiting episode, especially before brushing the teeth.
he November 24, 2005 issue of the New Blood potassium can drop significantly because of regular vomiting or the use of
T England Journal of Medicine (353:2270,
2005) contains an X-ray view of a fork inside a
certain diuretics. This drop can disturb the heart's rhythm and even produce
sudden death.
woman's stomach. The woman had an eating Salivary glands may swell as a result of infection and irritation from persistent
disorder and used the fork to induce vomiting. vomiting.
Stomach ulcers and tears in the esophagus develop in some cases.
Constipation may result from frequenr laxative use.
Ipecac syrup, sometimes used to induce vomiting, is toxic to the hearr, liver, .md
kidneys and can cause accidental poisoning when taken repeatedly.
Overall, bulimia nervosa is a potentially debilitating disorder that can lead to death,
usually from suicide, low blood potassium, or overwhelming infections.
Concept I Check
Bulimia nervosa is characterized by episodes of binge eating followed by purging, usually
by vomiting. Vomiting is very destructive LO the body, often causing severe dcnral decay,
stomach ulcers, irritation of the esophagus, and low blood potassium.
Treatment of Bulimia Nervosa

Therapy for bulimia nervosa, as for anorexia nervosa, requires a team of expericrn:cd
clinicians. 11 Bulimic patients arc less likely than those with anorexia to enter rreacment
in a state of scrnistarvation. However, if a bulimic patient has lost signitic•l11L \\cight,
this weight loss must be treated before psychological treatment begins. Although cli-
nicians have yet LO agree on the best therapy for bulimia nervosa, they generall)' agree
that treatment should last ac least 16 weeks. Hospitalization may be necessary in cases
of extreme laxative abuse, regular vomiting, substance abuse, and depression, especial!~·
if physical harm is evident.
The first goal of trcatmcnr for bulimia ncrvosa is to decrease d1c amount of food
consumed in a binge session in order to reduce the risk of esophageal tears from re-
lated purging by vomiting. A decrease in the frequency of this type of purging will alw
decrease damage LO the teeth.
Tbe primary aim of psychotherapy is to improve patients' self-acceptance .rnd help
them to be less concerned about body weight. Cognitive behavior therapy is generally
used. 11 Psychotherapy helps correct the all-o r-none thinking typical of bulimic per-
Figure 1 5·3 I Excessive tooth decay is sons: "If I eat one cookie, I'm a failure and might as well binge." A patient may be
common in bulimic patients. asked to analyze the statement as a scientist wou ld do when resting assumptions. In
this way, patient .rnd therapist together examine the validity of food and weight beliefs.
The premise of chis therapy is that if abnormal arriwdes and beliefs can be altered, nor-
mal caring will folio\\. ln addition, the cherapisc guides the person u1 establishing food
habits that will minimize bingeing: avoiding fasting, eating regular meals, and using .tl-
ternative methods-other than eating-to cope with stressful siruations. Group ther-
apy is often useful to foster strong social support. One goal of therapy is to help
bulimic persons accept some depression and self-doubt as normal .
Although pharmacological agents should not be used as the sole u·eatmcnt for bu-
limia nervosa, studies indicate that some medications may be beneficial in conjunction
with other therapies. II Fluoxetine (Prozac) is the only antidepressant that has been ap-
proved by FDA for use in the treaanent of bulimia nen·osa, but physiciam ,1lso may
prescribe other forms of SSRI antidepressants, other psychiatric medications, such as
imipramine (TofraniJ) and lithium carbonate (Li thane), and certain antiseizure med-
icarions, such as topiramate (Topamax). This last medication, however, can lead to sig-
nificant side effects, such as mental confusion.5
Nutritional counseling has rwo mai11 goals: correcting misconceptions about food
and reestablishing regular eating habits. Patients are gi\·en information about bulimia
ner\'os.1 and its consequences. AYoiding binge foods and not constantly stepping on a
scale may be recommended early in treatment. The primary goal, howe\'er, is to de-
\·elop a normal eating panern. To achieve this goal, some specialists encourage patiencs
to develop daily meal plans and keep a food diary in which they record food intake, in-
ternal sensations of hunger, environmental factors th:H precipitate binges, and
thoughts and feelings that accompany binge-purge cycles. Keeping a food diary not
only is an accurate \\'ay to monitor food intake but also may help identif)• situations
that seem tO trigger binge episodes. WiLh the help of a therapist, patients can develop
Purging episodes add to the despair felt in
altcrnari\'e coping strategies.
people with bulimia nervosa.
In general, the focus is not on stopping bingcing and purging per se but on devel-
oping regular eating habits. Once this goal is achieved , the binge-purge cycle should
starr LO break down. Patienrs are discouraged from following strict rules about healthy
food choices because such rules simply mimic the typical obsessive attitudes associated he binge·purge cycle can creole an initial
with bulimia nen·osa. Rather, encouraging a mature perspective on food intake-that slate of euphoria in the person. Giving up
is, regular consumption of modern re amounts of a \'ariet)' of foods balanced among rhe this euphoria hos been equated lo giving up an
food groups-helps p.niencs overcome this disorder. 1 addiction. Still, it is important lo do so.
Sening rime limits for finishing meals and snacks is important for people with eat-
ing disorders. f\fany bulimic persons cat very quickly, reflecting their difficulties with
!.atiet:y. Suggesting that the patient put his or her utensil down after each bite is a be-
havioral techn ique Lhat a therapist might try with a recovering bulimic person. (In
comparison, many anorexic persons eat in an excessivclr slow manner-for example,
taking l hour to ear a muffin cut into tiny, bite-size pieces.)
People with bulimia ncrrnsa must recognize that they arc dealing witl1 a serious dis-
order that can have grave medical complications if nor treated. Because relapse is likely,
therapy should be long term. People with bulimia nervosa need psychologica l help be-
cause they can be very depressed and are al a high risk for suicide. About 50% of peo-
ple with bulimia nervosa recover completely from the disorder. Others cominuc to
struggle with it, to varying degret:s for the rcsr of their lives. This fact w1d.erscorcs the
need for pre,·enuon because treatment is difficulc.
Concept I Check
Treatment of bulimia ncrvosa using nutrition counseling and psychotherapy attempts to rc-
srorc normal eating habits, to help the person correct distorted beliefs about diet and
litestyle, and to find tools to cope with the srresses of life. Medications such as fluoxctine
(Prozac) can ai<l recovery \\hen added to this regimen.
Eating Disorders Not Otherwise Specified

(EDNOS)
ED NOS is a broad category of earing disorders in which individuals have partial syn-
dromes that do not meet the strict criteria for anorexia nen·osa or bulimia nervosa. 3
About 50% of people \\ith eating disorders full inro this EDNOS category, especially ado- Bulimia nervoso affects many college students.
lescents. Examples of disordered earing in this categor)' include ( l ) a woman \\'hO meets Counselors ore aware of this and ore available
all the criteria for anorexia nervosa but continues to menstruate; (2) an individual who to help.
572 Chapter 15 Eating Disorders: Anorexia Nervoso, Bulimia Nervosa, Binge-Eating Disorder, and Other Conditions
meets aU the criteria for anorexia nen·osa but, despite a significant weight loss, has a
current weight in the normal range ( this could be a person who \\'as once obese ); ( 3) a
person who meets all the criteria for bulimia nervosa except that binge eating occurs
less than 1:wo rimes a week; (4 ) a person who meets all the criteria for bulimia nt:rvosa
but does not binge (this person might eat normal amoums of food but purges regu ·
larly out of fear of weight o r fat gain); and ( 5) a person who repeatedly chews and spits
out food but docs not swallow it.
Treatment as outlined for anorexia nervosa or bulimia nervosa should be sought in
such cases, depending o n the specific symptoms exhibited.
Binge-Eating Disorder
EDNOS also includes binge-eating disorder. The typical characteristics for this disor·
der were listed in Table 15-2. Generall)', it can be defined as binge-eating episodcs not
accompanied by purging (as typifies buUmia nc rvosa) at least two times per week frir
at least 6 mo nths. Today health-care professionals recognize binge-eating disorder as
a complex and potentially serious problem. 14
Approximately 30 to 50% of subjects in organized weight-control programs h ~nc
binge-earing disorder, " hereas abour 1 ro 2% of North Americans in general have thi ~
nother eating disorder under study is night disorder. ~lany more people in the general population have less seYere forms of the dis
A eating syndrome. In this disorder people
eat o lot in the late evening or eat food in order
ease, but do nor meet the formal criteria for diagnosis. The number of cascs of bingc-
eating disorder is fur greater than that of either anorexia nen·osa or bulimi,1 ncnosa.
lo foll osleep again once awakened in the night. This disorder is also more common among the severely obese and those \\'ith ,1 long
This night eating con contribute to weight gain, history of frequent restrictive dieting, although obesity is not a criterion for h,1\ ing
so affected persons ore urged to seek treatment. binge-eating disorder.
Development and Characteristics of Binge-Eating Disorder

Individuals with binge-eating disorder (about 40% of whom are males ) ofccn percei\ c
themselves as hungry more ofi:en than normal. They usually starred dieting at a voung
age, began bingcing during adolescence or in their early twenties, and did nm succccd
in commercial weight control progran1s. Almost half of those with severe binge-eating
disorder exhibit clinical depression.
Typical binge ea ters isolate themselves and cat large quantities of their favorill' food
or foods readily availabk. Binge eaters usually consume foods that carry the s<><:ial
stigma of " junk" or "bad" foods-ice cream, cookies, sweets, potato chips, anJ simi-
lar snack foods. Stressful events and feelings of depression or anxiety can trigger thii.
behavior. Giving themselves permission to cat a forbidden food can also precipitate a
binge. Other triggcrs include loneliness, anxiety, self-pity, depression, anger, rage,
aUenation, and fru~tration. 14
s noted in Chapter 2, spreading one's di· In general, people engage in binge eating to induce a sense of well-being and per·
A etory intake into numerous, small meals
over a day does not pose a problem, and even
haps e\•en numbness, usually in an attempt to avoid feeling and dealing \\'ith cmot10n.1l
pain and anxiet). They cal without regard co biological need and often in a recurrent,
hos some health advantages, if overall energy ritualized fashion. Some people with this disorder eat food continually oYer Jn e:..-
intake remains appropriate. tended period, callcdgrnzing; others cycle episodes ofbingeing with norm.11 eating. 1-l
For example, someone with a stressfu l or frustrating job might come home every night
and graze until bedtime. Another person might cat no rmally most of the time but find
comfort in consuming large quantities of food when an emotional setback occuri..
Although people with anorexia nervosa and bulimia nervosa exhibit persistent pre-
occupation with body shape, weight, and thinness, binge eaters do nor necessarily
share these concerns. Thus, neither purging nor prolonged food restriction is ch.lI:lc·
teristic of binge-eating disorder. Some physicians classify binge-eating disorder as an
addiction ro food involving psychological dependence. The person becomes an.1chcd
to the behavior itself and has a drive to continue ir, senses only limited control m·cr it,
and needs to continue despite negative consequences. Food is used to reduce 1.trcl.s,
produce feelin gs or power and well-being, avoid fee lings of intimacy with others, and
avoid Life problems. Note that obesity and binge eating arc not necessarily linked. Not eople with binge-eating disorder may come
all obese people arc binge eaters, and although obesity may result from trying ro numb
emotional pain with food, it is not necessarily an outcome of binge eating.
P from families with alcoholism or may hove
suffered sexual abuse. Members of such dys-
Binge-eating disorder is most likely to develop in people who never learned to ex- functional families often do not know how to
press and deal appropriately with their feel ings. Rather than face their frustration, deal effectively with emotions. They cope by
anger, and pain, they rw·n to food. The frustration will continue because they never turning to substances. Family members learn to
confront the basic problem. Binge eating makes them foci the~ cannot control the be- cover up dysfunctional patterns and learn to nur-
ha' ior pattern and therefore cannot cona·ol their lives. Worse, the binge eating usually ture the behavior of others at the expense of
increases feelings of guilt, embarrassment, and shame. their own needs.
Often people who practice binge eating have been shaped by families who do not
address and express feelings in healthful ways. The parents nurture and comfort their
children with food rather than engage in healthy exchanges of self-disclosure of tt:el-
ings and potential solutions. Members of such families k.un to eat in response to emo-
tional needs and pain instead of hunger. Those who regularly practice binge eating may
grow up nurturing others instead of themselves, avoiding their own feelings and tak-
ing little time for themselves. Not knowing how to satisfy their personal and emotional
needs in more healthful ways, people in these families turn to food.
For some people, frequent dieting beginning in childhood or adolescence is a pre-
cursor tO binge-eating disorder. During periods when little food is eaten, they get very
hungry and obsessive about food. When allowed to eat more food, they feel driven to
car in a compulsive, uncontrolled way. The pattern of strict dieting alternating with
binge eating may continue over time.3
Help for the Person with Binge-Eating Disorder

People \vith binge-eating disorder must learn co eat in response ro hunger-fl biological
signal-rather than in response to emotional needs or external factors such as Lhe time or
day or the simple presence of food. 14 Counselors often ask binge caters to record their
perceptions of physical hunger throughout the day and at the beginning and end of every
meal. These people must learn to respond to a prescribed amount of fullness at each meal.
They should initially avoid weight-loss diets because feelings of food deprivation can lead
to more disruptive emotions and a greater sense of llnmet needs. Diets ~ue likely to en-
courage more intense problems, such as extreme hw1ger. Many people with binge-eating
disorder may experience difficult)' in identif)ring personal emotional needs and expressing
emotions. Because this problem is a common predisposing factor in binge eating, com-
munication issues should be addressed during treatment. Binge eaters often must be
helped to recognize their own buried emotions in anxiety-producing situations and then
encouraged to share them with their therapist or therapr group. Learning simple but ap-
propriate phrases to say to oneself can help stop bingeing "hen the desire is strong.
Self-help groups such as O\"ereaters Anonymous aim to help recO\·ery from binge-
earing disorder. The treaanenr philosophy parallels that of Alcoholics Anonymous and at-
tempts to create an environment of encouragement and accountability to overcome this
eating disorder. Dietary advice typically includes avoiding restraint when eating and limit-
ing binge foods. Some experts foci that learning to eat all foods-but in moderation-is
an effective goal for binge caters. This practice can prevent the feelings of desperation and
deprivation that come from limiting particular foods. Fluoxetine (Prozac) and related
SSRI antidepressants, as well as other psychiaLric medicaLions, also have been found to
help reduce binge eating in these indi\iduals by decreasing depression. The antiscizure
medication topiramate (Topa1mn:) may also be used. o,·crall, people who ha\"e binge- Bing~oting disorder is seen in both men and
eating disorder are usually unsuccessful in controlling it without protCssional hclp. 14 women. Professional help is advised for people
with this disorder.
Other Examples of Disordered Eating
In recent years, another condition-female athlete triad- has been recognized as re- female athlete triad A condition characterized
quiring professional treatment. Although thi!. disordered eating pattern shares some by disordered eating, lock of menstrual
characteristics with anorexia nervosa and bulimia nervosa, it has distinctive qualities. periods, and osteoporosis.
Dr. Jackie Berning discusses this condition in detail in the Expert Opinion.
574 Chapter 15 Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, Binge-Ealing Disorders, and Other Conditions
Expert Opinion i
The Female Athlete Triad
Jackie Berning, Ph.D., R.D.
For the post 20 years participation in women's sports has surpassed all cases, women with established eating disorders might choose to participate
imagination. Today, women have many more opportunities to participate in in a particular sport to help control her weight.
high school and collegiate sports as well as the potential to continue their
athletic careers in the professional ranks. While these women derive signifi-
Amenorrhea
cant health benefits from the physical training associated with sports, they
are also at risk for a syndrome of disordered eating, amenorrhea, and bone Most amenorrhea seen in female athletes is classified as secondary amen·
loss. This triad of disorders is known as the female athlete triad. orrhea, because it results from the disease process rather than being a pri-
mary cause of the disease itself. Secondary amenorrhea is the loss of
menstruation for three or more consecutive cycles in a female who has ex-
Disordered Eating
perienced the onset of menstruation. Between I to 44% of female athletes
Disordered eating is a medical term that covers a brood spectrum of eating experience amenorrhea. Amenorrhea can be as high as 50% in elite runners
disorders from poor nutritional habits to the potentially lethal complications and ballet dancers. The cause of the amenorrhea seems to be related to
of anorexia nervosa and bulimia nervoso. In female athletes, depending on changes in the hypothalamus in the brain, but may be multifoctorial.
the sport studied, the prevalence of eating disorders ranges from 15 lo 62%. Potential factors include energy restriction, poor eating habits, disordered
Sports that emphasize leanness (such as endurance sports or aesthetic eating, energy imbalance, rapid weight loss, and increase in training.
sports) are more likely to have a higher percentage of athletes with eating
disorders.
Osteoporosis
Many female athletes wi th eating disorders may not meet the strict diag-
nostic criteria for anorexia nervosa or bulimia nervosa. Instead, they engage This risk is related to less estrogen output, and so the athlete loses the pro-
in regular energy restriction and fail to meet the energy demands for living tective effect of estrogen on bone. Athletic amenorrhea causes bone loss like
and training. The motivation for this energy restriction is multifoctorial. The that seen in menopause. Numerous studies have shown significant bone loss
most frequent factor is nutrition misinformation, which is the easiest to ad· in amenorrheic athletes. Unfortunately, the bone that is lost is not replaced
dress. Dispelling myths and facts about training and diet or offering credible even if menstrual cycles are resumed. Because many of these young athletes
nutrition counseling con place the athlete back on track. Unfortunately, the are at a critical age of bane mass, many may never be able lo reach their
problem is often more complex. Female athletes in lean profile sports are peak bone mass, and because 70% of bone mass is acquired during ado-
under intensive pressure from coaches, peers, and judges about body weight lescence and early adulthood, these female athletes are at high risk for hip
and image. This intense pressure and any insensitive comment may play a and spine fractures in later life stages. In addition, omenorrheic athletes are
key role in promoting disordered eating in these young athletes. In other more prone to injury, especially stress fractures.
Prevention of Eating Disorders

A key to developing and maintaining healthful eating behavior is to realize that some
concern about diet, hcald1, and weight is normal, as arc variations in what we cat, ho\\
we feel, and even how much we weigh. For example, most people experience some
minimal weight change (up to 2 to 3 lb) thrnughour the day and even more over the
course of a week. A large \\'eight fluctuation or ongoing weight gain or weight loss is
more likely to indicate that a prob km is present. If )'Ou notice a large change in your
eating habits, how you feel, or your body weight, it is a good idea ro consult your per-
sonal physician. Treating physical and emotional problems earJy helps lead you to
peace of mind and good health.
Identifying and Managing the Problem injuries or other medical complications. Treatment strategies to reach these
goals may include a slight reduction (I 0 to 20%) in the amount of training
Members of the sports medicine team, such as registered dietitians, must and a higher energy intake for a 2 to 5% increase in weight. Some omenor-
constantly be aware of the symptoms and signs of female athlete triad. In the rheic athletes who gain weight either by cutting bock on training or consum-
athletic culture, episodes of amenorrhea, weight loss, and injuries oken may ing more energy hove a better chance of resuming normal menstrual activity.
be attributed to some cause other than the female athlete triad. For this rea- In addition to weight gain, other foctors that need proper attention for normal
son, it is important for clinicians to obtain and maintain records of amenor- menstruation are adequate sleep, management of stress, and nutritional in-
rhea among female athletes. Eoch athlete with amenorrhea should be take. Most omenorrheic athletes fear weight gain and must be counseled that
referred to a physician who can
on increase in muscle weight could improve their stamina and performance.
rule out other causes of the amen-
Calcium supplementation should be implemented in all athletes presenting
orrhea, such as pregnancy or thy- with amenorrhea. Vegetarianism is another contributing factor to amenorrhea.
roid disease. If on athlete appears Vegetarian athletes may be at risk for low energy, protein, and micronutrient
to be excessively concerned about intakes because of elimination of food groups such as meat and dairy. Some
her weight or dieting or if she pre- researchers point out that along with the insufficient energy intake, inade-
sents with marked thinness, obses-
quate amounts of protein may also ploy a role in the amenorrheic athlete.
sive compulsion about training, Regardless of the cause of the amenorrhea in the female athlete, a qual-
fine lanugo hair, or erosion of tooth ified nutrition professional can help improve the quality and quantity of the
enamel, further investigation or
athlete's diet so that normal menstruation hos a better chance of resuming.
confrontation about the eating dis-
In addition to working individually with the athletes, the registered dietitian
order is recommended. Finally, a
should also work with the coach, athletic trainer, physician, and strength and
clinician or physician who encoun-
conditioning professional to provide omenorrheic athletes with the best pos-
ters any athlete with a stress frac-
sible environment for maximizing their performance as well as providing a
Low body weight coupled with ture should obtain a menstrual
normal, healthy functioning body.
excessive exercise con lead to cycle history and baseline nutri-
amenorrhea and ultimately female tional assessment. Dr. Berning is a registered dietitian and associate professor at the
athlete triad. The management of the athlete University of Colorado-Colorado Springs. She specializes in sports
presenting with symptoms of the fe- nutrition and consults for numerous professional sports teams in the
male athlete triad is best accomplished in o multidisciplinary approach in- United Stoles. She works extensively with female athletes at the
cluding o physician, registered dietitian, psychologist, and athletic trainer. University of Colorado-Boulder and hos been involved with counsel-
The primary goals of treatment ore to control and manage the athlete's eating omenorrheic athletes For over 15 years. She has coauthored two
ing disorder, to restore normal hormone levels, and lo monitor and treat any books and numerous articles and chapters on sports nutrition.
T - - --- --
-~ ~--~ --. __, - - --.·. --~ -.- -- ·--~- -= ,= - - - - - - - -
Many people begin co form opinions about food , nutrition, health, weight, and
body image prior to or during puberty. Parents, friends, and professionals wo rking
"ith young adults can help form positive habits and appropriate expectations, espe-
cially regarding body image.9 Here is some advice Lhat these people can extend to
young adults to help them avoid eating disorders:
• Discourage restrictive dieting, meaJ skipping, and fasting (except for religious
reasons) .
• Provide information about normal changes that occur during puberty.
• Correct misconceptions about nutrition, healthy body weight, and approaches to
weight loss.
• Carefully phrase any weight-related reco mmendations and comments.
ol on~ is treatment of eating disorders for • Don't overemphasize numbers on a scale. Instead, primarily promote healthful eat-
more difficult than prevention, these disor- ing irrespective of body weight.
ders also hove devastating effects on the entire • Encourage normal expression of disruptive emotio ns.
family. For this reason, caregivers and health- • Encourage children to eat only when they're hungry.
care professionals alike must emphasize the im- • Teach the basics of proper nutrition and regular ph)1sical activity in school and at
portance of on overall healthful diet that focuses home.
on moderation as opposed lo restriction and • Provide adolescents with an appropriate, bur not unlimited, degree of indepen -
perfection. Restricted diets ore especially detri- dence, choice, responsibility, and self-accountability for their actions.
mental to children because they do not supply • Increase self-acceptance and appreciation of the power and pleasure emerging from
enough energy to sustain growth. In response, one's body.
nutritional counseling con assure ca regivers that • Enhance tolerance for diversity in body weight and shape.
including some sweets and fast food in o child's • Build respectful environments and supportive relationships.
diet is appropriate (see Chapter 17 for more • Encourage coaches to be sensitive to weight and body-image issues among athletes.
details). • Emphasize that thinness is not necessarily associated with better athletic
performance.
Our society as a whole can benefit from a fresh focus on bealthfuJ food practices and
a healthful outlook toward food and body weight.
Organizations to Help You Understand More

about Eating Disorders
You can gain more insight into eating disorders not only from the technical articles in
the references but also from the following resources designed for the lay public:
Academy for Eating Disorders, 6728 McClean Village Dr., McLean, VA 2210 I ;
703-556-9222; • ,,." Kltk 1 d1~ ors
American Anorexia Bulimia Association, 165 West 46th St., #1108, New York,
NY 10036; 212 575-6200; e h I 11
The National Eating Disorders Organization, 603 Stewart St., Suite 803, Sc:mle,
WA 98101; 206-382-3587 or 800-93 1-EDAP;
,, 1 I r 11 ~
Harvard Eating Disorders Centers, 356 Boylston St., Boston, MA 02116;

617-236-7766; \\\ \\ . h1:tk . 111·~
T he National Institute of Mental Health has recently published a concise review
of eating disorders ( " 11 1 1,J."', 11 1h.:.1 is. k 1 111..n.1 ).
1'hlh lkri Concept I Check

Food bingeing and grazing without purging arc two behaviors characrerisric of bingc-
Tom, a high school feacher, is concerned abouf
eating disorder. Emotional disn1rbances are often at the root of this eating disorder.
eating disorders. He wants to try fo prevent
Treatment addresses deeper emotional issues and endorses avoiding food deprivation and
young adults from falling into fhe discouraging
restrictive diets while restoring more normal eating behaviors. The female athlete triad con-
traps of anorexia nervoso and bulimia ner-
sists of disordered eating, amenorrhea, and osteoporosis, and most commonly affects
voso. Whaf ore some of fhe topics and issues
women in appearance-related and endurance sports. Parents, coaches, teachers, and health
he should discuss with sfudenfs in his health
professionals need to initiate efforts to prevent and treat this problem.
classes?
Summary
\'Omiting or misuse of laxati,·es, diuretics, or enemas. Alternately,
I. Anorexia ncrvosa is most common among high-achieving, perfec- fasting and excessive exercise may be used. Both men and women
tionist girls from families marked by conllicr, high expectations, arc at risk. Vomiting as a means of purging is especially destructive
rigidity, and denial. The disorder usually stares with dieting in early to the body, causing severe tooth decay, stomach ulcers, irritation
puberty and proceeds ro the near-total refusal to eat. Early warn- of the esophagus, low blood porassium, and ocher problems.
ing signs include intense concern about weight gain and dieting a~ Bulimia nen·osa poses a serious health problem and is associated
well as abnormal food habits, such as cooking food that they with significant risk of suicide.
won't :illow themselves to eat. 5. Treatment of bulimia nervosa includes psychological as well as nu-
2. Anorexic persons become irritable, hostile, overl}' critical, and joy- tritional counseling. During treatment, bulimic persons learn to
less; they rend to withdraw from family and friends. b·entually, accept themselve!> and to cope wirh problems in ways that do nor
anorexia nerrnsa can lead to numerous physical effects, includmg mvolve food. Regular earing parrerns are developed as these pa-
a profound decrease in body weight and body fut, a fall in body tients begin to plan meals in an informed, healchfi.d manner.
temperature and heart rare, iron deficiency :incmia, a low white Certain medications can be a helpful addition to the regimen.
blood cell count, hair loss, constipation, low blood potassium, and 6. Binge-eating disorder, which is more widespread than either
the loss of menstrual periods. People with anorexia nervosa arc in anorexia nen·osa or bulimia nen·osa, is most common among
a state of physical illness. people with a history of frequent, unsuccessful dieting. Binge
3. Treatment of anorexia nervosa includes increasing food intake caters rypically either binge without purging or graze (i.e., cat
to support gradual weight gain. Psychological counseling :it- conanually over excended periods). Thus, this condition fall~
ccmpts to help patients establish regu lar food habits and to under the category Eating Disorders Not Ot11erwise Specified
find means of coping with rhc lifr stresses that led to the disor- (E D NOS). Emotional disturbances are often at the root of thi~
der. Hospitalization may be necessary as well as use of ccrcain disordered form of eating. Treatment addresses deeper emotional
medications. i'sues, discourages food depri,·arion and restricri,·e diets, and helps
4. Bulimia nen·osa is characterized by secretive bingcing on large restore normal eating beha,fors. Certain medications ma) be a
amounts of food within a short time span and t11en purging by useful addition to chis therapy.
Study Questions
l. What are the typical characteristics of a person wit11 anorexia ncr- 7. How, in you r opinion, has society contributed to the development
vosa? What may influence a person to begin rigid, selt:imposed di- of various forms of disordered earing? Provide an example.
etary patterns? 8. How does binge-eating disorder differ from bulimia ner\'Osa?
2. List the detrimental physical and psychological side effects of bu- Describe the factors rhar conrribucc to d1e de,·elopmcnr and treat-
limia nervosa. Describe important goals of the psychological and ment of binge-eating disorder.
nutrition therapy used to treat bulimic patients. 9. List the three symptoms that constitute the female athlete triad.
3. What is the current thinking concerning medication use for What is the major health risk associated wim loss of menstrual pe-
anorexia nervosa and bulimia nervosa? riods in t11c female athlete?
4 . Explain the role of cxcessi,·e exercise in eating disorders. 10. Pro,·ide two recommendations to reduce the problem of c.:atmg
5. How might parenrs significantly contribute to the de,·elopment of disorders in our ~ocicty.
an earing disorder? Suggest an actinide rhac a parent or an adult
friend of yours displayed t11.\t may not have been conducin: rode-
veloping a normal relationship to food.
6. Based on rour knowledge of good nutrition and sound dietary
habits, answer the following questions:
a. How can repeated bingeing and purging lead to significanc BOOST YOUR STUDY
nutrient deficiencies?
b. How c:in significant nuLricnr deficiencies contribute to major Check ou t the Perspectives in Nutrition: Online Learning
health problems in later life? Center ,.,,,, n ri . • < •nl ,., II 'v >f>r. 7 for quizzes, Aash
c. A friend asks you, t11e nutrition expert, if it is okay to cards, activities, and web links designed to further help you learn
"cleanse" the body by eating only grapefruit for a week. Wha1 about eoting disorders.
is your response?
578 Chapter 15 Eating Disorders: Anorexia Nervoso, Bulimia Nervosa, Binge-Eating Disorder, and Other Conditions
l. ADA Rcporcs. Position of the American Dmtists m·c so111cti111rs rbrjfrsr /Jcnltln11rc pro· rmt~)' prol'idcs thcgrcn tat likt'li/Jood jiw m.-rc.rs·
Dicreric A~ociarion: Nutrition inrer\'cnrion in ftssio11nl ro raog11i=e 1111 mri11..n disordrr i11 n11 Jul t/Ji-rnp.v. ~ot skippiltn 111c11/s is 11 kry pnrt of
the trcumenr of anorexia net\'OSa, bu hmia ner· individ11nl. Rcpcnttd 1'111111t111g c11mu tooth de· the 111m·11io11 tbcrnp_v.
\'OSa, and eating di~ordcrs nor ochcrwisc speci· str11ctio11 1111d glr111d11lnr Sll'elli11g, but t/Jcrc nrc 15. Stein D nnd others: Arccmptcd suiod c .md sdt~
lied (cDNOS). }011rm1I oft/Jr Amcric1111 .few pnitorolr i11pl11CI'tll11.rsist tfe11t1m ll'it/1 nft:1·· injury in patients diagnosed with e;Hing disor·
D1rtmr Associntio11 101:810, 2001. mis for en ting diso1·d1·r tlm·11p_r. ders. C11111prcltmsive Psycbint1·_v 45:+47, 200.J..
£ui11..n disorders nrc romple:i: nud so·io111 ill· 8 Holtkamp K and mhcrs: Depression, ,uu.iery,
l11divid11nls wit/J cnti•i._n disordrr1 bn1·c n lm..lfbt·
ne.rs(s, ns 1fescrilmf in dctnil in rim 11n1cle. To be and ob~es~ionali[) in long term reco\·crcd pa·
wed risk of do•elopillg micid11/ bd1111•wr.
cfficril>c iu rr.:nring 111di1•id11als w/Jo suffcrji·om tienrs with adolc.sccnt· onsct anorex ia nen·osa.
Partimlnrly nt risll nre t/Jllsc who bi11,f/t n11d
these ilhusrcs, the e:o:prrr iutcmrrimi bcn1w11 E11rnprn11 Cbiltf n11d A1iolrscmr Psyc/Ji11try
jlmlJe; 11s1• 11101·c tbn11 out type ()f p111lfi11..n
profi·.rsio11nls in 111n11y disciplines is rcqutrcd. 14:106, 2005.
method; h11rc n hisr01:v of tfmg use, 1111p11/sc ro11·
2. American Acadcm) of Pediatrics: ldcm:il)ing Anorrxin 11er1•os11 oftm is nssocinud 11•1t/J dcpres· trol dij]icult_v, n11d/or b1po/11r d1sorda; n11d n
and crcari ng caring Jisordcrs. Pediatrics l 11: sion, m1:.:icty, n11d obs1·.rs11•c·co111p11/sil'<' bdmJ>1or. lcngthy /Jistor.v of011tpntfrnt 1111d i11pn11mt
204, 2003. 171csc trnit.s nppenr to rfn•tlop scco11dn1·.v to semi· t1·entme11t.
stnrMti1111 /mt frtq11m1(1• tfo not mbsidt• cl'c11
Enri11..n disorden nn: bceomillg 11101·e common i11 nftcr rcc111'c1",1' fi·om n1101·rx111 11crvosn /Jns 16. Tozzi F and od1ers: <;ymptom flucnuuon in
011r socirty. 171is nniclc rn1ien•s tbc rnrreut ding· occurred earing disorders: Corrclarcs of d1agnosac
11ostic nud trentmmt options for mc/J dtsorders. croSSO\'Cr. A111•.,.icm1 ]011m11/ of Ps_vrlnntn 16~
9 Jackson K: Eating ll imrdcrs revealed Todn.v's
732, 2005.
3. Amcrkan Psyd1intrk Associariun: Di11g11osrir Dietitin11, p. 37, MJrch 2004.
n11d st11tisticnl 111111111nl of ment11/ disorders. 4th E11ti11..n disorders lll"C oftm bnrd ro rcco..{/111:;e be· Some i11di11id1111/s fint din,q11os.-d ll'it/J 1111orc.:i11
ed. (re\r mision ) (DS~l-1\'-TR). Washington, cn11sc 111dh•id11nls 111n1• lndc t/}( rnriom prncrius. 1m·11osn ll'ill i:.\-pcrimce 11 rr11sso1'cr ro n d111..n1wsif
DC American Psychiarric Association, 2000. 171is 111·tulc disrn.rsa tbr 111n11y clmrncu1·istics of of b11/i11111111er1•osn wirhi11 rbe firsr 5 .vrnrs uj'
cnri11g duordcn rbru e1111 be used m the tbeir illness. Fcn•er i11diliid11n/J n1irb buli111i11
This 111n111111/ co11rn111s tbc criteri11 used in ding·
di11gno.ris. ncr11os11, /J11wc1•c1; cxpcrir11CL" n crosso1•cr r11
11osi11..n n11 cnri11g disonfc1: Tbc specijir criw·ia
n11orcxin 1ur1>11m. A1101·cxic iiidh•idunls 11'b11
for 1111111"<".\~11 1uri•osn, b11/imm 11e1·posn, n11d l 0. Kouba S and others: Pregnancy and neonatal
perceil'r hLnh p11rmtnl rririris111 1111d b11/i111ic 111 ·
b11111r·mtm..n disorder nr,· prol'ided. ourcome~ m women \\Uh eating disorders.
d1vid11nls 11'/Jo strz'.!lnle ll'irb nlcobol nb11u nrc
4. Brouss.ud BB: Women\ C\pc ri cncc'> ofbu limi.i Obstcmcs nnd Gy11eco/1~11.~ 105:255, 2005.
most like~y to t.'<pcrience 11 rronorcr 1111d br ding·
ncrvos.1. Jo11mnl of AdP1mced N111·si11g 49:43, Pr~g111111t 1J111111c11 w11b p11sr or ncti1•c 1111(11'•".>:ill 11oscd with 11 new cnti11g tfis111·dc1:
2005. 11cr1111.m 111· b11/i111in 11erJ111s1J hm•c 11 grmtt1· risk
for tfd1r•Ti11..n 111f11nts 11•11/J /01r birrlJ wc(q/Jt 1111d 17. Van Wl'mclbcke V and mhers: I-actor' .l"><>ei·
Four 01•0-nll thcmrs dmrnrteri-:;e lil'iu..n ll'itb bu· ated \\ich rhe increase in rc~ting energy c\pco-
S111111! bend cirwmftrmu n11d who 111·.- 1111n/I for
/1111111 1w·1•111n: isolnr111..11 rclf, livmg 111 fmr, dirurc dunng rcfcedmg m nulnoumhcd
bci11..n nt wm· with rbr mind, n111f pncifi.'i11..n rht· gestntionnl 11gc.
anorexia ncrvosa patiem~. A111e1·icm1 }111m1nl uf
brni11. JJ11/imic i11dii•id1tnlt fenr /Jci11gJ11dg,;d by 11 . Mehler PS: Bulimia ncrvo>.l. The Ne111 l:i11gln11d
Clillicn/ N11tritio11 80: 1469, 2004.
or/Jen ll'ho might discni•cr rluir bi11ge·p111lfe /01m1nl of Medicine 349:875, 2003.
r_i·cl.-, n11d som& fmr '11•i11..lf ll'ithour b11/i111in 11tr· 171c co111b11111tin11 of co_n11it11•c bebni•ior tbcrnp_1• IV/Jen n11orn:tc pntierw nn· Jeri ns pnn 11/1/Jrir
1•osn brcnuse tbe di,-msc /;11d become mch 11 sig· n11d n1mdcprcss11m mrdicntions pro1•1du r/Jr best trcntmau, resting t11cr..n.v cxpn1dirurr 111crtma.
1Jijic11 nr pnrt 11/tb.-ir identities. bope for trmtmcllf ofb11l11111n 11erJ111sn. A11xiet:y, pbysicn/ nctivity, n11d c(q11r.-rtc m111ki11..11
N11ti·iri111111 / co1111seli11g nl<11IJ11s11 m/r, sucb ns ll'cre nfl /111kcd to rcsti11._q t 11t1Jfy cxprndiflll'I"
5 Coughlin )W, Guard.1 AS: Behavioral di sorders
flddrrssill,I/ rn11rems nb11111 spccifir "jill'biddru" 1111d co11tri/111ud to resis1n11cc to ll'c[11bt ..f/11111,
aftccrmg food inrakc· Earing di~ordcrs and
other psyd1iarric .:ondJtions. In Shi ls i\I E foods. 18. Walsh BT: l:.aw1g disordcr1. In Kabpcr l)f , Jnd
and orhcr.. (eds): .\!udcm 11un-itio11 i11 IJenlrlJ 12. Miller KK .md others; ~lcdic.tl find111gs in out· ochers ( ed~. ): Hnrriso11 s pmmplcs 11f 111um11/
1111d dismsc. 10th ed. Philadelphia, PA: patients mth anorexia nervosa. A rcl1il•es of medicine. New York: McGraw-Hill, 2004.
Lippincott Williams & Wilkins, 2006. lnteru11/ ,\/rdici1u 165:56 l, 2005. This cbnpw· fr 1111cxcdll'llt1·c1•icll' of rnti11.n dis·
C11rrmt rc1•icn• of r/Jr en mes n11d trmtments of Jfcdirnl pr11/Jlems 111-r: apirnl~v seen i11 proplr orden b_v n 11oud expert. /1111/J din..1111usts n11d
vnno11J cnti11g disorders. 17Jc specific 1·olc of rlu ll'it/J 1111orrxin in our sncuty. fa:nmples nrc 1011•· crtatmm t 11 re higblighud.
1111trit11111nl profesti1111nl ns pnrt of tbt· rre11tmmt ered i111111m11: s_vsu111 Itnrur n11d b1111c loss ll'itb re·
19. Woods S· Untreated recovery from eating dis·
tmm }ill" time dism·dcl'S is /Jigblig/Jrctf. /nud himll".Y of bonr frnrt111·es. orders. Ado/escmce 39:361, 2004.
6. Courb;w.on C;\ I and 01hcn.: Substance use dis- 13. Prim $1), Susman /: DiJgno>is of eating Jisor·
dcr« 111 primary care A 111erirn11 F11111il)' Some i11dil'1d11nls cnn reroi•rr from n111wfxtn
ordch, anorexia, bulimia, and concurrcnr dis·
Ph_rsici1111 67:297, 2003 11crvosn 01· b11li111in 11crl'osn witbo11t prof.-.rsi111111I
order.. Cn1111di1111 J1111n111/ of P11bltc Hmlt/J
96: I 02, 2005. 111is nrt1rfr is n11 cxrdlmt m•i&ll' ~f t/Jt ding110· trcnmum. Among tbcse i11d11•1d11n/s, tbosr "''"'
lm11e t/Jc sburrm cnti11g dis1J1·da· d11rnti11111111d
fodiJ1id1111/s, pnrticulnr~1·fe111nlcs, wbo cxpcri· .ris 1111d .rrll,l/«S 11ftrcnt111rnr rlf mti11g disorden
most cnmplru recuve1:v l11111c pn1·01ts ll'l1111111r1··
mu mbstn11a: nbusc b111•c n /Jeigbtmcd 1·isk fo1· 171c 1111111.i• pb_1•s1cnl effrrts 11ftbis dism·d,.,. nls11 nre
l'tncd e111·(v 011 in r/Jc dis111·dr1· 's prognssir111
cnti11..11 disorders; b11n•n•r1-, trcnt111e11t fnciliria drscrib.-d.
typic11/ly spccin/i:;e eitlm· 111 substn11u nb11sc or 14. Sh:mt.1· Rcrclny \': Binge eating inro obesity. 20 \"ager J, Andersen AE: Anorexia ncr\'0\.1. ·111,·
enti11..r1 tfisonfcrs mid 11111y 11or be p1·011idi11g np· T/ldn.r 's Dictitin11, p. 34, May 2004. New Ertnln11d Jo11m11l of 1\1.-duwe 353: 1441,
p1·oprinu thcmpy ro pnrirnts. Billgc·rn1i1w d1so1·dtr is 11 com1111111 problem in 2005.
.., Fn·dr\'ch u\ I and orhcrs: Eating J1~ordcrs and people f<'tki11,n t/Jcrnp.v fiw 11bi-siry. 171r ro111bi11n· Detniletf dt-pictio11 oft/Jr di11g11osis n11d nw1t·
or.ll hc.drh: A rnicw of rhc lircrarurc. rio11 of t1tn11itii•.- bdmvi111· tlternpy n11d urrni11 mmr of1111orcxin 11en•usn. l11dtcntio11s for r/J,·
A11strnli1111 Drnrnl J1111mn/ 50:6, 2005. ps_vc/Ji11rrir r111d 1111tisri:;11re 111cdicntin11s mr· need for /Jospitnli:ntilJ11 11rt 111c/11dtd.
Take I Action
I. Assessing Risk of Developing an Eating Disorder

British investigators hove developed a five.question screening tool called the SCOFF Questionnaire for recognizing eating disorders:
1. Do you make yourself ~ick because you feel lull?
2. Do you lose £ontrol over how much you eot?
3 Hove you lost more than Qne stone (about 13 lb) recentty?
4. Do you believe yourself to be fat when others soy you ore thin?
5. Does food dominate your lile?

Two or more positive responses suggest on eating disorder.
1 Aker completing this questionnaire, do you feel that you might hove on eating disorder or the potential to develop one?
2. Do you think any of your friends might hove on eating disorder?
3 What counseling and education resources exist in your area or on your campus lo help with a potential eating disorder?
4. If a friend hos on eating disorder, what do you think is the best way to assist him or her in getting help?
Source: Morgon JF and others: The SCOFF Questionnaire, British Medical Journo/ 319: 1467, 1999.
580 Chapter 15 Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorders, and O ther Conditions
Take I Action
II. Helping Prevent Eating Disorders

You hove been asked to speak lo o junior high school class about eating disorders. What four major points would you make to help
prevent disordered eating in this population?
1.
2.
3.
4.
Here ore points you may consider:
l . Extreme thinness is oversold in the media. Extremely low weight (i.e., BMI of less than 17.5) is generally not healthy.
2. Self-induced vomiting is dangerous. Damage to the teeth, stomach, and esophagus ohen results.
3. Loss of menstrual periods is o sign of illness. It is important to see a physician about this symptom. Bone deteriora tion is a com·
mon result.
4. Early treotmenl of eating disorders aids success. These diseases ore difficult to treat once firmly established.
PREGNANCY AND BREASTFEEDING

Planning for Pregnancy Tracey ond her husband of 4 years hove decided that they ore ready to hove o
Expert Opinion: Folic Acid Interventions: Public child. Tracey hos been reading everything she con find on pregnancy because she
Health Outcomes
Prenatal Growth and Development
knows that her prepregnoncy health is important to the success of her pregnancy. z
Early Growth: The First Trimester Is a Very She just turned 25 ond so is in the recommended childbearing age of 20 to c-I
Critical Time • Second Trimester • Third 35 years. She knows she should ovoid alcohol: alcohol is particularly toxic to the
::io
Trimester =l
Definition of o Successful Pregnancy growing fetus in the first weeks of pregnancy, and she could become pregnant and 0
Increased Nutrient Needs to Support Pregnancy not know about it right owoy. Tracey is not o smoker, does not toke ony medica-
z
)>
Increased Energy Needs • Adequafe Weight tions, and limits her coffee intake to 4 cups o day ond sofi drink intake to 3 colas -0
Goin • Increased Protein ond Carbohydrate -0
,..-
Needs • Increased Vitamin Needs • Increased per doy. ()
Minero/ Needs • Is There on Instinctive Drive
during Pregnancy to Consume More Nutrients?
Based on her reading, she hos decided to breastfeed her infant and hos already ~
Food Pion for Pregnant Women inquired about childbirth classes. She hos modified her diet to include some extra 0
Use of Prenatal Vitamin and Mineral protein, along with more fruits ond vegetables. Recently, she started swimming z
(/)
Supplements • Pregnant Vegetarians
Effect of Nutritionol Status on the Success of
5 days a week, and she plans to continue swimming throughout her pregnancy. She
z
Pregnancy hos also started toking on over-the-counter vitamin and mineral supplement. -I
I
Nutrition Focus: Effects of Other Factors on Tracey ond her husband think that they hove covered oll the key areas of m
Pregnancy Outcome prepregnoncy core. List o few positive attributes of her current practices. Con you c
..,,
Prenatal Core and Counseling m
identify some potential problems and what information they moy hove missed?
Cose Scenario Follow-Up ()
Physiological Changes of Concern during
-<
()
,..-
Pregnancy m
Heortbum, Constipation, and Hemorrhoids •
Edema • Morning Sickness • Anemia •
Gestational Diabetes • Pregnancy-Induced
Hypertension
Breastfeeding
Ability to Breastfeed • Production of Human
Milk • let-Down Reflex • Nutritional Qualities
of Human Milk • Food Plan for Women Who
Breastfeed • Breastfeeding Today •
Environmental Contaminants in Human Milk •
The Breastfeeding of Preterm Infants
Toke Action
.:
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581
P regnancy is a very special time. Along with the responsibility of shaping a child's health and per-
sonality comes the prospective exhilaration of watching a child develop and grow. Parents-to-be
often feel an overriding desire to produce a healthy baby, which can arouse new interest in nutrition and
health information. They usually want to do everything possible to maximize their chances of having a
robust, lively newborn.
Despite these intentions, the infant mortality rate in North America is higher than that seen in many
other industrialized nations. In Canada, about 6.1 of every 1000 infants per year die before their first
birthday, whereas in the United States the figure is 6.9. These sta-
tistics are alarming for two countries that have such a high per
capita expenditure for health care compared to many other
TO ALLOW YOU TO:
countries in the world. And compare these numbers to Sweden,
1. List major physiological changes that occur in the body during
at roughly 3 of every 1000 infants. In addition, in the United
pregnancy and how nutrient needs are altered.
States, about 20% of pregnant women receive inadequate pre-
2. List factors that predict a successful pregnancy outcome.
natal care in the early months of pregnancy. Expectant teenagers
3. Specify the optimal weight gain during pregnancy for the
are at the highest risk for this problem. normal adult woman.
Producing a healthy baby is not just a matter of luck. True, 4. Plan an adequate, balanced meal plan for a pregnant or
some aspects of fetal and newborn health are beyond our con· lactating woman using MyPyramid as a basis.
trol. 1 Still, conscious decisions about social, health, and nutri· 5. Identify the nutrients that may need to be supplemented during
pregnancy and explain the reason for each.
tional factors during pregnancy significantly affect the baby's
6. Explain the typical discomforts of pregnancy that can be
future. 5 Choosing to breastfeed the infant adds further benefits.2 minimized by dietary changes.
This chapter examines how a woman who eats well during preg· 7. Describe the physiological processes involved in breastfeeding
nancy and breastfeeding can help her baby to have a healthy as well as some advantages of breastfeeding for both the infant
start in life. and mother.
8. Describe fetal alcohol syndrome and discuss its implications for
an infant.

OF NUTRITION IN PREGNANCY AND BREASTFEEDING
IN CHAPTER 16, YOU MAY WANT TO REVIEW:
Typical fortification m meal replacement bars in Chapter l and ready-ta-eat breakfast cereals in Chapter 2.
Causes and effects of ketosis in Chapter 4.
The components of the macronutrient classes-carbohydrates, proteins, and lipids-in Chapters 5 lo 7, especially
amega-3 fatty aids.
Alcohol content of various beverages in Chapter 8.
The food sources of folate in Chapter l 0, calcium in Chapter 11, and iron and zinc in Chapter 12
The calculation of body moss index in Chapter 13.
Endocrine, reproductive, and immune systems m Appendix C.
Planning for Pregnancy

Because many practices or conditio ns o f che mo ther can harm the de' doping fctu~,
planning for pregnancy is very impo rta nt. The fo llowing arc some potc nri.111~ harmful
ea/thy People 20 I 0 includes a goal of in·
habics that can be mod11ied when planning ro have a baby:l,3,l5,20
creasing to 80% the number of pregnan·
cies that begin with optimal folate status from the • Lack of e no ug h symhctic folic acid in the diet (at least 3 mo nths before becoming
current estimate of 21 %, in on effort to reduce pregnant)
the occurrence of neural tube defects. • Any amo unt o r alcoh o l co nsum ption
582
• Use of certain medicines, such as aspmn and related NSAJDs (e.g., ibuproten
[Ad' ii]), as \\'ell as rypical medicines used co treat the common cold
• Use of illegal drugs, such as marijuana and cocaine
• Any herbal therapies
• Job-rebtcd hazards and stresses
• Smoking
• Inadequate intake of other nutrients, such as coo little iron, magnesium, and zinc
• Excess vit:imin A intake and megadosc use of other nutrient supplements
• Hcavv catleine use
• Lack of medical treatment with HI\'·posirh·e starus or AIDS
• Poor, control of ongoing diabetes or hypertension
• X-ra) e\'.posure, including dental X rays
Women need to pay attention to these risks in the months before conception. This
precaution is necessary because women often do not suspect they arc pregnant during
the first few weeks after conception and may no t seek medical :iu cmion until after the
first 2 to 3 months of p regnancy. 3
Still, even without fanfare, the child· to· be grows and de\'clops daily. For tl1at rea·
son, the health and nutrition habits of a woman who is trying to become pregnant-
or has the potential ro become pregnant-arc particularly import•ll1t. Although some
aspects of fetal and newborn health are beyond control, a woman's conscious decisions
about social, health, and nutritional factors affect her infunt's health and furure. For
example, an adequate \'itamin and mineral intake at least 8 \\'eeks before conception
and then during pregnancy can help prevent birth defects such as neur-.11 rube defects
(review Figure 10-7 in Chapter 10).5 Neural tube defects especially have been linked
to a folic acid de ficiency. Recall fro m Chapter 10 that neural LUbe defects develop
with in 28 days after conception and that adequate folic :icid status before and during
this part of pregnancy reduces the risk of such defects by about 70%. In addition, be-
cause about 50% of pregnancies are unplanned, all women of childbearing age should omen who hove previously given birth to
be aware of the role nutrition plays in the development of a healthy infant, both be· on infant with o neural tube defect such
fore and during pregnancy. Following a healthy diet is then ,·cry important. The os spino bifido should consult their physician
American College of Obstetrics and Gynecology reminds women char it is especially obout the need for folic ocid supplementation;
important to meet folic acid needs (400 µg of synthetic folic acid ), which is possible if on intake of 4 mg of synthe~c folic ocid per doy
the woman makes careful dietary choices. Alternately, addjng a b.1lanced multivitamin ot least one month prior lo conception is recom·
and tninera1 supplement co one's diet is ~1 l so appropriate for meeting this goal. mended, but it must be token under o physi·
Dr. Lynn Bailey d iscusses fo lic acid and related pregnancy outcomes in greater detail cion's supervision.
in the Expert Opinion.
embryo In humans, the developing in utero

Prenatal Growth and Development offspring from about the beginning of the third
week to the end of the eighth week otter
For 8 \\'eeks .ifter conception, a human embryo develops from a fCrtilized o vum into conception.
a fetus . For about another 32 weeks, the fetus continues to develop. \Vhcn its body fi-
nally matures, the infant is born. Until birth, the motl1er nourishes it \'ia a p lacenta, ovum The egg cell from which o fetus
eventually develops if the egg is ferti lized by a
an organ that forms in her uterus to accommodate the growth and development of the
sperm cell.
fetus (Figure 16-1).
The specific role of the placenta is to exchange nutrienti., oxygen and other gases, and fetus The developing life form from about the
wa~te products between the mother and the fews. To accomplish these tasks, the placenta beginning of the ninth week otter conception
uses all the absorption mechanisms employed by the GI U':l.ct ( re\•icw Chapter 3 ). £yen until birth.
though the tissues of the placenta and the embryo are "interdigitated," the blood of the placenta An organ thot forms in the uterus in
fccus and mother never mix. In face, the tctal blood is separated from the maternal blood pregnant women. Through this organ, oxygen
by just cwo byers of ceUs (5.5 µ.m ). Fetal blood tra\'Cls from the fetal hcarr co the pla- ond nutrients from the mother's blood ore
centa by way of cwo umbilical arteries and re cums (nutrient-enriched :ind waste-free) co transferred to the fetus and fetal wastes are
d1e focus by means of one umbilical vein. In addition, the placenta abo is a major sire of removed. The plocento olso releases hormones
hormone production during pregnancy. As d1c pregnancy continues, the placenta en- tho! mointoin the stole of pregnancy.
brgcs along with the fetus and usually weighs about 1.5 lb (0.7 kg) ar delivery.
584 Chapter 16 Pregnancy and Breastfeeding
·'t:i!~-----;-'';'-;fJHln~R-7-- Umbilical arteries

~-----;-~~~~~~~- Umbilical vein
Cervix
Maternal blood
Diffusion
Oxygen and
nutrients into
fetal blood
Diffusion
Waste substances
into maternal blood
Blood Row from fetvs, branch of umbilical a~
Blood Row to fetus, branch of umbilical vein
Figure 16· 1 I The fetus in relationship to the placenta. The placenta is the organ through which
nourishment Rows lo the fetus. The inset shows how blood circulation of the mother and fetus work
together to provide the fetus with oxygen and nutrients while also removing fetal waste products
Early Growth: The First Trimester Is a Very Critical Time

The fo rmatio n or l he human o rganism begins when an egg and a sp erm u n ite w form
zygote The fertilized ovum; the cell resulting th e zygote (Figure 16 -2). About 30 ho urs arter th e egg is fertilized, the zygote re-
from the union of on egg cell (ovum) and sperm produces irselfby d ividing in half. Tbe p rocess of cell division then repeats many times.
until it divides. As the cluster of cclb drifts down the fallopian tu be to the woman's u ecrus, several
conceptus A generic term for any kinds of ceUs emerge. The cm.ire generic code is passed to every ceU, bur c.ich cell me'
developmental stage derived from the fertilized only a segmenr of rhc code to produce proteins. lf this partial use did not take place,
ovum (zygote} until birth. The conceptus there would be no differenc organs or body parts. For example, all cell<; carry genes
includes the exlroembryonic membranes as that dictate hair color and eye color, but only the ceUs of the hair follicles and irisc~ re-
well os the embryo or fetus. spond to that specific information.
O n abouc the fourth day after fi:rtilization, the conceptus, now about 128 cclb and
ho llow, arrives in the uterus. By the seventh day, the con cepms implan ts into the uter-
Sperm
ovum
ova
Implantation
Figure 16· 2 l After ovulation, the discharged ovum first enters the abdominal cavity and then finds
its way into the fallopian tube, where conception, or ferti lization, takes place. Sperm cells "swim" up
the fallopian tube toward the ovum. fertilization most often occurs in the outer one-third of the fallopian
tube. The ovum also lakes on active role In the process of fertilization by attracting and "trapping"
sperm with special receptor molecules on its surface. As soon as the head and neck of one
spermatozoon enter the ovum (the tail drops off), complex mechanisms in the egg are activated to
ensure that no more sperm enter. The 23 chromosomes from the sperm combine with the
23 chromosomes already in the ovum lo make up the 46 chromosomes of the conceplus.
The time to begin thinking about prenatal
nutrition is before becoming pregnant. This
includes making sure folic acid intake is
adequate (400 µ,g of synthetic falic acid per
ine lining. Two weeks after conception the cell number has increased further, and the
day) and that any supplemental use of
concepms is now termed an embryo. By day 35 of gestation, the heart is beating, and
preformed vitamin A does not exceed l 00% of
although the embryo is only 8 mm (about 3/8 inch) long, the eyes and so-called limb the Daily Value (1000 µg RAE or 5000 IU).
buds, which ultimately form the arms and legs, are clearly visible. From about the end
of the eighth week after conception to its birth about 32 weeks later, the developing
offspring is known as a fetus.
For purposes of discussion, the duration of pregnancy-normally, 40 weeks, mea-
sured from the first day of the woman's last menstrual period- is commonly divided
into three periods, called trimesters. Growth begins in the first trimester with a rapid trimesters Three 13- to 14-week periods into
increase in cell number (hyperplasia). This type of growth dominates embryonic and which the normol pregnancy is somewhat
later fetal development. The newly formed cells then begin to grow larger (hypertro- arbitrarily divided for purposes of discussion
phy). Further growth and development then involve mostly hyperplasia with some hy- and analysis (the length of a normal pregnancy
pertrophy. By the end of 12 weeks-t11e first t:J.imester-most organs are formed and is about 40 weeks, measured from the first day
the fetus can move (Figure 16-3). of the women's last menstrual period).
As the embryo or fetus develops, nutritional deficiencies and other insults have the Development of the offspring, however, is
continuous throughout pregnancy, with no
potential to impose damage or risk to organ systems. 11 For example, adverse reactions
specific physiological characterizations
to medications, high intakes of vitamin A, exposure to radiation, or trauma can alter demarcating the transition from one trimester to
or arrest the current phase of fetal development, and the effects may last a lifetime (re- the next.
view Figure 16-3). The most critical time for t11ese potential problems is during the
first trimester. Most spontan eous abortions-premanire terminations of pregnancy spontaneous abortion Cessation of pregnancy
that occur naturally-happen at tl1is time. Cmrently, about one-half or more of all and expulsion of the embryo or nonviable fetus
pregnancies end in this way, often so early that a woman does not even realize she was prior to 20 weeks gestation. This is the result of
natural causes, such as o genetic defect or
pregnant. (An additional 15 to 20% are lost before normal delivery.) Early spontaneous
developmental problem; also called
abortions usually result from a genetic defect or fatal error in fetal development.
miscarriage.
Smoking, alcohol abuse, use of aspirin and NSAIDs, and iJJicit d rug use raise the risk
for spontaneous abortion.5
A woman should avoid substances that may harm the developing fetns, especially
during the first trimester. This caution holds true, as weU, for d1e time when a woman
is trying to become pregnant. As previously mentioned , a woman is unlikely to be
aware of her pregnancy for at least a few weeks. In addition , die fetus develops so rap-
idly during the first trimester tllat if an essential nutrient is not available, the fetus may
586 Chapter 16 Pregnancy and Breast Feeding
Expert Opinion 11
Folic Acid Interventions : Public Health Outcomes

Lynn B. Bailey, Ph.D.
Folic Acid and Neural Tube Defects United States and Canada now man·
dote the addition of folic acid to all
One of the most exciting recent public health discoveries is that folic acid, a "enriched" cereal groin products.
wa ter-soluble vitamin, will significantly reduce the incidence of neural tube In the United Stoles, food forti fi-
defects (NTDs), major birth defects affecting the spinal cord and brain. The ca tion was originally proposed by
key scientific evidence proving that folic acid alone prevents a large per- FDA to provide only a portion (100
centage of NTDs is evidence from a randomized controlled trial conducted µg/doy) of the recommended dose
by the Medical Research Council in 199 1. This study, confirming numerous (400 µg/doy) associated with NTD
observational studies, demonstrated that folic acid supplements token just risk reduction and was to be coupled
prior to conception and during the initial period ofter conception (pericon- with dietary advice to increase the
ceptionol period) con reduce NTD ri sk by as much as 70%. The form of the consumption of folote-rich foods
vitamin linked to the reduction in risk for NTDs in the research studies is the (e.g., orange juice, dork green leafy
monoglutomote form (folic acid), used commercially in supplements and in vegetables). It is now recognized
folic acid- fortified foods. that the estimated doily increase in Delivering a healthy baby is more
Metabolically, folote is converted to coenzyme forms required in numer- folic acid consumption due to fortifi- than just luck. Many nutrition- and
ous one-carbon transfer reactions involved in the synthesis of DNA, amino cation is approximately twice (- 200 health-related practices, such as
acids, and other essential structural and regula tory compounds required for µg/doy) tha t originally proposed. folote intake, need to be
normal cell division and growth. During the first 28 days of gestation, before This higher-than-expected increase considered.
most women even know they ore pregnant, there is on explosion of new cell occurred because the food industry
division within the embryonic tissue that develops into the spinal cord and added substantially more folic acid to many forti fied products than was re-
brain, a process dependent an an adequate supply of folate. quired by low.
Several thousand food items, including mixed dishes and snack foods,
Folic Acid Fortification now contain folic acid. The good news is that the widespread consumption
of folic acid-fortified foods hos resulted in significant increases in blood fo-
The strong scientific evidence that taking periconceptional folic acid supple- lote concentrations in all age groups in the United States. It hos also been
ments dramatically reduces the risk of NTDs prompted the U.S. Public Health associated with significant reducti ons in NTDs in both the United States and
Service in 1992 to recommend that all women of reproductive age consume Canada, demonstrating the successful translation of science into on effective
400 iJ.g/ doy of folic acid. Three approaches were recommended: improve public health policy.
dietary habits; fortify foods with folic acid; and toke dietary supplements
containing folic acid.
Compliance wi th this 400-!J.g/day recommendation for folic acid con- Folic Acid and Heart Defects
sumption was not good; the majority of women capable of becoming preg- This development of widespread folic acid fortifica tion of our food supply
nant were not meeting folic acid needs. In response, countries including the now allows researchers to evaluate evidence for on association between
be affected even before evidence of the nut rient deficiency appears in the mother. Still,
although a mother's decisions, practices, and precautions during pregnancy contribute
to the health of her ferns , she cannot guarantee her fetus good health because some
genetic and environmental fuctors are beyond her control. She and others involved in
the pregnancy should nor hold an u nrealistic illusion of total control.
The quality-rather than the guantiry-of nutritional intake is most important dur-
ing the first trimester. Tn other words, women should consume the same amount of
energy, but the foods chosen should be more nutri.cnr densc. 1 Although some wo men
lose their appetite and feel nauseated during the first trimester, they should be carefol
to meet nutrient needs as much as possible.
I
!
I
I
I
periconceplional folic acid and other common congenital anomalies, includ- ond multiple births wos no longer significant. Several recent evaluations of
ing heart defects. Heart defects affect 1 in 110 newborns and account for a the effect of folic acid fortification on the rote of multiple births in the United
third or more of infant deaths due to birth defects, more than for any other Stales following mandatory folic acid fortification in 1998 led lo the conclu-
congenital anomaly, including NTDs. It is estimated !hot 6000 deaths ollrib- sion that there was no evidence that multiple births hove increased. Women
utoble lo heart defects occur in the United Stoles eoch yeor. Research sup- of reproductive age and their health-core providers con support the pericon-
ports the conclusion thot toking multivitamins containing folic ocid during ceptionol goal of consuming 400 ~1g/day of folic acid to reduce NTDs with-
early pregnancy is ossocioted with o significant risk reduction for heart de- out concern that this practice will increase the occurrence of multiple births.
fects. A randomized controlled lriol would allow a comparison between the
effect of folic ocid alone relative lo other vitamins ond lo a placebo. The re- Conclusion
sulting doto could show a couse-and-effecl relationship between folic odd
ond heart defects. Such a study is required before definitive conclusions ond Over the post 20 years, scientific proof of the connection between folic acid
public health recommendations similar lo those for NTDs con be mode. ond NTDs led to mandatory cereal-product fortification and hos ultimately re-
sulted in o significant decline in NTD-offected pregnancies and births in the
United States ond Conoda. Preliminary evidence suggests thot folic ocid
Safety Issues Regarding Folic Acid supplementation con also contribute to a reduction in the incidence of con-
genital heorl defects. It is no surprise, then, that further programs lo educate
It is important to address the question of safety of folic ocid intake because
women ond their health-core providers of the benefits of folic ocid could re-
many of us ore consuming more than we hove in the past. Based on the
sult in even fewer NTD-offected births.
Institute of Medicine's thorough consideration of this question, there is no sci-
entific evidence that high intakes of folic acid result in toxic side effects.
There is, however, o Tolerable Upper Level for folic ocid of 1000 µ.g/doy, Dr. Bailey is Professor in the Food Science and Human Nutrition
based on evidence that high doses of supplemental folic acid in vitamin Department of the University of Florido, Gainesville, Florida. Dr.
B-12-deficient individuals {predominantly older adults) may correct the re- Bailey received her master of science From Clemson University and
lated anemia (often used to diagnose o B-12 deficiency), which moy delay her Ph.D. from Purdue University. Dr. Bailey's research area of ex-
diagnosis and treatment ond thus allow the progression of the neurological pertise is folate metabolism, estimation of folate requirements, and
degeneration associated with the B-12 deficiency. This issue is the primary factors that influence disease and birth defect risk, including genetic
reason that countries outside the United States and Canada hove not man- polymorphisms. Dr. Bailey has conducted human metabolic studies
dated folic ocid fortification. over a period of 25 years, generating data that has been instru-
Some reports suggest that the use of periconceplional folic ocid increases mental in establishing new dietary intake recommendations for indi-
the risk of multiple births, a concern because multiple births ore associated viduals throughout the life cycle, including pregnant women and
with more pregnancy complications and ore more likely lo result in prelerm older adults. Dr. Bailey has received numerous awards for her re-
delivery. When the data in these studies were corrected for factors such as search, including the 2004 American Society for Nutritional Sciences
the use of reproductive technology ond increased maternal age, known lo in- Centrum Center Award for her accomplishments related to human fo-
crease the likelihood of multiple births, the ossociotion between folic ocid lote requirements.
Second Trimester
By rhe beginning of the second trimester, a fetus weighs abour 1 oz. Arms, hands, fin-
gers, legs, fet:t, and toes are fu lly formed. The ferus has ears and begins ro form rooth
sockets in its jawbone. Organs continue to grow and mature, and \\ith a stethoscope,
physicians can detect the fetus's heartbeat. Most bones are distinctly evident tlu·ough
the body. Eventually, tl1e fetus begins to look more like an infant. Ir may suck its thumb
and kick strongly enough to be felt by the mother. As W•lS shown i.n Figurc 16-3, the fetus
can still be affected by exposure to toxins, but not to the degree seen in the first
trimester.
Sperm and egg

unite and implant
Week 2 3 4 5 6 8 16 38
Risk from Physiological defects and
Low Ma jor structural abnorrnalities
toxic agents minor structural abnormalities
Central
nervous
system
Heart
Limbs
Eyes
Ears
Palate
Teeth -- ------- -- --- --- - --- --- - -- --- --- - --- -- --- -- ---- --- ----- ---- --- - '--- - - - - - - + -- - - - - - - - -- --l
External
genitalia
Figure 16· 3 I Harmful effects of toxic agents during pregnancy. Vulnerable periods of fetal
development are indicated with orange bars. The orange shading indicates the time of greatest risk to
the organ. The most serious damage to the fetus from exposure to toxins is likely to occur during the first
8 weeks after conception, two-thirds of the way through the first trimester. As the white bars in the chart
show, however, damage to the eyes, brain, and genitals can also occur during the last months of
pregnancy.
During the second trimester, the mother's breast weight increases by approximatel~·
30% because of the development of mi lk-producing cells and the deposition of 2 to
lactation The period of milk secretion following 4 lb of fat for lactation. T his stored fat serves as a reservoir for the extra energy needed
pregnancy, typically called breastfeeding. to produce breast milk. 1
Third Trimester
By the beginning of the third trimester, a fetus weighs about 2 to 3 lb. The thfrd
trimester is a crucial time for fetal growth . The fotus will double in length and will mul-
tiply its weight by three to fo ur times. An infant who is born after about 26 weeks of
gestation has .1 good chance ofsun·ival if cared for in a nursery for high-risk newborns. gestation The period of intrauterine
Howe\'cr, the infunt will not contain the stores of minerals {mainly iron and calcium) development of offspring from conception to
and fut that are normally accumulated du1ing the last month of gestation. This and birth; in humans, gestation lasts for about 40
other medicaJ problems, such .1s a poor ability to suck and swaUo\\, complicate nutri - weeks after the woman's lost menstrual period
tionaJ care for preterm infants. Note aJso that the fetus takes higher priority lhan the
mother with regard to iron, and will deplete the stores of the mother. If the molher is
not meeting her iron needs, she can be se,·erely depleted after deli\'ery. 1
At 9 months, the tctus usually weighs about 7 to 9 lb ( 3 to 4 kg) and is abour 20
inches (50 cm ) long. A soft: spot on the top ofrl1e head indicates where the skull bones
{fontanels) are growing together. The bones finaUy close by the time the baby is about
12 to 18 mond1s of age.
Definition of a Successful Pregnancy

One common criterion ora successfi.tl pregnancy is t he protection of the mother's
physical and emotional health, so that she can return to her prepregnancy health Sta-
rns. As for the infant, two widely accepted crite1ia are
• a gestation period longer than 37 weeks
• a birth weight greater than 5.5 lb (2 .5 kg) A healthy full-term newborn usually weighs
about 7 .5 lb and is 20 in. long.
Sufficient lung devdopmenr, which is likely to have occurred by 37 weeks' gestation,
is critical to the survi\'al of a newborn. The longer the gestation, the greater the ulti -
mate bird1 weight and maturation state, leading to tc"·er medical problcms.9
Low-birth-weigh t (LBW) infants are those weighing less than 5.5 lb (2.5 kg) ar low birth weight (LBW) Referring lo any infant
birth. ~lost commonly, LBW is associated \\'irll preterm birth. 1 0te tlut hospital- weighing less than 2.5 kg (5.5 lb) at birth,
rclated costs of caring for lo\\ -bird1-weight newborns totaJ more rllan $2 billion per most commonly results from prelerm birth.
year in the United Scates, ranging from $20,000 to $200,000 per infant. Compare this preterm An infant born before 37 weeks of
amount with .111 average hospiral-related cost of $4300 for a normaJ delivery and an gestation; such on infant is also referred to as
a\'erage of $800 for prevcnti\'c prenatal care. Full-term and pretcrm infants who weigh premature.
less than the expected weight for their duration of gestation, the result of insufficient
small for gestational age (SGA) Referring lo
growth, arc described as sm all for gestationaJ age (SGA). Thus, a f'uJl -term infam
infants who weigh less than the expected
weighing less than 5.5 lb (2.5 kg) at birth is SGA but not preterm, whereas a prcterm
weight for their length of gestation. This
infant born .u 30 weeks' gestation is probably low bird1 weight without being SGA. corresponds lo less than 2.5 kg (5.5 lb) in a
lnfunts who are SGA arc more likely than normal-weight infants to have medical com - full-term newborn. A preterm infa nt who is also
plications, including proble ms with blood gl ucose control, temperature regulation, SGA will most likely develop some medical
growth, and development in the early weeks <1fi:er birth. complications.
The newborn 's quality oflife must also be considered in rating the success of a p reg-
nancy. Overall, the goal of preprcgnancy and prenatal care is to ensure that the baby is
born healthy, on time, and \\'ith the mental, physical, and physiological capabilities to
take ad,·ancagc of \\'hatever life offers, while also protecting the mother's hcalrh. 1·3,l 5
gaol of Healthy People 2010 is lo reduce
low birth weight and prelerm births by
Concept I Check one-third.
To help ensure the optimal health of both the mother and her oflSpring, adcqu,ltc nutri-
tion, especially meeting folatc needs from a synthetic source starring at least 3 months be-
fore pregnancy begins, i~ ''ital both betore and during pregnancy. Organs and bod~ parts in tudies from Britain suggest that infants who
the offspring begin to de\'elop \'cry soon after conception. The fir~t trimester is a cricical are small for gestational age ore likely lo
period during "hich inadequate nutrient intake or alcohol and drug use can result in birth develop obesity, diabetes, hypertension, and
defects. other health problems during later adult years.
Infant!> born after 37 weeks of gestation who weigh more than 5.5 lb (2.5 kg) have the Reduced growth of the liver, the pancreas, the
fewc~t medical problems at birth. To reduce infant and maternal medical problems or kidneys, and other argons during gestation is
death, the expectant mother, family, and medical care providers should take the steps ncccs· one possible reason. This increase in health risk
sary 10 allow the mother to carry the baby in her uterus for the entire 9 months, which in is likely to be more pronounced if the infants
tum contributes to adequate growth. Good nutrition and health practices aid in this goal. also foil to gain enough weight in the first year
of life.
I Increased Nutrient Needs to Support Pregnancy

Pregnancy is a time of increased nutrient needs. Mothers-ro-be need individual assess-
ment and counseling, because the nutritional and health status of each woman is dif-
ferent. Still, some general principles arc true of most women with regard to increased
nurrient needs. 1
Increased Energy Needs

To supporr the growth and development of the fetus, pregnant women need ro in-
crease their energy intake. Energy needs during d1e first trimester are essenriallv the
same as for the nonpregnant woman. However, during the second and d1ird trime~ters,
a pregnant woman must consume approximately 350 to 450 kcal more per day than
her prepregnancy needs (the upper end of the nmge is needed in the thi1·d trimester). l
This e.\.'l:ra energy should be in the form of nutrient-dense foods, not sugary desserts
or far-filled snacks. For example, throughout the day, about six whole-wheat crackers,
1 ounce of cheese, and 1/2 cup of fat-free mi lk would supply the extra energy (:rnd
Many women recognize the benefits of
also some calcium). Although she "eats for two," the pregnant woman must not dou -
remaining active during pregnancy. Health-care ble her normal energy intake. The eating for t'vVO concept refers more appropriately to
providers typically encourage healthy, weJJ. increased needs for several vitamins and minerals. Micronutrient needs are increased by
nourished women to engage in moderate up to 50% during pregnancy whereas energy needs during the second and third
exercise as long as increased energy and trimesters represent only about a 20% increase. 1
nutrient needs are met. If a woman is active during her pregnancy, she may need ro increase her energy in-
take by even more than the estimated 350 to 450 kcal per day. Her greater body
weight requires more energy for activity. Pregnancy is not the time to begin an intense
fimess regimen, but women can generally take part in most low- or moder:ue-intensity
activities dLLt'ing pregnancy. Walking, cycling, swimm.ing, or light aerobics for 30 min-
utes or more on most days of the week is generally advised and may actually promote
an easier delivery. 12 A fow types of activities can potential ly harm the ferns and should
be avoided, especially activities with inherent risk of falls and abdominal trauma.
Examples of exercises to avoid, especially dming d1e second and third trimesters, in-
clude downhill skiing, weight Lining, soccer, basketball, horseback riding, certain cal -
isthenics (e.g., deep knee bends), any contact sports (e.g., hockey), and scuba diving.
Because mru1y women find that they are inactive during the later months, part!}• be-
cause of their increased size, ru1 extra 350 to 450 kcal in their daily diets is usually
enough.
Women with high-risk pregnru1cies, such as those experiencing premature labor
he American College of Obstetrics and
T Gynecology suggests the following guide-
lines for physical activity during pregnancy:
contractions, may need to restrict their physical activity. To ensure optimal heald1 for
bod1 herself and her infant, a pregnant woman should first consult her physician abour
physical activity and possible Limitations.
1. Do not allow heart rate to exceed 140
beats per minute.
Adequate Weight Gain
2. Avoid exercising in hot, humid weather.
3. Discontinue exercise that causes discern· Adequate weight gain for a mother is one of the best predicrors of pregnancy outcome.9
fort or overheating. Her diet should allow for approximately 2 to 4 lb (0.9 to 1.8 kg) of weight gain during
4. Drink plenty of liquids to avoid dehydra- the first trimester and tl1en a subsequen t weight gain of 0.75 to l lb (0.3 to 0.5 kg)
tion and overheating. weekly during the second and third t1imesters. A healthy goal for total weight gain for
5. After about the fourth month, don't exer· a woman of normal weight (based on BMI; Table 16-1) averages about 25 to 35 lb
cise while lying on your bock, because (11.5 to 16 kg). Adolescents and African-American women, who often have smaller ba-
this decreases cardiac output. bies, are strongly advised to aim for the greater amount. Women carrying twins should
6. Avoid an abrupt decrease in exertion. In gail1 35 to 45 lb, and d1ose canying triplets should gain 50 lb (23 kg). 1
other words, don't just stop and stand For women witl1 a low BMl (less tl1an 19.8), tl1e goal increases to 28 ro 40 lb ( 12.5
around after a hard workout; rather, con· to 18 kg). The goal decreases to 15 to 25 lb (7 to 11.5 kg) for women at a high BMT
tinue exercising but at a slow pace, grad· (26 to 29) and 15 lb (7 kg) (or more) for an obese woman ( BMI greater than 29).
ually reducing pulse rate. Figure 16-4 shows why the typical recommendation begins at 25 lb.
www.mhhe.com/wardJaw pers7 591
Table 16· 1 I Recommended Weight Gain in Pregnancy Based on Prepregnancy uring pregnancy, women in North America
Body Mass Index (BMI). ore more likely lo gain excess weight ond
make poor food choices than to eot loo little.
Total Weight Gain•
Prepregnoncy BMI Category (lb) (kg)
Low (BMI less than 19 .8) 28 lo 40 12.5 to 18
Normal (BMI 19.8 to 25.9) 25 to 35 11.5 to 16
High (BMI 26 to 29) 15 to 25 7 to 11.5
Obese (BMI greoter than 29) 15 (or more) 7 {or more)
Reprinted with permission fTom N11trihon Dunng Pregnancy and Lactation, Copyright 1992 by !he Notional Academy ol Sciences.
Courtesy of the Notional Academy Press, Washington, DC
'The listed values ore lor pregnancies with one fetus. Short women (less than 62 in.J should strive for gains ot the lower end ol the
ranges For women ol normal BMI who ore carrying twins, the range is 35 ta 45 lb (16 lo 20 kgJ Adolescents within 2 years of
beginning menses and African-American women should strive lor gains al lhe upper end of the ranges.
25
Maternal
fat stores
20 (4-8 lb)
~.. Uterus and

.c 15 breasts
OI
'Qi (6 lb)
~
Blood
(4 lb)
10
Fetus, placenta,
amniotic fluid
5 (11 lb;
fetus itself weighs
about 8 lb)
Figure 1 6·4 I The components of weight gain in pregnancy. A weight gain of 25 to 35 lb is

recommended For most women. Note thot the various components lotal about 25 lb.
A weight gain between 25 and 35 lb (11.5 to 16 kg) for :i wom:in sr:irting at nor-
m.11 weight has repeatedly been shown ro yield optimal he:ilth for both mother and
fetus if gestation lasts at least 38 weeks. 1 The weight gain should yidd :i birth weight
of 7.5 lb (3.5 kg). Although some extra weight gain during pregnancy is usually not
harmful (about 5 to 10 lb), it can set the stage for a panern of weight gain during the
childbe:iring years if the mother docs not return to her approximate prepregnancy
weight.
Weight gain during pregnancy, cspeci:illy in the teenage years, should generally ful-
low the panem in Figure 16-4. Weight gain is a key issue in prenatal care and a con-
cern or
many mothers-to-be. Remember that inadequate weight gain can cause many
59 2 Chapter 16 Pregnancy and Breastfeeding
problems. Many pregnant women keep weekly records of their weight gain to help
I 11,Jrik~ng tbem adjust their food intake.
Alexandro wonts to hove o baby. She hos If a woman deviates from the desirable panern, she should make the appropriate ad-
read that ii is very imporlon/ for women lo be justment. For example, if a woman begins to gain too much weight during ber preg·
healthy during pregnancy. However, Jone, her nancy, she should not Jose weight to get back on track. Even if a woman gains 35 lb
sister, tells her that the lime lo begin to assess in the first 7 months of pregnancy, she must still gain more during the last 2 months.
her nutritional and health status is oc/uolly be- She should simply slow the increase in weight to parallel the rise on tbc prenatal weight
fore she becomes pregnant. What oddilionol gain chart. In other words, the sources of the unnecessary calories should be found and
information should Jone give Alexandro? minimized. Alternately, if a woman has not gained the desired weight by a given poim
i11 pregnai1cy, she shouldn't gain the needed weight rapidly. Instead, she should slowly
gain a little more weight tha11 tl1e typical pattern to meet the goal by the end of the
pregnwcy. A registered dietitiw can help make any needed adjustmcnts. 1
Increased Protein and Carbohydrate Needs

The RDA for protein increases by an additional 25 g/day during pregnancy. A cup of
milk alone contains 8 g. Many nonpregnant women already consume protein in excess
of t11eir needs and therefore do not need to increase protein intake any further.
However, all women should check to make sure they are actually eating enough pro·
rein (as well as enough energy so this protein is not used for energy needs).
The RDA for carbohydrate increases to 175 g/day. This amount prevents ketosis,
which can harm the fetus (see t11e Nutrition Focus section on the effects of many fac·
tors on pregnancy outcome). Most women already consume tl1is amount and more. 1
t is important to note that vitamin A needs in·
crease only by 10%, so o specific focus on
Increased Vitamin Needs
this vitamin is not needed. And remember, ex·
cess amounts of vitamin A ore very harmful to Vitamin needs gencraUy i.ncrease from prepregnancy RDAs/Adequate Intakes by up to
the developing fetus.5 30% for most of tl1e B vitamins, and even greater for ''itamin B-6 (45%) wd folate
(50%). The extra amount of vitamin B-6 and oilier B vitamins (except fo!ate) needed in
the diet is easily met via \vise food choices, such as a serving of a typical ready-to-ear
breakfast cereal and some animal protein sources. Folate needs, however, often merit
specific diet planning and possible vitamin supplementation. Because the synthesis of
DNA, and therefore cell division, requires fo!ate, this nutrient is especially crucial dur·
ing pregnancy. Ultimately, bom fetal and maternal growtl1 depend on an ample supply
of folate. Red blood cell formation, which requires folate , increases during pregnancy.
Serious folate-related anemia tl1erefore cai1 result if folate intake is i.nadequate. The
RDA for folate increases during pregnancy to 600 µg DFE/day. This goal is critical in
the nutritional care of a pregnant woman. 3 Increasi.ng folate intakes to meet 600 µg
DFE per day for a pregnant woman can be achieved through either dietary sources or
a supplemental source of folic acid or a combination of both. Choosing a diet rich in
synthetic folic acid, such as from ready-to-eat breakfast cereals or meal replacement bars
(look for approximately 50 to 100% of the Daily Value), is especially helpful in meeting
folate needs. Recall from Chapter 10 that synthetic folic acid is much more easily ab·
sorbed than the various forms of folate found naturally in foods.
Increased Mineral Needs

Mineral needs generally increase dming pregnancy, especially the requfrements fo r io-
dide and iron. Zinc needs also increase. (Calcium needs do not increase but still may
deserve speciaJ attention because many women have deficient ii1takes.) 3
Pregnant women need extra iodide (total of220 µg/day ) for prevention of goitc.:r.
Typical iodide intakes are enough if the woman uses iodized salt. Animal proteins or a
fortified ready-to-eat breakfast cereal in the diet can easily provide enough extra zinc.
Pregnancy leads to increased nutrient needs for Extra fron (total of 27 mg/day) is needed to synthesize the greater amount ofhemo·
the mother. Meeting these nutrient needs is on globin needed during pregnancy and to provide iron stores for the fetus. Women often
important step toward a successful pregnancy. need a supplemental source of iron , especially if they do not consume iron -fortified
www.mhhe.com/ wardlawpers7 .593
foods, such as highly fortified breakfust cereals containing close to l 00% of the Daily regnant women who ore not anemic may
Value for iron ( 18 mg). Because iron supplements decrease appetite and can cause nau· wait until the second trimester, when
sea and constipation, they should be taken between meals or just before going co bed. pregnancy-related nausea generally lessens, to
Milk, coffee, or tea should not be consumed with an iron supplement because these start iron supplementation if needed.
beverages have substances that interfere with iron absorption. Eating foods rich in vi -
tamin C along with nonheme iron-containing foods and iron supplements helps in·
crease iron absorption from those sources.
The consequences of iron-deficiency anemia-especially during the first trirnester-
can be severe. Negative outcomes include pretem1 delivery, low-birth-weight infants,
and increased risk for tetal death in the first weeks after birth. 1
Is There an Instinctive Drive during Pregnancy to Consume

More Nutrients?
[t is a common myth that women instinctively know what to cat during pregnancy.
Cravings of the last two trimesters arc often related ro hormonal changes in the mother
or to famil)' traditions. Such "instincts" cannot be trusted, however, based on obser-
vations that some women crave nonfood items (called pica) such as laundry starch, pico The practice of eating nonfood items,
chalk, cigarette ashes, and soil (clay). This practice can be extremely harmful to the such as dirt, laundry starch, or clay.
mother and the ferus. Overall, though women may ha,·e a natural instinct to consume
the right foods in pregnancy, humans arc so far removed from living by instinct that
relying on our cravings to meet nutrient needs is risky. Nutrition advice by e:\'])erts is
more reliable. 1
Food Plan for Pregnant Women

One approach to a diet tbat supports successful pregnancy is based on My Pyramid. For
an active 24-year-old woman in the first trimester, about 2200 kcal arc recommended.
The plan should include:
• 3 cups of calcium-rich foods from the milk group, or USC of calcium-fortified foods
to make up for any gap between calcium intake and need
• 6 ounce-equivalents from the meat & beans group
• 3 cups from the vegetable group
• 2 cups from the fruit group
• 7 ounce-equivalents from the grain group
• 6 teaspoons of vegetable oil Pregnancy, in particular, is not a time to self.
Specificall)', choices from the milk group should include low-fut or fat-free versions prescribe vitamin and mineral supplements (or
of milk, yogurt, and cheese. These foods supply extra protein, calcium, and carboh} 1• medications in general). For example, although
vitamin A is a routine component of prenatal
drate as well as other nutrients. Choices from the meat & bean~ group ~hould include
vitamins, it is important to note that intakes over
both animal and \'egetable sources. Besides protein, these foods help provide the extra
three times the RDA for vitamin A have been
iron and zinc needed. The vegetable and fruit group choices provide a variety of vita- shown lo have toxic effects on the fetus.
mins and minerals. One cup from this combination should be a good vitamin C source,
and one cup should be a green vegetable or other rich source of folare. Choices from
the grain group should foc us on whole-grain and enriched foods. One ow1ce of a
whole-grain ready-to-eat breakfast cereal significantly contributes to meeting many vi-
tan1in and mineral needs. Finally, inclusion of plant oils in the diet contributes essen-
tial fatty acids. Discretionary calories (up to 300 kcal) can then be added to allow for
weight maintenance.
In the second and third trimesters, about 2600 kcal arc recommended. The plan
should now include:
• 3 cups of cakium-rich foods from the milk group, or use of calcium-fortified foods
• 6 1/2 ounce-equivalents from the meat & beans group
• 3 1/2 cups from the vegetable group
5 94 Chapter 16 Pregnancy and Breastfeeding

• 8 ounce-equivalents from the grain group
• 7 teaspoons of vegetable oil
Discretionary calories (up to 400 kcal) can rhen be added. The overall diet should
allow for gradual weight gain.
Table 16-2 illustrates one daily menu based on the basic diet plan for women in the
second and third trimesters. This menu meets the extra nutrient needs associated with
pregnancy. Women who need to consume more than 2600 kcal-and some do for var·
ious reasons-should incorporate additional fruits, vegetables, and wbole-grain breads
and cereals, not poor nua·ient sources such as desserts and sugared soft drinks.
Table 16·2 I A Sample 2600 kcal Daily Menu That Meets the Nutritional Needs
of Most Pregnant and Breastfeeding Women
Vitamin 8·6 Folate Iron Zinc Calcium

Breakfast
Kellogg's Smart Start cereal, l cup I I I I
Orange juice, 1 cup I
fat-free milk, 1 cup I I
Snack
Peanut butter, 2 tbsp I I I I
Celery, 2 stalks I
Whole-wheat toast, l slice I I I
Plain low-fat yogurt, 1 cup I
Strawberries, 1/2 cup
Lunch
Spinach salad, 2 cups with 2 tbsp oil and
vinegar dressing I .!
Tomato, 1/2
Whole-wheat toast, l slice I I .!
Provolone cheese, 1 1/2 oz I I
Snack
A salad each day provides many nutrients for Whole-wheat crackers, 5 I .! .!
the prenatal diet. Grape juice, 1 cup
Dinner
Lean hamburger, 3 oz, broiled
(with condiments) .! .! I
Baked beans, 1/2 cup .! I .! .!
Hamburger bun, 1 I .!
Sliced tomato, 1/2
Cooked broccoli, 1 cup I I
Soft margarine, 1 tsp
Iced tea
Snack
Granola bar, 2 oz I I
Banana, 1/2 .!
Discretionary calories up to 400 kcal*
TI1is die! meets nutrient needs for pregnancy and loclotion. Lock of o check (/) indicates o poor source of the nutrient. The vitomi1>-
ond mineral.fortified breakfast cereal used in this example makes on imporlonl contribution lo meeting nutrient needs. Fluids con be
added as desired. Total intoke of fluids, such os waler, should be I 0 cups or so per doy.
•Amount of discretionary calories will vary based on the actual food choices mode within each MyPyromid group.
Use of Prenatal Vitamin and Mineral Supplements ercury con harm the nervous system of
the fetus. FDA warns pregnant women to
Special supplements formulated for pregnancy are prescribed routinely fo r pregnant
ovoid swordfish, shark, king mackerel, and tile
women by most physicians. Some are sold over the counter, whereas others arc djs-
fish because of possible high mercury contomi·
pensed by prescription because of their high synthetic fo lic acid content (1000 µ,g),
notion. Largemouth boss are also implicated. In
which could pose problems for otliers, such as o lder people (review Chapter 10).
general, intake of other fish and shellfish should
These supplements are very high in iron (27 mg per pill). There is no evidence that
not exceed 12 oz/week. Note a lso that because
use of such supplements causes significant bealth problems in pregnancy, aside perhaps canned albacore tuna is o potential mercury
from the combined amounts of supplementary and dietary vitamin A. During preg-
source, it should not be consumed in amounts
nancy, supplemental preformed vitamin A should not exceed 3000 µ,g RAE/day
exceeding 6 oz/week.
{15,000 IU per day). Toxicity of vitamin A is linked with teratogenic birth defects (re-
\'iew Chapter 9). Toxicity occurs mainly during the first trimester. The primary in-
scances when prenatal supplements especially may contribute to a successfal pregnancy
are with poor women, teenagers, women with a generally deficient diet, women car- teratogenic Tending ta produce physical
rying multiple fetuses, women who smoke or use alcohol or illegal drugs, and vegans. defects in a developing fetus.
In other cases healthy diets can provide the needed nutrients. L
Pregnant Vegetarians
vVomen who are either lactoovovegetarians or lactovegetarians generally do not face
special difficulties in meeting their nutritional needs during pregnancy. Like nonvege-
tarian women, they should be concerned prirnarily with meeting vitamin B-6, iron, fo-
late, and zinc needs.
On the other hand, for a vegan, careful diet planning during preconception and
pregnancy is crucial to ensure sufficient protein, vitamin D (or sufficient sun expo-
sure), vitamin B-6, iron, calcium, zinc, and especially a supplemental source of vitamin
B-12. 1•14,16 The basic vegan diet listed in Chapter 7 should be modified to include
more grains, beans, nuts, and seeds to supply the necessary extra amow1ts of some of
these nutrients. And as just mentioned, use of a prenatal multivitamin and mineral sup-
plement also is generally advocated to help fill micronutrient gaps. Note, however, that
although these supplements are high in iron, they are not high in calcium (200 mg per
pill). If iron and calcium supplements are used, they should not be taken together, to
a\'oid possible competition for absorption.
Concept I Check
Energy needs increase by an average of about 350 to 450 kcal/day during the second and
third trimesters of pregnancy. Weight gain should be slow and steady, up to a total of 25 to
35 lb (11.5 to 16 kg) for a woman of normal weight (i.e., prepregnancy BMT ofl9.8 to
25.9). Protein and certain vitamin and mineral needs increase during pregnancy. Most im-
portant to consider are vitamin B-6, folate, iron, iodide, and zinc. A pregnant woman's diet
should be varied and generally follow My Pyramid. A prenatal multivitamin and mineral
supplement is conunonly prescribed but may not be necessary depending on one's diet and
current health status. Taking too many supplements-especially vitamin A-can be haz- ecause of the nutrient demands of preg·
ardous ro the fetus. nancy coupled with chronic undernutrition,
women in many developing countries hove o 1
in 20 chance of dying from pregnancy-related
causes. In contrast, North American women face
Effect of Nutritional Status on the Success a risk of only l death from pregnancy-related
of Pregnancy causes in about every 8000 births. Pregnoncy-
related death is, in fact, the social indicator with
Is this attention to nutrition worth the effort? Yes; evidence shows that the effort is the biggest difference between the developing
justified. Extra nutrients and energy are used for feral growth and for changes in the and industrialized worlds. Smaller differences
mother's body to accommodate the fems. Her uterus and breasts grow, the placenta exist for literacy, life expectancy, and infant mor-
develops, her total blood volume increases, the heart and kidneys work harder, and tality. These statistics again show the importance
stores of body fat increase. of meeting women's nutrient needs in pregnancy.
Although it is difficult to specify what degree of poor nutrition will affect each
pregnancy, a daily diet containing only 1000 kcal has been shown to greatly restrict
fetal growth and development. 9 Increased maternal and i11fant death rates seen in
famine-stricken areas of Africa supply further evidence.
Genetic background can explain very little of che observed differences in birth
weight in North America. Both environmental factors and nutritional factors arc more
important. The worse the nutritional condition of the mother at the beginning of
pregnancy, the more valuable a good prenatal diet and/or use of prenatal supplements
arc in improving the cou rse and outcome of her pregnancy.
During World War U, parts of Russia and much of Holland were blockaded. Food
supplies were qLLickly exhausted. The resulting undemutrition greatly affected the
birth weights of infants developing in the second or third trimester. Birth defrccs also
occurred more commonly, and the number of new pregnancies fell. As •veil, the chil-
0 besity also increases pregnancy risks, be-

cause hypertension and/or diabetes is
likely presenl. These pregnancies require intense
dren born in those conditions exhibited a greater risk of mental disorders later in lite.
After the blockades were lifted, birch weights, subsequent infant health, and the num-
bers of new pregnancies quickly returned co prewar levels.
monitoring and pose on increased risk of pro- At die same time, researchers in Boston noticed that an adequate protein intake was
longed labor during delivery of the infant as associated with a greater success of pregna11cy. It appeared that the mother's di er-not
well as a greater risk for birth defects in the in- only during pregnancy bur also preceding conception-affected the health of both
fant, primarily because of excess fetal growth.10 mother and infant. Studies in Toronto dien showed that dietary supplements and nu-
tritional counseling improved the health of the pregnant mother and produced a
healthier baby. As health improved, complication rates also decreased. Researchers in
Grear Britain rook this one reseai·ch step furtJ1er. They showed that height and social
class are better predictors of pregnancy outcome than dietary intake during pregnancy.
Supporting di.is finding is a study of middle-class African-American women in Chicago.
Even wid1 nutritional supplements, their risk of having LB\iV infants still exceeded diar
of middle-class whites, possibly reflecting die effects of poverty on previous genera-
tions. This finding suggests that long-term nutritional intake may be critical to preg-
nancy outcome.
Laboratory animal studies support the importance of diet during pregnancy. Food
deprivation in pregnant laboratory animals leads to smaller organ size in the offspring,
affecting even the brain, which usually resists nutritional insults. In addition, placentas
weigh less, and fewer healthy offspring survive the first weeks of lite.
omen with acquired immune deficiency

W syndrome (AIDS) may poss the virus that
causes this disease to the fetus during pregnancy
Prenatal Care and Counseling
The chances of producing a healthy baby are maximized with education, an adequate
or the birth process. About one in three infected diet, and early and consistent prenatal medical care. 115 Also, avoidjng the controllable
newborns will develop AIDS symptoms and die risks discussed in this chapter-especially smoking, over-supplementation witJ1 vitamin
within just a few years. Studies show that these
A, and use of certain medications, illegal drugs, and alcohol-will promote a healthier
odds of mother-infant transmission can be cut
outcome of pregnancy for bod1 the mother and the baby. If anemia, AIDS, diabetes,
significantly if the woman begins taking the drug
or hypertension are present or developing, these conditions must be carefully ad-
azidothymidine (AZT) and other related AIDS
dressed to minimize complications during pregnancy. Treating ongoing infections is
medications by the fourteenth week of preg- also imporrant, as is avoiding X-ray exposure.
nancy. Providing these medications just before Ideally, women should receive examinations and coLmseling before becoming preg-
birth is helpful as well. Thus, screening pregnant nant and during pregnancy. Zvlany potential problems d1at develop drning pregnanL)' 1.:an
women for AIDS and treating those with AIDS be diagnosed and quicldy treated medically.
using AZT are currently advocated by some Food habits cannot be predicted from income, education, or lifestyle. Although some
experts. women already have good dietary habits, most cai1 benefit from nutritional advice. All
should be reminded of habits dur may harm die growing fems, such as severe dieting or
fasting. By focus ing on appropriate prenat~1J care, nutrient intake, and health habits, par-
ents give their fetus-and, later, d1eir infant-d1e very best chance of th1iving.
Several U.S. government progntms provide high-quality healtJ1 care and foods to re-
duce infant mortality. These programs are designed to alleviate the effects of po\'crry
and insufficient education and nutrient intake. An example of such a program b chc
www.mhhe.com/ w ardlaw pers7 597
Special Supplemental Nutrition Program for Women, Infants, .rnd Children ('VIC).
This program offers health assessments and vouchers for foods Lhat supply high-quality
protein, calcium, iron, and vitamins A and C to pregnant women, infants, and children
(up to age 5 years) from low-income popu lations. Tht: WIC program is available in all
areas of the Un ited States and has a staff trained co help women have healthy babies.
From a dietary standpoint, Tracey is smart to take a close look at her protein in-
take because needs will increase somewhat during pregnancy. More fruits and
~ vegetables supply extra folate, and her use of an over-the-counter vitamin and min·
eral supplement ensures tha t she will have an ample amount. Still, she should discuss this supple-
ment use with her physician. She would probably eventually benefit more from a prenatal
supplement, because it will hove more Iron than over-the-counter multivitamin and mineral sup-
plements. Her diet may not hove enough calcium, so she should pay as much attention to con-
suming extra calcium as she does to consuming protein. Avoiding alcohol is a smart move.
Many experts would say that Tracey is consuming too much caffeine and would be wise to In the United States, low-income pregnant
cut back on coffee and caffeine-containing soft drinks to a total of three servings or less per day. women and their infants (and children) benefit
from the nutritional and medical attention
Swimming is an excellent choice for exercise, as long as it is not too vigorous. Brisk walking or
provided by the WIC program.
stationary biking (spinning) are also appropriate.
Concept I Check
Infants born after 37 weeks of gestation and weighing more than 5.5 lb (2.5 kg) have the
ti:\\ est medical problems at birth. Limiting the factors that incre.tse the risk of ha,·ing a
pretcrm or small-for-gestational-age infant is a worthwhile goal for indi,iduals and for soci-
et\ .ts a whole. Such contributing high -risk factors , besides m i11adequatc diet in general,
include lo\\ socioeconomic status; closely spaced births; inadequate or absent prenatal care;
cigareu e smoking; alcohol consumption; aspirin and NSAJD use; illegal drug use, such as
marijuana and cocaine; teenage pregnancy; obesity; and inadequ.1te prenatal weight gain.
Adequate nutrition can reduce the risk of man)' medical problems in pregnancy.
Physiological Changes of Concern during

Pregnancy
During pregnancy, the fetus's needs for oxygen, nutrients, and excretion increase the
burden on the mother's lungs, heart, and kidneys. Although a mother's digestive and
metabolic systems work very efficiently, some discomfort accompanies the changes her n,._t,.;~
body undergoes to accommodate the fcrus.
Hannah, a 16-yeor-old high school student,
hos iusl discovered that she is pregnant. Al
Heartburn, Constipation, and Hemorrhoids
5' 3" and I 05 lb she is underweight and her
Hormones (such as progesterone) produced by the placenta relax muscles in both the typical diet locks many essential nutrients. For
uterus and the gastrointestinal trace, which often causes heartburn as sromach acid re- breakfast, she will have coffee and a dough·
fluxes into the esophagus ( rC\ie'' Chapter 3 ). When reflux occurs, rhe \\'Oman should nut, if anything of all. She often skips lunch or
a\·oid lying down after eating, cat less fat so that foods pass more quick!) from the eats chips From the vending machine. She then
stomach into the small intestine, and a\'oid spicy foods she cannot colcrate. She eats a well-rounded dinner with her family.
should also consume most liquids between meals to decrease the \Olume of food in What risks do you see in this situation for
the st0mach .tfter meals and thus rclic\'C some of the pressure thaL encourages reflux. Hannah and her baby?
vVomen with more severe cases may need antacids or related mcd ic:irions.
Effects of Other Factors on Pregnancy Outcome
In North America, maternal death as a result of are about half d1at amounc. Teenage pregnanc~·
childbirth is uncommon-only about 11 deaths in poses speci<1l health problems for both d1e mother
every 100,000 Jive births. The infant mortality and child. Young women continue maturing into
rate, however, is much higher: for each l 00,000 physical adulthood for 5 years after the onset of
menarche The onset of menstruation. Live births, about 600 ro 700 infants die within the menstruation (menarche). Because d1e average age
Menarche usually occurs around age first year. The infant death rate among African- for menarche is 13 years in the United States, a
13, 2 or 3 years ofter the first signs of Americaos is more than double the rates among woman younger d1an 18 years is not as physically
puberty start to appear. whites and Hispanics in d1e United States. Such ready to be pregnant as she will be later. HoweYer,
grim and discomforting statistics can be attributed by age 16, birth outcomes begin to imprO\'e.
largely to the current number of teenage pregnan- Pregnant teens frequently exhibit a \'ariery of
cies and to inadequate prenatal care as weU as to otller risk factors that can complicate pregnancy
marginal mmitional health among poor pregnant and pose a risk to me fetus. For instance, teenagers
women. Also, many factors other d1a11 nutrition af- aJe more likely than adult women to be under-
fect the health of mother and fetus. weight at the beginning of pregnancy :rnd ro gain
too little weight during pregnancy. ln addition,
their bodies generaUy lack the matmity needed to
Low Socioeconomic Status carry a tetus safely. Sixteen percent of low-binh-
weight infants are born to teenage mothers, e,·en if
Several characteristics that arc typical of low so- the mothers receive adequate prenatal care.
cioeconomic status, such as poverty, inadequate
health care, poor health practices, lack of educa-
tion, and W1111a.rrjed stanis are associated with Advanced Maternal Age
problems in pregnancy. Currently, in tile United
States about 31% of all births are tO unwed moth- The risks of low birth weight and preterm de Livery
ers, many of whom are poor. increase modestly but progressively wilh maternal
age beyond 35 years (tl1e ideal range is 25 to
35 years). Given close 11101utoring, however, a
woman older man 35 years bas an excellent chance
Closely Spaced and Mu ltiple of producing a he;1lthy infant. Most women in this
Births age group exhibit typical pregnancy-related prob-
Healthy nutrition, proper prenatal core, lems, which usually are manageable if the woman is
and avoiding unsafe behaviors, such as Siblings born in succession to a mother, with less under close medical supervision.
smoking and drugs, are key factors in than a year between binh and subsequent concep-
promoting o successful pregnancy. Too tion, are more likely to be born wid1 low birth
often very young mothers ore ill- weights than are those further apart in age. The Inadequate Prenatal Care
equipped to cope with the physiological, risks of low birth weight, pretenn birth, or small
emotional, and societal pressures of on size for gestational age are 30 to 40% higher for in-
unplanned pregnancy. These factors
If prenatal care is inadequate, delayed, or absent,
fants conceived less than 6 months fo llowing a untreated maternal nutritional deficiencies can de-
contribu te to the added risks they face.
birth compared to those conceived 18 to 23 prive a developing fetus of needed nutrienrs.5 In
months following a birth. These poor outcomes are addition, untreated chronic iliseases, such as hyper-
probably linked to a lack of enough time for the tension or iliabetes, increase the risk of fetaJ dam-
mother to rebuild 11utrient stores that were de- age. Withem prenatal care, a woman is three rimes
pleted by tile pregoancy. L3 more likely to deliver a low-birch-weight baby-
one who will be 40 times more likely to die during
the tirst 4 weeks of Life than a normal-birth-weight
Teenage Pregnancy infant. Although tile ideal time to start prenatal
care is before conception, about 20% of women in
About half a million teenagers give birth in the the United States receive no prenatal ec"lre tlu-ough-
ultiple birth s (i.e., twins) increase United Stares each ye,u·, accounting for about 13% out tile first trimester-a critical time to posirivcly
the risk for preterm birth. of all births. In Canada, d1e comparable statistics influence the outcome of pregnancy.
598
or products produced by the metabolism ofalcohol
Lifestyle Factors
(acetaldehydc), cause faulty movcmi.:nr of cells in
Smoking, use of some medications, alcohol con- the brain during earl)• stages of nerve cell develop-
sumption, and illicit drug use during pregnancy all ment or block the action of certain brain neuro·
lead to harmful effects. (Use of a sauna or hot tub transmitters. In addition, inadequate nutrient
aho can cause problems.) Smoking is linked to intake, reduced nutrient and oxygen transfer across
the placenta, cigarette smoking commonly associ- goal of Healthy People 20 I 0 is
preterm birth and low birth weight and appears to
increase the risk of birth defects, sudden infant ated with alcohol intake, drug use, and possibly 100% abstinence from alcohol, cig-
death, and childhood cancer. Problem drugs in· otl1er factors cont1ibute to the overall result. For arettes, and illicit drugs by pregnant
dude aspilin (especially when used heavily}, hor· more informarion about fetal alcohol syndrome, women.
mone oinrmencs, nose drops and related cold visit the website ' ' ,, .cd · ro r d Id/fas/.
medications, rectal suppositories, weighr-concrol
pills, and medications prescribed for previous ill-
nesses. Prenatal Ketosis
Marijuana is the most common illegal drug
used during the reproductive years. For pregnant Ketosis can result from fasting and is not desirable
women, marijuana use is very risky and porenti.tlly for the growing fetus. Ketone bodies are thought
can resulr in reduced blood flow and oxygen ro the to be poorl~ used by the fetal brain, implying pos-
ucerus and placenta and poor fetal grO\\th. Low sible slO\\ing of feral brain de\'clopmcnt. Because a
birch weight and higher risk of premantrc dclhery pregnant woman can develop \ignificanr ketosis
often arc seen in inf.mes whose mothers used mari· after only 20 hours of fasting, experts oppose crash
juana during pregnancy. Cocaine use also has dev- diets or fasting for more than 12 hours during
astating consequences for the developing fetus. pregnancy. Eating at least 175 g of carbohydrate
Conclusive evidence shows that repeated con· every day pre\ ents such ketosis. Even nonpregnant
sumpcion of tour or more alcoholic drinks at one women usual!~ ear this amount and more.
sitting harms the fetus. 20 Such binge drinking is es-
regnant women should recognize
pecially perilous during the first 12 weeks of preg-
that many cough syrups contain al-
nancy, \\hen critical early developmental events Caffeine Consumption
cohol. Coses hove been reported of in·
rnke place il1 utero. Although scientists don't know
fonts with FAS born lo mothers who
whether pregnant \\'Omen must totally clin1inate al· Caffeine decreases the morher's absorption of
consumed generous amounts of such
cohol use to a\'oid risk of damage to the fetus, until iron and mar reduce blood flow through the pla-
cough syrups but no other alcoholic
a sate b·el can be established women are ad\'ised centa. In addirion, the fetus is unable to detoxify
cafteine. Animal experiments have shown that the beverages.
not ro drink any alcohol during pregnancy or when
there is a chance pregnancy might occur. The em- risk of spontaneous abortion increases in the first
bryo (and at later stages, the fetus ) has no means of trimester and early in the second trimester with
detm:i~1 ing alcohol. heavy caffeine consumption (greater than 500
Women with chronic alcoholism produce chil- mg/day, or the equi,·alent of about 5 cups of cof-
dren with a recognizable panern of malformations fee per day ). In addition, as caftcine intake in-
called fetal alcohol syndrome (FAS).7 A diagno· creases, so does the risk of dcli\•eriog a fetal alcohol syndrome (FAS) A group
sis of FAS is based mainly on poor feral and infant low-birth weight infant. Hca\')' caffeine use dur- of irreversible physical and mental ab-
gro\\'th, physical deformities (especially of fucial ing pregnancy may also lead to caffeine with - normalities in the infant thal result from
features), and mental retardation (Figure 16-5). drawal symproms in the newborn. Researchers the mother's consuming alcohol during
The infanr is frequently irritable and may develop advocate that women dsink no more tl1an three pregnancy.
hyperacth'iry and a short attention span. Limited cups of coffee and no more than four cups of caf-
hand-eye coordination is common. Defects in vi- feinated soft drinks per day during pregnancy, or
sion, he.iring, and mental processing often de, clop when pregn.rncy is possible. Paying attention to
O\·cr rime. caffeine intake from tea, over-the-counter medi·
Exactly how alcohol causes these detects is not cines containing caffeine, and chocolate is also
kno\\'n. One line of research suggests that alcohol, important.
599
Small head
circumference
Low nasal bridge
Small eye opening
and eye folds
r-- - Short nose

Small midface
No groove between
nose and upper lip
Thin upper lip
Figure 16·5 I Fetal alcohol syndrome. The facial features

fetal alcohol effect (FAE) Hyperactivily,
shown are lypical oF affected children. Additional abnormalities in
attention deficit disorder, poor judg- the brain and other internal organs accompany feta l alcohol
ment, sleep disorders, and delayed syndrome but ore not immediately apparent from simply looking at
learning as a result of prenatal exposure the child. Milder forms of alcohol-induced changes from a lower
to alcohol. alcohol exposure to the fetus are known as fetal alcohol
effects. Affected children exhibit behavior problems without
physical effects such as altered facial fea tures.
Aspartame Use blue cheeses), and raw cabbage can be sources of

Listeria organisms, it is especially important that
Phenylalanine, a component of aspartame (e.g., pregnant women (and other people at high risk for
NutraSweet and Equal), causes concern for some infection) avoid these products. Experts advise
pregnant women. High amounts of phenylalanine conSLLming only pastemjzed milk products and
in maternal blood disrupt fotal brain development cooking meat, poultry, and seafood thoroughly to
ir the mother has a disease known as phenylke- kill this and other foodborne organisms. It is unsafe
to111ffia (review Chapter 4). rfthe mother does not in pregnanc~' to eat any raw meats or other raw an-
have this condition, however, it is unlikely that the imal products, uncooked hot dogs, or any under-
baby will be affected by moderate aspartame use. cooked poultry.
Toxoplasmosis is another infection that causes
birth defects, leading to about 3000 such cases per
year in the United States. Pregnant women sboul<l
U SDA also warns pregnant women
(and other people at high risk) to
thoroughly cook (e.g., microwave) all
Listeria and Toxoplasmosis
Infections limit exposme to the organism that causes toxo-
plasmosis by avoiding contact with cat feces (have
ready-to-eat meats, including hot dogs Infection by the bacterium Listeria monocytogmcs someone else clean the cat's litter box or wear
and cold cuts, until they are steaming to causes mild flulikc symptoms, such as fever, gloves), avoiding contact with kittens, bird feces ,
reduce risk of listeria infections. headache, and vomiting, about 7 to 30 days after and garden soil (by wearing garden gloves), and by
exposure. However, pregnant women, newborn in- not eating raw or undercooked meat. Chapter 19
fants, and people with depressed inumme function covers foodborne illness, such as Listeria and toxo-
may suffer more severe symptoms, including spon- plasmosis infections, in more detail.
taneous abortion and serious blood infections. In Many of the risk faccors described in this sec-
these high-risk people, 25% of infections may be tion are avoidable. The goal of a reduction in ma-
fatal. Because unpasteurized milk, soft cheeses ternal and infant deaths requires that more
made from raw milk {brie, Camembert, feta, and attention be paid to these problems.
600
Constipation often results as the intestinal muscles relax during pregnancy. L7 It is

especially Likely to develop late in pregnancy as the fetus competes with the GI tract for
space in the abdominal cavity. To offset these discomforts, a woman should perform
regular exercise and consume more fluid, fiber, and dried fruitS such as prunes (dried
plums). The Adequate Intake for fiber in pregnancy is 28 g/day, slightly more than for
the nonpregnant woman. Fluid needs are 10 cups/day. These practices can help pre-
,·ent constipation and a problem that frequently accompanies it, hemorrhoids.
Straining during elimination can lead to hemorrhoids, which are already more likely to reevaluation of the need and dose of iron
occur during pregnancy because of other body changes. supplementation should be considered, be·
cause high iron intakes are linked to
constipation.
Edema
Placental hormones cause various body tissues to retain fluid during pregnancy. Blood
volume also greatly expands dming pregrnmcy. The extra fluid normally causes some
swelling (edema). There is no reason to resa·ict salt severely or LlSe diuretics to limit
mild edema. However, the edema may limit physical activity late in pregnancy and oc-
casionally requires a woman to elevate her feet to control the symptoms. Overall,
edema generally spells trouble only if it is accompanied b)' h)'PCrtension and the ap-
pearance of extra protein in the urine (see the subsequent section titled Pregnancy-
Induccd Hypertension).
Morning Sickness
About 70 to 85% of pregnant women experience nausea during the early stages of
pregnancy. This nausea may be related to the increased sense of smell induceJ by
pregnancy-related hormones circulating in tl1e bloodstream. Aliliough common!)
called "morning sickness," pregnancy-related nausea may occur at any time and persist
all day. It is often the first signal to a woman that she is pregnant. To help control mild
nausea, pregnant women can try the following: avoiding nauseating foods, such as
fried or greasy foods; cooking witll good ventilation to dissipate nauseating smells; ear-
ing saltine crackers or dry cereal before getting out of bed; avoiJing large fluid intakes
early in the morning; and eating smaller, more frequent meals. Because the iron in pre-
natal supplements triggers nausea in some women, changing the type of supplement
used or posrponing use until ilie second trimester may provide relief in some cases. If
a woman thinks her prenatal suppkmenc is related to morning sickness, she should dis-
cuss switching to another supplement with her physician.
Overall, if a food sounds good to a pregnant woman with morning sickness,
whether it is broccoli, soda crackers, or lemonade, she should cat it and eat when she
can while also striving to follow her prenatal diet. The American College of
Obstetricians and Gynecologists recommends the following for the prevention and A few saltine crackers upon waking or between
treatment of nausea and vomiting of pregnancy: meols can help lessen the nausea of morning
sickness.
• History of use of a balanced multivitamin and mineral supplement at the time of
conception
• Use ofmegadoses of vitamin B-6 (10 to 25 mg taken 3 to 4 times a day), especially
coupled with the antihistamine doxylamine ( 10 mg) '' ith each dose. Use of ginger
(350 mg ta.ken 3 times per day) may also be helpful in reducing such nausea.
Usually, nausea stops after tlle first trimester; however, in about l 0 to 20% of cases,
it can continue throughout tlle entire pregnancy. In cases of serious nausea, the pre-
ceding practices offer little relief. Excessive vomiting can cause dangerous dehydration xcessive vomiting during pregnancy that
and must be avoided. When vomiting pcrsisrs (about 0.5 ro 2% of all pregnancies), leads lo dehydration and weight loss is
medical attention is needed. called hyperemesis gravidarum.
Anemia
To supply fetal needs, the mother's blood volume expands to approximardy l 50% of
normal. The number of red blood cells, however, increases by only 20 to 30%, .md this
increase occu rs gradually. As a result, a pregnant woman has a lower ratio ol" red blood
physiological anemia The normal increase in cells to total blood volume in her system. This hemodilution is known as physiologi-
blood volume in pregnancy that dilutes the cal anemia. Ir is a normal response to pregnancy rather than the result of inatkqu.ne
concentration of red blood cells, resulting in nutrient intake. If during pregnancy, ho\\'ever, iron stores and/or dietary iron intake
anemia, also called hemodilution. are not sufficient to meet needs, any resulting iron-deficiency anemia requires medical
anention.
Gestational Diabetes
Hormones synthesi1ed by the placenta decrease the efficiency of insulin and le.1d to a
mild increase in blood glucose, which helps supply energy to the fetus. An cxcessin:
gestational diabetes A high blood glucose rise in blood glucose can lead to gest ationa l d iabetes, often beginning in weeks 20 to
concentration that develops during pregnancy 28, particularly in women who have a fami ly history of diabetes or who are obese.
and returns to normal ofter birth; one cause is Other risk factors include maternal age over 25 and gestational diabetes in J prior preg-
the placental production of hormones that nancy. In North Amelica, gestational diabetes de\'elops in about 4% of pregnancies;
antagonize the regulation of blood glucose by bowe\'er, it increases to 7% in the Caucasian population. Today, pregnant women oftrn
insulin.
arc screened for diabetes at 24 to 28 weeks by checking for ele\·ated blood glucose
concentration l co 2 hours after consuming 50 to 100 g of glucose. A woman ''ho de-
,·elops gestational diabetes needs to implcmem a special diet d1ar distributes lo\\ -
glycemic load carbohydrates throughout the day. Sometimes insulin injections .1re also
needed. In addition, regLtlar physical activity helps to control blood glucose. 6
The primary risk of uncontrolled diabetes during pregnancy is that the Ictus can
grow quite large. ts This growth is a result of the oversupply of glucose from maternal
circulation coupled with increased production of insulin by the fetus, allo\\'ing fetal tis-
sues to rake up building materials for growth. The mother may require a cesarean sec-
I l'li.in inn tion if the size of the fetus is not compatible with a \'aginal delj\•cry. Another threat ts
that the infant may have low blood glucose at birth because of the rendem:r to pro-
Sandy, who is 4 months pregnant, hos been duce extra insulin th,1t began during gestation. Other concerns are d1e potenti.11 for
having heartburn ofter meals, constipation, and early deli\'ery and increased risk of birth trauma and malformations. Although gest.i-
difficult bowel movements. As o student of nutri- Lional diabetes oli:cn disappears after the infant's birth, it increases the mother\ risk of
tion, you understand the digestive system and developing diabetes later in lifr, especially if she fails to maintain a healthy body weight.
the role of nutrition in health. What remedies Recent studies show Lhal infants of mothers with gestational diabetes m:ty also ha\'e
might you suggest to Sandy to relieve her higher risks of <.kvcloping obesity and type 2 diabetes as they grow to adulrhood. For
problems? all these reasons, proper control of gestational diabetes (and any diabetes present in the
mother before pregnancy) is extremely important.
Pregnancy-Induced Hypertension
pregnancy-induced hypertension A serious P regnancy- ind uced hypertension is a high-risk disorder and occurs in about 5 LO 7%
disorder that con include high blood pressure, of pregnancies. Jn ici. mild forms, it is also known as preeclampsia and, in ~C\ ere forms,
kidney failure, convulsions, ond even death of as eclampsia. Early i.ymptoms include a rise in blood pressure, excess protein in the
the mother and fetus. Although its exact cause urine, edema, changes in blood clotting, and nervous system disorders. Very severe cf
is not known, on adequate diet (especially frets, including convulsiorn., can occur in d1c second and third t:rimcsters. 19 I I' not con-
adequate calcium intake) and prenatal core
trolled, eclampsia eventually damages the liver and kidneys, and mother and ti.:llls both
may prevent this disorder or limit its severity.
Mild coses ore known as preeclampsio; more
may die. The populations most at risk for d1is disorder arc women under ,1ge 17 or
severe coses ore called eclampsia (formerly O\'er age 35 and women "ho ha\'e had multiple-birth pregnancies. A famil\' histor\' of
called toxemia). pregnancy-induced hypertension in the mother's or father's side of the family, di.ibeccs,
African-American race, Jnd a woman's first pregnanc) also raise risk. A diet inadequate
in vitamin E, \ itamin C, calcium, zinc, and other nutrients may also be part of the
cause.
Pregnancy-induced hypertension resolves once rhe pregnancy ends, making dcli\'-
cry the most reliable treatment for the mother. However, because the problem often
begins before the fetus is ready to be born, physicians in mJJ1)' cases must use treat-
ments co pre\•cnc the worsening of the disorder. Bed rest and magnesium sulfate arc
cmrently the most effective treatment methods, although their effectiveness varies.19
Magnesium likely acts to relax blood vessels and so leads to a fa ll in blood pressure.
Several other treatrnencs, such as vario us :mtiseizu re and antihypcn cnsivc medicatio ns,
arc under study.
Concept I Check
Heartburn, constipation, hemorrhoids, nausea and rnmiting, edema, anemia, and gesta-
tional diabetes are possible discomforts and complications of pregnancy. Changes in food
habits can often ease these problem~. Pregnanq·-induced hyperccn~ion, with high blood
pressure and kidney failure , can lead to severe complications or even death of both the
mother and ferus if not treated.
Breastfeeding Breastfeeding is the preferred way to feed o

young infant.
Breastfeeding further fosters the nC\\ infant's health and so complements the atten tion
gi,·en co dice during pregnancy. The American Dietetic Association and the American
Academy of Pediatrics recommend brcasrteeding cxclusi,•cly for che first 6 monchs,
with the continued combination of breastfeeding and infant foods until l year. 2 The
World Health Organization goes beyond that to recommend breastfeeding (with ap-
propriate solid food introduction; sec Chapter 17) for at least 2 )'Cars. However, sur-
veys show that only about 70% of North American mothers now begin to b reastfeed
their infan ts in the hospital, and at 4 and 6 months o nly 33% and 20%, respectively, arc any of the benefits of breastfeeding con
still brcastlcc.:ding their infunts. The number fa lls ro 18% at 1 year of age. T hese statis-
tic~ refer to Caucasian women; minority \\'Omen a.re e\•en less likely to be breastfeed-
M be found in Tobie 16·3 and at
www.4womon.gov./ Breastfeeding/ 1ndex.htm,
ing at these time i.nten·als. sponsored by the U.S. Surgeon General.
Women who choose to breastfocd usuaUy find it an enjoyable, spcci.ll time in their
Ii\ es and in their relationship with their new infam. AJthough bottle teeding witl1 an
infant formula is safe for infants, as discussed in Chapter 17, it docs not equal the ben-
etits dcri\'cd from hwnan milk in all aspects. If a woman doesn't breastfeed her child,
breast weigh t retm ns to normal very soon after birth .
Ability to Breastfeed
Almost all women are physically capable of breastfeeding tl1eir children (see the later
section titled ~kdical Conditions Prl.'.cluding Breastfeeding for c.:xceptions). In most
case!>, problems encountered in breastfeeding arc due to a lack of appropriate infor-
mation. Anatomical problems in breasts, such as inverted nipples, can be corrected ea/thy People 2010 hos set a goal of 75%
during pregnancy. Breast size generally increases during pregnancy and is no inclication of women breastfeeding their infants of
of success in breastfeeding. Most women notice a dramatic increase in the size and time of hospital discharge, 50% breastfeeding
\\'eight of their breasts by the third o r fou rth day of breastfeeding. Tf these changes do for 6 months, and 25% still breastfeeding at
not occu r, a woman needs to speak with he r p hysician o r a lactatio n consultant. 1 year.
Breastfed infun ts must be fo llowed closely over the first days of life to ensure that
feeding and weight gain are proceeding normally. Monitoring is especially important
with a mother's first child, because the mother \\'ill be inexperienced witl1 the tech-
nique of breastfeeding. Currently, morhcrs and healthy infants .1re commonly dis-
charged from the hospital 1 to 2 days after delivery, \\'hereas 20 years ago they stayed
in tl1e hospital for 3 or 4 days or longer. One resu lt of such rapid discharge is a de-
crea~ed period of infant monitoring b~ health-care professionals. Incidents have been
reported of infants deYcloping dehydration and in mm blood clots soon after hospital
discharge when breastfeeding d id nol proceed smoothly. Cardi.ii monitoring in tl1.is
first week by a physician or lactation consu ltant is ad vised.
Figure 1 6·6 I The a natomy of the breast.

Many types of cells form a coordinated network
to produce and secrete human milk.
Milk-producing/storage
cells (lobules)
Ducts to
w~__;;::.......~--- carry milk
to nipple
Nipple
Areolar
margin
First-time mothers who plan to breastfeed should learn as much as they can about
the process early in their pregnancy. 2 Interested women should learn the proper tech-
nique, what problems to expect, and how to respond to them . OveralJ, breastfeeding
is a learned skill, and mothers need knowledge to breastfeed safely, especialJy with the
ftrst child.
Production of Human Milk

lobules Saclike structures in the breast that Dur.ing pregnancy, cells in the breast form milk-producing cells called lo b u les
store milk. (Figure 16-6). Hormones from the placenta stimulate these changes in the breast.
After birth, the mother produces more prolactin hormone to maintain the changes in
prolactin A hormone secreted by the pituitary
the breast and therefore the ability to produce milk. During pregnancy, breast weight
gland. It stimulates the synthesis of milk in the
breast. increases by about 1 to 2 lb.
The hormone prolacti.n also stimulates the synthesis of mill<. Infant suckling stimu-
lates prolactin release from the pituitary gland. :Milk synthesis then occurs as an infanr
breastfeeds. The more the infant suckles, the more mi lk is produced. Because of this,
even twins (and triplets) can be breastfed adequately.
Most protein found in human milk is synthesized by breast tissue. Some proteins
also enter the 111.iU' directl}' from the mother's bloodstream. These proteins include im-
mune factors (e.g., antibodies) and enzymes. Fats in hw11an milk come from both the
mother's diet and those synthesized b)' breast tissue. The sugar galactosc is synthesized
in the breast, whereas glucose enters from the mother's bloodstream. Toged1er, these
sugars form lactose, the main carbohydrate in human milk.
Figure 1 6-7 I Let-down reAex. Suckling sets

into motion the sequence of events that lead to
milk let-down, the flow of milk into ducts of the
breast.
fJ Nerve pathways
carry stimuli to
hypothalamus.
II Suckling stimulates nerve

endings in nipple and
areola of breast.
B Milk II Oxytocin causes

let·down lobules to release
occurs. milk from storage.
Let-Down Reflex
An imporrnm brain-breast connection-commonly called the let-down reflex- is nec- let-down reflex A reRex stimulated by infant
essary for brcasdeeding. The brain rcle:u.cs the hormone OA-ytocin co allow the breast suckling that causes the release (ejection) of
tissues to let down (release ) the milk from storage sites (Figure 16-7). lt then tra"els milk from milk ducts in the mother's breasts;
to the nipple area. A tingling sensation signals the let-down reflex shorrly before mill<. also called milk ejection reflex.
flow begins. If the let-down reflex doesn't operate, little milk is avai lable to the infant. oxytocin A hormone secreted by the pituitary
The infant then gets frustrated, which can in turn frusu·ate the mother. gland. It causes contraction of the musclelike
The let-down reflex is easily inhibited by nervous tension, a lack of confidence, and cells surrounding the ducts of the breasts and
fatigue. Mothers should be especially aware of the link between tension and a weak let- the smooth muscle of the uterus.
down rellex. They need to find a relaxed em'ironment in which they can breastfeed.
After a few weeks, d1e let-down reflex becomes automatic. The mother's response
can be triggered just by thinking about her infant or seeing or hearing another infant
er~. At first, however, the process can be a bit bewildering. Because she cannot mea-
sure the amount of milk the infant takes in, a mother may fc.1r that she is not ade-
quately nourishing the infant.
As a general rule, a well-nourished breastfed infant should ( 1) have six or more wet isposoble diapers con absorb so much
diapers per day after the second day orlifc, (2) show a normal weight gain, and ( 3) pass urine that it is difficult to judge when they
at lease one or two stools per day that look like lumpy mustard. 2 In ,H:ldition, soften- ore wet. A strip of paper towel laid inside a dis·
ing of the breast during the feeding helps indicate that enough milk is being con- posoble diaper makes a good wetness indicator.
sumed. Parents who sense that their infant is not consuming enough milk should Alternatively, doth diapers may be used for o
corn.ult a physician immediately because dehydration can de,·elop rapidl). day or two lo assess whether nursing is supply-
lt generally cakes 2 to 3 weeks co fully establish the feeding routine: infant and ing sufficient milk.
mother both feel comfortable, the milk supply meets infant demand, and initial nipple
soreness disappears. Establishing the brcascfceding routine require~ patience, bur me
rewards arc great. The adjustments .ire easier if supplemental formula feedings are not
introduced unril breastfeeding is well established, after at least 3 to 4 weeks. Then it is
fLI1e if a supplemental bottle Or tWO orinfant formu la per day is needed.
Nutritional Qualities of Human Milk

Human milk is very different in composition from cow's milk. Unless altered, cow's
milk should never be used in infant foeding until the infant is at least 12 mo nths old.
Cow's milk is too high in minerals aod protein and does not contain enough carbohy-
casein A protein found in milk that forms curds drate to meet infanr needs. In addition, the major protein in cow's milk (casein) is
when exposed to acid and is difficult for infants harder for an infant to digest than the major proteins ( lactalbmnin and other whey
to digest. proteins) in human milk. The proteins in cow's milk also may spur allergies in the in-
whey Proteins, such as loctolbumin, that ore fant. Finally, certain compow1ds in human mi lk presently under study show other pos-
found in great amounts in human milk and ore sible benefits for the infant.
easy to digest.
colostrum The first fluid secreted by the breast Colostrum

during late pregnancy and the first few days At the end of pregnancy the first fluid made by the human breast is colostrum. This
ofter birth. This thick fluid is rich in immune thick, yellowish fluid may leak from the breast during late pregnancy and is produced
factors and protein. in earnest for a few days to a week after birth. Colostrum contains antibodies and im-
Lactobacillus bificius factor A protective factor mune s~rstem cells, some of which pass unaltered through the infant's immature Gl
secreted in the colostrum that encourages tract into the bloodstream.8 The first few months oflife are the only time when we can
growth of beneficial bacteria in the newborn's readily absorb whole proteins across the GI tract. These immw1e facto rs and cells pro-
intestines. tect the infant from some GI tract diseases and od1er infectious disorders, compensar-
ing for the infant's own immatme immune system during the fo-st few months of life.
One component of colostrum, the Lactobaciltus bifidiu factor, encourages the
growth of Lactobacillus biftdies bacteria. T hese bacteria limit the growth of porcntially
toxic bacteria in the intestine. Overall, breastfeeding promotes the intestinal health of
the breastfed infant.
c ow's Milk Compared to Human Milk M ature M ilk

Human milk composition gradually changes until it achieves the normal composition
Energy Some of mature milk several days after delivery. Human milk looks very different from cow's
Protein 3.2 times higher milk. (Table 17-1 in Chapter 17 provides a direct comparison.) Human milk is thin
Fat 0.2 times lower and almost watery in appearance and often has a slightly bluish tinge. Its nutritional
Carbohydrate 0.3 times lower qualities, however, arc quite impressive. The overall energy content of human milk is
Minerals 3.5 times higher abour the same as t11at of infant formulas (67 kcaljlOO ml ).
Human milk's whey proteins form a soft, light curd in the infant's stomach and arc
easy tO digest. Some human milk proteins bind iron, reduciJ1g t11e growth of iron -
requiring bacte1ia, some of which can cause diarrhea. Still other proteins offer die im -
portant immune protection already noted.
T he Lipids in human breast milk are high in linoleic acid and cholesterol, which arc
needed for brain development. Breast milk also contains long-chain omega-3 farry
he fat composition of human milk changes acids, such as docosabexaenoic acid (DHA). This polyunsaturated fatty acid is used for
during each feeding. The consistency of milk the synthesis of tissues in the brain and the rest of the central nervous system, and in
released initially (fore milk) first resembles tha t of the retina of the eye. 2
fat-free milk. It later hos o greater fat propor- Human milk composition also allows for adeqLtate flu id status of the infant, pro-
tion, similar to whole milk. Finally, the milk re- vided the baby is exclusively breastfed.2 A question commonly asked is whed1er t11e in-
leased after 10 to 20 minutes (hind milk) is fant needs additional water, if stressed by hot weather, diarrh ea, vomiting, or fever.
essentially like cream. Infants need lo breastfeed Providing breastfed infants with up to 4 oz of water a day from a botdc is fme. Note,
long enough (e.g., a total of 20 or more min- however, that greater amounts of supplemental water can lead to brain disorders, low
utes) to get the energy in the rich hind milk to be blood sodium, and other problems. Thus, extra water should be given only with a
satisfied between feedings and to grow well. physician's guidance.
Food Plan for Women Who Breastfeed

Nutrient needs for a breastfeeding mother change to some extent from those of the
pregnant woman in the second and third trimester (see the inside cover of this book).
There is a decrease in folatc and iron needs and an increase in the need for energy, \'i-
ramins A, E, and C, riboflavin, copper, chromium, iodide, manganese, selenium, and
zinc. Still, these increased needs of the breastfeeding mot11er will be met by t11e gen -
era! diet plan proposed for preg1unt \\'Omen in the latter stages of prcgnancy. 2 Recall ost substonces that the mother ingests are
that each day this diet plan includes at least: secreted into her milk. For this reason,
she should limit intake of or ovoid all alcohol
• 3 cups of calcium-rich foods from the milk group, or use of calcium -fortified foods
and caffeine and check all medications with o
• 6 1/2 ounce-equivalents from the meat & beans group
pediatrician. Some mothers believe that some
• 3 1/2 cups from the vegetable group
foods, such as garlic and chocolate, flavor the
breast milk and upset the infant. If a woman no-
• 8 ounce-equivalents from the g rain group
tices a connection between a food she eats and
• 7 tea!>poons of vegetable oil
the infant's later fussiness, she could consider
Discretionary calories (up to about 400 kcal) can then be addeJ, depending on the avoiding that food. However, she might experi-
need for slow weight loss or weight maintenance (or even weight gain in some cases). ment again with it later, because infants become
Table 16-2 provided a menu for such a plan. Substituting a soyburger (veggie fussy for other reasons. Some researchers, on
burger) for the hamburger in that menu would make this menu plan a practical guide the other hand, feel that the passage of flavors
for a lactovcgetarian woman as well. from the mother's diet into her milk affords on
As in pregnancy, a serving ofa highly fortified ready-to-eat breakfast cereal (or use opportunity for the infant to learn about the fla-
of a balanced multivitamin and mineral supplement) is advised LO help meet extra nu- vor of the foods of its family long before solids
trient needs. And, as mentioned for pregnant women, breastfeeding mothers should ore introduced. These researchers suspect that
consume lish at least twice:: a week (or 1 g/day of omega-3 fatty acids from a fish oil bottle-fed infants ore missing significant sensory
supplement) because the omega-3 fatty acids present in fish are secreted into breast experiences that, un~I recent times in human his-
milk and arc likely to be important for de,·elopment of the infant's nervous system. tory, were common to all infants.
Milk production requires approximately 800 kcal/day. The Estimated Energy
Requirement during lactation is an extra 400 to 500 kcal daily above prepregnancy rec-
ommendations. The difference between that needed for milk production and the rec-
ommended intake-about 300 kcal-may allow a gradual loss of rhe extra body fat
accumu lated during pregnancy, especially if breastfeeding is continued for 6 months or
more and the woman performs some physical activity. 2
After giving birth, women arc often eager to shed the excess "baby fut."
Breastfeeding, howe\'er, is no time for crash diets. A gradual weight loss of 1 to
4 lb/ month in the breastfeeding mother is appropriate. Ar significantly greater rates
of \\'eight loss-when energy intake is restricted to less than about 1500 kcal/day-
milk output decreases. A reasonable approach for a breastfeeding mother is to eat a bal-
•mced diet that supplies at least 1800 kcal/day, has moderate fat content, and includes
a ,·ariety of dair~· products, fruits, vegetables, and whole grains. 2
To promote the best possible foeding experience for the infant, there are several
other dietary factors to consider. Hyd ration is especially important during breastfeed-
ing; the woman should drink fluids ever)' rime her infant breastfoeds. D rinking about
13 cups of fluids per day encourages •Hnplc milk production. Poor health habits, such
a!> smoking cigarettes or drinking more than two alcoholic.: drinks a day, can decrease
milk output. (Even less alcohol can ha\'e a deleterious effect on milk output in some
Eating fish at least twice a week wil help
women. ) To a\'oid exposure to harmful le\·els of mercury, precautions concerning fish breastfeeding women ensure that their infants
that are likely to contain mercury should extend past pregnancy for the breastfeeding receive important omego-3 fatty acids. It is
mother. Brcastteeding women also may want to a,·oid eating peanuts or peanut butter, important, however, to ovoid those fish that ore
because several studies have shO\\ n that peanut allergens pas!> into breast milk, poten- likely contaminated with mercury (listed on
tially increasing the infant's risk for peanut allergy. page 595).
Concept I Check
Recognition of the importance of breastfeeding has contributed to its greater popularity in
recent years. Almost all women have the ability to breastfeed. The hormone prolacrin stim-
ulate!> breast tissue ro synthesize milk. Some components of human milk come directly
from the mother's bloodstream. £nfant suckling triggers a let-down reflex, which releases
the milk. The more an infant breasrteeds, the more milk is synthesized. The nutrient com-
posmon of human milk is \'cry difierenr !Tom that of cow's milk and changes as the infant
matures. The first fluid produced, colostrum, is rich in immune factors. The diet fur breast-
foeding is generally similar to that for pregn,111cy, except for necessary additional
fluids.
Breastfeeding Today
As noted already, the vast majority of women are capable of breastfeeding and their in-
B reostfeeding provides distinct advantages,
but none so great that a woman who de·
cides to bottle-feed should feel she is signifi·
fants benefit from it. 2 The many benefits are listed in Table 16-3. Nonetheless, a
woman's decision to breastfeed depends on a variety offucrors, some of which, you will
cantly compromising her infant. see, make breastfeeding impractical or ttndesirablc for a woman.
Advantages of Breastfeeding
Just as the milk of aU mammals is the perfect nutrition somcc for the )'Onng of thar
species, human millc is tailored to meet infant nutrient needs for the first 4 to 6 months
of life. The possible exceptions are the relative lack of fluoride , iron, and vitamin D.
Infant supplements, used ttnder the guidance of a pediatrician, can supply r.bcse nutri·
ents and are often recommended, especially vitamin D . The American Academy of
Pediatrics recommends that all breastfed infants be given 200 IU of vitamin D/day
until they are consuming that much from food, sud1 as at Least 2 cups (0 .5 liters) of
infant formula per day. Some sun exposure also helps in meeting vitamin D needs.
Fluoride may be found in the household water supply. If it is not present in adequate
amounts or the infant is not receiving rap water, a fluoride supplement should be con·
sidered and a dentist consulted. Vitamin B-12 supplements are recommended for the
breastfed infant whose mother is a vegan.
Fewer Infections Breastfeeding reduces the infant's overall risk of developing infec·
tions, partially because an infant can use the antibodies in human milk. 4 •8 Breasrfcd in ·
fan ts also have fewer ear infections (otitis media) because they do not sleep with a
bottle in their mouths. Experts strongly discourage allowing any infants to sleep with
a bottle in their mouths, because when that happens, milk can pool in tl1c moutl1, back
up through the throat, and eventually settle in the ears, creating a growth medium for
bacteria. Infant ear infections arc a common problem. By avoiding tl1esc problems,
parents can decrease discomfort for tl1e infant, avoid related trips to the doctor, and
Table 16·3 I Advantages of Breastfeed ing
Infant
• Bocteriologicolly safe
• Always fresh and ready to go
• Provides antibodies while infant's immune system is still immature and provides substances that
contribute to maturation of the immune system
• Contributes to maturation of gastrointestinal tract via Lactobacillus bifidus factor; decreases
The American Dietetics Association supports incidence of diarrhea and respiratory disease
breastfeeding as the ideal feeding method for • Reduces risk of food allergies and intolerances as well as some other allergies
infants. In addition to breastfeeding's nutritional • Establishes habit of eating in moderation, thus decreasing possibility of obesity later in life by
benefits for the infant, ADA also promotes about 20%
breastfeeding as a public health strategy for • Contributes to proper development of jaws and teeth for better speech development
improving infant survival rotes, decreasing • Decreases ear infections
mothers' risks of developing certain diseases, • Moy enhance nervous system development (by providing the fatty acid DHA) and eventual
controlling health-core costs, and conserving learning ability
natural resources. • Moy reduce the risk of later developing hypertension and other chronic diseases, such
as diabetes
Mother
• Contributes to earlier recovery from pregnancy due to the action of hormones that promote a
quicker return of the uterus to its prepregnoncy state
• Decreases the risk of ovarian and premenopousal breast cancer
• Potential for quicker return to prepregnoncy weight
• Potential for delayed ovulation and therefore reduced chance of pregnancy (short-term benefit,
however)
prevent possible hearing loss. Tooth decay from nighttime bottles is anot11er likely con-
sequence of sleeping with a bottle in the mouth (see Chapter 17 ).
Fewer Allergies and Intolerances Breast feeding also reduces the chances of some al-
lergies, especially in allergy-prone infants (see Chapter 17). The key time to attain tl1is lthough not o nutritional benefit, breast·
benefit from breastfeeding is during the first 4 to 6 months of an infant's Life. A longer feeding frees the mother from the time and
conunim1ent than 4 to 6 months is best, but the first few months arc most critical. expense involved in buying and preparing for·
Breastfeeding for even just the first few weeks is beneficial. Another benefit of breastfeed- mulo and washing bottles. Human milk is ready
ing is that infanrs are better able to tolerate human milk than formulas. Formulas some- to go and sterile. This benefit allows the mother
times must be switched several times until caregivers find the best one for the infant. to spend more time with her baby.
Possible Barriers to Breastfeeding

Widespread misinformation, the mother's need to ren1rn to a job, and social reticence
all serve as barriers to breastfeeding.
M isinformation Probably the major barriers to breastfeeding arc misinformation,

such as the idea thar one's breasts are too small, and the lack of role models. One pos-
itl\"C note has been the " 'idespread increase in the availability o f lactation consultants
over the past several years. These consultan~ are a valuable resource for new mothers
in tl1e adjustment to breastfeeding. If a woman is interested in breastfeeding, she
should find support by talking to women who have experienced it successfully because
they can be an invaluable help to the first-time mother. The first-time mother should
find a friend she can caJJ on for advice. In almost every community, a group called La
Lcchc League offers classes in brcastfecc..ling and advises women who have problems
with it (800 -LALECHE or ' \\'\\ I tin.I d1. ~uc or~ ). Othcr resources are "''" rozen human milk should not be thawed in
r ,, 11 \ Ii 1:-·'-' 1 1 , ' '"' l rc.1\ kcding or• , and '"'". 1 I I • ·orh. o microwave. The heat con destroy immune
factors in the milk and create hot spots that may
scold the infant's tongue.
Return to an Outsid e Job Working outside the home can complicate plans to breast-
tccd. One possibility after a month or two of breastfeeding is for the mother to express
and save her own milk. She can use a breast pump or manually express milk into a ster-
ile plastic bottle or nursing bag (used in a disposable bottle system ). Saving human
milk requires carefi.tl sanitation and rapid chilling. It can be stored in the refrigerator
for 3 c.fays or be frozen for 3 months. There is a knack to learning how to express milk,
but the freedom can be worth it, because it aJlows others LO feed the inf.mt the
mother's milk. A schedule of expressing milk and using supplemental formula feedings
is most successful if begun after l to 2 months of exclusive breastfoeding. After 1
monm or so, the baby is weU adapted to breastfeeding and probably tCcls enough emo-
tional security and other benefits from nursing to drink both \\ ays.
Some women can juggle both a job and breastfeeding, but otl1ers find ir too cumber-
some and decide to switch to formula. A compromise-balancing some breastfeedings,
pcrhap~ earl~ morning and night, with infant formula feedings during the day-is possi-
ble. HO\\ ever, too many supplemental infant formula feedings decrease milk production.
Social Concerns Anotl1er barrier for some women is embarrassment about breast-
feeding a child in public. Historically our society has stressed modesty and has dis-
couraged public displays of breasts-t.:vcn for as good a cause as nourishing babies. In
the United States, no state or terrirory has a law prohibiting breastfeeding. However,
indecent exposure (including the exposure of women's breasts) has long been a com-
mon la\\ or statutory offense. Dunng the 1990s, some indi,·iduaJ states, such as Florida
and Nord1 Carolina, began to clari~· the right to breastfeed and to decriminalize pub-
lic breastfeeding. Since then, several other stares have passed similar laws. Women who
led reluctant should be reassured that they do have social support and that breast- Breastfeeding o baby ofter relurning to work is
feeding can be done very discreetly with little breast exposure. possible, but requires planning.
reostfeecling mothers should get their physi· Medical Conditions Precluding Breastfeeding Breastfeeding may be ru led out by
B cion's permission before embarking on a
vigorous exercise program. Breastfeeding
certain medical conditions in either the infant o r mother. For example, breastfeeding
may be detrimental to infants with phenylkeronuria; the high concentration of pht!ny-
women must also toke care to drink plenty of flu· labnine in breast milk may overwhelm the impaired ability of these i.nfams to metab-
ids before and after workouts and should avoid olize this amino acid, leading to production of toxic products.
exercising when fatigued. Certain medications, which pass into the milk and adversely affect t he nursing in-
fanr, are best avoided while breastfeeding. In addition, a woman in North America or
other developed regions of the world who has a serious chronic disease (such .1s tll-
berculosis, AIDS, or I-ITV-positive status) or who is being treated with chemotherapy
medications shou Id not breastfoed. 2
Environmental Contaminants in Human Milk

Then: is some legitimate concern over the levels of ''arious en vironmental contarni·
nants in human milk. However, the benefits from human milk are very weU established
and the risks from em·ironmental contaminants are still largely theoretical. Thus, it is
probably best ro contimte with what has been shown to work until sufficiently su·ong
research data contradict it. A few measmes a woman could take to counteract some
known c.:onraminants are to (1) avoid frt:shwate r fish from polluted waters, (2) care-
fully wash and peel fruits and vegetables, and (3) remove the fatty edges of meat, be-
cause pesticides concentrate in fat. ln addition, a woman should n ot try to lose weight
rapid ly while nmsing (more than 3/4 to l lb/week) because contaminan ts stored in
her fat tissue might then enter ht:r bloodstream and affect her milk. If a woman ques-
tions whether ber milk is safe, especially if she has lived in an area known to have a high
concentration of toxic wastes or environmental pollutants, she should consult her local
health department.
The Breastfeeding of Preterm Infants

There is no universal answer ro whether a woman can breastfeed a prererrn infant. Tn
some cases, human milk is the most desirable form of nourishmenr, depending on in-
fant w<.:ight and length of gcsrarion. If so, ir must usually be expressed from the brcasL
and fed through a tube until tbe infant's sucking and swaUowing reflex develops. This
type offeeding demands great maternal dedication. Fortification of the milk with such
nutrients .is cakium, phosphorus, sodium, and protein is often necessary to march th<.:
preterm infiu1t's rapid growth. In or.her cases, special feeding problems may prevent the
use of human milk or necessitate supplementing it with formula. Sometimes total par-
enteral nutrition (intravenous feeding) is the only option. Working as a ream, the pc·
diatrician, neonatal nurses, and registered dietitian must guide the parents in th is
decision.
If human milk is used lo feed the preterm infant,
fortification of the milk with certain nutrients is
often needed. Concept I Check
Human milk supplies most of an infunt's nutritional needs for the tirs r 6 months, although
supple1rn:ntntion with \'itamin D, iron, and fluoride may be needed. Breastfi:e<ling is often
more convenient than fornrnla feeding. Compared with formula-fed [nfunts, breastfed in-
fants have fewer intestinal, respiratory, and ear infections <Uld arc less susceptible: to some
allergies and food intolerances. Despite the adYantages of breastfeeding, a rnotha ma} be
dissuaded from breastfeeding by misinformntion, job responsibilities, and socinJ reticence. A
combination of breastfeeding and formula feeding is possible when a mother is regularly
away from rhc infant and is not able to express and store her mill;; for later use.
Br<.:asrfeeding is nm desirable if a mother has certain diseases or must tnke medication po·
tentially harmful to the infanc. The prcrerm infant, depending on its condition, may benefit
from consuming human milk.
Summary
1. Adcqll.ltC nutrition is 1·ital during pregnancy ro ensllre the well· drate intake (less th.111 l 75g/day), heavy caffeine use, ,rnd 1•arious
being of bmh the infant and mother. Poor matermil nutrition and inkctions, such as Uste1·in.
use of some medications, especially during the firsr tiimestcr, can 6. Pregnancy-induced hypertension, gestational diabetes, hc.1nburn,
came binh detects. Growth rcsrriction and alrered development consripation, nausea, 1•omiting, edema, and anemia arc .111 possible
can abo occur if these insults happen later in pregnancy. discomforts and complications of pregnancy. Nurrition therapy
2. lnfanb born preterm (before 37 wee~ gestation) usually have can help mini mile some of rhese problems.
more medical problems at .lild following birth than normal infants. 7. Almost all women are able to bn:asrfocd their infants. The nurri ·
3 A woman typically needs an additional 350 to 450 kcal/day dur· ent composition of hum:111 milk is \'ery different from that of un-
mg the second and third trimesters of pregnancy to meet her en altered cow's milk and is much more desirable. Colmtrum, rhe
ergy needs. A better measure of meeting energy needs is adequate first tluid produced by the human breast, is very rich 111 immune
weight gain. This should occur sl011"1y, reaching a total of25 ro 35 factors. Mature milk is rich in protein and in laccoi.e. The diet plJn
lb ( 11.5 to 16 kg) in a woman of healthy weight. recommended for pn:gnanc\' is also appropriate for mecring rhe
4. Protein, carbohydrare, fiber, vitamin, and mineral needs in crca~c nutrient needs of the lactating woman, except that more fluid~ in
during pregnancy. Following MyPyramid is recommended, in· general should be consumed.
duding \\'hole-grain bread and cereal choices. A supplemcnml 8. For the infant, the adl'antages of breastfeeding over formu la feed
source of iron, in particular, may be needed. Folate nutritun: es· ing are numerous, including fo\\"er intestinal, respiratory, and car
pecially should be adequate at the umc of conception. Any nutri infections and fewer allergies and food intolerances. Morcm·er,
cnt supplement use needs co be guided by a physician, bec.1use an breasrfeeding is also less expensive and possiblr more co1wcnicnc
excess intake of 1·icamin A and other nutrient:> during pregnancy for the mother than formula feeding. Howe1·er, an infant can be
can have harmful effects on the fotus. adequately nourished with formula if the mother chooses not to
5. The factors that contribute to poor prcgnanq ourcome include breasrfeed. Breastfeeding is nor desirable if the mother has ccrrain
inadequate health care in general .rnd prenatal care in particul.1r, diseases or must take medication potentially harmful ro the infant.
reenagc pregnancy, closely spaced births, smoking, alcohol con· Likewise, breastfeeding is not ad1·ised for infants with certain med-
sumprion, illicic drug use (such as coc:Linc), insufficient carbohy- ical conditions, including some preterm infants.
Study Questions
1. Prm ide three key pieces of advice for parc.:nts seeking ro maximize 8. \Vhar guidelines can a 11oma11 use to determine whether her
rhcir chances of ha1•ing a health)' infant. Why did you identil}· breastfed infant is receiving sufficienr notu·ishment?
those specific factors? 9. How should the basic food plan suitable for pregnancy be modi
2. Outline current weight-gain recommendations for pregn.mcy. fled dwing breasi:fecding?
What is the b.1Sis for these recommendations? 10. Where can first-time mothers go for help in esrablishing successful
3. ldenci~· four key nutrients for which intake should be s1gniticantlr breastfeeding?
increased during pregnancy.
4 . \Vh~ 1s folloll'ing MyPyramid ad1·ocared to meet the increased nu
tricnt needs of pregnancy?
5. Wh~ docs teenage pregnancy receil'e so much attention these BOOST YOUR STUDY
dJys? At what age do you think pregnancy is ideal? Why?
6. Gil'c three reasons a 11oma11 ~hou l d seriously consider breastfeed- Perspectives in Nutrition: Online Learning
Check out the
ing her infant. Center www.mhhe.com/wardlawpers7 for quizzes, flash
7. Describe the physiological mechanisms that stimulate milk pro cords, activities, and web links designed to further help you learn
ducrion and release. Ho11 can kno11ing abour these mechanisms about nutrition for pregnont and breastfeeding women.
help mothers breastfeed successfully?
ADA Report!. ~ Pmirion of the American 6. Crowther CA .rnd nthcrs: Effect of1rc.11111cm of s11bopti111nl fern/ 1111tritio11. ,\tl'tr11I 11/1.<cra•n·
Dtcrcnc Associac1on: :-\ucmion and tifcsrylc for gestational diJbe1e~ mclhtU!. on pregnancy out· tiounl n11d i11tcr1 cnrio11 swdus Sll..flfft'St tlmt
1
.1 hc.ilth)' pregnancy outcome. Jrmrnnl of tbr comes. 77u Nell' E11..11l1111d J1111mnl of .\Jcdici11r ditrs loll' 111 csso11i11/ l'ir11111im n11d mi11crnls,
A111ericn11 Dicutir Associntw11 102:1479, 2002. 352:2477, 2005 such 11s 1•1rn111im A, 8-6, n11d R-12 n11d the
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n11u of11lco/Jol, tobncrn, 1111d ot/m· hnrmjitl mb· blood gluC1•sc 111011i111ri11g nrc i111pon11111 p11ns of pre..11111111c_1• complimtio11s.
1tn11u1; nm! s11fa food /Jn11dlill..11. l'itnmi11 n11d rlu 1/urnp_1·; i11 st1111f cnscs i11mli11 i11jerrio11J nrr 12. Kclh Al-.'\\': Praaical cxcn:t'>C .tlhi.:c dunng
111111ernl mpplcmmtntio11 1s npproprinre for somr also 11ud,·d to C/llltrol blood gl11cos,·. prcgnanq·. TIJt Pl~mcin11 1111d \p1wts .11.-dimu
11111rirnrs, pnrtiwlnr(v in rcrrnill sit11ntions, 33(6):24, 2005.
7. Eustace L\V .111d mhers: Fetal akohol 5)'n-
SttdJ ns for vc._111111s. It is .rnfr fiw prcgn1111t ll'u111m t111•wrriH iftbc_v
dromc: A gro\\'ing concern for health cJ re pro·
2. ADA Reports: Po~irion of rhc American lessionah. ]01m1nl <!f'Obsmria, G_w1ecology, n11 d 11ri: 1•.vpcnwc111g 1111co111plic11tL'rl prrg11n11cits.
Dicn:tic: Associ.1tion: Promoting .md support· Ncrmntnl N11rsi11g 32(2):215, 2003. T/Je nuthtw 1111tcs tbnt i11 f11rt 1111rnr pomil't' <f
ing brca)tfceding. ]1111mnl of the A11w·ia111 fcrtt 11f1·xcrcisc rl111'i11g pn:(fl1nmy 111.,· pomblc.
T7Jr disorders frrnl 11lcc1hol sp1tfro111e 1111d fern/
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11lcohol effrct 11n 111crrns111g i11 rbc Uniud
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p11rts the brenstfudm..1111/ 111f1111rs. I1Jis nl'ficlc tio11 of nlc11/JQ/ d111•i11g pre_m11111cy cn11 /J11rm tbe ll'OlllCll. Exercise progrnms s/Jo11fd b1:11i11 11'it/J 15
d1muscs tbe brncjiufrnm l1re11stftedi11g tbnt fetus irrc·pnrnb(1·. C11rre11tf.y the n11101111r ~f'nlc11· 11111111u.< 1ifc.wrcisc three rtmr.r n •Ntk n11d
r1Ccr11e to the 111ot!Jt·r 1111d il1ji111t ns 11>el/ ns di- /Joi, if rut.I', r/Jnt rn11 bf snfc(i• co11mmed d11ri11g flrttqress ns t11lcrntcd. 17Jc 1111t/Jm· duoma boll' to
ctnry rousidcmrillw r/Jnt 11ud to /Jr nddrrn·rd, p~·eg11n11c_1• n.i1d r/Jt' cxnct physiologicnl 111ccbn-
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k111111'11 tn co11tr1i11bi._qb11111omtrs of mt'rClll~Y· /Jnpc _1·ct m be 1dmrijicd. 13. King JC: The risk of m.m:riul nutritionJI Jc·
3 Allen LH: J\lulnple m1cronutrients in preg· 8. Field CJ: The im1mmologkal components of plcnon .rnd poor outcomes incrc.1\c\ 111 earl! or
nancy .ind lacr.uion An O\"en·iew. Amrricn11 human milk JnJ clmr eflecr on unmune de,d· close!)· sp.1c.:ed prcgnancic\ /11111·11nl of
/1111mnl ofClm1cnl .\11mt1011 81: l206S, 2005. opmem 111 inf.lnb ]1111m11/ of S11rr1t1011 135:1, N11m11011 133:17325, 2003.
N11111.-row m1trioirs rn11tnl111u ton hc11/th.v 1111r- 2005. A1111dcq1111tc s11ppl_v of1111trimts 11 prt1b11bf.1 tfJI'
ro111c afpreg11n11cy, i11c/11tf111..rr 1111111_y B 11it11111im H11111n11 milk co11tn111s 1111111.v fflctrll'S rbnt i111· single most i111porcn11r e1n1fro11111mtnl frucor nj-
nurl iron. TIJe n11rbor 1111tl'S r/Jnt i11 1111111.v cnsrs pnm: im11111111·ji111m1111 i11 rhe i1ifn11t. TfJis nrri· fecri11g pn:q11fl11cy 011tco111c. A sbort illt1T1•nl bL'-
dirt c/Jn11..11es nlloll' JllOlll<'ll t11 meet tbtsc uccds, cir l'tl'icn•s 111111111btT1ift/Jtu quite· (11111pfrx t11'cr11p1·(_q111111cies111· nu c11rf.y p1·i:1111n11cy 1J1irbm
bur i11 some cnsrs mppk111mtnrio11 is uecdl'tf, fncton 2 ycnn 11[ r/Jc omct of 111011tm11/ pr,.illds 111-
meb ns for poor n•omw. Dia cbnugcs should crensr.r the rl.<k for p1·ctcr111 birth n11d ..111·mrtb-
9 . Hulsev TC and other': i\l.itcrnJI preprcgnam
br._11i11 before pre._1111111u.1· son no11111n11 /ms n rcrnrdcd i11f1111ts. Jlntcr11nl 111111·1011 dcpkt1011
body ma~> inJc\ .ind" eight g.iin related to lo"
/Jrnlt/~y nnt11s i11 r/Jt' jirit 11wk.r wbm 1/Jc does 1101 nrumg from closcf.r spnced pri:1111n1uio is 1111r
birch weight in South Carolina \011rlur11
rcr know she is prc._111111111. cnusr of t/J(Jc poor prcg11n11c_y 1111u11111c·s
Medicnl fo11mnl 98:411, 2005.
4 Bachr.ich VGR J nd other': lkcastfecding and S11pplmm11Mi1111 JPirb food n11d 111irm1111trirnts
A /Jenlr/J_v weig/Jr at r1111tcprio11 n11d ndeq11ntc during the i11terjn·eg111111c.-v pcnod 111n.v i111pn11•L'
the risk of hospic.1lii.1rio11 for respiratory di~
1Pcigbt gni11 d111'i11JJ prcg111mcy ro11trib11ud Ill fl preg111111cy 1111tco111cs nnd m11f1T1wl lm1l1/J
ea,cs in inf.i nc)': A met.i·.111.tlysis. Affbil'c'S of
S11bst1111tinl 1·td11ct11m iii fow·bin/J·n•t'i,.11llf i11- 11111011..11 1J10111w ll'ir/J rrn·ly m· rl11sL'f\o spnrrd
Pt'tf111tries e~ Ad11/eswir i\frdiri11e 157:237,
fnnts fo r/Jis st11d1•. For t.mmplc, wo111r11 111i1/J i11· prr_(fl11111cics
2003.
ndrq11nt.- wti,.11'1r..11n111s /Jnd 11bo11r n 1.5 to 2
Brcnstfacdi11g n11 111fn11r mbnnminl~v rcducu Ins 14. Kocbmck ( and others: Long term O\O·la.:co
timcsg1·tnur risk ofdd1rcri11._11 n low-birt/J-
01· her risk of de1•dopi11._11 rcsp1mtor.Y disenscs. "Iii \"cgcr.1riJ11 diet impair~ \'itamin R 12 \tJtu~ in
ll'tiglJt illf11 Ill
1uhitl'C this bmcjit, nt knst 4 11w11tbs of c:o:c/11· prcgnam women. fo11r11n/ 1'.} 1\11tri1io11
I 0. Kabiru i-.·w, Ra) nor BD: Obsrcrric omcomc~ 134:3319, 2004.
si1•r brmstfadiu..11is1wo111111c11dcd.
associaccd \\'i th increase in BMT caregory dur·
5. BrundJgc S: Preconception health ca re. Png11nnt ll'011tt11 co11-m111i119 fl lo11._q·ur111 prc-
ing prcg11.1nc)'· A111crirn11 ]011rnnl of Obstetrics
Americnu Fnmi(1• P/Jysicin11 65:2507, 2002. do111i11n111/y 11cgerMin11 diet hnd n11 i11rrc11scd
1111d G_vuerology 19 1:928, 2004.
Ac/J1tl'iug oprimnl pnro11reptioii benltb rn11 brlp 1·islt of d1·11cl11pi11g n 11itn111i11 ll-12 dcjirimcy i11
Obesiry i11 p1·r._(f11n111 1110111m leads ton '11..11'1 ruk rhis swd_v. Attmrion to Pirn111i11 R· /2 mrnkr is
to reduu adJ'crsc prcg11n11cv outcomes. It iJ 1·u-
for complicntio11s i11 thr prtg11n1u\• nnd so rt· rf111s mcrtted i11 women w/Ju nrt t'•'flt'tnrinm,
0111111wded t/Jflt 11•omm wbo nrc pla1111i119 to bc-
q11frcs cnrcf11/ 1110111toml.!J b;r the p/J_vnc11111 \ucb n11d tlm 1110111tor111g needs to b,· dun.- before rlu.1·
flllll<' p1Yg1tn11t co11111111r at lc11st 400 µg of
complicntious md11dcd.fJCITfltio11n/ di11bttts n11d br:come prfg11n11t.
symhmc Jolie ncid, gcr scremcd and if neccssnr_r
the 11eed fo1· usnrcn11 rlclil'cries. l5. Moore V1\ I, Davies MJ: Diet during prcgnanc~.
be tl'cnted for 1111.1• i1lfecrio11s diseases, limit t/Jcfr
t.x·pos11rc to wviro11mwtnl toxins, n.11d optimize J l. Keen KL anJ others: The plmt.ibility of mi· neo natal o utcomes, aml l.11er health.
co11rr11I of n11y clmmic discnscs. In 11dditio11.• cronurriem d cficicncic~ being a >ignifkam con· Reprod11ctio11, Fertility, n111f {)cfh•n:v 17:341,
111111~v experts rrcommwd tbnr 111omm pln1111m.11 rributi ng fu~tor to the occurrence of pregnancy 2005.
n prc-g111111c_y pnrricipnu i11 ngulnr modernu complica11ons. ]1111mnl of S111,.,1io11 133: A111111nl e.-.:pcrimwts clcnr~y 1/1011' 1/1111 n/w·ing
f.wrcist, ni•oid bor/J obtsil')· 1111d 1mderwcig/Jr, 15975,2003 t/Jc maumnl diet before n11d d11rill..11 pre._1111nm'_l
n11d steer clenr ofnlcobol, mcgfldoscs of v1rnmiu N11me1·011s smdw mpport rbe c1111upt 1h11t n cn11 111d11u pcr1111111mr c/Jflll.!JCI i11 rlu offspring
A, n11d lm;gc 1111101111ts ofcnffii11c. 11111jor cnwc of pr(_qlln11c_\· comp/Jmtio11s cn11 /Jr bzrrb siu, nd11/t bcnlrb, n11d lift spn11 .
Comc1[11cnces of i11nrfr1[11nte mntcmnl 1111triri1111 Consripn ti1m is n com 111011 compin illt in preg- 111111cies mid is 11 sig11~fic1mt cnusc of b11t/J illness
far the offtpriug depcud 011 r/Je specific ti111e i11 nrmcy. bi mos! cases, dit:trH')' 111ensm·cs such ns and d eat/; hi the mother n11d fetus.
9cstnti1111 tlmt thc_v occm: The rmtbors c111pbnsi::.c i11c1·c11scd fiber nrc mfficie111 tn trent tbt disor- Mm1n.gcme11t re1[11ires cnrefu/ 1111mitori11g of tlJc
t/Je importn 11 ce of improiii11g dier before n !ln: A11y ln.xnrivc us" needs to br 1·epie11>ed by n. motlm· a11d fi;tw mice tbc disorder rlcvcl1Jps.
1pomn11 becomes p1·eg11n11t in onlcr tn protccr her pJ~vsicin 11 because some n re 11or 11ppmprin.tc for C11n·c11rly, 111ag11c.ritt111 s11/jhte is the mnjor tbcr-
Inn/th re11d tin /Jrnlt'1 of her offspring. use d m·iIll) prcg11n11 c_v. llPJ' 11sl'd, but 111cdicnti1111.i to cout1·11l rclntcd /Jy-
16. Pawley N. Bishop NJ: Prcnacal and infanr prc- 18. Rosenburg Tl and others: i\ latcrnal obesity and pcrte11si011 may n/so be employed. T71is nrtic!c
dictOro of bone health: The influence ofvitamin diabetes a> risk fa,rors for adverse pregnancy reviews preec/nmpsin. i11 detail.
D. A111cricn11 fo11mnl oj' Cliniml N11tritio11 outcome.~: DiITcrmccs among four racial/eth- 20. Welch-Carre E: The ncurodc,clopmcnral con-
80: l 748S, 2004. nic groups. Amcricn11 }011mn/ of Public Henltb sequences or prcnaral alcohol exposure.
Women tl'bo n.re 1>itmni11 D-dcficic11t d111-i11g 95:1545, 2005. Advn11ccs in Nco11n.m/ Cnre 5:217, 2005.
pregnn 11cy delil'&r inf11.1m wir/J difrm·b"d .rkelc- !11 tbis lm;gt pop11lntio11-/mscd rt11dy, obesity nllff Prenntnl 11/whol e.>:pomre n11d t•elaurl fem/ a/co·
rnl dcvtlopmmt n.11d in some cnscs cJ>cn wit/; cvi- dinbctcs wen: clenr/y associated 1Pith nd11crsc bot .<J•11dm111e i.r 1111c of r/Jc /c11di11g rn1<scs of binb
deucc elf rickets nnd fi·nctm·es. Pop11lntio11s n.t p1·cg111111c.1• 1111tro11m: T71i.r jfodi11g higlJ!ig/Jts tbc defects, dcr>dopmmta./ disordc1·s, n nd 111cntn.l re-
risk .for Pita111i11 D dcficimcy 111·c tbosc for w/Jic/J, ueerl Joi· women to c1111tro/ these conrlitio11s as bur tm·dn.ti011 i11 cbildreu. The 11e1·po11s system of tbr
for euvironmrntn!, culturnl. or medical rcnso11s, as possiblr d11ri11g rhcir cbildbcn ri.11g .imrs i11 fetus is partic11/nr~)' p11fttemblc to nlcol;ol. 771c
e:o.,"j!omrt to su11/ighr is poor 1111d tbe dicrn.ry in- lll'der t11 p1'0tect the /Jenlt/J of t/1cir f11t111·.- i11frmt. n.m/;01· rccom111e11!1s rhnt clinicirms pr1111idc n.11-
mke of11itami11 D is low Espccial(v in t/Jc.r<" 19. Wagner LK: Diagnosis and martagements of ticipn.to1Jg11id11.11cc nnd co1mse/i11g nb11111 n/C11 -
cnsa, nttentio11 ro meeting vitnmin D 11eerls is preeclampsia. Amcrica11 Family Ph.vsicinn /;11l we frw wo111c11 d1wi11g tbcil' c/Ji/dbeari11g
very i111 portant. 70:2317, 2004. yen.rs in order to pre1•1m r tbi.r d iso1·de;:
l7. Prather CM: Pn:gnancy-rclarcd constipation. Prccclmupsin is fl 11111!1isysrc111 disorrle1· of 1111-
C111nnt G11.strowtcl'Olo9y Repol'ts 6:402, 2004. /mown rnuse. it ({fccts nbo11r 5 ti/ 7% o.fprcg-
Take I Action
I. Targeting Nutrients Necessary for Pregnant Women

This chapter menlioned that pregnant women may hove difficulty meeting th eir increased needs for folote, vitamin B-6, iron, and zinc.
List six foods rich in each of these nutrients next to the appropriate heading below. Refer to Chapters 9 through 12 if necessary.
Nutrient Foods Nutrient Foods

Folote Iron
Vitamin B-6 Zinc

614 Chapter 16 Pregnancy and Breast Feeding
Take I Action
11. Putting Your Knowledge about Nutrition and Pregnancy to Work

A college friend, Angie, tells you that she is newly pregnant. You ore aware that she usuolly likes to eat the following foods for her
meals:
Breakfast
Skips this meal, or eats a granola bar
Coffee
Lunch
Sweetened yogurt, I cup
Small bagel with cream cheese
Occasional piece of fruit
Regular caffeinated soda, 12 oz
Snock
Chocolate candy bar
Dinner
2 slices of pizza, macaroni and cheese, or 2 eggs with 2 slices of toast
Seldom eats a salad or vegetable
Regular caffeinated soda, 12 oz
Snacks
Pretzels or chips, 1 oz
Regular caffeinoted soda, 12 oz
1. Using NutritionCalc Plus software or Appendix N, evaluate Angie's diet for protein, carbohydrate, iron, vitamin B-6, folote, and
zinc. How does her intake compare with the recommended amounts for pregnancy?
I J
2. Now redesign Angie's diet and make sure that her intake meets pregnancy needs for carbohydrates, protein, folate, vitamin B-&,
and zinc. (Hint: Fortified foods, such as breakfast cereal, are generally nutrient-rich foods, which con more easily help meet her
needs.} Increase her iron content as well, but it still may be below the RDA for pregnancy.
NUTRITION FROM INFANCY
THROUGH ADOLESCENCE

Nutrition and Child Health: An Introduction Damon is a 7-month-old boy who hos been token into a clinic for a routine checkup.
Infant Growth ond Physiological Development On examination, he seemed thin, and he plotted on the growth chart al the 25th
The Growing Infant • Effect of Undernutrition
on Growth • Assessment of Infant Growth and percentile for weight and the 501h percentile for length. His physician scheduled a
Development • Brain Growth • Adipose Tissue follow-up appointment in 3 months. Al the 10-monlh-visil, Damon appeared sluggish.
Growth • Failure lo Thrive • Infant Nutritional
Needs • Formula Feeding for Infants • He was again plotted on the growth chart and was now al the 5th percentile for
Development of Feeding Skills in Older Infants weight but still at the 50th percentile for length.
• lntraduclian of Sa/id Foods al about 6 Months
of Age A registered dietitian interviewed Damon's 16-yeor-old mother to collect informa-
Cose Scenario Follow-Up tion on his dietary intake The 24-hour diet recall consisted of two bottles of formula,
Health Problems Related lo Infant Nutrition three bottles of Kool-Aid, and a hot dog. However, the mother was still in school,
Nutrition Focus: Food Allergies and Intolerances
and al night she ohen leh Damon with the neighbor so that she could go oul for a
Preschool Children: Nutrition Concerns
Helping o Child Choose Nutritious Foods • few hours. Thus, she was not aware of all that he ale, because much of her time
Childhood Feeding Problems • Use of was spent away from him.
Multivitamin and Mineral Supplements • Other
Nutritional Problems in Preschool Children •
Modifications of Childhood Diets lo Reduce
What problems do you think ore present in Damon's diet? What potential dan- z
gers await Damon if his health status continues along this current growth trend? -I
Future Disease Risk I
m
School-Age Children: Nutrition Concerns
Breakfast, Fol Intake, and Snacks • Type 2 c"Tl
Diabetes • Overweight and Obesity m
()
Expert Opinion: Are Savvy Marketers
Contributing to the Obesity Epidemic -<
()
in Children? r-
m
The Teenage Years: Nutrition Concerns
Nutritional Problems and Concerns of Teens
• A Closer Look al the Diets of Teenage Girls
• Helping Teens Eat More Nutritious Foods
• Working with the Teenage Mind-Set
• Teenage Snacking Practices
Toke Action
615
A s humans grow through early years into adulthood, our needs for energy and nutrients change.
Infants need more energy, protein, vitamins, and miner·
ols per pound of body weight than do adults lo support their
rapid pace of growth and development.5 As growth tapers, chi~ CHAPTER OBJECTIVES CHAPTER 17 IS DESIGNED TO
ALLOW YOU TO:
dren need and eot proportionately less. The erratic eating be-
1. Describe normal growth during infancy and childhood, and
haviors of young children pose major challenges for parents and
state why growth with regard to weight and height is on
other coregivers. 11 In turn, childhood becomes on important indicator of the adequacy of on infant's diet.
time to establish healthful habits, including those related to food 2. Identify the nutritional needs of infants and children.
choice and physical activity. 3. Explain why infant formula is on acceptable substitute for
Family behaviors wield important influences over the child.17 human milk and why cow's milk is not.
Thus, education designed to change children's eating behaviors 4. Develop on adequate eating pion for on infant or child using
food labels ond MyPyromid.
must be directed simultaneously at the main caregivers. They usu·
5. State why feeding on infant o high·iron food at 6 months is
ally determine what foods ore purchased and how those foods recommended.
ore prepared. To help children adopt a lifelong healthy dietary 6. Explain the rationale-from the standpoint of both nutrition and
intake, parents and caregivers should provide a variety of foods ongoing physical development-for the delay in feeding on
infant solid foods until 4 to 6 months of age.
at home, limit fast food to a few times per week or less, and in·
7. Help parents overcome obstacles associated with children's
traduce new foods regularly. Maintaining a pattern of healthful
eating habits.
eating (and physical activity) should continue as children grow
8. Relate nutrient needs lo growth rote in adolescence
into teenogers. 4·9, l3,20 In exploring all these stages of life, this
9. Explain some nutrihon-reloted health issues facing children and
chapter looks at the key role nutrients ploy and how food choices teenagers today in North America.
should be tailored to meet a child's changing needs. 10. Distinguish between food allergies and intolerances and
provide recommendations for treating both.

OF NUTRITION FROM INFANCY THROUGH ADOLESCENCE
IN CHAPTER 17, YOU MAY WANT TO REVIEW:
MyPyrom1d and the 2005 Dietary Guidelines far Americans in Chapter 2
Diagnosis and treatment of type 2 diabetes in Chapter 5.
Common sources of saturated fot and trans fat in Chapter 6
Vegetarianism in the Nutrition Focus in Chapter 7.
Rich sources of iron and zinc in Chapter 12.
The concept of body mass index jBMt) and the treatment of obesity in Chapter 13
The benefits of regular physical activity in Chapter 14.
Anorexia nervoso and other eating disorders in Chapter 15
Nutrition and Child Health: An Introduction

Current trends in nutrition and overall health among children and adolescents 1n
North America have shown both positive and negative results. On a positiYc note,
more children are receiving \'accinations than ever before, fewer teenagers arc giving
birth, and the pO\crty rate for children ha~ fallen considerably. In contrast to thi~ good
news, the number of children and tccn.1gcrs with obesity, the metabolic syndrome, and
type 2 diabetes is rising, and physical activity in general is on the decline as more Lime
is spent sitting in front of computer screens and television sers. 9 ·20 Low calcium intakes
arc also receiving much attention, as soft drinks have replaced much of rhe milk that
chi ldren m1d teenagers uscct to consume on a daily basis. Whole grains are also in short
616
supply in children's diets.2,19 This chapter looks at these trends, especially their effects
on nutrition and overall health in this age group.
Infant Growth and Physiological Development

During infancy, a child's attitudes coward foods and the whole eating process begin to
rake shape. lf parents and other caregivers practice good nutrition and are flexible, they
can lead an inf.int into lifelong healthfol food habits. Such an infant ha:. a good chance
both of starting lite with the nutrients needed to support brain and body growth spurts
and of developing a willingness to cry new foods.
Thest: physical and psychological ,1dvantages, however, don't guarantee that a child
will thrive. Children also need specific attention focused on them; they need to grow
in a stimulating environment, and they need a sense of securi ty. ror example, children
hospitalized for growth f.'lilure gain weight more quickly when loving care accompa-
nies needed nutricnts. 1 1
The Growing Infant

All infants seem to do is eat and sleep. There's a good reason for this. An infant's birth
weight doubles in the first 4 to 6 months and triples within the first year. Never again
is growth so rapid. 11 Such rapid growth requires a lot of both nourishment and sleep.
After chc first year, growth is slower; it takes 5 more years to double the weight seen Children benefit from the love and ottention of
at l year. An infant also increases in length in the first year by 50% and then continues adults.
to gain height through the teen years. These gains arc not necessarily continuous-
spurts of growth alternate with plateaus. Height is essentially maximized by age 19, al-
though increases of several inches may occur in the early twenties, especially for boys
(Figure 17-1 ). Head size in proportion to total height shrinks from one-fourth to onc-
eighrh during d1e climb from infuncy to aduJd1ood.
13 Boys 13
I
12 12
11 ;::- 11
;::- 0
2 10 ~ 10
.......
>- 9 9
....... "'
Q)
~ 8
..c
u 8
~
1lc 7 .,, 7
·5
.. 6 .,,.,,
Q)
6
..
C1I
..c 5 0 5
C1I
'Qi ..c
.4 C1I .4
~ "Qi
3 ::z:: 3
2 2
3 5 7 9 11 13 15 17 3 5 7 9 11 13 15 17
Age in years Age in years
(a) (b)
Figure 17-1 I Growth rotes. (a) Average gains in weight for girls and boys. (b) Average additions lo
height for girls and boys. The higher the line in any one year, the greater the amount of annual gain
compared wilh !hot in other years. Lorge gains in weigh t occur in both infancy and puberty, whereas
the very high length gain in infancy is never reached again. If graphs such as these were plotted in
smaller time segments, they would appear as zigzag lines, rather than smooth lines, reflecting short,
periodic spurts in growth in the course of each year.
618 Chapter 17 Nutrition from Infancy through Adolescence
The hum,rn body needs a lot more food Lo support growrh and dC\'elopmcnr than
it doc:. ro mercl~, maintain irs size once g rowth ceases. \\Then nutrienls .u-e mbsing ar
critical phases of growlh and development, growth slows and may even stop. From ob-
servations of Egyptian mummies, we sec that infants were abour the same size in 300 B.< .
as rhcy arc tod.iy. Howc\·er, adult mummies ,lre much smaller than adults tod,n·.
l-urrhermorc, rhe suits of armor 111 musetrn1 collections of Lhc Middle Ages typ1,al1)
wou ld not fit modem .1dulrs. T he .weragc heig ht of No rth American men in 1700 was
approximately 5 teer 8 inches, whereas today it is approximately 5 feet l 0 inchc'>. These
i111.:rease:. suggest that people of earlier times generally ate nurrienr-poor diets that did
not suppon the gnm th we rypic<llly experience today.
Jn count ries of the developing world today, about o ne-third of the chi ld re n t1mkr
5 ycars or age arc short and underweight for their ages. Poor nu trition e;1lled
1111denmtritin11- is at the heart ol the problem. Undernutrition occurs ro a 1c~,er e\ -
tcnt in Norrh America. The undernourished children are simply smaller \·ersion~ of nu-
tmionally lit children. In poorer cou ncries, when breastfeed ing ceases, chi ldren arc often
led a high-carbohydrate, Im\ -protein d iet . T his d iet sup ports some growth but docs not
allow children to attain rheir full genetic potential. To gro,,, children must consume ad-
equate amounts of cnerg), protein, calcium, iron, zinc, and other nutrienrs. 1
Infant devdopmcnt follows a p~ntc rn in which body water falls from about 70% ,n
birth to 60% at l year. T he larter 1~ also rhc proportion typical in adults. By age 1, a
healthy intant's body nitrogen content (and thus protein content} has increased from
2% of bod) weight at birth ro 3%, in<licating chat the infant has synthesL~ed much ne\\
lean tissue. 11
Effect of Undernutrition on Growth

A~ wirh Lhe fetus in utero, the long term effc.:cts of nutritional prob l em~ in infanC.:\' .rnd
chi ldhood depend on t he severi ty, timing, and duratio n o f" the nu trit io nal insu lt to cell
proc.:es:.es.
The single best indicator of a child's nutrition.ti status is growth, partic.:ularl) weight
gain in the short run ,md length ( height ) in the lo ng ru n. Mild zinc deficienc.:ics in
North Americ;m children have been linked LO poor g rowth . Improving the d icL:. of
t hese d1ildrcn rhen leads ro improved growth. Overall, c.uing a poor dieL as .in infanr
or a child hampers the c.:ell diYision that occurs at that critiC<ll stage. Consuming an ad-
equate diet later usuall) \\On't compensate for lost gro\\'th, because the ho rmonal .md
o the r cond iLions needed fo r growLh will no r likely be present. In addition, growth
ceases in girls and boys'' hen the skelcron reaches its final size. This h.1ppens as gro'' th
epiphyses Ends of long bones. The epiphyseal plates at the ends of the bones, called epiphyses, fuse. This process begins at around
plate-sometimes referred to as the growth 1-! years of age m girls and l 5 years of age in boys and ends at about 19 ye.1rs of .1ge
plate-is mode of cartilage and allows growth in gi rls a nd 20 years of age in boys. Furthermo re, muscles can increase in diameter later
of the bone to occur. During childhood, the in life but the gro\\th is limited by the length of the bone. 11
cartilage cells multiply and absorb calcium to For these reasons, a 15 -year-olJ Central American girl who is -1- tcct 8 inches tall can-
develop into bone. not anain the adult height of a typical North American girl ~i m ply by eating bener. Girls
experience their peak rate of growth before the o nset of the menses. Once the time for
growth cc,1ses (in women, about 5 years after they start menstru ating), a suffidcnt nu-
trient intake hdps maintain health .md weight but cannot make up for lost growth .
Assessment of Infant Growth and Development

Health protessionals ,\ssess a child's increases in height and weight by comparing. Lhem
with [)-pica! growth p.merns recorded on charrs (Figme 17-2). The charts contain 7 to
percentile Classification of a measurement of a 9 percen tile divisions,'' hich represent the t)'Pical measuremems ofabom 96% ofchild ren.
unit into divisions of 100 units. A pcrcemile represems rhe rank of the person among 100 peers mardted for age and gen-
der. ff a young boy, for e\ample, is ,\t the 90d1 percentile height for age, he is shorter tlun
10% (of c.:hildren ) and taller than 89% (of children ). A child at rhe SOd1 percentile is con-
sidered average. Fifty children \\'ill be railer th,m this child; 49 will be shorter. 11
Birth to 36 months: Girls NAtJE - - - - - - - -

Length·fOr·age and Welght·for·age percentile& llECORD • IWl.E _ _ _ _ _ _ __
2 to 20 years: Boys
..-
- -
s ..111 3 s e 12 1s 1a 21 24 v 30 33 36 Body mass lndex.for-.age percentiles RECORD•
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~~~~ /
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'-2 kg m' AGE (YEARS) kg m~
(a) lb kg (bl
81rth 3 6 9 2 3 • s 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Figure 1 7-2 I Growth charts for assessment of children in the growing years. The growth of a
youngster is plotted to show how the charts ore used in health-core settings. (o) Growth charts used lo
assess length (height) and weight in young girls. A certain weight and length (height) correspond lo a
percentile value, which is a ranking of the person among 100 peers. This chart shows that al 36 months
of age the girl was at the 75th percentile for length and the 62nd percentile for height. (bl Growth
charts used to assess weight.for.height relationships in boys ages 2 to 20 years. At 6 years of age the
boy was at the 85th percentile for BMI. Todoy these charts for older children and adolescents typically
utilize BMI for the evaluation.
Source: Developed by the Nolionot Center lor Heollh Slotistics in collaboration wilh the Notionol Center lor Chronic
Disease Prevention and Heollh Promotion (2000). 'W"' d JOv/ gro· ·thchorls. Revised November 21, 2000
IndiYidual growth charts are available for both males and females. For ages ranging
from birth to 36 months, options for growth charts include weight-for-age, length-for-
age, weight-for-length, and head circumference-for-age. For males and females who
are 2 to 20 years old, growth charts are arnilable to determine weighr for age and
height-for-age; however, the preferred growth chart for children and adolcscems is hildren under 2 lo 3 years of age ore
body mass index ( B~H )- for-age. For adults, BMI has fixed cutoff points (for example, measured lying on their bocks with knees
a BMI of25 for .m adulr is considered o\·erweight). As Figure 17-2 shows, Lhis is not unAexed so the term length is used rather
true for children, for" hom BMI is both gender- and age-specific. than height.
Infants and children should have their growth assessed during regular health check
ups. le takes I to 3 years for an infant to establish his or her own genetic percentile.
Once chis figure is established, such as length ( height) for age, the chi ld's measurcmem
should then track along that percentile. If the child's growth doesn't keep up with his
or her length-for-age percentile, the physician needs to investigate whether a medical
or nunitional problcrn is impeding the predicted growth. Inappropriate weight gain-
tOO little or too much-should also be invcstigated. 11
lnfants born preterm may catch up in growth in 2 to 3 years. Catching up requires

that die child move up in the percentiles-especially in length-for-age- and such move-
ment is usually no cause for alarm. On the o ther hand , moving up percemilcs in wcighc-
for-heigbt can be disturbing if the child approaches the 80ch to 90th percentiles. A child
at the 85th pen:emile or abo,·e for BMI is considered at risk for ovenveight. At or abon:
the 95d1 percentile, chc child is considered overweight. Ar the 95tb percentile, me di-
agnosis of obesity can also be established if the physical exam of the child indicates he
o r she is truly overfut , which is generally me case at this percentile.
Brain Growth
The brain grows faster in infancy than at ao~· omer time of life. To accommodate the
growth, an infant's head circumforcnce must be very large in proportion to rhe rest of
the body. The rapic.J growth stops at about 18 mo nths of age. The rest of the body
eventually grows to reach a typical proportion to head size . Jn early physical checkups,
a healm profi.:ssional usually measures the head circumference as another means of as-
sessing growth, especially brain growth. How nutritional status affects brain de\'clop-
ment and intelligence quotient (IQ) is difficult to measure because scienrisrs h:l\'en't
tigured out ho\\· to separate the eftccts of nature from chose of nurture. I JoweYer, seY-
eral studies ha\'e determined that breastfed infants have higher IQs than do infant$ who
were fed with infanr formula. 11 At the same time, studies from Central America sug-
gest d1at IQ after age 5 years relates more closely lO the amount of schooling a cl1ild
receives than to nucritionaJ intake during childhood.
Adipose Tissue Growth

Brain grow1h is foster in infancy lhon in ony Since 1970, researchers have specubtcd d1at overfeeding dlll'ing infancy may increase
other stage of life. Therefore on infant's head adipose tissue cell numbers. Today, \\'e know that the number of adipose cells can also
needs to be larger in comparison to the body in increase as adulLhood obesity develops. Still, if energy intake is limited during infancy
order lo allow for such growth. to keep down the number of adipose cells, the growth of other o rgan systems m<ty also
be severely restricted. Special concern revoh-es around bod)' growth and dc,·elopmenr,
especially brnin and ner\'ous system de,·elopment. ln addition, most obese infants be-
come normal -\\'eighr preschoolers without excessive diet restrictions. For these rea-
sons, it's unwise tO greatly restrict diet and especially fat intake in infants. After the first
12 mo nd1s, fat inr<1ke can range from 30 to 40% of energy intake for ages l to 3 years
and 25 tO 35% for older ch ildren (and teenagers). 1
Failure to Thrive
Occasionally, an infant doesn't grow much in the first IC" months. Physical problems
d1at may contribute to resu·icred growch range from poor o ral ca,·ity den:lopment, in-
fections, and heart irregularities to constant diorrhea associated wid1 intestinal prob-
lems. However, more than half the infants who fail to thrive have no app.lr<::nt disease.
Sometime!> d1e cause is poor inf.mt-parent interaction that can stem from misinforma-
tion, mental depression in the mother, Jack of a parent role model, or too little con-
cern about the child's welfare. In general, the problems arise from the parent!>'
inexperience rather chan intentional negligence. In addition, many children who fail to
d1rive have inborn errors of metabolism mat arc very difficult to diag nose. For exam-
ple, unusual enzyme deficiencies cou ld lead to poor nutrient absorption and then mal-
nuuition ( revic\\' the Nuu·irion Focus in Chapter 4 ). In all cases a physicia n shouJd
determine the actual cause. 11
Infants not onlr need cuddling; they also respond to \'Oices and eye contact, espe-
cially at feeding rimes. ~ew parents need to appreciate the importance of mese prac-
tices co their infant's \\'CU-being. Some parents aJso may be oven:ommitced to
maintaining a Jean child in the hope of preventing future obesity. T he result, even
though the intention was good, can be failure to t11rive.
When clinicians encounter an infant who is failing to thri\'C from a nutritional stand- hildren older than 2 years ore less likely to
point, they must first determine whether formula-fed infants are consuming enough experience failure to thrive because they
energy (see this chapter's section on formula teeding of infanrs for details). For a con often get food for themselves. Younger chil·
breastfed infant, the clinician needs to make sure tbat sufficient milk intake is taking dren, for the most port, ore limited to what core·
place. As mentioned in Chapter 16, the child should be breastfoeding about six to eight givers provide.
times a day for about 20 minutes a session and have six co eight wet diapers each day.
Concept I Check
Growth occurs rapidly during infancy: birth weight doubles in about 4 to 6 months and
triples within the first year. Lean tissue increases, and the percentage of body water fulls
during the first year. Undernucrition in childhood can irre,·ersibly inhibit growth and maru-
rarion, so that an indi,~dual never anains his or her full genetic potential tor height. Infant
and child growth is assessed by tracking body weight, length (height), and head circumfer-
ence over time. Body mass index (BMI) is generally used co assess weight for height after 2
years of age. It is not desirable for infants to become obese, although 110 evidence strongly
indicates that obese infants become obese adults. However, severe restriction of energy in-
rake i~ not recommended for infants because it may slow the growth or organ systems.
When infants do not grow properly, their fuilure to tl1ri,·e may mm from physical disorders
or inadequate care, including inappropriate feeding practices.
Infant Nutritional Needs

lnfancs' nutritional needs vary as they grow, and these needs diftcr from adult needs in
both amount and proportion (Figure 17-3). 5 Initially, human milk or infant formula
{generally using heat-treated cow's milk as a base) supplies needed nutrients. Solid
foods are not needed until around 6 mo nths. Even after solid foods arc added, the
basis of an infant's diet for the first year is still human milk or infant for mula. Because
of rhc critical importance of adequate nutrition in infancy and the difficulties encoun-
tered in feeding some infants, more time is spent in this chapter on this developmen-
tal period than on the later periods of childhood.
Energy
Estimated Energy Requirements (kcals) in infancy are (89 kcal x weight of infant
[kg]) + 75 from 0 to 3 months. from 4 to 6 months, such needs are (89 kcal x
weight of infant [kg]) + 44; 7 to 12 months (89 kcal x weigh t of infant [kg]) -
78. At 6 months of age, this amount is about 700 kcal daily. Based on body weight Infants who ore formula.fed should remain on
i:omparisons, this amount is two to four times more energy than adults need. Infants formula until 1 year of age.
need an easy way to get this amount or energy. Either human milk or infant formula is
ideal for rhc first few months. Both are high in fat and supply .1bout 640 kcal per quart
oftluid (about 670 kcal per liter; Table 17-1). Later, human milk or infant formula,
supplemented by solid foods, can pro\ ide eYcn more energy. 5
The infant's high energy needs arc primarily driven by its rapid growth and high
metabolic rate. The hjgh metabolic rate is caused in part by the ratio of d1e infant's
body surface to its weight. More body surface allows more heal loss from the skin; the
body must use extra energy to replace that heat.
Carbohydrate
Carbohydrate needs in infancy arc 60 g/day at 0 to 6 months, and 95 g/day at 7 to
12 months. These needs arc based on the typical intakes of human milk by breastfed
infants .md their eventual use of solid foods.
Protein
Dail) protein needs in infancy arc roughly 1.5 g/kg of body weight/day, or 9 .1 g/day
for younger infants and 13.5 g/day for older infants. These needs also a.re based on
typical intakes by breastfed infants for 0 to 6 months, and then on the needs for growth
2001 Infant - 4 months

Child - 5 yeors
Mole teen - 16 yeors
150
Mole adult - 19 years
QI 140
.,, YI
0 ..
.. c 130
c QI
QI E 120
t QI
QI ..
o..·-::i 110
0 IT
100
"'f
..,_
0 GI
90
,, 0
:l E 80
C,!:
._
.. ::i
c-,,
.~ 0
70
60
'S 0
z 50
40
30
20
10
Energy Protein Vitamin Vitamin Thiamin Vitamin Calcium Iron Zinc

A D ~6
Figure 1 7 . 3 I Nutrienl needs for infants, children, ond teenagers as percentages of those for adult
moles. Compared with adults, infants' relative energy needs ore lower than ore their needs for other
nutrients, as illustrated by the different heights of the light blue bars. Thus, infants need to obtain
relatively larger amounts of nutrients from o smeller intake of food than do adults. This is also true of
young children (dork green bars), but too lesser extent.
of o lder infants. About half of total protein intake should come from essemial amino
:icids. As with carbohydrate, protein needs are easiJy satisfied by either human milk or
in fan t formtila. Protein intake should nor greatly exceed this standard. Excess nio·ogen
and minerals stipplicd by high-protein diets would exceed the ability of an infanr's kid-
neys to excrete the rcsuJting metabolic waste products from protein metabolism, thus
putting much stress on O\'eraU kidney function. 11
In North Amc1ica, infant protein deficiency is unlikely except in cases of mistakes in
formula preparation, such as when an infant's formula is excessively diluted with water.
ollergy A hypersensitive immune response that Protein deficiency may also be induced by elimination diets used to detect food aJlergies
occurs when immune bodies produced by us (hypersensitivitics). 12 As foods arc eliminated from the d iet, infants may not be offered
react with o protein we sense as foreign (on enough protein to compensate for the high-protein sources no longer pre~enr (sec the
antigen). Nutrition Focus in this chapter).
Fat
In fan ts need about 30 g of fat per day. The Adeq uatc Intake ranges from 30 to 31
g/day. Essential farty acids sh ould make up abo ut 15% of total fat intake (about 5
g/day). Both recommendations arc again based on the typical intakes or brc,1stfod in-
fants from both human milk and the eventual introduction of solid foods. 1-.m are an
imporrant part of rhe infant's diet because they arc energy-dense and vital w the de-
velopment of the nen·ous system. As a concentr,ued energy source, fat also helps rc-
soh·e the potential problem of the infant's high energy needs and small stomach
capacity. Agai n, infancy is not an age ro greatly restrict fat intake (Figure 17-4 ). 1
ooking at Tobie l 7· I, it is easy to see why

Table 17·1 I Composition of Human and Cow's Milk and Infant Formulas
fat-free milk products are not recommended
per Liter (L)
for infants-these products do not supply ode·
Energy Protein Fat Carbohydrate Minerals• quote fat and energy to meet needs. fat-free
Milk or Formula (kcal/l) (g/l) (g/l) (g/l) (g/L) milk (and reduced fat and whole milk as well)
also would provide too much protein and miner·
Milk als if it were used to meet energy needs.
Human milk 750 11 45 70 2
Cow's milk, whole 670 36 36 49 7
Cow's milk, fat-free 360 36 1 51 7
Casein/Whey-Based Formulas
Similac 680 14 36 71 3
Enfomil 670 15 37 69 3
Carnation 670 16 34 73 3
Soybean Protein-Based Formulas
ProSobee 670 20 35 67 4
Isom ii 680 16 36 68 4
Predigested Protein
Nutramigen 670 19 26 89
Alimentum 680 18 37 68
Transition Formulos/Beverogest
Similac Toddler's Best 670 25 33 75 3
Enfomil Next Step 670 17 33 74 3
Carnation Follow-Up 670 17 27 88 3
Al 3 month$ of oge 1nlonb lypicotly consume 0.75 to l Vdoy.
'Colcium, phosphorus. and other minerals.
rfor use offer 6 months al age or later (see label).
T\\'o long-ch:iin farry .Kids, Jrachidonic acid (AA) and do.:osalH:\aenoic acid
( DHA), have ,·cry important roles in infant development. The nt:rvoul. system, espe-
cially the brain :ind eyes, depend on these fatty acids fr>r proper development. During
the bst trimester, DHA :md AA provided by the mother accumtilate in the brain and
retinas of the eyes in the fetus. lnfants who arc breastfed arc able to continue to ac-
quire these fatty acids from human milk, especially if their mothers are regularly caring nfants who drink goat's milk need a dietary
fish. Until recently, no infanr formulas sold in the Uni red St:ires included AA or DI IA, supplement of folic acid because this milk
but certain brands with both AA and DHA are now arnilable. These formul..is MC p.11·- doesn't supply o sufficient amount of this essen·
ticulary useful for teeding prctcrm infuncs, but they also benefit other infants. 11 tial nutrient. Goat's milk is also low in iron, vita·
min C, and vitamin D, making it a poor choice
Vitamins of Special Interest for human infants.
As noted in Chapter 9, '1t.tmin K is routinely gi\'cn by injection to .ill in fonts at birth.
Formufa-ted infants receive the rest of the \'itamins they need from the formula.
Breasrtcd infants should be gh·en a Yitamin D supplement (200 IU/day) unril they arc
weaned co infant formula and are consuming 500 ml of it. 8 Breastfed infants whose
mothers arc ,-cgans should rccci\·e ,·iramin B-12 in a supplement form.
Minerals of Special Interest

lnfunts are born with some internal stores of iron. Ho\\'ever, by the time birth weight
doubles by 4 tO 6 momh~ of .tgc, iron stores are gener:iliy depicted. If the mother \\'a~
iron deficient during the pregnancy, rhcse iron stores will be exh:iul>ted C\'Cll sooner.
As you will recall from Chapter 12, iron deficiency anemia can lead to poor menc,tl de
\'elopment in infants. To maintain a desirable iron status in infants, the American
6 24 Chapter 17 Nutrition from Infancy through Adolescence
Figure 17- 4 I The labels on infant foods,

like those on adult foods, contain a Nutrition
Facts panel. However, the information provided
on infant food labels differs from that on adult
food labels, especially with respect lo total fat,
RICE
CEREAL FOR BABY
saturated fot, ond cholesterol content (review
Figure 2-9 for a comparison). Note also that Serving Size
Nutrition Facts
some cereal brands ore fortified with various
Serving Size l/4 cup (15g) - ~ Serving sizes for infant food s ore based on
other micronulrienls. Servings Per Container About 15 the overage amount eaten ot one time by a
child under 2 years.
Amount Per Serving
Calories 60
Total Fat Total Fat
Trans Fat Shows the amount of total fa t in a serving of the
Sodium food. Unlike adult food labels, labels on infant
Potassium foods do not list calories from Fat, saturated Fat,
or cholesterol, since infants and toddlers under
Total Carbohydrate 2 years need Fat. Parents should not attempt lo
Dietary Fiber limit their infant's fat intake.
Sugars
Protein
Infants Children
% Daily Value 0-1 1-4 Daily Values
Protein 4% 4% Food labels for infants and children under 4
VitaminA 0% 0% years list the Daily Value percentages for
protein, vitamins, and minerals. Unlike adult
VitaminC 0% 0%
food labels, Doily Values for fat, cholesterol,
Calcium 15% 10% sodium, potassium, carbohydrate, and fiber
Iron 45% 45% are not listed.
Thiamin 45% 30%
Riboflavin 45% 30%
Niacin 25% 20%
Phosphorus 10% 6%
' Intake should be as low as possible.
INGREDIENTS: RICE FLOUR, SOYOIL·
LECITHIN, TRI-AND DICALCIUM
PHOSPHATE, ELECTROLYTIC IRON,
NIACINAMIDE, RIBOFLAVIN (VITAMIN
B-2), THIAMIN(VITAMIN B-1).
Academy of Pediatrics recommends that formula-fed infants should be given an iron-

~l I 'nc. fortified formula from birth. 11 Low-iron infant formulas are sometimes presc1ibed to
Tatiana has been breastfeeding her baby ex- treat infants with various GI tract problems, but their use is discouraged. In conn·ast,
clusively since he was born 7 months ago. breastfed infants need solid foods to supply extra iron by about 6 months of age. In fact,
When she and her husband took the baby for this need for iron is a major consideration in deciding when to introduce solid foods .7
his checkup, they were told that he was ane- To aid in tooth development, clinicians recommend fluoride supplements for
mic. They were very surprised, because they formula-fed infants over 6 months of age if tJ1e water supply doesn't contain fluoride. 6
thought that human milk contained all the nutri- Note tJ1at formula manufacturers use fluoride-free water in formula preparation. Parents
ents the baby needed for the first year of life. should consult their dentist for advice on meeting the infant's need for Auoride.
How might you explain the baby's anemia?
Water
An infant needs about 3 cups (700 to 800 ml) of water per day. Infants typically con-
sume enough human mi lk or formula to supply this amount. In hot climates, however,
supplemental water may be necessary. Fmthermme, any conditions that lead to water
loss-diarrhea, vomiting, fever, or too much sun-can call for supplemental water.11
Infants are easily dehydrated, a condition that has serious effects if not remedied.
Dehydration can result in a rapid loss of kidney function, and the infant may then re-
quire hospitalization for rehydration. Special fluid -replacement formu las containing
electrolytes such as sodium and potassium arc available in supermarkets and pharma-
cies to treat dehydration. A physician should guide any use of these products.
Note d1at in some stores, bottled water products marketed specifically for infants
may be placed alongside infant formulas and electrolyte-replacement solutions. This
placement may give parents and caregivers d1e mistaken impression that bottled water
producrs are appropriate for fluid replacement for infants; d1ey arc not and should not
be used for such purposes. Tt is important to remember that excessive fluid can be
harmful, especially to the brain.
Overall, iris best to limit supplemental fluids to about 4 oz (120 ml) per day, tm-
less d1e physician thinks that a greater need exists because of disease or od1er condi-
rions. In sum, extremes in fluid intake-either too little or too much-can lead to
healtl1 problems. 11
Concept I Check
Most nutrient needs in the first 6 months arc met by human milk or infunt formula.
Breastfed infants need a vitamin D supplement; formula-fed infunts and breastfed infants
may need fluo1ide supplements after 6 months of age. Infants usually receive enough water
from the human milk or formula they drink.
Formula Feeding for Infants Supplemental Auids should be limited to 4 oz

Breasrtecding was covered in detail in Chapter 16. This section focuses on formula per day unless the infant's physician prescribes
feeding. You'll recall tl1at a major advantage of breasrfeeding is the provision of im- o larger amount.
m unc protection to the infant. Overall, in areas of the world where higb standards for
water purity and cleanliness are common, formula feeding is a safe alternative for in-
fants (but generally is not as beneficial as breastfeeding).
reterm infants ore fed either o specially de-

Formula Composition
Infants cannot tolerate cow's milk as such because of its high protein and mineral con- P signed formula or human milk. Total par·
enterol nutrition may also be required in the
tent. Cow's milk reflects the growth needs of calves, not of human infants. Thus, cow's
milk must be altered by formula manufacturers to be safe for infant feeding. It is im- initial phase of hospitalization. As noted in
portant to note iliat goat's mjlk, sweetened condensed milk, and evaporated milk also Chapter 16, nutrients may be added to human
are inappropriate substances for infants. Altered forms of cow's milk, known as infant milk to increase its protein, mineral, and energy
formulas, are required to conform to strict federal guidelines for nuu·ient composition content. Preterm infants must be fed immediately
and quality. Formulas generally contain lactose and/or sucrose for carbohydrate, heat- because their bodies store little fat or carbohy-
t.reated proteins from cow's milk, and vegetable oils for fat (review Table 17-1). 11 Soy drate. The body composition of o full-term infant
protein-based fom1ulas are available for infants who can't tolerate lactose or die types includes about 12% fat, whereas the composition
of proteins fow1d in cow's milk. If the soybean-based formula is not tolerated, the next of o very preterm infant con include as little as
step is to try a predigested (hydrolyzed) protein formula in which d1e proteins have 2% fat.
been broken down into peptides and amino acids, such as Nutramigen or Alimentum.
A variety of other specialized formulas also are available for specific medical conditions.
In any case, it is important to use an iron-fortified formula LlDless a physician recom-
mends otherwise. orents should consult o physician when
Some mmsition formulas/beverages have been introduced for older infants and tod-
dlers (review Table 17-1). Some of these products are intended for use after 6 months
P choosing on appropriate infant formula.
Not all formula-like products are designed for
of age if the infant is consuming solid foods, whereas others are intended for use only infant use. A 5-month-old girl was admitted to o
by toddlers. These transition products are lower in fat tl1an human milk or standard in- hospital in Arkansas with symptoms of heart fail-
fant formulas; their iron content is higher than that of cow's milk, and their overall minure, rickets, inRamed blood vessels, and possible
eral content is generally more like that of human milk than cow's milk. According to nerve damage ofter being fed Soy Moo (o soy
the manufacmrers, d1e advantages of these transition formulas/beverages over standard beverage sold in health-food stores} since
formulas for older infants and toddlers include reduced cost and better flavor. Parents 3 days of age. The symptoms suggest severe vi-
should consult ilieir physician wid1 regard to the use of tl1est: products.L 1 tamin deficiencies.
Formula Preparation
Today, bottles of formula are oflen prepared one at a time. Some infant fornrn las come
in rcady-to-~ced !(>rm. These are poured into a cle.m bottle and fe<l immediate!) .
Room-temperature formula is acccpr.1blc for many infanrs. Otherwise, LO "arm a bot-
lie of formula, .1 caregin:r can run hot water over it or place it brieA) in .1 p.m of sim
mering water. Nore that infant formul.1s should not be heated in a micro" •We oven
because hot spot!> may develop, which can burn the infant's mouth and esophagus.
Powdered :md concentrated fluid formula preparations are also commonly used. All
utensils used in preparing formula from these preparations should be washed and thor-
oughly rinsed. Powdered or concentr.1ced formul.ts arc poured into a bottle w \\'hich
clean, cold \\'atcr 1s added (following l.lbd directions) .md then mixed. The formula is
rhen warmed, if desired, and fed immediately co the infant. Hot warcr from the faucet
should not be used co make formula, because it poses a risk for high lead content ( ~ec
Chapter 19). Cold water poses much less risk.
Refrigerating prepared formula for I day is safe. However, formula ldi over from a
feed ing should be discarded because it will be contaminated by bacteria and cnLymes
in the infum's salh a. If well water is used, it should be boiled before making formub
for at least the infant's first 3 months of life, and it should be analyzed for cxccssiYe
concentration of naturally occurring nitrates, \\ hich can lead to a SC\ ere form of ,me-
mia. Note that il nitrates arc high in municipal water systems, consumers \\ i!J be
Careful attention during feeding allows the warned (such as in ,, local newspaper) nor to use the water for making infom formula
caregiver to notice the infonl's signal as to until the concentration falls to a sale .1111ount. Alternately, if water contamin.111ts arc a
when the feeding should cease. concern, formul.1 c.:.111 be mixed with bottled nurseqr water, which is avail~1blc .1longsidc
infant l:Ormulas in most supermarkets.
Feeding Technique
Because inf.111~ swallow a lot of •lir as thC)' ingest either formula or human milk, it's im-
portant to buq1 :m infant after either l 0 minutes of foeding or l to 2 o:l ( 30 ro 60 ml)
li·om a bottle and again at the end of ~ceding. Spitting up a bit of milk is normal ;1r this
time. Once fod, infants should be placed on tl1eir backs, not their stomachs. Infants should
not be placed on chcir sromad1S because this sleeping position has been linked ro sudden
infant death syndrome (SIDS). The B.1ck to Sleep campaign, started in 1994 in Lhe United
Stares, has reduced SIDS by 40%; however, plagioct:phaly, otl1crwise known as tlat-head
syndrome, has increased as a resuJt. lnfam skulls a.re sofi: and can take on a different form.
Flat-head syndrome can occur if an excessive amotu1t or ,\11 infant's life is spent on his or
her back, or ,\gainst a high chair or car scat. In response to this concern, chc Amcric.m
Academy of Pediatrics has recommended periodic repositioning of an infant's head while
,1sleep and allowing for time on his or her stomach while awake. In addition, some infants
may need to wear specially fitted helmets co correct d1e shape of their he.1d. 11
\Vhen the inf.mt begins acting foll, b0ttle-feeding should be stopped, even if some milk
is left in tl1e boule. Common cues that signal that an infant has had enough include tLLrn-
ing the head away, being inattentive, fulling asleep, and becoming playful. Gener;.1lly, die
infant's appt:tite is '' better guide than standardized recommendations concerning foeding
amounts. Bre,15ttceding infants usually have bad enough to eat after about 20 minutes.
Although it's Jiftlcult to cell hm' much milk breastfed infants are getting, the) .tlso giw
signs when full. Bv carefully obsening boctle-teeding or breastteeding infants and re-
sponding to their cues appropriately, caregi\'ers not only can be assured thal rhc infants'
energy needs arc being met but also can foster a climate of trust and responsiveness.;;
The Bock to Sleep campaign advises that

infants be placed on their bocks for sleeping. Development of Feeding Skills in Older Infants
By 6 co 7 momhs che infant bas learned to grab and transfer objects from one lund co
the other (Table 17-2). At about this rime, tcctl1 begin co appear, and the infanr be-
www.mhhe .com/wardlawpers7 627
Table 17·2 I Typical Progression of Infant Eating Skills and Solid-Food Introduction*
Age Feeding Skills Oral Motor Skills Types of Food Suggested Activities
Birth-4 months Rooting reflex Human milk Breastfeed or bottle-feed
Suckling reflex Infant formula
Swallowing reflex
Extrusion reflex
5 months Is able to grasp objects Disappearance of extrusion Possibly introduce thinned
voluntarily reflex cereal if baby not satisfied by
Is learning to reach mouth with breastfeeding or bottle feeding
hands
6 months Sits with balance while using Transfers food from fronl of Infant cereal Prepare cereal with formula or
hands tongue to bock Strained fruit human milk to a semiliquid
Strained vegetables texture
Egg yolk (if no family history of Use spoon
egg allergy) Feed from a dish
Advance to 1/3-1 /2 cup
cereal before adding fruits or
vegetables
7 months Has improved grasp Mashes food wilh loteral move- Infant cereal Thicken cereal to lumpier
Can transfer objects from hand ments of jaw Strained to junior texture of texture
lo hand Learns side-to-side, or Nrotary," fruits, vegetables, ond meats Sit in high chair with feet
chewing supported
Tooth eruption Introduce cup
8-10 months Holds bottle without help Juices (small amounts) Begin finger foods, such as
Drinks from cup Soh, mashed, or minced table toast or crackers
Decreases Auid intake and foods Avoid adding salt, sugar, or
increases solids fats lo food
Coordinates hand-to-mouth Present soh foods in chunks
movement ready for finger-feeding
10-12 months Feeds self Improved ability to bite and Soh, chopped table foods Provide meals in pattern similar
Holds cup without help chew Whole egg and whole milk (at to rest of family
1 year of age) Use cup at meals
Adapted with permission from Handbook of Pediatric Nutrition, 2nd ed., Somour ond Athens, p. 87 © 1999, Aspen Publishers, Inc.
"This lime line is just on estimate, and individual infants moy vary by several months from the ages given. A pediatrician should be consulted if caregivers ore concerned about on infant's developmental
progress. In general, there is no nutritional reason to begin introducing solid foods before 6 months of age
gins to handle finger foods with some dexterity. Dry toast, sliced in strips, offers hours
of enjoyment.
By age 7 to 8 months infunts can push food around on a plate and play with a drink-
ing cup, can hold a bottle, and ~elt:feed a cracker or piece of coast. Jn maste1ing these
manjpulations infants develop seli:confidcnce and selfesteem. It's important that parents
be patient and support these early feeding attempts, e,·en though they appear inefficient.
At about 10 months of age, infants practice in earnest self-foe<ling finger tOods .111d
drinking from a cup. Feeding time is often very messy. Food is used as a means ro ex-
plore the em ironment. B) the first birthday, their bodies ha\'e den:lopcd sufficiently
to accommodate crawling, probably walking, and selt:feccting. Although attempts at
feeding arc still erratic, developing children rake great pride in doing more things in -
dependently. As children drink from a cup more frequently, fewer borcle feedings
and/or breastfoedings arc necessar~'. The added mobility of walking shou ld naLurally
lead to gradu~11 weaning from the bottle or breast.
Introduction of Solid Foods at about 6 Months of Age

The rime co introduce solid foods into an infunt's diet hinges on a few important fuccors: 11
1. Nim·itional 11ecd. fron stores arc exhausted b}' about 6 months of age. Either solid
foods or iron supplements arc then needed to suppl}' iron if the child is breastfed
or fed a formula not supplemented \\;th iron. Iron, however, is not the onl} nu -
trient low in human milk .111d unfortified infant formulas. Vitamin D may also de-
serve attention. Still, before 6 months or so, it's generally unnecessary to add solid
foods.
2. Physiological capabilities. Infanrs cannot readily digest starch before 3 months. As
they age, their digestive capabilities increase. Kidney function likewise is quite lim-
ited until about 4 to 6 weeks of age. Until then, waste products from exccssi,·c
amounts of ruetary protein or minerals arc difficult to excrete.
3. Physical ability. Three markers indicate that a ch ild is ready for solid foods: ( l) the
disappearance of the extrusion reflex (thrusting the tongue forward and pushing
rood out of the mouth), (2) head and neck conu-ol, and (3) t he abilit·y to sit up
with support. These abiliLies usually occur arou nd 4 ro 6 months of age, but the\'
vary with each infant.
4. Allergy p1·cpmtio11. An infant's intcsrinal tract can readily absorb whole proteim
from birth until 4 to 5 months of age. Thus, early exposure to many types or pro
ccins-particubrly the protcins found in cow's milk and egg whites-may prcdis
pose a child to future .11lcrgics .md other health problems because some types of
In the early stages of solid food introduction, these proteins ma) be absorbed intact. For this reason, it's best to minimize rhe
these foods complement rather than replace number of different types of proteins in a child's diet, especially during the first 3
human milk or infant formula in the diet. months, b,· focusing exclusiYcl\I on human milk or inf.mt formula as a nutrient
source. 12 • ~ •
With these considerations in mind- nucritional need, physiological and physical n.-.1di
ncss, and allergy prevention- the American Academy of Pediatrics recommends that
solid foods not be introduced unril about 6 months of age and that infants recci\'e no
unaltered cow's milk before l year.5,l I
P arents may believe that the early addition

of solid foods will help the infant sleep
through the night. Actually, this achievement is a
In general, a child starting solid foods should weigh at least 13 lb ( 6 kg) and should
be drinking more than 32 oz ( 1 L) of formula daily or breastfeeding more than 8 w
10 times within 24 hours. This description generally applies to 6-month-old infants
developmental milestone; the amount of food and to a few 4-month-old infants.
consumed by the infant is irrelevant. Before 4 to 6 months, infunrs arc not physically mature enough to consume much
solid food. Attempts to Iced solid foods co infants have sometimes led t0 forcdccding
with a teeder (a giant syringe) or mixing inf.mt cereal with milk and putting it in a bot
tle. Even if tl1cse are traditional altcrn::tti\'eS in your fami ly, there is no reason to carr)
on these practices. The inconvcnicncc alone should make you consider whether all the
effort is worth it. This practice is nutritionally unnecessary, tedious, and possibl) dan -
Typical Solid Food Progression, gerous for the infant because it increases the risk of allergies and choking or inh.lling
Starting at 6 Months'
food when crying. Onl)' occ,1sionally docs a rapidly growing infant-one \\ho con-
Week 1 Rice cereal sumes more tl1an 32 oz ( 1 L) of formula daily-really need solid foods at 4 months to
Week 2 Add strained carrots meet high energy needs.
Week 3 Add applesauce
Week 4 Add oat cereal
Solid Foods That Should Be Fed First
Before 6 months of age, the first solid foods should be iron fortified cereals.7 A good
Week 5 Add cooked egg yolk
idea is to offer foods after some breastfeeding or formula feeding, when the edge ha"
Week6 Add strained chicken been taken off the infant's hunger. This practice aids in early spoon-feeding. Rice ce-
Week7 Add strained peas real is the best cereal to begin with because it's least likely to cause allergies. After the
Week 8 Add plums age of 6 months, the first food is not such an important issue. Although yogurt .111d
cottage cheese arc well tolerated and their consistencies make tl1em good candidate\
•Extending the rice cereal step for a month or so is advised for early foods, they arc not good sources of iron.
ii solid food introduction begins ot d months of age. Note
also !hot ii 01 any point signs of allergy or intolerance de- Start witl1 teaspoon amounts ora single-ingredient food item, such as rice cereal,
velop, subslituto another, similar food item. and increase the serving size gradually. Once the new food has been fed for about a
\\'eek without ill effects, another food can be added to the infanl's diet. At first, thb
food can be another type of cereal or perhaps a cooked and strained (or mashed ) \'Cg-
etablc, meat, fruit, or egg yolk. It is best to add ,·egetablcs before fruits. If fruits arc
offered first, the infant will prefer the sweet taste and may resist \'egetables. Overall,
build each feeding step on the pre\'ious step, making sure to add only a single ingre-
dient each time.
\Vaiting about 7 days between new foods is important because it can take that long
for e\·idence of an allergy or intolerance to de\'elop. 11 Symproms w look for arc diar-
rhea, \'Omiting, a rash, or wheezing. If one or more ofd1ese symptoms appear, the sus-
pected problem food should be avoided for seYeral weeks and then reintroduced in a
small quantity. 1f the problem continues, a physician should be consulted.
lt's important not to introduce mixed foods until each componcnr of the mixed
food has been given separately. Othern~se, if an allergy or intolerance develops, it will
be difficult to identif)r the offending food. Note d1at many babies outgrow food sen-
sitivities in ch ildhood. Some foods that commonly cause a n al lergic response in infants
are egg whites, chocol,n c, mirs, and cow's milk. It's best not to in troduce these foods
in infancy. 12
A variety of strained foods is available for infam feedi ng at the supermarket.
Investigate these and other foods intended for infams the next time you 're shopping.
Single-food items arc more desinble man mixed dinners and desserts, which are less
nutrient-dense. Most br.\llds have no added salt, but some fruit desserts contain a lot
of added sugar.
As an alternati\'C, plain unseasoned cooked foods- vegetables, fruits, and meats ( no
seasoning added )-can be ground up in an inexpensi,·e plastic baby food grinder/ mill.
Another option is co puree a larger amount of food in a blender, freeLe it in ice-cube
portions, store in plastic bags, and defrost and warm as needed. Careful ,lttenrion to Rice cereal is recommended as the first solid
cleanliness is necessary. lnfunt foods made at home should be ground before season- food to be fed to infants.
ings arc added to please the rest of the family. The infant doesn't nonce the difference
if salt, sugar, or spices are omitted. It's best to introduce infants to a \'aricry of foods,
so that by the end of the first year the infant is consuming many foods-milk, meals,
fruits, vegetables, and grains.
In the first attempts to introduce solid foods, just getting the food into the in fant's
mouth proves to be a c h ~lllcnge. The caregiver must proceed slowly. Initially, toblc
foods supplement-rather than replace-formula or human milk. Intants control the
situation by signaling when they are hungry and when they have had enough to cat.
Sdf-foeding skills require coord ination and can develop only if the infant is allowed to
practice and experiment. At 9 w 10 mond1s, the infant's desire to explore, experience,
and pla~· wi th food can also hinder teeding. Presenting new foods for several consecu-
tive days can aid in an infant's acceptance of that food. 5
Caregivers need ro relax and rake this phase of infant dc\'elopment in stride. Sloppy,
friendly mealtimes ,Kntally moke for good memories.
To ease efforts in feeding solid foods, consider the foilo\\ing tips:
• Use a bab~ -sized spoon; a small spoon with a long handle is best.
• Hold the infant comfortably on the lap, as for breasrteeding or bottle feeding, bur
a litdc more upright co case S\\'allowing. When in this position, the infant expects
food.
• Put a small dab of food on L11e spoon tip and gently place it on the infant's tongue.
• Con\'ey a calm and casual approach to the infant, who needs time to get used to
food.
• Expect the infant to take only mo or rl1fee bites of me first meals.
By the end of the lirst year, finger-feeding becomes more efficient, drinking from a
cup impro\'cs, and chewing is easier as more teeth erupt. Foods in the diet begin to re-
semble a balanced diet (Table l 7-3) .5 Still, experimentation and unpredictability arc to
be expected.
Summary of Infant Feeding

Table 17·3 I A Sample Doily Menu for o 1-Yeor-Old Child*
Recommendations
Breastfed Infants Breakfast Snack
• Breastfeed for 6 months or longer, if possible. Applesauce, 1-2 tbsp Cheddar cheese, 1/2 oz
Then introduce infont formula if and when Cheerios, 1/ 4 cup Wheat crackers, 4
breastfeeding declines or ceases. Breast milk Whole milk, 1/2 cup Whole milk, 1/2 cup
can also be pumped and placed in a bottle Snack Dinner
for later use.
Hard-cooked egg, 1/2 Hamburger (crumbled), 1 oz
• Provide a vitamin D supplement (200 IU/day)
Wheat toast, 1/2 slice, with 1/2 tsp Mashed potatoes, 1-2 tbsp with 1/2 tsp
(until at least 500 ml of formula is consumed). margarine margarine
• Ask the infanrs physician about the need for Orange juice, 1/2 cup Cooked carrots (cut in strips, not coins), 1-2 tbsp
fluoride, vitamin B· 12, and iron supplementa· Whole milk, 1/2 cup
lion to prevent deficiencies.
lunch Snock
Formula-Fed Infants
• Use an iron-fortified infant formula for the Roasted chicken, minced, 1 oz Banana, 1/2
Rice, 1-2 tbsp with 1/2 tsp margarine Oatmeal cookies (no raisins), 2
first year of life. Cooked peas, 1-2 tbsp Whole milk, 1/2 cup
• Ask the infonrs physician about the need for Whole milk, 1/2 cup
a Auoride supplement if the water supply is
not Auoridated. Nutritional Analysis
All Infants Total energy (kcal) % energy from 1100
• Provide a variety of bosic, soft foods after 6 Carbohydrate 40%
months of age, advancing to a varied diet. Protein 19%
Fat 41%
• Add iron-fortified cereal at about 6 months of
age. ' This diel is jusl o start. A I·year-old may need mo<e or le» food. In rhose coses, serving sizes should be adjusted The milk con be
led by cup; some con be put into a bottle if the child hos not been fully weaned from me bot!le. The juice should be fed in a cup.
Weaning from the Breast or Bottle

Around 6 months or so, juices can be oflcred in a sippy cup with a wide, tht bouom
early childhood caries Tooth decay that results Drinking from a cup helps prevent early childhood caries (Figure 17-5). lfan infant
from formula or juice (and even human milk) drinks continually from a bottle, the carbohydrate·rich fh1id bathes the teeth , prO\'id
bathing the teeth as the child sleeps with a ing an ideal growth medjum for bacteria. Bacteria on the teeth then make acidi., which
bottle in his or her mouth. The upper teeth are d issolve tooth enamel. Infants should never be p ut to bed with a bottle or placed in an
mostly affected, because the lower teeth are infant seat with a bottle propped up, because fl uid (even milk) pools around the reerh,
protected by the tongue; formerly called increasing the likelihood of dental caries. Again, infants need careful attention when
nursing bottle syndrome and baby bottle tooth
being fed, and being propped up with a bottle does not constitute careful attention. 11
decay.
Getting a baby out of the bedtime-bottle habit is difficult. Determined caregivers
can either wince tlu·ough .t fo" nights of their baby's crying or slowly wean the baby
away from the bottle with either a pacifier or warer (for a week or so) .
What Not to Feed an Infant

Following are se\'ernl foods and practices to a\'oid when feeding an infant:
• Honey. This product ma) contain spores of Clostridium botulinum. The spores can
evenrually de\'elop into bacteria in the sromach and lead to a foodborne illness
known as botulism. This illness can be fatal, including in children under 1 year old
(see Chapter 19).
• Very sn lty muf J>cry sweet foods. Infants don't need a lor of sugar or salt added to their
foods. They enjoy bland foods much more d1an do adults.
Figure 17·5 I An extreme example of tooth • E~ccssivc illfrmt fornmln or b1t111n11 mil/1. After 6 to 8 months, solid foods should pla)
decay caused by early childhood caries. This a greater role in satist)·ing an infam 's increasing appetite. T he main reason to S\\itch
child was probably put to bed with a bottle. is that solid foods contain considerably more bioavailable iron than do human milk
The upper teeth have decoyed almost all the and low-iron formu las. About 24 to 32 oz (3/4 to 1 L ) ofhmnan milk or formu la
way to the gum line. daily is ideal after 6 months, with food supplying the rest of the infant's energy needs.
• Foods t/Jnt tr:11d to caust c/1oki11g. These foods include hot dogs (unless finely cur into
scicks, not coin shapes), candy, whole nuts, grapes, coarse!) cut me.us, r:iw carrots,
popcorn, and peanur butter.
• Co11• ~r mi!lt, cspecialZl' low:/ht 1w fnt-frce cow's milk. The American Academy of
Pediatrics strongly urges p•trcnts not to give infants (and children under age 2 as
\\'ell) fat-reduced, l %, or fot-frec milk. 11 Only after age 2 year~ c.111 children drink
fat reduced, 1%, or fat-free milk because by then they arc consuming enough solid
foods to supply energy and fat needs. Before that age, the amount of this milk
needed for energy needs would supply too many miner;ils .rnd in turn could O\'er-
"hclm the kidneys' ability ro e\crete the excess. The lower fat intake might also
h.1rm nen·ous system development.
• Fccdi11lf c.\:ct'ssiJJe amounts ofrrpple or pcnr ptice. The fructose and 1>orbitol contained
in these juices can lead to diarrhea because they are slowly .1bsorbed. Also, if fruit
juice or related drink products are replacing formula or milk in the diet, the infant
may not be receiving adequate amoums of calcium and other minerals that are es-
sential for bone growth. In fuct, su1diei. have shown a link between excessive
amounts of fruit juice and failure to thri\'e, GI tract complicatiom., obesity, short
stature, and poor dental heath. Thus, these substances should be used sparingly. gg whites should not be fed lo children be-
Infants O\'er the age of 6 months can usually safely consume up to 6 oz of juice in fore 1 year of age to prevent the develop·
the ~nurse of a day, \\ith no more than 2 to 4 oz at a rime. 16 menl of allergies.
Damon's diet is inadequate for a l O-month-0ld infant because ii lacks enough of

the nutritious foods his growing body needs to support weight gain. These foods
include iron-fortified cereal, pureed infant foods, and appropriate table foods.
Damon should stay on the infant formula until l year of age and should not be given sugary
drinks, nor should these drinks be fed by bottle if used. Damon needs a more energy-dense diet
containing a healthful variety of solid foods to provide him with enough energy and essential nu·
trients to grow and develop.
Concept I Check
Infam formulas generally contain lactose or sucrose, hear-created proteins from cow's milk,
and n:gct.1blc oil. Formulas should be fortified with iron. Sanit.nion is \'cry important in
preparing and storing formul.1. Solid foods should not be added co an infant's diet until the
child t~ both ready for and needs solid food, usually at abour 6 months of age. The first
solid t(>od c:an be iron-fortified infonr cereals, \\id1 ,·ery gradual .1ddittons of other foods-
onc .1r a time each week. Some foods to :woid gi,·ing infanrs in rhe first \'ear arc honey,
CO\\ 's milk (particularly fat-reduced, I%, or for-free milk), 'ery salty or sweet foods, foods
that ma\' cause the child to choke, and excessive amounts of fruit juice or related products
(e.g., fruit drinks).
Dietary Guidelines for Infant Feeding

In response to various contro\'ersies surrounding infant feeding, the American
Academy of Pediatrics has issued a number of statements concerning infant diets. The
follo\\'ing guidelines are based on the~c statements: 1 I
• Buzld to a vai·frty offoods. For rhe tirsr months of lite, human milk is all an infant
needs. When the infant is ready, start adding ne\\ food~, one at a time. During the
first year, the goal is to teach an infant to enjoy a \'ariery of nutritious foods. A lifc- Early feeding attempts should be encouraged,
rime of healthy eating habits begim with this important first step. even though they're messy.
632 Chapter 17 Nutrition from lnfoncy through Adolescence
• Pay atte11tio11 to _vour infant)s appetite to avoid overfeeding or unrierjecrii11..r1. Feed in-
fants when they are hungry. Never force an infant to finish an unwanted ~c rving Qf
food. Watch for signs rhar indicate hunger or fullness.
• Infants 11eed fat. Although fat is Lhe cause of many adult health problems, it's an es-
sential source of energy for growing infants. Fat also helps the nervous system
develop.
• Choose jb1iu, 11cgctables, a11fl .[Jraius, but don't overdo high:fiberfoods. AJ Lhough many
adu lts benefit from higher-fiber diets, they are no t good for infants. T hey arc bu lky,
tilling, and olh.:n low in energy. The natural amounts of fiber and nutrien ts in fruits,
\'egetablcs, and grains are appropriate as part of a healthy infant diet.
• Infants need s11..r1ars in modcmtiou. Sugars arc an addirionaJ source of enerro for ac-
ti\'C, rapidly growing infunts. Foods such as human milk, fruirs, and juices arc naru-
r:il sources of sugars and other nurrients as well. Foods rhat contain ,1rtificiaJ
sweeteners should be avoided; they don't provide the e nergy growing infants need .
• Infants 11ecd sodium in modemtirm. Sodium is a necessary mjneral found naturally in
almost all foods. As part of a healthy diet, infants need sodium for Lheir bodies to
work properl> .
• Choose foods co11tni11i11g iron, zinc, mld calcium. lnfunrs need good sources of iron,
zinc, and calcium for optimum growth in the first 2 years. These minerals arc im-
portant for healthy blood, proper growth, and strong bones.
The older infant enjoys finger-feeding. Tn essence, there is no evidence th.H very restrictive diets during infancy have positive
effects, whereas their hazards arc well documented .
Health Problems Related to Infant Nutrition

Parents, other caregivers, and clinicians shouJd be alert for a variety of potcnri.11 heaJth
problems rebted to infant nutrition, so that corrective action can be taken quickly. In
some cases, such problems stem from inappropriate feeding practices and inadequate
nutrient int,1kes, including the fo llowing:
• Diet pro\'iding insufficient iron
• Absence from the diet of an entire food group from My Pyramid as solid foods are
introduced and become the main source of nutrients
• Drinking r:m (unpasteurized) milk, which may be contaminated with bacteria or
\'iruses
• Drinking goat's milk, which is low in folate, iron, viramin C, and vitamin D; if used,
ir must be paste urized and given in conjunction with a balanced multivitamin and
mineral supplement
• Failure to begin drinking from a cup by 1 rear of age
• Continuing to teed from a bonle past 18 months of age
• intake of supplcmcmaJ vitamins or minerals above l 00% of the appropriate RDA or
other nutrient standard
• Drinking large amounts of fruit juice after 6 months of age, especially as a substi-
tute for infanr formula or human milk. ( Recall that fruit juice is not LO be fed at all
before 6 momhi. of age.)
The following sections look more closely at five common infant heahh problems
thar cause concern for caregi\'crs: colic, diarrhea, milk allergy, iron deficiency anemia,
and gasa·ocsophageal reflux. Parents and other caregivers usually need tO consult with
a physician in dealing with these conditio ns. The website of the American Academy of
Pcdiau·ics ('""' ..1.1p or~ ) can also p rovide useful information.
Colic
The first time .m oLhawise healthy, "ell-fed infant has a lengthy, unexplained cr~ing spell,
most parent.'> panic. Repeated crying episodes, lasting 3 or more hours that don 't respond
to typicaJ remedies-such as feeding, holding, o r chang ing diapers-are characteristic of
infants who develop colic. Colic affects about 10 to 30% of all infants, starting at about colic Shorp abdominal pain thot generally
2 ro 6 weeks of age and lasting tmtil about 3 months of age, so it is neither w1com- occurs in otherwise healthy infants ond is
rnon nor abnormal. Colicky infants typically cry during the late afternoon and eady ossocioted with periodic spells of inconsolable
evening, and their nighttime sleeping is almost always disturbed by crying spells. In ad- crying.
dition, these infants frequently pass gas rectally, clench their fists, draw up their legs,
hold the body straight, and want to be held. The only good news is that colic usually
goes away after a few months. 1 1
Colic generally occurs in the absence of any physical problem in the infant. It tends
to be most common in "temperamental" infants-those who are more sensitive, more
irritable, more intense, less adaptable, and less consolable than average for their age. In
addition, a lack of harmonious interaction between parents and the infant may con- ost parents benefit from the counsel ond
n·ibute to the problem. Some researchers have speculated that inm1anire central ner- support of other adults during the anxiety
vous system mechanisms may cause colic. of dealing with a colicky infant, a period of time
Parents can do several things to help reduce excessive crying. For instance, many in- that may lost for several months. Talking with
fants tend to become quiet and alert when held snugly to the shoulder. Parents should others who have been through similar experi-
also check to see whether the infant is tired or bored or wants to suckle. Some infants ences can help parents improve their tolerance
can be calmed by rhythmic sounds or movement or with pacifiers. of stress and ability to cope ond con increase
Breastfeeding of colicky infants should continue. The breastfeeding mother's tem- their confidence in their parenting abilities.
porary decrease or cessation in consumption of milk and milk products, caffeine, Furthermore, to optimize their ability to be sensi-
chocolate, and vegetables such as broccoli and onions may help reduce colic in her in- tive and responsive to their infant, parents need
fant. Formula-fed infants with severe colic are sometimes helped by changing from a lo be well rested and to set aside some time for
standard formula ro a soy-based or predigested protein formula (review Table 17-1) themselves.
but more often this change provides no relief from the problem. ln addition, physi -
cians may prescribe medication to cal m colicky infants and reduce gas buildup. 11
Diarrhea
Diarrhea in infants, charactetized by numerous loose stools per day, results from vari-
ous causes, including bacterial ai1d viral infections. In the United States, about 500 in-
fants die eacb year of simple dehydration resulting from diarrhea, and about 210,000
are hospitalized for this disorder. Typical symptoms include dry mouth or tongue, few
or no tears when crying, no wet diapers for 3 hours or more, irritability and listless-
ness, and sunken eyes and cheeks. To prevent dehydration, infants with diarrhea should
be given plenty of fluids, under dte advice of a physician. Specialized electrolyte-
replacement fluids, such as Pedialyte, may be recommended for one day or less. These
products contain glucose, sodium , potassium, chloride, and water. LI
Once diarrhea subsides, a bottle-fed infant may be switched to a soy-based, lactose-
.free formula for a few days, but this change is typically not necessary. The use of a
lacrose-free formula is intended to allow time for the intestine to produce sufficient lac-
tase enzyme to digest tl1e large amount of lactose typically found in fornmlas. A breast-
fed infant should continue at the breast for the duration of tl1c diarrhea.
Milk Allergy
Cow's milk contains more than 40 proteins that can cause allergic reactions in in-
fants. Although some of these proteins arc inactivate;:d by heating (scalding) milk,
others are very heat stable. A true milk allergy develops in about 1 to 3% of formula -
ted infants. Such infants may experience vomiting, diarrhea, blood in the stool, con -
stipation, and other symptoms. If milk allergy is suspected, a formula-fed infant can
be switched to a soy-based formula. ln 20 to 50% of cases, however, the use of soy
formu la provides only temporary relief because the SO}' protein eventually triggers an
allergic reaction in some infants. In such cases a predigested-protein formu la is nec-
essary (review Table 17-1). lfthe child is breastfeeding, the mother may experiment
with eliminating cow's milk from her diet. Fortunately, milk allergies seldom last be- Caring for an inconsolable, colicky infant can
yond 3 years of age.11 couse parents to feel frustrated and helpless.
Iron Deficiency Anemia

Iron deficiency anemia typically occms in older infants (a bout 10 to 15% of 1- to
2-yeru·-olds), especially those who consume few solid foods and whose diets are dom-
inated by cow's milk, which both contains little iron and causes intestinal bleeding in
young infants. Iron stores are then quickly depleted by the daily need to synthesize
new red blood ceUs. The best way to prevent iron deficiency anemia is to feed the in-
fant an iron-fortified formula beginning at birth, if formula is used. Then start rhe in-
fant on iron-fortified cereals and meats at about 6 months. Infant formula shou ld also
be limited to 16 to 25 oz (500 to 750 ml) daily at this age. If anemia does develop,
medicinal iron is used under a physician's guidance.7
Gastroesophageal Reflux
Many intanrs develop gastroesophageal reflux (GER), more commonly known as ·'spit-
ting up," during their first year of life. In most cases, GER develops before 2 to 3
months of age and usually resolves on its o-..vo by the infanr's first birthday. The prob-
lem arises because the lower esophageal sphincter may not close completely, whid1 al-
lows milk or solid food in the infant's stomach to move back up into the esophagus.
The result can be a burning sensation, which causes the infant pain or discomfort. Or
the infant might spit up the milk or food. In the majority of cases, GER poses no se-
rious medical concerns. In very rare cases, sw·gery may be required to remedy the
problem.ll
Concept I Check
Colic is commonly associated with inconsofoblc crying. It may be hdptiiJ for breastfeeding
mothers w decrease or avoid intake of milk and milk products, caffeine, chocolate, and cer-
tain vegetables, under a physician's guidance. Diarrhea requires additional Buids ro pre\'ent
dehydration. lnfants allergic to proteins in standard cow's milk formula can be S\\~tchcd to
an infunt formula containing soy protein or predigested protein . lmroducing iron-
containiog solid fuods ar an appropriate time and avoiding the use of cow's mi lk during the
first year can genera!Jy prevent iron deficiency anemia in infants. Any gastroesophageal re-
flux that devdops rypicalJy resolves within the first year of life.
I Preschool Children: Nutrition Concerns

The rapid growth rate that characterizes infancy tapers off quickly during the subse-
quent tew years. The average annual weight gain is only 4.5 to 6.6 lb (2 to 3 kg), and
the average annual height gain is only 3 to 4 in (7.5 to 10 cm) berwecn the ages of2
and 5 (review Figure 17-1 ). 11 As a toddler's growth rate tapers off, eating behavior
changes. For example, the decreased growth rate leads to a decreased appetite, often
C orbohydrote needs in order to supply en-

ergy for the central nervous system and to
prevent ketosis in childhood ore 130 g/ day, the
called "picky eating,'' compared with infants. Estimated Energy Requircmcnts (krnls )
are now (89 kcal x weig ht of child [kg]) - 8 0 for children I ro 3 ycru·s. Formulas
for older preschool children are listed in the section titled School-Age C hildren:
some as for adults. The protein needs to allow Nutrition Concerns.
for growth vary from l . l g/kg of body Because of the reduced appetite of preschool children, planning a diet that meets
weight/day (13 to 19 g/day) for children 1 to 3 their nutrient needs poses a challenge to caregivers. 1 Choosing nutrient-dense foods is
years, to 0.95 g/kg of body weight/day (34 to particularly important with chikfren who eat relatively little. This is a good time to em -
52 g/doy) for older children. No specific needs phasize some whole grains, fruits, and vegetables without increasing fat and simple
for total fat intake hove been set, but the diet sugar intake. A whole-grain ready-to-ear breakfast cereal with limited f~u :111d sugar is
must contain at least 5 g/ day of essentiol fatty an cxccllenr choicc.2 There is no need to decrease fat or simple sugar intake se,·erely,
acids (see the inside cover for details). The gen- but fatty and sweet food choices should not overwhelm more nutritious ones. 1• 16
eral recommendation is that total fat inta ke The preschool years are the best time for a child to start a hcalthfol pattern of liv-
gradually falls so as to fit into the adult range of ing and eating, focusing on regular physical activity and nuo·irious food. Parents and
20 to 35%of total energy intake by age 19. other caregivers are rok models: if they eat a variety of foods, the children will eat a
Food Allergies and Intolerances
Adverse reactions to foods-indicated by sneezing, same room where it is being cooked without re-
coughing, nausea, vomiting, diarrhea, hives, and sponding to it. Altl1ough any food can trigger ana-
other rashes-are broadly classed ~ food allergies phylactic shock, the most common culprits are
(also called hypersmsitivities) or food intolerances. peanuts (actually a legume, not a nut), tree nuts food intolerance An adverse reaction to
Allergies involve responses of the immLme system (walnuts, pecans, etc.), shellfish, milk, eggs, soy- food that does not involve an allergic
designed to eliminate foreign proteins, called aller- beans, wheat, and fish. For a small number of peo- reaction.
gens.12 The symptoms experienced by susceptible ple, avoiding foods such as peanuts or shellfish is a allergen A foreign protein, or antigen,
people, such as rapid increase in heart rate and matter of life and deatl1. l 2 that induces excess production of cer·
shortness of breath, are the result of this battle. In Almost all food allergies are caused by proteins lain immune system antibodies; subse-
contrast, the symptoms of food intolerances do not in milk (also look for casein on tl1e label), eggs quent exposure to the same protein
result from a true allergic reaction. Rather, food in- (also look for albumin on the label), corn, tree nuts leads to allergic symptoms. Whereas all
tolerances are caused b)' an individual's inability to and peanuts, seafood, soy products, and wheat. allergens are antigens, not all antigens
digest certain food components or by the direct ef- Other foods frequently identified witl1 adverse re- are allergens.
fect of a food component or contaminant on the actions include meat and meat products, fruits, and
body. This section examines each process, first aller- cheese. These foods contain acidlike proteins, usu-
gies and then intolerances, so you can learn how to ally wim a molecular weight between about 10,000
reduce tl1e risk of suffering from the food you eat. and 70,000, that stimulate tl1e production of anti-
bodies (specifically tl1e immunoglobulin (IgE) in immunoglobulins Proteins found in the
susceptible people. blood that are responsible for antibody-
Food Allergies: Symptoms mediated immunity and that bind specifi-
and Mechanism cally to antigen; also called antibodies.
Testing for a Food Allergy lmmunoglobulins are produced by cer-
Allergic reactions to foods are common and occur The diagnosis of a food allergy can often be a diffi- tain white blood cells in response to a
more frequently in females ilian males. Food aller- cult task (Table 17-4). 12 It requires the participa- foreign substance (antigen) in the
git:s occur most often during infancy and young tion of a skilled physician. The first step in bloodstream.
adultl1ood. Experts esrimate that up to about 2% of determining whether a food allergy is present is to
adults and up to about 8% of children are allergic record in detail a history of symptoms, ti.me from
to certain foods. Three types of reactions may ingestion to onset of symptoms, duration of symp-
occm after ilie ingestion of problem foods b)' sus- toms, most recent reaction, quantity and oarure of
ceptible people: food needed to produce a reaction, and food sus- eople with a history of serious aller-
pected of causing a reaction. A family history of al- gic reactions should carry a self-
• Classic-itching, reddening skin, asthma,
lergic diseases can also help, because allergic administered form of epinephrine, such
swelling, choking, and a runny nose
reactions tend to run in families. A physical exami- as EpiPen, to subside an episode of ana-
• GI tract-nausea, vomiting, di:irrhea, intestinal
nation may reveal e\·idencc of an allergy, such as phylactic shock.
gas, bloating, pain, constipation, and indigestion
skin diseases and asthma. Various diagnostic tests
• Gmeml-headache, skin reactions, tension and
can rule out other conditions.
fatigue, tremors, and psychological problems
The best laboratory test for determining which
Any reaction that is milder tlm1 these distinct aller- compounds a person is allergic to is the RAST test.
gic ones is referred to as a food sensitivity. This test estimates the blood concentration of anti- food sensitivity A mild reaction to a sub-
Allergic reactions vary not only in the body sys- bodies tl1at bind certain foodbome antigens. (Skin stance in a food that might be ex-
tem affected but also in tl1eir duration, ranging rests can also be used; a drop of antigen is placed pressed as light itching or redness of the
from seconds to a few days. A generalized, all- under me skin where it has been scratched or punc- skin.
systems reaction is called anaphylactic shock. This tured. If a person is allergic to t11e test antigen, a anaphylactic shock A severe allergic re-
severe allergic response results in low blood pres- red eruption wi!J develop.) sponse that results in lowered blood
sure and respiratory and GI tract distress. Tt can be The next srep is ro eliminate from the diet for pressure and respiratory and gastroin-
futaJ. Overall, allergic reactions result in 30,000 1 to 2 weeks all tested compounds that appear to testinal distress. This reaction can be
emergency room visits and 150 to 200 deaths per cause allergic symptoms, plus all other foods sus- fatal.
year. A person who is e:x'tremely sensitive to a food pected of causing an allergy based on tl1e person's
ma)' not be able to touch the food or even be in the food history. The person generally starts out eating
635
,...,. 17· 4 I Assessment Strategies For Food Allergies
History Include description of symptoms, time between food ,ingestion and onset of
symptoms, duration of symptoms, most recent allergic episode, quantity of food
required to produce reaction, suspected foods, and allergic diseases in other
family members.
Physical examination look for signs of on allergic reaction (rash, itching, intestinal bloating, etc.).
RAST test Determine presence of lgE antibodies in blood that bind to antigens tested.
Elimination diet Establish o diet lacking the suspected offending foods and stay on it for
1 to 2 weeks or until symptoms clear.
Food challenge Add back small amounts of excluded foods, one at o time, as long os onophyloctic
shock is not o possible consequence.
Skin test Place o sample of the suspected allergen under the skin and watch for on
inflammatory reaction.
foods to which almost no one reacts, such as rice, physician and registered dietitian to make sure she
vegetables, noncitrus fruits, and fresh me.ns and still consumes an adequate diet. In addition, when
Eggs, wheat, milk, nuts, and seafood poultry. If symptoms are still present, the person food allergies are common in the family, women arc.:
pose the greatest risk for food allergies can more severely restrict the diet or c\·en use spc· ad\ iscd co breascteed their infants exclusively for 6
in childhood.
cial formula diets that are hypoallergenic. months. Human milk contains factors that play a
Once a diet is found that causes no symptoms, role in the maturation of the smaJJ inte.'>tine
elimination diet A restrictive diet that called an elimination diet, foods that are known not Formula-fed infants, especially those on CO\\\ milk-
systematically tests Foods that may cause to trigger anaphylactic shock can be added back one bascd formulas, have a greater risk for de\·cloping
an allergic response by First eliminating at a time. 11 Doses of l/2 to l te~poon (2.5 to 5 food allergies. Breastfeeding, thus, should continue
them for 1 lo 2 weeks and then adding ml} are gil'en at first. The amount is increased until tor~ long as possible, preferably to l year. 12
them bock one ot o time. the dose approximates usual intake. Reintroduction The prognosis for food allergies that fim ap·
prognosis A Forecast oF the course and should be done using a double-blind approach (re· pear before 3 years of age is good. About 80'10 of
end of o disease. view Chapter l }, especially when the reaction has a young children with food allergies outgro\\ them
psychological component or when symptoms arc before 3 years.l 1 Parenrs should be madt a\\ arc of
vague or ill defined. Dried foods can be encapsulated this prognosis and not assume that the allerg) will
and then given to d1e person. Any reintroduced food be long-li\•ed. Food allergies diagnosed after 3
that causes significant symptoms to appear is identi· years of age, however, are often more long-lired,
fied as an allergen for the person. but nor always. In diese cases, about 33% of people
ourgrow their food allergies within 3 years. for
orhc.:rs, the condition may be prolonged; some
Treating Food Allergies food allergies can last a liferime, such as tOr
Once potential allergens are identified, the best tre,u- peanuts, tree nuts, and shellfish. Periodic reintro-
mcnt is to avoid diem, especially for people with 7ero duction of offending foods can be rried every 6 to
tolerance. Careful reading of food l.1bels is esscmial 12 months or so to see whedier die allergic reai.:·
for many allergic people and advisable for .111. 12 A lion has decn:ascd. If no symptoms appear, tolcr
major challenge for the clinician treating ,1 person .mcc to the food has de\•eloped.
with a tood allergy is to make sure that \\hat rcmarns
in the diet can still prmide essential nutrients. The Food Intolerances
tn Inn
small food intake ofchildren permits less lee\\3) in re-
rood intolerances are ad\·erse reactions to food~
Irene and Chris had a baby 11 months moving the offending foods that may contain nu-
that do not inrnll'e allergic mechanisms. Generally,
ago. At the last checkup, the doctor told merous nuoients. A registered dietitian can help
larger amounts of an offending food arc required
them to start feeding the baby some new guide the diet-planning process to ensure that die re
co produce the symptoms of an intolerance dun to
solid foods. After 5 days of eating o new maining food choices still meet nuoient need~ or to
trigger allergic symproms. Common causes of food
food, the baby woke up with o runny guide supplement use, if t11at is necessary.
intolerances include
nose and vomiting. The doctor told them [fan allergy-prone woman is pregnant or breast·
lo slop giving the baby that food. How feeding, she should avoid offending foods-such as • Constituents of certain foods (e.g., red \\inc,
can the doctor ;ustify his eggs, shellfish, and peanuts-because allergens can tomatoes, pineapples} that haYe a druglike acci\'ity,
recommendations? cross the placenta dwing pregnancy. Allergens arc causing physiological effecrs such as changes in
also secreted in her milk. She should work with her blood pressure
636
• Certain synthetic compounds added co tOods, commonly contain sultites. A reaction to ~ISG he American Academy of Allergy
such as sulfircs, food-coloting agents, and may include an increase in blood pressure, numb- and Immunology hos o 24-hour toll-
monosodium glutamate ( ~ISG ) ness, S\veating, \'omiting, headache, and facial free ho~ine (800-822-2762) to answer
• Food contaminants, including antibiotics and pressure..MSG is commonly found in restaurant 'questions about food allergies and to
other chemicals used in the production of live- food and maJ1) processed foods (e.g., soups). A re- help direct people to specialists who treat
stock and crops as well as insect pam not removed action to tart.razine, a food-coloring additive, in- the problem. Free information on food al·
drning processing cludes spasm of the airwa)', itching, and reddening lergies is available by contacting The
• Toxic contamin,mts resulting from the ingestion skin. Tyraininc, a derivative of the amino acid ry- Food Allergy & Anophyloxis Network.
of improperly handled and prepared foods con- rosine, is commonly found in "aged" foods, such The telephone number is
taining Clostridi11m bot11li1111111, Sn/111011clln bnctc-
as cheeses and red wines. This natll ral food con- (703) 691-3179; the website is
rin, or other foodborne microorganisms (see stituent can cause high blood pressure in people www.foodallergy.org.
Chapter 19) taking monoaminc-oxidase (MAO) inhibitor med-
• Deficiencies in digcstin~ enlymcs, such as lactaseications, which may be prescribed for mental
(sec Chapter 5) depression.
The basic creacmenc for food intolerances is to
Almost e,·eryonc is sensiti,·e co one or more of a\'Oid specific offending components. Howc,·er,
these causes of food incolcrancc, many of which total elimination often is not required because peo-
product GI tract symptoms. ple generally .ire not as scnsiti\'e to compounds
Sulfites, \\hich arc added to foods and lm·er- causing food intolerances as they arc to allergens.
ages as antioxidants, cause flushing, spasms of the for instaiKe, a slight amount ofsulfires in a glass of
airway and a loss of blood pressure in susceptible \\foe may be rolcrable, whereas a large amount
people. Wine, dehydrated potatoes, dried fruits, from a chers salad made with sulfite rrcated salad
gra\~, soup mixes, and restaurant salad greens greens may cause a reaction.
variety or foods. One possible policy is the one-bite rule: \\'ithin reason, chi ldren
should take at least one bite or taste of the foods presented to them. For snacks, par-
ents should select several possibilities of acceptable choices and allow children to
choose one; responsibility for food choice ideally should start early.
Helping a Child Choose Nutritious Foods

One way adults can encourage young children to eat nutritious, \\'cll-bafanced meals is
to sen·e new foods and repeat exposure to them. 11 lf a child obserYeS adults and older
children eating and enjoying a food, there's a good chance that, most of the time, he
or she will e\enn1ally accept it. The dirmer hour is a good time for children to cxperi
ence ne'' foods and co de,clop th<.:ir 0\\11 food preferences. Preschool children espc-
ciall) tend co be wary of new foods. One reason is that they have more taste buds, and
their taste buds a.re more sensitive than those of adulcs. Tn addition, they have a gen-
eral distrust of unfamiliar foods. If adults can be patient and persevere, children \\'ill
build good food habits. Above all, the dinner rable should not become a battleground,
and using one food as a bribe to ear another-for example, a piece of pie for peas- is
strongly discouraged.
Perseverance with children is critical, because it cakes effort and comm itment co
guide them into liking a variety of foods . Be ready for some surprises. Also, if left. lO
637
their own dcvkes, preschool children would find a few foods they like and eat them
every day. However, by constantly being introduced to new foods, children at this age
can expand their nutritional choices, develop an experimental approach, and learn to
appreciate a variety of foods. Ir may take 10 ro 15 exposures, bur eventually chi ldren
will accept most foods. A positive outlook by the caregivers helps a lot. 1
Children generaUy like certain foods-especiaUy those with crisp texrnres and mild
flavors-and familiar foods . Yow1g children are especiaUy sensitive to hot-temperature
foods and tend to reject them.
P:ll"ents and other caregivers play a central role in teaching by example.17 Children
more rearuly learn good table manners alongside others who practice them. The harmony
that comes from working at being polite creates a positive environment for learning good
nutrition habits. Preschoolers eventually develop skill witl1 spoons and forks and can even
use dull knives (Table 17-5). However, it's stiU a good idea to serve some finger foods. A
goal should be to make mealtime a happy, social time, sharing enjoyment of healrhfol
foods. A regular family meal daily-whether bre.:'lkfast, lunch, or dinner-is an appropri-
ate setting for children to learn about healthful eating and to build good eating habits.
Childhood Feeding Problems

Tensions between parents, or between parents and children, especiaUy during mealtime,
ofi:en contribute to eating problems. Getting to the root of family problems and creat-
Interest in food starts early in life. ing a more harmonious family atmosphere are important steps toward resolving many
Table 17·5 I Observed Emotional Traits, Eating Behavior, and Food-Related Skills of Preschoolers
Age
{years) Emotional Traits Eating Behavior Food-Related Skills
1-2 • Fears new things • "Finicky" eater • Uses spoon with some skill (especially if
• Sharing difficult • Holds food in mouth without swallowing hungry)
• Requires constant supervision • May insist on eating the same food at meal • Can begin to tear, break, snap, and dip
• Enjoys helping but can't be left alone after meal (called o food jog) foods
• Curious • Hos good control of cup-lifts, drinks, sets
• Often defiant ii down, holds with one hand
• Eager for attention • Helps self-feed
3 •The "me too" age-wants lo be included in • Eats most foods, except for certain • Uses spoon in semiodult fashion; may
everything vegetables spear with fork
• Responds well to options rather than • Dawdles over food when not hungry • Medium hand muscle development
demands • Comments on how foods ore served • Feeds self independently, especially if
• Sharing still difficult hungry
• Somewhat rigid about the "right" way to • Can pour milk and juice and serve individ-
do things ual portions from a serving dish if given
instructions
4 •Shores well • Eating and talking get in the way-prefers • Uses all eating utensils
• Needs adult approval and attention-shows to talk • Small-finger muscle development
off • Strong food likes and dislikes • Can wipe, wash, set table, and pour pre-
• Understands; needs limits • Refuses lo eat, to the point of tears measured ingredients
• Follows rules most of the time • Con peel, spread, cut, roll, and mash
• Still rigid about the "right" way to do things foods; cracks eggs
5 • Helpful and cooperative with family chores • Likes familiar foods; prefers most vegetables • Fine coordination in fingers and hands
and routines row • Makes simple breakfast and lunch
• Still somewhat rigid about the "right" way • Latches on to food dislikes of family mem- • Con measure, cut, grind, and grate with
lo do things bers and declares these as own some supervision
• Very attached to parent, home, and family
Modified from M. Sigmon-Gron!, "Feeding Preschoolers: Boloncing Nulrilionol and Developmenlol Needs,• Nutrition Today. July/August 1992, p. 13. Used wilh permission
childhood feeding problems. ln addition, many parents must be educated as to what to

expect of a preschool child and what food-related goals to set (re\'irn Table 17-5).
Consider some typical complaints and concerns of parents, the causes of the problems,
and suggestions for correcting them.
wo-year-olds commonly prefer particular

"My Child Won't Eat as Much or as Regularly as He Did
as an Infant"
T foods, but parents needn't worry about this.
A child may switch from one specific food focus
This bd1a,·ior is typical of preschoolers, because their growth r,lte slows after infuncy; (otten called a jog) to another with equal inten·
thus, the~ don't need as much food. Parents often need reminding th.lt .1 3-year-old can't sity (older infants may also ad this way). If the
be expected to eat as ,·oraciously .is an infant or to car adult-size portions. 1 Table 17-6 caregiver continues to offer choices, the child
shows ,1 gcner.il food plan, based on MyPyrarnid, that is appropriate for preschool and will soon begin to eat a wider variety of foods
school-age children. Until about 5 years of age, portion sizes in the \'egetabk group, again, and the specific food focus will disappear
fruit group, and meat and beans group should be about\ 1 tablespoon per year of life as suddenly as it appeared.
and can be increased <lS needed. The s:imc advice does not apply to the grains or milk
group, bm nore that consuming mo much milk can leave the dice shore on iron.
Luckil\', norm~1l-weigbt children have a built-in kcding meclunism, which adjusts
hunger ro regulate food intake at each stage of growth. lf .1 child 1s developing and
growing normally and the carcgi' er is providing a variety of healrhfol foods, all can be
confidenr that the child isn't st.ining.
A pJrtcrn of picky eating is usually just another expression of independence for chil-
dren, "ho ha\'C a strong desire to establish a self-determined routine. Caregi,·ers
should .woid nagging, forcing., and bribing children to encourage eJting. Tndfrectly,
these t.\Ctics reinforce picky-eating behaviors because of the added ,utencion given to
them. Overall, parents should focus on offering a variety or healthy choices and allow-
ing tl1e r.:hild to exert some autonomy mer the specific type or
food and tl1e amount
eaten. A child's sudden loss of appetite, howe\'er, may be reason for concern because
.i poor appetite may be a sign of underlying illness. 11
Parents should also be reminded chat food likes and dislikes ch,111ge rapidly in child-
hood and are influenced by food rempcramre, appear.ince, cexwrc, and taste.
Sometimes children object to having foods mixed, as in ste\\ s and casseroles, even if
tl1ey normally like the ingredients separately.
In addition, parents should rccogni1c that this is an irnponam age ft>r children to ex-
pion: the world around them. fa·cn good caters are sometimes more interested in ex-
ploring th•rn eating. There's room for occasional indulgences, <l skipped meal or two, or
Table 17·6 I Food Plan for Preschool and School-Age Children Based on
MyPyramid
Approximate Number of Servings 1

Food Group Serving Size Age 22 Age 53 Age 83 Age J23A
Groins ounce 3 5 5 6-7
Vegetables cup 1.5 2 2.5-3
Fruits cup 1 l.5 1.5 2
Milk cup 2 2 3 3
Meat & Beans ounce 2 4 5 5.5- 6
Oils teaspoon 3 4 5 6
Discretionary
Calories kcal up to 165 up lo 170 up lo 130 up to 265-290
1
Log on to www mypyramid.gov for other oges and other activity levels
2 Based on less than 30 minutes of physi,ol o'fivity
3 Based on 30-60 minutes of physical activity.
~The tower amounts refer lo girls.
640 Chapter 17 N utrition from Infancy through A dolescence
once in a while "less than ideal,, choices. It's eating and lifestyle habits over the course
of a month and lifetime that matter. Children master their eating when adults provide
opportwlitics to learn, give support for exploration, and limit inappropriate behavior.
"M y Child Is Always Snacking, Yet She Never Finishes Her M eal"
Children have small stomachs. Offering them six or so small meals succeeds better than
limiting them to three meals each day. Sticking to three meals a day offers no special
nutritional advantages; it's just a social custom. Snacking is fine as long as good den-
tal habits are practiced. 1 Wh en we eat isn't nearly as important as what we eat. If nu-
tritious snacks are readily available, these are good to offer at midmorning or
midafternoon when the child becomes hungry (Table 17-7). Fruits and vegetables
(fresh, frozen, or juice) and whole-grain breads and crackers are good snack choices.
It is important that these snack choices be planned ahead in order to have healthy
choices available. Working parents should make sme thei1· clliklren are provided wid1
nutritious snacks to tide them over w1tiJ dinnertime.
Table 17·7 I Ideas for Nutritious Snacks and Beverages
Snack Serving Suggestion Snack Serving Suggestion Snack Serving Suggestion

Fresh raw Serve with a dip of col- Ready-to-eat cereals Use brands low in sugar Parfait Make with yogurt, fruit,
vegetables toge cheese or yogurt and containing fiber; and granola.
blended with dried but· serve with raisins.
Gelatin Add fruit or vegetable
termilk dressing.
Pila bread Place sliced meat, juice, vegetables,
Celery Spread with peanut but- cheese, lettuce, and frui ts, or cottage
!er and sprinkle on tomato in open pocket. cheese.
raisins, shredded car-
English muffin s or pita Top with spaghetti Frozen fruit cubes Freeze pureed apple-
rots, or finely chopped
bread sauce, grated cheese, sauce or fruit juice into
nuts.
meats; broil or bake cubes.
Bananas Dip in sweetened yogurt and cut in fourths.
Fruit fizz Add club soda to juice
or spread with peanut
Potato skins Sprinkle with shredded instead of serving soft
butter and roll in co-
cheese, broil, and top drinks.
conut, chopped nuts,
with yogurt and bacon
or granola. Fruit shake Blend milk with fresh fruit
bits.
(bananas, berries, or a
Sliced apples Serve with a dip of
Canned chili with beans Heal and top with peach) and a dash of
or crackers peanut butter, honey,
onions, lettuce, and cinnamon or nutmeg.
nuts, raisins, and
tomato; use as dip for
coconut. Yogurt frost Combine fruit juice and
Italian or French
yogurt; add fresh fruit,
Bagels Spread with cream bread, biscuits, or
if desired.
cheese or peanut but- cornbread.
ter ond top with Hot chocolate Make hot chocolate or
Kobobs Make with any combina·
chopped bananas, cocoa with milk choco-
lion of fruit, vegela·
crushed pineapple, or late and a dash of
bles, and sliced or
shredded carrots. cinnamon.
cubed cooked meat
Quick bread Make with carrots, zuc- (remove toothpicks be- Seeds Choose shelled sun-
or muffins chini, pumpkin, ba- fore serving). Rower seeds.
nanas, nuts, dotes, Serve plain or make 3 Fish Put tuna salad on
Popcorn
raisins, lemons, crackers.
quarts and sprinkle
squash, or berries. with 1/ 4 cup grated Conned soup Serve a cup of vegetable
Flour tortillas Spread with refried cheese and 1/2 tsp or minestrone; nice on
beans or conned chili garlic or onion salt. a cold winter day.
with beans, sprinkle
with grated cheese
and broil; top with
chili sauce.
When a child refuses to cat, it's best not tO overreact. Doing so may give the child hoking is o very preventable hazard for
the idea that eating is a means of getting attention or manipulating a scene. Most chil- young children. Some suggestions for core·
dren don't starve themselves to any point approaching p~1ysical harm. When children givers include:
refuse to eat, have them sir at the table for a while; if they still aren't interested in eat- • Seto good example al the table by toking
ing, remove the food and wait until the next scheduled meal or snack. small bites and chewing foods thoroughly.
• Insisting that children sit at the table, toke
"My Child Never Eats Vegetables" their time, and focus on the food during
Children generally cat enough fruit but not an adequate amount of \'Cgctables. meals and snacks.
fa·cryone dislikes certain foods. Again, the one-bite policy can be used, including for • Avoid giving children any foods that are
' 'egetablc sen-ings. It rakes time for a child to become enthusiastic about a new food; round, firm, sticky, or cul into large chunks.
howc\'er, wiLh continual exposure and a positive role model, chances arc die child may Some examples of foods lo avoid ore nuts,
even grow to like it. grapes, raisins, popcorn, peanut butter, ond
Children cannot and should not be forced to cat. They need LO develop indepen- hard pieces of row fruits or vegetables.
dence and identities separate from L11cir parents. As already stated, children have tO
choose for themselves-a practice that shou ld be encouraged. No one food is an es-
sential part of a diet. Hunger is still the best means for getting a chi ld tO cat. It may
be effoctivc to feed children vegetables at the start of a meal, when rhcy are hungriest.
Ofter new foods with familiar ones. A platter of raw or lightly cooked carrots, broccoli,
green and red peppers, cabbage, and mushrooms eaten as a snack '' ith friends may be
accepted. A 4 - or 5-ycar-old child can safely eat raw vegetables without tear of chok-
ing. Recall that children often are more sensitive than adlllts co strong flavors and
odors. Nutritious dips, such as small amounts of ranch dressing, "sell" vegetables to
many children. Vegetables may acquire more appeal when children help prepare them.
And, as with any food, it is important to remember that children arc entitled to d1eir
own Likes and dislikes, too.
Use of Multivitamin and Mineral Supplem~nts

Major scientific groups, such as the American Dietetic Association and the American
Society for Clinical Nutrition, belie\'e that multivitamin and mineral supplements are
generally unnecessary for health}' children; it's better to emphasize good foods.
Fortified ready-to-eat break.fast cereals with milk are especially helpful in closing any
gap between current micronutrient intake and needs, such as for ,·it:imin E, folate, and
vitamin D. Two micronutrients of particular concern are iron and zinc. These may be
lacking in chi ldren's diets because children consume such small portions of rich
sources, such as animal protein foods. ln addition, because d1e 2005 Dietary Giiidelines
for Americans suggests that children over age 2 years follow a diet low in saturated fat
and cholesterol, rich sources of iron and zinc may be lacking in their diets. To com- Milk is o nutrient.dense source of protein,
calcium, zinc, and olher nutrients to support
pensate, parents can search for a whole-grain breakfast cereal that the child likes that
growth. It is especially challenging to meet
also has about 50% of the Daily Value for iron and 25% of the Dailr Value for zinc. calcium needs in childhood without regular
(These quantities will supply sufficient amounts of both nutrients because the Daily dairy product consumption (review Chapter 11
Values are based on the higher needs of adults.) If that's not possible, especially for a for alternative sources of calcium).
child who is ill, who has a very erratic food preference pattern or appetite, or who is
on a weighr-loss diet, the American Academy of Pediatrics suggests that the child may
benefit from a children's multivitamin and mineral supplement not exceeding 100% of
Daily Values on the label, especially if these conditions pcrsist. 11 Still, as mentioned
many Limes in this textbook, such a practice does not substitute !Or an od1crwisc
healthy diet, children included.
[f current childhood feeding practices are to become more healthful, the focus hildren who follow a totally vegetarian diet
should shift to whole-grain breads and cereals, fruits and vegetables, ,md low-fat milk should also focus on protein and vitamin
and milk products. 1•14•2 0 Caregin:rs can model this beha' ior by ordering from the 8-12 intake.
salad bar more often and ordering french fries less often at fast food restaurants.
Children do not need co be severely restricted but, rad1er, should modi~· food habits
\\ ith small changes. Some easy diet changes to begin \\~th arc bagels instead of dough-
nuts, fat-free frozen yogurt instead of ice cream, fut-reduced or I% mi lk instead of
whole milk, fruit instead of crackers and cheese for snacks, and air-popped popcorn in-
stead of chips.
Other Nutritional Problems in Preschool Children

hapter 5 noted that sugar is not the cause Three nutrition-related problems fow1d in preschool chi ldren are iron deficiency ane-
of hyperactivity or antisocial behavior in mia, constipation, and dentaJ caries. Proper diet can help correct o r relieve these con-
most children. ditions. Vegetarian diets can also pose problems.
Iron Deficiency Anemia

The best way to prevent iron deficiency anemia in chiJdxen is to provide foods that arc
adequate sources of iron. Iron-fortilied breakfust cereals and a few ounces oflean meat
are convenient means of getting more iron into a child's diet.1 The high proportion of
heme iron in many animal foods allows the iron to be more readily absorbed than is
iron from plant foods . Consuming a vitamin C source along with the Jess readily ab-
sorbed iron in plants and supplements aids absorption.
Childhood iron deficiency anemia is most likely to appear in children between the
ages of 6 and 24 months.7 It can lead to decreases in both stamina and learning abil-
ity because the m~·ygen supply to cells decreases. Another effect is lowered resistance to
disease. Forrunatcly, childhood anemia is less common today in North America, prob-
ably because of children's use of iron-fortified breakfast cereals. Also deserving of
credit in the United Stares is the Special Supplemental Nua-ition Program for Women,
Infants, and Chilrucn (WIC), sponsored by tl1e U.S. government. This program em-
phasizes the importance of iron -fortified formulas and cereals and distributes tl1em-
along with nua-ition education-to low-income parents of infants and preschool
children considered to be at nutritional risk.
Constipation
Constipation may be associated 'vVith a more serious disease, yet some young children
experience constipation that is unrelated to any medical condition. When presented
witl1 a constipated child, a physician first has to rule out a medicaJ cause, such as in-
testinaJ blockage. And although the most common GI tract symptom tl1at reflects in-
tolerance to cow's milk is diarrhea, clu·onic constipation may also resulc. This
possibility should be investigated by the physician. Treatment for constipation gener-
ally consists of first evacuating the bowels, generally with an enema. The promotion of
regular bowel habits then follows, witl1 laxative use as directed by the physician. Several
mond1s to years of supportive intervention may be required for effective treatment.
Dietary interventions include eating more fiber and <.frinking more fluids. Soy milk
may also be substituted for cow's milk in the initial stages of treatment. Foods to em-
phasize for fiber are fruits, vegetables, whole-grain breads and cereals, and beans. The
current daily fiber goaJ for chilruen set by the Food and Nutrition Board varies by age:
1-3 years, 19 g/day; 4- 8 years, 25 g/day; 9-13 years, 31 g/day for boys and 25
g/day for girls. After age 13 years, typicaJ adult recommendations are appropriate (see
Chapter 5). CtuTently few children meet this goaJ. 14 Accompanying fluid recommen-
dations axe 4 cups (900 111.l) per day for toddlers and about 5 cups ( 1200 ml ) per day
for older chi ldren.
Dental Caries
Excessive fruit drink and fruit juice use is A proper diet goes a long way in reduci11g the risk for dental caries in young children.
anolher potential problem in preschool (and (Earlier in this chapter it was mentioned that infants are prone to early childhood
later adolescent) years. The American caries, which can lead to excessive tooth decay.) The foUowing tips can help reduce
Academy of Pediatrics recommends no more dentaJ problems in children:
than 4 lo 6 oz/doy for children 1 to 6 years
(and 8 to 12 oz/day for ages 7 lo 18 years). • Begin oral hygiene when teeth starr to appear.
Sweetened so~ drinks should also be limited. • Seek early pediatric dental care.
• Drink fluoridated \Yater.

• Use !>mall am0tmts of fluoridated toothpaste twice daily.
• Snack in moderation.
• Ha\'C a dentist apply tooth sealants if needed.
• Avoid sticky, high-sugar snacks, especially between meals.
• lf toddlers or preschoolers are chewing gum, sugarless gum is the best choice, be-
cause it has been shown to redw.:c the incidence of dental c.1rics.
Chaprerl> 5 and 12 provide a Ii.tiler description of diet and dental health. If needed,
these discussions will aid in putting this list of recommendations into perspective.
Vegetarianism in Childhood
Vegetarian diets can pose several risks for young children. These risks include the pos-
!>ibility of dc,•eloping iron deficiency anemia, a deficiency of vitamin B-12, and rickets
from a viramin D deficiency. During the fi rst few years of life, children also may not
consume enough energy when following a bulky vegetarian diet. But these known pit-
falls arc easily avoided by informed diet planning (revie" the Nutrition Focus in
Chapter 7). Diers for children who cat totally vegetarian fare lthould focus on vitamin
B- 12, iron, and zinc content, with additional emphasis on \ it,1min D (or rcguJar sun
exposure ) and caldum. 1 Some of these dietary inadequacies can be compensated for
b~ increasing oils, nuts, seeds, rcady-ro-eat breakfast cereals, and fortified soy milk in
the diet.
Modifications of Childhood Diets to Reduce future Disease Risk

Earlier chapters covered the role of diet in development 1or· cardiovascular disease and
hypertension and the recommendations concerning did to reduce rhe risk for these
diseases. Parents sometin1es wonder whether similar diet modifications arc appropriate
an<l bend'icial during childhood.
Diets Designed to Limit Cardiovascular Disease for Children 2 Years

of Age and Older
The development of atherosclerosis often begins in childhood. As a result, many ex-
perts recommend screening for blood cholesterol in chil<,iren whose families have his-
tories of early development of cardiovascular disease or lhigh blood cholesterol, and
treating chi ldren fow1d to have high blood cholesterol \\'ith appropriate diet and pos-
sibly drug therapy, as discussed in Chapter 6.3 With regard to diet, children in the
United States currently derive about 33% of their energ)' from fat, with about 13% of
energy from sarurated fut. The Food and Nutrition Board recommends that fat intake
range from 30 to 40% of energy inrake for children 1 ro 3 years, and 25 to 35% for
children 4 to 18 years, so this fat imake is appropriate. HO\\'e\ er, saturated far, trans
far, and cholesterol intake should be minimized (no set limit ). Thus, more work is
needed in this regard. These recommendations an: consistent with those of the
National Cholesterol Education program in the United Stares and \\'itl1 those from the
American Heart Association. An emphasis on plant oils such as canola oi l as a major
source of fat in the diet helps meet the goals of reduced saturated fat, tnms fat, and
cholesterol intake. In general, it's unnecessary co discourage chi ldren from consuming
nutrienr-dcnsc foods, such as milk and animal proteins, just because they contain some
animal fac. The overriding message is moderation in these and other far sources \\'ith a Children benefit from opportunities to be
focus on limiting saturated fat, trn.11s far, and cholesterol intake. physically active. This contributes to
cardiovascular health. The current gool is 60
Solt-Restricted Diets minutes of such activity each day, the same as
for adults. Many children currently ore not
Scientific data neither confirm nor refine the notion tlrnt caring Jess salt (sodium) re- meeting this goal.
duces the risk of future hypertension. Mc)dcration in salt consumprion docs help build
good health habits for the future-especially if the person later develop~ hypertension
and needs to eat even less salt. If children become accustomed to less salt, they'U be
less inclined to eat very salty foods as adults. This reduction Ln salr also contributes to
better calcium retention in the body, as covered in Chapter 11. If a child with hyper-
tension does not respond to cliet and lifestyle therapy, typical antihypertensive medica-
tions may be used, but at lower doses tban adults require. 9
Concept I Check
The rapid growth rate of an infant's ftrst year slows during the toddler and preschool years
(ages 1 to 5). As a child's appetite decreases, adu lts need to serve nutrient-dense foods and
allow the child to decide how much to eat. Sudden shifts in food preferences are to be ex-
pected. Snacking is fine if attention is given to the selection of healthful foods and good
dental hygiene. Although children's multivitamin and mineral supplement is usuall>' not
needed-a plan following M yPrramid that includes a serving of fortified ready-co-car
Sweets should be consumed in moderation in
childhood but do not have lo be avoided breakfast cereal should meet nutrient needs-such use is a reasonable practice. Children
altogether. need plenty of iron-rich food to prevent iron deficiency anemia and need zinc for growth.
Adequate fiba and fluid help prevent constipation. Developing heart-healthy habits after
the age of 2 years is advocated, bur highly restrictive diets are not appropriate during child-
hood. Diets for children who cat totally vegetarian fare should focus on meeting needs for
proreill, vitamin D (or regular sun exposure), vitamin B-12, calcium, iron, and zinc.
School-Age Children: Nutrition Concerns

In general, the nutritional concerns and goals applicable to school-age children m·e the
same as those discussed in relation to presd1oolers. The MyPyramid for children ages 6-11
years is a good basis for diet planning, with an emphasis on moderatiJ1g fat and sugar
intake and ensuring adequate iron, zinc, and cakiurn intake (Figure 17-6). 1otc :ilso
that the mtmber of servLngs Lncreases as age, and so energy needs, increase ( revie\\'
Table 17-6). The Estimated Energy Requirements (kcals) arc now 88.5 - (61.9 x
Age [y]) + (PA x (26.7 x Weight [kg] + 903 x Height [meters]) + 20 for boys
3 through 8 years. RecaU from Chapter 13 that PA stands for physical activity. In this
case, PA = 1.00 if the child is sedentar y; PA = 1.13 if the child is low active; PA=
l.26 if the child is active; PA = l .42 if the child is very active. For older boys the for-
m ula is the same except that d1e last value (20) is replaced by the value 25.
For gis ls ages 3 through 8 years the formufa is 135.3 - (30.8 x A ge (y]) + (PA
x (10.0 x Weight [kg] + 934 x H eight [meters] ) + 20. In dlis case, PA = L.00
if the chi ld is sedentary; PA= l.16 if the child is low active; PA = 1.31 if the child is
active; PA = 1.56 if the child is very active. For older girls the formuJa is the same ex-
cept again the last value (20 ) is replaced by the value 25. The rest of th.is major section
addressc::s several nutritional issues of particular concern dtuing the school-age years.
Breakfast, Fat Intake, and Snacks

Once children enter school, cheir eating patterns become more sched uled and the con-
sumption of regular meals-especially breakfast-becomes an important focus. A for-
tified ready-to-eat breakfast ccreaJ is typically the greatest source of iron, vitamin A,
folic acid, and fiber for children ages 2 to 18. 2 Although there is controversy over rhc
true benefit of breakfast for cognitive ability, children who eat breakfast likely meer
their needs for \'itamins, minerals, and fiber compared to children not eating breakfast.
' I Tf,jqtl'lg
To influence morning test performance, it currently appears d1at bn:akfast must be
Tim refuses lo eat breakfast before school. He eaten widtin a few hours of a test; the rise in blood glucose is t hought to enhance
doesn't like cereal, toast, or any of the other performance.
usual breakfast foods. What can Tim's parents Breakfast menus need not be limited to traditional fare. A little imagination can
do fo ensure that he eats nutritious foods be- spark the interest of even the most reluctant child . Instead of conventional breakfast
fore leaving for school? foods, parents can offer leftovers from dinner-pizza, spaghetti , soups, yogurt topped
with trail mix, chili with beans, or sandwiches, for starters.
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Figure 1 7 ·6 I The USDA hos created o version of MyPyromid for children ages 6 to 11. The
accompanying website (http://mypyromid.gov/hds/index.html) also features kid-friendly resources-
such as on interactive MyPyromid Blast Off Gome ond o meol tracking worksheet-designed lo
encourage children to make healthier eating ond activity choices. This site olso contains informolion ond
resources tho! adults can use in educating children about proper nutrition.
Diets of school-age children should include a variety of foods from ead1 major
group, nor necessarily excluding any specific food because of its far concem.
Overemphasis on fat-reduced diets during childhood has been linked to an i.ncrease in
eating disorders and encourages an inappropriate "good food, bad food" attitude.
Steering children toward healthfu l foods, in school and at bome, is likely to be more
successful if children are exposed to nutrition education. Because children spend much
of their younger years in school, it is a great place to learn abour positive, health)' eat-
i11g habits. 17 Such education can help children w1derstand why eating a proper diet will
make them feel more energetic, look better, and work mo re efficiently. One survey of
U.S. schoolchildren highlighted the need for nu trition education. On tlie day of the
survey, 40% of the children ate no vegetables, except for potatoes or tomato sauce; 20%
ate no fruits. Another srudy showed tliat only 2% of about 3300 children 2 to 19 years
old had met their recommended servings from the six groups of My Pyramid. Clearly,
the diets of many school-age students can stand general improvement, particularly with
regard to fruit, vegetable, whole grain, and dairy choices. Drinking minimal amounts
Nutrition education ideally begins in the home
of sugared soft drinks is also advised.
as parents and other caregivers provide a
healthy, well-balanced diet.
Type 2 Diabetes
Type 2 diabetes is gencrall~1 thought of as an adult condition. As the Nutrition Focu~
in Chapter 5 explained, it frequently occurs in overweight people who are older tlian
40. However, recently physicians have noted an alarming increase in the frequency of
the disease among children (and teenagers). This increase is primal"ily due to tl1e risc
in obesity i.n tliis age group, coupled with minimal physical activity. Up ro 85% of chil-
dren witl1 the disease arc overweight at diagnosis. Experts arc currently calling for the
screening of fasting blood glucose i.n at-Lisk children every 2 years, starting at age 10
or at the onset of puberty. Besides obesity and a sedentary lifestyle, otl1er risk factors
include having a first- or second-degree relative with the disease, or belonging to a
non-vVhite population. 11 Appropriate diet and lifestyle intervention should be imple-
mented, along with t11e use of medications when necessary. A focus on low glycemic
load fruits, vegetables, and whole-grain breads and cereals is especially recommendcd.
Overweight and Obesity

In the United States, about 15% of school-age children arc overweight. The number
of cases is rnrrently increasing, especially in minority populations. Obesity is generally
diagnosed when a child reaches tl1e 95th percentile for BMI and a physical exam indi-
cates the child is truly overfat, which is usuaUy true for a child who reaches tliis degree
of BMI. In tl1e short run, ridicule, embarrassment, possibly depression, and short
stature linked to early puberty ;u·e tl1e main consequences of such obesity. In the long
run, significant health problems associated witl1 obesity, such as cardiovascular disease,
type 2 diabetes, and hypertension, usually wiU appear in adultl1ood. However, an in-
crease in these health-related complications has been noted i.n children. Childhood
obesity is a serious health tlireat, because about 40% of obese children (and about 80%
of obese adolescents) become obese adults. Significant weight gain generally begiru;
between ages 5 and 7, dming puber ty, o r dming tlie teenage years. 13
Current research points to many potential causes of childhood obesity. Recall the
nature versus nurture discussion in Chapter 13. Some infants are born with lower
metabolic rates; they use energy more efficiently and in turn can more easi ly save: en-
ergy intake for fat storage. Studies also suggest, tliough, tliat this genetic link accounrs
for only one-th.ird of individual differences in body weight.
Researchers believe that altl10ugh diet is still an impon;.u1t factor, inactivity is also a
key to the incrcase in childhood obesity. 19 Today's generation of children no\\' glues
Regular physical activity is an important port of itself to the TV for an average of 24 hours a week; many children spend anotl1er 10
prevention and lreatment of weight problems in homs or so playing computer and video games. The American Academy of Pcdiatri1:s
childhood. recommends a limit of 14 hours of TV and video time per week. 11 In addition, execs-
si\·e snacking, O\'erreliance on fast-food restaurants, parental neglect, the media, lack of
safe areas co play, and high-fat/high-energy food choices also conrribuce co childhood
obesity. Sugared sofr drinks arc especially implicated. 10 Dr. Carol Byrd-Bredbenncr
dii.cusses these trends in more detail in the Expert Opinion.
The iniLial approach in treating an obese child is to assess how much physical activ-
ity he or she engages in. If a child spends much free time in sedenrar~' activities (such
as \\'atching te\e\'ision or playing video games), more physical activities should be en-
cournged. Both the U.S. governmenr and health professionals recommend 60 minutes
or more of moderate t0 intense physical activity per day for children and adolescents.
An overall active lifestyle will help children not only tO attain ,1 healthy body weight
bur also ro keep a similar body weight lacer in lite. An increase in physical activity won't
just happen; parents and other caregivers need to plan for it. Two good ideas are get-
ting d1e family together for a brisk \\'alk after dinner and finding an after-school spore
the child enjoys.
Moder~1rion in energy intake is important, especially the limitacion of hjgh-fat and
Lorge porlions of foods such as hamburgers
high-energy foods, such as sugared soft drinks and whole milk. The focus should be
and sugared sok drinks served to children ore
more on healthy snacks and foods rich in \'itamins and mincrals. 1 contributing lo lhe obesity and type 2 diobeles
Resorting to a weight-loss diet is usually not necessary. As a start, ic's best to em- epidemics lhey ore experiencing.
phasize changing habits that allow for weight maintenance. Children ha,·e an advan-
tage C)\'er adults in dealillg with obesity; their bodies can use stored energy for growth.
Thus, if weight gain can be moderated, increases in height and resulting lean body tis-
sue may reduce d1e percentage of body \\'eight accounted for as stored far, yielding a
more healthful weight-to-beighc ratio. Further growth can contribme to success.
If a child is still obese after attaining ultimate adult height, a \\'eight-loss regimen o gel kids involved in exercise, new physical
may be necessary, especially after the adolescent growth spurt. Weight loss should be educolion classes hove been introduced into
gradual, perhaps 1/2 to l lb per week. In addition, the child shou ld be watched closely schools. These classes provide lifelong fitness Jes·
to ensure that the rate of growth continues tO be normal. The child's energy intake sons in such activities os rock climbing, in-line
shoukln 't be so low that gruns in height dimirush. In addition, medications may be pre- skating, and recreolionol jogging. These classes
scribed under a physician's care to reduce food intake (sibutramine [Meridia]) or fat help promote activity because they toke the focus
absorption (orlistat [Xenical]). (Older children may even be candid:ncs for obesity- owoy from teams and competition, which often
related surgical approaches.)10 discourage ond embarrass kids who lock athletic
Obese children often need ro find a ne\\' way to relate to foods, especially snack to lent.
foods. An important family rule could be d1at children are allowed tO eat only while
sitting at the djrung table or in the kitchen. Tlus rule could stop endless hours of snack-
ing in front of the television and make all family members more conscious of when they
are eating. It also might be helpful to put portions of snack foods on plates rather than
ro a.How snacking to go on indefinitely, as often happens when chi ldren cat direcdy
from a full box of crackers or cookks.
A child's self-esteem is extremely fragile. Obesity itself often affects the child's psy-
che and mental outlook (e.g., depression). Humiliation doesn't work; it only makes
the child foci worse. Support, admiracion, .md encouragement of the chjld's efforts at
\\'eight control are more effectfrc and should be emphasized.
Finally, it is important to understand tl1at not all children are designed to look like
society's ideal. In other \\'Ords, some cluldren simply weigh more than others. A
healthful lifestyle with plenty of physical acti,·iry and nutritious foods remains the key
concern.
Concept I Check
The school-.1ge child is ad,ised to follow ~!)'Pyramid, moderating choices high in fat and
simple sugars. Breakfast is an important meal to refuel the body for a ne\\ school day and
to help ensure fulfilling nutrient needs for the day. Artcntion to regular physical acti\'ity and
health) diet should help prevent or treat childhood obesity and build a desirable lifestyle
pattern for later life.
Expert Opinion . I
Are Savvy Marketers Contributing to the Obesity
Epidemic in Children?
Carol Byrd-Bredbenner, Ph.D., R.D., F.A.D.A.
In industrialized notions, we hove the most nutritious, safe, and abundant Environment: Do a quick Internet image search for a national soft-drink brand
food supply of any time in history. So, logically speaking, we should be bet· or major fast-food chain and see what you discover! You'll find T-shirts, toys
fer nourished and healthier than ever before; but we're not. Diet quality hos (dolls, modeling clay kits), shrink-wrapped cars and buses, hot air balloons,
diminished-soft drink consumption is up, snacking is on the rise, portions ore basketball backboards, race cars, umbrellas, children's books that teach
super-sized, the family meal is just about extinct, and children in the United math using popular candy brands, and morel
States ore getting half their energy intake from added sugar and fat. All these
Schools: Visit most schools these days and you'll see food company logos on
factors and more ore ploying a role in the escalating obesity epidemic.
book covers and educational posters; branded foods sold in the cafeteria
Most experts believe that obesigenic or "toxic" environmenls ore at the
and vending machines or as fund-raisers; learning incentives that reword
root of this epidemic because the increase in obesity rotes parallels the obe-
children with o fast-food meal; and promotions for rebate programs span·
sigenic environmental changes seen over the post several decodes.
sored by food companies that provide schools with equipment or cash in re·
Obesigenic environments promote obesity-favoring behaviors by facilitating
turn far product labels.
sedentary behavior with labor-saving devices and sedentary leisure activi-
ties; offering easy access to large quantities of affordable, highly palatable, Cross-promotions: A trip down the cereal or cookie aisle at the supermarket
energy-dense foods; and encouraging {advertising) the overconsumption of is a great place to find examples of cross-promotions-the pairing of a pop-
these foods, which results in the displacement of other, lower-energy bui ular spokescharacter like Shrek or a toy with a food. Children's meals at fasl-
more nutrient-dense foods. food restaurants often cross-promote menu items and o toy. Cross-promotions
food advertising messages to eat! eat! eatl hove received o great deal help create o positive perception of products and increase brand recognition
of attention lately. Of course marketing affects everyone, but the main con- by young children.
cern of policymakers and health professionals is the effect of slick marketing
Viral marketing: Tell o friend about a product and you've engaged in viral
methods targeted to children. This concern is particularly well placed when
marketing, which is also called buzz marketing or word of mouth (mouse).
you consider that children usually cannot tell the difference between odver·
Viral marketing is the most basic type of advertising, but in recent years it has
tisements and TV programs until they ore age 5 or so. It is only ofter about 11 11
become more sophisticated. Marketers now recruit e-fluentials (individuals
age 7 or 8 that children understand tha t advertisements aim to persuade
who shape opinions and atti tudes of others online) to go to chat rooms and
them to buy a product, and even then, ii takes until about age 11 for them
to automatically activate thought processes that help them question the VO·
lidity of an advertisement. Plus, some advertising is so disguised (e.g., ad-
vertising games) that it is hard for even some adults to resist.
Why Do Marketers Target Children?

You may wonder why marketers would advertise to children; after all, few of
11 11
them earn o paycheck. In actuality, children in the United States control bil-
lions-those under 12 spend $25 billion of their own money annually and
influence $200 billion in household spending. Marketers have come to see
children as a vast consumer group that con help companies maximize their
profits. Marketers reach out to children as soon as they ore bornl (Some bibs
and baby bottles ore emblazoned with fast-food or soft-drink logos.)
Where Is Advertising Encountered?

Today, food marketing is similar to surround sound al movie theatres-it is
all around us. Television hos a powerful influence on the eating habits of children .
tout a product or post messages on bulletin boards or listservs. Some go to Advertising increases the number of food purchase requests children make.
neighborhoods to recruit the kid identified by peers as being the "coolest" For many children, their first purchase req uest occurs in the grocery store
(i .e., on influencer) to use their products and give samples lo friends. around age 2. The most common requests are for breakfast cereals, snacks,
beverages, and toys-paren ts give in to this pester power more than half the
Websites: Check out the website of o popular candy, soft drink, or snack chip
time.
and see how " sticky" they ore. These sites use odverloinment (a blend of ad·
vertising, entertainment, and product branding) to engage visitors and keep Advertising influences food preferences, choices, and intake. Television ods
them at the website interacting in o positive, fun way with the advertised prod· affect kids' breakfast cereal, snack, and beverage preferences and choices
uct. Advertoinment might include screen savers, phone ring tones of on odver· and increase their intake of advertised foods. One fast.food chain reported
tising jingle, kids' clubs, chat rooms, puzzles, and games. Advertoinment is that their toy cross-promotion doubled soles of children's meals.
particularly effective because it disguises promotions as games and comics,
Advertising affects children's knowledge of nutrition and health. Children
making it harder for children to be skeptical of odverHsing messages.
who frequently viewed TV believed that to maintain good health they should
Newspapers, magazines, radio, and television: Open a magazine or chan· take advertised medicines, drink soft drinks, and eat fast foods.
nel surf and you will find a wide variety of food advertisements. Despite the
rise in all the other types of marketing venues, television remains the favorite
of food advertisers. Television advertising is of special concern because chil·
So Are Savvy Marketers Contributing to the
dren in the United Stoles watch an average of 2 to 3 hours daily and see
Obesity Epidemic in Children?
about 38,000 N commercials yearly-a quarter of which are for foods or
beverages high in sugar or fat. Food marketing on TV is not limited to ad· Advertising expenditures and academic research both seem to indicate that
vertisements; there are product placements, too. Product placement is using advertising does affect food choices. But advertisers argue that their goal is
a product in the program itself as o prop or part of the storyline. Product to increase demand for one specific brand-not lo increase demand for the
placements also can be found in movies (ET's snack of Reese's Pieces food in general. That is, if one fast-food chain steals market shore from other
boosted product sales 80%) and music (McDonald's is recruiting hip·hop and brands, its advertisements do not increase intake of competing brands; thus,
rap artists to feature the Big Moc in their songs). advertisements do not contribute to obesity. On the other hand, academic re-
search findings indicate that the large expenditures spent on food odvertis·
ing, which promotes primarily high-calorie foods, does affect food choices,
Does Food Advertising Affect Food Choices?
creates desire for advertised foods, and promotes preferences for th ese
It is clear that food adverti sing is all around us, but does it affect food foods. At this lime, researchers cannot flatly stole that food advertising con-
choices? Most marketing and advertising research is done by food compa· tributes to obesity in children. However, nutrition and health experts from the
nies and is largely unavailable to outsiders. However, food marketers' spend- Food and Agricultural Organization and World Food Organization of the
ing patterns suggest that advertising works. According to the USDA United Nations have concluded that the research evidence is sufficiently
Economic Research Service's latest estimates, more than $11 billion is spent strong to state that pervasive marketing of fast foods and other high-calorie
on food advertising each year-of this, $7 billion is spent on convenience foods and beverages are a probable cause of weight gain and obesity in
foods, sweets, alcoholic beverages, and restaurants (mostly fast food). A sig- children.
nificant amount of this advertising is targeted to children.
Dr. Byrd-Bredbenner is Professor of Nutrition at Rutgers University.
Although academic research on the effects of food marketing on children
She earned her doctorate of The Pennsylvania State University. Her
is surprisingly thin and focused mostly on television, we do know this:
research focuses on environmental factors that affect dietary choices
Watching TV is associated with increased snacking and poorer quality and health, including advertising, media, nutrition labeling, portion
meals. Families who routinely watch TV during mealtimes eat fewer fruits and sizes, and food preparation skills. Dr. Byrd-Bredbenner has authored
vegetables and more pizzas, snack foods, and soft drinks than those fami- nutrition texts, ;ournal articles, and computer software packages. She
lies who separate eating ond television-watching activities. In addition, foods has received teaching awards from the American Dietetic
ore requested by children and purchased by parents in the some frequency Association, Society for Nutrition Education, and U.S. Department of
that they are advertised during children's N viewing hours. Agriculture.
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I The Teenage Years: Nutrition Concerns

Most girls begin a rapid gro'' th spurt between the ages of 10 and 13, and most bo~ ~
experience rapid growth betwee n the ages of 12 and 15. Nearly every organ in the
body grows during these periods. Most noticeable are increases in height and weight
and the de\'elopment of seco ndary sexual characteristics. Girls usually begin menstru·
ating during this gro\\'th spurt, and they grow very little beyond 2 years after menar·
che. Early-maturing girls may begin their growth spurt as early as age 7 to 8, whereas
early-maturing boys may begin growing by age 9 to 10. 11
During the growth spurt, girls gain about 10 in (25 cm) in height, and boys gain
about 12 in (30 cm). Girls .1lso tend to accumulate both lean and fat tissue, whereas
boys tend to gain mostly lean tissue. This growth spurt provides about 50% of ultimate
The teenage years ore noted for snacking. With adult weight and about 15% of ultimate adult height (review Figure 17-1 ).
reasonable food choices, teenagers con hove
healthful diets. As the growtl1 spurt begins, teenagers begin to eat more. Estimated Energy
Requirements are tl1e same as previously listed for older children. ff teens choose nu-
tritious food, they can take advanrnge or their increased hunger and easily satisf)' their
nutrient needs. As with younger age groups, MyPyramid can provide the basis for
meeting these nutrient needs, with the major difference being three servings of milk
and milk products (Table 17-8 ). Following such a plan will meet carbohydrate need-.
( 130 g/ day) and protein needs (0.85 g/ kg of body weight/day, or 52 g/day for male!.
and 46 g/ day fur fornales).
Nutritional Problems and Concerns of Teens

rinking soft drinks in place of milk causes Anorexia ner\'osa and bulimia nervosa were covered in detail in Chapter 15. Other nu -
many teenagers to hove inadequate col· tritional problems are more common during the teen years. A survey of high school
cium intake. Over the lost 20 yeors soft drinks students showed that onl) a little over 25% had eaten five serTings of fruits and \'eg-
hove been replacing milk as the preferred bever· etables on tl1e previous day, and they arc consuming approximately 25% more sodium
age of adolescents. This trend hos been linked lo tlun recommended. Another concern is that many teenage girls stop drinking milk, so
decreased bone moss and increased bone froc· they may not consume enough calcium to allow for maximal mineraljzation of bones
lures in this age group. through t11eir early twcnties. 18 Many young women who don't consume enough cal-
cium are likely to develop o~tcoporosis later, as discussed in Chapter 11.
The Adequate Intake for calcium for both males and females between ages 9 and 18
years is 1300 mg per day, compared with only 800 mg per day for younger children .
Three servings per day from the milk group arc recommended for all teenagers and
strictly vegetarian diet must be monitored Table 17·8 I Food Plan for Teenagers Based on MyPyramidl ,2
for adequate energy, protein, iron, vitamin
B· 12, calcium, and vitamin D (the lotter if sun Approximate Number of Servings
exposure is not sufficient). These nutrients be· Food Group Serving Size Age 13 Age 16 Age 18
come particularly important in teenagers, be· Groins ounce 6-7 6-10 6-10
cause their diets ore often olreody Vegetables cup 2.5-3 2.5- 3.5 2.5-3.5
compromised. fruits cup 2 2-2.5 2-2.5
Milk cup 3 3 3
Meot & Beans ounce 5.5-6 5.5-7 5.5-7
Oils teaspoon 6 6-8 6-8
Discretionary calories kcal up lo 265-290 up to 265-425 up to 265-425
1 Assumes 30-60 minutes of physicol activity per day. Log on lo mypyromid.gov for other ages ond levels of physicot aclivity.
2 Lorger omovnts refer lo boys.
young adults to meet calcium nc<.:ds. Figure 2-1 in Chapter 2 shows the st.1rk concrast
between milk and typical soft drinks with respect to calcium and other nutrients. If
milk and milk produces arc not consumed, alternative calcium sources need co be in-
cluded. f\lany teenagers arc nor meeting their calcium needs.
A further concern is iron deficiency. Iron deficiency aocmi.1 sometimes appear'> in girls
after they start menstruating (menarche ) and in boys during their growth spurt. About
10% of teenagers have lo\\ iron scores or related anemia. Teens \\'ho stri,·c to forge an
identity by adopting dietary patterns unfamiliar to their fumilies-vegctarianism, for ex-
ample-may not kno\\ enough about the alternate diet pattern to keep from developing
health problems, ~uch as iron deficiency anemia. It's important that Lccnagcrs choose
good food sources of iron, such as lean meats, whole grains, and enriched cereals.
Teenage girls, particularly those with heavy menstrual flows, need to eat good sources of
iron (or regularly consume an iron supplement). Iron deficiency anemia is a highly un-
desirable condition for a teen. It can produce increased fatigue and decreased .1bility to
concentrate and learn. School and physical performance may suffer. 11
Acne is a common teen concern-about 80% of teens experience iL AILl1ough it's
popu larly believed that eating nuts, chocolate, and pizza can make acne worse, scientitic An active lifestyle coupled with a healthy diet
studies have failed ro show a strong link between any dietary factor and acne. It is im- should be port of the teen years. Both habits
portant to note that man)' acne medications contain analogs of vitamin A (e.g., I 3-cis contribute to bone development and bone
retinoic acid [Accurane]). Although these treatments can be quite ctlcctive, the close strenglh.
supen·ision by a physician is crucial, because these ,;ramin A analogs can be toxic.
Vitamin A itself is no help in [rearing acne, and excess amounts of,itamin A or rcl,ued
analogs can cause birth defects. Thus, girls taking these Yitamin A medications must besity is a growing problem among
not become pregnant. teenagers, and about 30% of these
teenagers hove the metabolic syndrome
(Syndrome X) discussed in Chapters 5 and 6. If
A Closer Look at the Diets of Teenage Girls o teen is still obese ofter attaining ultimate adult
height, especial~ ofter the adolescent growth
Teenagers in general ,uc apt to adopt fud diets, ear away from home or miss meals com spurt, o weight-loss regimen may be necessary.
pletcly, and snack a lot. Teenage girls especially are very concerned with \\'eight gain, Weight loss should be gradual, perhaps
appearance, and social acceptance. U.S. government statistics re\'eal that female stu- 1 lb/week, and should generally follow the ad·
dents arc significantly more likely ro report current attempts to lose weight (44%) than vice in Chapter 13. Weight-loss medications
arc m,ue students ( 15%). Moreover, 27% of female students who considered tl1emsclvcs such as sibutromine (Meridio) or orlistot
the right weight report they were currently trying to lose weight. It is imporram Lo in- (Xenicol) may be prescribed. Obesity-related
form teenage girls that weight gain in tl1e form of increased body fat is to be expected surgery also may be recommended. I I
in tl1e adolescent growth spurt.
In an attempt to reach personal goals, teenage girls may eat dangerously little, sc
lcct just a fe" items, and freq uently skip mcah altogether. If their limited food choices
then consist of french fries, sugared soft drinks, and pastries, little room is left for foods
that .ire good nutrient sources. Another common practice among teenage girls is hav-
ing a fat phobia, focusing primarily on foods that are fat-free . However, many teens
may not realize that some far is essential for body functions. This concept is discussed
in Chapter 6. The diets of teenage girls often lack adequate sources of folare, e,1lcium,
zinc, and vitamins A and C. The common use of diet pills and the increasing number
of bulimia nen·osa cases further add co these nutritional problems.
Helping Teens Eat More Nutritious Foods

Teenagers face a variety of challenges. They pursue tl1eir independence, e\pericnce
identity crises, seek peer acceptance, and worry about physical appe.lrance. All these
factors affect food choice. As noted in the Expert Opinion in tl1is chapter, ad\'ertisers The eating habits of teenage girls con vary
take adrnntage of this situation by pushing a vast array of producls-candy, gum, soft widely. Some severely restrict their intake
drinks, .md snacks-at the teenage market. Potato chips and french fries make up more because of the fear of gaining weight, while
than one-third of the vegetable servings consumed by teens. Additionally, m:111y others use their growing independence to opt
schools offer frem:h fries on a regular basis, and soft drink machines can be found in almost exclusively for fast-food and fat.laden
school hallways and catcrerias, in rurn competing with tl1c school lunch. snacks.
lcoholism, a significant health problem that Teens ofccn don't think abom the long-term benefits of good health. They han: .1
may hove its roots in the teen years, is hard time relating today's actiorn. to tomorrow's health outcomes. Man~· teenager'>
covered in detail in Chapter 8. Smoking-onother tend to think they can just change habits later; there's no hurry.
habit that compromises health-also often begins Still, healthful teen food habits don't have to include gi,•ing up favorite foods. ' mall
in teen years. Some of this behavior is on at- portions of fatry foods can complement larger portions of fut-free and reduced-fat
tempt to control body weight-not on advisable dairy products, lean meats, vegetable proteins, fruits, ''egerables, and whole-grain
method. products. 2 •4 •15·20 An example i~ a plain hamburger with a garden salad ( minimize the
amount of regular dressing or use a low-fat variety), small order of french fries or chili,
and a medium diet soft drink or reduced fat or far-free milk.
linicions who work with teenagers, includ- Working with the Teenage Mind-Set
C ing physicians, registered dietitians, and
nurses, need to be prepared to discuss and deol One strategy for working with teenage boys is to stress rhe importance of nutrition and
physical activity for physical devclopmenr-cspecially muscular development- and for
with a voriety of concerns: sports nutrition, eat-
fitness, vigor, and health. W ith Leen~1gc girls, o ne approach is to help them undersl,tnd
ing disorders, use of steroids, ond drug (and al-
how to choose nutriem-dense foodl> and activities that lead to better health while
cohol) abuse. Except for substance abuse, these
maintaining a healthy weight. For teenagers, it's more effective to focus on the benc·
topics usuolly are not o concern when working
fits of healthful foods and regular physic.11 activity they can reap righr now than cu t.1lk
with older adult clients.
about heald1 hazards that may or may not happen later.
Teenage Snacking Practices

Teens often obtain one-fourth to one-third of all their energy and major nutrients from
snacks. Unfortunate!) , studies havc found just what you might expect- tlut teem
snack mostly on potato and corn chips, cookies, candies, and ice cream. Key rea~orn.
for snacking include an opportunity LO get out and socialize ,,-ith friends, acccssibili~ ,
hunger, and cekbration of a 1>pecial e\'ent. Teenagers can obtain many nutricms !Tom
snacking. Even fast-food restaurants offer some good food choices. By choo~ing "i~cly
and eating in moderation, teens can eat at fasL· food restaurants and still consume ,1
healthful diet. 11 Snacks and fast-food resrnurants themselves are not tl1c problem; poor
food choices are.
Poor d ietary habits and exercise for med during teenage years often continue into
adulthood, giving rise to an im:reascd risk of chronic diseases, such as cardiovascular
disease, osteoporosis, and some types of cancer. Getting this message across to
teenagers is an important and challeng ing task for parents and health profession,1ls.
Concept I Check
A second period of rapid growth occurs during the teen years. Girls generally start this
growth spurt earlier than boys. MyPyramid can direct meal planning. Common nutritional
problems in these years arise from poor food choices and include inadequate calcium intake
in girls, iron deficiency anemia, and sometimes excessive intake of total fat, saturated far,
One way to reduce energy intake in a and tram fat. Because changes occur so rapidly during these rears, and in so many are.:i\-
restaurant is to choose water or diet soft drinks
in place of regular soft drinks This will greatly psychological, social, and physical- it may be ditlicult to stress the importance of nutmion
reduce sugar and overall energy intake in the ro teenagers. ~loderacion in fat and sugar intake arc important goals to consider when
meal or snack, especially considering the large choosing snacks.
serving sizes typically offered.
Sum ma ry
1. Growth is n:ry rJpid during infancy; birth weight doubles in 4 to 6. Introducing iron-containing solid food at the appropriate omc
6 months, and length increases b~ 50% in the first year. An ade- and nm offenng cow's milk until 1 year of age can generall~ prc-
quate dier, especially in renm of energy as well as the nurrients Yellt iron deficiency anemia in lace infancy.
prorein .md 1inc, is essential to support normal growth. Undcr- 7 A slower growrh rate in preschool years underlies the importance
nucricion can cause irrc,·crsible changes in growth and dc,•clop- of children\ eating nurrienc-dense foods and reducing their food
menr. Growth in infants and children can be assessed by scn"ing sizes. Choo:.ing iron-rich foods, such as lean red meats, is
measuring body weight, height (or length ), and head cin:umtcr- imporc.1nr .u chi\ age. Portion sizes of 1 rablcspoon of each food
ence over lime. Growth charcs have recently been redscd co in· for each yc.1r of Lite is a good starting point for Yegcrablcs, fruits,
dude a more valid measurement for determining children\ .md meats.
growth: body mass index (BM!). 8. Preschoolers should be given some Jeewar in derermining serving
2. Nutrient needs in rhe tirsr 6 months can be mer by human milk or size :ind should be encouraged to try new foods. Highly restrictive
iron-fortified infant formula. Supplementary vitamin D is needed diets designed to reduce the risk of cardiovascular disease or hy-
in the first 6 monrhs for breastfed infants, and some infants may pertension .lre not recommended for preschoolers or older chil-
need supplemental iron or fluoride after 6 monchs of age. dren unlc~s prescribed by a physician.
3. Tnfonr formulas gcncrnlly contain I.Klose or sucrose, heat-m:arcd 9. Obese children and adolescents arc more likely LO become obese
proteins from CO\l"'S milk, .rnd vegetable oil. Thcse formulas m.ly .1dulrs and, so, incur greater health risks such as type 2 diabetes.
or ma~ nor be fortified with iron. Sanitation is very important Parems can provide heald1ful food choices, and children shoulJ
when preparing and storing formula. con1rol portion sizes. When controlled early through diet and C\
4 . l\lost infants don't need solid foods before 6 mond1s of age. Solid ercise intcn·cmions, the problem of obesity may correct itself as
food should nor be added to an infant's diet until the nutrients are tl1e child continues to grO\\ in height.
needed, the GT tract can digest complex foods, the inf.mt has the LO. During 1hc .1dolescent grO\\th spurt, bod1 boys and girb hJ\C in
phy..,ical ability co control tongue thrusting, and the ri~k of dcvcl- creased needs for iron and calcium. Inadequate calcium intake by
op111g food allergies has decreased. tccn.1ge girls is a major concern because it can set the st•1gc for
:>. The firsr solid food gi,·en should be iron-fortified infant cereals or the de\'cl<>pmcnc of osteoporosis later in life. Teenagers gcner;1ll}
ground me.us. Other single foods can be added gradually, ar the <,l10ukl moder.He their intake of high-fat and sugar-rich foods-
rate of about one each week. Some foods to avoid gh-ing infants espcciall)' snacks .md fast food, which d1cr often comumc in
in the first \·e.1r include honq, cow's milk (especially far-reduced abundance-and should perform regular physical activin.
\".\fietic~), \'Cf}' s.1ln or ~\\'Cct foods, and foods that m.1y cause
choking.
Study Questions
I. I .ist rwo focrors that limit "catch-up" growd1 in adu llhood Jren over 2 and aduJts cfocussed in Chapter 2. Which guideli ni:s
when a nutrient-defic ient diet has been consumed throughout arc similar? Do any contradict each otl1cr? If so, why?
childhood. 8. Describe 1hrcc pro~ and cons of snacking. What is the basic advice
2. Describe how you would asses~ whether an 8-month-old inf.mt is for he.ihhful snacking from childhood c:l1rough rhe teenage ~·cars?
consuming a healthful diet. 9. Which lWO nutrients are of particular concern in planning diets for
3. Ouc:linc three key factors thar help determine when to introduce teenagers? \Vhy does each deserve to be singled out?
solid foods inro an mfant's diet. I 0. List three nutrients of concern for a teenage vegecarian .
.+. A 3-month-old infant 1s taken to a clinic with failure to tl1ri\e.
\Vhat arc two possible explanations? BOOST YOUR STUDY
5. Lise three reasons why preschoolers are noted for "picky" eating.
For each, c.lescribc an appropriate. parent response. Check out the Perspectives in Nutrition: Online Learning
6. What three factors .trc likely ro contribute to obesity in a typical Center www.mhhe.com/ wardlawpers7 for quizzes, flash
l 0-ycar-old child? cords, activities, and web links designed to further help you learn
7. Compare the guidelines for 111fant teeding summarized in the about nutrition for infants and adolescents.
chapter with the 2005 Dicrn.1·_1· G11ideli11es for Americnm for chit
654 Chapter 17 N utrition from Infancy through Adolescence
1. ADA Repons: Position of the American 6. Douglas KNI ,md others: A practicaJ gu ide to This article is au excel/mt 1·n•ic:w of the cn11ses
Dicretic Association: Diemry guidance for i11fant hca lrh. Amc1·icn11 Fnmil_v Physician t111d COllSCIJllWCCS ofjiJod nllcrgics. It is ofre11 II
heafl11)' child ren ages 2 co l) )'Cars. Jourunl of 70 :2 11 3, 2004. c/Jnllenge tQ help people sr.ill follow n bnla11u
the American Dietetic Association 104:660, If a11 i11fa11t''s tfier docs nor pro11ide flttm·idc diet if tbcy b111•c food 11tle1;gics. li'nming hom ro
2004. (e.g., fammla is not mixed with jl1101·itfatcd read labels 1111d mbstimte foods ni·e tiv11 cools
lvf.Yl~·m111itfcombillcd wit/J the Dictni-y w11tcr),fl11oridc shcmld bcgii1m nfm· 6 mcmrbs t/Jnt cnsc mcb fi1od plmming.
G11idcli11cs for Americans provide nn appropri- 1ifnge. 7711'.r nrticlc 011tli11cs proper 1111d mft i11- 13. Kopla.n JP and o thers: Prevencing childhood
fJte b/tl~pri11t fi1rftedi11g cbildrc11. Diets of stntctio11s. Tbe nutbors do 11ot 1·ccom111C11d fltto- obesity: Health in the balan(c-Ei.ccurivc
mn.11.r c/Jildrcn n.r.: not folfo 111i11g this nd11icr nnrl ritft- t1Jempyfa1· b1·cnstfed i11f1111ts. Sum mary. ]01m111I of tbc A111&1·im11 Dictcrit
iii tum nre comrib11ring to the 111ttritio1'nl 7. Fitch C: Preventing iron deficiency in infants Associnriou I 05: 131, 2005.
proble111s rbat n.rr co111mo11 i11 chilrlhood n11d and toddlers. Today 's Dietitian, p. 32, Decem- 1'1·evc11ti11g c/Jild/Jood obnity im•o!Pcs n /Jmltby
later 11d11lthood. ber 2004. en.ting pn.ttem nntf regular physical ncriviry.
2. Affcniro SG and ochers: Breakfast consumption 771c nut/Jor stresses the need to pre11c11t i,.011 defi- TIJegonl should be n.chievi11g nnd 111ni11tniui11g
b)' African-American and white adolcsccnc girls ciemy in i11fn11ts nnd toddlen. After 4 to 6 n hcaltby body 111eig/Jt. The authors nr1tr tlJnt
correlates po~iri1•clr wid1 calcium and fiber in- mo11 tbs of ngc it is important to hm•e n ricb 1111111_-y socin.l factors will hm•e to be nlrcn:tf ro Jn·
take and ncgari"cly with body mass index. .rom-ce of il-011 in mt i11fa11t's diet, sucb ns ii-011· cilitnte r./Jisgonl, suc/J ns pn1vidi11g 11111rc 1m1/as
Jo11rnnl 1if the A111eric1111 Dietetic Association fi1rtijicd ccrcnls. A11y injiwr fom111ln used far physiml nctit1ity.
105:938, 2005. should be iro11fortified. Pn:i>entio11 ofim11 dcfl- 14. Kranz S and ochers: Dietary fiber imakc by
Earing brcnkfnrt 1111 a n:g11lnr bnsis co11trib11tes cimcy in torfdlc1·s i11cl11dcs limiting col!''s milk to American preschoolers is associated wich more
to the 011emll bcnltb of ndolescmtgfrls in t/Jis 3 wps per dny, bccnuse it is n poor source~( i1·011. nurricnc-dcnse diets. Jo11n1nl of t/Jt A111erirn11
study. B1·enl1fnsr helps,f}frls meet cnlcium and 8. Harun S and others: Vitamin D deficiency in Dietetic Association 105:221, 2005.
fiber needs while ir nls11 ctn1t1·ib11tcs to weigbt early infancy. /01m111l of Nutrition 135:279, Children in general 111011/rl benefit from dim
co11trol. 2005. /Jig/Jer iu ftbc1: lmprovi11g diet c/Joices i11 gcn-
3. AHA Scien tific Scarcmem: American Hearr Pre111mtio11of11itnmi11 D deficimcies in i1~fn11ts ern/ will allow for rbis change, i11c/11di1111111-
Association guidelines for primary prcvenrion is essential. T711t nrtic/e rcco111111rnds mpplemcnt- crense.r i11 wholegmin, frttit, 1111d l'egcrnbfr
of athcrosckrotic cardiovascular disease begin- i11g rhe rliet cJf 111/ brenstfed i11frmts n•ith i>ita- content. The healthier t/Je 01•1·rnll diet, t/Je
ning in ch ildhood. Cfrwlaiiou 107:1562, min D soon nftcr bi1·th. grrn.ter 1111111ber offiber -rich f011ds.
2003. 15. Lytle L: Nurrirional issues for adobccms.
9. Hdlckson K: Report on d1e diagnosis, cva lua-
Ir is clcnr thnt rnrrliol'llsmlnr discnsc begim in rion, ,111d treatment of high blood pressure in Jottmn.l of the AnJeric1111 Dietetic Ass11cin.tirm
cbi/dbood. A healthy dier, reg11/a1· ph:;sicnl 11cti11- l02:S8, 2002.
t:hi ldren and adolesccms. American Family
ity, 1111d 11ot s11111ki11g n re thr~e key ll'll)(r t11 fore- Physicin.1171:I014, 2005. Dntn from lmJJe, pop11!atio11-bnsrd studies .WJJ-
.rtnll t/Jc dcvd11p111.:ut 11f cnrdim•nmlinr disease gcst t!Jflt tlie t)•piml ndolcscent's diet placa r/Jcm
Sciw11ing for bigh bfllorf premm· is mi i111por-
bcgi11nillfl i11 c/Jildbood. After ngc 2 it is imp11r- m i11cnnsed risk fo1· cnrdioimsc11/n,. disensc, ca11·
tr111t parr of rcgttlnr checkups of chiIhm by t/Jc
t1111t ro limit mrnmted fnt, trans fnt, and cl1oh-s- ce1; osteoporosis, dinbetes, mid obesity i11 ndtrlr-
child's physician. 77Jt lrrtcsr 1-.·co111111mrfn.tio11s
rcrol imn.kc, while cspccia/~1· emphnsizing intnke /Jood. The rypicnl 1idolcscmt's diet cuntn.im too
fa1· tm1ti11g high blood pressm·c iffounrf i11dutfe
~(fhiits, Pegcrnbles, a11d ivbole-gmi11 breads 11111rh torn! fnt, sat11mtcd fnt, sodium, n11d s11p
n d ict rirl; i11 pcg,;tnblcs, fmit, and lowfnr
11.nd cereals. Rich protein som·ces me/; as dnir.v rfri11ks, n11d not enough fruits, i>eg.:tnblr..<, jibo;
dai1:Y products; lnll' in snlr; 1111d 111odrmte i11
p1·od11crs, lm11 meats, fish, nnd lrg11111cs (bcn11s) nnd calci11111.
bigh-cnlorie foods n11tf drmks. Rcgu/nr phy.ricnl
also desct'l'r n.ttcutio11. 16. Mrdjenovic G, Levitsky, DA: Nutritfonal and
nctil>ity is nlsr1 import1111t, as is mc(lf/Jt fem if
4. Bounds W anJ nrhcrs: The relarion~hip of di- 11cctfctf. energetic consequences of sweetened drink
etary and lifestyk facrors co bone mineral in- consumption in 6- ro 13-ye.ir-old children.
10. Kirk S and orhcrs: Pcdiau·ic obesiry epidemic:
dexes in ch ildren. Journal of rhc Ame1·ica11 ]nur1111I of Pedintrics l 42:604, 2003.
T n:atmcnc options. Jourunl of t/Jc Americn11
Dicwic Association I 05:735, 2005. Children arc notgood at reg11lnri11f1 Ol'trn!I rn -
Di~r.:ric Associntirm 105:S44, 2005.
A primnr.v i11jl11mcc 011 hcalth.1• bo11e mnss pn- et:!JY intnkr in lll'dcr to compcnsnrc for the i11-
Reducin..ir CllC1lf)' intnke and i11crcnsi11g cueiw• crensed enet;.IJ.Y coming ftwn. s1vecrmcd di-inks.
mmeters i11 tbis stlldJ• wn.s n m1rritio11s diet
L'.vpwrtit111"C ar.· important fiw trcnti11g pcdi-
nmple i11 p1·otei11, cnki11111, phosphrm1s, 11it11111i11 T/Jis lnck of rtg11lario11 results i11 cxrcss e11nm•
nt'l"ic obcsit)•. Medicntiom n11ri obesity·rclntcd imnke n.11rf Ol'cml/ poo1• 111m·itirm. C/Jiltfrm
K, mng11csi11111, zinc, c1m:o.v, n.11d i1'011. Height
Stt1lJCl'J 11111y nJ.ra bt employed. T/Je 1111thors rtrm s/Jo11ld hnJ>c restl'irtions Ml sweetened dri11ks nr
nnd n1cigl1r mere n/so positive(v cm-re/n.tcd to boue
the importmJCc oj'i11v11Lvi11g thcf11111ily to Cl'enrc
st11t11s. /Jome n11rf n.t school, 1111d sho11ld be c1uot1rnJ1clf t11
n supporrii•e ,;m>ii'o1111w1t ns pnrt of the m•crnl/ drink mu1·e n>ntcr.
5. Bune N ;md od1ers: T he Scarr Healthy Feeding thrmpc11tic n.ppnmch.
Guidelines for Infants and Toddlers. ]ottmnl of 17. Patrick H, Nicklas TA: A review of family and
11 . Klcinmam RE (ed. ): Pedintric 1mtritio11 hand-
the Americm1 Dier.etic Ass11cin.tio11 104:142, social dererminams of chi ldren's eating patterns
2004.
brJok. Chicago, IL: Amcri(an Acade my o r
and diet qualiry. Jo11n111I of tbe A1110-im11
Pediatrics, 2004.
Co111prd11..,aiPc guide to tlJc wlJnt, 111lm1, 1111d College of N11tricio11 24(2):83, 2005.
how of i11fn11t nnd toddler feeding. A colo1jiil TI1is book is n comprdmisivc ,.•,,;.;.,,. of im1,;;· s-tw- l'/~1·sic11/ e1111i1'011111mt lms 1i big i11fl11c11cc 11J1 tb1:
nud i11fim1111riveg11irfr tot/Jc timing offeeding rrnmding pediatrir 11 urritio11. T71is n:fcre11u wns qunli(Y of the diets of childre11 ns does r/1c i11fl11·
sllills rmd solid food i11n·od11ctio11 is i11cl11rlcd. fi'cquently c1msultcd i11 t/Jc 1·c11isir111 rf this cl111pte1: wee of r/Je pn.re11ts. Th improve the diets uf chil-
Tbcgcmralg11ideli11c is to i11tr11d11ce solid foods 12. Kli ne DA: Food ~llcrgy ~i·mproms and causes. dren, 111n11y pnrnmacrs 1mut be ndd1·esscd: child.
to i1(ft111 rs n t 6 months ofage. Today's Dictitia11. p. I 0, August 2005. parents, school, n.11d cm11m11nity.
18. Rajeshwari Rand others: Longirudinal changes 19. Strong W'B and ochers: Evidence-based physical 20. Yoo S and orhcrs: Comparison of dietary in·
in intake and food sources of calcium from accivity for school-age youth. joumnl of cakes associated with metabolic syndrome risk
childhood co young adu lthood: The Bogalusa PcdiMrics 146:732, 1995. fucrors in young adults: The Bogalusa Heart
Heart Snidy. J1mr1111l ofthe A111ericrm College of Srudy. American ]01muil of Clinical Nntritio11
N11tntio11 23(4):341, 2005. 171c rmr/Jors conclude that school-age children 80:841, 2004.
Mnny cbildrm nrc not mecti11g their m lcimn should pnrticipare in nt lcri.<r 60 minutes of de-
needs. Despite n.gmdmrl i11crcasc i11 c11&1JJ.V in- Pel1ip111c11tafly approp1·iatc, modemte-to-vig111·011.r Low fruit n11d 11egeta/;le intake and /Jigh sweet·
tnkc ns children age, cnlcittm intake does not physical ncth>ity c11cry da_r. Tbis 11ctivit)• would rned beverage co11s11111ption n•erc a.<socinti:rl 11'ith
generally incrcfl!e nppreciab~)'. 01•cml~ a lead to bemr weight co11trol, loJVer blood prcs- the metnbolic syr1d1·0111e in this study. Low-JM
gn:awfoc1u on calcium -ricb food choice needs sm·e, a11d imp1·01icd 11111sc1ilar health rmd a&1•0- milk nnd milk producrs were found to be
to be made in tbis age group. bic fitness. protecti11e.
Take I Action
I. Getting Young Bill to Eat

Bill is 3 years old, and his mother is worried about his eating habits. He absolutely refuses to eat
vegetables, meat, and dinner in general. Some days he eats very little food. He wonts lo eat
snacks most of the lime. His mother wonts him to eat a sit.down lunch ond dinner to make sure
he gets oll lhe nutrients he needs. Mealtime is a bottle because Bill soys he isn't hungry, bul his
mother won ts him to eat everything served on his plate. He drinks five or six glasses of whole
milk per day because that is the one food he likes.
When his molher prepares dinner, she makes plenty of vegetables, boiling them until they are
soft, hoping this will appeal to Bill. Bill's dad wails to eat his vegetables last, regularly telling the
family that he eats lhem only because he has to. He also regularly complains oboul how dinner
has been prepared. Bill saves his vegetables until lost and usually gags when his mother orders
him to eat them. Bill hos been known to sit ot lhe dinner table for an hour until lhe wor of wills
ends. Bill's mother serves casseroles and slews regularly because they ore convenient. Bill likes lo
eat breakfast cereal, fruit, and cheese and regularly requests these foods for snacks. However,
his molher tries to deny his requests so lhat he will have an appetite for dinner. Bill's mother
comes to you and asks you what she should do to gel Bill to eat.
Analysis
l . list four mistakes Bill's porenls ore making thal contribute to Bill's poor eating habits.
2. list four strategies they might try lo promote good eating habits for Bill.
...
Take I Action
II. Evaluating a Teen Lunch

The following ore lwo typical teen lunches and nutritional information for each:
Meol 1 Meol 2
Cheese pizza, 2 pieces Lorge hamburger sandwich with condiments, 1 large
Milk chocolate candy bar, 1 French fries, 30
Colo, 20 oz Colo, 20 oz
Meol 1 Meal 2 Nutrient Needs for Teens

Energy (kcal) 990 1000 Moles: 3000
Females: 2200
Protein 32 20 Moles: 59
Females: 44
Vitamin C (mg) 5 18 Both genders: 45 to 75
Vitamin A (µg RAE) 300 10 Moles: 900
Females: 700
Iron (mg) 3 4 Moles: 11
Females: 15
Calcium (mg) 545 100 Both genders: 1300
1. Keeping in mind that meals should meet about one-third of nutrient needs, what ore the shortcomings and excesses of these meals
(i.e., given the nutritional information, compare these meals with one-third the RDA for protein, vitamin C, vitamin A, and iron and
the Adequate Intake for calcium)?
2. How would you change these meals to improve balance and to meet the nulrienl needs above? {Hinl: Use your NulrilionColc Plus
software program or Appendix N.)
-
3. Reflect on your food choices as a teenager. Do you think your meal choices were balanced and varied? Why or why not? What
could you hove done to improve your nutritional habits at that time?
f ff
r...!....:::=-==----=;=,._,_.,-:....=-_.:.:=-,-~,--=--7,--==-..:::,:~~~~~~~~~~__:::::::~~~
NUTRITION DURING ADULTHOOD
~
CHAPTER OUTLINE
Nutrition and Adulthood: An Introduction
CASE SCENARIO:
Frances is a 78-yeor-old woman who suffers from moculor degeneration, osteoporcr =
""
Compression of Morbidity
A Diet for the Adult Years
sis, and arthritis. Since her husband died a year ago, she has moved from their fam- ~
A Closer look at Middle and Older Adulthood
ily house to o smoll one-bedroom apartment. Her eyesight is progressively getting z
c
life Span • life Expectancy • The Graying of worse, making it hard to go to the grocery store or even to cook (for fear of burning -I
;;:o
North America • The Definition of Aging herseln . She is often lonely; her only son lives 1 hour away ond works two jobs, but =l
Nutritional Implications of Aging
Decreased Appetite and Food Intake • Decline
he visits her as often os he con. Frances hos lost her appetite ond, as a result, often 0
in Dental Health • Reduced Thirst Sensation • skips meals during the week. She has resorted to eating mostly cold foods, which ore
z
.,,.,,
Foll in Gastrointestinal Tract Function • )>
simple to prepare but are seriously limiting variety and polatobility in her diet. She is
Changes in Liver, Go/lb/odder, and Pancreatic
r-
Function • Decline in Kidney Function • slowly losing weight as a result of her dietary changes and loss of appetite. ()
Reduced Immune Function • Reduced Lung
Function • Reduced Hearing and Vision • Her typical diet usually consists of a breakfast that may include l slice of wheat
~
Decrease in Leon Tissue • Increases in Fat toast with margarine, honey, and cinnamon, and 1 cup of hot tea. If she has lunch, 0
Stores • Reduced Cardiovascular Health •
Decline in Bone Health she normally has l /2 can of peaches, half of a turkey and cheese sandwich, and z
(/)
l /2 glass of water. For dinner, she might have half of a tuna fish sandwich mode
Other Factors That Influence Nutrient Needs in
Aging with mayonnaise and 1 cup of iced tea. She usually includes one or two cookies at
z
-I
Depression in Older Adults • Alcoholism in I
Older Adults • Alzheimer's Disease bedtime. m
Nutrition Focus: Complementary and Alternative What ore the potential consequences of such a poor dietary pattern? What ser- c
11
Medicine Practices vices ore available that could help Frances improve her diet and possibly increase
m
()
Nutrient Needs and Dietary Planning in Middle
ond Older Adulthood
her appetite? What other convenience foods could be included in her diet lo make it -<
()
more healthful and more varied? r-
Expert Opinion: Nutrition ond Healthy Aging m
Community Nutrition Services for Older Adults
Toke Action
E ating is one of our great pleasures. Guided by common sense and moderation, eating well is also
a means to good health. Most of us want a long, productive life, free of illness, yet many people
from early middle age onward suffer from obesity, cardiovascular disease, hypertension and strokes, type
2 diabetes, osteoporosis, and other chronic diseases. 1 We can slow the development of, and in some
cases even prevent, these diseases by consuming a diet that works against them. The effect of such o diet
is most profitable if we begin early and continue throughout adulthood. We serve ourselves best-as in-
dividuals and as a nation-by striving to maintain vitality even in the later decodes of life. This concept
was first explored in Chapter l and is discussed again in this
chapter, along with the special nutrition needs of older persons.
Keep in mind that present day-to-day health practices con sig-
nificantly influence health during later life. Although genetics TO ALLOW YOU TO: r
does ploy a role, as discussed in Chapter 1, many of the health 1. Identify how the basic concepts that underlie the 2005 Dietary
problems that occur with age ore not inevitable; they result from
Guidelines for Americans relate to adult health.
2. List possible causes of aging.
diet-related disease processes that influence physical health.
3. Explain how aging affects nutritional status.
Much can be learned from healthy older people whose attention
4. list the potential benefits and risks associated with the use of
lo a healthy diet and physical activity-along with a little luck-
keeps them active and vibrant well beyond typical retirement
various complementary and alternative medicine practices. -·
5. Discuss how nutrient needs change as individuals get older.
yeors. 15, 18 Successful aging is the goal. Age quickly or slowly-
6. Make recommendations for dietary changes in the prevention
it is portly your choice. and treatment of nutritional problems in older adults.
7. Describe community nutrition services for older persons.

STUDY OF ADULT NUTRITION ISSUES IN CHAPTER 18,
YOU MAY WANT TO REVIEW:
The effect of genetics on health in Chapter 1.
Implications of the 1994 Dietary Supplement Health and Education Act in Chapter 1.
The various body systems in Chapter 3 and Appendix C.
The sources of fiber in Chapter 5.
Guidelines for alcohol intake in Chapter 8.
The dietary sources of vitamin D, the various B-vitamins, and calcium in Chapters 9, 10, and 11, respectively.
Definition of healthy body weight in Chapter 13.
The benefits of regular physical activity In Chapter 14.
esides having other long-lived fami ly Nutrition and Adulthood : An Introduction

B members, people who live to 100 years
generally: Health-conscious adu lts in North America today are typically doing what is within
• Do not smoke or do not drink heavily their control to achieve a healthy lifestyle, such as consuming a healthful diet, main -
• Gain little weight in adulthood taining a healthy body weight, and following a regimen of regular physical activity.
• Eat many fruits and vegetables Coupled with avoidance of tobacco products; limitation of or adaptation to stress; ad-
• Perform daily physical activity equate sleep; adequate fluid intake; maintaining friendships and optimism; lifelong
• Challenge their minds learning; keeping blood cholesterol, blood glucose, and blood pressure under control;
• Have a positive outlook and consultation with health-care professionals on a regular basis, these actions con-
• Maintain close friendships tribute t0 a healthful, long life. 15 Overall, the key ro maximizing health throughout life
• Are (or were) married (especially true is for people to establish harmony among their physical, mental, psychological , and so-
for men) cial states (see Part 1 in the Take Action section at the end of this chapter).
• Have blood lipoproteins with a large Based on the needs for various nutrients set by the Food and Nutrition Board, the
particle size adult years can be divided into four stages: ages 19 to 30, 31 to 50, 51 to 70, and
658
beyond 70 years of age. The two intervals encompassing ages 19 through 50 are young
adulthood; 51 to 70 is middle adulthood; and beyond 70 years of age is older adult-
hood. Some examples of the dynamic in the nutrition needs of aging are:
• Calcimn. Needs for this bone-related mineral increase after age 50 for males and fe-
males to help counter the harmfol effects of accelerated bone loss.
• Vitamin B-12. People over the age of 50 should consume foods fortified with vita-
min B-12 or take a balanced multivitamin and mineral supplement containing vita-
min B-12. Recall from Chapter 10 that about 10 tO 30% of older people may have
decreased absorption of food-bound vitamin B-12 in part because of reduced acid
production by the stomach.
• Vitamin D. Compared to the amount of vitamin D needed by individuals of ages
19 to 50, needs increase by 50% for the 51 to 70 age group. Adulrs over age 70
need three times more vitamin D than they did when they were ages 19 to 50.
Attention to these differing needs for vitamin D is especially important for people
who do not receive regular sun exposure, such as those residing the wiJ1ter months
in the northern Unfred States or Canada. Experts recommend that these older
adults be checked yearly for vitamin D status (i.e., be measured for 25 -0H vitamin
D in the blood). As we age, our nutrient needs change. For
Overall, attention to healthy nutrition and lifestyle habits is important at all ages. 1 example, vitamin D needs ore higher for
persons in older stages of adulthood.
Providing dietary advice for adults ages 19 to 50 years is the focus of the beginniJ1g of
Chapter 18; the chapter will then look at additional recommendations for adu lts 51
and older.
Compression of Morbidity
Although most of us wish for long Life, we do not Like the thought of failing health in
old age. And tightly so! Rather than suffer the ravages of cardiovascular disease, obe-
sity, diabetes, osteoporosis, and other chronic diseases from age 40 to 60 years until
deatl1, we should strive to be as free of disease as possible and enjoy vitality through-
out even our last decade. 15 Life expectancy is at a record high of about 77 years for life expectancy The average length of life for a
the general population in North America today, although the span of healthy life is given group of people (usually determined by
only about 65 years. Thus, an important focus here is nor necessariJy on living longer the year of birth).
but on living healthier. compression of morbidity The delay of the
Striving to have the greatest number of healthy years and the fewest years of illness onset of disabilities caused by chronic disease.
is often referred to as com pression of morbidity. [n otl1er words, a person tries to
compress significant sickness related to aging into the last few years- or montl1s-of
life. An ex:i.mple of this concept is illustrated for cardiovascular disease in Figure 18-1.
Of the three lines shown, the Line on the top depicts rapid deterioration in health;
symptoms of cardiovascular disease appear by about age 40, and deatl1 occms at about
age 60. In addition, between the ages of 40 and 60 years, symptoms of the disease, and
therefore disability, are present.
A healthier lifestyle follows the middle line in Figure 18-1. Here, cardiovascular dis- eep in mind that extending life without de-
ease is postponed so that tl1e first symptoms are not apparent until age 60; severe
symptoms occur at age 80, witl1 death following a few years later_ The Line on the bot-
K laying onset of chronic disease prolongs
suffering in many cases. In addition, the greater
rom is ideal. Disease progresses so slowly that symptoms do not appear during a per- number of disabled years is very costly to all
son's lifetime; therefore, tl1e disease process never hampers activities. North Americans. For these reasons, prolonging
Body cells age no matter what health practices we follow. However, to a consider- life without compressing the number of disabled
able extent, you can choose how quickly you age throughout your adult years. In light years is called the "failure of success."
of the many studies showing the ability even to reverse atherosclerosis, we can say tl1at
the rate at which you age is partly your choice. 1
Altl1ough there is little doubt of the benefits of a healthy lifestyle, scientists have also
found a strong genetic component to longevity as well as to certain diseases (review
Chapter l ). Studies of families, and of twins in parricu lar, provide some support for a
genetic contribution to human longevity.
660 Chapter 18 Nutrition during Aduhhood
Figure 1 8-1 I Compression of morbidity. Death (fatal

The goal is to postpone illness until the final heart attack)
days of life. Cardiovascular disease is used as
on example. The line on the top shows rapid
deterioration in health status, in which More severe symptoms
symptoms of cardiovascular disease appear by (mild heart attack)
about age 40 and death occurs at about age
60. In addition, between the ages of 40 and
Symptoms (angina - Threshold
60 years, symptoms of cardiovascular sharp pain in heart
disease-and therefore disability- are present. during exercise) Postponed
A healthier lifestyle follows the middle line
pattern. Here, cardiovascular disease is Developing disease
postponed, so that the first symptoms are not (cholesterol plaque
apparent until age 60; severe symptoms occur buildup)
at age 80, with death following a few years
later. The line on the bottom is the ideal: the
disease progresses so slowly that symptoms do
not appear during th e lifetime; therefore, the 20 40 60 80
disease process never hampers life's activities. Age (years)
A Diet for the Adult Years

Long-term nutritional health in adu lthood is best achieved by following a health)' diet.
One blueprint for a healthy diet comes from the 2005 Dietary G11idcli11cs for
Atncricans, discussed in Chapter 2. Its advice refers to people age 2 years and older and
can be summarized into three main points.
1. Consume a variety of nutrient-dense foods and beverages within and among the
basic food groups of My'Pyramid, while choosing foods that limit the intake of sat-
urated and trans fats, cholesterol, added sugars, salt, and alcohol (if used ). Foods
to emphasize are vegetables, fruits, legumes (beans), whole-grain breads and cere-
als, and fat-free or low-fat milk. or equivalent mi lk products.
2 . Maintain body weight in a healthy range by balancing energy intake from foods
and beverages with energy expended. For the latter, engage in at least 30 minutes
of moderate-intensity physical activity, above usual activity, at work or home on
most days of the week.
3. Practice safe food handling when preparing food. C lean hands, food contact sur-
faces, and fruits and vegetables before preparation, and cook foods to a safe tem-
perature to kill microorganisms_
You may wonder if, in general, adults in North America are trying to follow many
of these recommendations. Since the mid-1950s, they have consumed less saturated far
as mo re people substitute fat-free and low-fat milk for cream and whole milk. They eat
more cheese, however, which is usually a concentrated for m of saturated fat. Since:
1963, they have eaten less butter, fewer eggs, less animal fat, and more vegetable oils
and fish. These changes generally follow the recommendations to reduce the intake of
saturated fat and cholesterol i.n favor of unsan1rated fat choices. Today, animal breed-
ers are raising much leaner cattle and hogs than tl1ose produced in 1950, which also
helps reduce saturated fat intake.
Many adults find that regular physical activity
Other aspects of the average adult diet arc less promising. The latest nutrition sur-
odds on important dimension to their lives. Men
vey of eating habits in the United States shows that the major contributors to energy
over 40 and women over 50 years of age
should obtain physician approval before
intake for the average adult diet are sugared soH: drinks, white bread, beef, doughnuts,
beginning a program of vigorous physical cakes and cookies, whole milk, chicken, cheese, alcoboJjc beverages, salad dressing,
activity. This is especially important for people mayonnaise, potatoes, and sugars/syrups/jams. If tl1c trend in diets were truly toward
with evidence of cardiovosculor disease, decreasing sugar and samratcd fat intake and increasing fiber intake, many of these
hypertension, or diabetes. foods would not appear at the top of tl1e list.
The overriding consideration should be quality and lengrh of life and the impact that ppendix D reviews diet planning guide·
dietary changes might have on them. IS,IH,20 Adu lts in general should learn more about
risk factors for chronic diseases and do something about each one, when possible. 1
A lines issued by the Canadian government
for Canadians. In addition, Chapter 1 discussed
Healthy People 2010, o U.S. federal agenda
aimed at disease prevention and health
Concept I Check
promotion.
A basic plan co promote health and prevem disease includes eating a healthy diet. More
specifically, the 2005 Dietary Gi~idclincs for Americans directs people co cat a variety of
foods; maintain healchy weight; choose a diet low in saturatctl fa1 and cholesterol and trans
far; choose a diet with plenty of vegetables, fruits, legumes (beans), .rnd whole-grain prod-
ucts; use sugars and salt sparingly; and drink little or no alcohol.
A Closer Look at Middle and Older Adulthood

How long do your family members generally live? Of those who died early in adult-
hood, can you pinpoint some causes? Do you plan to live longer chan your parents did
or will? How long "ill that be? Some basic statistics can help you predict this.
Life Span
L ife s pan refers to the maximum number of years a human can live. As far as we know, life span The potential oldest age a person con
life span hasn't changed in recorded time. The longest human life documented to date reach.
is 122 years for a woman and 114 years for a man. Genes play a kC)' role in determin-
ing longevity, but environment is also important. Note also by comparison that the do-
mestic dog has a life span of 20 years; a rat, 5 years.
Life Expectancy
life expectancy The overage length of life for a
Life expectancy is rhc Lime an average person born in a specific year, such as 2005, can
given group of people (usually determined by
expect to live. Currently, life expectancy in North America is about 75 years for men the year of birth.
and about 80 year!> for women, with a span of "healLhy years" of about 64.
Furthermore, if you survive to the age of 80, you can tack on another 7 to l 0 years of
life expectancy.
Life expectancy hasn't always been this long; for primitive humans, it was about 20
ro 35 years. It increased to 40 years in Medieval England and increased to 49 years by
the turn of the twentieth century. During the last 80 years, life expectancy for nearly
all people has increased, mainly because of changes in the principal causes of death.
fn the early 1900s, infectious diseases were the first three causes of death. Vaccines
and antibiotics have tremendously lowered the rate of death from these causes. The de- orldwide, the highest overage life ex-
cline in infant and childhood deaths, coupled v.Tith better <liets and health care, has al- pectancy is in Japan, 82 years for
lowed more people to age first into maturity and then into older years. Now the women and 76 years for men, especially on the
principal causes of death in Western societies arc related to cardiovascular diseases and island of Okinawa. Researchers suggest that
cancer diseases that typically surface in middle age (review Table 1-1 ). their traditional Okinawan diet based on rice,
Historically, the trend in the United States, Canada, and other developed nations fish, vegetable protein sources, fruits, vegetables,
has been toward an ever older population. For example, during Colonial times, half the tea, herbs for seasonings, and small amounts of
U.S. population was over 16 years of age. By 1990, half were over 33. By 2050, half meat, as well as a generally low energy intake
the U.S. population cou ld be over 43, and approximately 20% wi ll be 65 years and (BMI remains "" 21), contributes to this record
older, twice as many as reach 65 today. This age-65 years- is arbitrarily listed as a di- longevity. Alcohol and salt intake is also
viding line for the beginning oflater life because at this age a person can currently qual- minimal.
il)• for full Social Security benefits in the United States. The time at which old age
occurs, howe\:er, var\cs for each person according to health and independence.
Among the older population, the group constituting those age 85 years and over is the
fustcsr growing segment. Between 1997 and 2050, the number of people age 85 years and
over in the United States is expected to increase from 3.4 million to 19 miUion. This is
662 Chapter 18 Nutrition duri ng Adulthood
the first time in history that North America and other Western nations will need to ac-
corn modate such a large population of older people. The associated expense will be
enormous if a large perccntag<.; need special care because of ill health. Even more amaz-
ing, 1 million or more people in the United States alone could be over 100 years old
in 2050.
The Graying of North America

This "graying" of North America poses some problems. Today, although people older
than age 65 account for 13% of the U.S. population, they account for more than 25%
of all prescription medications used, 40% of acute ca1·e hospital stays, and 50% of the
federal health budget. Hip fractmes alone cost the nation about $12 billion per year.
(Note that regular physical activity reduces such risk.) Of older persons, 65% or more
have nutrition-related problems such as cardiovascu lar disease, type 2 diabetes, hyper-
tension , and osteoporosis.
Postponing these chronic diseases for as long as possible will help people control
health-care costs. The more independent, healthy years people live, the better life can
be for them and the less they bmden the health-care system, which will be increasingly
burdened by a growing elderly population . Keep in mind that aging is not a disease.
Of all North Americans who hove lived to age Furthermore, diseases that commonly accompany old age-osteoporosis and athero-
65, more than half ore now olive.
sclerosis, for example-are not an inevitable part of aging. Many can be prevented or
managed. Some people do die of old age, not as a direct result of disease.
The Definition of Aging

One view of aging describes it as processes of slow cell death , beginning soon after fer-
tilization. When we are young, aging is not apparent because the major metabolic ac-
tivities are geared toward growth and maturation. We produce plenty of active cells tO
meet physiological needs. Dming late adolescence and adulthood, the body's major
task is to maintain cells. Inevitably, though, cells age and die. Eventually, as more cells
die, the body can't adjust to meet alJ physiological demands, and body functioning be-
reserve capacity The exlenl lo which on organ gins to decrease (Figure 18-2). Still, organs usually retain enough reserve capacity
con preserve essentially normal function despite that, for a long time, the body shows no outward disease. Although no symptoms ap-
decreasing cell number or cell activity. pear, subclinical disease may develop, and if the disease is allowed to progress
unchecked, organ function and then body function eventually deteriorate noticeably.
The aging process is clearly ill ustrated by changes for many people in the function
of the enzyme lactase. For some people, lactase activity in the small intestine slows dur-
-;:-
cQI 100 Nerve velocity conduction
u
a;.
QI
-~a. 90
'i:i
&.
0
80
u
en
c 70
·c:
·c;
Cardiac output
e
QI
60
a;.
QI
Vital capacity
en of lungs
e
QI
50
Maximum breathing capacity
Figure 1 8·2 I Declines in physiological
function seen with aging. The decline in many
~
30 40 50 60 70 80 90
body functions is especially evident in
sedentary people. Age (years)
ing childhood. Generally, however, clear symptoms of this decl ine- gas and bloating
after milk consumption-do not appear until adulthood. Although lactase output de- I '1'hink=-t'
creases in these cases, perhaps from birth, enough enzyme is present to digest the lac- The "fountain of youth" remains a mystery.
tose consumed until adulthood . Many people believe a source exists that can
Cells age probably because of automatic cellular changes and environmentaJ influ - stop the aging process, allowing youth to re-
ences. Even in the most supportive of environments, cell structure and function in- main. However, Neil, a history student, asserts
evitably change with time. Eventually, cells lose their ability to regenerate the internal that the fountain of youth is not a place or a
parts they need, and they die. This inevitable dying off of deteriorating cells is actually particular thing but, rather, a combination of
beneficial; researchers have concluded that it likely prevents diseases such as cancer. diet and lifestyle. How can he justify this
Unfortunately, there are negative consequences to this natural cell progression, be- claim?
cause as more and more cells in an organ system die, organ function decreases. For ex-
ample, kidney nephrons are continually lost as we age. In some people, this loss leads
to eventual kidney failure, but most of us maintain sufficient kidney cells to allow the
organ to function throughout life. Again, in aging, there is first a reduction in reserve
capacity. OnJy after the reserve capacity is exhausted does actual organ fLmction no-
ticeably decrease.
The causes of aging are still a mystery. Most likely, the physiological changes of
aging arc the sum of nauiral processes, as listed in Table 18-1, a11d lifostyle prac-
tices. 8,1O,l5,16,18,19,20
Adopting diet and lifestyle practices that minimize a decline in body function in the
adult years is an investment in your futw·e health. 1 You can obtain a free fact sheet kidney nephrons The units of kidney cells that
from the website for the NationaJ Institute on Aging at " '" '''' 111a nih.gm· or by call- filter wastes from the bloodstream and deposit
ing (800) 222-2225. The first Take Action activity in this chapter outlines a compre- them into the urine.
hensive approach to healthful aging.
Concept I Check
Although life span has not changed, life expectancy has increased dramatically over the past
century. Ao increasing proportion of the North American population is over 65 years of
age and will live for decades longer. Avoiding continually rising health-care costs and maxi-
1ni7ing satisfaction with life require postponing ru1d minimizing chronic illness. Aging be-
gins early in life and probably rcsnlrs from botJ1 automatic cellular changes and
environment:tl influences. A healtJ1y diet can play a role in slowing such processes.
Nutritional Implications of Aging

There is more variation in health status among adults over age 50 than in any other
age group. This means that chronologicaJ age is not useful in predicting physical health
status (physiological age). Among people age 70 and over, some are totaJly indepen-
dent, healthy people, whereas others are frail and require almost totaJ cru·e. To predict
tJ1e nutritional problems of an older person, it is necessary to know the extent of phys-
iological change caused by aging and whether the person shows early warning signs for
long-term poor nutrition. As you exam.inc how aging affects body systems and how
these changes contribute to nutritional health, note the suggested ways to lessen health
risks (Table 18-2 ).
Decreased Appetite and Food Intake harmaceutical companies hove begun to

market liquid meal-replacement formulas to
Decreases in body weight arc common in adu lts age 70 ru1d older who may not eat older adults. Previously, these products were pri·
enough to meet energy needs. This phenomenon is a problem for older people in par- marily used in hospitals and nursing homes.
ticular because it increases tht: risk of nutrition-related ill ness.9 Many of these products have an unusual taste
Many cau.ses of inadequate food intake in older people are possible. Researchers because of the vitamins and types of proteins
suggest that biological origins, such as changes in neuroendocrine facrors that influ- that have been added. Older adults can decide
ence feeding, account for some of this decl ine (review Chapter 13 for a list of these fac- if the convenience, cost, and taste make this a
tors). When older men are underfed in experiments, they do not later increase food wise diet choice.
664 Chapter 18 Nutrition during Adulthood
E ven very healthy people have a shortened

life expectancy if they are exposed to suffi·
cient environmental stress, such as radiation and
Table 18·1 I Current Hypotheses about the Causes of Aging
Errors occur in copying the genetic blueprint (DNA).

certain chemical agents (e.g., industrial sol-
Once sufficient errors in DNA copying accumulate, a cell can no longer synthesize the major
vents). Because cell aging and diseases such as proteins needed to function, and it therefore dies. Damage lo DNA in the mitochondria also
cancer are aggravated by environmental factors, contributes to the aging process.
it makes good sense to avoid such risks as ex·
Connective tissue stiffens.
cessive sunlight exposure and hazardous
chemicals. Parallel protein strands, found mostly in connective tissue, cross-link to each other. This decreases
flexibility in key body components.
Electron-seeking compounds damage cell parts.

Electron-seeking free radicals can break down cell membranes and proteins. The small amount of
DNA in mitochondria typically shows this type of damage, and this damage is linked to the aging
process. One way to prevent this free radical damage throughout the body is lo consume adequate
amounts of vitamin E, selenium, and carotenoids.
Hormone function changes.

The blood concentration of many hormones, such as testosterone in men, falls during the aging
Alexis has read several books supporting the process. Replacement of this and other hormones is possible, but the resulting risks and benefits are
idea that reducing one's lypical energy intake largely unknown.
by 30%con significantly extend one's life.
Glycosylation of proteins.
Because she wants to do what is best For her
two preschool children, she is thinking about Blood glucose, when chronically elevated, attaches to (glycates) various blood and body proteins.
adjusting lier family's dietary habits to match This action decreases protein function and can encourage immune system attack on such altered
proteins.
this calorie restriction. What should you discuss
with Alexis before she proceeds? The immune system loses some efficiency.
The immune system is most efficient during childhood and young adulthood, but with advancing
age it is less able to recognize and counteract foreign substances, such as viruses, that enter the
body. Nutrient deficiencies, particularly of protein, vitamin E, vitamin B-6, and zinc, also hamper
glycosylation The process by which glucose immune function.
attaches to (glycates) other compounds, such as
proteins. Autoimmunity develops.
Autoimmune reactions occur when white blood cells and other immune system components begin to
attack body tissues in addition to foreign proteins. Many diseases, including some forms of arthritis,
involve this autoimmune response.
Death is programmed into the cell.

Each human cell can divide only about 50 times. Once this total number of divisions occurs, the
cell automatically succumbs.
Excess energy intake speeds body breakdown.

Underfed animals, such os spiders, mice, and rats, live longer. Usual energy intake must be
reduced by about 30% to see this effect. Currently this approach is the only proven way to
substantially slow the aging process.
intake ro compensate for reduced food consumption when given the opportunity.
Changes in taste and smell may also be important, as are the effects of current med·
ication use. Io addition, social aspects play a role in reduced food intake. Many older
people Live alone, a circumstance that is associated with less food consumption.
A doily serving of a whole.groin breakfast
To maintain health, older adults need to address the issue of declining weight.
cereal provides a rich source of vitamins, Significant weight loss in o lder people, sometimes termed the "dwindles," increases
minerals, and fiber and so contributes to risk of death. It may also indicate ongoing iilness and reduced tolerance to medication
healthy aging. or simple withdrawal from liJe itself.5 •13 Even in apparently healthy older individuals,
Table 18· 2 I Typical Physiological Changes of Aging and Recommended Diet and Lifestyle Responses
Physiological Changes Recommended Responses Physiological Changes Recommended Responses
Appetite • Monitor weight and strive to eat enough to Vision • Regularly consume sources of carotenoids,
<!> maintain healthy weight. <!> vitamin C, vitamin E, and zinc (e.g., fruits,
• Use meal replacement products, such as vegetables and whole-grain breads and
Boost and Ensure Plus. cereals).
• Moderate total fat intake.
Sense of taste and smell • Vary the diet.
• Wear sunglasses in sunny conditions.
<!> • Experiment with herbs and spices.
• Avoid tobacco products.
Chewing ability • Work wi th a dentist to maximize chewing • Perform regular physical activity (to lessen
© ability. insulin resistance).
• Modify food consistency as necessary. • In the case of diagnosed moderate
• Eat energy-rich snacks. mocular degeneration, talk with a
physician about following a protocol of
Sense of thirst • Consume plenty of fluid each day.
zinc, copper, vitamin E, vitamin C, and
© • Stay alert for evidence of dehydration
beta-carotene supplementation.
(e.g., minimal output or dark-colored
urine) . lean tissue • Meet nutrient needs, especially protein
Note that dehydration con lead lo many <!> and vitamin D.
problems, especially in older adults. • Perform regular physical activity, including
strength training.
Bowel function • Consume enough fiber daily, choosing
© primarily fruits, vegetables, and whole- Cardiovascular function • Use diet modifications or physician-
grain breads and cereals. <!> prescribed medications to keep blood
• Meet fluid needs. lipids and blood pressure within desirable
ranges.
lactose production • Limit milk serving size at each use.
• Stay physically active.
© • Substitute yogurt or cheese for milk.
• Achieve and maintain a healthy body
• Use reduced·loctose or lactose-free
weight.
products.
• Seek nondairy calcium sources. Bone mass • Meet nutri ent needs, especially calcium
<!> and vitamin D (regular sun exposure helps
Iron status • Include some lean meat and iron-fortified
meet needs for vitamin D).
© foods in the diet.
• Perform regular physical activity,
• Ask physician lo monitor blood iron status.
especially weight-bearing exercise.
Liver function • Consume alcohol in moderation, if at all. • Women should consider use of approved
<!> • Avoid consuming excess vitamin A. osteoporosis medications at menopause.
• Remain at a healthy weight (especially
Insulin function • Maintain healthy body weight. avoid unneeded weight loss) .
<!> • Perform regular physical activity.
• Limit high glycemic load carbohydrates. Mental function • Meet nutrient needs, especially for vitamin
<!> E, vitamin C, vitamin B-6, folate, and
Kidney function • If necessary, work with physician and vitamin B-12.
<!> registered dietitian to modify protein and • Strive for lifelong learning.
other nutrients in diet. • Perform regular physical activity.
Immune function • Meet nutrient needs, especially protein, • Obtain adequate sleep.
© vitamin E, vitamin B-6, and zinc. Fat stores • Avoid overeating.
• Perform regular physical activity. © • Perform regular physical activity.
lung function • Avoid tobacco products.
<!> • Perform regular physical activity.
Registered dietitians, physicians, and pharmacists con help with any needed adjustments arising from these problems.
successful weight maintenance may requfre an increased conscious control over food
intake, compared to yOLmger individuals. Adding more spices to food may also stimu-
late food intake. Consuming energy-dense sn acks, such as cheese, nuts, yogmt, oat-
meal cookies, and bananas, between meals is also a strategy. vVhen assessing weight in
older people, compare present '''eight with the previous year's weight.
Decline in Dental Health

About 30% or more older people in North America have lost all their teeth. Attention to
dental hygiene aod dental c;u·e throughout Life greatly lessens this risk. Periodontal (gum)
disease common ly causes tooth Joss. Replacement dentures enable some people to chew
normally, but many older adults--cspccially men-have denture problems. Solving indi·
vidual dietary needs requfres identifying foods that need to be modified in consisrerK)'.9
When people have problems chewing, nutrient-dense snacks can help. Sometimes just al·
lowing extra time for chewing and swallowing encourages more eating.
Reduced Thirst Sensation

Older aduJrs often partially lose their sense of thirst and in turn don't drink enough
fluids. They arc then more likely to become dehydrated, a condition that leads to con·
fi.rsion and sometimes hospitalization.9 In addition, 25% of fluid comes from food. If
older adul ts are not eating enough food, they increase the risk of becoming dehy·
drated. It is important for older people to consume enough fluids, :rnd if necessary,
they should be monitored to ensure they do so. 1 About 9 cups (women) to 13 cups
(men) of fluid daily is a good goal. This amOlrnt must be adjusted if diuretics are used
or in certain other medical conditions, such as the presence of an ostomy. Some im-
Age is no reason not to continue whatever
portant signs of dehydration, other than confusion, include dry lips, sunken eyes, in-
physical activity is possible. Physical activity
creased body temperature, decreased blood pressure, constipation, decreased urine
con tributes to many aspects of good health,
including improved functioning of the GI tract.
output, and nausea.
Fall in Gastrointestinal Tract Function

ostomy A surgically created short circuit in
intestinal Row where the end point usually The main intestinal problem for older people is constipation (review Chapter 3 for a re·
opens from the abdominal cavity rather than view of this problem). To keep the intestinal tract performing efficiently, older people
the onus, for example, a colostomy. should meet fiber needs. The goal for adults over 50 years is 21 g/day for women and
30 g/day for men, unless a physician recommends ot!1erwise. The regu lar consumption
of nuts, fruits, vegetables, beans, and whole-grain breads and cereals provides enough
fiber. Fiber medications are generally lllmecessary but may be used if overall energy in·
take does not allow for enough fiber iotal-.e. Older persons should also drink more fluid
to move along masses that could form from high fiber intake. 1 Physical activity likewise
helps promote peristalsis. Because some medications can induce constipation, a physi-
cian should be consulted if constipation might be related to a medication. If mineral oiJ
is taken as a laxative, it should always be used with caution-and not at mealtimes- be-
cause it binds fat-soluble vitamins and limits their absorption.
ncontinence, the inability to control the muscle Lactase production frequently decreases wit!1 age. Chapter 5 listed several options
responsible for retaining urine, affects up to for people with lactose malabsorption and intolerance.
20% of older adults living at home and about The stomach slows its acid production as people age as well as the synthesis of in·
75% of those in nursing homes. The embarrass· trinsic facror. These changes can contribute to poor absorption of vitamin B-12 and
men! of having to wear adult diapers causes eventually to pernicious anemia. Adults age 51 years and older need to meet vitamin
many to ovoid fluids (resulting in dehydration B-12 needs witl1 foods or supplements fortified with synthetic vitamin B-12.
and constipa tion) ond to become socially Reduced stomach acid production may also hamper iron absorption. Other condi·
isolated. tions that affect the body's iron status in particular occur with the regular use of os·
pirin, which frequently causes blood loss in tl1e stomach, and the use of antacids, which
may bind iron. Ulcers and hemorrhoids can also cause blood loss. Carefol attention to
iron status is necessary in t!1esc cases.
Changes in Liver, Gallbladder, and Pancreatic Function

With age, tl1e liver functions less efficiently. When there is o history of significant oleo·
hol conSLtmption, fat buildup in the liver accounts for some decline. Alcohol abuse is
a problem among a small but significant group of older individuals who may continue
this pattern from earlier in life or develop heavy drinking patrerns and alcoholism beer.
Later development of this problem sometimes arises from the loneliness and social iso·
lation of retirement or loss of a spouse. Alcohol-related sickness is high in older peo-

ple, so the health consequences of this exctss are considtrabk.5 Also, older adults are
more likely ro rake medications affecLed by alcohol intake. Cf cirrhosis develops, tht
liver functions even less tfficirntly, resulting in a reduced abiliry ro detoxify many sub-
stances (review Chapter 8). The possibilicy for vitamin A t0xicicy in turn increases.
The gal lbladder also functions less efficiently as we age. Gallstones may dam up the
bile in the gallbladder, causing it to pool and back up into the liver. Gallstones can also
interfere with fut digestion by allowing less bile into the small intestine. Obesity is a
prime risk factor for gallbladder disease, especially in older women. A low-fat diet or
surgery to remove the organ ma} be necessary for treatmcnc.
Although the digesti,·e function of the pancreas may decline wirh age, the pancreas
has a large reserve capacity. One sign of a failing pancreas is high blood glucose, al-
The limit for alcohol intake for older adults is
though this can occur as the result of several conditions. The pancreas may be secret-
one drink per day.
ing less insulin or cells may be resisLing insulin action-especially muscle cells and, as
well, adipose cells in obese people with upper-body fat storage. Another cause can be
insufficient chromium intake . Where appropriate, improved nutrient intake, regular
physical acti\'ity, and weight loss (when needed) can improve insulin action and blood
glucose regu lation. 1
Decline in Kidney Function

Over time, the kidneys filter wastes more slowl)' as tl1ey lose ncphrons (the functional
filtration unit). The deterioration significantly decreases the kidneys' ability to excrete
the products of protein breakdown, such as urea, and in turn typically requires a re-
duction in protein i.make from habitual amounts to about the 1U)A or slightly below
(0.6 g/kg of body weight).
Reduced Immune Function

Wilh age the immune system often operates less efficient!). Consuming adequate pro-
tein, the full gamut of vitamins (especially enough vitamin E .tnd ,·itamin B-6), and
zinc helps maximize the health of the immune system. Rccurrelll sicknesses and poor
wound healing are warning signs of a deficient diet, especially with regard to protein
and zinc. 13 Eating too little food in general or too few animal proteins is usually the
reason. O lder people often eliminate meat from their diet because ir's too hard to
chew. ff necessary, a balanced vitamin and mineral supplement can help bridge gaps in
vitamin and mineral intake. On the oLher hand, overnutrition appears to be equally
harmful to the immune system. For example, obesicy and excessive fat, iron, and zinc
intake can suppress immune function.
Reduced Lung function

Lung efficiency declines somewhat with age and is especially pronounced in older peo-
ple who have smoked and continue to smoke tobacco products. Breathing becomes
shallower, faster, and more difficu lt ~1s the amount of active lung tissue decreases.
Smoking often leads to emphysema and lung cancer. The decrease in lung efficiency
conrribmes to a general downward spiral in body ft.u1ction; breathing din:iculties limit
physical activity and endurance and frequently discourage eaLing.
Besidel> not smoking, being physically active helps prevent lung problems. People
need not lose their capacity to breaLhe deeply as long as adequate aerobic activity is
part of their regular routine.
A diet based on vegetables, fruits, posto, and
Reduced Hearing and Vision olive oil os o source of fat-with o small
amount of alcohol in the form of red wine--
Hearing and vision bot11 decline with age. Hearing impairment occurs maiJtly in mem- contributes to the many healthy years of life of
bers of industrial societies with urban Lraffic, aircraft noise, and loud music. Older peo- southern Italians. Their active lifestyle is on
ple may avoid social contacts because they can't hear. additional contributing factor.
recent sllJdy discussed in Chapter 12 Declining eyesight, frequently caused by retina degeneration, can affect a person's
showed thot megodose zinc supplements ability to get co a grocery store, locate t11e foods desired, read labels for nutritional
(80 mg/doy of zinc oxide with 2 mg of copper content, and prepare the foods at bome. M:u.:ular degeneration, one form of failing
oxide) reduced progression of moderate coses of eyesight in old age, is quite common, affecting about 1.75 million adults in the United
moculor degeneration. The zinc supplements States. A major risk factor is cigarette smoking- yet another reason to avoid the habit.
worked even better when provided in combina- On a positive note, the reguJar consumption or foods rich in carotenoicls- in par-
tion with 400 IU of vitamin E, 500 mg of vitamin ticular, dark green, lea~, vegetables, such as kale, collard greens, spinach, swiss chard,
C, and 15 mg of beto-corotene. Adults who mustard greens, and romaine lettuce-may decrease me risk of developing this fr>rm of
hove evidence of moculor degeneration ond ore retina degeneration. These vegetables arc 1ich in lutein and zeaxanthin, two
considering this protocol should tolk to their carotenoids found in the portion of me eye subject to damage from age related
physician ond eyecore specialist first because changes. Adequate zinc intake is also important. The risk of developing ca ta races of the
these supplements con olso lead lo health eye is decreased by following a diet rich in fruits and vegetables. Note mat e\·enruall)
problems. such vision losses may make people afraid to socialize, be active, or take care of im-
portant routines or daily lifo, such as shopping. 10
Decrease in Lean Tissue

Some muscle cells shrink and others arc lost as muscles age; some muscles lose their
elasticity as rhey accumulate fat and coUagen protein_ Lifestyle greatly dccermincs the
rate of muscle mass deterioration. As you might predict, an active lifestyle cend~ to
maintain muscle mass, whereas an inactive one encourages its loss.
The loss of muscle mass leads to a decrease in basal metabolism, muscle strength,
and energy needs. Furthermore, less muscle mass leads to lower physical activity, which
makes the prognosis for maintaining muscle mass even worse. Clearly, it is besr to avoid
this vicious cycle. Just when all seems lost, though, note that the benefits of exercise
are quite striking, especially after the age of 50. Ideally, an active lifestyle shou ld in -
clude some resistance activity (weight training) throughout life (Table 18-3).1 7
Physical activity increases muscle strength and mobility, improves balance, ca:.e:.
daily tasks that require some strength, improves sleep, slows bone loss, and increases
joinr movement, thus reducing injuries. It also has a positive impact on a pcrson 's men -
tal outlook. 12 •16 However, when older adults stop their strengm-training program,
gains in muscle strength are quickly lost.
After obtaining,\ physician's approval co gee started, older people can seek our pro-
grams to begin strength and aerobic training at community recreation ccnrcrs or rhe
local YMCA or YWCA. Cardiac rehabilitation centers an: <tnother possibility. Most of'
t11esc organizarions have qualified trainers who can help set up a program. Dumbbells
arc inexpensive and thus ideal for engaging in strength training at home.
Older people benefii from both aerobic ond Table 18· 3 I Strength Training Recommendations for Older Adults
strength-training exercises. Strength-training • Exercises should be performed ot leost two doys per week.
(resistance) activity especially helps reverse
some of the decline in doily function ossocioted • If weights ore used, stort with I to 2 lb ond groduolly increase this amount over time.
with the muscle loss typically seen in older
• Perform exercises thot involve the moior muscle groups (e.g., orms, shoulders, chest, abdomen,
adulthood. Much of whot we ossociote with old
back, hips, ond legsl ond exercises that enhance grip strength.
oge is due to o lock of o lifetime of such
physical activity. • Perform 8 to 15 repetitions of eoch exercise, then perform o second set.
• Breathe during strength exercises.
• Rest between sets.
• Avoid locking joints in arms ond legs.
• Stretch after completing oil exercises.
• Stop exercising if poin begins.
Source: Notional Institute on Aging .
www.mhhe.com/ ward law pers7 669
Increases in Fat Stores

As lean tissue decreases with age, the body often takes on more fat. Much of this in-
crease results from overeating and minimal physical activity, although even athletic
men and lean women typically gain some degree of midsection fut after the age of 50.
ff obesity results, it can raise blood pressure and blood glucose and make walking
and performing daily tasks more difficult. Although a small fat gain in adulthood may
not compromise health, large gains are problematic.
Reduced Cardiovascular Health

The heart often pumps blood less efficiently in older people, usually because of insuf-
ficient physical activity. Poor heart conditioning allows fatty and connective tissues to
infiltrate Lhe heart's muscular wall. rlowever, this decline in cardiac o utput is not in- cardiac output The amount of blood pumped
evitable with aging and does not occur among older people who remain physically ac- by the heart.
tive. ln fact, it is thought that the inactive lifestyles of nearly 60% of North American
adults may contribute as much to the risk for cardiovascu lar disease as docs smoking a
pack of cigarettes per day. 16
Hean attack and stroke, two of the three major causes of death in adults, are caused
primarily by atherosclerosis and hypertension. As we age, atheroscleroric plaque accu-
mulates in the arteries, reducing their elasticity, constricting blood flow, and conse-
quently elevating blood pressure.
You already know the main way to limit the buildup or at herosclerotic plaque: keep uch controversy surrounds the treatment
LDL-cholesterol and the total cholesterol/HDL-cholesterol ratio in the desirable for elevated LDL-cholesterol in people
range (review Chapter 6). New evidence shows that a diet very low in fut can cause over the oge of 70. If these people adhere lo ex·
some pl.tqucs to decrease in size. Other studies use diet and medications to lower tremely restrictive diets limited in fat a nd energy
blood cholesterol, which in turn reduces the amount of plaque in the arteries supply- to the point that they can't keep up their weight,
ing the heart. These findings suggest that a heart-healthy diet is more important dur- or if their diets lack variety, they may become
ing middle to late adulthood than researchers previously thought. Consuming undernourished. Therefore, treating elevated
sufficient vitamin B-6, folate, and vitamin B-12 arc also important co avoid elevated LDL·cholesterol in an older person who hos other
blood homocysteine, a likely risk fuccor for cardiovascular disease. illnesses, such as chronic lung disease or
Hypertension is heavily implicated in both stroke and heart attack in older adults. 4 de mentia, is probably inappropriate.
Blood pressure can be lowered in many people by restricting salt int•lke. A limit of 1200 However, if a healthy 70-yeor-old who is likely
mg/day (ages > 70) to 1300 mg/day (ages 51 to 70) is recommended, but that diet is to live another I0 to 15 years has both elevated
difficult to plan and follow for older people who rely on convenience foods. AJternatively, LDL·cholesterol and evidence of cardiovasculor
a mild sodium restriction (not to exceed 4000 mg of sodium d;tily) may be effective for disease, an eating and exercise plan is probably
salt-sensitive people but is not so hclpfi.tl by itself for people whose hypertension is not in order to reduce the chance of heart attack.
salt sensitive; it does, however, aid the action of certain diuretics used ro treat hyperten-
sion. (The Nutrition Focus in Chapter 11 reviews d1e effects of other nutrients such as
calcium and poCtSSium as well as lifestyle interventions on blood pressure.)
We can do much to prevent heart attack and stroke just by eating a balanced diet,
walking briskly and other\\'isc performing regular physical activity, controlling blood
pres~ure, not smoking, and maintaining healthy weight. 18 Regular physical activity and dementia General persistent loss or decrease
a diet rich in fruits and vegetables arc also associated with fewer strokes as adults age, in menial function.
as is a moderate use of alcohol for ischcmic strokes.
Decline in Bone Health

Cluptcr l L discussed the decline in bone mass associated with aging. Recall that bone
loss in women occurs primarily after menopause. Bone loss in men is slow and steady
from middle age throughout later life. Use ofbisphosphonate medications is one treat-
mem to lessen bone loss in women, but other medication regimens arc aJso effective
( revie\\ Chapter 11 ). For adults in general over age 50, increasing calcium intake to
1200 mg/day (200 mg/day greater than the young adult Adequate Intake) is recom-
mended. Meeting (or slightly exceeding) protein needs is also important, but easy to
accomplish.
6 10 Chapter 18 Nutrition during Adulthood
Maintaining adequate vitamin D nuerjcure is also critical, especially if the person ex-
periences little sun exposure ( 10-15 µg/ day [ 5- 10 µg/ day greater than the young
adult Adequate Intake]). This amow1t corresponds to 400 to 600 TU/day. Note that
the higher recommendation is for adults 70 years and older.
Many older people may suffer from Lmdiagnosed osteornalacia, a condition prima-
rily caused by not enough sun exposure and therefore diminished vitamin D syntl1esis
in the skin. When they can't get regular sun cxposme-during the winter or when the~·
are homebom1d- older people need a dietary (e.g., milk) or supplemental sow·ce of vi -
tamin D.
To these rwo measmes, add not smoking and drinking alcohol moderately or not at
all. In addition, underweight women arc at especially high risk for developing osteo-
porosis. Performing weight-bearing activity, such as walking, can help preserve bone
mass.
Very severe osteoporosis limits rhe ability of older people to move about, shop, pre-
pare food, and live normally. They eat less and as a result consume fevvcr nutrients.
Older people should also work with their physician to develop a plan for limiting falls.
FaHs may be caused by the side effects of medication, lack of regular physical activity,
gait and balance disorders, impaired vision, <lnd environmental hazards. Protective hip
padding can reduce the risk of fracture in individuals who rend to fall.
Other Factors That Influence Nutrient Needs

Some sun exposure greatly contributes to
vitamin D needs in older people. in Aging
Medications and old age often go together. Medications can improve health and qual-
ity of life, but some of them also profoundly affect nutrient needs at all ages, includ-
ing me later years (Table 18-4 ). 13 Most older adults take prescription drugs;
one-quarter of older adults regularly take multiple prescription drugs, called polyphar-
rnacy. Many drugs affect appetite or the absorption of nutrients. Often, people must
rapefruil juice con increase or decrease
G the potency of some prescription medico·
lions, such as certain blood pressure medico·
rake medications for long periods. These people should work with their physician and
pharmacist to coordinate all medications taken. Pharmacists can advise when to take
drugs-with or between meals- for maximtm1 effectiveness.
lions, tranquilizers, antihistamines, blood Drug-related nutritional problems include (1) increased need for potassium when
cholesterol-lowering medications (statins), and certain types of diuretics increase excretion from the body and (2) changes in appetite
others, such as a class of drugs used to treat caused by antidepressant agents or certain antibiotics. Blood loss from the long-term
HIV/AIDS. For this reason, a physician, reg is· use of aspirin or aspirin-like medications depletes i.ron reserves and can lead to anemia.
tered dietitian, or pharmacist should be con· People who must take one or more medications for more than just a tew weeks should
suited before grapefruit juice is ingested by closely watch their diets, cat nutrient-dense foods, and possibly take nutrient supple-
people on prescription medications. ments to counteract the effects of cert.:-lli1 medications. A physician should supervise
this last practice, because some supplements can interfere witl1 the function of certain
medications. For example, vitamin K can reduce the activity of oral anticoagulants (re-
view Chapter 9).
Depression in Older Adults

Depression occurs in about 12 to 30% of nursing home residents and 17 to 37% of
older adults who reside outside of nursing homes. About 15% of persons who arc 65
years old or older experience depression. This depression-combined \.vi.tb isolation
and loneliness as fami.ly and frjends die, move away, or become less mobile-frequently
contribures to apatl1er.ic eating and weight loss. 2 Depression can lead to a continual de-
cJjne in which poor appetite produces weakness, which leads to even poorer appetite
(Figure 18-3). In older adults, tl1e resulting poor nutritional state can produce further
mental confusion and increased isolation and loneliness.
Many older adults ore healthy. The goal is to 1f depression is left untreated, it is estimated that 15% of tl1e cases may be fatal (sui -
remain that way as long as possible. cide). Depression also may be a sign of an underlying illness, which is another reason
Table 1 8·4 I Potential Drug-Nutrient Interactions for Some Commonly Used Drugs
Drugs Uses Nutrients Affected Potential Mechanism

Antacids (Maalox) Reduces stomach acidity Calcium, vitamin B-12, and iron Decreased absorption due to altered
gastrointestinal pH
Anticoagulants (Coumodin) Prevents blood clots Vitamin K Interference with utilization
Aspirin Is on anti-inflammatory; reduces Iron Anemia from blood loss
pain
Cathartics (laxatives) Induces bowel movement Calcium and potassium Poor absorption
Cholestyromine Reduces blood cholesterol Vitamins A, D, E, and K Poor absorption
Cimetidine (Togomet) Treats ulcers Vitamin B-12 Poor absorption
Colchicine Treats gout Vitamin B-12, corotenoids, Decreased absorption due to
ond magnesium damaged intestinal mucosa
Corticosteroids (prednisone) Is on onti-inflommotory Zinc Poor absorption
Calcium Poor utilization
Furosemide (Losix) Decreases blood pressure; is o Potassium and sodium Increased loss
potassium-wasting diuretic
Hydrochlorothiozide Decreases blood pressure; is a Potassium and magnesium Increased loss; decreased
diuretic absorption
MAO inhibitors !Pornate) Is an antidepressant Tyromine (in aged foods) High blood pressure caused by
limited tyramine metabolism
Tricyclic antidepressants {Elovil) Is an antidepressant Weight gain from appetite
stimulation
Social isolation; perhaps spouse has died. Figure 18-3 I The decline of health often
seen in older adults. This decline needs to be
Loses interest in food: diet deteriorates. prevented whenever possible.
Poor diet leads to weakness; this

increases a feeling of isolation and
abandonment.
Further isolation can then decrease
desire for self-core.
Health declines visibly;

weakness remains.
rhar early detection is important in older adults. Depression is often treatable, but
medication alone will not help people who arc experiencing major life changes such as
the death of a spouse. Adequate social support and possibly psychological intervention
are also important. 5
Alcoholism in Older Adults

Alcoholjsm is a problem in the older population. Approximately two-thirds of these al-
cohol abusers turn to alcohol much earlier in life and simply continue the habit. About
one-third begin later in lite because of a variety of factors-more free time, social
671
events centered around drinking, loneliness, or depressio n. Some of the symptoms of

alcoholism in older persons include trembling hands, sleep problems, memory loss,
and unsteady gait; these symptoms can be easily overlooked simply because they arc
common symptoms of o ld age in general.
O lder adul ts become intoxicated on a smaller amow1t of alcohol than when younger
because they metabolize alcohol more slowly and have lower amounts of body water
in which to dilute the alcoho.1 compared to younger adu lts. Even smalJ amounts of al-
cohol can react negatively with various medications that many older persons take. In
addition to having adverse effects on the liver, dri nking large amounts of alcohol in-
creases the risk of hemorrhagic stroke and may worsen hypertension in older adults.
Because drinking large amounts of alcohol produces adverse effects, both men and
women over d1e age of 65 should limit alcohol consumption to no more than one
drink per day. Recall from Chapter 8 d1at one drink per day is defined as 5 oz of wine,
12 oz of beer, or 1.5 oz shot of 80-proof liquor.
Alzheimer's Disease
Alzheimer,s disease often takes a terrible toll on the mental and eventual physical
heald1 of older people. About 4 .5 million adults in t he U nited States have the disease.
Aging is no reason to withdraw from life.
Learning and practicing new skills throughout
In general terms, Alzheimer,s disease is a type of dementia best described as a pro-
life is important. Such activities con include gressive brain disorder marked by an inability to remember, reason, or comprehend. 3
perhaps volunteering services to the community The ten warning signs of Alzheimer's disease are listed in the margin. Age is the pri-
or helping one's friends. mary risk factor. Scientists propose various causes, including alterations in cell devel-
opment or protein production in the brain, strokes, altered composition of
lipoproteins in the blood (e.g., apo E4), obesity, poor blood glucose regulation (e.g.,
diabetes), high blood pressure, and high blood cholesterol. Meeting needs for vitamin
E and vitamin C is in1portant. Meeting needs for vitamin B-6, folate, and vitamin
B-12 is especially important, because elevated blood homocysteinc is also a risk factor.
Caregivers should consider several nutrition recommendations in meal preparation.
en Warning Signs of Alzheimer's Disease
Food intake should be monitored to ensme maintenance of a healthy weight and nu-
tritional state. Other tips are including fish in meals twice per week, minimizing satu-
1. Recent memory loss that affects job
rated and trans fat intake, and making sure meal habits do not pose a health risk (e.g.,
performance
holding food in one's mouth or forgetting to swaUow). Regular physical activity has
2. Difficulty performing familiar tasks
also been shown to improve mental status in people afflicted by this disease. Four med-
3. Problems with language
ications have been approved to treat d1e disease (e.g., donepezil [Aricept ]); their ef-
4. Disorientation to time and place
fects arc modest at best. 11
5. Faulty or decreased judgment
Preventive measures for Alzheimer's disease focus on maintaining brain activity
6. Problems with abstract thinking
through lifelong learning, following a diet 1ich in fruits and vegetables, and use of
7. Tendency to misplace things
ibuprofen.7 Other earlier "promising" strategies such as estrogen therapy, use of Starin
8. Changes in mood or behavior
medications to lower blood cholesterol, and megadose vitamin E therapy have been
9. Changes in personality
shown to be ineffective in recent studies. To find out more about Alzheimer's disease, go
10. Loss of initiative to the website for the Alzheimer's Association at \\'\\'\\ ..\lz.org or calJ (800) 272-3900.
You can also call the Alzheimer,s D isease Education and Referral Center of the
National Institute of Aging at (800) 428-4380.
Concept I Check
NutritionaJ problems common ro aging adults relate to both the process of chronjc diseases
and the normal decrease in organ function that occurs witb time. ALI these organ systems
and functions can decrease as we age: appetite; sense of taste, smell, thirst, hearing, and
sight; digestion and absotption; liver, gallbladder, pancreatic, kidney, lung, and heart func-
tion; and the inunune system. In addition, bone mass and muscle mass gradually decrease,
the latter largely because of a deficient diet and inactivity. Approptiate dietary changes and
regular phrsicaJ activity can often help reduce the impact of these results of aging.
Complementary and Alternative Medicine
Practices
Consumers today may be interested in comple- representation or effectiveness by people who be-
mentary and alternative medicine (CAM ) (also lieve rhc remedy is clfoctive.
called complementary care and integrati,·c medi- In truth, linle scientific e\•ideace is available tor
cine). About 34% of people recently surveyed in physicians and he.11th-care professionals to decipher
the United States used altemati\'e medical practices the positive and negative aspects of natural thcra ·
in the past year, and most of tl1e .1ssociated ex- pies. Indeed, Western medicine is based on accu-
penses for these often expensive products and ser- rate scientific knowledge, which scncs as a
vices (about $4 billion per year) were paid protective device LO prevent harm. On the other
out-of-pocket. Interest in herbal supplements, hand, alternative therapies often ai·e based on folk folk medicine A medical treatment
however, is currently waning, likely because many medicine .rnd h.we little or no scientific evidence to based on the beliefs, traditions, or cus-
people lm·e tried them but have not experienced support them (due w l.1ck of large research trials). toms of a particular society or
enough benefit co justify c:he cost. The m.1joriry of Still, health proti:ssionals should be aware of the ethnic/cultural group.
me consumers also did not discuss me practice with scientific knowlcdgl.'. surrounding some alternati\e
meir primary care physician. tl1erapies, because clients may express interest in
Given the phenomenal advances in medicine c:hcsc merapies. Many clients wish physiciai1s would
O\'er the past decades, what brings people in such take tl1e time to e\plain (in simple terms) the na-
numbers to embrace alternative therapies? [t may ture of the problem; ro acknowledge nutritional in-
be that many people assume that natural subsrn nces fluences on health, rarhcr than just recommend
arc gentler forms of therapy, lacking rhe harsher drugs and surgery as Lhe only approaches for treat-
side effi:cts of some pharmacological medicines. ing illness; to answer questions intelligently abour
People m.ty also seek complementary medicine be- dietary supplements; to be sensitive ro mind-bod}'
cause standard medical treatments didn't work, interactions; Jnd to respect questions about alter-
standard medical treatments had too many adverse native practice5.
effects, the)' wanted to participate more actively in To date, le\\ complementary and alternative
treatment, or they wanted to combat poor physi- therapies ha\e been subjected to scientific scrutiny,
ci:m communication. The majority of consumers and many of the praaiccs arc based on presump
using Jlternative medicines ha\'C illnesses for which tions chat arc 11111.:onvincing at best, yet some of the
conventional medicine cairnot offer a cure, such as therapies (e.g., anipuncrure and chiropractic tl1era-
arthritis, terminal stages of AIDS, and srn:ss-rebted pics) show promise in the treatment of certain con-
condiLions. These people will almost ccrt:iinly ben- ditions. The N.1tional Institutes of HcalLh in the
efit from the reassurance, hope, and n:lief that United States has cre.ued the following seven cate-
comes with being in a healing situation. gories of complementary and alternative therapies:
In many instances, self-prescription or healing
rinials inrnl\'e tl1e participants' optimism, commit- 1. Mi11d-bod.v i11term1tiom: the use of the mind,
ment, attention, and high expectations for im- such as hypnosis, meditation, biofeedback,
provement. The mind is a powerful component of and yoga, to enhance hcalm. Integrative med- Some herbal products are effective for
treatment, which is proven by the placebo effect. A icine teaches health-care prm~ders to focus on treating specific medical problems.
placebo is a "sugar pill" administered to someone the subtle yet complex interactions of mind, Follow label instructions carefully. Note
potential side effects listed as well as
who believes chat he or she is being Lrcatcd with a body, spirit, community, and environment.
who should not use the product. The best
real medication and subseq uently fceb better. Ay11n1erin is .1 muural healing process from
advice is to use these substances only
Many alternative or natural treatments probably India that includes eating healthful, fresh under strict supervision of a physician.
have no intrinsic merapeutic value beyond the ben- foods and taking medicinal herbs suited to
efit of the placebo effoct. There also .uc some oilier one's particular mind-body type.
wavs a traditional remedy may seem co work, such 2. Bioclectrical 11llll/1Utic therapies: me USC of
as me natural ups and downs of symptoms, the re- electrical currents or magnetic fields to pro-
mission of disease, me possibil.iry mar the rcmedr mote healing, such as the use of electrical cur·
contains me effective dose of a pharmaceutical rents to help heal broken bones.
medicine or ii. adulterated with medicines not listed 3. Altemn.tii>t' systems of medical pmcticc: tl1e use
on the label, and the denial of symptoms or mis- of medicine from another culture, such as
6 73
Native American medicine and Chinese medi- vice docs not substitute for scientific \'C1incation
cine (for example, acupuncLure). Acupuncture ofsafct)• and cffecti\'eness when it come~ to health
likely works by stimulating sensory nerves practices.
leading co the spinal cord, which leads ro a re- • The U.S. federal go\'cmmenr prmidcs linlc regu-
duction in pain. Acupuncture also mar be ef- lation regarding nutrient supplemcncs or reme-
fecti\'e for treating people ''ho experience dies. "Ler the buyer bcw·are" is prudent .tthice
nausea and vomiting following surgery or to tallow when using these products. Knowl-
chemotherapy, nausea that accompanies preg- edgeable, professional gujdance is needed.
nancy, pain experienced after certain dental • Fraudulent claims for diet- and health-rcl:ued
procedures, and recovery from a drug addic- remedies have always been a part of'our culture. h
tion. Typically, a course or treatments shou ld is important to scrutiruze carefully the credentiafa
end after 10 sessions if it is not showing bene- and motives of anyone providing medical or
fit. FDA supports the use of acupuncrurc for heahh ad\ice. PhoO)' credentials and bogm prac-
Aromalherapy is typically used to such purposes. However, a qualified, certified titioners are widespread.
promote relaxation and relieve stress. To practitioner must use sterile needles intended • If it sounds too good ro be true, it probabl\' is.
date there is little scientific evidence to for single use and made from nonreactive The medical community gruns nothing by hold-
suggest that aromatherapy can be used
materials. ing back effective cures from tht: public, despite
to treat or prevent diseases.
4. Manual healing 111ct/Jods: the use of the hands what the alternative practitioners may say.
LO promote healing, such as chiropractic or os-
teopathic manipulation or massage. FDA rec-
ognjzes the effectiveness or chiropractic care
Vitamin and Herbal
for the treatment of acute low back pain.
5. Plmrmacologic and biologic trent111e11ts: the use Supplements Are Regulated
of various substance5 to treat specific medical Loosely by FDA
chelation The use of medicinal com- problems. This category includes chelation
pounds, such as ethylenediominete- therapy. Unless FDA has evidence that a supplcmt:nt is in-
lraacelic acid (EDTA), lo bind metals 6. Herbri/ medicine: the use of plants as medicines herently dangerous or its label makes illegal claims,
and other constituents in the blood. to treat or prevent disease. Ry definition, an FDA will not regulate it doscly. 1-1 FDA is, in fact,
herb is any plant or part or a plant that is used preven ted from doing so by che Proxmire
primarily for medicinal purposes. This cate- Amendmen t Lo the 1938 Food, Drug, and
aromatherapy The use of the vapors of gory includes ai·omatherapy. Dosage forms Cosmetic Act, along with follow-up lcgisl.nion-
essential oils exlracted from flowers, include capsules, tablets, extracts or tinctures, rhe Dietary Supplement Health and Educ.1tion Act
leaves, stalks, fruits, and roots for there· powders, dried herbs, ccas, aeams, and oint· (DSHEA}, which was passed in 1994 (.rnd re·
peutic purposes. ments. FDA has established regulations that viewed in Chapter I ). FDA requires a standardized
rcqwre the labels of such supplements to in- Supplemem Facts label on herbs and other related
clude name, quantit), dosage per day, and in- supplements. These labels must list the ingredients,
gredient amounrs. the percent of Druly Value if applicable, common
7. Diet a11d nutrition: the use of foods, vitamins, name of the plant, tl1e part of the plant that \\'as
and minerals to prevent illness and treat used, how much is present in each pill, and a sug-
disease. gested daily dose (Figure 18-4). It is permissible
nether concern regarding use of for tl1e labels on such products to claim .t benefit
The National lnstitutcs ofllcalth is also sponsor-
herbal and related supplements is related to a classic nurrient-deficicncy dise.1se, de-
ing sites around the United States to study com-
the actual content of the active ingredient scribe how a nutrient aflects human body \tructurc
plementary and alternative medicine practices.
or ingredients in the product. Recen~y, or function (i.e., strucrure/funccion claim ), and
Thus we may knO\\ more .1bout these practices in
many of these products have been tested state that general well-being results from comump·
the future. tion of tl1e ingredient or ingredicnri.. On the other
by independent laboratories and been
found lo contain either less than or more The following arc a fr" practical tips on using hand, a supplement label cannot claim th.it a prod-
complementary and alternative medicine practices: uct rrcats, cures, or prevents a tfacase not com-
than the stated label content (see the
website www.consumerlabs.com for • We often tend ro believe what we hear or what pletely related to a given nutrient deficiency. For
details). close acquaintances tell us. This well-meaning ad- example, an herbal product label can claim th.tt it
674
Supple•ent Facts
Serving Size 1 Softgel Suggested serving size
Each Soflgel Contains
Ginseng Extract (Panax ginseng) (root) 100 mg .
% DV
Product and amount
(Standardized to 4% Glnsenosides)
·oaily Value (DV) not established
INGREDIENTS: Gelatin, Soybean Oil, Panax Ginseng Extract,
Vegetable Oil, Lecithin, Palm Oil, Glycerin, Sorbltol, Yellow
Beeswax. Hydrogenated Coconut Oil. Titanium Dioxide. Yellow
5, Blue 1. Red 40, Green 3, Chlorophyll.
may help brain function, but not that it cures DIST. BY NUTRA ASSOC., INC. Nome and address
Alzheimer's disease. The latter would constitute a 4411 WHITE POINT RD., SPRING CITY, IL 12345 of manufacturer
drug claim. Once in a while, a company will decide Suggested use: Adults- 1 to 2 capsules dally Suggested use
to market a supplement as a drug. In that case, the taken with a full glass of water, or as a tea. add
one to two capsules to a cup of hot water
company has co go through the same FDA process
mandated for any drug. However, most supple- When you need to perform your best, take ginseng. - - Structure/fvnction claim
ment companies prefer to a\'Oid this whole process This statement has not been evaluated by the Food - - Standard FDA disclaimer
and Drug Administration. This product is not intended
and keep their product labels in compliance with to diagnose, treat, cure, or prevent disease.
OSHEA.
Figure 1 8·4 I Supplement facts label on an herbal product. Any nutrients or
other food constituents would also be listed if contained in the product.
Dietary Supplement Claims
Although structure/function claims do not have tO
be approved by FDA, manufacntrers must have ev- panics from ~ponsoring research on their products
idence that their marketing statements are truthful because their competitors might "borrow" tl1eir re-
and not misleading. In addition, the labels of prod- search (many people would call it stealing, not bor-
uces bearing such claims must prominently display ro\\'ing). Therefore, borrowed science ends up to
in boldface type the following disclaimer: "This be a major barrier co much needed research being
statement has not been evaluated by the Food conducted in the supplement area. How can bor-
and Drug Administration. This product is not rowed science be stopped? FDA can investigate
intended to diagnose, treat, cure, or prevent any only a limited number of cases, given its budget.
disease." Despite tl1is statement, consumers may Alternatively, lawsuits can be filed by an individual
mistakenly assume FDA has carefully evaluated the company against the "borrower," buL Lhis solution
products and related claims, as is done for pharma- is expensive and time consumini;. Another possibil-
ccucicals and appro"ed health claims. ity is the emerging government and industry ap-
It is also noteworthy that FDA's requirement proaches just mentioned, but we'll have to see how
for "e,~dence" for a claim is not a very stringently effective Lhey will be.
enforced requirement. Tn many cases, the evidence
used to support a claim is vague or unsubstanti-
ated. However, FDA only ends up challenging a A Closer look at Herbal
relati\'cl)' low percentage of these claims. For chis Therapy
reason, some other means are emerging for chal-
lenging such claims. Some in\'olve government Throughout hist0ry, healers have gone to the gar-
agencies other than FDA (e.g., the Federal Trade den, forest, and sea to seek herbal remedies. Some I T1Hi"t~ i""'
Commission [FTC]). Tn addition, tl1e supplement natural products may be harmless, others are po-
industry itself is trying to develop means of self- tentially toxi<:, and still others may be effective for Jamila went to her local pharmacy
policing. It will be interesting to see ho\\' much im- some problems but dangerous when taken in the yesterday to look for a product lo help
pact results from these efforts by government and wrong dose or by people witl1 certain medical con- her stay awoke while studying. On the
industry groups. One of the biggest areas of conditions (Table 18-5).6,I+ Herb-drug interactions shelves she found a dietary supplement
cern is so-called borrowed science. For example, can be especially severe, such as an increase in the claiming to be a Chinese herbal remedy
Company A does research on tl1eir garlic capsule 1isk of bleeding in a person taking anticoagulant for sleepiness ond fatigue. She thought
that shows that this product Jowers blood pressure. medications. The National Cancer Institute is the that because a pharmacy carried the
Company B may also tout this research for their world's leader in the search for medicinal com- product, it should be safe and should
garlic product. Howe,·er, their product can be pre- pounds in planes. for example, the institute has work as indicated on the label.
pared quite differently than Company A's producr. tested extracts of more than 30,000 plant species Is she correct in these assumptions?
How do we know that the research on the product for acti\·ity against cancer. This work identified Are there specific risks associated with
of Company A applies to the product of Company some anticancer compounds trom flowering plants taking such herbal remedies?
13? We don't. This situation discourages many com- that have been approved for use in cancer patients.
675
Table 18·5 I Popular Herbal Remedies, Food Supplements, and Hormones
Herbal and Related
Substances Potentiol Effects Side Effects Who Should Avoid Them
Block cohosh Moy reduce postmenopausal Nausea, fall in blood pressure Women toking estrogen, hypertension
symptoms medications, or aspirin and related
drugs
Coenzyme Q. J0 Fat-soluble vitamin-like substance with Mild gastrointestinal distress No specific persons ore at risk
antioxidant properties; some people
with chronic conditions, such as heart
failure, have low amounts in the body
and so moy benefit from use
Echinoceo Moy stimulate the immune system and Nausea, skin irritation, allergic reactions Anyone with on autoimmune disease or
shorten the duration of Rulike illnesses; who has allergic reactions to daisies
current studies show little or no effect
Feverfew May reduce the pain and frequency Abdominal pain, mouth sores, skin rash Anyone allergic to ragweed or taking
of migraines onti-inflommotory drugs, such as aspirin
Garlic Moy hove antibiotic properties ond In large amounts, burning of the mouth, Anyone toking anticoagulant medica-
slightly lower blood cholesterol nausea, sweating, stomach irritation, tions, such as warfarin, for cardiovascu-
and blood pressure lightheodedness, reduced blood clotting lar disease, or AIDS medicines
Ginger May prevent motion sickness and nausea Gastrointestinal (GI) tract discomfort with People with history of gallstones
related to surgery and pregnancy high doses on on empty stomach
Ginkgo bilobo May increase the circulation of blood in GI tract upset, headache, irritability, Anyone toking anti-inflammatory or anti-
the body, especially to the brain and reduced blood clotting coagulant medications, including vita-
lower extremities; evidence is very min E and aspirin; anyone who has
weak hod o stroke or is prone to them
Ginseng May decrease weakness and fatigue Hypertension, asthma attacks, irregular Anyone taking onti<oogulant medico·
and increase the body's resistance heart beat, insomnia, headache, ner- tions, such as warfarin; women on hor-
to stress; studies have not confirmed vousness, GI tract upset, reduced blood mone replacement therapy; anyone
any benefit clotting with a chronic GI tract disease; anyone
with diabetes
Glucosomine May decrease joint inflammation ond GI tract discomfort, which may Moy disrupt blood glucose regulation in
pain associated with osteoarthritis, but disappear ofter 2 weeks people with diabetes
a recent, large scale trial showed no
such benefit.
Milk thistle May have a protective effect on the liver, Diarrhea No specific persons are at risk
thought to be due in port to its ability to
prevent toxins from contaminating liver
cell membranes
SAMe Moy promote cartilage formation and de- Mild headaches, which lost for short Anyone with cardiovascular disease, ob-
creases joint inflammation and pain as- periods of time sessive compulsive disorder, monic-
sociated with osteoarthritis; may also depression, or addictive tendencies
act os o mild antidepressant (active in·
gredient is S-odenosylmethionine)
Other plant·deri\'ed compounds arc currcmly The German go\·emment publishes a manual
being tested for safety and effectiveness in clinical that is the most authoritative reference for the use
trials but haven't yet been approved. of popular herbal products ( Co111111issio11 E
Traditional knowledge of the healing properties Monographs). Unfortunately, little scientific data
of plants provides leads for such scientists to ex- are available concerning the therapeutic value and
plon:. Any promising compounds they isolate arc safety of chc 7000 or so herbs used in Lradicio1ul
subjected to iigorous FDA-approved tests to deter- medicine, which has been practiced and (hroniclcd
mine safety, effectiveness, and side effects. This con- primarily by the Chinese. Proponents of Chinese
troUed testing provides a wealth of information fur herbal medicine suggest that its safety .111d efficacy
exceeding that available for most herbal remedies. have been well esrablished dw'ing its 4000-ycar his·
676
Ta•I• 18·5 I Popular Herbal Remedies, Food Supplements, and Hormones (continued}
Herbal and Related
Substances Potential Effects Side Effects Who Should Avoid Them
St. John's wort Mild antidepressant effect that may work Nausea, fatigue, dry mouth, dizziness, People toking medications lo control de-
by inhibiting monoomine oxidose (on pholosensitivity; increases metabolism pression, HIV, epilepsy, cardiovascular
enzyme in the brain that destroys "feel- and removal of many prescription drugs disease, asthma, ond to suppress the
good" hormones such as serotonin, epi- from the body immune system to keep the body from
nephrine, and dopamine) rejecting a transplanted organ
Sow palmetto Moy reduce symptoms of enlarged Generally uncommon; when token in People toking medication lo treat en-
prostate gland (otherwise known as large doses: headache, GI tract upset larged prostate or BPH; anyone with a
BPH or benign prostotic hyperplasia) by chronic GI tract disease
increasing urinary Row and easing uri-
nation; some studies show moderate
evidence of effectiveness, while other
studies hove shown little or no benefit
with such use.
Valeri on Moy alleviate restlessness and other Headache, morning grogginess, irregular Anyone toking central nervous system de-
sleeping disorders ihot stem from heart beat, GI tract upset (also hos o pressants, such as sedatives; anyone
nervous conditions disagreeable odor) who drinks alcohol
Hormones
DHEA Hormone that when token orally turns to Mosculinization of women, acne, irritobi~ Women, due to possible irreversible mos-
estrogen and testosterone in the body; ity, decreased HDL<holeslerol, possible culinizotion qualities
few, if any, benefits of supplemenlolion prostate or breast cancer
ore proven, such os on aid to weight
loss or to treat depression; research is
ongoing
Growth hormone Hormone that stimulates cell synthesis, Carpal tunnel syndrome; breast de- Only available by prescription; requires
such as muscle cells, and overall body velopment in men; swollen ankles and close physician scrutiny (very
growth in children; may be useful in legs, hypertension, diabetes, cancer expensive)
adults who foil to make enough of the
hormone
Melatonin Hormone that may help people foll Reduced ovulation in women, drowsi- Anyone with cardiovascular disease, or
asleep foster ond reduce jet log ness, confusion, headache or morning anyone of childbearing age
grogginess
Testosterone Hormone that affects muscle moss and Masculinizotion of women, decreased Only available by prescription; requires
strength; con reduce menopausal symp- HDL-cholesterol, prostate gland enlarge· close physician scrutiny; risky in men
toms in women and possibly depression ment in men (and possibly increased showing prostate gland enlargement
in older men prostate cancer risk)
Nole lhol pregnant or b<eostfeediog women, children under 2 yeors old, onyone over the oge of 65 yeors , ond onyone wilh o chronic diseose should never lake supplemenls unless under 1he guidonce
of a physicion.
tory. These individuals also point to the widespread ten, paraguay tea, kombucha tea, tung shueh carpal tunnel syndrome A disease in
use of herbal therapies in Europe. Still, numerous (Chinese black balls), and willow bark.
which nerves that travel to the wrist ore
reporcs haYc documented significant health risks as· There is also a distinct risk that a traditional
pinched as they poss through a narrow
sociatcd with the use of some herbal and alcernati\·e herbal product may be mislabeled, adulterated with opening in a bone in the wrist.
remedies, sometimes resulting in death. Studies es- prescription drugs or contaminants (such as lead ),
pecially implicate germander, pokeroot, sassafras, or subject to extreme variations in potency.
mandrake, pennyroyal, comfrey, chaparral, Chinese combination herbs should always be
yohimbe, lobelia, jin bu hmm, kava kava, produces avoided because of the reported cases of adverse
containing Stephanie and magnoLla, senna, hai gen health effects ,111d ;idulteration.
677
The following are questions that should be medicine interactions may develop. 14 Pn:gn.1111 and
asked when e\•aluating a company's products: nursing women, anyone with a chronic disease, .md
• What forms of produccion control lab analysis children under 2 years of age, especially, shoulJ not
arc used to ensure quality, quantity, and take herbal supplements unless their physidons
reproducibility of the ingredients in individual consent to the practice and moniror them for po
doses as labeled? tenrial complications.
• rsthe product labeled with L1tin botanical names? Some herbalists claim that natural herbs can -
Simply because herbal remedies come • Does die label have expiration dates and lot num- not harm people. Scientific evidence strongly con
from noturol sources does not mean they bers, and ifso, what is the basis tor the labeled ex- tradicrs this claim. Indeed, if there's one thing
are without health risks. Even those that piration dates? experts agree on, it's this: an herb d1at has the abil -
have been used for centuries may ity to heal also has d1e ability, if misused, m harm.
• Docs die manufacmrer offer a certificate of analy-
produce harmful effects when combined Tn addition, many conditions for which herbs ~He
with standard medications. sis for each product?
• Has d1e manufacturer been in business for at least recommended (such as diabetes and ard1riris ) arc
5 years and ha\'e national dimibution of die not suitable for self-treatment. For a balanced dis
product? cussion of herbal remedies, consult the following
websites:
Still, what me label indicates as the acti\•e in-
Alternative Medicine Foundation
gredient and the amount of the ingredient that a
\\Ww.amfoundation.org/
product claims to contain may or may nm be ''alid,
based on the recenr analysis of many popular The NCCAM Complementary and
brands of herbal products. Alternative Medicine (CAM) Citation lndc\
A rational approach to alternati\'c therap}' is for (Cl)
people to keep a diary of symptoms, folto\\ only nccam.nih.go\/nccam/rcsourccs/cam-ci/
one therapy at a time, check with their physician American Botanical Cow1cil
fast before discontinuing a medication, and find www.herbalgram.org/
recent concern hos been raised out if the alternative practitioner has experience Complementary and Alternative Medicine
with regard to patients who with d1e medical problem to be treated. Interested Program at Stanford (CAMPS)
abruptly end alternative medicines at the consumers might also see if they can enter a swdy scrdp.stanford.cdu/camps.htmJ
start of hospital treatments or simply deny of the substance or procedure in question. In addi-
that they are involved in alternative ther- Center for Complementary and Alternative
tion, FDA advises anyone who experiences adverse
apy. Interactions between alternative ther- Medicine Research in Asthma, located at the
side effects from an herbal remedy ro concact a
University of California, Davis
apies and pharmaceutical drugs can be physician. Physicians arc encouraged to report such
www.c.1mra.ucdovis.edu/
drastic and include complications such as adverse effects to FDA and state and local health
delirium, clotting abnormalities, and departments and consumer protection agencies. National Institutes of Health Office of
rapid heart beat, resulting in the need for Overall, herbal products should be used with Alternative Medicine
intensive core. If these patients had dis- great caution and only in consultation with a per- altmed.od.nih.gov /
closed their treatments, many of the com- son's primary physician. Otherwise, potential side Natural Medicine Comprehensive Database
plications could hove been prevented. effects may go undiagnosed, or dangerous herb· "W\\.naLUraldatabasc.com
Experts recommend that, if time permits,
patients slop toking herbal products for
about o week before o scheduled surgery
or otherwise toke all original supplement
containers to the hospital so that the
anesthesiologist con evaluate what was
token.
678
I
!
Nutrient Needs and Dietary Planning in Middle

and Older Adulthood
The latest RDAs and related standards for nutrients and energy needs include cate-
gories for both men and women who are 51 to 70 years of age and more than 70 years
of age. t-. lacronutrient needs do not change from young adults' needs, but needs for
some micronutrients do. In addition, because the lifestyle or an act ivc older person can
<lifter considerably from that of a nursing home resident, establishing nutrient needs
during these wide age ranges is problematic.
A well-planned diet chat follows MyPyramid can meet all nutrient needs for healthy
older people within about 1800 kcal, except for probably \'itamin D and vitamin B-12.
Meeting the vitamin B-12 standard is aided by use of fortified foods , such as ready-to-
eat breakfast cereals. The use of a b:ibnced mu ltivitamin and mineral supplement is es-
pecially hclpfol for meeting vitamin [)needs if the person does not receive regular sun
exposure. Any supplement shou ld be low in or free of iron, because it may have a
prooxidant effect. Currently, many nutrition experts recommend a daily balanced mul -
ti,·iramin and mineral supplement for older adults, especially for rhose 70 years of age
and older. As we age nutrient needs change, but not the
need to follow o heohhy diet.
Recommended dietary practices for later years would be co increase the diet's nu -
trient density and to make sure fiber and fluid intake is adequate. 1 In addition, some
protein should come from lean meats to help meet protein , vitamin B-6, vitamin B-12,
and zinc needs.
Singles of all ages face logistical problems with food: purchasing, preparing, staring, f rich calcium sources ore not consumed, o
and using food with minimal waste :ire challenging. Economy packages of meats and person would need o calcium supplement, be·
vegetables are normally too large to be useful for a single person. Many singles live in cause typical multivitamin and mineral supple·
small dwellings, some without kitchens and freezers. Creating a diet to accommodate ments contain little calcium (about 200 mg). As
a limited budget and facilities and a single appetite require~ speci:il considerations. noted in Chapter 9, providing more calcium
Following are some practical suggestions for diet planning for singles: than that would greotly increose the pill size.
• 1f you own a freezer, cook large amounts, divide into portions, and freeze .
• Buy only what you can use; small containers may be expensive , but letting food spoil
is also costly.
• Ask the grocer to break open a fumi ly-sized package of wrapped meat or fresh veg-
etables and separate it into smaller units.
• Buy on ly several pieces of fruit- perhaps a ripe one, a medi um-ripe one, and an un-
ripe one-so tl1at the fruit can be eaten over a period of several tfays.
• Keep a box of dry milk handy to add nutrients ro recipes for baked foods and other
foods for which this addition is acceptable.
Table 18-6 pro,·ides e\·en more ideas.
Nutritional deficiencies and protein-caloric undernutrition ha\e been identified
among some aging populations, particularly those in nursing homes or long-term care
facilities and those who are hospitali.Ged. These nutritional problems increase the risk
for m~my diseases, including bed sores (pressure ulcers), and compromise recovery
from illness and surgery. l3 Friends, relatives, and health -care perwnncl shou ld look for
poor nutrient intake in all o lder people, including those who live in nursing home set-
tings. Family members have a unique opportunity to make sure nutrient needs are met
by looking for weight maintenance based on regular, healthfu l meal patterns. If prob-
lems arise in consuming a healthful diet, registered dietitian:; can offer profossiooal and
personali;,ed advice.
Q,·erall, good nutrition benefits older adults in many ways. Meeting nutrient needs Great attention to food safety is also important
delays the onset of some diseases; improves the management of some existing diseases; for older adults. Chapter 19 provides advice
hastens recovery from many illnesses; increases menral, physical, and social well-being; on this topic, such os washing one's hands and
and often decreases the need for and length of hospitalization. 1 work surface before preparing food.
680 Chapter 18 Nutrition during A dulthood
Expert Opinion Il
Nutrition and Healthy Aging
Katherine Tucker, Ph.D.
Research continues to confirm lhe lomin B-12 are each involved in methionine metabolism and ore required lo
central role of nutrition in main- clear homocysleine, on intermediary amino acid, from the bloodstream and
taining health and independence cells in general. Elevated blood concentrations of homocysteine have been as-
wilh age. II is clear lhal continued sociated with risk of cardiovascular disease and stroke and more recently also
physical activity is critical for main- with bone fracture and cognitive decline. Surveys hove regularly shown that
taining weight and lean muscle, large proportions of the older population hove both inadequate intake and in-
and ii is generally accepted 1hot a adequate blood concentrations of these three vitamins. In the 1990s, the U.S.
"good" diel is importonl. What is Food and Drug Administration mandated that oil refined grains in the food
often less appreciated is that many supply be fortified wilh folic acid. This change has reduced the prevalence of
older adults ore al risk of micronu- folate deficiency, but vitamins B-6 and B-12 remain important problems.
trienl inadequacies and lhol these Vitamin B-6 is of central importance lo protein metabolism and immune
contribute to a variety of chronic function. It is found widely in foods thal have not been processed, including
conditions, disability, and loss of whole groins, nuts and seeds, unprocessed meat and fish, legumes, and se-
independence. Dietary quality is lected frui ts. Although this vitamin hos received less attention lhon folote, ii
particularly important for older is often inadequately consumed, and some investigators believe the current
adults. With advancing age, en- RDA should be increased for older adults.
ergy requirements and therefore Wilh few exceptions, vitamin B-12 is found only in animal-based products.
Healthy eating is a key component total food intake tend to de- Vitamin B-12 is a particular problem for the older population because for many,
of healthy aging. crease-but the requirements for a deficiency may exist even when intake appears to be adequate. Up to 40%
most nutrients do not decrease of lhe older population may suffer from some degree of stomach inflammation,
and, in some cases, increase. Surveys show that large segments of the older leading to loss of stomach acid, which is required to separate vitamin B-12 from
adult population consume diets wilh inadequate amounts of protein, vita- the protein to which ii is bound in food. For this reason, consumption of the RDA
mins, and minerals and that these deficiencies ore associated with risk of for vitamin B-12 does not ensure adequate plasma concentrations. Current rec-
chronic disease. Nutrients of porliculor concern include protein; folote; vita- ommendations emphasize thal older adults obtain vitamin B-12 from fortified
mins B·6, B-12, D, and E; carotenoids; calcium; and magnesium. breakfast cereals or supplements. Some older individuals will require amounts
much higher than the RDA to achieve adequate concentrations.
Protein
There is a commonly held belief that the U.S. population consumes more than V itamin D
enough protein. Although this statement is certainly true for some segments
Inadequacy of vitamin D is considered by some researchers to be epidemic in
of the population, ii is not always true for older adults. Because of lower ef-
the older population. Many older adults do nol spend time outside and there-
ficiency of prolein utilization and loss of lean body mass, aging adults have
fore hove limited exposure to sunlight. Further, the abilities of the skin to syn-
higher protein inloke requirements lhon do younger adults. Until recently,
thesize vitamin D and of the kidney to convert it to the active form decline with
many researchers and physicians recommended that older individuals limit
age. Food sources of vitamin D ore limited in lhe U.S. diet, and the major
protein intake to protect against bone loss. However, recent studies hove
sources-fatty fi sh and fortified milk-ore not widely consumed by older
demonstrated that both muscle mass and bone mass are better preserved
adults. Inadequacy of vitamin D contributes to the high prevalence of low bone
when protein intakes ore relatively high. Some scientists currently recom-
moss and osteoporosis and thereby to the incidence of fracture in the older
mend thol individuals over 70 years old consume from 1.0 to 1.25
population. This connection is critical because many elders do not recover from
g/kg/day, which is higher than the current adult RDA of 0.8 g/kg/day.
the extended bed rest after o hip fracture, which is often the beginning of a
downward spiral lhat leads to loss of muscle moss, loss of mobility, and fre-
B vitamins quently to death. In addition, vitamin D deficiency hos been linked with o va-
Several vi tamins ore inadequately consumed by older adults. Among these, riety of other conditions, including immunological and neurological conditions.
three of the B vilomins hove recently received considerable attention due to Just 10 minutes per day of sunlight can make a large difference in vitamin D
their importance in prevention of chronic disease. Folote, vitamin B-6, and vi- status. For individuals who cannot get out, supplements are recommended.
Vitamin E men! is being consumed. Recent studies show that optimal bone health re-
quires many nutrients in addition to calcium and that a good-quality diet may
Current recommendations for vitamin E intake ore based on on increasing have better long-term protective effects than calcium supplements alone.
understanding of the importance of this potent antioxidant in the prevention There are many advantages to consuming calcium-rich foods such as low-fat
of age-related declines in a variety of functions. This vitamin is particularly dairy products, fish (with bones, like sardines or conned salmon). and leafy
important to immune function and is thereby linked with reductions in infec- green vegetables. Improved intakes of such dietary sources should be encour-
tious disease; there is also evidence of protective effects against cardiovas- aged because, in addition to calcium, they also tend to include vitamin D, mag-
cular disease, cognitive decline, cataract, and cancer. The dietary intake of nesium, potassium, and other important nutrients.
the majority of the population falls short of recommendations. Vitamin E is
another nulrienl that is found in large quantities only in selected foods. The
moior dietary source is vegetable oil. Nuts and seeds hove the highest con- Magnesium
centrations but ore rarely consumed in the U.S. diet. Many older individuals Dietary surveys consistently show that the majority of the adult population
hove been persuaded to lake vitamin E supplements, but recent studies hove falls short of meeting the magnesium intake recommendation. Magnesium is
identified much stronger protective effects from dietary vitamin E than from requ ired for numerous metabolic reactions in the body, and although clear
supplemental vitamin E, and clinical trials of vitamin E supplements hove deficiency is rarely diagnosed, a constant inadequacy may contribute to a
been disappointing. variety of chronic conditions. Sudden death from poor heart rhythm is the
best known concern, but general cardiovascular disease, osteoporosis, and
Carotenoids diabetes are other conditions that hove clearly been linked with low mag-
nesium intake. Like vitamin B-6, magnesium is widespread in an unprocessed
The lock of success of single nutrient supplements hos also been seen for food supply, including whole groins, legumes, and fresh vegetables, but is
other antioxidant nutrients. For example, although beta-carotene from diet easily lost with processing.
hos consistently been shown to protect against cardiovascular disease and
cancer in dietary studies, randomized trials of beta-carotene supplements
failed to show protective effects-and even suggested greater cancer risk in Summary
some studies. Dietary intakes of other carotenoids have been shown to hove
Much research in the post has focused on the use of single nutrient supple-
a variety of important antiaging and health protective effects. Specifically,
ments to prevent specific conditions. The failure of many of those trials with
lutein and zeoxonthin (from dark green leafy vegetables, egg yolk, and corn)
the persistence of evidence of protective effects from diet suggests that we
have been linked with prevention of cataract and age-related moculor de-
must continue to emphasize good dietary patterns in the population and to
generation, and lycopene (from tomato products) hos been linked with pre-
work toward improving access to the older population. Current recommen-
vention of prostate cancer. The evidence suggests that in the case of
dations for the aging population to optimize health and prevent both physi-
antioxidants, a variety of nutrients and food chemicals work optimally to-
cal and cognitive decline include a focus on continued physical activity,
gether and therefore intake should be encouraged from diet rather than from
including resistance training; a nutrient-dense diet that includes plenty of
supplements. Diets high in fru it and vegetables, the major sources of
fruit, vegetables, nuts and seeds, whole groins, fish, and low-fat dairy prod-
corotenoids and other beneficial phytochemicals, ore consistently shown to
ucts; and use of fortified breakfast cereals or supplements to ensure ade-
be protective of a wide variety of age-related conditions.
quate vitamin B-12 and D.
Calcium
Calcium intake is essential to prevent bone loss, particularly among post-
menopousol women. Adequate calcium intake is also known to be important
for blood pressure regulation and is currently being explored for a possible
link with weight maintenance. Few adults meet intake recommendations, par- Dr. Tucker is Professor of Nutritional Epidemiology at the Friedman
ticularly older adults, who tend to consume fewer dairy products. Calcium School of Nutrition Science and Policy at Tufts University and is Director
absorption is a complex process, and the capacity for efficient absorption of the Dietary Assessment and Epidemiology Research Program at the
declines with age. Because it is difficult for older adults to meet recommen- Jean Moyer USDA Human Nutrition Research Center on Aging. Her re-
da~ons from diet, supplements are otten recommended. Although there is search focuses on the role of dietary intake and nutritional status in the
good evidence that calcium supplements improve bone mineral density and prevention of chronic diseases in aging populations. She received her
reduce h~c\ure risk, these effects appear to continue only while the supple- Ph.D. in nutritional sciences from Cornell University.
o leorn obout meol programs for senior citi· Table 1 8-6 I Guidelines for Healthful Eating in Loter Years
zens in your area, call the Administration
on Aging's Elder Core Locator (800) 677· 1116. • Eat regularly, small frequent meals may be best. Use nutrient-dense foods as a basis for menus.
For general information on programs for older • Use convenience foods and labor-saving devices.
persons, visit the following websites: Notional • Try new foods, new seasonings, and new ways of preparing foods. Don't use just convenience
/nslilule on Aging, www.nih.gov/ nio/; foods and canned goods.
American Geriatrics Society, www.
• Keep easy-to-prepare foods on hand for limes when you feel tired.
omericongeriotrics.org/ ; and Administration on
Aging, www.ooo.dhhs.gov/ . • Hove a treat occasionally, perhaps on expensive cut of meal or a favorite fresh fruit.
• Eal in a well-lit or sunny area; serve meals attractively; use foods with different Aavors, colors,
shapes, textures, and smells.
• Arrange kitchen and eating area so that food preparation and clean-up ore easier.
• Eat with friends, relatives, or al a senior center when possible.
• Shore cooking responsibilities with a neighbor.
• Use community resources for help in shopping and other doily core needs.
• Stoy physically active.
• If possible, toke a walk before eating to stimulate appetite.
• When necessary, chop, grind, or blend hard-to-chew foods. Softer protein-rich foods con be
substituted for meal when poor dental function limits normal food intake. Prepare soups, stews,
cooked whole-groin cereals, and casseroles.
• If your feeding movements ore limited, cul the food ahead of time, use utensils with deep sides
or handles, and obtain more specialized utensils if needed.
Obtaining enough food may be difficulc for some older persons, especially if the\'
are tmab1e to drive and relatives do not live close enough to help with cooking or l>hop·
ping. For an older person,·' request for help may be equated to a loss of independence .
Pride, or fear of being victimized by those they hire, may stand in the way of much
aeeded help. Jn these cases, friends ca n be a big help. Special transportation arrange
ments may also be available thro ug h a local transit company or ta.Yi service.
Many eligible older people arc missing meals and arc poorly nourished simply be·
cause they don't know of available prog rams to help them. Irregular meal patterns and
Grocery shopping con become more difficult in weight loss, often caused by difflculcics in preparing food, are warning signs that· un ·
one's older years. Assistance from others is dernutrition may be developing. An cffon should be made to identify poorly nour-
often very helpful. ished people and inform them or
community scrviccs. 5
Community Nutrition Services for Older Adults

Health-care advice and services for older people can come from clinics, private practi ~
tioners, hospitals, and health maintenance organizations. Home health-care agencies,
hospice care A facility offering core that adult day-care programs, adult overnight· care programs, and hospice care (for the ter·
emphasizes comfort and dignity in death. minally ill) can provide dail)' care.
The Nutrition Screening Initiative, a nutrition checklist for health-care worker~ ,
family members, and older persons, can be used as a tool to increase heald1 and nutri·
tion awareness and to plan related education of older persons (Figure 18-5 ). The
Nutrition Screening Initiative uses the acronym "DETERMINE" (see page 683 ) to
help identify o lder people whose health needs require extra attention.
Figure 18· 5 I A nutrition checklist for older

A Nutrition Test for Older Adults adults.
Reprinted w ith permission by the Nutrition Screening
Here's a nutrition check for anyone over age 65. Circle the number of points for each
Initiative, o projecl of the American Academy of Family
statement that applies. Then compute the total and check it against the nutritional score.
Physicians, the A merican Dietetic Association, and 1he
N otional Council on Aging, Inc., and funded in port
Points by o grant from Ross Products Division, Abbott
Laboratories.
2 1. The person hos a chronic illness or current condition that
hos changed the kind or amount of food eaten.
3 2. The person eats fewer than two full meals per day.
2 3. The person eats few fruits, vegetables, or milk products.
2 4. The person drinks 3 or more servings of beer, liquor, or
wine almost every day.
2 5. The person hos tooth or mouth problems that make eating
difficult.
4 6 . The person does not have enough money for food.
1 7. The person eats a lone most of the time.
1 8. The person tokes three or more different prescription or
over-the-counter drugs each day.
2 9. The person has unintentionally lost or gained 10 pounds
within the lost 6 months.
2 l 0. The person cannot always shop, cook, or feed himself
or herself.
Total
I'
Nutritional score:
0-2: Good. Recheck in 6 months.
3-S: Marginal. A local agency on aging has information about nutrition programs for
the elderly. The National Association of Area Agencies on Aging can assist in finding help;
call (800) 677- 1116. Recheck in 6 months.
6 or more: High risk. A doctor should review this test and suggest how to improve Help is available in most communities to assist
nutritional health. older adults in daily tasks. This, in turn, helps
older adults meet nutrient needs.
Nun-ition programs for people age 60 and over in the U ni ted States include con-
gregate meal programs, which provide lunch at a central location, and home-delivered
meals (often known as Meals on Wheels if sponsored by the local private o r pti blic etermine:
agencies). About 2 .6 millio n older adults are served each year. C urrently about half the
people receiving meals use the home-delivered metl1od. • Disease
The U .S. government sets specific standards fo r home-delivered meals and for those • Eating poorly
served in congregate feedin g centers. T he meals are designed to provide one-third of • Toath loss or mouth pain
RDA/Al. The social aspect often improves appetite and general outlook on Life. • Economic hardship
Still, congregate meal programs generally provide one meal a day (some provide • Reduced social contact and interaction
more) and usually just 5 days per week. Anotl1er problem with h ome-delivered meals • Multiple medications
is that the one or two meals deUvered may never be eaten , and if not eaten on deliv· • Involuntary weight loss or gain
ery and left at room temperature, tl1ey may become unsafe to cat later. Thus, these • Need for a ssistance with self-care
programs can help older adults bu t probably don't met:t aU tht:ir nutritional needs. 1 • Elder at an advanced age
In addition to congregate and home-delivered meals, federal commodity distribu-

tion is available in some areas of the United States to low-income o lder people. Food
stamps can benefit older people wbose incomes are below the poverty level (see
Chapter 20 for details on these programs). Food cooper atives and a variety of clubs,
religious, and social organizations provide additional aid.
Concept I Check
Specific nutrient requirements for older adLLlts are o nly now bei11g extensively studied. Diet
plans should be modified for decreased physical abilities, the presence of drug-nutrient in-
teractions, possible depression, and economic constraiJ1ts. Parrirnlar attention should be
paid to the opportunity for sun exposme and intake of the vitamins D, B-6, E, folate, and
Healthful aging provides many benefi ts, such B-l 2 as weU as the minerals calcium and zinc and fiber. A nutrient-dense diet helps meet
os an increased abilily to interact with younger these needs. Carefolly planned multivitamin and mineral supplement use can also help, es-
family members and friends. pecially adults 70 years of age and older. Jn the Onited States, maJ1y nutrition senrices-
such as congregate and home-delivered meals-arc available to help the aging population
obtain a he<llthful diet.
wo other websites for organizations that

T focus on issues surrounding age ore:
www.ifcusa.org Frances could contact a local government office that offers congregate meal pro-
www.aging·institute.org grams of a central location. She could inquire about location and available trons·
portotion to the site. This meal program would give her social contact with other
older persons, which is probably on important element that is missing in her life, and could help
alleviate her loneliness. She could also request Meals on Wheels (if available) to provide one
hot meal a day, which may be just what she needs to help stimulate her appetite. She could
also hove groceries delivered to her home if her budget could withstand the extra cost. Other
convenience foods that could be included in her diet are milk, assorted nuts, peanut butter,
breakfast cereals, conned chicken or deli meats, yogurt, sliced cheese, cottage cheese, colcium-
fortified orange juice, canned or frozen frui ts and vegetables, and some fresh fruits and vegeta-
bles that do not require preparation, such as prewoshed lettuce and bananas. A further
possibilily is a nutrition bar or a liquid nutritional supplement, such as Ensure Plus. The resulting
increase in her nutrient intake would help prevent disease in the fu ture and increase her sense
of well.being.
Summary
1. Compression of morbidity means delaying symproms of and dis- 4. Nutritional problems of o lder adults are related co the presence of
abilities from chronic disease for as man y years of life as possible. chronic diseases and co the normal decreases in organ function
Most scientists agree upon diet recommendations for the general that occur with time. These include loss of teeth, lessened sensi-
public, including those provided by the 2005 Dietary Guidelines tivity to caste and smell, ch anges in GI tract function, and deteri-
for Americans. Such amhorities recommend that individuals ear a oration in cardiovascular and bone health. Although disease affects
variery of foods; balance the food eaten with physical activity to nutritional state, the reverse is also true. Undernutrition adversely
maintain or improve weight; choose a diet with plenty of grai n affects immune function, allowing for infection.
products, vegetables, an d fruits; choose a diet low in saturated fut 5. Scientists are o nl y now beginning extensive sn1dy of specific nu-
and cholescerol; choose a diet moderate in su ga rs and salt; <tnd trient needs for o lder people. Diet plans shouJd be based on a
Limit or avoid alcoholic beverage intake. Regular physical activity nutrient-dense approach and individualized for existing health
is also important, as is safe food preparation. problems, decreased physical abilities, presence of drug-nut1ient
2. Altho ugh maximum life span hasn't changed, lifo exp ectancy has interactions, possible depression , and economic constraints.
increased dramatically over the past century. For man y societies, Specific nutrients-such as protein, vi tamjn D, vitamin B-6, folare,
an increasing proportion of the population is over 65 years of age. virnmin B-12, zinc, and calcium along with fiber <tnd fluid-often
As health-care rnsts rise, the goal of delaying disease becomes deserve special attention in diet planning. A balanced multi\1itamin
more important. and mineral supplement can be used to help meet needs, especial!)'
3. Aging begins before birth. CeU aging probably results from auto- in people age 70 years and older.
matic cellular changes and environmental influences such as DNA 6. Health-care workers and fam ily members sho u ld use available op-
damage. Add to this list damage caused by e lecrron-seeking free- tions for t he procurement of food for older adulrs, especially for
radical compotmds, high blood glucose, hormo nal chan ges, and those who are nu tritionally compromised. Most communities have
alterations in the immune system as possible causes. congregate or home-delivered meal system s, food stamps, and
other provisions for those who qualify.
[ Study Questions
1. List foi.ir important points made in the 2005 Dietnry Guid elines 8. What three resources in a communi ty are widely ava ilable ro aid
fo1· Americans and g ive an example of wh)' each o ne may b e diffi- o lder adults in maintaining nurritional health?
cult fo r older adults to implement. What arc some solutio ns to 9. Describe some warning signs of depression and note a possible nu-
these barriers? tritional implication as t his problem advances.
2. What is the difference between life span and life expectancy? 10. List four warning sig ns of undernu tri tion in older p eople that are
3. Name rwo hormones t hat decl.ine with aging and the functions of part of t he acron ym DETERMINE. Briefly justify the inclusion of
each. each.
4. Describe rwo hypotheses proposed to explain the causes of aging,
and note evidence for each in your daily life experiences.
5. List four organ systems that can decl i.ne in fi.mction in later years, BOOST YOUR STUDY
and list a diet/Lifestyle response co help cope with th e d ecline. Check out the Perspectives in Nutrition: Online Learning
6. Defend the recommendation for regular physical activity during Center www.mhhe.com/wardlawpers7 for quizzes, Rash
older adulthood, including some resistance activit)• (weight u·aining). cards, activities, and web links designed to further help you leorn
7. How mig ht th e mmitional needs of older people differ from those about nutrien t needs in adulthood.
of younger people? How are their needs similar? Be specific.
1. ADA Rcporrs: Position of the American 2. Birrcr RB and Vermu ri SP: Depression in later tbor notes that tl.elnying the disease should be the
Dicrctic Association: Nuu·it:ion across the spec· life: A d iagnostic and therapeutic challenge. 11Jni11 fl1c11.r, became current medicatimu nre 1111r
Lrum of aging. ]011rn11/ of the American Dietetic Amcricn11 Fnmi~y Physicin11 69:2375, 2004. 11ttt')' cffecti11c.
Associatio11 105:616, 2005. Depressi011 is 11. common p·oblm1 in 11Ltler ntlnlr- 4 . Dickerson LM, Gibson MV: Managemem of
Bcbavim·s mch 11s n healtl~ful diet, bei111J physi- hood. ft 11ceds to be ndtlressed bemuse it mi.res hypertension in o lder persons. A mc1·icm1
cally 11cti1•e, and nor u.sin.!} tobacco in any form the risk flw suicide. Diagnosis nud t1w1tmmr of Fami~v Ph.ysicia11 71:469, 2005.
nre three keys ti/ herilthfi1l aging. Tin A111eric1111 tl.ep1-essi1m 11re re11i.:JJ1etl. i11 detail i11 this rrrticlc.
Hypcrtensio11 is a too·com111011 1-cmlr of the
Dietetic Association mpports these prnctices nut/. 3 . Cu mmings IL: Alzheimer's disease. Tbe Ne11 1
agi11g prnci:ss, especi11llv clc1111tcd systolic b/011d
encourages older adults to seek medical and n11 - E11glrwd jnumal of Medicine 351:56, 2004. pr,;ssm·c. Tbc attthors S11!1!J&st that older pt·opl.:
tritio11al care to treat ongoi"!J healtb p1·0/Jlcms 171is nrticlc co11tni11s n tl.etniled r.:viell' 11fthe t:1·y to c11mlmt this trend by fo/10111i11g 11 hmlt/Jy
such ns diabetes and hypertmsion. ltit«st.fi11di11gs 011 Alzheimer's disease. T71e au· diet loll' in sodium a11d nlc11/m/ (if cons1mud)
trnd ns J11clf pe1'fi1r111 regular p/Jysical actiPity. 10. Moeller SM and others: Overall adhere nce ro (c,g., meeting energy, calcium, iron, n11d 11itn·
T.1•pical medications med tll tt·cnt hypertension rhc Diemr)' Guidelines for Americans is associ- 111i11 D needs), aerobic a11d streugth·trniuing
in the pop11lario11 nre rrlso rc11ie1J1ed. an:d with reduced pn;valem;c of early age- phyS'ical ricti11itics, and appropr·i!Jte medical
5. DiMaria-Ghali li RA, Amelia E: Nurrition in related nuclear lens opaciLies in women. sc1·ee11i11g tests for each decade of ndulr life.
older adulrs. American Jo1trnnl of Nm·sing Jrnmwl of N11.ti·itio11l34:1812, 2004. 16. Sisk J: Aging and fit- the shape of thin~ co
105(3):40, 2005. A high-quality diet, sucb ns om that follows the come. Today's Dietitian, p. 34, July 2004.
M11ln11tritior1 in older persons is important to Dietary Guidcti11es fo1· Americn.115, 1vas shonm ro Rcg11lrrr physical acti11iry is vital to prc11&11t ngc·
prevent, been me it is n biggu· risk thau irve1·- prC11erzt or delay tbe dcveuJpment of lens r>j/flcities rcl1ited declines i11 many aS'pects ofhealth. A key
weight to the bealth of this populritiois. Risk Jae· (i.e., cntnmcts) in women in this stttdy. point is tbat one is 11e1>e1· too old to start rrn ex·
tot's that comribute to mnlmitritioti include 11 Implementing all the reco111111mdations wn.< ercise program and achi&l'f hcalt/J bmcfirs.
poor diet, limited income, isolation, cbronic ill· more help.f1tl than fotloming one 01· t1110 in isol.n·
tio11, such as just c1msumi11g ri diet rich in fruits 17. Szuk P a nd others: Hormonal and lifestyle de-
11ess, a11d various physiological changes that re·
and 1vho/c grn.im. rermi nanrs of appendicular skelcml mtL~clc mass
mltfr11m agi11g. These factors in tttrn r.a11 be
in men: The MINOS smdy. Awe1·ica11 jo11n1nl
addressed by app1·op1·iate lifestyle interventions 11. Pecersen RC and others: Vitamin E and
o.fClinical Ntitrition 80:496, 2004.
rei>iewcd i11 the 111•ticle. doncpa.il for che trcabncnt of mi ld cognitive
impairment. The New England ]01w11al of In older men, Ion• physical acrivif')> tobncco
6. Fragalis AS: Popular dietary ;1~pplements. 2nd
Mcdicfoe 352:2379, 2005. smoking, thiimcss, loll' blood tcstostenme, nut!
ed. Ch icago, IL: American Dietetic Associa-
po01· vitnmin D statm were fo1111d ro be risk jhc·
tion, 2003. Megnd11se 11itm11in E tbempy did 11ot sl1111' de1>et·
to1·sfo1· reduced muscle mnss, termed snrcopcnin.
T71is book pro1>idcs n comfn·cbcnsive review of n.n- opmmt of mild cognitii•c impairment in this
Lllck 11f physical activity is especially i111pona111
tricnt rind he,.bnl wpplcms11ts. Any use of study. 7J1is 1·csult qucst:iom erirlier studies that
to nddl'ess in orrf.cr to maintain n henlth,v
bcrbnf remedies .:specially deserves caution; po· showed a modest {mt s/Jort·li1>cd effect ofsuch
m1101mt of m11Scle mass as 011c nges.
tential brne.fits Mid risks in this 1·egard arc therapy. The medication donepezil wns some·
described. what e!Jecth>c, but e11c11 this therapy fed tn <111ly a 18. Trichopoul o u A and ochers: Modified
modest be11efit. Mediterra nean diet and survival: EPIC-elderly
7. Gerting smarr abom Alzheimer's. Tufts Univer·
prospective cohort study. British Medical
sityHcaltlJ1111d Nutrition L.:tter23(3):l, 2005. J 2. Rao SS: Prcvenrion or foils in older persons.
}011mal 330:99 1, 2005.
As ma11y ns 4.5 milti1111 Americam mf]c1from Ame1•icn11 Fami~y Pbpician 72:8 1, 2005.
A diet chnrnrw·ized by higb inrnkes o_f11egrtn·
Alzhcimet-'s disensc. Conmmilig a diet 1-icb in Risk factorsf11r [nils i11 11/drr pcl'.l-o11s-rnch 1u
blcs, leg1m1cs, frttits, ccl'mls, n11d munturnrcrl
brighrly colored j1-i1its n11d 11egetables, n•hich co11- 11111sc11lar wcak11ess, he11.11y use of111edicnti.ons,
fats; moderate n11101mt.r offlsli a11d nlc11/Jol; and
tni11 111a11y pbyt11chemic11ls, ma)' fwe11e11t the dis· old age, imtiainueut ofgnit a11d baln nee, a11d
ltiw·to·modemte a11101mts of ti.air)' pr11d11rts nnd
ease. Co11mmi11J1 fis/J 011 a regular btHis is also poor vision-11rc reviewed iu this anicle.
meats lessened tbe t·isk 1Jj'devcloping cn,.dim•ns·
i111pona11 t, as is m•oidi11g obcsi ty, cxc rcisin.g 1·eg· />rc11e11tio11 ofjhtlr rJ.rpcciril~y should f11e11s 011 wlm· disease in people i11 rhis st'lldy. Tomi 111111 ..
11fnrly, 1111d keepiug tumtal~~· active. Meeting B pl~yrical exercise tll imp1·(}1•c m11srnlar stre11gt/J
rnlity was al.so 1·cduced, cspccial~y stJ in pcoplr
l'itnmi11 needs i.s also cmcinl bemuse mnny, mch 1111d gait n.< rvel/ as n 1·c1 1icw of all medicn tiom who close~)' adhered to rbis diet partem.
as 11inci11, co11trib11te t11 bmitt /Jenlth. used. HnJ1i11g n homf i11S'pertion ~l' n profes·
8. Heilbronn JK, Ravussin E: Caloric resu·iction si1mal is nls11 helpful t11 idc11tify pliysical lmza.rds 19. Trumbo R; Hormone changes in aging adults
and aging: Rc1·icw of the lircratun: and implica· that ca11 be con•cctcd, such as lnck of hnndrnils probed. ]011r111il of the American Mcdicnl
tions for srndies in humans. American journal on stairs. Associntio11 294:663, 2005.
of Clinical Nutrition 78:361, 2003. 13. Robertson R.G, Monragnini M: Gcriat1ic fui lure Hormones that typicnll;11 decline ill aging nrc
Cn/t/rfr restriction l111s bee11 long kno1v11 to ex· to thrive. Aniericnn Fmui~y J>J~11sicia11 70:343, testostc1·011e, ~f{romth bor111011e, and tbyroid /Jor-
tend tl1e Life span and retard related chr1111-ic 2004. monc. Rcplacc111cnt of all tl11·ce is possible, b11t
diseases tifrnts, mice,fish,jlics, and 11ther species. each carry risks, and so m1y 11se 11eeds to be rn n··
171c ma11:v factors 1·clated to failure tll thril'c in .f11//y considered by the 11ldo· pcrso11 n 11tl bis or
171is ma_"I be due to a 1·ed11ctio11 in metabolic olde,. adults arc 1·cl'ie111cd. U.re of 11111/riple med·
rate a11d O.'Cid11ti11e stress, improved ins11lin se1t· he,. physician. Gro rpth hormone themp.v is 1•ay
ictitio11s and dcprcssi1111 rrrc two co111111()n causes
sitivity, and nltc1·ed nervous system and hor· cxpcmivc, n11d so lensr likeZv of tJJc t/Jrec to bt
that often need to be addressed.
mo11al nctiliities. Trials tll"e m1den1111y to test administered.
111/Jctber prolonged caloric restriction increases 14. Schardt D: Arc )' Our supplements safe? 20. T ucke r KL an d others: T he combination o l
Ni1tritio11 Action Henlthletter 30(9 ):], 2003.
life span 01' 1·etfl.'rds the aging p1·ocess in hmnn.ns. hig h fruit and vegerablcs and low sarurared fur
9. Litchford MD: Declining nutritional Starns in 7J1is article pro11ides n. co111p1·clie1uivc rer•icw of intakes is more p rotective against morraliry in
o lder adulrs. Today~r Dietitfo.11, p. 12, Ju l)' 2004. populm· IJerbal mpplemmts. Lt also coven herbs aging men i:han is either alone: The Baltimore
The most com111011 causes of declining 1mtri·
and orbet• substances t11 m•oid been 11se of n hig/J lon g irndinal smdy or
aging. Jmmial of
pote11ti11/ for to."icity. N1m-itio11 135:556, 2005.
tio11al stntti.s i11 olde1· adults arc poo1· food
choices, faili11g cognitive st11N1.s, oral health pn1b· LS. Staying well-ar your age. Co11s11111cr Repm·ts 1111 A diet rich in fruits nnd vcgetnblcs aurl loll' 111
le111J; loss of appetite, rmd dehydration. 'ffcn.Lrb 17(9): l , 2005. sn.tttmted fat intnkes i-cduced mo1·taliry iu
lmplemc11ti11g an nction plan to trcnt these A dctn.ilcd pta11 of bcaith p>"omotion a11d discnsc aging 1>1&11 in this st11d;v. P11tti11g 11/I t111w 1·ec·
pmblc111s is important; n registered dietitian pt·eveuti/111 ns one ages is pi·eswted ill the m·tick. l)mmendn.tions into pi·actict· was espccialfr
can help develop mc/J a plmi. 111is pln11 includes dietary rccommmdations lielp.fi1l.
Take I Action
I. Am I Aging Healthfully?
Take Control of Your Aging by Dr. William B. Malarkey [Wooster Book Ca. , Wooster OH, 1999) includes a plan that incorporates vari-
ous diet and lifeslyle factors that are associated with successful aging. Indicate the degree to which you are following such a plan (or
alternatively fill this out wi th o parent or another older relative in mind) .
Physical: Do you eat o well-balanced diet, exercise on a regular basis, remain free of illness, abstain from smoking, refrain from
drinking alcohol excessively, and experience refreshing sleep?
Intellectual: Are you analytical, do you read regularly, do you learn new things each day, do you engage your mental abilily al
work (or at school), and do you often reflect on your life?
Emotional: Are you ot peace, do you like who you ore, ore you optimistic, and do you laugh and relax regularly?
Relational: Are you o good listener, do you feel supported by friends, do you attend social functions, do you talk with family
members often, and do you feel close ta coworkers (or fellow students)?
Spiritual: Do you appreciate nature, give lo or serve others, meditate or seek religious warship, and feel life hos meaning?
The mare of these factors that you include in your life, the mare well rounded your plan is far maintaining overall health. Any one of
the five areas in which you ore not achieving success should show you characteristics la work on in the future.
•
.. I •
11 I ••
t ••
I .. "'t I
~}--
" I C.. - r".t
-~ t;-:.
Take I Action J .
II. Helping Older Adults Eat Better

During their lifetimes, most people usuolly eot meols with fomilies or loved ones. As
people reoch their older oges, mony of them ore foced with living and eoting olone.
In o study of the diets of 4400 older odults in the United States, one man in every
five living olone and over oge 55 ale poorly. One of four women between the ages
of 55 ond 64 years followed a low-<juolity diet. These poor diets con con tribute to
deterioroting mento l and physicol health. Consider the following example of th e liv-
ing situation of on older adult.
Neal, o 70-yeor-old man, lives alone in o home in o locol suburbon oreo. His
wife died one yeor ago. He doesn't hove many friends; his wi fe wos his primary
confidante. His neighbors ocross the street ond next door ore friendly, and Neal
used to help them with yard projects in his spore time. Neol's heolth hos been good,
but he hos hod trouble with his teeth recen~y His diet hos been poor, ond in the
post 3 months his physicol ond mental vigor hove deteriorated. He hos been slowly
lapsing into a depression and, so, keeps the shades drown and rarely leoves his
house. N eal keeps very little food in the house becouse his wife did most of the
cooking ond shopping, and he just isn' t thot interested in food .
If you were one of Neol's relatives and learned of Neal's situation, what six thing s could you do or suggest to help improve his nu-
tritionol stotus and mental outlook? look bock through this chapter to get some ideos.
1.
2.
3.
4.
5.
6.
•
SAFETY OF FOOD AND WATER

Safety of Food and Water: Setting lhe Stage Aaron attended a gathering of his officemales on a worm July Saturday. The theme
What Are the Effects of Foodborne Illness? •
Why Is Foodborne Illness So Common? was international dining, and he and his wife were told lo bring Argentine beef, a
Food Preservalion: Past, Present, and Future slewlike dish. They followed the recipe and cooking time carefully, removing the
Foodborne Illness: When Undesirable dish from the oven at 1 P.M. and keeping ii warm by wrapping the pan in a towel.
Microorganisms Alter Foods
They traveled in !heir cor lo the party and set lhe dish out on the buffet table at
General Rules for Preventing Foodborne Illness
Expert Opinion: Food Safety-Why Should You 3 P.M. Dinner was to be served at 4 P.M. However, the guests were enjoying them·
Care? selves so much lounging around the host's pool and drinking ginger beer (also on
A Closer Look al the Microorganisms That
the menu) that no one began to eat until 6 P.M. Aaron made sure he sampled the
Cause Foodborne J/lness
Cose Scenario Follow-Up Argentine beef that he and his wife mode, but his wife did not. He also hod some
Food Additives salad, garlic bread, and a sweet dessert mode with coconut.
Uses of Food Additives • Intentional versus The couple returned home at 11 P.M. and went to bed. About 2 A.M., Aaron
Incidental Food Additives • The GRAS Lisi •
Synthetic Compounds • Tests of Food Additives knew something was wrong. He hod severe abdominal pain and hod to make a
for Safety • Approval For a New Food Additive mod dash to the bathroom. He spent most of the next 3 hours in the bathroom with
• Common Food Additives • Risks of Food
Additives severe diarrhea. By down, the diarrhea hod subsided and he hod started feeling
Substances That Occur Naturally in Foods and better. After a few cups of tea and a light breakfast, he was feeling like himself by
Can Couse Illness
Environmental Contaminants in Foods
noon. z
~
Lead • Dioxin • Mercury • Urethane in Some What type of foodborne illness did Aaron contract? What precautions for ovoid· 0
Alcoholic Beverages • Polychlorinoted
Biphenyls (PCBs) • Cadmium • Protection from
ing foodborne illness were ignored by Aaron and lhe resl of the people at the
party? How could this scenario be rewritten lo substantially reduce the risk of food·
")>
;;:o
Environmental Toxins in Foods ()

~
Our Water Supply: Safety Issues borne illness?
()
Bottled Water • Monitoring the Sofety of Your m
Water • Options Regarding Your Water
Source
Nutrition Focus: Pesticides in Food
Take Action
A t the turn of the twentieth century, conditions in Chicago's meat-pocking industry were sicken-
ing. Moldy, spoiled meat was commonly doused with borax to cover up the smell, and glycer-
ine was added to make it look fresh. By 1906, increasing public pressure forced the passage of the first
Food and Drug Act in the United States. Federal inspection then safeguarded the public from worm-
infested and diseased meat and generally improved food preparation standards.
Today, warnings about the safely of food and water appear everywhere. Attention hos turned lo more
conlemparary concerns, such as microbial and chemical contominolion. On one hand, we ore told lo
eel more fruits, vegetables, fish, and poultry and to drink more water; on the other hand, we ore warned
that these may contain dangerous substances, so we still must ask,
#How safe is our food and water?"
Scientists and health authorities agree that North Americans
enjoy o relatively safe food supply, especially if foods ore stored
TO ALLOW YOU TO:
-
and prepared properly. Our water supply is also generally
safe.2 Over the post 100 or so years, tremendous progress hos
1. List some of the lypes of bacteria, fungi, viruses, and parasites
found in food and their common sources. ..'
been mode lo allow for this. Nonetheless, microorganisms and 2. Describe common means by which food and water become
contamina ted.
certain chemicals in foods still con pose a health risk. 1•l9 Thus
3. State conditions that support growth of food microorganisms.
the nutritional and health benefits of food and water must be bol-
4. Describe the procedures that con be used to limit the risk of
onced against any related hazards. Chapter 19 focuses on these foodborne and waterborne illness.
food- and water-related hazards-how real they ore and how 5. Compare and contrast how food-preservation methods, such as . •
you con minimize their effect on your life. Note that you bear pasteurization, conning, irradiation, and aseptic packaging,
some responsibilily for this-government agencies and industry control the growth of microorgonisms in food.
con only do so much.12 Recall from Chapter 2 that the 2005 6. Describe the main reasons for using chemical additives in
foods, the general classes of additives, and the functions of
Dietary Guidelines for Americans emphasize safe food proc· each doss.
!ices. One goal of Healthy People 2010 is to reduce by 50% the 7. Identify loxic environmental contaminants in food, related
number of coses of foodborne illness from lypicol bacterial
causes.
complica ti ons of ingestion, and sources.
8. Understand the reasons behind pesticide use, the possible long·
'~
term health risks, and the safely limits set for their use.
•"'
OF FOOD SAFETY IN CHAPTER 19, YOU MAY WANT TO REVIEW:
The disease phenylketonuria (PKU) in Chapters 4, 5, and 7
Alternative sweeteners m Chapter 5.
fat substitutes in Chapter 6.
The causes of cancer in Chapter 12.
Safety of Food and Water: Setting the Stage

During the c01rly stages o f urbanization in Nord1 Americ.1, contaminated water and
food- notably, milk-were responsible for many lar ge outbreaks of typh oid feve r, scp·
pasteurizing The process of heating food tic sore throat, scarlet feve r, diphtheria, and other deYastating human diseases. Th c~c
products to kill pathogenic microorganisms and contaminations led to the dc,·elopment of processes for pur~'in g w ater, treating
reduce the total number of bacteria. sewage, and pasteuriz ing milk. Since that time, safe warer and milk ha,·e become uni-
ve rsally a\·aibble, with only occasio nal p ro blems fro m cither.2 •3
690
The greatest health risk from food and water coday is comaminntion by viruses and
virus The smallest known type of infectious
bacteria and, to a lesser ex rent, by \'arious forms of fungi and parasites. 12 These mi- agent, many of which cause disease in
croorganisms can all cause foodborne illness and can also cause illness when in the humans. Viruses do nol metabolize, grow, or
water supply.3 For example, in one recent case a child died and 50 others became ill move by themselves. They reproduce only with
from Escherichia coli (E. coli) bacteria found in apple ju ice. 1n another case, 170 chil- the aid of a living cellular host. A virus is
dren became ill when their school lunch contained strawberries contaminated by hep- essentially a piece of genetic material
atitis A ,·irus. In 1993, 400,000 people in Milwaukee became ill and 100 died from surrounded by a cool of protein.
water contaminated with the parasite Ct·yptosporidium.
bacteria Single-cell microorganisms; some
Even though microbial contamination is the cause of most incidents of food- and produce poisonous substances that cause illness
water-related illness, North Americans seem more concerned about health risks from in humans. They contain only one chromosome
chemicals in foods and water. Of U.S. consumers surveyed in a Gallup poll, about 75% ond lock many organelles found in human cells.
said that pesticide contamination was a major concern to them. In the long nm, this Some con live without oxygen and survive by
concern has some merit. On a day-to-day basis, however, it is not very important in means of spore formation.
North America. 19
spores Dormont reproductive cells capable of
Because microbial contamination of food is by far the more important issue for our
turning into adult organisms without the help of
day-co-day health, it will be discussed first. Chapter 19 wi.11 then cover the use and another cell. Various bacteria and fungi form
safety of food additi,·es, concerns over the safety of our water supply, and the risks of spores.
pesticides to our health.
fungi Simple parasitic life forms, including
molds, mildews, yeasts, and mushrooms. They
What Are the Effects of Foodborne Illness? live on dead or decoying organic matter. Fungi
con grow os single cells, like yeast, or as a
According to the U.S. Centers for Disease Control and Prevention, foodborne illness
multicellular colony, as seen with molds.
caused 76 million illnesses, 325,000 hospitali.lations, and 5000 deaths in the United
States in 2002. Hospira! costs for foodborne illnesses are estimated at more than parasite An organism that lives in or on
$3 billion per year; costs from related lost productivity are estimated at S8 billion per another organism and derives nourishment
year.3 Some people are particular!)' susceptible to foodborne illness, including: 8 •9 from it.
• Infants and children foodbame illness Sickness caused by the

• Older adults ingestion of food containing toxic substances
produced by microorganisms.
• People with liver disease, diabetes, HN infection (and AIDS), or cancer
• Pregnant women
• People taking immunosuppressanr agents (c.g" n·ansplant patients)
As you can sec, foodborne illness has the greatest effect on the most vulnerable peo-
ple in terms of health status (estimated to be about 30 million people in the United
States alone). Some bouts of foodborne ilL1ess, especially when coupled with the on-
going health problems, are lengthy and lead ro food ::illergies, seizures, blood poison-
ing (from toxins or microorganisms in the bloodstream), or other illnesses. toxins Poisonous compounds produced by on
Because foodborne illnesses often result from the unsate handling of food at home, organism that con cause disease.
we each bear some responsibility for preventing tbem. 10•12 Because you can't usually
tell by taste, smell, or sight that a particular food contains harmful microorganisms,
you might not e,·cn be aware that food has caused your distress. [n fact, your last case
of diarrhea may have been caused by foodborne illness (Table 19-1). Government
agencies are also at work on problems regarding food safety, but their work docs not
substitute for indi,•idual safety effortS (Table 19-2 ).
Why Is Foodborne Illness So Common?

Foodborne illness is carried or cransmitted to people by food. Most foodborne illnesses .1rc
rransmictcd through food in which microorganisms arc able to grow rapidly. These foods
are genera.Uy moist, rich in protein, and have a neutral or slightly acidic pH. Unfortunately,
this desetibes many of the foods we car every day, such as meats, eggs, and dairy produccs. 2
Our food industry tries whenever possible co increase the shelflife of food products; ote that some restaurants that will serve re·
however, a longer shelf life allows more time for bacteria in foods to multiply. Some quested undercooked food ore now worn·
bacteria even grow at refrigeration temperatures. Partially cooked-and some fully ing patrons (on the menu) of the health risks of
cooked-produces pose a particular risk because refrigerated storage may only slo", ordering such foods, porticulorly with under·
not prevent, bacterial growth.2 cooked eggs and meals.
692 Chapter 19 Safety of Food and Water
Table 19· I I Some Examples of Coses of Foodborne Illness

We generally hove o safe food supply, but there ore occasional instances of foodborne illnesses, such as the incidents listed in this table.
Viruses
• An estimated 6 million oysters from Louisiana were bathed with the machine. During the Gulf War, Norovirus was one of the most common
Norovirus after ships with ill crew members dumped their sewage causes of gastroenteritis among U.S. troops. Recently passengers on cruise
overboard. By the time the outbreak was recognized, an estimated ships have also con tracted Norovirus illness.
20,000 lo 30,000 people hod become ill. Another outbreak of the • Over 500 adults in the United States contracted hepatitis A after eating row
virus was attributed to an infected bakery worker who stirred o vat green onions in a Mexican restaurant. The onions were contaminated
full of buttercream frosting with his bore hond and arm. In Florido, during growth in Mexico and were not properly washed by food service
83 fraternity members cought the virus from the fraternity house ice workers.
Bacteria
• A previously healthy 5-month-old girl suddenly died at home from sources of infection. One of the largest E. coli 0157:H7 outbreaks on
contact with a pet iguana infected with Solmonello. Unpasteurized record infected more than 1000 people in upstate New York al a county
juice products were recalled after 57 cases of Solmonello illness fair. The bacterium was found in infected well water. It killed a 79-yeor-old
were reported in California and Colorado. Eight people become ill man and o 4-yeor-old girl, and ii caused 10 other children to undergo
from Salmonella ofter consuming tiramisu, a dessert that contains kidney dialysis. Six adults and o 2-year-old child were killed ofter on E. coli
row eggs. outbreak from contaminated drinking waler in Canada. The bacteria
• Six persons were reported ill from o Shige//o infection after eating entered the water supply from animal manure ofter flooding from a heavy
chopped, uncooked parsley that was served on chicken sandwiches storm. In northeastern Oklahoma, five children were infected with E. coli
and in coleslaw. A cruise ship hod lo return lo port when more than ofter consuming unpasterized apple cider. Recently 25 million pounds of
600 people developed shigellosis and one person died. hamburger hod to be recalled because of potential E. coli 0157:H7
• The first documented foodbarne illness caused by Listeria organisms contamination. A woman died in Columbus, Ohio, after she was infected
In North America occurred in commercially prepared coleslaw. Loter, with E. coli 0157:H7 bacteria.
48 deaths were associated with soft, Mexican-style cheeses. A • A man in Arkansas developed botulism ofter eating stew that was cooked
listeriosis outbreak associated with undercooked hot dogs and cold and then kept at roam temperature for 3 days. He spent 49 days in the
cuts resulted in more than 82 illnesses and 17 deaths in 19 states. hospital-42 of them on mechanical ventilation. Another recent case involved
Another outbreak of Listeria sickened at least 120 people and killed a man who ale hord-boiled eggs that were left in a pickling solution al
20 in the northeastern United Stoles. Recently 14.5 million pounds room temperature for 7 days.
of ready-to-eat meat and poultry products were recalled because • Since 1992, 17 people in Florido died of Vibrio vulnificus infections
of possible Listeria contamination. A meat-pocking firm recalled ofter eating row oysters.
27.4 million pounds of turkey and chicken after finding Listeria • A teenage boy and his lather experienced abdominal pain, vomiting, and
bacteria at the plant. diarrhea within 30 minutes of eating 4-doy-old homemade pesto. The pesto
• The first community outbreak in the United Stales of E. coli had been reheated and left out o number of times during the 4.cJay period.
0111 :H8 sickened 58 teenagers at o cheerleading comp in Texas. It was apparently contaminated with Bacillus cereus. As o result, the boy
The comp salad bar and a communal water barrel were suspected died of liver Failure.
Parasites
• A group attending a dinner banquet developed diarrhea 3 lo 9 days illness were positive for Cryplosporidium. Food workers at the restaurant
after eating green onions, which wos the likely cause of the outbreak. reported they did not consistently wash green onions before using them.
Eight of 10 stool specimens obtained from the group with loodborne
Risks from Seafood

• Four adults become ill with scrombroid fish poisoning after eating Bahamas. All 17 men become ill with nausea, vomiting, obdominol cramps,
tuna-spinach salad at a restaurant in Pennsylvania. and diarrhea within hours of eating the fish. Within 2 days, all of the men
• An outbreak of ciguatero fish poisoning involved 17 crew members suffered from muscle poin and weakness, dizziness, ond numb or itchy
of a cargo ship that caught, cooked, and ate a barracuda in the feet, hands, and mouth.
The risk of contracting foodborne illness also is high because of recent consumer
trends. FirsL, there is greater consumer interest in eating raw or undacooked animal
products. In addition , more people receive medication rhat suppresses their abilit) to
co mbat foodbome intcctious agents. Another factor is the continuing increase in the
number of older adulrs in the population.
The risk of illness from food borne microorganisms increases as more of our foods
are prepared in kitchens outside the home . Supermarkets ha,·e become majo r food
processors over the past decade and now offer a variety o f prepared fr>ods from spe-
cialty meal shops, salad bars, and bakeries. WiLh the increasing number of two-income
Table 19·2 I U.S. Agencies Responsible for Monitoring the Food Supply
Agency Name Responsibilities Methods How to Contact

United States Deportment • Enforces wholesomeness and • Conducts inspections www usdo.gov/fsis or
of Agriculture (USDA) quality standards for groins ond • Establishes trading www.nal. usda. gov /fn1cf..xxlborne/
produce (while in the field), meat, • Administers "Safe Handling foodborne.htm or coll
poultry, milk, eggs, and egg Lobel" 1-800-535-4555
products
Bureau of Alcohol, Tobacco, • Enforces lows on alcoholic • Conducts inspections www.atf.treos.gov

and Firearms and Explosives beverages
(ATF)
Environmental Protection Agency • Regulates pesticides • Approves oil U.S. pesticides www.epo.gov
(EPA) • Establishes water quality • Sets pesticide residue limits in
standards food
Food and Drug • Ensures solely ond wholesome- • Conducts inspections www.fdo.gov or coll
Administration (FDA) ness of oll foods in interstate • Conducts food sample studies 1-800.FDA-4010
commerce (except meat, poultry, • Sets standards for specific foods
and processed egg products!
• Regulates seafood
• Controls product labels
Centers for Disease • Promotes food safety • Responds to emergencies con· www.cdc.gov
Control ond Prevention cerning foodborne illness
(CDC} • Surveys and studies environmen·
tol health problems
• Directs/enforces quarantines
• Conducts notional programs for
prevention and control of food-
borne and other diseases
Notional Marine • Monitors domestic and interno· • Conducts voluntary seafood in· www nmfs.nooo gov
Fisheries Service or NOAA tionol conservation and manage· spection program
Fisheries ment of living marine resources • Con use mark lo show federal
inspection
Stole and local • Promotes milk safety • Conducts inspections of food· Government pages of telephone
governments • Monitors food industry within related establishments book
their borders
Government ogencies responsible for monitoring food sofety in Canada and the specific lows followed ore listed in Appendix D
families, more people are looking for convenient, easy-to-prepare, nutritious foods.
Supermarkets offer enm~es that can be ser\'ed immediately or reheated. The foods arc
usually prepared in central kitchens or processing plants and shipped to individual
stores.
This centralization of food production by the food -processing and restauranc in-
dustry enhances the risk of foodborne illness. If a food product is contaminated in a
processing plant, consumers over a wide area can suffer foodbornc illness. For exam-
ple, a malfunction in an ice cream plant in 1\ \innesota resulted in 224,000 suspected
cases of Salmonella bacrcriaJ infections, linked to use of contaminated ice cream mix.
At lease 4 people died and 700 became ill in Washington and surrounding western
states after eating at a chain of fast-food restaurants. The source of rhc problem was
undercooked hamburger contaminated with the bacterium E.coli Ol57:H7. Note that
restaurants generally encounter inspection by local health deparrmcncs about e\'ery Food contaminated in o central plant con go on
6 months. We must primarily rely on each restaurant to practice good food sa!Cty. to produce illness in people in surrounding
Greater consumption of ready-to-car foods imported from foreign couna-ics is stiJJ states or even across the notion. In the case of
another cause of increased foodbomc illness in North America. ln the past, food im- juices, shown here, it is only important that they
ports were mostly raw products processed here under strict sanitation srandards. No\\, are pasteurized lo reduce risk of foodborne
howc\'er, we import more ready-co-cat processed foods-such as berries from illness, especially for the more susceptible of us.
Guatemala and shellfish from Vietnam-some of which are contaminated. U .S. au-
thorities arc currently reexamining inspection procedures for tl1esc impor ts.
T he use of antibio Lics in animal !<.:eds is also increasing the seve rit>' of cases or food -
borne illness. Thjs antibiotic use cncomages bacteria to develop antibiotic-rcsisram
strains, chose that can grow e\·en if exposed co typical antibiotic medicines. This issue
is cmrenrly receiving considerable attention by scientists in the field.
Finally, more cases of foodbornc djsease are reported now because scientists are
more aware of the roles of vaii ous players in the process. Every decade the list of rni-
croorganisms suspected of causing foodbornc illness lengthens. 1 [n addition, physi-
cians arc more likely ro suspect foodbornc contaminants as a cause of illness.
Furthermo re, we now know that food , besides serving .1s a good growth med ium for
some microorganisms, simply transmits many others as well . Seafood is receivin g
greater scrutiny and sun•eillance by FDA as a cause of foodbome illness. In addition,
FDA is conducting a $500,000 campaign ro educate U.S. consu mers abour the risks
of eating raw oysters. For more info rmation about these risks, contact FDA's Seafood
H oll.inc at 1-800-FD A-4010 or log on to \\'\\\\'.s,1fcfood .g.m .
Food Preservation : Past, Present, and Future

hen traveling lo developing countries, ii For centuries, salt, sugar, smoke , fe rmentation, a nd drying have been used to prl'-
W is recommended that you uboil ii, peel
it, or don't eat it." Ironically, up lo 70% of our
scrve food . Ancie nt Ro mans used sul fi tes to disinteCL wi ne containers and prcscn·c
wine. For thousands of ycai·s, sailed fish and meat have fed vast segments o( the
fruits and vegetables during certain seasons human population. ~ l ost presening method!. work o n the principle of dccrc.tc,ing
come from these countries. In other words, you water conrcnt. Bacteria need abundant srorcs of water to grow; yeasts .111d molds can
do not have to travel to acquire troveler's diar- g row with less water, but some is still necessary. Adrung sugar or salt binds\\ ater and
rhea. In response, we should carefully inspect so decreases the wate r ~wailablc to these micro bes. T he process o f drying evaporates
and wash produce, os we would in a foreign off free water.
country. D ecreasing the water content of some high-moisture foods, however, would c.rnsc
them ro lose essential characteristics. To preserve such foods-cucumber pickles, s.\Uer-
kraut, mi lk (yogurt), and wine- fermentation has bee n a traditio n<tl altcrnati\'C.
Selected bacteria or yeast arc used to ferment or pickle foods. The fermenting bacteria
or yeast make acids and alcohol, \\ hich minimize the growth of other bacteria and
yeast.
Today we can add pasteurization , ste ri lization, refri geration, freezing, foot!
irradiation A process in which radiation irradiation, canning, and chemical preservation to the list of food presen ·arion tech-
energy is applied lo foods, creating niques. An additional method of food preservation-aseptic processing-simultane-
compounds (free radicals) within the food that ously ste rilizes the food and pack<tge separately before the food ente rs the package.
destroy cell membranes, break down DNA, link Liq uid foods, such as fruit juices, are especially easy to process in this man ne r. With
proteins together, limit enzyme activity, and aseptic packaging, boxes of sterile milk and ju ices can remain on supermarket ~helves,
alter o variety of other proteins and cell
free of microbial gro\\ th, for man) years.
functions of microorganisms that can lead lo
Food irradiation uses minimal doses of radiation in order ro con trol patl1ogens such
food spoilage. This process does not make the
food radioactive.
as E. coli 01 57:H7 and Sainumellri. 14 Even though FDA has permi tted irradiation of
certain food products for more than a decade, the history of the technology goes back
radiation literally, energy that is emitted from nearly a century, including scienafic research, evaluation, and resting. The radiation
a center in all directions. Various Forms of e nergy that is used docs not make the food radioactin:. T he e nergy essential!) passes
radiation energy include X-rays and ultraviolet through tile food, as in microwave cooking, and no radioactive residues arc left behind.
rays from the sun.
However, the energy is strong e nough to break chemical bonds, destroy cell walb and
aseptic processing A method by which food cell membranes, break down DNA, and link proteins together. Irradiation thcrcb~
and container are separately ond controls growth of insects, bactcna, fungi, and parasites in foods.
simultaneously sterilized; ii allows FDA recently approved the use of irradiation for raw red meat to reduce nsk of
manufacturers to produce boxes of milk that E. coli an d other infoct ious microorganisms. Some food processors arc now doing so.
con be stored at room temperature. Other additions to the appro\'cd list arc shell eggs and seeds. Prior to this recent ap-
pro,·al, the o nly animal products so treat ed were pork and chicken. lrraruation also e\-
tends the shelf life of spices, dry vegetable seasonings, meats, and fresh fruits and
\'egetablcs.
Irradiated food, except for dried seasonings, must be labeled with the international
food irradiation symbol, the Radura, and a statement that the product has been treated
by irradiation. Foods treated in this way arc safi: in the opinion of FDA and many other
health authorities, including the American Academy of Pediatrics. 14 Although the de-
mand for irradiated foods is still low in the Un ited States, other countries, including
Canada, J;1pan, Italy, and Mexico, all use food irradiation technology widely. Certain
consumer groups continually try to block its use in the United States, claiming d1at ir-
radiation diminishes the nutritional value of food and that it can lead m the formation
of harmful compounds, such as carcinogens. Future research should he able to sort out
this controversy, but in any case the risk is very low. Keep in mind also that, even when
foods, especially meats, have been irradiated, it is still important to folio\\' basic food -
satcty procedures, because later contamination in food preparation is possible.
This is the Radura, the internalional label

Foodborne Illness: When Undesirable denoting prior irradiation of the food product.
Microorganisms Alter Foods

Most cases of foodborne illness are caused by specific viruses, bacteria, parasites, and
fungi. Prions-proteins invoh·ed in maintaining nen·e cell function-can also tw-n in-
fectious and lead to diseases such as mad cow disease. 11 Bacteria specifically cause
health problems either directly b)' im·ading the intestinal wall and producing an i11fec-
tio11 via a toxin contained in die organism, or indirectly by producing a toxin that is se-
creted into the food, which later harms us (called an i11toxication). The main way to
distinguish an infectious route from an intoxication is time: if symproms appear in 4
hours or less, it is an intoxication.
Many rypes of bacteria cause foodborne illness, including Bacillus, Campylobactcr, gool of Healthy People 2010 is to reduce
Clostridimn, Eschcrichiri, Listerin, Vibrio, Sal111011ella, and Stnpbylococcus (Table 19-3). the number of coses of foodborne illness
Bacteria arc everywhere: a teaspoon of soil contains about 2 billion bacteria. Luckily, from Compylobocter, E. coli, Listeria, ond
onJr a small number of bacteria actually pose a threat. [n addition, experts speculate Solmonello by 50%.
that about 70% of cases of foodborne illness go undiagnosed because they result from
viral causes, such as Norovirus, and there is no easy way to test for these pathogens. 20
A website coordinating the U.S. efforts on food safety is '" ' .trn 1d,.ifct~ . ~m . Other
useful websites arc " '''" ·rnu .1 ~n org/ !oodbnrne and \\'\\'\\ . homdi iodsafrty.org.
General Rules for Preventing Foodborne Illness T he World Health Organization's

Golden Rules for Safe Food
Preparation
You can greatly reduce the risk of food borne illness by following some very important
rules. It's a long list, because many risky habits need to be addrcsscd. 3 •4•10,l 2.l8 1. Choose foods processed for safety.
2. Cook food thoroughly.
Purchasing Food 3. Eat cooked foods immediately.
4. Store cooked foods carefully.
• When shopping, select frozen foods and perishablt: foods, such as meat, poultry, or
5. Reheat cooked foods thoroughly.
fish, last. Al\\'ays have these products put in separate plastic bags, so that drippings 6. Avoid conloct between row and cooked
don't contaminate other foods in the shopping cart. Don't let groceries sit in a
foods.
warm car; this allows bacteria to grow. Take the perishable food11 such as meat and
7. Wash hands repeatedly.
egg and dairy products home and promptly refrigerate or freeze them. 8. Keep oll kitchen surfaces meticulously clean.
• Don't buy or use food !Tom damaged containers that leak, bulge, or arc severely 9. Protect foods from insects, rodents, and
dented or from jars that are cracked or have loose or bulging lids. Don't rnste or use
other animals.
food that has a foul odor or spurts liquid when the can is opened; the deadly 10. Use pure water.
Clost1·idium botttlinmn roxin may be present.
• Purchase only pasteurized milk and cheese (check the label). This caution is espe- The USDA recently simplified these rules into
cially important for pregnant women because high ly toxic bacteria and 'iruses that four aclions as a port of their Fight SAC!
can harm the fetus thri\'e in unpasteurized milk. Program (check out www.fightboc.org):
• Purchase only the amount of produce needed for a week's time. The longer you 1. Cleon. Wash hands and surfaces often.
keep fruirs and vegetables, tl1c more time is available for bacteria to grow. 2. Seporofe. Don't cross·contominate.
• \Vhen purcl1asing precut produce or salads, avoid those that look slimy, brownish, 3. Cook. Cook to proper temperatures.
or dry; these are signs of improper holding temperatures. 4. Chill. Refrigerate promp~y.
Table 19·3 I Important M icroorganisms and Related Factors That Cause Foodborne Illness: Their Sources, Symptoms,
and Prevention
Microorganism Sources Symptoms Prevention Methods
Viruses
Norovirus (Norwalk found in the human intestinal tract Onset: 1-2 days. • Sanitary handling of foods
and Norwalk~ike and feces. Severe diarrhea, nausea, and vom- • Use of pure drinking water
virus), human rotovirus Contamination occurs: iting. Respiratory symptoms. • Adequate sewage disposal
( 1) when sewage is used lo en- Usually lasts 4-5 days but may • Adequate cooking of foods
rich garden/form soil last for weeks. • Good personal hygiene
(2) by direct hand-to-food contact
during the preparation of meals
(3) when shellfish ore harvested
from waters contaminated by
sewage.
Hepatitis A virus Fecol-0rol route that contaminates Onset: 15-50 days. • Sanitary handling of foods
food, beverages, or shellfish. Anorexia, diarrhea, fever, jaundice, • Use of pure drinking water
and fatigue. Moy cause liver dam- • Adequate sewage disposal
age and death. • Thorough cooking of foods
Bacteria
Compylobocter jejuni found on poultry, beef, and lamb Onset: 2-5 days ofter eating, or • Thorough cooking of foods
and con contaminate meat and longer. • Sanitary food-handling
milk. Chief food sources ore row Diarrhea, abdominal cramping, practices
poultry and meat and unpasteur- fever, and sometimes bloody • Avoidance of unpasteurized
ized milk. stools. Lasts 2-7 days. milk
Salmonella species Found in row meats, poultry, eggs, Onset: 1-3 days ofter eating. • Sanitary food-handling practices
fish, sprouts, unpasteurized milk, Nausea, fever, headache, obdomi· • Avoidance of any use of unpas-
and products mode with these nol cramps, diarrhea, and teurized row eggs or under-
items. Multiplies rapidly at room vomiting. cooked eggs
temperature. The bacteria them- Con be fa tal in infants, the elderly, • Thorough cooking of foods
selves ore toxic. and the sick. • Prompt refrigeration of foods
Shigello species Transmitted via fecal-oral route and Onset: l-3 days. • Handwoshing and sanitary food
somewhat in food and water. Abdominal cramps, diarrhea, fever, production
bloody stools.
Escherichia coli Undercooked beef, especially Onset: l -8 days. • Thorough cooking, especially of
(0157:H7 and ground beef. Fruits, vegetables, Bloody diarrhea, abdominal beef
other strains) sprouts, and yogurt ore also possi- cramps, kidney failure. • Avoidance of unpasteurized milk,
ble sources. untreated apple cider
Clostridium found throughout the environment Onset: 8-24 hours ofter eating (usu- • Sanitary handling of foods, espe-
perfringens Generally found in meat and poul- ally 12 hours). cially meat and meal dishes,
try dishes. Multiply rapidly in Abdominal pain and diarrhea. gravies, and leftovers
anaerobic conditions when foods Symptoms lost a day or less, usually • Thorough cooking and reheating
ore left for extended lime at room mild. Con be more serious in of foods, especially leftovers
temperature. older or ill people. • Prompt and proper refrigeration
listeria Found in soft cheeses mode with un- Onsel: 9- 48 hours for early symp- • Thorough cooking of foods
monocytogenes pasteurized milk and in unposleur· toms; 14-42 days for severe • Sanitary food-handling practices
ized milk itself. Resists acid, heal, symptoms. Fever, headache, vom- • Avoidance of unpasteurized milk
salt, nitrate, and refrigeration iting, and sometimes more severe
temperatures. symptoms. Moy be fatal.
Stophylococcus Found in nasal passages and in Onset: 2-6 hours ofter eating. • Sanitary food-handling practices
oureus cuts on skin. Toxin is produced Diarrhea, vomiting, nausea, and • Prompt and proper refrigeration
when food contaminated by bac- abdominal cramps. of foods
teri a is left for extended lime al Mimics flu. • Covering cuts on skin
room temperature. Meats, poultry, lasts 24-36 hours.
egg products pose the greatest Rarely fatal.
risk.
Table 19·3 I Important Microorganisms and Related Factors That Cause Foodborne Illness: Their Sources, Symptoms,
and Prevention (continued)

Bacteria (continued)
Clostridium Found throughout the environment. Onset: 12-72 hours oher eating. • Use of proper methods for con·
botulinum However, bacteria produce toxin Neurotoxic symptoms include dou- ning low-acid foods
only in a low-acid, anaerobic en- ble vision, inability lo swallow, • Avoidance of commercial cons of
vironment, such as in conned speech difficulty, and progressive low-acid foods that hove leaky
green beans, mushrooms, paralysis of the respiratory seals or ore bent, bulging, or
spinach, olives, and beef. Honey system. broken
may carry spores. OBTAIN MEDICAL HELP IMMEDI- • Discording of food if toxin is sus-
ATELY. BOTULISM CAN BE FATAL. pected !off odors ore a sign)
Vibrio vulnificus Row seafood, especially row Onset: 1-7 days. • Thorough cooking of seafood
oysters. Diarrhea, fever, weakness, blood
infection, death.
Vibrio cholerae Human carriers, infected shellfish, Onset: 2-3 days. • Hondwoshing oher using the
contaminated water and food. Vomiting, severe watery diarrhea, bathroom
which con lead to dehydration
and cardiovascular collapse;
death.
Yersinia Found throughout the environment; Onset: 2-3 days. • Thorough cooking
enterocolitica carried in food, water, and feces. Fever, headache, nausea, diarrhea, • Sanitizing of cutting instruments
Multiply rapidly al both room and and general malaise. and cutting boards before
refrigerator temperatures. Mimics Au and appendicitis. preparing foods to be eaten row
Generally found in row vegeta- Moy cause diarrhea in children. • Avoidance of unpasteurized milk
bles, meats, water, and unpasteur- and untreated water
ized milk.
Parasites
Trichinella spiralis Pork and wild game. Onset: weeks lo months. • Thorough cooking of pork and
Muscle weakness, fluid retention in wild game
face, fever, Aulike symptoms.
Anisakis Row fish. Onset: 12 hours. • Thorough cooking of fish
Stomach infection, severe stomach
pain.
Tapeworms Row beef, pork, and fish. Moy cause abdominal discomfort, • Thorough cooking of all animal
diarrhea. products
• Avoidance of row fish dishes
Cyclospora Carried lo food via contaminated Onset: 1- 11 days. • Irradiation (not yet in practice)
cayetanensis water; Guatemalan raspberries Prolonged diarrhea, vomiting, mus-
suspected in recent outbreaks. cle aches, fatigue.
Cryptosporidium Contaminated water (especially Onset: 1- 12 days. • Hondwoshing
fecal material). Lorge outbreaks Diarrhea, vomiting, fever. • Use of clean or treated water
hove been caused by such con· • Use of boiled water if at high
lamination of municipal water in risk, such as one who is on im·
Milwaukee, Wisconsin. mune suppression drugs or hos
AIDS
Toxoplasma gondii Row or undercooked meat, un· Onset: 5-20 days. • Thorough cooking of meats
washed fruits and vegetables, cot Fever, headache, sore muscles, di- • Adequate washing of row fruits
feces. arrhea (con be deadly to the fetus and vegetables
of pregnant women). • Hondwoshing oher changing col
litter (ovoid cot litter when
pregnant)
Table 19·3 I Important Microorganisms and Related Factors That Cause Foodborne Illness: Their Sources, Symptoms,
and Prevention (continued)
Fungi
Mycotoxins produced by molds, Found in foods that are relatively Moy cause liver and/or kidney • Discording of foods with visible
such as off otoxin B-1 high in moisture. Chief food disease. mold
sources ore beans and groins. • Proper storage of susceptible foods
Ciguotera Large tropical fish, especially Onset: generally within 6 hours. • Avoidance of grouper, omber-
grouper, snapper, and barracuda. Diarrhea, abdominal pain, nausea, jock, and barracuda from
vomiting, and nerve disorders. Caribbean water, especially
larger fish
Paralytic shellfish Shellfish that hove consumed large Onset: within 4 hours. • Observance of local precautions
poisoning amounts of dinoAogellote algae Respiratory difficulty. when harvesting shellfish
(i.e., red tide).
Scombroid Spoiled fish, especially tuna, mack- Onset: 1-180 minutes. • Avoidance of spoiled fish
poisoning erel, and mohi-mohi. Facial flushing, burning sensation in • Proper refrigera tion and prompt
the mouth, intestinal distress, and use of fresh fish
headache.
Prions
Proteins that help maintain nerve Cows, goats, and sheep harboring Onset: 2-30 years. Three coses of mad cow disease
cells. These can turn into infec- infectious prions. These ore Dementia and psychosis, leading hove been confirmed in U.S. cat-
tious prions, leading to diseases spread from one animal to an- eventually to seizures, blindness, tle, some of which were imported
such as mod cow disease other if certain by-products of the paralysis, and death. Once symp- from Canada. (These animals
(bovine spongiform en- infected animal (e.g., broins) ore toms begin, death usually occurs were infected before strict preven-
cephalopathy). used to feed other animals (this within 1 year. At autopsy the per- tive actions were put in place in
process is banned in the United son shows numerous holes in the Canada.) The biggest risk is con-
States and Canada). Cooking brain. sumption of meat from cows,
does not destroy prions. goats, and sheep in Europe or
Asia. FDA and USDA hove
banned imparts of such animals
from Europe.
egulorly cleaning surfaces and equipment Preparing Food

with o dilute bleach solution (1: 1OJ is very
• Thoroughly wash your hands for 20 seconds with hot, soapy water before and after
helpful in reducing the risk ol cross·
hand ling food. This practice is especially important when handling ra" meat, fish,
contamination of foods.13
poultry, and eggs, after using the bathroom, ali:er playing \\~th pets, or afler chang·
ing diapers.
• Make sure counters, cutting boards, dishes, and other equipment arc thoroughly
saniti7Cd and rinsed before use. Be especially careful to use hot, soapy water to wash
surfaces and equipment that ha,-e come in contact with raw meat, fish, pouln·y, .md
eggs as soon as possible to remove Saltnone!la bacteria that may be present.
Otherwise, bacteria on the surfaces will infect the oexr foods that come in comact
with the surface, a process called cross-contamination. ln addition, replace sponge~
and wash kitchen towels fi-equt:ntly. (Microwaving sponges for 30 ro 60 second~
also helps rid them ol Ii' e bacteria. )
• If possible, cut foods to be eaten raw on a clean cutting board reserved for thar pur·
pose. Then clean this cutting board using hot, soapy water. If the same board must
be used for both meat and other foods, cut any potentially contaminated items, ~ucl·
as meat, lase. After cutting the meat, wash the cutting board tl10roughl).
FDA recommends cutting boards with unmarred surf.ices made of ensy-to-ckan
nonporous materials, such as plastic, marblt:, or glass. If you prefer a wooden board
Food safety logo of USDA make sure it is mnde of a nonabsorbent hardwood, such as oak or maple, and has nc•
ob,·ious scams or cracks. Then reserve it for a specific purpose; for example, set iL aside
for cutting raw meat and poultry. Keep a separate wooden curring board for chopping
produce and slicing bread to pre,·cnt these products from picking up bacteria from ra\\
mi:ar. Nore that many foods are served raw, so any bacteria clinging ro them are not
destroyed.
Furthermore, FDA recommends that all cutting boards be replaced when they be-
come streaked with hard-to-clean grooves or cuts, which may harbor bacteria. In ad-
dition , cutting boards should be sanitized once a week in a dilute bleach solution.
Flood the board with the solution, let it sit a fo\\' minutes, then rinse thorough!}'.
• When thawing foods, do so in the refrigerator, under cold running water, o r in a
microwa\'e oven. Cook foods immediately a.fter tha\\'ing under cold water or in the
microwa,·e. Never let froLen foods thaw w1refrigerated all day or night. Also, mar-
inate food in the refrigerator.
• Avoid coughing or sneezing over foods, e,·en when you're healthy. Cover cuts on
hands with a sterile bandage. This helps stop Stapbylococcus from entering food.
• Carefully \\'ash fresh fruit and vegetables under running \\'ater ro remove dirt and
bacteria clinging co the surface, using a vegetable brush if the sk.iJ1 is to be eaten.
People ha,·e become ill from Sa/moue/la that was introduced from melons used in
making a fruit safad and from oranges used for fresh -squeezed orange juice. The
bacteria were on the outside of the melons Jnd oranges.
• Completely remove moldy portions of food or don't car the food. Wl;en in doubt,
th1·ow the j(wd our. Mold growth is prevented by properly storing food at cold tem- Washing hands thoroughly (for at least 20 to
peranircs and using the food promptly. 30 seconds) with hot water and soap should be
• Use refrigerated ground meat and patties in 1 to 2 days and frozen meat and pat- ihe first step in food preparation. The four Fs of
food contamination ore fingers, foods, feces,
ties \\·ithin 3 ro 4 months.
and Ries. Handwoshing especially combats the
fecal and finger routes. 10
Cooking Food
• Cook food rhoroughl) using a bin1erallic thermometer co check for <loneness, es-
pecially for beef and fish ( l45°F [ 63°C]), pork ( 160°F [71 °C]), and poultry ( l 65°F
[74°C)) (Figure 19-1). Eggs should be cooked until the yolk and \\hire arc ha.rd.
Alfa.lta sprouts and orher rypes of sprouts should be cooked until they are steaming.
Cooking is by far the most reliable \\'ay to destroy foodborne viruses Jnd bacteria,
such as Noro,·irus and toxic strains of E. coli. Freezing only hairs \'iral and bacterial
growth. FDA docs not recommend that eggs be prepared sunny-side up o r over
easy.
Many restaurants now include an advisory on menus stating that an increased risk Jon wonts lo buy a culling board for his new
offoodbome illness is associated \\ith earing undercooked eggs. As long as restaurants kitchen. He's been looking at all of the possibil-
provide this warning on their menus, however, they are allowed to cook eggs to any ities: plexigloss, plastic, and wood. How
temperature requested by the consumer. FDA warns us not to consume homemade ice would you advise him, so that he con minimize
cream, eggnog, and mayonnaise if made with unpasteurized, raw eggs because of the the risk of any foodborne illness from his food
risk of Salmonella foodborne illness. It is safer to use eggs or egg products that ha\'C preparation?
been pasteurized, which kills Salmonella bacteria. Overall, a good general precaution
is to ear no raw animal products. USDA answers questions about the safe use of ani-
mal products (800-535-4555, 10 A ..M. ro 4 r.~t. weekdays, Eastern time).
• Seafood also poses a risk of foodborne illness, especially oysters. Properly cooked
seafood should flake easily and/ or be opaque or dull ru1d firm. Ifir's translucent or
shiny, it's not done. Raw fish dishes such as sushi, however, can be safe for most
people to eat if they are made with ,·ery fresh fish that has been commercially frozen
and then thawed. The freezing is importrull ro eliminate potential health risks from
parasites. rDA recommends that the fish be frozen to an internal temperature of
-10° F for 7 days. If you choose ro ear uncooked fish, purchase the fish from rep-
utable establishments that ba,·e high srandards for quality and sanitation. People at
high risk for foodborne illness would be wise to avoid ra\\' fish products.
MEAT
Fresh ground beef, veal, lamb, and pork 155°F (68°C)
Beef. veal, lamb (roast, steal<s, chpps)
Medium rare 1'45°F (63°C)
Medium 160°F (71°C)
Well done 170°F (77°C)
Fresh pork (roast, steaks, chops)
Medium 160°F (71°C)
Well done 170°F (77°C)
Ham, cooked before eating 160°F (71°C)

Ham, reheat fully cooked 140°F {60°C)
Poultry!
Ground chicken, turkey 165°F (74°C)
Whol~ cpicken, turkey 165°F (74°C)
Breasts, roasts 145°F (63°C)
S\utting, alone or in bird 165°F (74°C)
Egg dishes, casseroles 145°F (63°C)
Leftovers, to reheat 165°F (74°C)
urrent Safe Handling Instructions

Issued by USDA for Labeling Meat
and Poultry Products: Figure 19· 1 I Minimum internal temperatures established by USDA for cooking or reheating foods.
This product was prepared from inspected and
passed meat and/or poultry. Some food prod-
ucts may contain bacteria that could cause ill-
ness if the product is mishandled or cooked
improperly. For your protection, follow these
handling instructions.
Keep refrigerated or frozen. • Cook stuffing separately from poultry, or stuff immediately before cooking and then
Thaw in refrigerator or microwave. transfer t:he stuffing co a clean bowl immediately after cooking. Make sure the sniff
Keep raw meal and poultry separate from ing reaches 165°F (74°C). Salmonella is the major concern with poultry.
other foods. • Once a food is cooked, consume it right away, or cool it to 41°F (5°C ) within
Wash working surfaces (including cutting 2 hours. Ifit is not to be eaten immediately, in hot weather (80°F and abo\'e ) make
boards), utensils, and hands otter touching sure this cooling is done within 1 hour. Separate Lhe food into as many shallow pans
raw meal or poultry. as needed co provide a large surface area for cooling. Be careful not to recontami
Cook thoroughly. nate cooked food by contact with raw meat or juices from hands, cutting boardl..
Keep hot foods hot. Refrigerate lettovers imme- dirty utensils, or in other ways.
diately or discord. • Serve meat, poultry, and fish on a clean plate-never the same plate that was used
Safe Handling Instructions for Eggs: to hold t:hc raw product. For example, when grilling hamburgers, don't put cookcc
To prevent illness from bacteria: keep eggs re- burgers on the same plate that was used to carry the raw panics out to the grill.
frigerated, cook eggs until yolks are firm, and • For outdoor cooking, cook food completely at the picnic site, wit:h no partial cook
cook foods containing eggs thoroughly. ing in advance.
; Expert Opinion
Food Safety- Why Should You Care?
Lydia Medeiros, Ph.D., R.D.
Why does every research journal article on food safety start out quoting sta- United Stoles Deportment of Agriculture is very similar in concept to the re-
tistics about how many illnesses, hospitalizations, and even deaths occur search findings of our group with the exception of how cleanliness is taught.
each year because of foodborne illness? It's so common that it's almost be- Hondwoshing and food preparation surfaces ore combined under the Fight
coming a cliche. The reason is that the numbers ore shocking. Just think, in BACI concept of "CLEAN ." We recommend seporofion of the concept info
a technologically advanced country such as the United States people die two control factors because the pathogens best controlled by cleaning and
from illnesses that could be prevented by simply cooking food adequately or sanitizing food prepara tion surfaces are Campylobacter iejuni, Salmonella
properly washing their hands. But, this information is boring-these ore in- species, Taxoplasma gondii, Yersinia enferocolitica, and Escherichia coli
structions our mothers nagged us about when we were children. And who 0 l 57:H7. This is o very different list from the ones controlled by personal
doesn't wash their hands before handling food? Apparently, plenty of peo- hygiene.
ple don't, or if they do they aren't doing it properly. Why else ore the sta- Cook Foods Adequately and Keep Food ol Safe Temperatures also hove
tistics on foodborne illness so high? similarities. Both factors focus on controlling temperature of food, except that
Could it be that people become confused with too many dos and don'ts- Cook Foods Adequately is concerned about end-point temperatures of cook-
too many rules to follow? As a food safety educator I certainly om asking ing and reheating, whereas Keep Food at Safe Temperatures advocates be-
myself that question. When I began compiling o list of all the behaviors that haviors associated with holding and storage of cold or hot perishable foods.
people should practice to control the most common foodborne illness Foodborne illness pathogens that cause food infections, or illness symptoms
pathogens, I found almost 60 behaviors scattered among numerous refer- due to ingestion of the pathogen itself, ore controlled by heal destruction of
ences. Aker editing the list for vagueness, overlap, and redundancy, our re-
search group asked nationally known experts in food safety to refine the
items and associate each behavior lo one of 13 pathogens known lo cause
the majority of foodborne illnesses.
We started lo think in the language of the Hazard Analysis Critical
Control Point (or HACCP) system, which identifies, first, hazards, and sec-
ond, control factors that, if practiced, will contain the contamination and
growth of foodborne illness pathogens. Of the 29 remaining behaviors on
our edited and refined list, we found that each could be organized under just
5 groupings that ore control points, like in HACCP. These control factors ore:
Practice Personal Hygiene, Cook Foods Adequately, Avoid Cross-
Contominalion, Keep Foods of Safe Temperatures, and Avoid Foods from
Unsafe Sources. These control factors con also serve as concise and easy-to-
remember educational messages.
As I hove applied our research findings to educational programs, I hove
found that two of the control factors fit well together, os do two others; the
lost one seems to stand separately. Practice Personal Hygiene and Avoid
Cross-Contamination ore similar because both involve human behaviors re-
lated to cleanliness, whether the hands, the body, or food preparation sur-
faces ore ot issue. The differences in the two control factors lie in the
microbial pathogens that cause the foodborne illnesses. Practice Personal
Hygiene, which focuses on hand cleanliness, is most applicable if the be-
haviors are practiced before food is touched and when the food is going lo
be served cold, such as salads. The pathogens controlled best by hond-
woshing ore Noroviruses and Norwalk-like viruses, Shigella species, and
foodborne sources of hepatitis A. Avoiding Cross-Contamination also con-
cerns cleanliness, but the focus is on food preparation utensils, cookware, Washing your hands before preparing food is the single
and food preparation surfaces. The Fight BACI educational program of the best way lo limit your risk for foodborne illness.
the microorganisms. These ore the some pathogens that ore also controlled foods have already been listed for the other control factors, such as f . coli
by avoiding cross-contamination. There are, therefore, two ways to control 0157 :H7 or Salmonella species. But for those pathogens, effective consumer
foodborne infections caused by microbial pathogens-by controlling con- behaviors con be used to prevent illnesses in the home. However, for one
tamination of the food initially or by heating to an adequate temperature, pathogen-and especially for immune-compromised individuals-avoidance
which will result in the destruction of the pathogen. The pathogens best con· is the most prudent behavior. That pathogen is listeria monocytogenes. (See
trolled by controlling holding and storage temperatures of foods ore some- the Listeria section in the chapter for ways lo minimize risk.)
what unique among foodborne illness pathogens. These are Clostridium With so much to remember about food safety, is there one single mes-
perfringens, Staphylococcus aureus, and Bacillus cereus. Uniqueness of sage that all people can remember that will control the majority of foodborne
these pathogens comes from the fact that either they contain spores, which illnesses? If there were, that message would be either to practice personal
are not destroyed during healing, or they cause illness due to a toxin pro- hygiene or wash your hands before you eat or touch foods. For pathogens
duced in a temperature-abused food. The toxin causes the illness. that cause the most severe illnesses or death, the public health concern
The one remaining control factor is Avoid Foods from Unsafe Sources. clearly remains high; however, the numbers of coses ore relatively few and
These foods include row eggs, unpasteurized milk or milk products mode susceptible groups con be targeted for special emphasis in educational
from row milk, unpasteurized fruit juices, row sprouts, and some types of pre- programs.
prepared foods served without heating (such as deli salads and hot dogs).
For immune-compromised individuals like the elderly, pregnant women, or Dr. Medeiros is Associate Professor in the Department of Human
people with drug· or disease-induced immune suppression, consuming these Nutrition at The Ohio State University. She is Extension Specialist in
foods con complicate existing condifions or, in extreme situations, cause Food and Nutrition for The Ohio State University and has an active
death. Certainly, foodborne illness pathogens that ore associated with these research program in food safety.
Storing and Reheating Cooked Food

• Keep foods out of the "danger zone" by keeping hot foods hot and cold foods cold.
Hold food below 41 °F (5°C) or above 135°F (57°C) (figure 19-2). Foodbornc mt·
T o reduce the risk of bacteria surviving dur·
ing microwave cooking, croorganisms thrive in more moderate temperatures (60°f to ll0°F I 16°C LO
43°C]). Some microorganisms can e\'cn grow in the refrigerator. Again, don't lca,·e
• Cover food with gloss or ceramic when possi·
cooked or refrigerated foods, such as meats and salads, at room temperature lc>r
ble lo decrease evaporation and heot the
more than 2 hours (or l hour in hot weather) because that gives microorganisms an
surface.
opportunity to gro\\. Store dry food at 60°F to 70°F ( 16°C to 21°C).
• Stir and rotate food al least once or twice for
• Rehc:u leftovers to 165°F (74°C); reheat gravy to a rolling boil to kill Clostridw111
even cooking. Then, allow microwaved food
perfi•ingens bacteria, which may be present. Merely reheating to a good eating tcm
to stand, covered, oher heating is completed
perarure isn 'r sufficient to kill harmful bacteria.
lo help cook the exterior and equalize the
• Store peeled or cut-up produce, such as melon balls, in the refrigerator.
temperature throughout.
• Make sure the refrigerator stays below 41°F (5°C). Either use a refrigerator ther
• Use the oven temperature probe or a meol
mometer or keep it as cold as possible without freezing milk and Lettuce.
thermometer lo check that food is done. Insert
ii al several spots. Cross-contamination is not on ly a threat during food preparation, it can also be
• If thawing meol in the microwave, use the come a problem during food storage. Make sure all foods, including lcftoYcrs, are con
oven's defrost setting. Ice crystals in frozen tained and co,·cred in the refrigerator to prevent drippings from uncooked am
foods are not heated well by the microwave potentially hazardous foods from tainting other fr)ods. It is a good idea to store fomL
oven and con create cold spots, which later that arc likely to pose risk of foodborne illness on lower shd\'es of the refrigerator, be
cook more slowly. neath other foods that arc to be eaten raw.
Figure 19·2 I Effects of temperature on

Temperature range for conning low-acid microbes that cause foodborne illness. Adopted
121 250 foods (kills spores) from Temperature Guide to Food Safety: Food and
116 2AO A pressure-conner is required lo reach these Home Noles. No. 25, Washington DC, June 20
temperatures. 1977, USDA.
100 212
Temperature range for destroying bocterio
(but not their spores), porositic worms,
and protozoa
165
Temperoture range for storing thoroughly
cooked food; prevents growth of bacteria
but doesn't necessarily destroy them.
57 135
52 125
DANGER ZONE
Bacteria grow quickly; do not store within this
temperature range for more than l to 2 hours.
15 60
5 41
Recommended refrigerator temperature;
0 32 still, some bocteria can grow.
Freezing. Bacteria can't grow, but many

0 will survive; growth can resume on
thawing.
Concept I Check
\ 'iruses and bacteria pose the greatest risk for foodborne illnes~. In the past, sugar and salt
were added to foods, or foods were smoked or dried, to pre\·cm the grm\th of microor·
ganisms. Today, we know that cnsuri11g clcanli11css, keeping hot foods hot and cold foods
cold, and cooking foods thoroughly offer additional protection from foodbornc illness.
Commercial processes, such as pasteurization a11d irradiation, do the same. Trear all raw an·
imal products, cooked food, and raw fruits and vegetables as potcnrial sources of food-
borne illness.
A Closer Look at the Primary Microorganisms That

Cause Foodborne Illness
Viruses
Viruses cause more cases of food borne illness than any other class or microorganisms. 5 otaviruses are an important cause of diar·
Viruses do not metabolize, gro" , or move by thcmseh·es. Instead, they reproduce rhea, mainly in children, leading to about
within a living hosr cell and, thus, cannot grow in food once it is harvested or slaugh- 55,000 hospitalizations per year in the United
tered. Viruses consist of a protein coat surrounding a nucleic acid core of either DNA States. Symptoms appear in 1 to 7 days. Doy·
or RNA. They ha,•c no cell wall. On entering a host 1:ell , a virus rakes o,·cr rhe cell 's care centers are common sites for infections.
DNA replication processes and causes ir to reproduce the virus's genetic materi.il. Thorough, regular handwoshing is a necessary
Generally, the hose cell dies in the process and bursts open, releasing new viruses into practice at these sites, porticularly after diaper
the surrounding medium . Many viruses cause disease In humans. And, because viruses changing.
cannot multiply in foods, they must enter in sufficient amounts through bits of feces
that concaminace food.
First noted in Norwalk, Ohio, in 1968, the Norovirus is a little known but leading
cause of stomach and intestinal distress caused by a virus. 20 Norovirus infection:. usu-
ally cause nausea, vomiting, diarrhea, weakness, abdominal pain, loss of appetite,
headache, and rever about 24 to 48 hours after exposure. The vi rus is found in water
and foods , and 'lhellfish and salads arc most often implicated. Cooking destroys tht:
virus. Noroviruses are probably responsible for about 30 to 40% of all cases of \-ir.11 in-
testinal infection in adults and arc the leading cause of foodborne illness in gcm:r.tl.
The infection is typicall) found in nursing homes and hospirals, restaurants, cruise
ships, and events with catered meals. The virus persists because it can sunfre chlori-
nation and because a low amount of the virus can cause illness. T he virus is of most
concern for infams, young children, older adults, and people with chronic ilJnesscs.
There is no specific treatment.
ecovery from hepatitis A generally occurs Hepatitis A is a well-known form of food borne illness caused by a virus, although
of its own accord in 3 to 6 months. This this route accounts for only a small percentage of the total number of hep.iticis A in-
foodborne illness constitutes the only exception foctions. As a food borne agent it most often thrives because of unsanirar) food h.in-
to the rule of immunity, ~ouse it is the only one dling by carriers of the virus in restaurants. People have also contracted hcpacilis A
in which people infected with the virus ore then infections from eating ra\\ or undercooked shellfish--dams, oysters, and musscls-
immune for the rest of their lives. harvesred from waters contaminati.:d with raw or improperly treated sewage. The ,·irus
that causes hepatitis A can endure notable hear, cold, and drying. Cooking fi.1ods ,1t
212°F ( l 00°C ) for more than 5 minutes inacti,•ates the 'irus, as does irradi.1tion .
Sym ptoms or 1he infection include intestinal problems, weakness, fatigue, jaundice,
and sometimes eYen the development of s..:rious liver disease, requiring hospitalization.
Because the S) mptoms or hepatitis A intCction do not usuaIJy occur until abour 15 to
50 days after eating contaminated food, the source is difficult ro identif)•. It is di.1g-
nosed by detccrion of hepatitis A antibodies. About 30,000 cases arc reported annu-
ally in the United States.
Raw clams and oysters are particu larly risky foods because they .1re filter tecders, .1
process that concentrates \'iruses .md toxins present in the warcr as it is liltered for
food. Consumption of these ra\\ shellfish results in the comwnpcion ofli,·e \'iruses and
bacteria, too. It is important to buy oysters and clams only from the most reli.1ble
sources. By law, shdlilsh offered for sale must come from licensed beds, but often they
do nor, M.> be carefol when )'OU either purchase these foods or h.1rvesr them your'>dt:
Check with the local health department if you question the safety of waters in an •lre.:i.
Proper hand" ashing by food sen·ice personnel is especially important in restaurants,
day-care centers, hospitals, and other instin1tions to lessen hepatitis outbreaks. The
chlorination of drinking water is a reliable means of destroying the virus.
Bacteri a
Bacteria ,\!so po)e a significant risk for food borne illness. 1• 2• 9 • 13 Bacteria arc e:-."Lremdy
simple strucn1res. They contain only one chromosome and lack mitochondria, endo-
plasmic reticu lum, golgi bod)', and lysosomes. Many bacteria arc enclosed in a
c.1rbohydrate-likc capsule, which protects them and aids their adherence to tissues.
Some bacteria can sun'ive harsh en\'ironmeatal conditions through spore formation.
ln the spore state, bacteria can remain stable for months or years.
Certain bacteria can thri\'e in almost freC7jng temperalllres, whereas others thri,·c ir
very high temperatures. The optimum temperature for most disease-causing bacteria i•
about 98°P (body temperature; 37°C). Bacteria living in the presence of oxygen an..
calJed nerobes, "hereas those living in the absence of ox11gen are called a11ni:1·nbes. Thost
that prefer free oxygen but can live in its absence are called frr.ettltati11e anaerobes. ~l.111~
bacteria produce toxins.
Finding the specific agent that has led to a foodborne illness requires \ome derec
Cook hamburgers to on intern al temperature of rive skills. Identifying the agent depends on knowing the food source, the incubatio1
160°F (72°C). At this temperature they are time for and types of symptoms, and the duration of the illness associated with an out
brown throughout, the juices run clear, and the break. The following sections look at the characteristics of the major conramimnt!
inside is hot. individually.
Campylobacter ;e;uni (C. ;e;uni)

In recent years, Cnmpylobrr.cter has jumped to the top of the list as the number one
cause of all domestic bacterial foodbornc illnesses, resulting in up to 4 million human
infoccions a year in the United States alone. The bacteria produce a toxin that destroys
the mucosa! surfuccs of the small and large intestines.
Because C. jej1mi is so difficult to detect in foods, an enormous number of case,r, of
this foodborne illness probably go unreported in this country. Also, most infections arc
very sporadic and are not associated wiLl1 a large outbreak, as arc other foodborne in-
feccions, such as E. coli and Salmonella. Jn a study conducted by USDA, more than
90% of the poultry tested was positive fo r Ca111pylobactc1:
Symptoms of the illnt:ss are acute intestinal inflammation with ft.:,·er, muscle pain,
headache, and diarrhea. During the peak of the disease, 10 or more bowel movements
per day arc common, and stools are often bloody. Cases arc ,1ssociatcd with comami -
nated water, ra\\ or inadequately cooked animal foods , including beef and unpasteur·
izcd milk. Poultry, especially chicken, is or most concern. Because thi,r, organism grows
slowly, the onset of symptoms is delayed, occurring 2 to 5 day~ after ingesting the con-
taminated food; it may even take weeks. Older adults, children, and people with weak-
ened immune systems arc at particularly hig h risk.
Treatment uses antibiotic medication, with most people recovering in less than l
week. Deaths arc rare. However, the number of Campylobnctcr i11fections that arc re-
sistant ta a class of antibiocics called Auoroquinolones have been on the rise. Antibioric
use in the U.S. poultry industry in fact is the main contributor to this antibiotic re-
sist:mce. A problem arises when physicians attempt to treat this food borne illness, be-
cause those people infected with the resistant strains are more likel) to ha\e se,·cre
infections and bloody diarrhea and to be hospitalized. Also, the bacterium is recog·
nized as a major contributing factor to Guillain-Barrc syndrome, \\'hich is rhe most
common cause of acute paralysis in both children and adults.
Luckily, Ca1-nfJ.Ylobacter organ isms arc very sensitive ro hear. This trait probably pro-
tects most people from infections. Prompt refrigeration, thoro ugh cooking, a\'Oidance
of cross-contamination, thorough handwashjng, and carefi.tl refrigeration of leftovers
are important ways to prevent its growth.
Salmonella
There are 2000 strains of Salmonella bacteria, many of which cause food borne illne!.s.
Salmonella can be killed by normal cooking. Nonetheless, they arc responsible for
many cases of foodborne illness, up to 23,000 per rear in the United States alone,
man)' of which go unreported. Related deaths average 33 per year.
Commonly found in animal and human feces, these bacteria enter food via inJecred DA warns us not to consume homemade ice
\\'ater, contaminated cutting boards, contaminated chicken and other animal products, cream, eggnog, and mayonnaise if mode
cracked eggs, and aci;ual bits of feces in food. Ingesting the live bacteria causes the with unpasteurized, row eggs because of the risk
problem. Recent outbreaks of salmonellosis have been traced back to alfalfa sprouc,r,. It of Salmonella foodborne illness. Use instead
is thought that the seed~ of these sprouts were contaminated by bird or rodent fi:ces. eggs or egg products that hove been posteur·
According to FDA, children, older adults, and persons \\'ith weakened immune systems ized, which kills Salmonella bacteria.
should not eat any ra" sprouts, such as alfalfu, mLrng bean, do\'er, and radish. Feces
from pet reptiles arc also sow·ces of Sah11onclln exposure. Infants and young children
are at high risk for salmoneUosis from indirect or direct contact with reptiles.
Symptoms of S11lmo11ella intccrion!> include nausea, fever, headache, abdominal
cramps, diarrhea, and vomiting, which can develo p in 24 to 72 hours. Bed rest and flu -
ids arc the only effecti\'e treatment, and reco,·ery usually occurs within 2 to 3 days.
Deaths arc rare. Sal111011clla attacks occur most frequently from consuming eggs,
chicken, meat, meat products, custard made with intcctc<l eggs, raw milk, and inade-
quately rerrigerated and rcheatcd leftovers. Unpasteurized orange juice and milk may
also be contamin:ited \\ ith Sn.lmonel/a. Raw chicken is often contaminated, and un ·
dercooked food- including eggs-poses a particular ri,r,k. Recently a warning label has
been added to egg cartons in an attempt to previ:nt the up to 66,000 illnesscs and
40 death!> per year from eggs contaminau.:d with Salmonella inside t he shell. The ne\\'
"arning label, shown on page 700, prO\ ides instructions for sate handling to help pre-
vent foodborrn: illness.
Most outbre•lks of Sn/111onel/11 infection can be traced to improper food hand ling.
Picnics pose a special challenge, bccwse food is frequently held for hours at a danger-
ously high temperature (between 41°F and 135° F, or 5°C and 57°C). It rakes only
about 8 hours for Snhnouelln bacteria to multiply sufficiemly to cause illness.
Therefore, keep foods abo\'e 135°F (57°C) or below 41 °F (5°C) 1.0 help pren:nt the
growth of Salu11mclla bacteria.
Sn/111ouc/ln also poses .t great risk for cross-conr:unination of foods. To avoid cross-
contamination, keep produce, cooked foods, and ready-co-eat foods separate from un-
cooked meats and raw eggs. Thoroughly dean hands, cutting boards, counters, knives,
and other utensils after handJing uncooked foods.
Cook chicken thoroughly to reduce the risk of

salmonella infections.
Shigella sonnei (5. sonnei)
Foodborne illness caused by the S/Jigclln bacterium is a common disease of youngsLers
in day-care cemcrs, nurseries, and custodial institutions. The infoaion is transmirted
by the fecal -oral route, primarily by way of the hands as well as via food and water. The
onset of symptoms usually occurs within L to 3 da)'S of being infected. The sympcoms
include abdominal cramps, diarrhea, fe,er, and bloody stools. Some carriers of S/Ji._ndln
display no symptoms but represent a potential threat to all who come in contact "id1
them. Wilh as little as 10 organisms able to cause ,m infection, person-to-person trans-
mission is easily ,tecomplished where hygienic conditions are poor.
Although reported infrequently, Shigc/la outbreaks have been associated wid1 r.l\\
produce, including green onions, crisp head lettuce, and uncooked, ra'' p<mle~.
Recenr outbreaks have been traced back to raw, chopped parsley that had been cut ,rnd
stored at room temperature. To avoid contamination from parsley, food handlers
should store chopped parsley for shore Limes, keeping it refrigerated, and chop snulle1
batches. Handwashing and sanitary food production offer the best protection ag.1ins1
Sbigellrr infecrions.
Escherichia coli (E. coli)

Escherichia coli ( E. coli) is commonly found in the intestinal tract of humans and othe1
an imals. Although there are hundreds or benign strains of the bacteria, Ol 57:H7 .lnL
0111:I18 are especial]~ 'irulem and cause severe illness. According to the U.S. Ce mer·
for DiseJse Control and Prevention, these £. cob bacteria, \\'hich .u·c most common!~
ecently 19 million pounds of ground beef found in ground beet~ ki ll about 60 people each year and c,lllse illness in an esrimatel
potties were recalled because of possible 73,000 more. The)' are quickly becoming a major threat for foodborne illness, wilh up
E. coli 0157:H7 contamination. to 4% of raw me.tt products in rhe United States possibly concaining such bacccria.
Children and older adults arc most susceptible to the disease. The bacterium i,
transmitted prim,ffily 'ia contaminated ground beef' and roast beef In response, a~ pre -
viously mentioned, FDA has approved the irradiation of mear to reduce thi!. risk.
Although ground beef is the most common source of the £. coli bacteria, fruits, n:g-
etables, and drinking \\'ater also can harbor the deadly pathogen. Unpasteurized milk,
uncreated ,1pplc cider, s.1lad greem grO\\ n in CO\\' manure, cantaloupe, dry-cured .sabrri
(because it is not cooked during processing), and many types of sprouts have also hen
implicated in E. coli infections. In one case, fresh apple juice was contaminated w11 1
E. coli because the apples used to produce tl1e juice had fallen co the ground and ha i
come into contact with ,mirnal feces. New methods for apple juice production .1r.:
being researched; pasteurization is now routine.
After an incubation period of L to 8 days, the disease normally lasts -1- to l 0 day·.
The symptoms include severe abdominal cramps, bloody diarrhea, and hcmol~ tic urv
mic syndrome, a condition tl1at can lead to kidney failure E. coli infoction should b:
investigated at. ,1 possible cause in any case of bloody diarrhea.
Cooking with a meat thermometer and then avoiding recontamination are impor-
tant ways to prevent this type offoodborne illness. Cider that is not pasteurized or that
does not contain preservatives can be heated to a slo\\' simmer until steam rises fro m
the pan before serving or refrigerating to reduce risk.
Clostridium perfringens (C. perfringens)

The bacterium Clostridittm perfringms ljves throughout the em·ironment, especially in
soil, the tntestines of farm animals and humans, and se'' age. It is called the "cafeteria Diano hod o party at her house for her son's
germ," because most foodborne outbreaks caused by th is orgarusm arc associated with birthday. While cleaning up ofter the kids hod
the food service industry or with events where large quantities of food are prepared gone home, she realized she hod forgotten to
and ser\'ed. The symptoms of an infection resemble those of Salmo11clla cases, but the put away the potato so/ad and coleslaw and
'ictirn usually doesn't \'Omit. The symptoms occur within 8 to 24 hours of consuming decided to discord it. However, her husband,
enough liYe bacteria. Again, bed rcsr and fluids are the only effecu\'(: treatment, and Tim, wonted her to iust refrigerate it. "After
recovery usually occurs within a day or so. o/I," he reasoned, "ii was only left out for o
C. perft'ingem thrives in an oxygen-free emironmenr. lt forms heat-resistant spores, couple of hours. Why was Diano right in
N
which become bacteria at temperatures between 70°F and 120°F (21 °C and 49°C ), wonting to throw away the leftover unrefriger-
and at d1e same time produces a toxin. T he bacteria then can quickly multiply to ated food?
disease-causing numbers. Foods stored in deep refrigerator pans arc especially ferti le
mcilia for the growth of these b,lCteria because me cenras arc isobn:d from air and
they stay wMm.
C. pcrfri1trrcns organisms are often found in cooked beef~ turkey, gravy, dressing,
stews, and casseroles. T he best way to prevent Lheir growth is to maintain proper hold-
ing temperatures and divide large leftover portions into smaller ones. Be especially
careful to cook meats completely and cool them rapidly in small containers.
Thoroughly reheat leftover meat to 165°F (74°C ) before serving. Always bring left-
over gravy ro a rolling boil. Refrigerate cold cuts and sliced meats below 41°F o r 5°C,
and serve them cold.
Listeria monocytogenes (L. monocytogenes)

Listei·in monocytogeucs is widely distributed in me environment and often enters food
from contamination \\ith animal or human feces. It is a very hardy microorganism that
resists heat, sal t, and acidity much better than many other bacteria. Th is bacterium sur-
vives and even grows at refrigeration temperacures. Because pasteurization destroys
Listeria organisms, reports of contanU!lated milk and cheese products suggest that
contamination occurred following pasteurization, probably from the addition of un-
pasteurized milk. Listeriosis in the United Snn cs is estirrnncd to kill 500 people a year n a recent period of 6 months, more than 45
and causes illness in 2000 more, which means that listcriosis kills 20% of me people it million pounds of hot dogs, luncheon meats,
infects. and other ready-to-eat meat products were re-
Listcrirr infections cause initial symptoms of fever, headache, and \'Omiting about 9 called because of contamination with potentially
to 48 hours after exposure. However, newborn infants, pregnant women, and people deadly Listeria bacteria.
wim depressed immune fimction may suffer severe symptoms, including meningitis,
spontaneous abortion, serious blood infections, and death. It is especially important
chat pregnant \\"Omen and other people at high risk avoid products such as unpasteur-
ized o r expired milk, uncooked hot dogs, undercooked chicken, fresh pate or meat
spreads (canned arc tine), Mexican soft cheeses (e.g., queso fresco ), and other soft
cheeses such as feta, brie, Camembert, and blue-veined cheeses, all of which arc sus-
pected of being major sources of Listeria infection. USDA also warns pregnant women
and other people at high risk to thoroughly cook all ready-co-eat meats, including hot
dogs and cold cuts, until d1ey arc steaming.
Consuming only pasteurized milk products; cooking me:tt, poultrv, and seafood
thoroughly; keeping food refrigerated; and washjng fresh produce thoroughly arc ways
to avoid Liste1·ia infection.
new tool in the bottle against foodborne Staphylococcus aureus (5. aureus)
A illness is HACCP, or Hazard Analysis and
Critical Control Point. This topic was discussed in
The organism Stnpl1ylococcus ntt1·c11s (S. atu-eus) produces toxins as it g rows in food.
Once ingested, the toxin causes nausea, vomiti ng, diarrhea, headache, and abdominal
the Expert Opinion by Dr. Medeiros. As she cramps. The symptoms usually de\ elop within 2 to 6 hours of eating the contaminated
noted, HACCP is a method of ensuring food food. People seldom die from the toxin, but they don't develop immunity against fu-
safety. Rother than treating the cause ofter a ture attacks. And, as is true for almost all foodborne illnesses, continued unsafe food
foodborne illness outbreak has occurred, by ap- handling will resu lt in repeated sil:kness. Bed rest and fluids are generally the only treat-
plying the principles of HACCP, food handlers ment needed. Recovery usually takes place withi11 2 to 3 days.
critically analyze how they approach food S. attrcm bacteria live mainly in the nasal passages and skin sores. These microor-
preparation and what conditions may exist that ganisms enter food when people sneeze and cough over food or handle food while they
might allow pathogenic microorganisms to enter have open skin sores. Once presenr in significant numbers in a food, S. n111·rnscan make
the food system. Once specific hazards and criti- enough toxin co cause human illness in about 4 hours if the food temperature stays
cal control points (where potential problems con near 100°F (38°( ). The toxin is undetectable b}' flavor, odor, and appearance and can
occur) ore identified, preventive measures con even withstand prolonged cooking.
be used to reduce specific sources of contamina- Foods commo nly associated with S. aureus int0xications are custard , ham, egg salad,
tion. In this way the food handlers ore using cheese, seafood, cream-filled pastries, and milk. A frequent sow-cc is whipped cream
HACCP to slop a problem before it starts. left standing for hours at room temperature. Keeping these and ocher foods abo,·e
135°F (57°C) or below 41°F (5 C ) prc\'ents both the bacteria's growth and fi.irther
toxin production. To limit the spread of this microorganism, it's import.mt to work
with clean hands, working surfaces, and utensils; tO direct coughs and sncc7es awa~
from food; and to cover skin cuts o n hands and arms when handling food.
Clostridium botulinum (C botulinum)

The Clostrirfi11111 botuli1111m bacterium can cause borulism, a foodborne illness that can
be ratal. This microorganism comes from soil and may exist as a bacterium or spore in
any food. As these bacteria multiply in food, they release a deadly toxin. The dearh rart.:
for botulism recch·es much public attention; however, o nly a few case~ arc reported
each ye<u· in Nonh America. At one time, botulism W•lS a serio us p roblem in the can -
ning industry, but now adequate heat processing and intact containers have 'irtuaUy
eliminated this danger from North American manufactured canned foods.
The symptoms of botulism appear within 12 tO 72 hours of ingesting contaminated
food. The roxin blocks acetykholine release at neuromuscular junctions, causing rnm-
iting, abdomin.11 pain, double 'ision, dizziness, and acute n::spiratory failure. The
prompt administration of the botu lism antitoxin can help pre\'ent the progression of
paralysis and reduce the duration of the illness. Sometimes treatmem requires inten-
sive care, including mechanical vcnLilacio n. The combination of the antitoxin and sup-
porti\'e care has reduced mortaliry to less thru1 l 0%. If the person survin:s, recO\'ery
occurs wichin J 0 days.
C. botuli1111m grows only in the .1bsence of air, so it thrfres primarily in canned food,
especially improperly home-canned, low-acid foods, such as string beans, corn, mush-
rooms, beets, •lnd asparagus. Recently, o ther foods with oxygen-deprh ed centers-
such as potato salad, sautced on ions, stew, and cho pped garlic-have also caused
botulism. fDA now requires that chopped garlic in oil be acidified to protect against
C. botuli111tm. Consumers should look for a commercially prepared product d1at con-
tains phosphoric or citric acid. Cured meats also pose a risk for botulism; however, d1e
nitrates and \itamin C used to preserve commercial products inhibit bacrerial growth.
Botulism has also occurred among Alaskan natives who consume uncooked, fermented
fish.
Home-canned foods arc the most common sources of botulism. Although the ca11-
ning process may kill all bacteria and the heat may drive o ut all oxygen, spores of
C. botu!i1111111 can still sw·"i,•e if the heating is insufficient. When the can or jar cools,
the spores germinate into bacteria that produce d1e toxin. E\'en foods that were pre\ i-
Inspect cons for bulges and foul-smelling liquid ously thought co be safe due to their acidity, such as tomatoes, require greater care, be-
as one sign of the presence of the botulism cause ne\\ varieties tend to have a higher pH. To ensure the safety of home-canned
toxin. foods, it is crucial to follow the canning directions exactl)'· To be sate, always check all
cans carefully, e\'en those from commercial facilities. Look for holes, rust on the scams,
and swollen sides or tops. Make sure the can sucks in air when opened to indicate that
the vacuum was maintained, and make sure the liquid inside is clear, not milky or foul-
smelling. If you see any signs of spoilage, return the can to the store or take it to the
nearest public health departmenr. Whatever you do, do nor raste the food. One green
bean can conrain enough toxin to kill you. For questions on proper canning tech-
niques, call the Ball Consumer Hotline at 1-800-240-3340.
Botulism also may develop in vivo (inside the living body). Infants between 2 and
9 months of age are at the highest risk because oflow stomach acid production. About
250 cases arc reported each year. Fortunately, the death rate is lo\\, 1 to 2%. Adults
with low stomach acid production are also at risk. Bacteria spores genninate in the
stomach and produce rhe exotoxin. For this reason, honey should not be given to
young infancs because it can concain the spores of C. botulimm1.
Parasi tes
Parasites th.u enter the body through the intestinal tract include some single-celled
protozoans, flukes, nematodes, roundworms, and tapeworms. Although not common
in ~forth America, the parasite most apt to bc in the food supply is Trichi11cl/n spi-
mlis.19 This tiny organism ma~· bc present in raw and undercooked pork and pork
products, such as sausage. Trichinosis is rare roday, probably because people rcalize
that pork must be cooked thorough!) to kill the nematode worm that causes it and be- Grill pork lo on internal temperature of 160' F
cause modern sanitary feeding practices have reduced Tric/Ji11elln in hogs. About 20 (72°C). This eliminates the risk of trichinosis
cases of trichinosis pcr year arc reported in the Un ited States. However, other cases ond produces o desirable product.
nM)' be unreported. 1n addition to pork, bear meat and other raw meats are potential
sources. It is seldom found in commercial meat.
Trichinosis begins with the consumption of meat containing the larvae. The larrnc larva An early developmentol stage in the life
<lre released during digestion in chc small intestine. Within 2 days, the larvae develop history of some organisms, such os parasites.
into adult nematodes. New larvae are then produced and move into the blood via the
intestinal mucosa. The blood carries the larvae to mw.clc fibers, where they become
resident.
In early stages, trichinosis is difficult to diagnose. The symproms in mi.Id cases de-
velop over weeks to months and arc usually thought to be flu. lf enough lar\'ac arc
present, muscle weakness, fever, and fluid retention in the face may cvcntually result.
Thoroughly cooking meat, especially pork, de!>troys the larvae.
Fungi
Fungi arc mostly multicellular organisms. Those of concern in food safety do nor in-
fect people, but some mushrooms are intrinsically toxic, and molds growing on foods
may produce toxins called m ycot oxins. 19 Fungi possess cell walls, a nucleus, and a nu- mycotoxins Toxic compounds produced by
clear membrane. They live on dead or decaying organic matter, living together with molds, such os oAotoxin B-1, found on moldy
other organisms either in mutual ad\'antage or as parasites. Fungi can gro\\ as single groins.
cells, like ycasrs, or as multicellular filamentous colonies, as witl1 molds. They cannot
synthesize their own food; ratl1er, rhey digest their food outside tl1eir cell walls and ab-
sorb the simpler organic substances for use within tbe cell.
Most fungi are molds that consist of long, branched threads called byphae. Hyphae
form a tangled mass of filaments called 111yccli11111. The mold often seen on bread con-
sists of this mycelia.
Fw1gi reqLLire moisture to gro\\' and can obtain water from the medium on which
they li,·e or from the atmospherc. When the atmosphere becomes dry, they can go
into a resting state or form spores. They can live in a pH range of 2 to 9 and can grow
in conccntrated salt o.nd sugar solutions. They thrive over a wide temperature range,
even in tl1c refrigerator. As spores, fungi can be scattered by rhe wind or carricd by
animals. When :in airborne spore lands on an appropriate target, such as a ripe peach,
the spore germinates and begins to grow, producing the typical mold obsen ed on
spoiled fruit.
ad cow disease, or bovine spongiform The best-known mycoroxins are d1e aflatoxins, substances believed t0 cause li\'er
encephalopathy, is caused by on infec· cancer. Aflaroxin B- l causes cancer in animals; ilius, human exposure is regulated b}
tious protein, called o prion, that kills by creot· FDA. The foods most often contaminated with aflatoxins are tree nuts (e.g., W<llnuts
ing voids in the broin.11 The human condition, o and pecans ), peanurs, corn, wheat, and oil seeds, such as cottonseed. FDA considers
variant of Creutzfeldt-Jakob disease, causes a aflatoxins una,·oidablc contaminants on foods and ilierefore has set practical limits for
form of dementia that hos killed about l 00 peo· atlaroxins in food and animal feed. Aflatoxins are also present in certain water supply
pie in Europe who apparently ate contaminated sources, such as pond and ditch water. Some people in China use this type of water for
beef. Because of the recent evidence of mod cow cooking, and iliey experience a high incidence of liver cancer.
disease in Europe, the U.S. government hos Cooking and freezing halt fungal growth but do not eliminate mycoroxins already
worked diligently to make sure the cattle here produced. Thus, moldy food should not be eaten, or at least not \\ithour disc.1rding
ore not exposed. The U.S. government has token the moldy portion and much of the surrounding area. Again, when in doubt, tlu·m,
steps to ban beef from Europe since the late the food out. Mold growth is prevented by properly storing perishable foods at cold
1980s, and has recentty banned cattle from remperatun:s and using them before evidence of mold growth appears.
Canada. FDA also hos implemented o bon on
the recycling of animal tissue from ruminant ani·
mols (e.g., cows, goats, sheep) for animal feed. Concept I Check
These ore suspected carriers of the prion. Three
Thoroughly cook all meat, poultn, and fish and other seafood to reduce the risk of food ·
coses of mod cow disease hove been seen to
borne illness from the Norovirus and the bacteria Campylobacter and Snl111011e/ln. Jn Jddi-
dote in U.S. cattle.
tion, always separate raw meats and poultry products from cooked foods. To pn:venr
foodbornc intoxication from Stnp/Jylococc11s organisms, cover cuts on hands and avoid
sneaing on foods. To arnid intoxication from Clostridium perfringe11s, rapidly cool kfton:r
foods an<l thoroughly n:heat them. To a\•oid intoxication from Clostrid111111 bomli1111111,
carefull y examine canned foods. Overall, don't allow cooked food to stand for more than
1 to 2 hour~ at room temperature. For other causes of foodborne iJJncss, precautions .11-
ready mentioned generally apply as well. In addition, consume only pasceurizcd dairy prod-
uces and wash all fruits and Yegetables; and thoroughly wash your hands with soap and
water before and after preparing food :rnd after using the bathroom.
Aaron likely contracted Closlridium perfringens, based on the fact that he hod dior·
rhea but did not vomit, and the symptoms occurred about 8 hours ofter consuming
the contaminated food. Spores of Closlridium perfringens are typically present in
meol. Thorough cooking will kill any of the live bacteria present, but the product still may con·
loin spores. These con later germinate ii the product is kept in o worm setting for a few hours.
The Argentine beef likely contained spores of Closlridium perfringens, and these germinated
and produced a toxin as the product sol in the car and on the buffet table. Ideally, this product
should hove remained at room temperature for no longer than l hour because the party took
place in the summertime. Thus, soon ofter Aaron and his wife took the Argentine beef out of the
oven, it should hove been separated into a few smaller pons for speed cooling and then refrig·
eroted. They should hove token these precautions because they knew the food was not going to
be served within l lo 2 hours. Before leaving for the party, they could hove recombined the dish
into one clean pan. Once they arrived at the party, the food should hove been refrigerated
again and then thoroughly reheated when it was time to eat. Overall, ii is ri sky to leave perish-
able items such as meat, fish, poultry, eggs, and dairy products at room temperature for more
than 1 to 2 hours.
I Food Additives
By the time you sec a food o n the market shelf, it usually contains subst.mces added to hen buying food products, especially
make it more palatable or to increase its nutrient content or shelf lite. 1\lanufacturers perishables, check the product date for
also add some substances to foods to make them easier to process. Other substances safety. Four types of dotes ore commonly used.
may haYC accidentally found their way into the foods you buy. All these extraneous The pock dote is the day the product was monu·
substances are known as additi11cs, and although some ma)' be beneficial, others, such foctured. The pull or sell dote indicates the lost
as suJfitcs, may be harmful for some peopk. All purposefully added substances must be dote the product should be sold. It allows some
evaluated b) FDA.19 time for storing food al home before eating.
Check the expiration dole of foods stored al
home, because that is the lost dote the food con
Uses of Food Additives safely be consumed. Lost, boked goods may
l-.lost additi,·es are used to limit food spoilage. Food additi,·es such as potassium sor- hove a freshness dote, indicating that the prod·
bate are used to maintain the safety and acceptability of foods by retarding the growth uct may safely be eaten for a short time otter the
of 1nicroorganisms implicated in foodborne illness. dote but may not taste the some.
Additives are also used to combat some enzymes that lead to undesirable changes
in color and fla\'Or in foods but don't cause anything as serious as foodborne illness.
This second type of food spoilage occurs when enzymes in a food react to oxygen-
for example, when apple and peach slices d.1rken or turn rust color as rhcy are cxposed
to air. Antioxidants arc a type of prcsen·ative that slows the action of OX)'gen-rcquiring
enzymes on food surfaces. These prcsen·atin:s are nor necessarily no\'el chemicals.
They include ''itamins E and C and a va1iety of su1fites.
Without the use of some food additives, it would be impossible to produce massive
quantities of foods and sately distribute them nationwide or world"'idc, as is now done.
Despite consumer concerns about the safetv of food addith·es, many ha,·e been cxten-
si\'ely studied and prove safe when FDA guidelines for their use arc followed.
Intentional versus Incidental food Additives

food additi\'es arc classified into rwo types: intentional food additives (direct!)' added intentional food additives Additives knowingly
to foods) and incidental food additives (indirectly added as contaminants). Both !directly) incorporated into food products by
types of agents are regulated by FDA. Currently, more than 2800 substances arc in- manufacturers.
tentionally added to foods. As many as I 0,000 other substances enter foods as con- incidental food additives Additives that appear
taminants. This category includes substances that may reasonably be expected to enter in food products indirectly, from environmental
food through surface contact with processing equipmenr or packaging materials. 19 contamination of food ingredients or during the
manufacturing process.
The GRAS List generally recognized a.s safe !GRAS) A list of
food additives that in 1958 were considered
ln 1958, all food additives used in tl1e United States and considered safC at that time safe for consumption. Manufacturers were
were put 011 a gener ally recognized as safe (GRAS) list. Congress established the allowed to continue to use these additives,
GRAS list because it believed manufacturers did not need to prm•e the safe[)' of sub- without special clearance, when needed for
stances that had been in use for a long time and were already generally regarded as safe. food products. FDA bears responsibility for
Since tl1ar time, FDA has been responsible for proving that a substance does not be- proving they ore not safe; ii con remove unsafe
long 011 rhc GRAS list.19 products from the list.
Since 1958, some substances on the list have been re\ iewed. A few, such a!> cycla-
mates, failed the review process and were removed from the list. The additi,·e red dye
#3 was banned because it is linked to cancer. Manv chemicals on the GRAS list have
not yet been rigorously tested, primari ly because of expense. These chemicals have re-
cci\'ed a low priority for testing, mostly because they luve long histories of use with-
out e\'idence of toxicity or because tl1eir chemical characteristics Jo not suggest they
are potential health hanrds.
712 Chapter 19 Safety of Food ond Woler
Synthetic Compounds
ome important definitions: Nothi11g ,1boul a natural product makes it inheren t!}' safer than a synrhe1 ic product.
Consider vit.rn1in E, which is often added to food to prevent rancidity of fats. This
toxicology The scientific study of harmful
chemical is safe "hen used "ithin certain limits. However, high doses ha\'C been asso-
substances
ciated with health problems, such as interfering with ' 'itamin K activity in the body (re-
view Chapter 9 ). Thus, e\'en well-known chemicals that we are comforrablc using can
safety The relative certainty that a sub·
be toxk in some circumstances and at some concentrations. Many synrhcric product~
stance won't cause injury
also are simply laboratory copies or chemicals that also occur in nature (see the dis-
hazard The chance that in jury will result cussion in Chapter 20 on bioted1nology for some examples).
from use of a substance Although human endeavors contribute some toxins tc> foods, such as S) ntheric pes·
toxicity The capacity of a substance to ticides and indu~uial chemical!., nature's poison~ arc often e\'en more pc>tent and
produce injury or illness ot some prevalent. Some cancer researchers suggest that we ingest at least 10,000 times more
dosage (by weight) n:nural toxins produced by plants than we do synthetic pesticide residues.
(Plants produce these toxins to protect themselves from predators and disease-causing
organ isms.) This comparison doesn't make synthetic chemicals any less toxic, but ir
docs put them in a more accurate perspective.
ote that this 1OO·fold margin of safety is Tests of Food Additives for Safety
more than 25 times thal for vitamin A
when you compare the RDA with a potentially Food additives an: tested under FDA scrutiny for safety on at Least two animal species,
toxic dose for pregnant women. usually rats and mice. Scientists dcLermine the highest dose of the additive that pro·
duces nn nbscn1nbfr effects in the animals. These doses arc proportionately m uch higher
than humans arc ever exposed to. The maximum dosage is then divided by at least
100 to establish a margin of safety for human use. The rationaJe for reducing the
no·observoble·effect level (NOEL} The highest n o-observable-effect level (NOEL) by a 100-fold margin is that we assume humans
dose of on additive that produces no arc at least l 0 times more sensiti' c to food additi\'eS than arc laboratory animals and that
deleterious health effects in animals. any one person might be 10 times more sensitive than another. This very bro<1d margin
e nsmes that the food additive in question will cause no harmful health effects in htm1ans.
In fuct, many synthetic chemicals are probably less dangerous at these low doses Lhan are
some of the natural compounds in common foods, such as apples or celery.
One important exception applies to the schema for testing intentional food additi\'es:
if an additi\'c is sho\\'n to cause cancer, even though only in \'cry high doses, no mar·
gin of safety is allowed. The food additi\'e cannot be used because it would "iobce the
Deloney Clouse A clause to the 1958 Food Delaney C lause in the 1958 Food Additive Amendments. This clause prohibits in-
Additives Amendment of the Pure Food and tentionally adding Lo foods a compound that was introduced after 1958 and causes
Drug Act in the United Stales that prevents the cancer. fa idence for cancer could come from eithe r laboratory animal or human stud·
intentional (direct) addition lo foods of o ics. Very fo,\ exceptions to this clause are allowed; the exceptions are discussed in the
compound that has been shown lo cause following section on cwi.ng and pickling agents.
cancer in laboratory animals or humans.
Tncidental food additi\·es are srill another matter altogether. FDA cannot simply ban
\'arious industrial chemicals, pesticide residues, .111d mold toxins from tC>ods, e\'en
though some of these contaminants can cause cancer. These produces are nor pur-
posely added lO foods. FDA sets an acceptable level for these substances. Basically, an
i11cidental subsL.mce found in a food cannot contribute to more than one cancer case
dming the lifetimes of 1 million people. lf a higher risk exists, the amount of t11c com ·
pound in a food must be reduced untiJ the guideline is met.
Approval for a New Food Additive

Today, before a new food additive can be added co foods, FDA m ust approve its use.
Besides rigorously testing an additive to establish its safety margins, manufacturers
must gi,·c FDA information tha1 (J ) identifies the ne\\ additi\'e, (2) gives its chemical
composition, ( 3 ) stares ho\\' ir is manufactmcd, and (4:) specifies the laborJC01T mcrh·
ods used to mea~ure its presence in the food supply at the amount of inrended use.
J\lanufacrun.:rs must also offer proof that the additi\'e will accomplish it~ intendi.:d
purpose in a food, that it is sa~c ••rnd that it is to be used in no higher .1mount than
Table 1 9 · 4 I Food Additive Categories ugor, salt, corn syrup, and citric acid consti-
Anticoking agents Flour treating agents Processing aids: clarifying, tute 98% of all additives (by weight) used in
Antimicrobial agents Formulation aids: carriers, clouding, catalyst, lloccu- food processing.
Antioxidants binders, fillers, plasticizers lonls, filter aids, crystol-
Color and adjuncts Fumigants lizolion inhibitors
Conditioners Humectants Propellants
Curing and pickling agents Leavening Sequestrants
Dough strengtheners Lubricants and release Solvents and vehicles
Drying agents agents Stabilizers and thickeners
Emulsifiers Nonnutritive sweeteners Surface active agents
Enzymes Nutritive sweeteners Surface-finishing agents
Firming agents Oxidizing and reducing Synergists
Flavor enhancers agents Texturizers
Flavoring agents pH controllers
needed. Additives cannot be used to hide ddcctive food ingn.;dients, such as rancid
oils; to deceive customers; or to replace good manufacmring practices. A manufacnircr
must establish that the ingredient is necessary for producing a specific food product.
Common Food Additives

A list of food additive categories appears in Table 19-4. Some serve the general func-
tion of preservatives: acidic or alkaline agents, antioxidants, antimicrobial agents, cur-
ing and pickling agents, and sequeso·ants. 19 The foUowing sections look at some of sequestrants Compounds that bind free metal
the specific categories of additives and explain why they are used and what substances ions. By so doing, they reduce the ability of
arc used. ions to cause rancidity in foods con taining lot.
Acidic or Alkaline Agents

Acids, such as calcium lactate, have many uses in foods. As Aarnr-cnhancing agents,
they impart a tart taste to soft drinks, sherbets, and cheese spreads. As presen·ati,·es,
they inhibit microbial growth. As ancioxidants, the}' pre\'ent discoloration and rancid-
ity. They also adjust acid and base balance. Adding acids during food processing re-
duces rhe larer risk of botulism from eating natura!Jy low-acid vegetables, such as beets.
Alkaline products, such as sodium hydroxide, can alter the texture and flavor of
foods, including chocolate. In processing, alkaline products arc ~ometimcs used to pro-
duce a milder flavor by neui:ralizing rhc acids produced during fi:rmentation.
Alternative Sweeteners
Current!), saccharin (Sweet'n Low), sucralose (Splenda), acesulfame potassium
(Sunctte), neotame, and tagatose (Narnrlose) are the onl) nonnutriti\'c sweeteners used
in foods. ( Cyclamate is a nonnutriti\'e sweetener available in Canada.) Because aspar-
tame (' utraSwcct) yields some energy, it is considered a nutritive sweetener. Recall
from Chapter 5 that the moderate use of these alternative sweeteners is considered sate.
Anticaking Agents
By .1bsorbing moisture, compounds such as calcium siJkatc, ammonium citrate, mag-
nesium stearate, and silicon dioxide keep table salt, baking powder, powdered sugar,
and other powdered food products free flowing. These chemicals pre\'Cnt the caking
and lumping that would make powdered or crystalline products hard to use.
Antimicrobial Agents
Sok drinks ore typical sources of alternative
Sodium benzoate, sorbic acid, and cakium propionate arc common preservatives. sweeteners for many of us. Moderate use of
Sorbic acid is a potent inhibitor of molds and fongal growth. Calcium propionate, a these products generally poses no health risk
natural part of some cheeses, inhibits mold growth. for most people.
Antioxidants
Antioxidants as a food preservative help delay food discoloration from oxygen expo-
sure, such as occurs when potatoes arc diced. They also help keep fats from turning
rancid. Two widely used antioxidants arc BHA (butylatcd hydroxyanisolc) and BITT
(butylated hydroxytoluenc). Alpha-tocophcrol (vitamin E), which occurs nawral ly in
nuts, whole grains, and oib, may be added to foods to keep them from becoming ran -
cid. Ascorbic acid (vitamin C), another antioxidant, when added to foods, helps m:iin -
tain the red color of luncheon meats and other cured foods, and it prevents the
formation of cancer-promoting nitrosamines. (Vitamin C is also added to such foods
as fruit drinks in order to increase the vitamin content; it is also used as a marketing
tool for these products. )
Sulfites, a group of sulfur-based chemicals, .1re wic.lcl) used as antioxidams in foods.
Some people ( 1 in 100, according to fDA estimates) are extreme!)' sensitive to sulfite\;
they may experic:nce i>hortness of breath, wheezing, and vomiting and ma}' develop
hives, d iarrhea, abdomina l pain, cramps, and d izziness. As a result, FDA nO\\ limits the
use of sulfites on ra\\ fruits and vegetables-an action directed main ly at salad bars.
FDA also requires manufocmrers to declare the presence of sulfites on the labeb of
packaged foods containing at least 10 parts per million (ppm) of sulfires. Labels on
wine bottles often contain a sulfite warning.
Colors
Color additivc:s don't impro,·e nutritional qu.1lities, but they can make foods more: ,·i-
sually appealing. Food colorings cannot be used to deceive consumers-for example,
by covering blemishes, concealing any inferiority, or misleading people in .my wa\.
Altl1ough colorings are arguably unnecessary addjtives, manufacturers luvc satisfied
FDA that color is "necessary" for tl1e production of certain foods.
Controversy has surrounded tl1e use of some food colors. Currently, the safct)' of
using taru·azinc (FD&C ydlo" No. 5) is disputed. It has caused allergic symptoms-
such as hi,·es, itching, and nasal discharge- in sensitive individuals, especially in people
allergic co aspirin. Although few of us arc sensitive to tartrazine, FDA requirc:s manu-
facturers to list FD&C yellow No. 5 on labels of food products containing it. ~ome
red dyes have also raised alarms, and some have: been banned. Currently, FDA requires
manufacrnrers co list ,tll forms of synthetic colors on the labels of foods ch.u cont.tin
Color odditives make some foods more them. Pigments extr.:ictcd from plant sources arc exempted from specific description.
desirable.
Curing and Pickling Agents
Nitrates and the rdated chemical group, nitrites, arc used as prescrvacives, cspcci~1llv to
prevent the growth of Clostridimn botuli1111111. Sodium and potassium nitrates and ni-
trites are used to pn:scn·e meats such as bacon, ham, salami, and hot dogs. Nitrates
and nitriLcs ha,·e been used for centuries, in conjunction with salt, m presc:n e meat.
An added eftcct of nitrates is their reaction wirh pigments in meat to form a bright p111k
ou might wonder why, if nitrates and ni- color. Thi~ gives ham, hot dogs, and ocher curc:d meats their characteristic appc:.1rance.
trites form chemical substances that con Nitrate and nitrite consumption from both cured foods and natural vcgct<tblcs ha~
cause cancer, they aren't banned from use in been associated with the synthesis of nitrosamincs in the stomach. Some nitrosa111incs
meats by the Deloney Clouse. In the United arc cancer-causing agems, particularly for the stomach lUld esophagus. An increa~e in
States, USDA regulates the use of chemicals in colon cancer risk is also under smdy. The actual risk for stomach or esophageal c:rncer
meats. The lows that govern USDA regulation of appears to be low, however, except for people who secrete little stomach acid (some:
foods ore different from those that govern FDA older people, for example).
regulation. Because of this difference, the U.S. government agencies surmise tl1at consumers rake for granted a ntJrgin of mi-
Deloney Clouse does not apply to USDA actions. crobial sate~· gained fro111 nitrate and nitrite use in cured meats. People ofren ~enc
Curren~y. USDA sees no dear threat to public these meats cold or at least underheated. Comcquently, the government agencic:~ h.:i,·e
safety from the regulated use of nitrates and ni- chosen not to b,111 nitrate or nitrite use in foods buc, rather, to change manufacturing.
trites in meats, so no action hos been token. practices co lower •lmounts of preformed nitrosamincs and suggest moderation in the
FDA also considers the risk of moderate use to use of these food products. Since 1975, there has been an 80% decrease in the amount
be minimal. of nitrites in cured mc:ats.
www.mhhe.com/wardlawpers7 71 S
The addition of\itarnin C (sodium ascorbate) to cured meats, such as bacon, is one
way to reduce the amount of nitrosamincs formed in foods. This is a common manu-
facturing practice. Other antioxidants, such as sodium erythrobate, also inhibit the syn-
the;:sis of nitrosamines.
Emulsifiers
By distributing and suspending fat in water, emulsifiers impro,·e the uniformity, smooth-
ness, and body of foods such as baked goods, ice cream, and candies. In mayonnaise, for
example, egg yolks act as emulsifiers in suspending the acids, such as 'inegar or lemon
juice, in the oil. Lecithin, deri\'ed from soybeans, acrs as an t:mulsifier in chocolate and Cured meals derive their pink color from
margaiinc. ~lonoglycerides and diglyccrides arc used as emulsifiers in cake mixes. nitrates and nitrites.
Fat Replacements
Fat n.:placements-such as Pasclli SA2, Dur-Low, Oatrim, Sta-Slim 143, Stellar, and
Z -trim- are being produced for commercial use. These carbohrdrare-based prod-
ucts are an addition to other fat replacement products, such as Olean, discussed in
Chapter 6.
Flavors and Flavoring Agents

Boch naturally occurring and artificial agems can impart more flavor to foods. These
agenrs include extracts from spices and herbs as well as synthetic agents. You've prob-
ably recognized flavors of some spices and of liquid derivatives of onion, garlic, doves,
and peppermint in foods. To meet the demand of industry, manufucturers have devel-
oped synthetic flavors that not only taste like natural flavors but also have the advan-
tage; of stability. Often artificial flavors, such as butter and banana flavors, have the
same chemical composition as the natural flavor.
Flavor Enhancers nfants ore more sensitive lo MSG than adults,

Flavor enhancers are substances, such as monosodium glutamate ( l-. ISG ), that help in port because infants hove not yel devel·
bring out the natural flavors of foods. Note that the glurnnute portion is simply a oped o complete blood-brain barrier ond so
nonessential amino acid. Glutamate in food provides a substanti<ll, meaty taste known they cannot fully exclude such substances os
as umami ( review Chapter 3 ). Mosr people associate MSG wiLh Chinese food, but MSG from the brain.
MSG is widely used in many North American processed foods, such as flavored chips
and canned soup. Much of the food prepared for the North American rcsraw·rult in-
dustry contains MSG. A small percentage of people are sensitive to d1e glutamate in
MSG and, after exposme, experience flushing, chest pain, facial pressure, dizziness,
sweating, rapid heart rate, nausea, vomiting, high blood pressure, and headache. The
onset of symptoms occurs about 10 to 20 minutes after ingestion and may last from 2
to 3 hours. People who find themselves sensith•e co MSG should a\•oid it. Ir may be
present alone (look for the word glutamate) as weU as in any isolated protein source
(caseinatc, texturized vegetable protein, etc. ), yeast extract, bouillon, soup stock, and
seasonings. Tomatoes, mushrooms, and pannesan cheese are also sources of free glu-
tamate. Fortunately, most of us find that moderate use of MSG or glutamate in foods
poses no significant risk to our health.
Humectants
Chemicals such as glycerol, propylene glycol, and sorbitol are added to foods to help
retain proper moismre, fresh flavor, and texture. They arc often used in candies, shred-
ded coconut, energy (sports) bars, and marshmallows.
Leavening Agents
Air and steam can be used to create a light texmre in breads and cakes; however, car-
bon dioxide bubbles are much more reliable for this purpose. Common leavening
agents that produce carbon dioxide gas include yeast, baking powder, and baking soda.
Baking soda must react with acids to generate carbon dioxide. Baking powder can be
used in either acid or alkaline condjtions.
Maturing and Bleach ing Agents

Such compounds as bromates, peroxides, and ammonium chloride hasten the natt1ral
aging and whitening processes of milled flow-. These compounds shorten the rime
needed for flour to become usable in baked products. Without these agents, freshly
milled flour Jacks the qualities necessary to make a stable, elastic dough and requires
several months of aging to be useful in baking.
Nutrient Supplements
Vitamin and mineral supplements arc added to foods to improve their nutritional qual-
ity. Sometimes they replace nurrients lost in processing, as occurs when emiching flour.
Vitamin A is added to margarine and some forms of milk and yogw-t. Vitamin D is
added to some dairy products. Potassium iodide is added to salt, and calcium and folic
acid are added to some flours, fru ir juices, and other products. Ready-to-eat brealdast
cereals often contain a variety of added nutiienrs.
Stabilizers and Thickeners

f you ore bewildered or concerned obout oil Stabilizers and thickeners impart a smooth texrnre and uniform color and flavor to can-
I the additives creeping into your diet, you con
easily ovoid most of them by emphasizing un·
dies, ice creams and other frozen desserts, chocolate milk, and artificially sweerened
beverages. Commonly used su bstances are pectins, vegetable gums (such as guar gum
processed whole foods (Figure 19·3). However, and carragecnan), gelatins, and agars. They work by absorbing water. Without stabi-
no evidence shows that this practice will neces· lizers and thickeners, ice crystals form in ice cream and other frozen desserts, and par-
sorily make you healthier. It omounts to a per· ticles of chocolate separate from chocolate milk. Stabilizers are also used tO prevenr the
sonol decision. Do you hove confidence thot evaporation and deterioracion of flavoriJ1gs used in cakes, puddings, and gelatin mixes.
FDA and food manufacturers ore odequately
protecting your health and welfare, or do you Sequestrants
want lo toke more personal control by minimiz·
Sequestrants include EDTA and citric acid. They bind many free chemical ions and, by
ing your intoke of compounds not naturally
doing so, help preserve food quality by reducing the ability of ions to cause rancidity
found in foods? in products containing fat.
(a ) (b)
Figure 1 9·3 I Depending on food choices, a diet con be either (o) essentially devoid of, or (b) high
in food additives.
www.mhhe.com/wa rdlawpers7 71 7
Risks of Food Additives

If you consume a variety of foods in moderation, the chances of food additives jeop-
ardizing your health arc minimal. Pay attention to your body. IC you suspect an intol-
Recognizing tho/ Joseph is toking a nutrition
class, his roommate asks him, "What is more
erance or a sensitivity, consult your physician for further evaluation. Remember that in
risky: the bacteria that con be present in food
the shore run, you are more likely to suffer either from foodborne illness due to poor
or the additives listed on the label of my fa-
food-handling practices that allow bacteria to grow in food or from the conswnption
vorite snack coke?" How should Joseph re-
of'""' animal foods containing cert•lin bacteria or viruses than from consuming addi-
spond? On what information should he base
th·es. Excess energy, saturated fat, tmns fat, cholesterol, salt, and od1er potential
his conclusions?
"'problem" nutrients in our diets pose the greatest long-term ri~k.
Concept I Check
Food addirh·es are used to reduce sroilage from microbial growth, oxygen, metals, and
other compounds. Additives arc also used to adjust pH, impro,·e flavor and color, leaven,
provide nutritional fortification, thicken, and emulsify food components. Additives are clas-
sified as intentional (direct), which arc purposely added to foods, and incidental (indirect),
which rum up in foods from environmental contamination or \'arious manufacn1ring prac-
tices. The amount of an additive allowed in " food is limited to L/l 00 of the highest
amounr that has no observable effccc when fed co animals. The Delancy Clause allows FDA
to limic incentional addition of cancer-causing compounds tO food under its jurisdiction.
Also limited by law are the permissible amouncs of carcinogens thac incidcncally emer
foods.
Substances That Occur Naturally in Foods

and Can Cause Illness
Foods contain a variety of naturally occurring substances that can cause illness. Here
are some of the more important examples: 19
Snfi·olc-found in sassafras, mace, and nutmeg; causes cancer when consumed in
high doses.
Soln11i11c-found in potato shoots and green spots on potato skins; inhibits the ac-
tion of neurotransmitters.
Mm/Jroom toxin.r--found in some species of mushrooms such as .1111inita; can cause
stonuch upset, dizziness, hallucinations, and od1er neurological symptoms. The
more lethal \'arieties can cause liver and kidney failure, coma, .rnd even death.
FDA regulates commercially grown and har\'ested muslu·ooms. These are culti-
vated in concrete buildings or ca\'eS. However, there are no systematic controls on
indi\ idual gatherers han·esring '' ild species, except in Michigan and Illinois.
A11idi11-found in raw egg whites (cooking destroys avidin ); binds the ' 'itamin bi-
otin in a way that prevents its absorption, and so a biotin deficiency can de\•elop.
T71iaminasc-found in raw fish, clams, and mussels; destroys tJ1e vitamin thiamin.
Tcn·oriotoxin-found in puffer fish ( fugu) liver; causes respiratory paralysis.
Oxnlic acid-found in spinach, strawberries, sesame seeds, and other foods; binds
calcium and iron in the foods, and so limits absorption of Lhcse minerals.
Hed1al tens-containing senna or comfrey; can cause diarrhea and liver damage. When hunting wild mushrooms, know what you
ore looking for. Many varieties contain deadly
People have coexisted for centuries with these naturall) occurring substances and toxins.
ha\'C learned to avoid some of them and limit intake of others. Today, they pose litde
health risk. Farmers know potatoes must be stored in the dark so that solanine \\'On't
be synthesized. Furthermore, we ha\'e de\'cloped cooking and food -preparation med1-
ods to limit the potency of other substances, such as thiaminasc. Spices are used in such
small amounts that health risks don't result. Nevertheless, as was noted in the discus-
sion on food additives, it's important to understand that some potentially harmful
chemicals in foods occur naturally.
I Environmental Contaminants in Foods

A variety of envi1·onmental contaminants can be foLU1d in foods. Table 19-5 in rhe
Nutrition Focus lists ways to limit pesticide residues in the dier. Aside from pesticide
residues and products of £imgaJ growth, though, other importallt contaminants de-
serve attention.
Lead
Ingesting lead can cause anemia, kidney disease, and damage to the nervous system,
which can interfere with nerve impulse conduction. Because lead has a high atomic
weight, it is a heavy metal. Many heavy metals a.re toxic at low doses.
Lead toxicity is a particular problem for children because it is associated with IQ
deficits, behavior disorders, slowed growth, impaired hearing, and possibly hyperten -
sion and kidney disease later in life. t 7 The precise mechanism by which lead affects the
brain is not clear; however, because lead is chemically similar ro calcium, it can disrnpt
brain mechanisms that depend on calcium. ln addition, lead competes for absorption
with iron , which means less o.xygen could be carried to the brain. Despite the reduc-
tion of lead expoSW'C in children over the past 20 years associated with the decline in
leaded gasoline and lead solder used in homes and in the canning industry, approxi-
mately 1.7 million children have elevated blood lead. Nearly 900,000 of all children
affected are under the age of 6, which is when the brain and central nervous system are
most vulnerable. Medical costs for a child with lead intoxication average $2500 per
treatmem, and most chiJdren require two or more treatments.
Exposed children who eat a higb -fat diet low in calciLU11 and low in iron absorb
An adequate calcium intake helps reduce risk more lead than do those who eat a more healthful diet. For children witb elevated lead
of lead poisoning. Of course, milk is one rich levels, federal experts suggest nutritional and educational intervention, the location oF
source of calcium. the source of Lead (and removal), and medical treatment.
Low-income African-American children who reside disproportionate!)' in inner
cities are at an especially increased risk of harmful lead exposure because of the lead-
based paint present on the interiors and exteriors of older buildings. As this paint flakes
off walls or is abraded from window trim as windows are opened and closed, lead paint
chips enter the environment and may be ingested. Regular home cleaning can be a par-
ticu.hu·ly effective way of removing contaminated household dust for those who, un -
crylamide is a potential neurotoxin and fortunately, arc unable to move to lead-free housing.
A carcinogen found in deep-fried
carbohydrate-rich foods. Acrylamide is a known
Approximately 90 to 95% of adult lead exposures occur in the work en\"ironment.
Occupations thal are linked to high blood lead in workers include radiator repair, bat-
carcinogen for laboratory animals; however, no tery manufacture and recycling, smelting, and construction or remodeling involving
studies have been conducted to dearly deter- lead-based paint.
mine the relationship between acrylamide inges- Other sources of lead include brass fittings on water pumps used in wells, leaded
tion and the development of cancer in humans. 6 glass or crystal, imported wine from areas where leaded gasoline is still used (especially
The average amount of acrylamide consumed by Eastern Europe), and lead caps on wine bottles in general. Wiping the neck of the bot-
adults is about 70 µg/day. This quantity is tle with a towel limits tllis type of exposure. An additional risk is posed by acidic prod-
above the highest amount recommended in ucts, such as fruit juice, sauerkraut, and pickled vegetables srored in galvcuuzed, tin, or
drinking water by the World Health other metal containers (except stainless steel). Acid can dissolve the metal, and any lead
Organization's Guideline Values for Drinking present can then leach into the food product. Foods packaged in ceramic jars from
Water Quality, yet significantly below the Mexico, some household candlewicks, and certain herbal remedies imported from
amount associated with toxicity in laboratory on· China and India have also been associated with lead poisoning. Lead is oo longer used
imols. While researchers learn more about the on commercially produced dishes in rbe United States. However, many decorative
relationship between ocrylomide in the food sup- glazes do contain lead-ensure the safety of all containers or dishes used for food sror-
ply and human health, you can act now to lower age or serving. Be sure not ro use antiques or collectibles, including any made of
your intake of acrylamide by consuming fewer leaded glass, for food or beverage storage.
corbohydrote·rich fried foods cooked at high Lead can leach from solder joints into copper pipes, so it is important to lee tap
temperatures for extended periods of time, such water run a minute or so before drinking it or cooking with it, especially first thing in
as french fries and potato chips. the morning or when tlie water has been off for a few hours. Always start with cold tap
water for drinking, cooking, and preparing infant formula, because hot tap water
causes greater leaching oflead from solder and pipes than docs cold t.1p water. Lead in
drinking water makes up about 20% of the average person's total lead exposure.
Laboratories certified by Environmental Protection Agency (EPA) can test drinking
water for lead content for about $20 co $50. Softening drinking water is also not ~ld
viscd, because soft water can leach lead from pipes.
Some ~igns of lead poisoning include tiredness, irritability, muscle an<l joint pain,
heat..faches, stomach aches and cramps, changes in beha,·ior, and changes in school per-
form.rncc. If you suspect that someone you know has lead poisoning, contact your
physician or the local health department. For more information, visit
L ,, 1.J l or caH the National Lead Information Center .rnd Clearinghouse at
1-800-424-LEAD.
Dioxin
Dioxin is a c hemical that contains chlorine and benzene. It can be crc.1ted by incinerat-
ing chlorine-b~lSed material, such as plastics, together with hydrrn.:arbon-based material,
such as p.1pcr. Dioxins arc potent .111imal roxins witl1 the potenti<1l ro produce adverse
cftects on reproduction and de\'elopmcnt, suppression of the immune system, and can-
cer. Because dioxin causes cancer and other harmful effects in animals, even in small
doses, it probably docs so in humans as well. Breast cancer in women 1s one possibility.
EPA characterizes most dioxins as likely human carcinogens. Besides trash-burning in-
cinerators, other sources of dioxin arc bottom-feeding fah from the Great Lakes-an
area wirh a great deal of industrial activity and chemical production. Dioxin exposures
or
also include smaU amow1ts from breathing air containing tr:icc amounts particles and
in vapor form, from the inadvertent ingestion of soil containing dioxin, and from ab-
sorption through the skin contacting ,1ir, soil, or water containing small .1mounrs.
For a typical person, dioxin exposure can also occur in the diet through the intake of
animal fats. EPA presumes that most dioxin exposure that occurs through the diet is due
to dioxin in the environment, which accumulates in the tissues of animals. This dioxin
exposure from food is a problem primarily for people who frequently consume fish
caught locally. People who eat commercial fish normally cat a va1iery, and c\·en people
who stick ro one rype of fish don't usually h.we a problem because fish in inrcrstate com-
merce generally wme from diflerent warcrs, only a few of\, hich may conrain dioxin.
Mercury
FDA first limited anotl1er hea\'y mct.11, mercury, in foods in 1969 afi.er 120 people in Japan
became ill from eating fish contaminated with high amounts. Birth defects in the offSpring
of some of chose people were also blamed on the mercury exposure. The fish most often
contaminated is swordfish. Shark may .1lso contain large amounts. 16 Such large predatory
fuh that li\'e for a long time can accumulate large amounrs of merctir). Currently, these
species .1rc rested more frequently to ensure that the commercial suppl) is s.tle. FDA sci-
entists responsible for seafood agree that these fish are safe for most people, provided they
are eaten infrequently (no more than once a week). Because mercury i~ ,, ncmotoxin, it
slows feral and child development .rnd causes irreversible deficits in brain function.
Therefore, pregnant women :111d women of chi ldbearing age who may become pregnant
arc .1dvised by FDA not to cat shark, swordfish, king mackerel, and rilcfish. Note that
otl1er r:. pes of fish and seafood, especially smaller, younger varieties, generally contain lit-
tle mercury. C.umcd tuna consumption also should be limited to t\\'icc a week, tl1ough it
is much lo\\'cr in mercury, espcciaJly "light" tuna, than the other fish listed.
Urethane in Some Alcoholic Beverages

Urethane forms during the fermentation of alcoholic beverages. If the tcrmcnrcd prod- Swordfish is a common source of mercury in
uct is heated, as ii1 the production of sherry and bourbon, urcth;rnc concentration in- our diets. It is best to primarily seek other lypes
creases. Although urethane causes c.rnccr in laboratory animab, it'!. unclear\\ hetl1er it of seafoods.
causes cancer in humans. A prudent choice might be to limit the consumption of prod-
ucts such as fruit brandies and sake because these consistently show brge amounts of
urethane.
Polychlorinated Biphenyls (PCBs)

PCBs were widely used for years in a variety of industrial products; however, because
they are linked to liver tumors and reproductive problems in animals, tl1cy are no
longer produced. FDA has banned their use in machinery associated witl1 food and an -
imal feed since 1977 and has established limits for PCBs in susceptible foods and in
paper used for food-packaging material. The most significant food source of PCB
enetic alteration of foods such as corn and residues is fish, primarily freshwater fish, such as coho and chinook salmon from the
soybeans has recently created concern, Great Lakes, and bottom-feeding freshwater species from waters in other industrial
especially in Europe. FDA considers genetically areas, such as the Hudson River Valley in New York. Again, a key guideline for fish
altered products safe if approval for human use consumption is variety and moderation when local sources have the potential for
has been granted (see Chapter 20 for details). contamination.
Cadmium
Cadmium is a natural element in the earth's crust. It is used in the production of bat-
teries, pigments, metal coatings, and plastics. When found in the water or soil it can
make its way into our diets, mostly from seafood harvested from water high in cad-
mium or from plants grown in soil bigh in cadmium. Still, exposure from the work-
place poses the highest risk for cadmium toxicity. Such toxic effects include kidney
disease, lung disease (when inhaled), Jjver disease, and bone deformities. Besides avoid-
ing occupational exposure, the best way to prevent cadmium-related health problems
is to consume a wide variety of foods, including seafoods. (Not smoking is also im -
portant because tobacco smoke is a common source.)
Protection from Environmental Toxins in Foods

Environmental toxins tliat cause disease can be present in foods. To reduce exposure,
find out which foods pose a risk. In addition, emphasize variety and moderatio n in
food selection. The presence of mercury in swordfish or shark may concern you , but
it's normally not a health risk unless your diet is dominated by these fish. The small
amOLLl1t of mercury in most swordfish or shark isn't harmfi.il for most of us if we are
exposed to it infrequently. Note also that tips provided in Table 19-5 in tlie Nua-ition
Focus for reducing pesticide exposure also apply to reducing exposure to environ-
mental contaminants.
Concept I Check
A general program to minimize exposure to environmental contaminants includes knowing
which foods pose greater risks and consuming a wide variety of foods in moderation.
I Our Water Supply: Safety Issues

These days, it is common to sec 5-gallon bottles of water being delivered to homes.
Grocery store shelves are now stocked with all kinds of bottled waters- more than 700
brands in tlie United States-ranging from simple plastic jugs containing "pure spring
water" to fancier, imported varieties of mineral water in glass bottles. In Europe, bor-
tled water is an institution, as popular as soft drinks arc in the United States.
Currently, it is guite fashionable to order a bottle of water at a restaurant or bar. Not
only are people looking for alternatives to alcoholic beverages and soft drinks, but they
are also attracted to the perceived heaJtl1 value or taste of bottled water. This popu lar-
iC) ha~ turned the bottled water industry into a business that rakes in more than $6 bil-
lion a year. It is debatable whether spending chis much money on bottled water makes
any sen!>e.
Bottled Water
Bottled waters vary, depending on the source, use, mineral content, and carbonation.
All botrled waters must list the source of the water on the label. This source can in-
clude ,,·ells, spas, springs, geysers, and quite often, the public water supply. Some bot-
tled water companies add minerals- such as calcium, magnesium, and potassium-to
gin: the water a better taste. FDA !>Ct.!> definitions for terms on the label such as arte-
sinn water, distilled water, purified 111n ter, sp1·ing w11te1; 111i11em./ ivn.tc1; and others. In
essence, the source must be the same one that is listed on the label. Thus, for exam-
ple, "spring water" must come from an underground spring. The presence of carbon
dioxide gas in rhe water source results in carbonation. Bottled waters from this type of
source ;lre said to be naturally sparkling. Other carbonated waters have had carbon
dioxide added during bottling. FDA also sets high standards for purity that bottled
water producers must meet.
Manr people choose bottled water O\'Cr rap water because tliey doubt die safe[)' of
their public drinking water. Some concern O\'Cr municipal water supplies is warranted.
For example, contamination of the public water supply by the parasite Cryptosporidium
is possible. This parasite is usually found in lakes and rivers; the typical chlorination
procedures used to treat public water supplies do nor kill Cryptosporirfimn. This para-
site poses little risk to healthy people-other than a case of diarrhea- but it can harm
Bottled water is a convenient but relatively
people who have AIDS or other diseases that compromise function of the immune sys-
expensive source of water. In most cases, tap
tem (such as some forms of cancer therapy or organ transplant rherapy). 8 Recently, water is just as healthy a choice to meet our
lhese high-risk people have, in fact, been advised to boil for at least 1 minute any tap water needs.
water they use for cooking or drinking to ensure tliat the parasite is destroyed.
Altcrnath cly, individuals can purchase a \\ ater filrer that screens out O·yptospm·idimn
( the National Sanitation Foundation at (800) 673-8010 can prO\ ide a list of manu-
facturers ) or use bottled water that is certified to be free of the parasite (contact the
supplier if in doubt). Generally, distilled water or that which has undergone re,·erse os-
mosis is parasite free.
Monitoring the Safety of Your Water

Under the Safe Water Drinking Act, all public drinking water supplies arc monitored
for contaminants such as bacteria, various chemicals, and toxic metals (such as lead and
mercuq ). The local municipal water department must mail the results of these tests
each vear co ics consumers. According co the Environmental Prorccrion Agency (EPA),
the U .$. water supply ranks among the safest in the world. Ne\'ertheless, this water
docs sometimes fail to meet the agency's standards for contaminant~ such as lead and
nitrates:~ Generally, the public will be warned about the latter, because it is dangerous
to use nitrate-rich water for mixing infant formulas (review Chapter 17). Some snidies
indk:ate diat in a year about one in five Americans consumes water that is not up to
standards, especially in rum! areas. These people could consider using a home water ni -
ter or bottled warer. The local water department can help a per~on evaluate whether
he,tlth risks are worth tlie cost of home water niters or bottled water.
As a safeguard against contamination, chlorine and ammonia .ire added to kill bac-
teria. The addition of such chemicals has raised concern thar dnnking water may in -
crease rectal and bladder cancer risk, though there is currently no conclusi,·e proof of
such risk. If chlorine in tap water docs mcrease cancer risk, the risk is likely extremely
small (perhaps two cases of cancer in 1 million people ).
If you find tlie taste of chlorinated tap water unpleasant or arc concerned about tl1c
possible cancer risk, you can remove the chlorine from tap water by boiling it or by let-
ting a large container filled with water stand uncovered overnight. Tn both cases, tl1e
chlorine \\;II C\'aporate, taking its characteristic 0.wor with it. AJternatively, )'OU l.'.an in
stall a filter on the household spigot from whi1:h you obtain your water. It should be
designed to remO\'C rrihalomcthanes, 1:ommon chlorine by-products.
Options Regarding Your Water Source

Keep in mind that by most standards, bottled water ranges from moderate!) cxpcnsi' e
to expensin!. In manr cases, you arc p.1ying for water that is not much different from
the water you get from your rap. ff you arc concerned about the sate[)' of ~·our t.1p
water, you can ask the municip.11 water department for its most recenr rest re~ulrs, or
you can have the water tested yourselt: A lorn] resting laboratory or state health de
partment can be of ser\'ice, as can the EPA at ( 800) 426-4791, iflocal information i~
not available (for ex.1mplc, iryou have a wd l). This testing can point out whcrher there
are indeed healtl1 risks associated with ~'our water supply. Compared with rhe cost of
bottled water, t he testing tee will be insignificant. As noted earlier io the chapter, let-
ting cold water run for a minute or so before taking, a dri11k or before using ir in mc:il
preparation is a good "ay to limit possible lead exposure, especiaJJy if the warcr lrns
been off for more th:in an hour. In aJdition, do nor use hot rap water for food prcpa
ration. For more information, sec the website W\\\\.ep.l gm /~.ul-,\ater.
Concept I Check
Orerall, the United States enjoys a \'Cr) safo water supply. However, peopk wich poor im
munc status should boil water used for drinking and cooking in order ro avoid waterborne
illness. Borrkd w:ircr can also be used if desired.
Pesticides in Food
Pesticides used in food production cause both ben- Once a pesticide is applied, iL can rum up in a
eficial and unwanted effects. Most health authori- number of unintended and unwanted places. It
ties believe that the benefits outweigh the risks. ma~· be carried in the air and dust by wind currents, ne of the problems with pesticides
Pesticides help ensure a safe and adequate food remain in soil mached to soil parricles, be taken up is that they creole new pests be-
supply and help make foods available at reasonable by organisms in the soil, decompose to other com- cause they destroy the predators (spiders,
cost. However, feelings are growing nationwide pounds, be taken up by plant roots, enter ground· wasps, and bee~es) that naturally keep
thaL pesticides pose avoidable health risks. water, or inv.1de aquatic habitats. Each is a route to most plontfeeding insect populations in
Consumers have come to assume that synthetic is the food chain; some are more direct than others. check. The brown plant hopper, which re·
d.rngerous and organic is safe. Some researchers be- cently plagued Indonesian rice fields, was
not o serious problem before heavy pesti·
lie,·e that chis sentiment is grow1ded in fear and ti.i- Why Use Pesticides? cide use began to kill its predators in the
ded by unbalanced reports. Other researchers sa~
that concern about pesticides is valid and O\'erdue. In the United States alone, pcm destroy nearly $20 early 1970s. In the United States, such
Most concern about pesticide residues in food billion of food crops yearly, despite e\tensive pesti· mojor pests as spider mites and the cot·
for Lhe a\'erage consumer ;ippropriatdy focuses on cide use. The primary reason for using pesticides is ton bollworm were merely nuisances until
chronic rather than acute toxicity because rhe economic-the use of agricu ltural chemicals in- pesticides decimated their predators.
amounts of residue pn:scnc, if any, are extremely creases production and lowers the ce>st of food, at
small. These low concentrations f0tmd in foods .ire least in the short run. ~lany farmers believe that it
noc known co produce .1dvcrse effects in the short would be impossible to stay in business without
term, although harm has been caused by the high pesticides, "hich help protect farmers from ruinous
amounts thac occasionally resulc from accidents or losses.
misuse. For humans, pesticides pose a danger Consumer demands also ha\'e changed over the
m.1inly in their cumul;iti\'e effects, so their threats year~. At one ti me, we wouldn 'L have thought
to health ;ire difticult to determine. However, twice about buying an apple with a worm hole; we
growing evidence, including the problem~ of rhe simply took it home, cur out the wormy part, and
conrnmination of underground water supplies and arc the apple. Toda~', consumers find worm holes
demuccion of wildlifr habitats, indicates that less acceptable, so fanncrs rd) more and more on
North Americans would probably be better off if pesticides ro produce cosmeLically amacri,·e fruits
we reduced our use of pesticides. Both the U.S. and \'Cgetable~. On the practical side, pesticides can
government and man}' farmers are working toward protect against Lhc rotting and decay of fresh frufrs
that end (e.g., integrative pest management). and \'Cgctablcs. This protection is hclpfol because
Chapter 20 discusses the latest use of biotechnol- our food dimiburion system doe~n 't usually permit
ogy to reduce pesticide use_ consumer purchase within hours of han•est. Also,
food grown without pesticides can contain natu-
What Is a Pesticide? rally occurring organisms that produce carcinogens
at concentrations far above current standards for
federal law defines a pesticide as any substance or pesticide residues. For example, fungicides help
mixture of substances intended to prevent, <lcstroy, prevent the c:ircinogcn aflatoxin (caused by growth
repel, or mitigate any pesr. The built-in coxic proper- ofa fi.mgus) from forming on some crops. Thus, al-
ties of pesricid~ lead to the possibilit) that other. though some pesticides may do little more than im-
nonrarget organisms, including humans, might also proYe the appearance of food products, others help
be harmed. The term pesticide tends to be used as a keep foods fresher and safer to eat. - .. - .. .,..~· .. .
generic reference to many types of products, includ-
ing insecticides, herbicides, fongicides, and rodcnti- How Are Pesticides Regulated?
ddes. A pesticide product may be chemical or Pesticide use poses o risk-versus-benefit
bacterial, natural or synthetic. For agriculture, EPA The responsibility for ensuring rhat rc~idues of pes- question. Each side hos points that
allo\\S about 10,000 pesticides co be used, containing ticides in foods arc below amounts that pose a dan- deserve to be considered. Rural
some ~\)() active ingredients. About l .2 billion ger to health is shared by FDA, EPA, and the Food communities, where exposure is more
pounds of pesticides are used each year in the United Safety and Inspection Sen'ice of USDA in the direct, experience the greatest short-term
Stares, much of which is applied to agricultural crops. United Stales. Table 19-2 listcd the roles of various risk.
723
food protection agencies. FDA is responsible for less than the risk from eating such common food!>
enforcing pesticide tolerances in all foods except as peanut butter, brown mustard, and basil. Plants
meat, poultry, and certain egg produces, which are manufacture their own roxic substances to dct~nd
monitored by USDA. A ncwlr proposed pesticide thcmsches against insects, birds, and grazing .mi-
is exhausti\'ely rested, perhaps o,·er 10 years or mals (including humans). When plants arc stres~ed
more, before it is approved for use. EPA muse de- or damaged, they produce e\·en more of these rm -
cide both that the pesticide causes no unreasonable ins. Because of this plant self-protection , man~
adverse effects on people and the environment and foods contain naturally occurring chemicals wnsid
that benefies of use outweigh the risks of using it. ered t0xic, and some arc even carcinogenic. Other
However, there is concern about older chemjcaJs sciemisrs argue that if natural carcinogens arc al-
registered before 1970, when less stringent testing ready in the food supply, then we should reduce
conditions were permitted. EPA is now asking the number of added carcinogens whenever possi-
chemical companies ro retest the old compounds ble. In other words, we should do what we can to
FDA's yearly evaluation of o "market using more rigorous tesrs. Unfonunaccly, inade- decrease rhe problem.
basket• of typical foods (267 food items) quate funding at EPA has hampered the m·iew of
shows that pesticide content is minimal older pesticides. The slow pace of this retesting has
in most foods. angered the critics of pesticide use. When \\'eigrung What Testing Is Conducted for
whether to approve or caned ,\ pesticide, EPA con- Pesticide Residues in Foods?
siders how much more it would cost the funner ro
use an alternative pesticide or process and whether FDA tcsb about 20,000 raw products each year for
cancellation would decrease producti\'ity. After de- pesticide residues. (A pesticide is considered illeg.u
termining the dollar rnst to the farmer, EPA then in this case if it is not approved for use on the crop
looks ~lt coses ro processors and consumers. Once a in question or if the amount used exceeds the .11-
pesticide is appro\'ed for use, it must follow the lowed tolerance. ) The latest FDA studies sho\\ no
margin of safety prmision~ required of food addi- residues in about 60%of samples. Lev> than l "\, of
rh·es (see the section titled Tests of Food Additi\'es dome~ric and about 3% of import s.1mpb ha\e
for Safety). residues that Jre continually over tolcr.rnce These
findings continue to support previous fDA studic~
over the past I 0 year:. diat pcstic:ide residues i11
How Safe Are Pesticides? food arc generally well below EPA tolcr.rnce~. and
they contirm the safety of the food supply rcl.HiYe
Dangers from exposure to pesticides through food co pesticide residues.
depend on how potent chc chemic.ii toxin is, how
concentrated it is in che food , ho\\ much and how
frequently ic's eaten, and the consumer's resistance What Personal Action Can
or susceptibility to the substance. Accumulating in- Be Taken?
formation links pesticide use co increased cancer
rates in farm communities. For rural counties in the We ofren take risks in our own li\'eS, but we prefer
United States, the incidence of lymph, genital, to ha\'e a choice in the matter after weighing. the
Fruits and vegetables grown without use brain, and digestive u·act cancers increases with pros and cons. With regard to pesticides in food ,
of pesticides ore available and may higher-than-average pesticide use. Rt:spiratory can- however, someone else is deciding what is accept-
bear an "organic" label (see Table 2-14 able and what is not. Our only choice is whether to
cer cases increase with greater insecticide use. In
in Chapter 2 for rules regarding the use
teses using laboratory animals, scientists ha\'e found buy or ro :woid pesricide-contaiJ1ing foods. In real-
of the term organic on food labels).
These products generally are more
that some of the chemicals present in pesticide ity it's almost impossible co a\'oid pesticides en-
expensive than those grown using residues cause birtl1 defects, sterility, tumors, organ tird), because e\·en orgaruc produce often conmns
pesticides and typically even contain damage, and injury co che central m:rvous system. traces of pesticides, probably as the result of cross
minor amounts of pesticides. Consumers Some pesticides persist in the em ironment for years. contamination from nearby farms.
need to decide if the potential benefits of Still, some researchers argue that the cancer Short-term studies of the effects of pesticides
the products are worth the extra cost. 15 risk from pesticide residues is hundreds of times on laboratory animals cannot precisely pinpoint
Taltle 19·5 I What You Can Do to Reduce Exposure to Pesticides
FDA's sampling and testing show that pesticide residues in foods do not pose o health hazard. Nevertheless,
if you wont to reduce dietary exposure to pesticides, follow this advice from the Environmental Protection
Agency:
• Consume o wide variety of foods, especially regarding fruits, vegetables, and fish.
• Thoroughly rinse a nd scrub (with a brush if possible) fru its and vegetables (don't use household soap to
clean them because ii is not intended for human consumption). Peel them, if appropriate-although some
nutrients will be peeled away.
• Remove the outer leaves of leafy vegetables, such as lettuce and cabbage.
• Because residues of some pesticides in animal feed concentrate in the animals' fat, trim fat from meat,
poultry, and fish, remove skin (which contains most of the fat) from poultry and fish, and discord fats and
oils in broths and pan drippings.
• When fishing, throw bock the big fish-the little ones hove hod less time to toke up and concentrate
pesticides and other harmful residues. In addition, pay attention to any warnings by local authorities (and
on the fishing license) about the high risk for contamination in specific waters or species of fish.
• Avoid lawns, gardens, and flower beds that have recently been treated with pesticides and herbicides. In
addition, follow all label directions when using products containing pesticides in or outside the home.
Adopted from Food ond Drug Adm1nis~otion: Solely first Protecting America's food supply, FDA Cons11mer, p. 26, November 1988
long-term cancer risks in humans. It should be limit exposure by following some simple ad,·ice
dearly understood, howe\'er, that the presence of (Table 19-5 ).7
minute traces of an e1wironmcntal chemical in a We can also encourage farmers to use fower
food docs not mean that any adverse effect will re- pesticides to reduce exposure to our foods and
sult from eating that food. water supplies, but we'll have ro settle for produce
FDA and other scientific organizations bclie\c that isn't pertl.:ct in appearance or that has been
that the hazards .1re comparati,·cly lO\\ and in the grown with the aid of biotechnology (again, see
short rw1 arc less dangerous than the hazards of Chapter 20 for details). Arc you concerned enough Rinse fruils and vegetables under
foodborne illness created in our own kitchens. We about pesticides on food to change your shopping running water to reduce pesticide
cannot a\'oid pesticide risks entirely, but we can habits or take more political action? exposure.
Summary
1. Viruses, bacteria, and other microorganisms in food pose the other food products, rapidJy cool and thorough!}' reheat leftoYers,
greatest risk for foodborne illness. In the past, sale, sugar, smoke, and use only pasteurized dairy producrs.
fermentation, and drying were used to protect against food- 4. Cross-contamination commonly causes foodbornc illness. It oc-
borne illness. Today, careful cooking, pasteurization, and keep- curs particularly when bacteria on raw animal products contact
ing hot foods hot and cold foods cold prO\·ide additional foods that can support bacterial growth. Because of the risk of
insurance. cross-contamination, no perishable food should be kept at room
2. i\Iajor causes offoodborne illness are the Norovirus and rhe bac- temperature for more than 1 ro 2 hours (depending on the envi-
teria Cnmp)'lobacte1· jej1mi, Salmonella, Shigella, StnpbylococC1ts ronmental temperature), especially if it may have come in contact
trnre11s, and Closf'1·idiit111 pufringens. In addition, such bacteria as with raw animal products.
Clostridium botulintttn, Listeria monocytogenes, Yersinia rnteroco- 5. Treatment for foodborne illness usually includes drinking lots of
Iitica, and Escl1ericJ1ia. coli have been found co cause illness. tluids, avoiding touching food while diarrhea i~ present, washing
3. To protect against bacteria, cook susceptible foods thoroughly. In hands thoroughly and frequently, and getting bed rest. Botulism,
addition, CO\'er cuts on the hands, do not sneeze or cough on hepatitis A infections, and trichinosis are types of food borne illness
foods, avoid contact between raw meat or poultry products and that require prompt medical attention.
725
6. Food additi,·es are used primarily to extend shelf life br pre,·enc \ ' Cnt bacterial growth. Sequestrants bind metals and thus prevent
ing microbial growth and the destruction of food components br spoilage of food from metal contamination.
oi.1·gen, metals, and ocher substances. Food additives are classi- 8. Toxic substances occur nanll"ally in a \'ariery of foods, such as
fied as rhose intentionally added co foods and those that incidcn- green potatoes, raw ti~h, mushrooms, raw soybeans, and 1-a'' egg
t;1llr appear in foods. An imenrional additive is limited to no more whites. Cooking foodi. l i mit~ their toxic effects in some c;1ses; oth-
rhan 1/100 of the greatest amount that causes no observed ers are best to avoid altogether, such as toxic mushroom spc.:des
symptoms in animals. The Delancy Clause allO\\'S FDA to ban the and the green parts of potatoes.
use of an~ intentional food additive under its jurisdiction that 9. A variety of environmental contaminants can be found in food~. lt
causes cancer. is helpful to know which foods pose risks and ro act accordmgly to
7. Antioxidants, such as BHA, BHT, vitamins E and C, and suJfircs, reduce exposure (e.g., washing fruits and vegetables before use )
prc,·enr oxygen and enz)•me destruction of food products. 10. O\'erall, the United Sr.ucs enjoys a ,·ery safe \Hter \upph
Emulsifiers suspend fat in warer, improving the uniformity, However, people with poor immune status should boil "au:r u~ed
smoothness, and body of foods such as ice cream. Common for drinking and cooking in order to avoid waterborne illness.
preservatives include sodium benwate and sorbic acid, which pre- Botclcd water can also be used if desired.
Study Questions
l. ldcnrify three major classes of microorganisms that arc responsible additives. Do you think use offood additi,·es is wonh che cffon m
for foodborne illness. terms of maintaining health? Why or why not?
2. Which kinds of foods are most likely co be invol\'ed in foodborne 9. Describe four recommendations for reducing the risk of coxiciry
illness? Why are they targets for contamination? from em·ironmemal conraminanci..
3. What three trends in food purchasing ,rnd production have led co I0. Hm' do various federal agencies work together co m,unt,un the
a greater number of cases of food borne illness in recenr years? safrry of food?
4. Why i~ thoroughly cooking food an important practice fur reduc-
ing the risk of foodbornc illness?
5. List four techniques other than thorough cooking that arc impor-
t:lnt in preventing foodborne illness.
6. Define the rcrm food rrriditii>c, and give examples of four inren BOOST YOUR STUDY
tional food additives. What arc their specific functions in food~?
Check out the Perspectives in Nutrition: Online Learning
What ii. their relationship to the GRAS lisr?
Center www.mhhe.com/ wardlawpers7 for quizzes, Rash
7. Describe the federal process char go\'crns cl1c use offood additi\'CS,
cards, activities, and web links designed to further help you learn
including the Delaney Clause.
8. Puc into perspecrh·e the bcndics and risks or using additi\'(:S in about issues surrounding food ond water safety.
food. Poinr out an easy \\'a)' ro reduce the consumption of food
1 Acheson DWK: Emerging food p;nhogcns. 3. ADA Report>: Pmirion of the American lmplcmmtiug r/Jc Fight BAC! C11111p11i._1711 rrr·
-:..' 1m·irio11 <:,~r/Je .lf.D. 29(3):1, 2003. Dietetic Association Food and waccr safety. ommmdntions, s1tch ns 111i11g n rhc1'11111111crrr 111
.\Ja11.Y disenscs k1101r11 to be tmmmirttd 1•in food jo11mal of the Amc11rn11 Diermc A.ssocinrio11 ttfl for do1wuss i11 meats, n•o11/rl 1111prol't' fo11d
IJnl'( hem idwtifted, i11cl11di11g il/11essts cn11scd 103:1203. 2003 hm1dli11g prntticcs.
h,Y 1111e1·001JJnnmns, toxim, c/Jemicnls, nnd pri- it is the positimi of the A111tricn11 Dietetic 5. Arrcya CD: Major foodbome illnc'>'> .:.ius111g
om. T71e ncwnl list of i111porta11t ngwrs is rda- Association rbnt rile public IJns n rigbt ton snfe viruses and current status of \'Jcc111c~ agaimc
ti111·Zv 1/J11n. Afn11.1• of these agents cn11 be food nnd JllnUr supply. Sttll, it is esrimared thnt che dise.1sc. Foorlbome Pnr/Jogens n11rf D1scns,·
rr111side1wl e11m;gi11g been.me tbey were 11ot 1·1·cvo- 011 nn 11111111nl bnsis tbere 111·c 76 111illio11 cases of 1(2):89, 2004.
11izrd 1111til recrnt times. T71e 11.rtir.k 1·evirws i11 faodbome il/11css /11 t/Jc United Stntcs, ivith sig- .As 111n11.v ns 67% of cnm offoorlborne il/11csm
demi/ rbc 11mjo1· nge11ts responsible fm'foodbome 11iftcn11t ecomm1ic con. 17111s 11101'1" work needs to m·c cn11sed h,v 1>i1'1tses. L'upt for bcpnriti! A
il/11w. be done wir/J ''C..llfll"ll ffl foorl s11ftry. 171e s11fety of l'irus, 110 Mccinc.r nrt m•ni/nblc fl1r tbt 111nj1w
2. Acheson D\VK.and Fiore AE: Preventing food- drill king wnter IS n lcJScl' ro11ce1·11 ill gmeml for pln:m"S, but l'tltci11es ma,Y be fll'ailnblr i11 rbr
bornc illness-what clinicians can do. T71c Ne1r most com11111ers, b11r mil drstncs comidcrntio11 11enr fimm:. T7Jis article revic111s r/Je rnr1·c11r
E11glnm{ jo1mml of Medicine 350:437, 200-1. ns 11 pote11ti11I so11rcr of il/11m. progress 111 r/Jis nren.
17Jf food 111pp(v i11 the United Smtts is mottly 4. Anderson JB and others: A camera's \;cw of 6 . Bren L: Turning up the hcJc on acf\1Jm1dc.
snft, bur more could be done to lessm tbt risk for consumer food· handling behaviors. Joumnl of FDA Co11S11111er, p. 10, January-rd>ruJf\, 2003
dtPdopmg foodborne ilium. 111is article dis- tbe AmC1·ica11 Dietetic Association 104: 186, FDA is wrn11r~y i1m:srigating r/Jt' 1·isks 11}
rnssu strattgiu to do so, flJ well as m111111nrizes 2004. ncr.vln111irlr i11 011r diets, bur rloes 1101 romido·
the c/Jnmcterisrics of tbe mnjo1· OllJnnisms thnr b11pl'Operfo11d bnmfli11.11 pmctias were common the t1•1drnce mj]icient tll wnr11 pcoplr nbn11r rbc
cn111e foudborm: illness. in tlJc /Jo111e/Jol1fs studier/ i11 tbis s111·11e.Y. p1'11poscd risk. FDA imtenrf is rcemphnsi::.i11.11 irs
tradirio1111/ advice to'"' 11 b11/1111ud dfrt, c/JoQs· disenst from meat i11 rbr United States rrmnim 16. Schardt D: f'ishmg for mcn.-ury: Who 1~ Jr risk?
i11g 11 Mrury of Low-fat 1111d bigb-jibcr.11r11ins, pc1:v low. Sri/I, Oii<' cn11/d cnmitfcr t11'nid11i.11 Nutrition Actio11 Henlth/crter, p. 9, March 2003.
fmits, 1111d vegetables. g1·01111rf 111mt products, mch as /Jot dt!fl.f, 1111d cow
People slJ011/d 111>11id eating swordfish 1111d sbnrk
7. Calvert GM: Hcalch effects or pesticides. br11i11s w ji1nher reduct risk because these prod· ng11lnrl_v 01· 11c all (became t/Jue fish are oftrn
A111mcn11 Fnmi~v Pb_vsuin1169:1613, 2004. ucts 111·c most likc~v to co11t11111 the lllfcllt rbnt is
/11gh in mtt·wry) n11d 1ho11/d rnr 11 vnnct.v of
linked t11 thr disca1c jisb. People wbo ear /oc11ll_v c1111ght fish s/Jmtld
Clrnr cnstt of disease from puricidt cxp111m·c are
seen fi·om acute e.xpos111·cs ivttb b1..11b 11111111111ts. 12. i\1cC.1bc Sellers BJ, Beanie SF: Food safety: rnke into 11cco1111t any stare n11d local ndvmmct
77Je t1·111: tffects 1!{' /mv·do.re, chro11ic e:.:pos111·e has Emerging rrcnds in loodhornc ill ncs!. surveil- n;g111·di11g rbc fish t/J11t rire rn11g/Jr i11 mc1·t111·y·
been hard to q11t111tify, bur most 11d11/ts llfll'I' de· lance ,md prncmion. f11urn11/ 1if tbc Awerica11 co11t11111i1111rcd lrtkcs, rwen, and streams.
tcctnblt prsticide kl'tls 111 cbefr blood. 17ms, if· Dietetic AssoC111tw11 1041708, 2004
17. Schardt D: Ger the lead out-What you don 'c
fm·rs sb1111/d be made tll rtduu puriC1dr 'xpomre T71is 111·11c/r proridcs 11 drtnilcd discmsio11 of the know can hurr you . N11triri1111 Ar1io11
ll'lm1 posriblt, espcci11/(1• n•irb use i11 1111d 111·01111d pre1>wti1111 ufflll)dbomr il/11css, irit/J sttll.ffl'Stio11s He11lthlmcr, p. 1, i\.1arch 2005.
th<' house. such as pnvi1i.t1 atte11ti1111 to ji-cs/J p1'oduu ns a
ll. Foodbornc lllne~~ Primer Work Group: source of rht primnr.v en 11.rntil•c ngwts-l'ir11ses Red11cin..r1 lcnd rxpoml'e ns 11111cb 11s possible is
Foodbornc illnc\S pnmcr for phy\ldans and a11d bncur111 Rcco111mrndnt1om for com1111urs import1111r co protea _vour /)(11/r/J. 171erc is t1•i·
other hc.1lthcarc proti:ssionals. l\·11n·u1n11 111 11111/ fn11d b1111d/crs arr gn•m to reduce risk of
dwcc tbnt ll)ptrtmsion, kid11cy distnsc, drclmcs
Cli111r11/ Care 7:131, 2004. fo11d/111r11r 1/"1w, wit/J prnpr'r persn1111/ b_i:f]ic11e ill brni11 fimcrio11, a11d cnrnmcts arc lmkerf to
bci1i..q 11 11111j111·fows. lend c...:p11m1·c. Testing )'0111' 11111ter mppl,Y jt11" /c11d
Foodbomc illness is n serious henltb pnibh-111,
nf 011rli11ed m rl11: 11n1clc 1s 1111c mc..'l:ptllSll'< 11'/IV
pri111111·1~v f11r rht l't'r.v young, older 11d11/rs, 1111d 13 . .\lusher Di\I, .\lusher RI.. Com.1giom .lcutc ro be n/crt.-d co a possible st111l'u. Usi11lJ 1111(v rnld
people mi11.n imm1111ompp,.cssi1•c mcdicnriom. bactcri.11 mfccuons. 'l71c \ell' E11gln11d Jo11r11al mp rMtcrfor cooking 1s 11/s11 advised.
T71is nnirlt proJ'ldcs prncticnl Ml'Jet 1111 rlu di· of Mcdici1u 351:2417, 2004.
ng110.ris, fl't'lltmcnt, 1111d p1·c1>cntio11 1'.ffi1odbomc l8. Sivapalasu1gam Sand others: rrcsh produce: A
171ae 1111t/Jrll's rc11frw t/Jc l'il'11scs 1111d /111ctrrin ns· growing .:ause of outbreak\ of foodlmrnc: ill-
ilt11ess.
socintcd 11'it/J jimdbonu il/lim. They oj)er sel'crnl ness m d1c United Stare\. ]oumnl 1ij F11od
9. Gerncr·.Sm1dc P amt other.: l0\-.1s1n listcriosis import1111t rero1111umd11tit111s for redtttlltfl '.vpo·
in r>cnn1.1rk 1994-2003: A rcvic\\ of299 c~c~ Protcctio11 67:23-12, 2004
m,.c, mc/11d11i.n b1111d11'11sb111.f1 n11d 1m· of dilured
\\ith '>pcci.11 cmpha~" on ri~k fuctoN for mor· blenclnol11rio11s (I: IO) 1111 s111f11ccs ll'hm p11ssible. Fresh prorfucr sucb ns lett11ce, juici:.r, 111c/1111.<,
ralit1. Cli11icnl M1crnbiologicnl lllfcctin11s sprouts, 1111d barics /Jll.J>f 1uc11tlv bern hiJflr
11:618, 2005. 14. Osterholm MT, Nmg.ln AP: The role of food
ligbrcd ns s1111rccs of11gcnts tbnt lend ro fi111tf·
irradiation Ill food 'ale(\' 171e z-:m bi..nl1111d
Lisunn mfcrtio11s lmd ro denrh pri11111riZr in bomc ill11css. C1111tio11 sho11/d bt used ll'it/J rime
jo11r1111/ 11fJfrdicim 350 1898, 2004
oldn· p.-oplr nntf pr11plr n•lfb 1111dcrl_ri11.11 cases of rrtm.r, JllSI as 011c 11>011/d ll'itb r1111' meat 1111d
cnucn: Ir is therefore apccin/Z\' import1111r for lrrndin 1i1111 of urrn i11 fo11ds snrl1 ns b11111b111:11cr dnir_y prodncrs.
rhm· pn1ple t11 b.- cn1·rf11/ 1'.f expomre 111 Lfrtcrin. gi·cnrf.r rt'd11ccs the rislt ,(01· rdnted fo11db111·11e ill·
ncss 1111d so sh1111/d be cmplo.wd wbm 11scji1/ jot 11 19.Taylor SL. Food additive\, .:onraminalll\, and
I 0. Hillers \'N and ochers: Con\umcr food- specific ji111d i11 q11estio11 . .\fnn_v g1wrm111mr 1111d naturJJ to~kants and their a~sessmem. In Shils
handling heha,;o~ 3\~odated "ith pre1 cntion profcssi111111/ 111lf111l1Z11t1011s mpport use of 11·rndi· ~IE .md othe~ (cd~): .\lodem 1111tritio11 i11
of 13 foodbornc illnc\ses. ]011m11/ 1'.f Food 11rio11. Still, pn1pCl'fl1od /J1111dli11g /~v 111a1111f11c· benlt/J and disease. 10th ed. Philadelphia, PA:
Pr11rmi1111 66:1893, 2003. rurcrs 1111d r1111mmers rc11111i11s i111p111·t11m, Lippmcon Wi lli~1ms & Wilkins, 2006.
Hrwd11'11sbi11g is bi..11Mv r.-eommwded In• r.\'pc1·ts espcci11/~1· btmust some ngmts t/Jnt cn11stji1od· A 1•11riecy uf 1111111rnlf.v 11cc111-r11ig co:.:ms 111·t pres·
for tbt pnl't'T1tio11 ojji)lltfbornc illmss. 171c im· bornt 1//11rss nn- nor msupt1blc to rbr rnrfi11rio11 mt in our food mppf.1·. 17Jc 111_1·cotoxi11s fi·nm
port1111u 1if11or c11ti11..n rcrt11i11 foods, md1asrn11• doses 11srd 1110/d ni-r co111111011, ru nre 11 l't11·iety of to:.:iw
senfood, is 1111otbcr imp11rrn11t h11b1t to ro1wda. 15. Roche SJ, Keenan /'vi}: Shm1ld we be caung or· pr.:sCl/f i11 11111.rhrooms. 17Jr 1111tbo1· disws.rcs tbesc
17Jc use of n t/Jer11111111atT in rooki11~11 is also 1111 gan ic.illy grown food~? Ttidn.v's Dietiti1111, p. 50 1111d orhc1· nntumlly occt11•ri1ig toxins, ns wdl 11.r
i111p11rt1111r prnaicc, 11s is 111•11idn11u of cl'llss· September 2003. fnotf ndd1cnw, 1111d pro1•id<'s nd1•icc jiJr 111m1·
eo11t11111innri1m ojjiJod products. mi~i•i..n txpomre.
Probnb~1· tbc 11101r 1111/id uns1111 for etms11111in.11
11 Ho\\ no\\ mad cow? litfts U1111'emtv Hcnltb OllJll1llmlJ.1•.11roll'11 foods mitmd of c0111•mt1011· 20. Widdow~on MA and others: Noro1·irm and
& Slutl'itinn Lctw; p. 4, ~lay 2004. 11/~1· ll/'1111•11 .fi>"ds is t/Jt pr111t·rri011 1!{ t/Jt t111'i1·on·
foodborne disease, Umtcd Stares, 1991-2000.
After rhi· l'fcmt cnsl' 11/ 11//ld cow rfiscllSI' in tl1e mmt, fir rm en, 1111tf wild/if~ fi·om pestirid1· £11mlfilllJ !nftctio11s Discn!t's 11 :95, 2005
U11iud St11Us, FDA (.\'p1111dcd 1·cg11'11rinm re· 'xposm·,- Promotion of 01tr1111te foods, b1>11'ei>er,
gnrdm.n rbr fredi11g 1111d s/1111ghur of cnrtle. 17m m11st br /111/1111tt:d by tbr 11bsrn•11rio11 1/Jnt me nf 17Jc Xorm•irus lends to more causes offn11db11mc
step .r111rs bcymd tbc nlrmtfy strict l'(flUl11T1011s pe.rricidcs byf111·111rrs mcn-11srs cfjictmn• 1111rf is a il/11ess tb1111 1111y ot/Jcr ngmr. lVlmr is 1111111
put 111 plnrt· in 1997 ro limit risf.. ~f'11111d cow lu:y rcns1111fl1r1b.- 11b1111d111ur 1iffood m•nilnblc 11eederf is /Jetter mn>eilln11ce ji11· this or..r111111s111 so
dismse. 01•<'1·11/l, the 1·isk 1ifcm1t1·11cri11JJ 11111d cm1• i11 tbr U11itcd States. br:tccr csti11111te.r of act1111/ cases c1111 be mndt.
Take I Action
I. Can You Spot the Improper Food Safety Practices?

In this chapter, you learned the following focts: (1) foodborne illness strikes about 76 million of us each year; (2) about 5000 deaths
each year ore caused by foodborne organisms. Read the following excerpt and find the food safety violations that could lead to illness.
A Local Health Deportment Inspector Gives the Following Account of His Visit to a Local Diner
As I walked through the kitchen of the Morningside Diner, I noticed that all food handlers washed their hands thoroughly with hot,
soapy water before handling the food, especially ofter handling row meat, fish, poultry. or eggs. Before preparing row foods, they
also thoroughly washed the cutting boards, dishes, and other equipment. As they used their cutting boards ofter cu tting foods, they
wiped them with a damp rag and used them again to cut more food.
When preparing fresh fruits and vegetables, they washed them but were careful to leave a little dirt on for fear of washing impor·
tont nutrients from the outside. The cooks generally cooked meals lo on infernal temperature of I 80°F (82°C). However, lo preserve the
Aovor, pork was cooked lo on infernal temperature of I 40°F (60°C). Some cooked foods lo be served later were cooled to below 41 °F
(5°C) within 2 hours, and foods such as beef stew were cooled in shallow pons.
The diner served conned foods, even when the cons were dented. When leftovers were reheated, they were raised to an internal
temperature of 150°F (66°C) and served immediately. Food handlers took great core to remove moldy portions of food. The cooks pre-
pared stuffing separately from the poultry. The temperature of the refrigerators was approximately 45°F (7°C).
1. list the violations of food safety practices that could con tribute lo foodborne illness.
2. If you were writing o report describing ways to correct these practices, what two key points would you make?
II. Take a Closer Look at Food Additives

Evaluate the food label of a convenience food item, either one in the supermarket or one you hove available.
1. Write out the list of ingredients.
2. Identify the ingredients that you think may be food additives. .. .

•
3. Based on the information available in this chapter, what ore the functions and relative safety of these food additives?
'
UNDERNUTRITION THROUGHOUT
THE WORLD
~
World Hunger: A Continuing Plague
World Hunger Today
Jamal traveled to the Philippines with his church group last summer. During their
stay, they helped build shelters for people in a village where, a few weeks before, a
"'-=
>.,,<
Critical Life Stages When Undernutrition Is
Devastating • General Effects of Semislorvotion storm hod destroyed several houses. Jamal noticed that many of the children were c
Cose Scenario Follow-Up very short, much shorter than the children in his neighborhood in the United States.
:::t
Undernulrition in the United States
z
Helping the Hungry in the United Stoles •
His group worked in a remote, low-elevation area where the storm and subsequent G>
Socioeconomic Factors Related to flooding hod caused the most damage. On several occasions he noticed young z
c
Undernutrition • Possible Solutions lo Poverty mothers crouched on curbs or in doorways, holding their child. These children rarely -I
and Hunger in the United States
Undernulrilion in the Developing World
moved-they appeared pole and listless. In contrast to the children Jamal's group '°
--1
Food/Population Ratio • War and hod met at a church in the capitol city, most of the children in this village were not 0
Political/Civil Unrest • Rapid Depletion of active and lively. One evening a nurse from the local clinic came to speak to Jamal's
z
Natural Resources • Inadequate Shelter and 7'\
Sanitation • High External Debi • The Impact of group. She said that many children in this area do not get enough lo eat and that z
AIDS Worldwide • Reducing Undernulrition in health problems were rampant. She considered the recent storm a blessing in dis- 0
the Developing World • Some Concluding
guise, hoping it would spur the Philippine government to send supplies to the vil-
~
r-
Thoughts m
Expert Opinion: Alleviating Food Insecurity and lage, particularly food and medicines. Jamal is shocked by such o degree of CJ
Hunger G>
m
suffering. He wonders why children in the Philippines con be starving to death while
Nutrition Focus: The Role of Biotechnology in
Expanding Worldwide Food Availability many children in his hometown in the United Stoles are overweight. z
Toke Action Should Jamal be surprised by widespread disease and general listlessness of 0
.,,
these Philippine children? What nutrients ore likely lo be deficient in their diets?
What other factors contribute to their poor health status?
'°
)>
(")
-I
(")
m
729
T he images ore vivid and heartrending. Emaciated children with enormous eyes and stomachs, too
weak to cry, store at us from news photos and television screens. or the nearly 12 million children
under 5 who die each year in developing countries, 55% of the deaths are attributable to undernutrition.5
Today, nearly one in six people worldwide is chronically undernourished-too hungry to lead a pro-
ductive, active life. Over the past 10 years, this problem hos become even worse. Throughout the world,
the problems of poverty and undernutrition are widespread and growing-despite the fact that there is
enough food available to sufficiently feed all of us. t
The majority (two-thirds) of undernourished people live in Asia.
However, the largest increases in numbers of chronically hungry
CHAPTER OBJECTIVES CHAPTER 20 IS DESIGNED TO
people currently occur in eastern Africa, particularly in Ethiopia,
ALLOW YOU TO:
Sudan, Rwanda, Burundi, Sierra Leone, Kenya, Somalia, Eritrea,
1. Define and characterize the terms hunger, malnutrition, and
and Tanzania. South American countries such as Argentina and undernutrilion.
Brazil are also experiencing such problems. The eyes of their 2. Evaluate the consequences of undernutrition during critical
children haunt us.20 periods in a person's life.
Chapter 20 examines the problem of undernutrition and the 3. Examine undernutrition in the United States and highlight
several programs established to combat this problem.
conditions that create it as well as some possible solutions If we
are to eradicate undernutrition, we all have to understand the
4. Examine undernutrition in the developing world and evaluate
the major obstacles that hinder a solution.
problem and assume responsibility for supplying some solutions.
5. Outline some possible solutions to undernutrition in the
Many political leaders and ci tizens worldwide through their ac· developing world.
lions contribute directly and indirectly to the economic and so- 6. List the worldwide effects of AIDS.
cial destruction that spawns hunger. 1 7. Consider how biotechnology may help solve the food shortage
and distribution problem in the developing world.

OF WORLD HUNGER IN CHAPTER 20, YOU MAY WANT
--
TO REVIEW:
The health effects of protein-energy malnutrition in Chapter 7
The role of vitamin A and rich food sources in Chapter 9
The roles of iron, zinc, iodide, and rich food sources in Chapter 12
The odvantoge of breastfeeding lo Infants in Chapter 16.
Methods to monitor the odequocy of growth in Chapter 17
World Hunger: A Continuing Plague

In November 1974 , lhe Unilcd Nations World l:'ood Conference proclai1rn.:d il~ bold
objective " that within a decade no child will go LO bed hungry, t hat no famil y \\'ill fc.1r
for its next day's bread, and that no human being's future and capacities wil l be !>CUnted
b y malnutrition." Totfay, this promise remains unfulfilled: w1certainty regarding, the
source of one's ne\t meal remains a daily experience for 1 in 6 people in chc de, elop-
ing world (800 million to 1.1 billion ) and 1 in l 0 households in North Amen ca. 1
\Ve must face the reality that the United Nations' members have yet co meet their
current pledge to eb •UC 3 billion people (half o f the world's popul.u ion ) oul of
poverty (living on bs than $2 per day). We also have to consider that 4 5% o f the
world's income curremly goes to die 12% of the world's people who live in rich in-
d ustrial nations such as the U nited States and Can.tda.
730
World Hunger Today

A study of the problem of world hunger and malnutrition today begins with the defi-
nition of some key terms.
Hunger is the physiological state that results when not enough food is eaten to hunger The primarily physiological (internal)
meet energy needs. It also describes an uneasiness, a discomfort, a weakness, or a pain drive lo find and eol food, mostly regulated by
caused by lack of food. The medical and social costs of the undernutrition that can re- innate cues lo eating.
sult from hunger are high-preterm births, mental disabilities, inadequate growth and
de\'elopment in childhood, poor school performance, decreased work output in adult-
hood, and chro11ic disease (Table 20-1 ). Although malnutrition does occur in North
America, it is not due to extreme poverty over a large section of the population.
Instead, then: are usually specific causes such as an eating disorder, alcoholism, prob-
lems in nmsing home settings, or homelessness. Also, some degree of moderate mal-
nutrition exists in some of the poorer segments of North American society (i.e., those
people earning Jess than the current poverty level of income). 1 Fortunately, resources
such as food banks and food stamps are :l\'ailable to man)' such people, though some
times bureaucratic obstacles keep these resources from the people who need them. In
.1ddition, a problem known as food insecurity categorizes indi,iduals who ha\'e anxi- food insecurity A condition of anxiety
ety about running out of food or running nm of money co buy more food. In 2002, regarding running out of either food or money
to buy more food.
Table 20· 1 I The Realities of Undernutrition Worldwide

• Nearly one in six people worldwide is chronically undernourished-too hungry to lead o
productive, active life. This includes one-third of the world's children. Iron
• About 55,000 people die of hunger each day-two-thirds of them ore children.
• About 2 billion people in the world suffer from o micronutrient deficiency.
• About 1 billion people in the world hove iron deficiency. The some is true for zinc deficiencies.
• Up to 500,000 children ore permanently blinded each year simply from lock of vitamin A.
Critical
l
About 100 million to 140 million children ore deficient in vitamin A.
Micronutrie)n
• About 50 million people worldwide hove developed brain damage from maternal iodide Deficiencies
deficiency; currently, 2 billion people ore at risk for iodide deficiency. Worldwide
• Residents in developed countries spend more money on pet food, perfumes, and cosmetics than
it would toke to provide basic education, water, sanitation, health core, and nutrition for all
people now deprived of it. Various
• Every day the world produces enough food to provide about 2400 kcal for each person, [ B Vitomin_s_
generally meeting overage calorie needs. A doily intake less than 2100 kcal would not likely
sustain on older child or adult, depending on workload.
• Poor women in developing countries face o 50. to 200.fold increased risk of death in pregnancy
compared with women in North America.
• In many developing countries, life expectancy of the population is one-half to two-thirds of that of
North Americans.
• Almost half of the world's people earn less than $200 a year-many use 80 to 90% of that
income to obtain food. About $2000 to $3000 of income each year is needed for a person to
reach the life expectancy seen in North America.
acquired immunodeficiency syndrome (AIDS) A
• Of the 6.2 billion people in the world, about 1.1 billion drink contaminated water. In Indio
disorder in which a virus (human
alone, 300,000 children die each year from drinking polluted water.
immunodeficiency virus [HIV]) infects specific
• About 2 billion people in the world live without proper sanitation, such os reliable toilet faci lities. types of immune system cells. This leaves the
person with reduced immune function and, in
• Developing countries hove 95% of the AIDS coses worldwide.
turn, defenseless against numerous infectious
• Developing countries bear 93% of the world's disease burden but use only 11 % of the world's agents.
health-core resources.
732 Chapter 20 Undernutrition throughout the World
over 11 % of households in the Un ited States reported that they experienced food in-
security. Of these, 3% reported that they experienced h unger at least one time during
that year. 1 Food insecurity is also a problem in Canada.
According to UNICEF (United Nations Children's Fund), the United States ranks
11th Out of 16 industrialized countries for child poverty. Fortunately, the United
States does have food assistance programs for low-income fumilies, and therefore most
children in the United States are shielded from hunger.
malnutrition Foiling health that results from Malnutrition is a condition of impaired development or function caused b)' either
longstanding dietary practices that do not meet a long-term deficiency or excess in energy and/or nutrient intake. When food supplies
nutritional needs. are low and the population is large, undernutrition is common, leading to nutritional
undernutrition Foiling health that results from a deficiency cliseases such as goiter (from an ioclide deficiency) and xerophthalmia (eye
longstanding dietary intake that does not meet problems caused by poor vitamin A intake). However, when the food supply is ample
nutritional needs. or overabundant, incorrect food choices coupled wirh an excessive intake can lead to
overnutrition-rclated chronic diseases; such as type 2 diabetes.
Undcrnutrition is the most common form of m;tln utrition among the poor in both
developing and developed countries. Currently, about half of the 4 million African
children under 5 years of age who die annually are undernourished. Undernutrition is
also the primary cause of specific nutrient deficiencies that can result in muscle wast-
ing, blindness, ~curvy, pellagra, beriberi, anemia, rickets, goiter, and a hoM of other
lood loss caused by intestinal and blood- problems (Table 20-2 ). 5
borne parasite infections is another com- The most critical micronutrients missing from d iets worldwide arc iron,\ itamin r\,
mon cause of anemia among poor populations, iodide, zinc, and various B vitamins (e.g., folate) as well as selenium and vitamin C. 7
especially when people do not wear shoes. About l billion people, mostly in r.he developing world, are affected by iron deficiency.
Parasites such as hookworms con easily pene- The same is true for zinc deficiencies. With poor iron status, cognitive development
trate the soles of the feet and legs and enter the will likely be impaired, particularly if prolonged dcficicncr occurs during c.uly infancy.
bloodstream. Although hookworm disease hos An estimated 50 million people worldwide also sutrer brain damage from prevenrable
been largely eradicated through improved sani- maternal iodide deficiency. Although severe vitamin A deficiency, which cau!>eS blind-
tation in the United States ond other industrial- ness, is on che decline, up to 500,000 preschool-age children are still blinded by ir each
ized notions, it continues to plague more than year. UNICEr reports that the lives of 1 million to 3 million children could be saved
one-eighth of the world's population, mostly in annually in the developing world if vitamin A supplements were provided a few times
tropical regions.12 each year. The annual cost per child would be about 6 cents.
Of the 6.2 billion people in the world, about 2 billion may experience episodes of
food shortages and be affected by some form of micronutrient malnutrition. 1 Death
and disease from infections, particularly tl1ose causing •lCUtc and prolonged diarrhea or
respiratory disease, increase dramatically when tl1c infections occur during a state of
chronic undernutrition. C hronic undernutrition leaves many people in the developing
Famine An extreme shortage of food that leads world in a continual state of depressed immune fuJ1ction, in turn greatly increasing rhe
to massive starvation in a population; otten risk of death, especially in childhood .18
associated with crop failures, war, and political Protein-energy malnutrition (PEM) is a form of undernunition caused by an ex-
unrest. tremely deficient intake of energy or protein generally accompanied by an illness. The
dramatic results of PEM-kwashiorkor and marasmus-were described in Chapter 7.
This chapter focuses on the more subtle effects of a chronic lack of food.
Famine is the extreme for m of chronic hunger. Periods of famine arc characterized
by large-scale loss of life, social disruption, and economic chaos that slows food pro-
duction. As a result of these extreme events, the affected commw1ity e>..periences a
T he Irish potato famine of 1840 to 1850

caused on estimated 2 million deaths and
resulted in nearly as many people emigrating to
downward spiral characterized by human distress; sales of land, livestock, and other
farm assets; migration; clivision and impoverishment of the poorest families; crime; and
tl1e weakening of customary moral codes, as seen in Sudan and Rwanda. In the midsr
other countries, such os the United Stoles and of all this devastation, undernutrition rates soar, infectious diseases such as cholera
Canada. More than 3 million people may hove spread, and many people die.
perished in the great famine of 1943 in Bengal, Special efforts are needed to eradicate the fundamental causes of famine. Causes
Indio. In 1974, another l .5 million starved in vary by region and decade, but the most common is crop railure. The mo!>t obYious
the country of Bangladesh. Chino suffered a reasons for crop failure are bad weather, war, and civil strife. War dcscnes a special
famine from 1959 to 1961-estimotes of mor- focus and \\'ill be specifically addressed in a separate section on war and political/civil
tality range from 16 million to 64 million. wu-est. 11
Table 20·2 I Nutrient-Deficiency Diseases That Commonly Accompany Undernutrition
Disease and Key

Nutrient Involved Typical Effects Foods Rich in Deficient Nutrient Target Populotions for Intervention
Xerophthalmia
Vitamin A Blindness from chronic eye infections, liver, fortified milk, sweet potatoes, Asio, Africa
restricted growth, dryness ond spinach, greens, carrots, cantaloupe,
kerotinizotion of epithelial tissues apricots
Rickets
Vitamin D Poorly calcified bones, bowed legs, Fortified milk, fish oils, sun exposure Asia, Africa, ond ports of the world
other bone deformities where religious dress codes prevent
women ond children from receiving
odequote sun exposure; older adults in
developed notions
Beriberi
Thiomin Nerve degeneration, altered muscle Sunflower seeds, pork, whole and Vidims of famine in Africa
coordination, cordiovosculor problems enriched groins, dried beans
Ariboflovinosis
Riboflavin lnflommotion of tongue, mouth, face Milk, mushrooms, spinach, liver, Victims of famine in Africa
ond orol cavity, nervous system enriched groins
disorders
Pellagra
Niacin Diarrhea, dermatitis, dementia Mushrooms, bron, tu no, chicken, beef, Victims of famine in Africa, survivors of
peanuts, whole and enriched groins wor-torn Eastern Europe
Megaloblastic anemia
Folote Enlarged red blood cells, Green leafy vegetables, legumes, Asia, Africa
fatigue, weakness oranges, liver
Scurvy
Vitamin C Delayed wound healing, internal Citrus fruits, strawberries, broccoli Victims of famine in Africa
bleeding, abnormal formation of
bones and teeth
Iron-deficiency anemia
Iron Reduced work output, retarded Meats, seafood, broccoli, peos, Worldwide
growth, increased health risk bran, whole-groin ond enriched
in pregnancy breads
Goiter
Iodide Enlarged thyroid gland in teenagers Iodized salt, soltwoter fish South America, Eastern Europe, Africa
ond adults, possible mental
retardation, cretinism
Although the nutrients ore listed separately to illuslrote the importonl role of each one. oken two or more nutrillon-Oeficiency diseases ore found in on undernourished person in the developing world.
Critical Life Stages When Undernutrition Is Devastating

Prolonged undernutririon is detrimental to many aspects of human health (Figw-e 20-1 ).
It is particularly damaging during some periods of growth and old age.
Pregnancy
Undernutrition poses the greatest health risk during pregnancy. 1 Currently about
500,000 women worldwide die each year from complications of pregnancy and child-
birtl1. A pregnant woman needs extra nutrients ro meet both her own needs and tl1ose
of her developing offspring. Nourishing the fetus may deplete maternal stores of ouoi-
ents. Maternal iron deficiency anemia is one possible consequence ( rc,~ew Chapter 16).
In Africa, women in tl1eir lifetime!> give birth, on a\'crage, to more than six lfre ba-
bies. Coupled '' ith chronic undernutrition, these high birth rates result in .1 l in 20
chance that a woman will die from pregnancy-related causes. In contra'>t, Norrh
Ame1ican women face a risk of only l death from pregnancy-rebtcd cau~es in about
8000 births. Pregnancy-related death is tl1e social indicator with the biggest difference
between the developing and industrialized worlds. Smaller differences exist for literac~,
life expectancy, and inf.mt mortality.
The bounly of food enjoyed in North America Fetal and Infant Stages
relies on rich agricultural resources. Many The fetus faces major healtl1 risks from undernutrition during gestation. 1 To support
developing countries do not hove such growth and development of the brain and otl1er body Lissucs, a growing fetus requires
resources to employ.
a rich supply of protein, \~tamins, and minerals. When these needs arc 1101 met, the in-
fant is often born before 37 "eeks of gestation, well before the 40 weeks of gestation
Reduced intellectual
and social development
Reduced work capacity
Increased maternal
mortality in pregnancy
Loss of parents, Exploitation of women

especially linked to AIDS
Figure 20· I I Undernutrition affects many aspects of human health and humanily.
that is considered ideal. The consequences of this preterm birth include reduced lung
function and a weakened immune system. These conditions nor only compromise
health but also increase the likelihood of premature death. Long-term problems in
growth .Uld development can result if the infant survives. ln extreme cases, low-birth-
\\'cighc infants (about 5.5 lbs (2.5 kg] or less) face 5 co 10 times the normal risk of
dying before the age of l year, primarily bec:lllse of reduced lung development. When
low birth weight is accompanied by other physical abnormalities, medical intcrvenrion
can cost $200,000 or more. These costs can be met onl)' in developed countries.
Worldwide, more than 30 million infants arc born c.1ch year with IO\\ birth \\"eight.
Currently, about 7% of infants born in the United States and 6% in Canada have low
birth \\'ciglm.. In the United Stares, low birth weight accounts for more than half of
all infant deaths and 75% of deaths of infants yOLmger than 1 month old. Whereas un-
dernuo·ition is a major contributor to low birth weight in developing countries, the
primary cause for this problem in industrialized countries is cigarette smoking.
Pregnancy during the teenage years, while a girl's body is still growing, contributes to
IO\\' birth weight in developing and industrialized countries <ilike.
The percentage of infants born \\ith low birth weight in the United States has been
ni.· l.
increasing steadily during the past 20 years. One reason is that more twins, triplets, and
higher-order multiple births are being born because of improvemenrs in medicine :md The risk of nutrient deficiencies in o person in-
tcrtility procedures. Rates of low birth weight also var~· by race. About 13% of infants creases during any period of rapid growth.
born to African-American women have low birch weights. Among Hispanics in the Why?
United Stares, infants of Mexican origin have the lowest rate oflO\\ birth weight ( 6% ),
while infants of Puerto Rican heritage have the highest (9%). Among Asian subgroups,
low-birth-weight rates range from 5% for infants of Chinese heritage to nearly 9% for
Filipino infants.
Childhood
Early childhood, when growth is rapid, is another period \\'hen undernutrition is ex-
tremely risky. The central nen·ous system-including the brain-continues to be \W-
nerable because of rapid growth rlu·ough early childhood. After the preschool years,
brain growth and development slow dramatically Lllltil maturity. Nutritional depriva-
tion, especially in early infancy, can lead to permanent brain impairmenc. Without an
eftecti,·e inren·ention, it is projected that ongoing undernutrition could leave more
than 1 billion children with mental impairment by 2020.
In general, poor children arc at the greatest risk for nutritiona l deprivation and
subsequent illness. 16 Stunted growth is an obvious effect, seen in about one-third of
children under 5 years of age worldwide. In addition, iron deficiency anemia is much
more common among low-income children than children from kss deprived fami-
lies. This deficiency can lead to fatigue upon exertion, reduced stamina, stunted
growth, impaired moror development, and learning problems. Undernutrition in
childhood can also weaken resistance to infection because immune function de-
creases ''hen nutrients such as protein, vitamin A, and zinc .ire very low in a diet.
Clearly, undcrnutrition and illness have a cyclical relationship. Not only docs under-
nurricion lead to illness, but illness, particularly diarrhea and infectious diseases,
worsens undernutrition. For this reason, many childn:n in developing countries are
dying from the combination of malnutrition and infection. Conversely, when miss-
ing nutrients such ,\s 'itamin A and zinc ,1rc restored Lo children's diets, improve-
ments in health can be ob,·ious.
Later Years
Minimal intakes of protein and zinc limil the
Older adults, especially older women living alone in poverty, arc also at risk for undcr- growth of children worldwide. About 30% of
nurrition. Older adults in gencr•ll require nutrienr-densc foods in amounrs dependent children in developing countries show evidence
on their stare of health and degree of physical acti,·iry. Because many older adults have of poor growth rates.
fixed incomes and incur signjficant medical costs, food often becomes a low-priori()'
item. In addition, depression, socia l isolation, and declining physical and mental health
can compound the problem or undernutrition in older adults (review Chapter l 8).
General Effects of Semistarvation

The effects of hunger ore widespread: In the initial stages, the results of undernutrition from scmistarva[ion are often so
mild that physical symptoms arc absent and blood tests do not usually detect the
• Reduced energy and strength slight metabolic changes. E"en in the absence of clinical signs and sympwms, how-
• Diminished concentration ever, undernourishment may affect reproductive capacity, resistance to and rcco\'-
• lmpoired ability to learn ery from disease, and physical activity and work output and may lead w fatigut: and
• Lowered productivity behavior problcms.6 •16•18 Recall from Chapter 2 that as tissues continue co be de-
• Worsening of chronic health conditions pleted of nutrients, blood teMs eventually detect biochemical change!>, such as a
• Increased susceptibility lo infectious diseases drop in blood hemoglobin concentration. Physical symptoms, such as body weak-
• Deterioration of mood ness, appear with further depiction. Finally, the foll-blown symptom!> of the pre-
• Slowed recovery from illness and injury dominating deficiency arc recognizable, such as when blindness accompanies a
vitamin A deficiency.
When a fc\\ people in a population develop a seYere deficiency, this situation may
represent only the "tip of the iceberg." Typicall)', a much greater number haYe milder
degrees of undernutrition. These deficiencies should not, therefore, be dismissed as
trivial, especially in the developing world. Ir is becoming clear that combined defi -
ciencies or specific vitamins and the minerals iron and zinc can seriously reduce work
performance even when they do not cause obvious physical signs and symptoms. This
resulting state of ill health, in turn, diminishes the ability of individuals, communities,
and even whole countries to perform at peak b ·cls of physical and ment.il capacity
(Figure 20-2).
In adrution to their lack of nourishment, the inhabitants of poorer countries must
also contend with recurrent infection:., poor sanitation, extreme weather conditions,
and regular exposure to infectious diseases. They require greater amounts of certain
nunients-espccially iron-to combat rampant parasite and other infections.
Deficiencies in both iron and zinc can lead ro reduced immune function and thereb)
increase the risk of diseases such as ruarrhca and pneumonia.
Figure 20·2 I The downward spiral of Nutrient-deficient diets

poverty and illness con ultimately end in death provoke health
(based on World Food Program graphic). problems;
undernulrition increase
Inadequate or susceptibility to disease.
inappropriate food
leads to stunted Disease decreases
development and/or people's ability to
premature death. Sickness cultivate or purchase
and loss of nutritious foods.
livelihood
Poor people may

eat and absorb too
little nutritious Food,
making them more
disease-prone.
n the 1940s a group of researchers led by

Dr. Ancel Keys examined the general effects
Jamal's shock upon encountering the effects of poverty and illness among of undernutrition on adults. The researchers
Philippine children is a natural human response. Sadly, given the conditions in maintained 32 previously healthy men on a diet
which these children grow up, their listlessness and poor health is hardly surpris- that averaged about 1800 kcal daily for 6
ing. Protein, vitamin A, iron, iodide, and zinc deficiencies contribute to poor growth and de- months. During this time, the men lost an aver·
pressed immune function. One or more of these deficiencies is likely presenl in many children in age of 24% of their body weight. After about 3
the village. The diets of these children may also be marginal in energy con tent, further depress· months, the porticiponts complained of fatigue,
ing growth and overall health. We know from many nutrition intervention studies that the provi· muscle soreness, irritability, intolerance to cold,
sion of calories and protein as well as vitamin A, iron, iodide, and zinc-among other and hunger pains. They exhibited lack of ambi-
micronutrients-can reverse some of this disease pattern and improve health. Still, many children tion, self-discipline, and concentration, and they
throughout the world exist in a stunted and immune-depressed state associated with their chroni· were often moody, apathetic, and depressed.
cally deficient diets. Their heart rote and muscle tone decreased, and
they developed edema. When the men were
permitted to eat normally again, feel ings of re·
current hunger and fatigue persisted even after
Concept j Check 12 weeks of rehabilitation. Full recovery re·
Hunger provokes uneasiness and pain when insufficient tood is eaten to meet energy needs. quired about 8 months. This study tells us much
Food insecurity is anxiety about running out of food or money ro bu)' more food. Chronic about the general state of undernourished adults
hunger leads to undcrnu trition, which can c.1use growth fai lure in children and physical worldwide. 13
weakness in adults. Risk of infection increases, and nutrient-deficiency diseases result. The
primary cause of undernutrition is po,·ercy. The critical periods for undernutrition occur
during pregnancy, infancy, childhood, and old age. Chronic undernutrition decre~es work
performance, motivation, and immune function. The adverse effects in pregnancy and in-
fancy arc quite dramaric, as e,·idenccd by rnort:1liry rates much higher than those of hcalthr
populations. Irre\•ersibk de,·elopmental damage in sun·hing children is also common.
Undernutrition in the United States

About 33 million people in the United State~ ( 12%) live at or below the poverty level,
currently estimated :It about $18,400 annually for a fami ly of four (Table 20-3). Of
those 33 million, 12 million (37%) are children.
Currently, 8% of Caucasians, 2~% of African-Americans, and 23% of Hispanics li\'e
in poverty. Many Native Americans are also poor, as arc 11% of Asian Americans.
(Many Native Americans in Canada also live in poverty.)
The poor often face difficult choices: whether to buy groceries fc>r thc family or pay
this month's rent; whether to have dental work done or pay the current utility bill;
whether to replace clothes the children have outgrown or pay for transportation to
apply for a job. Food is one of the few flexible items in a poor person's budget.
Whereas housing and utility costs, medical care, and transportation fares arc non-
negotiable, a person can always cat less. The short-term consequences of eating less
may be less dramatic than getting evicted, bur the long-term cumulative eflccrs are
significant . Food insecurity is part of the North American
landscape. A safety net of programs exists, but
ii is porous.
Helping the Hungry in the United States
Until the twentieth century, in d ividuals and a wide varit:ty of charitable, often ch urch-
rclated organizations provided most of the help to poor, undernourished people in the
United States. Early programs rarely distributed direct cash payments ro poor people
because such payments were thought to reduce recipients' motivation to impro,·c their
circumstances or change behaviors, such as excessive drinking, that contributed to their
povert). \~eginning in the early l 900s, t he involvemem of local, county, and state gov-
ernments in providing assistance to the poor has steadih increased.2
After obsen;ng cxtensh·e hunger and poverty dm;ng his presidenrial campaign in
the 1960s, John F. Kennedy revitalized the Food Stamp Program, which actually had
ndernutrition in North America is a much Table 20·3 I The Realities of Poverty and Undernutrition in the United States
more subtle problem than in developing
• About 7% of infants born in the United Stoles ore low birth weight. low birth weight accounts for
countries. To the untrained eye, undernourished
more than half of all infant deaths and for 75% of deaths of babies under 1 month of age.
children moy just seem skinny when, in fact,
their growth is being stunted by insufficient nulri· • The infant mortalily rate in the United States is higher than that of 26 other industrialized
ents. More likely, though, today's children from countries. Teenage pregnancy contributes to infant mortolily in part because young mothers
food-insecure households ore prone to be over· frequently don't meet their nutrient needs
weight. This tendency moy be the result of con· • Single-parent fami lies constitute about 25% of all families with children. The poverty rate (40%)
sideroble reliance on convenience foods tha t for the opproximotely 19 million children in such families is five times higher than that for
provide mostly fat and sugar. Also, food· children in two-parent families.
insecure families moy buy candies ond snack • About 33 million people in the United States live at or below the poverly level. These poor
foods as treats when expensive toys and clothing include about 16% of oil children; children, in fact, comprise 37% of the poor. Hunger
aren't affordable. frequently accompanies poverly.
• A family of four in the United Stoles at the bottom 20% of households hos an average income
one-fifth of the overage income of the top 20% of households.
• In the United States, on estimated 12 million people, or 6.5% of all adults, have experienced
homelessness sometime during their lives. An episode of homelessness nearly always lasts for at
least 1 week ond otten for a month or more.
• The Food Stomp Program for low-income people provides each household with $190 per month.
About 1 person in 16 currently participates in this program.
• Second Harvest, the largest U.S. food bank, estimates tha t more than 23 million people, or more
than 1 person in 10, rely on food depositories and soup ki tchens to feed themselves and their
families. Most of these people, the organization reports, ore workers who hove lost their jobs.
• Food thrown out in U.S. cafeterias, supermarkets, and restaurants could feed 49 million people
per yeor.
begun cwo dec,1dcs earlier, and expanded commod ity distribution programs. Today rhe
Food Stamp Program for low-income people allows recipients to use an Electronic
Benefit Transfer (EBT) card to purchase food and garden seeds-but not tobacco,
deaning items, ,1koholic be,cragcs, and nonediblc products-at stores authorized to
accept them. Each participating household recei\'es about SI 90 per month, on a\ er-
age. Cmrencly about 21 million people in the United States participate in this program
(Table 20-4).
The U.S. Congress established the School Rrcakfost Program in l 965 as politicians
became aware of the number of hungry children coming to school. School bn:akfast
and lunch programs still enable low-income srudenrs-8.4 million for breakfast and 27
million for lunch-to recei\'c meals free or at reduced cost if certain income gwdelines
are met ( under $23,920 to $34,040, respecti\'ely, for annual income of a family ol
four). In rhe same year, the U.S. Congress funded group noontime (called C01lfTl'Cgntc)
meals and home-ddi\'ered meals for all citizens over 60 years of age, regardless of in-
come (donations are requested, however). Both remain active programs, serving about
1 million meals each day, but they still do not reach all who need help. In .1ddition, in
1972 the Special Supplemental Nutrition Program for Women, Infants, .rnd Children
(\VIC) was authorized. This program prm·ides food rnuchers and nutrition education
to low-income pregnant and lactating women and their }'Oung children. Today, it
serves abour 7 .6 million people.
Between 1969 and 1971, some already large federal food programs were expanded
and others were created. For example, the food Stamp Program served only 2 millior
people in 1968, but by 1971 it was serving 11 million. The National School Lunch
Program, which i.er\'ed only 2 million poor children before 1970, \\'JS serving 8 mil
lion children lw 1971. Soon after, the School Breakfast Program, a pilot program fo1
children Li\ ing in impO\'erished areas, became a\'ailablc nationally. And, .1~ just men
tioned, in 1972 the Special Supplemental Nutrition Program for Women, Infants, ,111d
Children (WlC) began.
Table 20·4 I Some Current Federally Subsidized Programs That Supply Food for People in the United States
Program Eligibility Description

Food Stomp Program Low-income families Electronic Benefit Transfer (debit) cords ore given
to purchase food at grocery stores; the amount
is based on size of household and income.
The Emergency Food Low-income families Nutrition assistance is provided to needy
Assistance Program (TEFAP) Americans through distribution of USDA food
commodities.
Commodity Supplemental Certain low-income populations, such os USDA surplus foods ore distributed by county
Food Program pregnant women, children until the age of agencies; not found in all stoles; may be based
6 years, and seniors on nutritional risk.
Special Supplemental Nutrition Program Low-income pregnont/ loctoting women, Coupons ore given to purchase milk, cheese,
for Women, Infants, and Children (WIC) infants, and children less thon 5 years old at fruit juice, cereal, infant formula, and other
nutritional risk specific food items al grocery stores; includes
nutrition education component.
Notional School Lunch Low-income children of school age Free or reduced-price lunch is distributed by the
Program school; meal follows USDA pattern based on
MyPyramid; cost for the child depends on
family income. For students who do not
participate in the lunch program, special milk
program may be available.
School Breakfast Program Low-income children of school age Free or reduced-price breakfast is distributed by
the school; meal follows USDA pattern; cost for
the child depends on family income.
Child and Adult Children enrolled in organized child.core Reimbursement is given for meals supplied lo
Core Food Program programs and seniors in adult-care programs; children of the site; meals must follow USDA
income guidelines ore the some as those for guidelines based on MyPyromid.
the School Lunch Program
Congregate Meals Age 60 or over (no income guidelines) Free noon meol is furnished of o site; meal
for the Elderly follows specific pattern based on on~third of
nutrient needs.
Hom~Delivered Meals Age 60 or over, homebound Noon meal is delivered at no cost or for o
donation at least 5 days o week. Sometimes
additional meals for later consumption ore
delivered of the some lime; often referred to as
"Meals on Wheels."
Summer Food Residence in o low-income neighborhood or Free, nutritious meals and snacks ore given lo
Service Program participation in o program children in a low-income area at o central site,
such as o school or a community center during
long school vocations.
Food Distribution Low-income American Indian and non-Indian Distribution of monthly food packages; includes
Program on Indian households on reservations; members of nutrition education component; alternative to
Reservations federally recognized tribes Food Stomp Program.
Sometimes, severe undernutrition due to involuntary hunger does occur in the

U nited States. More often, though, Americans experience periodic episodes of hunger
and food insecurity. Unemployment, medical and housing expenses, and even occa- he availability of cooking facilities affects
sional holiday shopping can cause a household to be hungry or food insecure .1 nutrient intake among the poor. Without
Government food assistance programs arc like a safety net-they are strong, yet cooking facilities, people may buy expensive
porous. Privately funded programs have stepped in co take an important role in state convenience foods that require no preparation.
and federal efforts to combat hunger and related food insecurity in rhe United States. These typically highly processed snack foods
There are currently more than 150,000 charitable food providers (such as food banks provide energy but ore often locking in nutrients.
7 40 Chapter 20 Undernutrition throughout the World
and food pantries) helping to cope with this problem. They serve about 23 million
Americans. Many low-income U.S. households rely on food pantries, and a recent sur-
vey found that slightly more than two of every three people requesting such emergency
food assistance were members of families--children and their parents.
Socioeconomic Factors Related to Undernutrition

Tn the United States, persistent hunger and food insecuri ty are largely associated with
two interrelaLed conditions: po,·erty and homelessness. Thus, the economic, social,
and political changes that lead LO an increase in the number of poor or homeless peo-
ple also tend LO imens~· the problem of undenrnLrition.
omeless children suffer higher rates of Poverty

many medical problems than do other chil- Underemployment leads to poverty. An overabundance of unski lled manu.11 laborers
dren, some of which include: exists tlu·oughouL Nortl1 America. Many such people (and families) suffer hardships
Upper respiratory tract infections \\'hen layoffs occur seasonall) or because of d1anges in the economy. Conu-ary co com-
Scabies and lice mon perceptions, tl1e parents in most poor fumilies arc working-nearly two in dm~e
Tooth decay fumilies cont.1in .u least one worker. Often, howe,·er, the jobs available to untrained
Ear and skin infections adults are in the service sectors, such as the food service and retail industries, wl1icb
Diaper rash pay mi ni mum wage and may no t offer health and other benefits to employees. Even
Eye infections when one or both parents work al Lhese low-paying jobs, their fami lies may still be left
Developmental delays \\'ith the choice of either paying rent or buying groceries.
Trauma-related injuries Another prim.1ry factor contributing to po,·erry has been the dramatic increase in
the number of single-parent families in the United States, the result of high rates of di-
vorce and om-of-wedlock births. Currently, there are about 4 million single-parem
fami lies. T he poverty rate ( 40%) fo r lhc approximately 19 mill ion children in singk-
parent families is five times higher Lhan d1e rate for children in two-pa re nt families.
Homelessness
Homelessness is much more evident now than in 1980 because the economics of
poverty and undemurrition has changed in an imponant way. The economic status of
the working poor has declined because affordable housing is harder for t hem to find.
Due to Lhe nation's rising affluence, higher-income tenants have bid up the prices of
the aparu11ents in some cities beyond tl1e financial resources of poorer tenants. The
U.S. government considers housing costs, which include renr and utilities, to be af-
fordable if the) make up no more than 30% of a family's income. A recent U.S. gO\'-
ernmenr report stated tl1at 1 in 8 low-income famiJics pay more than half their
incomes for housing or Live in dilapidated units. T hese fa milies, although not home-
lt:ss, are likely to experience undern utrition without direct food assistance. Fam ilies
with children currently accoLLnt for about 43% of the homeless. An estimated 12 mil -
lion people in the United States, or 1 in 15 of all adu Its, have experienced homeless-
Food pantries and soup kitchens are important ness sometime during their li\'cS. This statistic rises to about 1 in 7 when it includes
sources of nutrients for a growing number of people who have mo,·ed into someone else's residence during periods "hen tlley bad
people in the United States. Consider nowhere else to live. Moreover, the continuing changes in the economic circLLm-
volunteering some of your lime lo a local stances they face could force such low-income fami lies into homelessness, at lease
program. temporarily.
Other important causes of homelessness include LLnemploymenc, personal crises,
and widespread release of mentally ill patients from mental institutions in tl1e 1980s.
The abuse of alcohol and crack cocaine is another notable cause. Up to 85% of all
homeless people in large cities in the United States abuse alcohol or drugs or ha\'e a
mental illness. Most people with such problems arc unable to find and hold employ-
ment; without support from family or friends, tl1ey and their dependents will probably
become homeless.
Possible Solutions to Poverty and Hunger in the United States

Few people would dispute the importance of supporting physically and mentaUy chal-
lenged adults and the multitude of poor children in the United States. The debate be-
gins when able-bodied adults arc rccci\'ing public aid. Many of these people have
extenuating circumstances or have dug such a deep financial hole for themseh·cs that
it is difficult to get out. The United States has enough resources to feed every citizen;
government-funded food assistance programs have helpcd to alleviatc some problems
ofundernutrition in the United St.Hes. The question is, Cnngorcrmumt p1·ogmms pro-
J1itfc n per111n11mt so/11t1011 to poJJer~)' rmtf u11dcrn11rritio11 ... n11d should t/Jey?
Pri\'atc emergency food network systems are also important to consider, but arc not
sufficient ro meet all food needs in the United States. furthermore, most of thc do-
nated items arc limited in nun·itionaJ ,•aJue. By necessity, processed and canned grocery
items predominate, rather than fresh or froz;en fruits and vegetables or protein-rich
foods such as milk.
Some observers believe that publicly funded as~istance programs have scli:prop<lgated-
that ther proYide an inccnri\'e for poor, single \\Omen to ha,·e more children, because
more children entitle a family to more benefits. New welfare reform IJ\\s haYc addressed
this issue by n:quiring abk-bodicd adults tO get jobs and by limiting futme direct support
to 5 years in a lifetime. It is up to each state to determine how to implement this work re-
quircmem and establish exceptions for certain situations, as in tlie case of disability, short-
term dO\\ mums in tlie economy, or otl\cr overwhelming hardships.
i\Iany states are improving child care, teaching parenting skills, .md expanding job
Homelessness con be the result of many
oppor tunities as they help people end their dependence on welfare payments. problems, including poverty.
Natiom,·ide, the number of people on welfare has fallen 60% since 1992, but recently
the number has stabilized and in some states has increased slightly.
Despite even tlie highest motivation, the ourlook is bleak for many people who ar-
tcmpt to gain independence from assistance programs. Teen pregnancy may have cut
short the education or\ ocarional training of one or both parents, thwarting efforts to
earn adequate income. Often, the expense of reliable and sate child care far exceeds the
meager income from a minimum-wage job. Illness of either tlie parents or children
may prevent the adults from holding steady employment. Poor communication skills,
inability to relocate, and a lack of economic reserves also complicate financial inde-
pendence. Regardless of how wa~teful governmem assistance appears co some people,
it ,,;JJ probably always be necessar) to some extent.
Many people in tlie United States consider an increase in ind ividual n:sponsibilit:y LO be
a critical goaJ. Government programs cannot easily fix po,·eny and d\e resulting hunger
that stem from irresponsible u1di\ idual bcha,·ior. Government programs can, howc,·cr, help
reduce or prevent the PO\'Cft)' that results largely from lack of education or oppornmiry.
Because long-term undernutrition-espccially among children-ha~ both individual
::tnd societal consequences, everyone in the United Stales is affected by tllis problem,
either directly or indircctly. 1 The next few years are likely to bring further changes in ne goal of Healthy People 2010 is lo in·
both go\'ernmem and private assistance programs, demanding ne\\ initiatives. As the crease food security among U.S. house·
welfare system is further reformed and government programs are redesigned, it is likely holds from the current 88% to 94%. Another is
that some individuals will suffer. The hope is chat these new approaches will lead to to reduce growlh retardation to 5% among low·
long-term progress and the eventual relief of poverty and hunger. income children under age 5. For the latest
thinking on food insecurity in the United Stoles
Concept I Check see the Morch 2006 issue of the Journal of the
111 response to reports of widespread poverty and hunger during the 1960s, me U.S. American Dietetic Association (106: 446, 2006).
Congress established se,·eral food assistance programs and substantially increased funding
for already existing programs. Largely as a result of these federal programs, undernutrition
had decreased substantially by tl1e mid-1970s. The presence of po,·erty, homelessness, and
undenrntrition is influenced by economic, cultural, and indi\'idual factors as well as go\'ern-
ment policies. The serious questions about me long-term effecti,·eness of many go\'ernment
assistance programs are causing major changes in tlleir program design. All citizens can
help reduce the problem of undernutrition.
Undernutrition in the Developing World

Undernutrition in the developing world is also tied to poverty, and any true solution
must address this issue. However, these countries have a multitude of problems so
complex and interrelated that the}' cannot be created separate!~. Programs that ha\e
pro,·ed immensely helpful in the United States (and throughout the rest of North
America ) arc only a starting poim in this context. The following major obstacles stand
in the way of easy solutions:S• 11, 15, 17, 20
• Extreme imbalances in the food/population ratio in different regions of a councr~
• War and political/civil unrest, especially in Africa
• The rapid depletion of narural resources, such as farmland, fish, and water
• The disease AIDS, especially in sub-Saharan Africa and Asia
• High external (foreign) debt, much of \\'hich is owed to developed nations
infrastructure The basic framework of a system • Poor infrastructure, especially poor housing, san itation and storage facilities, edu -
or organization. For a society, this includes cation, communications, and transportation systems
roods, bridges, telephones, and other basic
technologies. Each problem deserves individual consideration (Figure 20-3 ).
Food/Population Ratio
The world has 6.2 billion inhabitants. Currendy, population growth exceeds economic
growth in much of the developing world, and as a result, poverty is increasing. This dis-
rupts the b:ibncc in d1e food/population ratio, ripping it toward food shortages. If \\'e
want to ensure .1 decent lite for a \\idcning segment of humanity, many experts suggest that
the growth in the e-arth's most rnlnerablc populations should slow. ff not, by 2050 che
\\'Orld may ha\'e l to 3 billion more people than it docs today-most of them in countries
where the J\ erage person earns less than $2 per day. Currendy in A&ica 's poorest coun-
uies, nearly 65% of people live on less than $1 per day. Unless a catastrophe occurs, more
than 9 of 10 infants in the next generation will be born in the poorest parts of the world.
More than three-quarters of people in the world live in developing countries, and
more than half live in Asia. A recent United Nations report on worldwide hungcr re-
"ealed that almost two-thirds of the world's undernourished lj,·e in Asia and the Pacific
Rim. The world's food supplies also are not distributed equally among consumers.
Gross disparities exist between developed and developing countries, among th<.: rich and
the poor within couna-ies, and e\·cn withi n fami lies (males may be fed before tcmalcs).
Figure 20·3 I Many factors contribute lo

undernulrition in the developing world. Any
AIDS
solutions to the problem must take these factors
into consideration.
War and political/civil I Rapid depletion of

natural resources, such as
unrest
farmland, fish, and water
Hunger
in the
Developing
World
Extreme imbalances in
the food/ population ratio
1 Poor infrastructure
High external debt

Still, economists estimate that world food production "ill, in facr, continue co in-
crease more rapidly than world population in the near future, allowing the food/pop-
ulation ratio to increase through the year 2020. This increase will come at a high cost,
howe,·er, in terms of the water, ferti lizer, and pesticides needed to allow for this pro-
duction. Overall, in the short run, the primary problem .1ppears not LO be food pro-
duction but distribution and use, especially in poverty-stricken areas of de,cJoping
nations.
Eventually, though, food production will begin co lag behind population growth.
f\ lost good farmland in the world is already in use, and because of poor farming prac-
tices or competing land-use demands, the number of farmable acres worldwide de-
creases annually. For many reasons, sustainable world food output- •lll amo unt that
doesn't deplete the earth's resources-is now running well behind food consumption.
This discrepancy suggests that food production in lcss-<levcloped countries will barely
keep up with population growth and will soon lag behind.
Birth control programs, an obvious brake on population expansion, have been ef-
fective in c.kveloped counuies but relatively ineffective in many developing countries
that could really benefit from them. Among women, family planning and contrat.:ep-
tive use worldwide has increased to 60% today, up from I 0% in 1969. If the United
Nations, \'Olunrary organizations, and governments had not starred promoting fom ily Poverty aggravates the problem of hunger in
the developing world.
planning and contraceptive use, the population today might be as high as 7 or 8 bil-
lion. However, women (and men ) in many developing countries arc still lacking ade-
quate access to contraccprh·es. Organizations sut.:h as .Population Scr\'ices International
are n·ying to keep distribution costs lo\\' <tnd make the products av.1ilable to .1s many
people as possible by subsidizing condoms and oral comraceptives to areas such as hether the earth con yield enough food
Bangladesh. for all people hos been a long-standing
Promoting breastfeeding also contributes LO the go.ti of birth control. Although it ques~on. As early as 1798, English clergyman
is not a completely reliable med1od of contraception, exclusively breastfeeding an in- and political economist Thomas Malthus pro-
fam lessens ovulation, thereby lowering the likel ihood or fortilization, for an average posed o rather pessimistic view of our prospects.
of six months. (Women who do nor bre~tfoed generally begin Lo ovulate '' ithin a He said the population would increase in o
month or so after gi\'ing birth. ) When childbirths are more ''idcly spaced, not onl) do geometric ratio-2, 4, 8, 16, 32, and so on.
fower weal births occur, but the mother has a longer cham:e to recover from preg- Meanwhile, at best, the food supply would in·
nancy, and the infant receives feed ing priority for a longer time. One possible excep- crease only in on arithmetic ratio-2, 4, 6 1
tion ro the healthful nature of breastfeeding occurs, however, when mothers are 8, 10, and so on. This prediction means that
intecred with the human immunodeficiency vir us (H IV). The risk of transferring the while the food/popula~on ratio might begin at
,·irus through human milk is about 10%. Depending on the circumstances, this risk 2/2, eventually the population will grow to 32
may outweigh the benefits of breastfeeding. while food supplies will only increase to feed 10.
Experience with family planning programs in de,·eloping countries and historical However, eminent British scientists at the time
changes in birth rates in many developed countries suggest an in1porcanr conclusion: pointed out that scientific advances in agriculture
generally, only when people have enough to car and a.re lina.ncially secure do they foci would greo~y increase food production. In fact,
confident that havi ng fCwer child ren wil l still result in enough su rviving sons and/or their predictions hove proved true, to on extent.
d~lughters to pro,·ide for their care in later years. Increasing per capita income and im- The aptly named "population explosion" is cur·
pro,·ing education, especially for women in developing nations, are currentl~ consid- ren~y undermining this progress in the develop-
ered to be the most likely long-term solution!> to excessi,·e population growth. In the ing world.
I.1st few years this effort has led to a decline in family size in Brazi l, Egypt, lndia, and
Mexico. A major concern is whether d1ere are enough re!>ources worldwide to raise per
capita income and pro,·ide enough education to slow population gnm ch.
geometric ratio A series of numbers wherein
the division of each number by the one lo the
left of it yields the some answer.
Concept I Check arithmetic ratio A series of numbers wherein
Currently, world food production is sufficient co meet the energy needs of the world's pop- the difference between each number is the
ulation. Despite these adequate food resources, undernutrition continues to exist because some.
of poverty, politics, and trnequal food distriburion. Tn addition, projected population
gro" th ma\' soon ovcrn he\m food production. Most scientists and world leaders recom- human immunodeficiency virus /HIV) The virvs
mend limiting population growth, especially in developing countries where birth races arc that leads to acquired immunodeficiency
syndrome (AIDS).
high.
War and Political/Civil Unrest

The Millennium Summit of the Uniled Nations pledged to "spare no effon to free our
peoples from the scourge of \\ ar." Against that background stands the reality that
worldwide military spending has doubled O\'er the p:m 20 years. ln the twentieth cen-
tury, deadly \\capons of war rook an enormous toll on civilians living in poor, politi-
cally ''ulnerable, war-torn nations. Although Africa has been ravaged by economic
decay and famine !or )'ears, military spending in Africa more than doubled in the 1970s
and held firm through the 1990s. Currently, less than one-half of 1% of the world's
yearly production of goods and services is devoted to economic development assis-
tance, whereas approximate!~ 6% goes to military expenditures.
Aside from the economic impact of military spending, civil disruptions and "ars .1re
setting back the progress of the poor and contributing to massi,•c undcrnutrition. All
but two of the major conflicts in 2000 took place in the developing world. War-related
famine affects at least 20 million people in southern and northeastern Africa. The bor-
der war between Ethiopia and m.:ighboring Eritrea has had a tremendous negative im-
pact on food resources. A World Bank official stated Lhat the food shortage in Ethiopia
is a problem that will persist until political changes arc made. Currently, 12.4 million
people in Ethiopia. Eritrea, Djibouti, Kenya, Somalia, and Zimbabwe are at risk for
food shortages. Other contlicts continue berween Congo (formerly Z.1irc ) and the
Republic of Congo as well ai. in Angola and Sudan, where millions have been put at
Homes and infrastructure ore of1en damaged risk of starvation. In the capital of war-torn Traq, Baghdad, chi ld malnutrition nearly
during times of war and political unrest. doubled bcrwecn 2002 and 2003. Disruptions in infrastrucrure from bombing and
looting limit the safety of water, and as a result, health officials have observed a 250%
increase in case!> of diarrhea. Furthermore, health fucilities needed ro cope with un-
dcrnutrition and dehydration haYe been damaged and looted throughout Baghdad
and the surrounding area. Q,·crall, most people in war-torn areas arc without sufficient
shelter, clothing, food, or means of obtaining them. Worldwide, this enrirc problem i~
projected ro worsen over the next 15 years.
he recent conAicts in the Darfur region of Even when food is available, political divisions may impede its distribution to the
Sudan hove led to high rotes of death and point that undcrnutrition will plague many people for years to come. fapecially dur·
undernutrition among people displaced by ing emergencies, programs designed to help the poor have been undermined by un-
wor.11 stable administration, corruption, and political influence. During such political chaos.
relief agencies are often caught between warring faccions and the people they are uy-
ing co help. Thi!> dilemma occurred in the mid-1990s in Zaire, where Rwandan refugee
camps fell under the control of a militant group. T he rebels controlled the food com-
ing into the camps and would not allow relief agencies tO do their work.
During the 1960s and 1970s, the problem of undernutrition in dcYeloping coun-
tries was percei\'cd as a technical one: how to produce enough food l(>r the gro'' ing
world population. The problem is now seen as largely political: how to achieve coop·
eration among ,rnd within nations so that gains in food production and infr.istrucrurt
are not wiped out by war. The best answer lies in a combination of approaches-find
ing technical solutions to help with the problems of chronic hunger and poverty and
resolving political crises tlrnt have pushed developing nations into a stale of acutL
hunger and chaos.
Rapid Depletion of Natural Resources

green revolution Increases in crop yields
As we quickly deplete the earth's n:snurccs, population control grow~ increasingly crit
accompanying the introducti on of new
ic,tl. Agriculture production is approaching irs limits in many areas worldwide
agricultural technologies in less-developed
countries, beginning in the 1960s. The key
Environmentally unsusrainable farming mctl10ds arc undermining food production,
technologies were high-yielding, diseose- cspecialJy in de' eloping countries.
res1slonr slroins of rice, wheal, and corn; The green revolution was a phenomenon that began in the l 960i. ''hen crop yid&
greater use of fertilizer and water; and rose dramatically in some countries, such as the Philippines, India, and ~lnico (coun
improved cultivation practices. tries in Africa did not benefit because climates were not compatible with the crop~
used). The increased use of fcni likers and irrigation and the development or supcrio"
crops through careful plant breedjng made this boost in agriculrur:.11 production possi-
ble. 8 Man~ of the technologies associated wirh the green rc\'olution hm e now achic\'ed
their potential. Rice yields, for example, ha\'e nor increased signilicantly since the re-
lea~e of superior varieties in 1966. (Acwally, the green revolution w:is imcnded as a
stopgap measure until world leaders could control population growth.)
Future gains in productivity may be much h:1rdcr to accomplish because of the ex-
istence of less producti"e farmland. Until the introduction of another ~uperior strain
of rice or other grain, developing coumrics will not benefit greatly from recent, more
modeM breakthroughs in biotechnology (sec the Nutrition Focus section on use of
biotechnology).
Areas of the \Yorld that remain uncultivated or ungrazed arc mostly too rocky, steep,
intertile, dry, wet, or inaccessjble to sustain farming. Nearly all irrigation \\'ater avail -
able worldwide is currently being used, and groundwater supplies .1rc becoming de-
pleted :n rapid rates in many regions. An e\'enmal water shortage is projected to lasting gains hove come slowly in the world's
increase war and civil unrest in arid areas of the world, such as Northern Africa and the bottle against undernutrition.
Midd le East. China, which has more than 20% of the world's irrigated land, is also
plagued with .1 growing scarcit)' of fresh water. In the future, billions of people will fuce
ongoing water shortages.
The prospecrs of obtaining substantially more food from the oceans are also poor.
In recent }'Cars, the amount of fish caught worldwide has le,·eled off Fish was once
considered the poor person's protein, but this option is no longer a' ailable because
farming of fish currently docs not come close to compensating for the degree of re-
duction in wild fish populations. 15
Clearly, we can exploit the earth's resources only so far- the world population prob-
ably cannot continue to expand .1s it docs today without the potc111 ia l for serious
famine and death. T he Food and AgricuJn1re Organization (FAQ ) of the United
Nations works on this principle: "The fight to ensure that all people have enough nu-
tritious food to cat is worthy of our greatest efforts, bur it must be fought with the full
recognition that it cannot be won unless agricultural, fisher)', and forestry production
returns to the earth as much as-or more than-it takes." Thus, if food production is
to keep up with the expanding population, immeruate action is needed to protect tl1e
earth 'S already deteriorated en\'ironmcnt fTom further destruction.
Inadequate Shelter and Sanitation

n Brazil, migrants displaced by multinational
When people rue from undernutrition in developing countries, other factors, such as in-
adequ:1te shelter and sanitation, almost always contribute. Poor sanitation along with un-
dernutrition panicularly raises the risk of infection (Figure 20-4). for example, the 1994
I land developers have Aooded from the north
and northeast into Rio de Janeiro and Soo
plague in Surat (northwest Inrua), linked mainly to unsanitary housing condfrions, killed Paulo, attracted by the prospect of jobs. There
almost 5000 people and sparked lhe panicked exodus of another half a million . they have built shantytowns next to apartment
lnadcqu.1tc and deteriorating shelters rhrearen the lives of more than 500 million towers and afAuent suburbs, but the jobs do not
people today. .i\fany of the 15 million annual deaths of children- half of them under 5 materialize, and urban poverty simply replaces
years old-in deYcloping countries could be prevented by improving rhc standards of rural impoverishment.
environmental hygiene. Urban population:. of some developing countries arc currendy
gro\\'ing at •111 annual rate of 5 to 7%. Such a skewed popu l.ltion distribution will re-
sult in more poverty. The current urban explosion is d1e rcsulr ol'both high birtl1 rates
and continuing migration of people to the cities from rural .m:as. People go to the
cities to find employment and resources that the countryside can no longer provide.
\Vorld\\idc, 38% of people lived in urban areas in 1975. The figure is now about 50%
and is cxpectcd to reach 70% by 2050. Nine of the world's 10 l.1rgesr cities will be in
poor coumrics 20 years fi-om no\\. Currently 12 of the world's 15 most polluted cities
are in Asia alone.
In de,·cloping counaies, the poor make up most of the urban popul.1tion, and their
needs for housing and community services ofren go beyond a,·ailable governmental re-
sources. 1'vlost of these urban poor live in overcrowded, scll: madc ~helters tl1at lack a
safe and adequate water supply and arc onl)' partially served by public utilities. The
7 46 Chapter 20 Undernutrition throughout the World
Figure 20·4 I Nutritional status and overoll

food supply combine with a variety of Environmental
environmental factors to influence the risk of Entry of contominotion
infection and the ultimate outcome. infectious
agent
- Climate
Popul~tion
density
-
Immune Previous
response exposure
Ty~e of
pot ogen
Infection Illness
monogement
__...
in family
Illness
monogement
in fami ly
-
Response MedicoI
Immune
function
~
)
- core
~
Health
returns l noo•
occurs l
Health is
permanently
domoged
shan tytowns and ghettos of the developing world are o ften worse than the rural areas
the people left behind. Because the urban poor need cash to pw-chase food, they often
subsist o n diets that are even more meager t han the homegrown rural fare. Making
matters worse, haphazard shel ters often lack facilities to protect food from spoilage or
damage by insects and rodents. T his inability to protect food supplies in some devel-
oping colu1trics leads to the loss of as much as 40% of all perishable foods.
T he shi ft from rural to mban lite takes its greatest toll on infants and children.
I.nfants are often weaned early fro m the breast to infant formula, partly because the
mo ther must find employment and partly because she may be influenced by advertise-
ments depicti ng images o f sophisticated, fo rmula-feeding women. Unfo rtunately, be-
cause infant form ulas are relatively expensive, poor parents may try to conserve tl1e
formula by eitl1cr overdiluting the mixture or using too little to meet the infant's
needs. Because the water supply ma}' not be safe, the prepared fo rmula is also likely ro
be contaminated with bacteria. Human milk, in contrast, is much more hygienic, read-
ily available, and nutritious. It also provides infants with immwuty to some ailmcnrs.
Promoting breastfeeding is important when it is safe for tl1e in fa nt ( review the earlier
discussion of AIDS, H IV, and breastfeeding).
O veraJJ , me single most effective health advantage fo r people, wherever mey live, is
a safe and convenient water supply. 17 Inadequate sanitation and the consumption of
Inadequate sanitation facilities and the
contaminated water cause 75% of all diseases and more than one-third of all deaths in
consumption of confominoted water cause the developing countries. The World H ealtl1 Organization (WHO) estimates that 1.1 bil-
majority of all diseases. About l billion people lio n people, about one-sixth of all people, have an unsafe and inadequate water supply.
in developing countries lock access to a safe ln addi tion, up to 90% of the diseases seen in developing countries may be <lttributed
water supply. to contaminated water.
Poor sanitation, another example of inadequate infrastructure in the de,·cloping

world, creates a critical public health problem. Human teces, rotting garbage, and as-
sociated insect and rodent infestations are potent sources of disease organisms com-
monJy seen in urban areas of the developing world. Two of the most dangerous
substances encountered in routine daily living are human urine Jnd feces. The inabil-
ity to dispose of the massive numbers of dead people (and dead animals) resulting from
civil wars causes additional sanitation problems. In some developing counrries, diar-
rheal diseases account for as many as one-third of all deaths in children under 5 years
of Jge. WHO estimates that even with impro,·ements in housing, 2 billion people in
the world still lack proper sanitation facilities.
High External Debt

Since the 1970s many developing countries have become trapped in a cycle of bor- he Group of Eight-consisting of the world's
rowing repcatedJy from foreign countries and internationa l banks. Servicing these ex- most industrialized notions-is planning to
ternal debts, which now total about $2.5 trillion, has brought several countries to the forgive some external debt owed by developing
,·erge of economic collapse. About $6 billion is owed to the United States. The exter- countries. The $40 billion that hos been prom·
nal debt of Latin AmcLica represents 45% of the area's gros~ regional output of goods ised should end the external debt of 18 coun·
and sen·ices. tries, including some in Africa and South
~lany African nations also carry large debt bmdens--currcntly, $350 billion. This America. The debt repayment depends on the
problem is made worse by recent drops in prices for the raw commoditic~ they export, developing country's agreement to practice good
higher prices for imported oil, and embezzlement of funds by high -ranking officials. governance and to use the money saved to sup·
To m.lke up the difference between export income and import expenses, countries port health core, education, and infrastructure
ha\'e been forced to borrow millions of dollars from international banks. AJthough the improvements.
African debts are much smaller in absolute terms than those of Brnzil, Argentina, and
Mexico, for example, the actual burden is greater when national incomes and export
earnings arc considered. Nearly haJfrhe money African nations earn from exports goes
to paying off the continent's muJtibillion-dollar debt. Much of the rest goes to fund
imports of machinery, concrete, a·ucks, and consumer goods from de,·cloped coun-
tries. Little is left for domestic programs, necessitating cutback5 that translate into
fewer resources to counter already widespread undernutrition.
Concept I Check
\Var and civil strife, along with a decline in the world's natural re5ourcc~, contribute to the
difficulty of cndLng undernutrition in many developing countries. In addition, substandard
housing conditions, impure water, and inadequate sanitation worldwide increase the risk for
infection and disease. Infection then combines \\'ith undernutrition to compromise further
the health of impoverished people. Finally, many de,·eloping countries arc burdened by ex-
tremeh high external debts, which se,·ercly limit their ability tO implement programs to re-
duce undcrnutrition.
The Impact of AIDS Worldwide

Currently, Jbout 40 milJion people around the world arc inlectcd with the human im-
munodeficiency virus (HIV) or have gone on to develop AIDS from the intection. The
male to female ratio is about 1: 1, but the disease is now increasing faster in women
than men. 20 About 20 million people worldwide have died from AIDS.
An individuaJ can be infected with HIV through contact with bodily fluids includ- he lace of AIDS is quickly becoming the
ing blood, semen, vaginal secretions, and human milk. Thus the virus can be trans- face of a child. About 500,000 deaths of
mitted through sex-ua.1 contact, through blood-to-blood contact, and from a mother to children in subsharan Africa in 2004 were
an infant during pregnancy, dcli\'ery, or breastfeeding. The virus has a \·cry limited abil- linked lo AIDS. (Compore that to about 300
it) to exist outside the body. deaths of children linked to AIDS in developed
Once infected with HIV, the indi\'idual is said to be RN-positive. If untreated, the countries during the some year.)
,-iral disease progresses over the next fow years, and tlJe individual develops symptoms
of opportunistic infections such as diarrhea, lung disease, weight loss, and a form of
cancer. Once individuals have developed these symptoms, they are said to have AIDS.
Without treatment, an indi\'idual will likely die from AIDS within 4 to 5 years.
In Africa, particularly sub-Saharan countries, HIV is rampant throughout the enrire
population, both men and women. This region contains nearly 70% of the world's
HIV-positive people. In most areas of sub-Saharan Africa, AIDS is reducing life ex-
pectancy by one-half, especially if the person also has tuberculosis. Note also that in
2004 about 500,000 deaths of children in sub-Saharan Africa were Jinked to AIDS.
(Compare that to about 300 deaths of children linked to AIDS in developed countries
in the same year. ) In many countries, A.IDS is also creating orphans, an estimated
3.7 million worldwide (660,000 in South Africa alone).
North Arnerica also has an AIDS problem . In the United States alone, it is estimated
that about 1 million people (1 in every 280 persons) are infected with HIV, many of
whom are unaware of their infections. (Recent reports show 1 in every 100 persons in
New York Ciry is infected with HIV.) About 450,000 people in the United States have
died from the disease since it surfaced in the early 1980s, and each year abouc 50,000
new cases are reported. HIV affects a greater percentage of minority populations i11 rl1e
United States.
Although no vaccine is avai lable to prevent AIDS, the latest antiviral drugs can sig-
A particularly sod consequence of AIDS in nificantly slow the progression of the disease. However, there are many ba rriers to the
Africa is the number of AIDS orphans, children use of tl1ese drugs in the developing world. For example, the newest therapies require
whose parents hove both died of AIDS. The a person to take at least three different drugs in the form of about 14 pills each day.
United Notions hos estimated that there will be Just a few missed doses can significantly reduce the effectiveness of the drugs and re-
20 million AIDS orphans in Africa by the year su It in faster disease progression. Anotl1er barrier is economic: a typical drug regimen
2010. can cost approximately $14,000 per year, nor includ ing unforeseen hospital stays.
Certain drug companies and governments are working to lower the cost of AIDS drugs
for developing nations, or even provide them at no cost. Still, in many cases, the drugs
remain out of reach to the people who need them. It has been suggested that de\·eloped
nations should step in and cover most or all of tl1c costs. The United Nations is spear-
heading an effort to raise the $8 to $10 billion needed to fight the d isease.
The main goal for addressing the problem of AIDS in the developing world is pre-
vention oF new cases through education regarding safer sex and the importance of
clean needles, and through other behavior-linked approaches. Providing AIDS drugs
to pregnant women is also important. Tf a woman begins taking AIDS drugs such as
zidovudine (AZT) by the fourteenth week of pregnancy, the risk of transferring the
virus to her offspring is greatly reduced. Providing the drug immediately before birth
on eating a balanced diet prevent AIDS? also helps.
C The answer, unfortunately, is no. Healthy
eating does not cure the disease, but it con help
The devastating effects of AlDS on our civilization have been very rapid when mea-
sured by earth's scale of time. And the true costs to society-other than tl1e cost of
lo lessen the impact of infections associated with human lives-have yet to ernerge. 19 The very oarure of the disease is likely to inflict
AIDS. Poor nutritional status, such as for vitamin significant human devastation worldwide, partly because its primary route of transmis-
A and vitamin E, contributes to o quicker onset sion- sexual activity-is basic human behavior. A recenr study warns us that 57 cotm-
of symptoms such as body wasting and fever tries risk major HIV outbreaks. Reported HIV cases are increasing rapidly in Africa,
and to a more rapid demise. In fact, doily use of the Ind ian subcontinent, Southeast Asia, Chi11a, the Caribbean, Russia, and much of
o multivitamin and mineral supplement has been Eastern Europe.
shown in some studies to reduce disease pro- Behind the mind-boggling statistics on AIDS are less obvious costs to businesses,
gression in people with HIV infections and families, schools and universities, and society in general. For example, worker produc-
AIDS. lo Overall maintenance of nutritional status tivity will plummet because AIDS victims produce less and demand more, especially in
should be on integral port of the treatment for the latter stages of the disease. Business productivity drops even further when relatives
AIDS. 3 take time away from work and school to care for family members afflicted with AIDS.
Furthermore, AlDS demands a considerable amount of family income. Hard-pressed
families, who have to devote much of tl1eir income to doctors and medicines, have lit-
tle left for Living expenses. Otl1er family members must struggle to keep up with daily
dutic::s because they must care for orphans left behind in the disease's wake. To learn
more about AIDS, check out the website \\ "''·un.Ud!>.org.
www.mhhe.com/ wardlaw pers7 7 49
Concept I Check
Currently, about 40 million people around the world are infected with the human immu-
nodeficiency virus (HIV) or have gone on to develop acquired immw1odeficiency syn·
drome (AIDS) from the infection. The \'trus can be transmirted through sexual contact,
through blood-to-blood contact, or from a mother to a baby during pregnancy, deli,·ery,
and breastfeeding. Without treatment, an individual once infected will likely die from AIDS
within 4 to 5 years. The main hope for currently addressing the problem of AIDS in the
developing world is prevention of new cases.
Reducing Undernutrition in the Developing World

As you hnve probably guessed, greatly reducing undernmrition in d1e dc,·cloping
world will be complicated and "ill take considerable time to accomplish (Figure 20-5 ).
Today, it i:. a common practice for d1e more aftluent nations to supply famine areas
Support of
Inexpensive small-scale
methods of forming efforts, Improved
water purification including fish dieI
forming diversity
Family planning
programs and
availability of
reliable
birth control
methods
Fortification of Distribution of
indigenous foods Funding of credit AIDS drugs
and access to to small-scale and AIDS
nutrient supplements enterprises prevention
in high-risk settings education
Educational
opportunities, Improved
especially for infrastructure, including
women roods, schools, and
irrigation systems
Figure 2.0·S \Possible solutions to lhe puzzle of hunger in the developing world. Putting a ll the
pieces together employs the action steps that contribute to meeting the overall goal. •rhe Nutrition focus
section in this chapter discusses the genetic alteration of plants and animals in detail.
with direct food aid. HoweYer, direct food aid is not a long-term solution . Although
it reduces the number of deaths from famine, it can also reduce incentives for local pro·
duction by driving down prices. In addition, the affected cow1tries may have little or
no means of transporting the food to the people who need it most, and the donated
foods may not be cL1ltL1rally acceptable.
In tl1e short run, Lhere is no choice-aid must be given because people arc starving.
Still, improving t11c infrastructure for poor people, especially rural people, needs to be
the long-rerm focus. This furure-minded approach is necessary because tl1e most sig-
nificant factor affecting t11e L1ndernutrition of people in impoverished areas of tl1e
\\'Odd is their reliance on outside sources for basic needs. Their dependence makes
mem constant!) \ ulnerable.
Three basic approaches to counteract micronutrient deficiencies are suggested: in-
crease diversity of the food supply; furtify specific foods with nutrients; and provide nu-
a·ient supplementation for individuals when necessary. i ,4 ,to
Development Tailored to Loca l Conditions Is Important

Recall that in the p.lSl 40 years, world food supplies have grown faster than chc popu-
lation. Thus, the increase in undernuaition during this period has been caused by an
increase in the number of people cur off from their share of rbis supply. ~lilhons of
farmers are losing access to resources they need to be self-reliant. There is a gro" ing
realization that unless economic opportunities can be created as part of a plan for su~
Food security is fostered by communities raising tainablc development, rural people who own no land will flock to the overcrowded
ond distributing locally grown food. Dr. Hugo cities. In response, careful, small-scale regional development is one option.
Melgor-Quiiionez ond Dr. Ano Claudio Zubieto For the most part, the solution lies in helping people meet their own needs .111d di -
discuss this further in their Expert Opinion. recting them to resources and employment opportunities rather t han simply giving
them resources. Experience has shown that the provision of credit-along with train-
ing, food storage facilities, and marketing support-allows rural people to acti\'cl)' p.u-
ticipate in their own development, which will benefit their families and communities.
One U.S. program , the Peace Corps, has helped impro,•e conditions in de,·cloping
nations by prmiding education, distributing food and medical supplies, and building
strucrures for local use. The aim oftl1c Peace Corps is to help create independent, sdf-
sustaining economics around the world.
Impoverished women ,1re a special concern. [n addition to working longer hours
. l °tl.J.J. In,..
rhai1 men do, tl1cy grow most of the food for family consumption and make up three-
Stan hos reod about various relief efforts lo fourths of tl1e labor force in the informal seccor oCthe economy and an increasing pro-
help undernourished people in developing portion in the formal sector. Economic opportunities for women and education
countries, especially the emergency Food aid regarding family planning must be augmented. Of t he 3 billion people in the world li,·-
programs For Famine-ravaged areas. Many of ing on less tl1an $2 a day, 70% are women. Moreover, among tl1e developing world's
these efforts appear to be only temporary, and 900 million illiterate people, women oumumber men 2 to 1. Thus, an important
he wonders what long-range approaches might means of propelling nations our of poverty is co end the cycle of female neglect.
help alleviate the problem of undernutrition. Suitable technologies for processing, presen-ing, marketing, and distributing nua·i
What suggestions would you give Stan about tious local staples also need to be encouraged, so that small farmers C<\11 flourish.
possible long-term solutions For undernulrition Education on how to use these foods to create healthfol diets, such as preparing vita-
in developing countries? min A-rich vegerablcs, adds furtl1er benefit. Supplementing indigenous food!> \\'ith nu-
trients that arc in short suppl)', such as iron, vario us B vitamins, zinc, and iodide, also
deserves consideration. One cw-rent program involves adding iron to sugar in various
parts of the world. The N ua·ition Focus section examines the role of biotcch nology in
improving nutrient quality and other plant and animal chai·acteristics, another possible
positive step in lessening undernutricion. In addition, advances in water purification
need to be empl0) ed.
1
Promoring extcnsi,·e land ownership may also be one part of the solution . Increasmg
me a\·ailability of food is one of its many advantages. If food resources are concentrated
among a minoritv of people, as often happens with unequal land ownership, food is not
likely to be equally distributed unless efficient transportation systems are in place.
Inequitable distribution then proves to be a very difficult problem ro resolve.
Raising the economic status of impoverished people by employing them is as im-

portant as expanding Lhc food supply. I Can increase in food sup ply is achieved witho ut
an accompanying rise in employment, Lhe re may be no long term change in the num-
ber of undernourished people. Although food prices may fall with increased mecha-
nization, use of fertilizers, and other modern technologies, it needs to be reall/.cd that
these ad,·ances can also displace people from jobs, a result th<lt \\'Orsens rather than
helps the population.
Some Concluding Thoughts

Today, the economic loss from undernutricion is staggering, and the amount of human ltimately, the depletion of world resources,
pain and suffering is incalculable. With all the international relief efforts and assisr.mce the mossive debt incurred by poorer
from go\'emmenrs and pri\'ate o rganizations combined, we are ~till failing in our bat- countries, and the toll taken in human lives
tle against Ltndernutrition .20 affect the world economy and well-being. The
Life is not necessarily fa ir, but the aim of civilization shou ld be to make it more so. resulting instability can go on to affect the
The world has both enough food and the technical expertise to end hunger. What is developing world, as has been apparent in
lacking is the concerted political wiU to do so. recent years.
Concept I Check
Overall, o ne important solution to undernutrition in the developing world lies in providing
sufficient employment so that people can purchase the food their families need. Providing
access to land and other food production resources \\ill also counteract undernutrition.
Dc\'dopment program~ must be sensiti\'e to regional conditions to ensure that the ne\\
technologies introduced do not inrcnsi~· e\isting problems for the poore~t people
Expert Opinion
Alleviating Food Insecu rity and Hunger
Hugo Melgar-Quinonez, M.D., Ph.D., and Ana Claudia Zubieta, Ph.D.
Food security is defined as access by all people at all times to enough food from many different countries reaffirmed • the right of everyone to hove oc·
for on active and healthy life, including the ready availability of nutritionally cess to safe and nutritious food, consistent with the right to adequate food
adequate and sole foods and the ensured ability to acquire acceptable and the fundamental right of everyone to be free from hunger." Nevertheless,
foods in socially acceptable ways. On the other hand, food insecurity is de- the most recent figures on food insecurity and hunger by the United Notions'
fined os the limited or uncertain availability of nutritionally adequate and Food and Agriculture Organization (FAQ) estimate that worldwide, more
sole foods and the limited or uncertain ability to acquire acceptable foods in than 850 million people do not hove enough lo eol. Moreover, in "The Stole
socially acceptable ways. The degree of food insecurity of o given popula- of Food Insecurity in the World," the FAQ reports that despite o decrease in
tion is associated with the number of hungry people in developing countries during the first half of
the 1990s, there was a substonliol increase of almost 4 million hungry peo-
• factors related to "having sufficient food"
ple per year during the second half of that decode.
• factors that influence the types and diversity of the food supply
Food insecurity is associated with major health problems because of ils
• psychological issues, such as anxiety, stress, and conflicts, caused by depri·
direct impact on the nutritional status of individuals. Even though food·
volion and restricted choice of foods
insecure families may hove access lo enough food to meet energy require-
• social and cultural influences concerning the means used for the acquisition
ments, they typically struggle with severe micronutrient deficiencies This
of foods
paradox demonstrates the challenge these families face in not only obtain·
• periodic climatic changes, which con vary in duration
ing adequate quantities of food but also foods of high nutritional quality.
• environmental disasters, such as drought or Roods
With iron, for example, which is present in o variety of plant and animal
• political and social instability
foods, some forms ore better absorbed than others (heme versus nonheme
Also important ore available assets and resources, market dynamics, re- iron, respectively) and certain dietary factors con enhance or decrease
source ollocolion within households, and nutritional and health-core prac· iron's absorption (ascorbic acid versus phytole, respectively). Zinc is on·
tices that affect the way families and communities guarantee stable access lo other important micronutrient contained in protein-rich foods such as meat,
food. Finally, limited diversity of foods produced, poor posthorvest practices, fish and shellfish, and whole groins. II is possible for zinc deficiency to
soil infertility, land tenure conAicls, and lock of agricultural knowledge de- occur in the absence of overt malnutrition. This deficiency con be observed
serve consideration. in populations who hove poor quality diets (limited animal protein) or who
eat traditional foods that impair zinc bioovoilobility because of high phy·
tote content (e.g., maize, beans, and rice). Iron and zinc deficiencies ore
Why This Attention to Food Insecurity? usually associated with depletion of other micronutrients and con lead to
Food insecurity hos long been o concern of world leaders, as evidenced by multiple severe health problems, such os anemia, growth and cognitive re·
the Universal Declaration of Human Rights: "Everyone hos the right to o ston· tordolion, and impaired immune function. Moreover, micronulrient def1·
dord of living adequate for the health and well-being of himself and of his ciencies con affect the scholastic performance and productivity of
family, including food.• At the 1996 World Food Summit, representatives individuals and communities.
I
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www.mhhe .com/ wardlawpe rs7 7 53
hove shown to enhance the intake of essential micronutrients, with o related

improvement in nutritional status and cognitive development of schoolchild-
ren. In addition, sound policies and higher investments targeting key areas
such as access to markets, agricultural productivity, water management, in-
frastructure, and communication con strengthen food security and reduce
malnutrition across the developing world.
Given the complex causes of food insecurity, it is essential that re-
searchers and policymakers incorporate local perceptions, attitudes, and ex-
pertise in their research ond program design. This practice will positively
affect the accuracy of the data gathered as well as the outcome of interven·
tions. Community participation is now considered to be the key to successful
community development programs. Consequently, in recent years many in-
ternational development projects hove begun lo include more active com-
munity involvement in problem identification and project planning.
Participatory approaches emphasize the need to modify the practices and
local production of food is one step in conquering global food insecurity. attitudes of outside experts and extension workers toward the communities
lhey serve so that better dialogue is established between external agencies
and the local people. This approach would also provide o strong foundation
for empowering communities to assume greater roles in developing and im-
Conquering Food Insecurity-What Works?
plementing future interventions.
II is well recognized that the only sustoinoble approach to decreasing such
micronutrient deficiencies ore food-based strategies that include the diversi- Dr. Melgar-Quinonez is Assistant Professor in the Deportment of
fication of food production al the household level, promotion of a Human Nutrition of The Ohio Stole University. He received his med-
micronutrient-rich food intake, and development of local techniques for food ical and doctoral degrees from the Friedrich Schiller University, Jena,
fortification wi th one or more nutrients. Community-implemented food-based Germany. He and his research group hove conducted research in
strategies ore also seen as a sustainable approach to decreasing food inse- food security with Latino immigrant families in the United Stoles as
curity. In contrast, attempts to improve nutrition status based on supplemen- well as in rural and urban areas in several Latin American countries
tation and fortification hove been shown to hove serious limitations os (Bolivia, Brazil, Colombia, Ecuador, Guatemala, and Mexico},
long-term solutions. Africa (Burkina Faso and Ghana), and Asio (Philippines}. Dr. Zubielo
Although ii is often slated that food-based interventions must replace sup- is a postdoctoral research associate in the Deportment of Human
plements in the long run, remarkably little attention hos been paid lo the de- Nutrition al The Ohio State Un iversity. She received her Ph.D. degree
velopment of appropriate, sustainable, and effective programs. However, in nutrition from the University of California, Davis. She has partici-
there ore some examples of success in this area, shown in studies conducted pated in several community nutrition studies in Latin America and in
in developing countries and indigenous populations in Canada. For exam- other developing countries (Bolivia, Botswana, Ecuador, Guatemala,
ple, in rural Kenya, small increases in the availability of animal source foods Kenya, and Mexico).
The Role of Biotechnology in Expanding
Worldwide Food Availability
The ability of hwnans to manipul.ne nature has en- (now called a genetically modified organism
abled us to imprO\'C the production and yield of [GMO] or transgenic). It is important to note,
biotechnology A collection of processes man) important foods. Traditional biotechnology ho\\'e\'er, that the genetic engineering docs not re
that involve the use of biological systems is almost as old as agriculture. The first farmer to place com·cntional breeding practices; both \\'Ork
for altering and, ideolly, improving the impro,·e hb stock by sdeni,·cly breeding the best together.
characteristics of plants, animals, and bull with the best cows was implementing biotech- Already, genetic engineering of agm.:ultural
other forms of life. nology in a simple sense. The first baker to use products has allowed US to make USC of nC\\' types
rcast to make bread rise took advantage of of seeds, growth hormones, and microbial inocu-
biotechnology. lants to stop pests and frost damage. Biotechnology
he American Dietetic Association By the 1930s, biotechnology made possible the is also used to develop droughc-tolcr.1111 crops as
recently supported the use of biotech- selective breeding of bener plant hybrids. As a re- well as to detect Listeria and other microorganisrm
nology for combating undernutrition sult, corn production in the United States quickly that cause foodborne illness. Scientists arc engi-
worldwide (Journal of the American doubled. Through similar method~, :igriculrural neering plants that grow \\ith the use of fcll'er pes
Dietetic Association 106: 285, 2006). wheat was crossed \\ith wild grasses to conter more ticides, and nc\\ fomlS of potatoes that can be
desirable properties, such as gre.uer vicld, increased stored longer without preservati,·es. In addition,
resistance to milde\\ and b.1ctcrial diseases, and tol- biotechnolog}' can allow scienrim ro cre:ire fruits
erance to salt or adverse climatic conditions. :ind grains with greater amounts of nurne1w. sm:h
Another type of biorechnology uses hormones as beta-carotene (e.g., "golden rice") .rnd \'itamim
raLher Lhan breeding. In the las1 decade, Canadian E and G. Researchers are also examining \\ ays to
salmon have been treated wirh a hormone that allows modit)• rhc fatcy-acid makeup of vegetable oib.
them to mamrc three times faster than normal- Because biotechnology is being used cautiously and
without changing the fish in any other wJy. In gen- conservatively, these early benefits of the ne\\
eral terms, biotechnology can be understood as the biotechnology wilJ strike us as only subrl~ difkrent.
use of living thin~-plam~. ammab, bactc1ia-to The ultimate benefits, however, could be 1mpor-
manufacture products. ta111 if foods eaten by people in the de\'eloping
world can be so enhanced.
Few consumers in the United Stares re•1li1c that
The N ew Biotechnology currently about 40% of all corn and 90%of all soy-
beans produced in the United States ha\'C been ge-
The new biotechnology used in agriculture in - netica lly engineered to resist certain insects,
cludes several methods that directly modify prod- thereby reducing pesticide use, and/or survi\'e
ucts. lt differs from traditional methods because it when sprayed with herbicides that kill surrounding
genetic engineering Manipulation of the more directly changes some of rhe genetic material weeds. Some papaya plants ba\'e been genctic1llr
genetic makeup of any organism with (DNA) of organisms co impron: char.tcterisrics.9 engineered for \iral resistance.
recombinant DNA technology. Crossbreeding plants or animal~ is no longer the Generic modification ofcorn has rccci,·ed .t Im of
only tool. De\'elopment of the ne\\ process, called media attention. Corn can be genericalh altered by
recombinant DNAtechnology A test tube genetic engineering, began in rhe 1970s. The field inserting a gene from the bacterium Rncillus
technology that rearranges DNA se- now featmes a wide range of cell .rnd subcdl tech- tlmri11.t1imsis, usually referred to as the Br gene, into
quences in on organism by cutting the niques for the synthesis and pl:tccmcnt of genetic the corn DNA. The gene allows the corn plane to
DNA, adding or deleting a DNA se- material in organisms (Figure 20-6 ). This process make a protein that is lethal to certain catcq1ill.lrs th.tt
quence, and rejoining DNA molecules of recombinant DNA technology allows access to destroy the plant. The Br protein in rhe corn, ho\\'·
with a series of enzymes. a wider gene pool, and it permits l:lSter and more C\'cr, is presem in the plane in very low concentrations
.tccurate production of new .md more usefuJ mi- and has no dlect on huma.ns-it is digested along
genetically modified organism (GMO)
crobial, plJ11t, and .111imal spccies. Conventional \\idt the other proteins in corn. For many yc:ir.. or·
Any organism creoted by genetic
breeding is inefficient and has inconsistent resuJts; ganic farmers have used the Br bacrena .1s .1 du\t on
engineering.
biotechnology utilizes generic material more pre- plants in order to destroy pests. (Dusang crops, how ·
transgenic Organism that contains genes cisely. Scientists select the tr.tits they ''ant ,md ge- e\·er, docs not change the DNA of the pl.till. l
originally present in another organism. netically engineer or introduce the gene that FDA is confident that cmrently .tpprcm:d \,lrl
produces the desired tr<tic inm plants or animals cries of gcnetic:illy engineered food~ .ire s,tfc to
754
Figure 20·6 I Biotechnology involves various techniques
for transferring foreign DNA into on organism. In this
diagram, a sample of DNA is cleaved out of a larger
DNA fragment and inserted into the DNA of a host cell.
DNA of the host Gene from Bt gene inserted into Thus, the host cell contains new genetic information, with
plant, corn. bocterio (Bl gene) DNA of com pion!. the potential of providing the cell with new capabilities.
that produces a Now the corn plant is For corn, this could meon resistance lo the European corn
protein toxic to genetically modified. borer. The corn plant is now referred lo as a genetically
the European It makes the Bt toxin
modified organism (GMO). In another application, bocteria
corn borer. ond, so, is resistant to
the Europeon corn con be engineered lo produce the human form of the
borer. hormone Insulin.
consume. A conrroYers~ arose o,·er use of StarLink Although d1e risks of biocechnology may ap·
corn in 2000. In d1is case, me GMO corn variery pear to be momentarily negligible, they may be cu·
w.1s approved for animal teed bur noc human con· nrnlative ;md d1ercforc of concern in the long nm.
sumption, yet ic found its way into some corn In addition, will allergens, such as those found in
produces, such as taco shells. Food manufacturers pea.nuts, eggs, milk, wheat, and shellfish, be added
are not currendy required to disclose d1e GMO to genetically engineered foods that previously did
content on food labels. Some manufacturers, how- not contain them? Evidence of this contamination
e\'cr, haYC promoted their products as being has been seen in soybeans. Note, howe\'er, mat
"GMO-free" on labels. A recent study showed that FDA carefully examines all products de\•eloped
c\'en these foods cypically have GMO content. ln with this technology and wiJJ enforce labeling of
fact, 70% of processed foods contain ar least one potential allergens that may be newly present in
Gi\IO ingrcdiem. 14 So it is not surprising mat food altered by biotechnology.
when Gerber Products Co. cried co introduce a line The public has long been opposed to processes
of GMO-free baby foods, they found that they perceh·ed as harmfiil to the environment, such as
could not produce products from raw materinls producing unnatural products. Because food re·
currently available. serves arc high in the United States, Canada, and
FDA docs not belie"e mat labeling of G~lO Europe, some people question the need co increase
products is needed because me products pose no food production. Skepticism surrounds unnatural
healm risk. Public response to use of GMO biotech- products, as exemplified by Western Europe's ban
nology, nevertheless, has been mixed. fa·en the sci- of hormones used in beef and milk production and Both traditional plant breeding and
entific community has conflicting opinions about of nearly all G~IO foods. Some North Americans biotechnology hove produced high-
this technology, \\ith supporters as convinced about support this stance. Citizens believe the increase in yielding and disease-resistant plant
me benefits as opponents arc of the risks. The d1e food supply is not word1 the risks. varieties, such as with corn.
biggest debate in the United States SUtTOLtnds the
potential e1wironmenta1 hazards of introducing
genes from one species to another. Some chal- Role of the New Biotechnology
lengers e'en question the acmal reduction in pesti- in the Developing World
cide use that accompanies the cultivation of GMO
crops. Although the use of GMOs may reduce the Whether applications of genetic engineering will
need for em·irorm1entally harmful acth'itics, such as help to significantly reduce undernutrition in the
spraying crops \\~th pesticides, critics point out that developing world remains to be seen. Unless price
seeds produced \\'ith additional insecticide potential cuts accompany the increased production, only
\\ill lead to rapid insect resistance because the insec- landowners and suppliers of biotechnology will
ticides are continuous!) emitted. Use of traditional enjoy the benefits. Small farmers may benefit if they
pesticides involves prudent application, in part to can afford co purchase the GMO seeds. This point
avoid insect resistance. In addition, accidental re· deserves emphasis: the person who cannot afford
lease of generically modified animals, such as fish, to bu) enough food today will still face mat same Soybeans ore a common GMO food in
may go on to harm wild Yarieties. predicament in the future. the marketplace 180% of the total).
7SS
As with most innovations, the more successful modified foods today lies within the realm of plant
farmers-often those with large farms-will adopt breeding for micronutrients. Developing countries
the new biotechnology first. Therefore, the present will then have a tool to treat and prevent selected
trend toward fewer and larger farms will continue in nutrient deficiencies among their populations if
the developing world, a mo,·cment that undermines they have access to farming resources to augment
the solution to one of the most pressing undcrnu- the micronurrient composition of crop~ .9 l n addi-
Bobbie is in a debate class and has trition issues there. Furthermore, biotechnology tion, greater yields for indigenous pl.mts, such as
been assigned to argue the biotechnolo- docs not promise dramatic increases in the produc- tomatoes that tolerate high soil salinity, .1re another
gist's side of genetic engineering. Help tion or most grains and cassava, rhe primary food re- hopeful outcome. Biotechnology will likely be .i
her come up with a list of arguments in sources in developing parts of the world. useful tool against the complex scourge of world
favor of biotechnology. What would the With the introduction of drought· and pcst- undernutrition. Improved crops produced by this
list look like if Bobbie were on the op- resistant as well as self-fertilizing crops, agricultural technology, together with political and other ef-
posing side? biotechnology ma)' help ro lessen world hunger. forts, can comribute to the bank of world,,ide
Perhaps the most promising potential of generically undemutrition.
Summary
l . Po,·erry is common I)• linked to chronic or periodic undernurririon. to reduce our-of-wedlock pregnancies remains a national priori!')·
Malnutrition can occur when rhe food supply is either scarce or because single parents and their children are mud1 more likelr ro
abundant. The resulting deficiency conditions and degenerative li\'e in poverry.
diseases comribure ro poor health. 6. MulLiplc factors contribute to the problem of undcrnutrition in
2. Undernutrition is the most common form of malnutrition in de- the developing world. In densely populated countries, food re·
veloping countries. It results from in:idequare imake, absorprion, sources, as welJ as the means for distributing food , may be inade-
or use of nutrients or food energy. Many deficiency condition~ quate. Farming methods often encourage erosion, which depri,·es
consequentl)•appear, and infectious diseases thri,·e because the im the soil of ,·aluable nutrients and thereby hampcrl> ti.1turc ctforrs co
mune system cannot function properly. grow food . Limited water a\ .1ilability hinders food production.
3. The greatest risk of undernutrition o'curs during critical period~ Narurnlly occurring devastation from droughts, excCl>l>i\'C rainfall,
of growtl1 and dcvclopmenr: gestation, infancy, and childhood. fire, crop infestation, and human causes-such as urbanization,
Low birth weight is a leading cause of infant deaths worldwide. war and 'ivil unrest, debt, poor sanitation, and A IDS-all con-
Many developmenral problems are caused by nutritional depriva· tribute to the major problem of undernutririon.
tion during critical periods of brain growth. People in their later 7. Proposed solutions to world undernurrition must consider multi
years are also at great risk. pie interacting factors, many of which are thoroughly embedded
4. Undernutrition diminishes both physical and mental capabilines. in culruraJ traditions. Family planning efforts, for example, ma}
[n poor countries, this siniarion is worsened by recurrent infec- nor suC1:eed until life expcaancy increases. Through education, cf
tions, unsanitary conditions, extreme weather, inadequate shelter, forts should be made to upgrade farming methods, improve crops,
and exposure to diseases. limit pregnancies, encourage breastfeeding when it is ~afc to do so,
5. In North America, famine is not seen but food insecurity and un· and improve sanitation and hygiene.
dernutririon remain problems. Soup kitchens, food stamps, the 8. Direct food aid is only a short-term solution. In what may appear
school lunch and breakfast programs, and the Special to be a step backward, many experts recommend more l>ustainable
Supplemental Nutrition Program for Women, Infants, and subsisrence-lc,·el fuming. Small-scale industrial dc,·dopment is
Children (\VIC) have focused on improving the nutritional health another way to create meaningful emplormem and purchasing
of poor and at-risk people. When adequately funded, these pro· power for vast nwnbers of the rural poor. Various biorechnolom
grams have proved effective in reducing undernutrition. The need applications may also prove beneficial.
756
www.mhhe.com/wo rdlawpers7 757
Study Questions
1. Describe the difference bccween malnutrition and umlcrnutririon. 7. How important is population control in addressing the problem
2. Describe in a short paragraph any evidence of undcrnutrition that of world hunger now and in the future? Support your answer \\ith
you saw ,,·hilc you were growing up, ~uch as on tclc\'ision. What three main points.
are/were rhc likely roots of these problems? 8. Why is solving the problem of undernutrition a key Factor in the
3. What do you belie,·c arc the major fuctors contributing to under· dc,·elopmenc of the full potential of developing countries?
nutrition in wealth>' nations such as the United States? 'vVhat arc 9. Discuss how infrastructme could influence Lhc causes and solu-
some solutions to this problem? rions of chronic hunger in a developing nation.
.+. What three points would you make ro a group ofse,·enth grade girls l 0. Name three nutrients that arc often lacking in the diets of w1der
concerning the economic perils of teen pregnancy and parenting? nourished people. What effects can be expected wid1 each deficiency?
5. Personal responsibility is a common theme 111 polincal circles.
Hm' does ir relate ro the problem ofundernutririon in rhe United BOOST YOUR STUDY
States? Docs it apply to all causes of the problem?
6. Outline hm' war .md ch ii unrest in dc,·eloping countries h.we Perspectives in Nutrition: Online Learning
Check out the
wor~cncd problems of chronic hunger over the past tcw year:.. Center www.mhhe.com/wardlowpers7 for quizzes, flash
cords, activities, and web links designed to further help you learn
about issues surro unding world hunger.
1. ADA Reports: Position of rhc American cic.r i11 dt'vel11pi11g cn1111tl'ies. Sucb pmctices hnl't' genetic 111nuip11lntion. Grcntcr npplicntio11 of
Dietccic As\ociarion: Assessing world hunger, been show11 ro nd11cc t/Jc risk oj 11mru11t deft· both ttdmologm is nuded tu nrtnill tlie full
malnutrition, .md food securuy. Jo1m111I of the cic11cu.r. (Orbrr rccmt st11diu nl.ro s11pp111·1 rbc bc11cflrs with rr,.fTnrd to nn il1&rcnsr i11 ji111d
A111crir1111 D1acric Ass11cintio11 I 03:1046, 2003. tfJicnc~· 1if t/Jis pmcticc: Journal of Nmririon prod11ctio11.
It is the purzti1111 of rhr Amcrirn11 Dicraic 133:1834, 2003, n11d Journal o f Nutritjon 9 Dunford M: The G~I food debate. Todny's
Assoc1n11011 thnr ncccss ro ndcgunte n11101111t.; of 133:1339, 2003.) Dictitirw, p. 12, June 2004.
mfi:, 111t11·iti1111s, nud wlturnlfr nppropr1ntc 5 Black ltE and other~ : Why an: 10 million chi) 711c genetic wg111ceri11g offoods bas both risks
fonds rs n ftmdnmmtnl lmmn11 1·igb1. Ir is i111- dren d1·ing ca'h year? 111c J.,1111ccr 36 l :2226, and bmrfits, n11d both ni·e ducribcd i11 thi,r
porrn11t to c11co111·1111c prolframs r111d pmctices 200~. nrticle.
tlmt cambnt ln111gcr 1111d 11111/1111tritio11, i11crenu Mu1·e tlin11 JO 111il/iu11 d11/drw die ench .rear, 10 Fawz1 \V and ochers: Srudic~ of ' 'itarnins and
food su111·11')'. p1·0111ou sdf-m!Jir1mc_1j n11d nrc mosrZ1•ji·o111 prn•mtnblr cn11.ccs. U11der1111h·i1io11 mineral~ and I IIV transmission and cfocasc pro
c11vi1·1111111e11tn!Zv 1111d uo11omim!Zv sustnmablc. is t/Jr 1111der~vi11JJ en 11sr 1ifn s11bstn11tinl portion gress1on. Jo11r11nl of N11tritio11 135:938, 2005
2 ADA Report~: Position of the American of tlits<' childho11d dcntl1s.
Dnily mt of n 11111ltil>itn111i11 1111d 111i11t1·nl mp·
Dicteuc As~ociation. Child .rnd adobccnr food 6. Brown Kl I: Diar rh ea and malnutritio11. plemmt hns bun s/Jo11>11 m bt helpful i11 n fen•
and nutrition programs. }011m11/ of t/Jr ]011mnl ofN11mtio11 133:328'), 2003 m1dfrs n11d lllfl,l' be rspccinl/y helpful w redttcc
Amcricn11 Diacric Assorin11011 103:887, 2003. U11dcnwtrit11111 111Cl'cnscs the r1.<k of.r,· pcl'c d1n1·· discnsc progrcssio11, been.me n11tl'icnt drftrimcies
The Ctll're11t ji111d p1·0.!1rnms tnitfetcd nt /1111>- 1·bc11I d1smsc. Pn·11c11tio11 sn·nLe_flies i11d11dc pro· nre co111111011 i11 people ll'ith HIV infectiom nud
i11co111c lmusdmlds, mcb ns the Food Stnmp 111orto11 of brmsrfecd11~11 to pff1•r11t dinrl'i1ml AIDS.
Progrn111, lml'c l/011<' 11 l1111g 1J>n.1• 10 i11rrmsi11g discnu, ro11ti1111td fi'cdmg d11n1tf/ il/11css, tmd 11. Gramlcsso F and others: Mort.ility and malnu
tbc 111111·it'11t fotnkc of cbildrm mid 11d11lcscmrs s11pplo11c11tnrio11 with stlcctcd 111icro11111riwts to trition among populations li\'ing in South
Jr is imporr1111r rbnr tlJtst food progmms nn: prcrmt i11ftcttnm n11d reduce tlJl'tr sn'L'l'tty. Darfur, Sudan. ]011nrnl 1if the A111cricn11
supponcd b_v ndeq11ntc jimdi11/I, 7. Darron-Hill I and others: J\1icronutricm deli· Medicnl Associnrio11 293:1490, 2005.
3. ADA Reporc\: Position of the American cicndc' and gender: Social .ind economic co~t,, 111c 1umt co11j11cts 111 tlJC Dnrf11r reg11111 of
Dietetic As~ociation Jnd Dieticians of Canad.1: A111crien11 /0111'11nl of Cli111cnl N11tritio11 S11dn11 IJn.ve led ro /Jig/J mtes 11[ dcn.t/1 n11d 1111·
Nutrinon inrcn•cntion in the care of person<. 81:11985, 2005.
dem11tritio11 nmong people difplnced by ll'ar.
with human 1mmunodeficicnq ,·iru~ infection .\Iicro11111rieur dtfittcmus 111 drJ>dop11w co1111· 111is nrtrck describes w/Jnt bas bun sew 1111111rr·
]011r11nl of tll( A111c1·icn11 Diuetic A.rsociar1011 tries, mrfJ 1uf111· l'itn111i11 A, iodide, inm, nnd 011s ti111ts in the Inst SO yenrs-1111den111tr1tio11
104: 1425, 2004. ::i11c, lend to henlrh problems, tsptcinlly i11 ft· nnd rtlnttd dtnth is n n·picni cnmnlty of 1vnr.
Jfccrm.n 1mt1·u11t nuns is l'tl',Y 1111ponr1111 to mnlu. Addrrssmg tbcsc micro1111trit11r drftcien· l 2. Hoetz, PJ and others: Hookworm infccrion. TI1c
mni11tni11 tbc best health possible in people witb cies 1s i111port1111t in 111·drr to i111proJ1c eco110111ic Ne1v Englnnd journn/ ofMedici11c 351:799, 2004.
HIV inftctio11s 1111d AIDS. antm nr rile perso11nl, comm11111ty, n11d 11ntio11nl
A11 estimated 740 111il/ill11 cases ofbookll'orm i11·
4. Ash D~I and others: Randomized efficacy rri.11 lci•el 111 de1•el11pi11g co1111tries.
fectio11s exist i11 tbe 11'//1-lrf, p1·i111arily i11 t/Je h·op·
of a micronutrienc-forrified be' eragc in primary 8 . Davies PW: Historical per~pectivc from the ics n11d subtropics. E.xccllmt 111cdicntio11s nrt
school children in Tan;i:ania. Americn11 Jo1m1nl green re\'olmion to the gene rc\'Olution. nvailnble to trtnt tbe disease mid 1ho11/d he
ofC/i11icnJ N11rritio11 77:891, 2003. N111ritio11 Rcvien•s 61( 6):Sl 24, 2003. 11111de widely ai1ai/able.
Fonijjoi11g be1•crnges wit'1 111icrom1triwrs if 011t Improved m·ni11s of pl1111ts cn11 be nclmwd 13. Kalm L\11, Scmba RD· They starved so chat
Jtrnug;v to help n:d11ce micro1111triem drficie11 · thl'011gb rrnditio11nl pln11t breeding 1wd direct others be better fed: Remembering Ancel Keyi;
758 Chapter 20 Undernutrilion throughout the World
and the ~linncsoca experiment. /01mml of 16. Pelletier DL, hongillo l:.A: Changes in child .Uni11tni11i11l/ 1111n·iti1mnl hcnltb is i111pona11t
N11tr1t1011135:1347, 2005. sunwal are ~trongl) a~sociated \\ n.h changes in for proper fi111crio11i11..11 of tile i11111111111: system,
Demilttl 1md interesting nrco1111t of tile semi· malnutritio n in llc,·cloping countries. /11111'1111/ tbertby rerl11ci11g rlJe 1·isk of i11fcrrio1is di-smscs.
starrntion studies ro111iuucd i11 tile 1940s b;v of N1m·irion I 33:107, 2003.
19. Sreinbrook R: After Bangkok-E"pandmg d1e
A11crl Kqs am( col/engtw. 171ese expcrimmrs Co1wdcrn.b/c t'l'tdmu Sll,fl..IT&m rlmr 1mder1111tri· global response co AIDS. J71e z..·e1v E11gln11d
ll'erc co11d11cted r11/Jetter1111dc1'Stn11d rhr ej]erts tion nffras J111111n11 pc1jon11n11cc, 01•cmll bi:alt/J ]11111·11fll of Mcdici111• 351 :738, 2004.
ofJelll1stnrMtio11 that 111a11.v peoples 111 m1rld n.11d s111·1 i1•nl, pb_111c11I 91't1ll'tb, coll111rivc dn•dop-
1
me11t, r.-p1·od11ctto11, pbys1rnl IJ'ork mpnciry, and 771r advn11ccs 111 m:ntmmt of AIDS /Jn1•r lnrgcz1·
War II 1vcrc experimci11g n11d ro dcren11iru how
risks for mn11y r/11·011ic disrn.ses. Ej)orts ro reduce bmcjited del'rlnped co1111rries. 17m·" is a11 111;gem
bcsr to snfi'Zv refacrl m11istn1·vt·d imfh•idunls.
1mdcr1111n·itio11 worldll'irlc n1·e i111purm11r ~( ll't nrtd 111 proPidc tb1· bmcjits to people i11ji'Cft'rl
14. Palmer S· GE foods under the microscope. 1rir/J A IDS i11 r/Jc dwdoping 1r>orld
111« to 1·ed1<cr orrrnll mortnlity.
Toda_v's Dietiri1111, p. 34, J\lay 2005.
17. Perkin~ S: C ri \i\ on r.1r? Pollurion and bur· 20. Yach D and other\: The glob.11 burdl'n of
Abo11r -0% of nil p1·owsed foods sold in tbe
geomng populJtions stress Earrh's warcr rc- chronic disc.1scs: Q,·crcoming. impedimcm~ tc1
U11irtd States comai11 mbsta11ces rhnt llni•e 1111·
sour(CS. Sciwc1· i\"cirs 162·42, 2002 (July) prC\cntion and control. /011rnnl of tlu
dcr.gonr .romege11rric altcrntion. TJJis article ex·
App1·oxi111n.tcly onc-t/Jird of tlw world'.< p11p11fn· A111rricn11Mcrlicnl1lssncintio11 291:2616,2004
plora some of the bmcftts and co11m·1u
rrgnrdmg rile use ofrlmfn1rZv rrcellt teclmolog_v tio11 l11•cs in nrras uf1rntfr smro1.v. lnc/111ftd iu N11trimr dejicicucics nn co1111111111 i11 tbt dcl'd·
i11 0111'[011!1 mppZv. tbi.s csrimate nr' .JSO 111illio11 people w1Jo li1•.- 111 op111..11 world. ~mcll an-as al.so rxprne11u 1/11·
nl'Cfl S 1if' SCl'Cl'I' ll'nlCI' .IT/'tS.r. g1wrrst burd1·11 of rlrnths fro111 dinrr/Jm, Hll'
15. Paul) D, Walson R: Counting Lhc lase fhh.
a11d A l DS, a11d l'flriom c/Jild/11111d di.sen st'!.
Scirntifie A111mm11, p. 43, July 2003. 18 Scrim\h.i\\ NS: Hiscom:al conccprs of inccrac-
771t"rr needs be mar( 11rrmtio11 ro this r1111r111om
0Perfislm1g bas fed to dccli11cs in certain fish pop· tions, synergism, and .111tJgonisrn berwccn nu-
pr11blc111 i11 tb1· devdopm._q rv11rld.
11/nrio11s ll'Orldll'idc. Bertcr 111n11nge111mr offub trition .md inli:ction. ]111minl 1if' N11 tntio11
bnrrcst is needed to prrvmr f11rtbcr n~'l..f!rnvat1011s. 133 .•H6S, 2003
Take I Action
'
I. Fig hting World Undernutrition on a Personal Level
If you want lo do something about world and domestic undernulrilion, consider the following activities. It is a noble act lo try to make
a difference, even if you make just one small step. As with any change in behavior, do not try to do too many things at once. Try one
or two activities that represent your commitment to solving this problem.
l . Volunteer al a local soup kitchen or homeless shelter for a period of time {l month, for example). What insights could you gain?
2. Coordinate the efforts of a campus organization to donate some money to a voluntory agency that does ontihunger work, such as
the following:
Bread for the World Oxfom America Save the Children Foundation
50 F Street, NW, Suite 500 PO Box 1211 54 Wilton Rd
Washington, DC 20001 Albert Leo, MN 56007-1211 Weslport, CT 06880
CARE Second Harvest

650 First Ave. 35 E Wacker Dr. #2000
New York, NY 10016 Chicago, IL 60601
3. Make a contribution of nonperishable foods to the ongoing offering at a place of worship near you. If such on offering does not
exist, start one.
4. Get on a food recovery program's mailing list, and read its newsletters for information on upcoming fund-raisers and other activi-
ties; become involved.
5. Participate in food drives organized by local grocery stores by contributing food or services. Food-drive organizers may need vol-
unteers to transport the donations from the store to a food pantry. Pay special attention to events around World Food Doy,
October 16.
II . Joining the Battle against Undern utrition

.. •
Imagine that you recently spent your summer vocation in a developing country and sow evidence of undernutrition and hunger. Then
imagine that you ore now asking a large corporation to support your efforts to ease hunger and suffering in this area. Develop a two-
porograph statement outlining why it is important to address hunger issues in this area. Include how you think a large corporation
could assist you in your efforts.
,.
•
a en IX
CHEMISTRY: A TOOL FOR
UNDERSTANDING NUTRITION
You have already completed at least one basic high school and/ or college course in ne concept to keep in mind is that the
chemistry; consequently, this appendix serves only to review key chemistry principles physical and chemical properties of almost
that arise in the study of nutrition. The srndy of human n utrition requires a basic anything-whether atoms, molecules, or organ-
awareness of and familiarity with general chemistry, organic chemistry, and biochem- isms-are intimately related to its structure. A
istry. This appendix provides fundamental concepts regarding atoms, molecules, chem - basic knowledge of chemical structures con help
ical bonds, pH, organic compounds, and biochemical structures. An understanding of you visualize important fundamental concepts in
basic chemistry may make the study of nutrition easier and more intercst111g. Ir helps nutrition.
connect nutrient characteristics "itl1 the structural and chemical attributes of the indi-
vidual components of food (Table A-1 ).
Properties of Matter and Mass

Al l living and nonliving things are composed of matter. M.\tter exists in three states:
solid, liquid, or gas. An example of a solid is ice, a liquid is water, and a gas is steam.
Two characteristics of matter are ( 1) it has mass and (2 ) it occupies space (volume).
~lass is related CO me amount of force it takes to move an object-it take!> less force to
move a paper clip tl1an a pencil; therefore, the clip bas less mass. Volume is related to
the amount of space an object occupies-a pint of water occupies less space than a gal-
lon; tlierefore, a pint has a smaller volume. Both tllese properties depend on how much
of the substance tl1ere is.
Another property of matter is density. Density is defined as the mass of an object di-
' ided by its volume:
. Mass
Dens1rv
•
=- --
Volume
Density is independent of how much matter is available. The density of water in a lake
is d1e same as in a cup. Density is commonly expressed in units of grams per cubic cen-
timeter (g/cm 3 ) . Table A-2 lists me densities of several common substances.
You can use density to compare objects. Using the density of pure water as a com-
parison ( 1.0 g/ cm 3 ), lean body tissue has a density of about 1.1 g/ cm 3 . The density
of body fut in comparison is about 0.9 g/ cm". Substances that arc less dense than
water are buoyant (they tend to t1oat), whereas substances that arc more dense than
"ater sink. The next time you arc at the swimming pool, note the densit)' of men and
women. Women tend to have more body fat, so they Ooat; men arc generaUy more
muscular ~ha\e more lean tissue), so they tend to sink deeper in the water. This ph~1s
ical property is used to determine the amount of body fat stored in a person (sec
Chapter 13 ).
A-1
J>
~
Table A· 1 I Periodic Table of the Elements

Main-Group Elements Main-Grou p Elements
Atomic Number
1 18
Symbol
IA
I
1i:79.1 Atomic Mass (Aromic Weight) VITIA
2
2 13 14 15 16 17
l H He
L.00i94
lIA IlIA TVA VA VIA VIIA 4.002602
3 4 :ansitional Metals 5 6 7 8 9 10
2 Li Be B c N 0 F Ne
6.941 9.0l2l82 ( 9 L0.81 l l2.0l I l4.00674 15.9994 18.998403 20.1797
II 12 13 14 15 16 17 18
3 4 5 6 7 8 VTIIB 10 11 12
3 Na Mg
IIIB IVB VB VIB VIIB , IB IIB
AJ Si p s Cl Ar
22.989768 24.3050 ' 2t>.981539 28.0855 30973762 32.()6a 35.4527 39948
""Ci )9 20 21 22 23 24 25 26 27 28 29 .~o 31 32 33 34 35 36
0
·c 4 K Ca Sc 1i v Cr 1\ln Fe Co Ni Cu Zn Ga Ge /\..<. Se Br Kr
~
~
39.0983 40.078 44.955910 4788 50.9-11;; 51.9961 54..93805 55 847 ;l!9.B20 ;8,(>9 63 5-16 65.~9 69 ~13 I ~2.61 74.92159 7 896 -9.904 I 83.80
37 38 39 40 41 42 43 +I 45 46 ·r' 48 49 50 51 52 53 54
5 Rb Sr y Zr Nb .Mo Tc Ru Rh Pd Ag Cd ln Sn Sb Tc I Xe
85.467X 87.62 88.90585 91.224 92.')()()38 95.94 (981 10107 102.90550 106.42 107.81>82 112.411 I l4.82 ll8.7LO 121.75 127.C>O 126.90-l47 13l.29
55 56 57 72 n 74 75 76 77 78 79 80 Ill 82 83 84 85 86
6 Cs Ba La* Hf Ta w Re Os Ir Pt Au Hg Tl Pb Bi Po Ac Rn
132.90543 137.327 138.9055 178.49 180.9479 183.85 186.207 190.2 192.22 195.08 196.96654 200.59 204.3833 207.2 201!.9$037 (209) (210) (222 )
87 88 89 104 105 106 107 108 109 110 111 112
7 Fr Ra Ac** RF Db Sg Bh Hs Mt XJl.'X xxx xx.x
12231 (2261 227\ (261) '2621 (263) (262) 1265) r2671 (2691 (272) (27 7 1
Inner-transitional Metals
58 59 60 61 62 (>.~ 64 65 66 67 68 69 70 71
*Lanthanides Cc Pr Nd Pm Sm Eu Gd Tb Dy Ho Er Tm Yb Lu
H0.115 140.907(>5 14424 ( 145J 150.3(> 151.965 157.25 158.92534 162.50 IM.93032 167.266 168.93421 173.()4 174.967
90 91 92 93 94 95 96 97 9/l <J9 100 IOI 102 103
**Actinides Th Pa u Np Pu Arn Cm Bk Cf Es Fm Md No Lr
232.0381 t231) 23!!.0289 !2371 ,2441 (2431 1247) (247) (251) (2521 <257) (2581 (259) (262)
Elemenl1 110, 111 , 112 ho~e yet IO be nomed.

Table A·I concluded
Key to Abbrevia1ions
Nome Symbol Nome Symbol Name Symbol Name Symbol
Actinium Ac Europium Eu Mercury Md Scandium Sc
Aluminum Al Fermium Fm Molybdenum Mo Seoborgium Sg
Americium Am Fluorine F Neodymium Nd Selenium Se
Antimony Sb Francium Fr Neon Ne Silicon Si
Argon Ar Gadolinium Gd Neptunium Np Silver Ag
Arsenic As Gallium Go Nickel Ni Sodium No
Astatine At Germanium Ge Niobium Nb Strontium Sr
Barium Bo Gold Au Nitrogen N Sulfur s
Berkelium Bk Hafnium Hf Nobelium No Tantalum To
Beryllium Be Hahnium Ho Osmium Os Technetium Tc
Bismuth Bi Hossium Hs Oxygen 0 Tellurium Te
Bohrium Bh Helium He Palladium Pd Terbium Tb
Boron B Holmium Ho Phosphorus p Thallium Tl
Bromine Br Hydrogen H Platinum Pt Thorium Th
Cadmium Cd Indium In Plutonium Pu Thulium Tm
Calcium Co Iodine I Polonium Po Tin Sn
Californium Cf Iridium Ir Potassium K Titanium Ti
Carbon c Iron Fe Proseodym ium Pr Tungsten w
Cerium Ce Krypton Kr Promethium Pm Uranium u
Cesium Cs Lonthonum Lo Protactinium Po Vanadium v
Chlorine Cl Lawrencium Lw Rodi um Ro Xenon Xe
Chromium Cr Lead Pb Ro don Rn Ytterbium Yb
CoboIt Co Lithium Li Rhenium Re Yttrium y
Copper Cu lutetium Lu Rhodium Rh Zinc Zn
Curium Cm Magnesium Lw Rubidium Rb Zirconium Zr
Dubnium Db Manganese Mg Ruthenium Ru
Dysprosium Dy Meitnerium Mt Rutherfordium Rf
Einsteinium Es Mendelevium Mm Samarium Sm
Erbium Er
>
w
A·4 Appendix A Chemistry: A Tool for Understanding Nutrition
Table A·2 I Densities of Some Selected Substances

Example Density State
Oxygen 1.31 Gos g/I
Olive oil 0.92 liquids g/ml (g/cm3)
Water 1.00
Sucrose 1.59 Solids g/cm3
Solt 2.16
Physical and Chemical Properties of Substances

Every substance has a characteristic sec of physical and chemical properties. Physic.11
properties can be determined without altering the chemical composition of the sub -
stance. lee melts at l °C. Sugar melts at l 86°C. Melting and boiling points an: com
mon examples or physical properties.
Chemical properties, such as whether the compound is .Ul acid or a lusc, determine
chemical reaction An interaction between two thc changes that a substance undergoes in chemical reactions. Other substances .1ffecr
chemicals that changes both participants. the chemical properties ora substance. A chemical change or reaction is a procc~s
whereby the composition of one or more substances is changed. Wl1Jt .ictually takes
place is aftccced by the chemical properties of the participants. For e:\amplc, given rhc
right conditions, exposing glucose to oxvgen causes it ro break down LO carbon diO\
ide and waLcr.
+ 602 6C0 2 +
Oxygen Carbon dioxide ·water
Units
The SI unitS (Systeme Intcmn.tio11a/ rl 'U11 itcs) used for scientific measuremcncs dcsig
nate a specific metric unit. The uni rs used mosc frequently in nutrition arc mass {kilo
gram), length (merer), temperature, and amounr of subscance. Prcfi:-.es indic.uc
decimal fractions or multiples of the \'arious units. for example, lli/o means l X IO ·~
and I mi/Ii is 1 x io-3.
Celsius A centigrade measure of temperature. The temperature scale commonly used in scientific studies is the Celsius scale. On
For conversion: (degrees in Fahrenheit - 32) this scale, '' ater freezes at 0 °Celsius ( 32°Fahrenheit). Water boils al I 00°C (2 l 2°l- ).
x 5/9 = 0 ( (degrees in Celsius x 9/5) + Normal body temperature is 37.0°C (98.6°F). For English-metric co1wersiom for
32 = °F. length, weight, temperature, ,1nd ,·olume (amount) sec Appendix L.
Calories and Joules

Energy is measured in calorics or joules. A c.1lorie is t11e .rn10unt of cncrg) required to
raise the temperature of 1 gram of waccr 1 degree C. The SI unit of energy is r:he joule
(J). A mass or L g moving at a vdocity of 1 111/s possesses d1e energy equivalent of
L J. A caloric or joule is not a large amount of energy, so kilocalories ( kcal ) and kilo-
joules (kJ) arc \\idely used in nutrition chemistry, biology, and biochemi~try. In rcnm
of the joule, L kcal = 4.184 kJ.
Scientific Notation
In science, ,·cry large and n:ry small numbers frequencly must be used , but dit:~ .ire
J.wkward bccwse large numbers have a long string of trailing zeros and ~mall number'>
have a long string of leading zeros. A more convenient wa~' co express these numbers
is to use the power of 10, or scientific notation.
www.mhhe.com/wardlaw pe rs7 A-5
ln scientific notation, a number i:. expressed as a product of ,1 wefficienc multiplied o change a number greater than 1 into sci-
by a power of 10. The coefficient is a numbt.:r equal m or greaLcr than 1 but less t han entific notation, move the decimal point to
10. The power of 10 is the exponent. In other words: the left until the number is greater than 1 but less
than 10. This number is the coefficient. The num-
ax l01t
ber of places that the decimal is moved becomes
where n is the coefficient and bis the exponent. the exponent of 10. To change a number less
than 1 into scientific notation, move the decimal
6.02217 x 1023 = 602,217,000,000,000,000,000,000 point to the right until the number is greater than
1 but less than 10. This number is the coefficient.
2.99161 x 10 23 = 0.0000000000000000000000299161 The number of places that the decimal is moved
In the previous examples, che positive exponent for rhe number indicates that the is ogoin the exponent of 10, but this time a neg-
number is very large, whi le the negative exponen t indicates a very smaU number. ative sign is placed in front of it.
Atoms
The smallest unit of matter that can undergo a chemical change is called an at om . An atom Smallest combining unit of an element.
clemenr is composed of atoms of on ly one kind. For example, the element carbon is An atom contains protons, neutrons, and
composed of just carbon atoms. There are more than l 00 different elements. electrons.
proton The port of an atom that is positively
Atomic Structure charged.
The cenrcr of the atom is for the most part a nucleus containing two (subatomic) par- neutron The port of an a tom that hos no
ticles: protons, which carry a positi,•e charge, and n euo·ons, \\'ith no charge. Usually charge.
the mass of the proton equals the mass of the ncua-on. Adding the number of protons
~md nemrons together equals the atomic mass of the atom. An .1tom or carbon con-
taining 6 protons and 6 neutrons has an atomic mass of 12. The atomic mass of ni-
trogen is 14 and the atomic mass of o:-.~rgen is 16.
Tht! atomic number is equal to the number of protons in the nucleus. What arc the
atomic numbers of hydrogen, carbon, nitrogen, and oxygen?
Surrounding the nucleus of the atom arc negati,ely charged subatomic particles
called electrons. T he nucleus is acnially surrounded by an electron cloud. Electrons electron A port of a n atom that is negatively
haYe about 2000 times less mass than t he mass of protons or neutrons. Thus, all the charged. Electrons orbit the nucleus.
mass of .111 atom essentially is located within the nucleus. The structure of an atom can
therefore be pictured as a ' 'cry tiny, highly dense nuclear core surrounded by a cloud
of electrons. The number of electrons in an atom equals the number of protons, so the
net charge is zero.
Electrons surrounding the nudeu~ ha,·e a somewhat peculiar, nonintuitive (contrary ydrogen hos an atomic mass of 1 because
to what would be expected) behavior. For instance, it's inipossible to know precisely it hos 1 proton and no neutrons.
where any given electron is located at any given moment. It is only possible to define
a volume of space where the electron is most likely to be found. This ,·olume has a spe-
cific distribution of electron density in space and is called an orbital. An orbital is a vol-
ume of space. Each orbital has its own ch aracteristic energy and shape. Different
orbitals have different energies.
Orbitals of similar energy are grouped together into energy levels. The energy lev-
els are assigned coordinate mun bcrs-1, 2, 3, crc.-that increase as om: moves away
from the nucleus. Energy level 1 contains only one orbital, an s orbital. This orbital
can hold a maximum of two electrons. Energy lc\·cl 2 contains an s orbital and a p or-
bital; the s orbital can contain up to 2 electron~, and the p orbital up to 6. Energy le\•cl
3 contains ans orbital, a p orbital and ad orbital. As before, the s orbitaJ and p orbital
can hold up to 2 and 6 electrons respectively, while the d orbital can contain as many
as 10. Thus each energy le\·el can hold a maximum of 2, 8, 18, or 32 electrons, de-
pending on the number of orbitals, and any e nergy level can hold less than the maxi-
mum number of electrons.
Atoms tend to exist in the lowest possible energy state. Thus electrons tend to oc-
cupy orbitals at low energy levels before filling orbitals at higher energy levels. The first
A-6 Appendix A Chemistry: A Tool for Understanding Nutrition
Table A·3 I Atoms Commonly Present in Organic Molecules

Number of Chemical Bonds
Atom Symbol Atomic Number Atomic Mass Energy Level 1 Energy Level 2 Energy Level 3 to Attain Electron Stability
Hydrogen H 1 1 1 0 0 1
Carbon c 6 12 2 4 0 4
Nitrogen N 7 14 2 5 0 3
Oxygen 0 8 16 2 6 0 2
Sulfur s 16 32 2 8 6 2
nly the electrons in the outermost energy

0 level (if it is incomplete) con participate in
chemical reactions to form chemical bonds. The
energy lc\•d oursidc chc nucleus ha!. room for just two electrons. \Vhen that is full , the
next energy k\'el away from the nucleus is available for electrons, and there is room for
8 electrons. For example, hydrogen has one electron in ent:rgy level 1. Carbon ha:. 2
outermost electrons of on atom ore known as its electrons in energy level 1 and 4 in energy level 2. In energy level 3, there is room for
valence electrons. 8 electrons. Sulfur, with an atomic number of 16, has 2 electrons in the first enerID
level, 8 in the second, and 6 in the third (Table A-3).
An atom tends to bond with other atoms that will till its o utermost energy level .rnd
or
produce a number valence electrons equal to the noble gas that is the farthest to the
right in its row in the periodic table (e.g., helium and argon ). For instance, a hydro-
isotope An alternate form of a chemical
element. It differs from other atoms of the some gen atom, with only J single ekcrron, will react with other atoms that pro\'idc another
element in the number of neutrons in its nucleus. electron and fill the energy level with two electrons, the same number of electrons as
in the noble gas helium.
Isotopes and Atomic Weight

All the atoms of an clement have the same number of protons in the nucleus, but the
number of neutrons in d1e nuclei of element!. such as carbon, nitrogen, and o\ygen
may \'ary. All elements have such varieties, called isotopes, that differ from each other
only in the munber of neutrons and, consequently, atomic mass. Most hydrogen .1toms
have only one proton, bt1t isotopic forms can have one or two neutrons. Some ii.otopcs
12 Carbon arc radioactive, but most arc not. Tritium, a radioactive isotope of hydrogen, Ju~ one
6 Protons proton and two neutrons. Carbon nudei can contain fi\'e, six, se\·cn, or eight ncurrc>ns.
6 Neutrons Isotopes arc disti nguished by adding the number of protons and neutrons together
6 El~ctrons and writing the resultant sum as a superscript to the left of the symbol for the ele-
ment. For example, a carbon nuclei with si\ protons and six neutrons is wriucn as
12 C. The isotope containing seven neutrons is labeled 13 C, and the isorope contain-
ing eight m:utrons is labeled 14C. Note rhac because all these atoms have six protons,
they are all carbon atoms. Howe\er, because they possess different numbers of neu-
trons, they represenc isotopes of carbon. All isotopes of an clement behave d1e ~ame
way chemically.
13
Aromic weight acw.11ly takes imo accoum that an element is a mixtmc of isotopes.
Carbon
6 Protons
Tr aJJ carbon were 12C, the atomic weight would be d1e same as its ;ltomic mas!., 12.
7 Neutrons Bur because some carbon exists as 13C and 14C, the atomic weight is slightly higher,
6 Electrons 12.011. The atomic weight is based on d1e relative abundance of the various isotopes.
Although the ordin.uy chemical behavior of different isotopes of the same clement
is virtually identical, the radiochemical behavior is sometimes different. Isotopes ex-
hibit such differences in physical behavior because they decay (break down ) to more
stable isotopes b~' gh ing off nuclear particles of ionizing radiation. Certain unstable
isotopes (radioisotopes) are in an obvious process of decay. fa·ery clement has at least
one such radioisotope. These radioisotopes have a physical half-life, which is the time
required for 50% of its atoms to decay to a more stable state. Isotopes such as 32P
14 Carbon
( Phosphorus) emit radiation d1at can be measured by instrumenrs such as Geiger
6 Protons
8 Neutrons counters and scintillation counters. The isoropc 1-l·C decays more rapidly than other
6 Electrons isotopes of carbon.
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Other isotopes are not radioactive but can still be a-aced in bodily fluids or tissues
using other types of instruments. Examples include 13C and 1 5N; these are called sta-
ble isotopes because they decay very slowly and do not emit radiation.
Isotope "markers," such as 32 P and 13C, have a practical use, because they can be
used to trace nutrients as they follow various chemical pathways in the body. For ex-
ample, researchers can "mark" a glucose molecule will1 a radioactive carbon atom
(1 4 C). This marking allows the researchers to see where the carbons of glucose are dis-
tributed in the body, and it helps indicate what chemical transformations glucose un-
dergoes when metabol ized. Such studies have demonstrated that glucose can become
part of the lipid stored in .1dipose cells, or form C02 (detected as 14C02 ) that is ex-
haled. Isotope techniques are \\idely used in nutrition research.
Atomic and Molar Mass

Atoms are very small. One 12 C atom has a mass of 1.993 X 10 23g. The units used to
quanti~r atomic mass arc called atomic mass units (amu). T he carbon amu is calculated alton is another term used to indicate
by dividing the mass of a carbon atom by 1.6605 X 10- 24, which is essentially the mass atomic mass, such as for proteins, DNA,
of one proton or neutron. Ry performing this calculation on 12 C, you will find that the and RNA. One Dolton is equivalent to one amu.
mass of a carbon atom is 12 amu. The amu for each clement is listed in the bottom
portion of each entry in the periodic table. Each amu is based on comparing the ele-
ment's mass to that of 12c.
You are familiar with counting units, such as the number of sticks in a package of
chewing g um. In chemistry, the unit for counting atoms, ions (an clcctricaJly charged
atom), and molecules (a combination of atoms) is the mole. A mole is defined as the
amounr of matter that contains as many objects (things) as the number of atoms in 12 g
of 12 C. T he number of atoms in 12 g of 12 C is
, 1 atom
12 g 1-C x 1. x
_ g 12C = 6.023 x 10 23 atoms
993 10 23
fr is not their weight but the nm11ber of molccuks that determines the physiologi-
cal effect of a substance. Therefore, the number of "objects" in a mole of carbon (or
any other substance) is 6.02 X 10 23 , which is called Avogadro's number. For example:
l mot 12 C atoms = 6.02 x 10 23 12 C atoms
l mol of water molecules= 6.02 x 102 3 H 2 0 molecules
1 mol N0 3 - ions = 6.02 x 1023 N0 3 - ions
A single 12 Carom has a mass of 12 amu, but a single 24 l\1g is twice as massi,·e,
24 amu. Because a mole always has the same number of particles, a mole of Mg is twice
as massive as a mole of 12 C atoms. A mole of carbon weighs 12 g; a mole ol Mg weighs
24 g. The same number that refers to the mass of a single atom of an clement (in amu )
also represents the mass (in g ) of 1 mol of atoms of that clement. For example, one
12 C atom weighs 12 amu. One mot 12 C weighs 12 g. One 24 Mg atom weighs 24 amu,
and J mol 24Mg weighs 24 g.

The mass in g of 1 mole of a substance is called its molar mass. The molar mass (in
g) of any substance is always numerically equal co its formula ,,·eight (in amu ). For ex-
molecule A group of atoms chemically linked
ample, one H 2 0 molecule weighs 18.0 amu, and 1 mol ofH 2 0 weighs 18.0 g . One
together-that is, tightly connected by attractive
NaCl molecule weighs 58.5 amu, and 1 mol of NaCl weighs 58.5 g.
forces (see also compound).
bond A sharing of electrons, charges, or

Molecules, Covalent Bonds, Hydrogen Bonds, attractions linking two atoms.
and Ions and Ionic Compounds compound A group of different types of atoms
bonded together in definite proportion (see also
Molecules molecule). Not all chemical compounds exist as
molecules. Some compounds are mode up of
Molecules are fom1ed through the interaction of the electrons in the outermost or-
ions attracted to each other, such as Na.,.cl -
bitals (valence eleco·ons) of rwo or more electrons. ·when electrons are shared, chem-
(table salt).
ical bonds are formed . The term compoW1d refers to molecules composed of mo re
Ethanol than one element. Water is a compound. Each molecule {or compound ) possesses its
own properties, such as color, taste, and density.
Molecular C2HP Hydrogen can form just one chemical bond because it has room for just one electron
formula
in its orbital ofrwo electrons, in turn yielding a noble gas electron configuration. Carbon
H H can fom1 four chemical bonds, nitrogen three, and oxygen rwo (review Table A-3).
I I A molecular formula gives the elemental composition of a molecule or compound.
Structural H-C - C- 0 - H This formula consists of the symbols of the atoms in the molecu le plus a subscript de-
formula I I noting the number of each type of atom.
H H
A structural formula shows ho\\ the atoms are arranged with respect to each other.
As an extension, molecular and ball-and-stick models approximate the shape of the
Molecular
(space-filling)
~ molecule (Figure A- 1).
When molecules combine wi th each other, atoms do not increase or dccrea1;e in
model
number. Atoms present in starting materials must be present in the products. 1-or e\-
ample, compare the number of oxygen atoms in glucose and the oxygen itself co the
num ber in the products of the reaction ( 18 vs. 18). T his example also illustrates tbe
Molecular
(ball-and-stick) process of conservation of mass.
model
C6 H 120 6 +602 -... 6 C0 2 + 6 H 20
Covalent Bonds
Figure A· 1 I Examples of the molecular and When atoms share their \'alcncc electrons, a covalen t bond is formed {Figure A-2 ).
structural formulas and the molecular models of The electrons shared between atoms are bonding electrons; these represent the adhe-
ethanol. The space-filling model gives a more sive that holds the atoms together in molecular form .
realistic feeling of the space occupied by the When rwo identical atoms share electrons, such as in the formation of hydrogen gas
atoms. On the other hand, the boll-0nd-stick {H 2 ) or ox·ygen gas ( 0 2 ), the co,·alcm bond is very strong because the ekcrrons are
type shows the bonds and bond angles more
shared equally. This equal distribution between the atoms makes the molecule nonpo-
clearly.
lar. Consider the simple compound methane (CH4 ). Hydrogen has one valence ckc-
tron and iu, outermost (only) orbital can hold a maximum of rwo electrons. Carbon
has four electrons in its outermost energy lc\·cl or valence shell, and that shell can hold
covalent bond A union of two atoms formed by a maximum of eight electrons. Both carbon and hydrogen fiU their valence shells to the
the shoring of electrons.
maximum by sharing electrons with each other. Notice that each hydrogen in methane
contains rwo electrons and that the carbon atom ends up with eight electrons. A good
way to look at dlis is that the hydrogen atoms share one pair of electrons, wherc,1s the
carbon aroms share four pairs of electrons {review Figure A-2 ).
Guidelines that govern the formation of covalent bonds are as follows:
1. The valence shell of each element must have room to accommodate additional
electrons.
Figure A·2 Covalent bonds. I In each

of the four bonds, one electron of the carbon is H
shored with the electron of a hydrogen atom in
a single, sausage-shaped molecular orbital
encompassing the two nuclei. Methane is the
simplest organic molecule. Even the largest
organic molecules ore held together by strong
H
covalent bonds like these.
H
H
•H H ,
H
H
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2. Second-row nonmetallic clements of the periodic table (e.g., carbon, nitrogen,

and oxygen) and hydrogen typically till their outermost cnagy lc\'els by sharing
the necessary number of electrons with another clement.
3. Third-ro'' nonmetals and those beyond this point in the periodic lable (e.g., phos-
phorus and sulfur) frequently attain stability by giving up dectrorn. in the outer-
most energy level rather than adding them. Phosphoru~, for example, typically
makes five bonds to attain stability instead of the three that arc needed to have the
ekcrron configuration of the noble gas argon ( 18 electrons).
A single covalent bond forms when rwo atoms share one electron pair. A double co-
valent bond forms when two atoms share rwo electron pairs.
\Vhen electrons spend approximately cqu.11 time ar0tu1d each atom nucleus, the
bond is calJed a nonpolar covalent bond. These are the !itrongest covalent bonds. lf die
two nuclei are not equally attractive to electrons, their atoms can form .1 polar covalent
bond in \\'hich the electrons spend more time orbiting the more attractive nucleus. For
example, when hydrogen bonds with oxygen, the electrons arc more aLtractcd to the !\ denotes partial change
oxygen nucleus and orbit that nucleus more than the)' do rhc hydrogen nucleus.
Electrons carry a negative charge, which nl.lkes cJ1e oxygen region of the molecule
slightly negative and the hydrogen region slighlly posirive. The Greek letter delta (8)
is used to symbolize a charge less cJ1an that of one electron or proton. A slightly ncg-
ati\'e region of a molecule is shown as 3- and a slightly positive region is shown as 3-r.
A molecule such as this is called a dipole because it has two charged ends.
When two different atoms form a covalent bond, rhe bonding electrons arc ne\'er
shared equall). Consider again the H - 0 bond in water. It is unreasonable to expect
oter is o good example of o dipole com-
thal Lhc hydrogen nucleus (containing one proron) and cJ1e oxrgen nucleus (contain -
pound. The oxygen otom pulls electrons
ing eight protons) han! identical forces of attraction for rhe shared electron pair. In ad-
from the two hydrogen otoms toward its side of
dition, other factors come inro play, such as how many energy levels each atom has,
the woter molecule, so thot the oxygen side is
how many electrons arc in each, and the disrance the shared elcccrons arc from each
more negatively charged thon the hydrogen side
nucleus. AlJ these factors lead co an unequal sharing of ckctrons in a co' alent bond be-
of the molecule. Woter, the most obundont mole·
tween different atoms.
cule in the body, serves os o good solvent be-
The ability of an arom in a molecule to attract electrons is called dectroncgativiry.
cause of the nature of its basic structure.
Elements toward the top right corner of die periodic table h,l\'e the highest clec-
tronegati\'ity, and those coward the bottom left have the lowest ( clectronegati\'ity gen-
erally increases from lett to right in a row of the periodic table, and decreases going
do\\ 11 a column; cJ1e difference in the elcctroncgati,'ities of bonded atoms can be used
to determine cJ1e polariry of ,1 bond). Merals have low electronegativiry, whereas non-
metals have relatively high electronegativity. Oxygen and nitrogen ha'e die highest
electroncgati''ities of rhe elements typically found in compounds imporcanc to nutri-
tion. The elecrronegarivity values of atoms determine the c:ypc of chemical bond
formed. If rhe clectronegarivity values are not very different, a covalent bond is
termed. If the electronegativiry of two bonding atoms diners greatly, electron transter
occurs ro yield an ionic bond, .is in Na +c1- (sec tl1e subsequent section on ions and
ionic compounds).
olor molecules ore weakly ottrocted both to
ions ond to other polor molecules. The posi-
Hydrogen Bonds
tive end of the molecule con olign itself with on
Water, and most otl1er mokcules comaining an 0-H or N- H bond, exhibit a par- onion or with the negative end of another mole·
ticularly strong interaction called hydrogen bond ing (Figure A-3). fn this case, the hy- cule. These attractive forces, coiled, respectively,
drogen atom of one molecule is attracted to a non bonded electron pair (called a lone ion·dipole and dipole-dipole forces, ore much
pair) of a highly electronegative atom on a neighboring molecule, such as oxygen. Water weaker than covalent bonds individually, but
molceuks arc attracted to each otl1er by hydrogen bonds. This attraction is responsible when there ore many of them, they moke a sig-
for man~· of the biologically important properties of" acer. Hydrogen bonds, such as nificant contribution to the total energy of a col·
those found \n \argc proteins and DNA, help to hold the molecule together. These mol- lection of molecules. Water, for instance, hos a
ecules fold Or twist into three-dimensional sh:ipcS due in pal'l LO the action of hydro- much higher boiling point than expected be-
gen bonds. Hydrogen bonds arc usually symbolized by a dotted line between the .uoms: cause the molecules ore held together by such
-C-0 · · · H-N-. Hydrogen bonds arc the \\'eakcst of all chemical bonds. forces.
A·lO Appendix A Chemistry: A Tool for Understanding N utrition
Figure A·3 I Hydrogen bonds between H H Water molecule

water molecules. The oxygen atoms of water +
molecules ore weakly joined together by the
attraction of the electronegative oxygen for the
positively charged hydrogen. These weak [ - - - Hydrogen bond
bonds ore called hydrogen bonds.
H
···········
H
H
H
Ions and Ionic Compounds

Atoms that have an equal number of positively charged protons and ncgati\ ely charged
clectrom are electrically neutral. Atoms or molecules that ha,·e positive or ncgati\ c
ionic bond A union between two atoms formed charges are called ions. Ionk bonds result when one or more \'alcncc clecrrons from
by on attraction of o positive ion lo o negative one atom arc completely transferred to another atom or molecule. Element!> Lh,1C h,n e
ion, as seen in table salt (NA+c1- ). one tO three valence electrons have a tendency to give up electrons, and those with
four to seven Yalence elecLrons have ,\ tendency to accept electrons. The electrons Jrc
not shared. In both cases the clements ,ire giving up or taking on clectrom. to achie\c
Lhe electron configuration or the closc:.:st noble gas. Take the case of sodium chloride.
One atom loses electrons, so that its number of electrons becomes smaller than it~
number or protons; thus, it becomes posirh·cly charged as Na+ in sodium chloride
Now, sodium has the same number or electrons as neon. The other atom gains elcc
trons, so its number of electrons is grcJtcr than its nwnbcr of protons; it becomes neg
atively charged as c1- in sodium chloride. Now, chJoride has the same number of
electrons as argon.
Positively charged ions arc cal led cations; they move coward the negative pok in .rn
W oter molecules that surround ions attract
other water molecules to form hydration
spheres around each ion. This mechanism makes
electric field. An atom with more electrons than protons is negatively charged and is
known as .rn anion; it moves to the positive pole. NaCl is an example of an ionic com-
ions and numerous molecules soluble in water. pound. Note the name change that occurs when an element gains an e lectron to be-
come a negative ion; rhe suflix becomes -idc.
These charged atoms, where elcctron(s) have been added or remo,·cd, an: coUec
tivcly known as ions. Sodium (Na +}, potassium (K+), and calcium (Ca 2 + ) .trc fount
in the body as cations. Chloride (Cl - ) is a common anion in the body. Sec Table A-4
for a more complete list of common ions found in the body.
Ionic bonds arc weaker than polar CO\'alenr bonds. Ionic compounds easily separatl
when dissolved in water. Table salt (NaCl) is obvious when poured out of the sah
shaker, but when che salt is stirred into a cup or water it disappears. l t dissncintcs. Thl'
polar water's negative side (oxygen) is attracted to the Na+, and che posiri\'t: ~ide (hr
drogcn) is attracted to c1-'
Salts
Salts arc i,ubstanccs composed of cations and anions. Table salt is NaCl. The Na+ and
c1- are .ntracted to each other by electrostatic force, and the resulting ionic com
pound is knm' n chcmicall) as sodium chloride. Salts arc formed by the inti:r.Ktion ol
acids and bases in a neutralization reaction. Water is also formed in such a reaction. !11
www.mhhe.com/wardlawpe rs7 A· 11
Table A-4 I Important Ions in the Human Body

Common Ion Symbol Some Functions
Calcium Co2 Component of bones and teeth; necessary for blood dotting, muscle
contraction, ond nerve transmission
Sodium No+ Helps maintain membrane potentials (electrical charge differences across
o membrane) and water balance
Potassium K+ Helps maintain membrane potentials
Hydrogen w· Helps maintain acid-base balance
Hydroxide OH Helps maintain ocid-bose balance
Chloride Cl Helps maintain ocid-bose balance
Bicarbonate HC03- Helps maintain ocid-bose balance
Ammonium NH4 + Helps maintain ocid-bose balance
Phosphate PO 43 Component of bones and teeth; involved in energy exchange and
acid-base balance
Iron fe2 1 Necessary for red blood cell formation and function
Magnesium Mg2 + Necessary for enzyme function
Iodide 1- Port of the thyroid hormones
Fluoride F- Strengthens bones and teeth
this type of reaction, hydrogen ions of an acid are replaced by the positive ions of a ohs seporote to form positively and nego·
base, and a salt forms. For example, when hydrochloric acid reacts with sodium hy- lively charged ions when dissolved in water.
droxide, table salt is produced: Substances that dissolve in water and conduct
electricity ore called electrolytes. (A solute that
HCl + Na OH NaCl + produces ions in solution forms on electrolytic
Hydrochloric acid Sodium hydroxide Salt Water solution that conducts on electrical current.)
(Neutralization reaction) Sodium (No.. ), potassium (K't calcium (Co2 +),
chloride (Cl- ), magnesium (Mg 2+), phosphate
The formula for salts can be misleading. For example, NaCl suggests that table sale
(POi- ), and bicarbonate (HC03 ) ore various
exists as a discrete entity containing one sodium ion and one chloride ion. An inspec-
electrolytes commonly found in the body.
tion of the chemical structure of table salt shows that it is actually a three-dimensional
stack of layers-much like having a ream of paper with all the pagcl. glued together
(Figure A-4).
Figure A·4 I Molecules of sodium chloride

(table salt) in typical cube-shape formation.
aler molecules of two hydrogens and

one oxygen ore held together by polar
Acids, Bases, and the pH Scales
covalent bonds. Although these ore strong
You have a pretty good idea o f whar acids and bases are. You know that lemon juice is
bonds, o small proportion of them break, releos· an acid and drain cleaners are strong bases.
ing a hydrogen ion and a hydroxide ion. The
A solution tJur has a h igher concentration of protons (H+) is said to be acidic, and
hydrogen ion lo proton) is transferred lo another
one that is lower is basic, or alkaline. An acid is defined as a substance that c:tn ioni1c
oxygen in o water molecule, forming o hydro· and release protons (H +) into solution. It is a proton donor.
nium ion. This means that o pair of water mole-
Any substance that releases protons (hydrogen io ns) when in water is an ,Kid. For
cules con act as on acid and a base, because
example, hydrogen chloride (HCI ) forms hydrogen and chloride ions (H+ and Cl -) 1n
water self-ionizes, forming hydronium ions and
solution and therefore: is an acid.
hydroxide ions:
+ OH-
Wate r Hydronium ion Hyd rox ide ion Figure A -5 lists se\'eral common acids and bases. A base is a negatively charged io n
For simplicily, ionized water will be represented or a molcrnle that ionizes co produce an .inion. This then can combine" irh .1 proton
byWondOW: (H+), removing it from solmion. T his base is a proton acceptor. Any substance that
c,rn accept hydrogen ions while in water is a base.
Many bases c.rn function as proton acceptors by releasing hydroxide iom (OH )
when dissolved in water. Most strong bases rclcast: OH- into solution. The OH- com-
bines with H + to form water.
Na OH +
Sodium hydroxide Sodium ion H ydrnxid c ion
+ H+
H ydroxide io n Hydrogen ion
Figure A·S I pH scale. The diagonal line

indicates the proportionate number of
l
hydrogen ions to hydroxide ions. Any pH value
Increasing concentration Increasing concentration
above 7 is basic, and any pH value below 7 is of hydrogen ions [H+] of hydroxide ions [OH- )
acidic.
acid base
(~]
~
:;
CD
c [Oli]
_I
Ii ·r
0 2 3 4 5 9 12 13 14
CD
u 'O
·o
Cl)
lo "'CD CD
"'
'O -"" ·-Cl!c:::
(IS
Qi I'
e.
0 0)
Cl)
0 (IS "8 c::: 0(IS
fiU
as :§. Cl) .9 =a0 ...J 0 (/) (IS
.c c c::: as ~ - E Cl)
'O 0
as 0
·s; E -""
c::: <ii E 15 0 ~
·~
(IS
..: .9 en c
~c:::
E 0 Cl! Cl)
E QI as .c CD 'O
0 .9 .SI QI
:0 0
as iU '.Q > x0
'§ .0 CD 0 0
"' '- co ~ "'O E ~ as .c 0
::c0 ni ~ ~ 5. 8 .9 (.') ;;; 5l .0
lo -0
>.
0 m :oc::: ~ .c
e
-0
(.)
m
3:
c "'ni Cl)
c:::
g> .c
0 0
:0 E
>- -~ as -0 ~
.c 0
0 E 0 E '6
(.) (ii
E
~
.c "'c:::
0) 15
~
0
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0 '..><
c as
.0
E
www.mhhe.com/ wardlawpers7 A- 13
pH
Acidi~ is expressed in terms of pH, a measure of the molarity (the ratio of solute per
liter of sol ution) of H + . Molarity is expressed by square brackets, so 1he mol.lriry of
H + is symbolized as [ H +]. pH is defined as the negacive logarithm of the hydrogen
ion molarity (concentration ), or pH = -log [H + ]. The pH unit is the H + concentra-
tion of a solution. Pu re water has a neutral pH because it contai ns equal amounts of
hydrogen (hydronium ) and hydroxyl ions. The pH scale runs from 0 to 14 ( re\·iew
Figure A-5 ).
Because pH is a negative logaritlunic scale, a solution with a pf l of4 has ~ln acidic pH acidic pH A pH less than 7. Lemon juice hos
that is 10 times greater than t11at of a solution with a pH of 5, and is 100 times more on acidic pH.
acidic than a solution with a pH of 6. These number!. may be confusing because they
alkaline pH A pH greater than 7. Baking sodo
are inversely rdated to the hydrogen ion concentration: A solution wit h a high hydro- in water yields on alkaline pH.
gen ion concentration has a low pH number. A solution with a low hydrogen concen-
tration has a high pH nwnber. Acid solutions have a pH o f less than 7. Basic, or
alkaline pH , solutions have a pH greater than 7.
A slight disruption of pH can seriously disturb normal physiological functions, so it
is important me body be able to control pH. Blood normally has a pH range from 7.35
to 7.45. Any deviations from this range can cause dizziness, fainting, coma, paralysis,
or <learn.
Acids and bases arc classified as strong or weak. Strong acids and strong bases dis-
sociate completely when dissolved in water. Consequendy, they release all their hydro-
gen ions or hydroxide ions when dissolved. In general, the more completely an acid or
a base dissociates, the stronger it is. Hycfrochloric acid, for example, is a strong acid
because it completely dissociates in water.
Weak acids only partially dissociate in water. Consequently, they release only some of
0
II
their acidic hydrogens. For example, when acetic acid (CH 3 C-OH , the principal
component of \'inegar) dissoh·cs in \\ ,1ter, it dissociates only partially.
+
Acetic acid Acetate ion Proton
The equilibrium lies far to the left, so that onl)' a small fraction or the acetic acid in t11e
vinegar is dissociated into acetate ions and protons.
Most weak bases release hydroxide into solution by reacting with the water itself.
For example, ammonin (NH 3 ) reacts with water to form NH 4 + 0:111d OI-r.
+ NH4+ +
Amm onia Water Ammonium ion H ydroxid e ion
Buffers
Many of me biochemical reactions that occur in li\'ing tissues require tight control of
pH. To prevent changes in the H + concentration in the body and co concrol the pH,
a sy~tem of buffers is maintained. These buffers arc ions and molecules that stabilize
the pH of n solution. In the blood (plasma), the pH is maintained by me carbonic
acid- bicarbonate buffer system. The acid is formed b) the combination of\\ ater and
carbon dioxide. Carbonic acid separates into bicarbonate ion (HC0 3 -) and the hy-
drogen ion (H ... ).
C0 2
Bicarbonate Hydrogen ion Carbonic acid Water Carbon dioxide
he kidneys also ploy a buffering role in the The reaction can go either war. The direction depends on the concentration of ions on
body by absorbing or releasing W or either side of the arrows. For example, if an acid were released into the blood plasm;i
HC03 - , depending on the acid-base balance in (more H + in solution ), the reaction would be driven to the right. The carbon dioxide
the person. In fact, much of the excess acid produced could then be exhaled \"ia the lungs. Acids that are present in the plasma
leaves the body via the urine {urine has an acid come from ccllubr activities, but despite the increase in H + ions by these activities, the
pH). Thus, the kidneys and lungs keep this blood plasma pH hardly changes; it is essentially constant. The buffer, bicarbon.ite, ~K
buffering system functioning ond, in turn, ore complishcs this. It is constantly formed to maintain normal pH.
key to acid-base balance in the body.
Free Radicals
You arc aware that atoms tend to sharc electron pairs "vhen forming chemical bond~,
.111d there is a tendency to share enough electrons to completely fill the valence: shdl
so as to form a noble gas configuration. A con~equence is thac atoms or clements an:
rarel)' found with unpaired electrons. But when a molecule with an extra electron doc\
arise, it is called a free radical. An example is the superoxide anion. Oxygen is com
posed of two oxygen atoms (0 2 ) ; if an electron is added, it becomes supero~de, or
0 2 • -.The dot signifies an unpaired electron.
Supcroxide and other free radicals arc reactive, primarily because they contain an
unpaired electron. Free radicals seek an electron by attacking and remo,·ing eleca·ons
from other compounds, such as ac the location where hydrogens are attached to car
bon. This not only damages the other molecule but transforms it into a free radical.
R 0
+ -CH2 ~ RH+-cH-•
Free radicals are also formed when a co,·alenr bond breaks and each atom or molecule
fragment rcco\'eri. the electron o riginally used to make the bond. In this case, encrgy-
usually in the form of sunlight, ulrnwiolet radi,1tion, or heat-is used to break the
bond.
A-B + energy ~ A• + B 0
Because free radicals arc rc.1Cti,·e, rhey can generate thousands of other frel' radical\
within minutes in a chain-n:action process. The reactivity of free radicali. sometimes
produces dctrimemal effects in living systems. For instance, the development of cJr-
diovascul.1r disease and some types of cancer, such as skin and lung cancer, il> probablr
promoted by free radicals. Howe\'er, some normal ph~·siological functions in the bod~
involve free radical formation; for example, fi·ce radicals are used by various whice
blood cells to kill in\'ading bacteria.
The body has a number of mechanisms, such as antioxidants, for neurrJli1ing free
radicals. Amioxidanrs are substances that react with and neutralize free radical forms of
oxygen and nitrogen. The enzyme superoxide dismutase (SOD) convert~ supcroxidt
into oxygen and hydrogen peroxide. One form of SOD contains the mincrab coppet
and zinc, whereas another form contains manganese. Other antioxidanr~ obraincc
from the diet arc vitamin E and various phytochemicals.
Some substances are used extensively in the food industr~· to trap free radicals 01
prevent their formation. This use allows for increased srorage time of food by decreas
ing chemical breakdown. These substances arc part of a class of food addith·es callee
preservatives (see Chapter 19). Vitamin E added to cooking oils protecrs C= C bond~
by trapping free radicals.
Organic Chem istry

Organic compounds contain carbon in combination with other clements, such as h}
drogen, oxygen, and nitrogen. Carbon compounds are associated with living thing~.
but why carbon? It is because carbon forms very stable covalent bonds, such as single:,
double, and even triple bonds. Carbon also forms these bonds with many other atom~.
www.mhhe.com/ wardlaw pers7 A- 1 S
Carbon atoms can even form rings and chaim by bonding to other carbons. Variation OH
in the length of the chains, and their atomic configurations, allows the formation of a I
H -C-H
wide variety of molecules. Organic molecules generally also contain hydrogen. I
c--o
H
\
/ HI "-."-./H
C OH H C
Cyclic and Chain Compounds
Hd '\_Ic--cI / bH
Cyclic organic compounds are common forms of hydrocarbons. Nmc the diagram of
I I
butyric at:id (a chain) in the margin and compare that to the structure of glucose, H OH
which is .1 ring. E\'cn though the two compounds arc only carbon, oxygen, and hy- Glucose
drogen, each con\'cys a ,·er~· different property. Some ring srructun:s arc rctcrred to as
aromatic compounds.
Hydrocarbons as chains or rings provide the backbone of many groups of com- H H H
pounds that make up important organic nutricncs. Other groups arc attached to these I I I -:Yo
H-C-C-C-C
backbones. They usually contain atoms of oxygen, nitrogen, phosphorus, :rnd sulfur. I I I ' oH
The functional or reactive groups provide the unique chemical properties of organic H H H
molecules. Classes of organic molecules arc ki10\\ n by their fimctional groups. Butyric acid
A Closer Look at Functional Groups

Several important organic compounds contain a functional group called a carbonyl
group (C=O ). The carbonyl group is the parent compound for kcrom:s, aldchydes,
and man) related groups. Table A-5 has a list of all these compounds that arc impor·
tant tO nutrition.
Keroncs are organic compounds in which the carbon)'I group occurs in the interior
of a carbon chain and is therefore flanked by carbon atoms. Body fat that is breaking
0
II
dO\vn at a rapid rate produces ketoncs (C-C-C), some of which are removed from
rhe bodv. bv. wa\'. 0
of the urine (re,·ie\\' Chapter.+) .
II
Aldehydcs (-C-H) arc organic compounds that contain a carbonyl group to
which at least one hydrogen atom is arrached. This ac.:ti\'e group is found in one inl·
porrant form of \'itamin A. As an aldehyde, it plays a central role in vision.
Many of the most common substances in borh foods and the body contain
0
II
carboxylic acids. A carboxylic acid (-C-OH)comains the carbonyl group with an OJI
group attached. These acids are \\~dely distributed in tissues and natural products. Vinegar
wntains acetic acid. Citrus fruits contain citric acid, and \'itanlin C is ascorbic acid.
The carboxyl group is an acid because it can donate a H+ (proton) to a solution. A
very common acid formed in muscle cells is hctic acid. \Vhen lactic acid ionizes, it re-
leases the H+ and becomes lactate. Because both forms of the acid (ionized and non-
ionized) are in solution, the proportion depends on the pH of the solution.
An alcohol has the carbon-oxygen bond, but the 0 is also bonded to a single by·
drogen. This leaves only a single bond between the carbon and oxygen, forming an
-OH or hydro3de group (ROH).
II
An ester ( R-C-0 -C) is an organic compound that has an 0-C group attached to
a carbonyl group. An ester is the product of a reaction between a carboxylic acid and an
alcohol. The formation oflipids called triglycerides involves d1c formation of ester bonds.
The carbonyl portion of a compound such as an ester is called an acyl group. Thus,
removal of the hydroxyl group (OH) from an organic acid forms an acyl group.
T\\'O sulfur atoms (S-S), each attached to a carbon, produce a disulfide group. This
group is important to the structural characteristics of certain proteins.
A- 16 Appendix A Chemistry: A Tool for Understanding Nutrition
Table A-5 I Typical Chemical Groups Found in Nutrients

Functional Group Name Typically Found In Example
-OH Hvdroxide Alcohols CH-i-OH
-C=O Aldehyde Sugars CH 3C=0
I I
H H
C-C=O Ketone Ketones CH 3<f=0
I
c CH3
-C=O Corboxyl Acids CH 3C=0
I I
OH OH
-s-s- Disulfide Proteins -CH2-S-S-CH2-
-C=O Carbonyl Aldehydes, ketones, corboxylic (CH3) 2C=0
l acids, amides
I Amine Proteins
-C- NH CH 3-NH 2
I 2
-C=O Amide Vitamins

I
NH 2
0- Phosphate High-energy compounds
1
-O-P=O
I
0-
-C=O Ester Triglycerides 0
I II
0-C 0 C-0-C-CHr
II I
-CH2-<:-o-<: 0
I II
C-0-C-CHr
0 AcyI Triglycerides 0
II II
-0---C-CHr 0 C-0-C-CHr
II I
-CH2-<:-o-<: 0
I II
C-0-C-CHr
A single carbon with an amine (also called amino) group attached (-NH, ) is .1
component of all amino acids. -
Isomerism
Molecules that have identical chemical formulas but ditlcrcnt strucn1res arc c.tlled
isomers Different chemical structures for isomers. A simple example is two compounds with the formula C 2 H 6 0.
compounds that share the same chemical
CH3 0CH3
formula.
Ethanol Methyl ether
w ww.mhhe.com/wardlawpers7 A · 17
Both Lhcse compounds c,111 be harmful. Howevcr, thcre arc intake levels at which
ethanol produces no toxic symptoms (i.e., the amount in a small glass of wine ), but at
which methyl ether would cause vcr) roxic etlccts. This facr illustrates an important
point about isomers: because they have different structures, they can have different
chemicn I properties.
The difference in properties between two isomers can be great (as in the preceding
example ) or very subtle, but the differences are there and arc detectable. There are dit:
forent [)'pcs of isomerism, but only two of the common types \\'ill be briefly reviewed
in this section: structural isomers and stereoisomcrs.
Neopentane
Structural Isomers
Isomers in \\'hich the number and kinds of bonds differ are called structural isomers. CH3
i\lolecuks containing chains of carbon atoms typically have many structural isomers. I
CH -C-CH
Any variation in the way Lhc chain is branched gives rise LO a new isomer. for exam - 3 I 3
ple, pent:111e ( C 5 H 12 ) has three isomers, as shown in the margin.
CH3
Stereoisomers lsopentano
'
Srereoisomers have the same number and [)'pes of chemical bonds but with different
spatial arrangements (different configurations in space). Molecules containing double
bonds illustrate stereoisomers. Because t11ere is no freedom to rotate around a C= C
bond, molecules containing such bonds frequently exhibit stereoisomcrism. For ex-
ample, hydrogens or ' 'arious chemical compounds can be located on the same side of
the bond (cis configuration) or on opposite sides of the double bond ( trans configu - cis configuration A form seen in compounds
ration). with double bonds, such as fatty acids, in
Consider oleic acid and irs isomer elaidic acid (Figure A-6fl'.). Okie acid is a cis iso- which the hydrogens on both ends of the
mer, or the form found naturally in food. With food -processing teclmology, such as double bond lie on the some side of the plane
hydrogenation, some cis bonds of faery acids arc convened to tram bonds. When veg- of that bond.
etable oils are converted to vegetable fats, such as in margarine or shortening, some of trans configuration Compound in which the
the tra11s isomers arc formed. The trnns isomer elaidic acid is not ilie natural form. hydrogens lie opposite each other across a
Isomers of these types (i.e., cis and trnm) arc called geometric isomers. corbon<orbon double bond.
Describing each stereoisomerism depends on which way the functional groups are
arranged ,,;ili respect co each other. If there are rwo isomers, D stands for dextro or
right-handed, and L stands for lc\'O or left-handed, such as alanine in D alanine and
L-alaninc (Figure A-6b). Stereoisorners that can't be superimposed on t11eir mirror im
ages arc called optical isomers. Optical isomers can be identified from each other by
their reaction to polarized light. One solution of an isomer iliat rotates the plane of
polari:ted light ro t11e right is dextrorotary. And the solucion of its optical isomer ro-
rates the plane of light to the left and, so, is levorotary.
The difference between cwo stereoisomers is "fit." This diftcrcnce is important be- enerous intakes of /rans isomers of fatty
cause t11e molecule has to fit an enzyme in order to make the chemical reaction pro- acids ore associated with on increased
ceed. For exan1plc, human enzymes use only L-amino acids (bu iJding blocks of risk of cardiovascular disease (see Chapter 6).
protein ) and D -sugars to build compounds. D-amino acids and L-sugars jusr won't
function as such in the bod)'. It is rather like tqring to wear the lefi:-hand glove on the
right hand and do anything that requires manual skil l.
A carbon atom with four different atoms or groups of atoms attached is described
as being chiral (also called asymmetric). A molecule with one chiral carbon can have
cwo stcrcoisomers, such as alanine (sec Figure A-6b). When two or more (n) chiral car-
bons arc present, rhere can be 2° stereoisomers. Some stercoisomcrs arc mirror images
of each other, while others are not.
OH chfral OH ach iral
!~carbon l~carbon
CH3-CH 2-C-CH 3 CH 3-y--CH 3
I
H H
(a ) Oleic acid Elaidic a cid (b) H, 0

o II
'-c H
I /
"" H-C-N-H
I
c
~ H/J'-H
H
~
D-olonine 0 / H
II /o
H C
~ oz.• ' I
Cis form H-N-C-H
(backbone of Ill I
molecule is c
bent) ~ ~. H/l'-H
H
L-olonine
oz.
~ ~
•
f
Figure A-6 I (o) Cis and Irons isomers of folly acids. Cis forms ore the most common forms in
unprocessed foods. (b) Optical isomers of alanine-on amino acid. The L isomer is the most commonly
found amino acid in nature.
In living organisms, many molecules are chiral.

When compounds have more than one chiral center, the "RS" system of naming is
used, rather than the D and L system. Every chiral carbon is designated either R or S,
based on specific rules.
This RS terminology is important to understanding 'itamin E chemistry. It is no"
known that vitamin E as alpha-rocopherol has three chiral centers, and so has eight dif.
forcnt stcreoisomers (2 3 = 8). All three arc found in synthetic preparations. The three
chiral centers are identified as 2, 4, and 8 as related to the position on the tail of the
molecule (see Chapter 9). The RRR isomer (i.e., R form at all of the 3 chiral ccmers
on the phytal tail) is the natural form. A transfer protein in the liver only recognize~
the R form of the chiral center ar the 2 position. Of all the eight combinations of R
and S in the phytaJ tail of synthetic vitamin E, the only biologically active ones are
RRR, RSR, RSS, RR.S, because they all have the R form in the 2 posilion.
Biochemistry
The study of the chemistry or molecular basis of life and the reactions, scrucmrcs, ;me
composition of living materials is known as biochemistry. Biochemical reactions arc
possible because of enzymes. Living organisms convert the energy they extract from
food into energy for growth, maintenance, and reproduction. Energy can be stored fo1
future use. The energ} in the food is converted and used in the form of chemical en
www.mhhe.com/wardlawpers7 A-19
HO
RRR isomer
SRR isomer
Isomers of Vitamin E
RRR and SRR isomers of vitamin E. Of the two, only the RRR
isomer contributes lo vitamin E needs.
crgy contained in adcnosine triphosphate (ATP). The fact that living organisms can
self-replicate depends on deo~·yribonucleic acid (DNA) a.nd the genetic code. All forms
of life store and transmit genetic information in the form of DNA.
Approximately 98.5% of the body's weight is composed of the clements o:qgcn,
carbon, hydrogen, nitrogen, calcium, and phosphorus. Elements such as iron, zinc,
and copper are present in trace amounts in the body, but that doesn't mean they arc
unimportant. For instance, iron combines with a blood protein to form hemoglobin,
an oxygen carrier. Hemoglobin transports oxygen from the lungs to the tissues and as-
sists in returning carbon dioxide from the tissues to the lungs for removal.
\\Tater is the most abundant chemical in the body, making up to about 70% of
human tissue. Other important classes of compounds in rhe body are the proteins, car-
bohydrates, lipids, and nucleic acids.
Biochemical Reactions
AlJ the biochemical reactions that occur in the body arc described as metabolism. The
intermediate compounds in metabolism arc termed metabolites. Metabolic reactions
that build (synthesize ) complex molecules arc described a~ anabolic. An example is die
synthesis of protein from amino acids. The reactions that break down (degrade) larger
molecules into smaller ones arc described as catabolic. An example is search breaking
down to glucose molecules.
Carbohydrates i- and po/ysocchorides ore assembled by

a condensation reaction. Waler is a by-
Carbohydrates arc aldehydes with hydroxyl groups and ketones, containing carbon, product of the reaction. In contrast, hydrolysis,
hydrogen, and oxygen with the general formula CH2 0. (There are twice as many hy- or the splitting by the addition of water, digests
drogen aroms as carbon and ox.·ygen atoms.) The suffix -osc indicate!> a sugar. Hcxose di- and polysaccharides to smaller sugar units
refers to a 6-carbon monosaccharidc. Thl.!re are three structural isomers of hcxose: (for details, see the later section entitled
galacmse, glucose, and fructose. All have che same formula, C6TI 120 6 , but die Important Chemical Reactions Related to the
arrangement of their individual atoms differs slightly. Study of Nutrition).
The simplcsr carbohydrates are monosaccharides. vVhcn two monosaccluridcs arc

chemically bonded, they form a disaccharide, o r double sugar. T he table sugar sucrose
is an example or .l disaccharide, formed from glucose and fructose.
Polysaccharides are many monosaccharides joined by covalent bonds. Plant starch
and cellulose are examples of polysaccharides. Some starches ha\'c thousands of glucose
subunits. In animals, carbohydrate is stored as an animal starch called glycogen, found
in liver and muscle tissue.
Lipids
Lipids arc a class of nonpolar compounds that arc grouped according LO solubility in
organic solvents. They don't readily dissolve in \\'acer because most are non polar or hy-
drophobic.
Simple lipids include futty acids and steroids. The lipid cholesterol sen es as the pre-
cursor (parent) for tht: steroid hormones, such as testoslerone, estrogen, and proges-
terone. Complex lipids include triglycerides (often rderred to as triacy/g~'VCt:l'Ols), which
are esters of glycerol and faery acids. Phospholipids are composed of glycerol, phos-
phoric acid, and long-chain fatty acids; sphingolipids arc composed of sphingosinc,
phosphoric acid, long-chain fart~ acids, and choline; and glycosphingolipids arc com-
posed of sphingosine, fatty acids, and carbohydrates.
rostaglandins are a special type of fatty Triglycerides represent fuel found in food and stored in adipose tissues.
acid produced by almost all organs in the Phospholipids arc part polar and part nonpolar, which allows them to interact wirh
body and have specific regulatory functions. water and function as emulsifiers. Sphingophospholipids make up the material sur
They ore all derived from certain dietary (essen· rounding nerves. Glycosphingolipids arc stmccural material for brain and ner\'e tissue.
tial) fatty acids (see Chapter 6 and Appendix B). These complex lipids can be hydroly7ed to yield furry acids.
Proteins
Proteins arc polrmers of amino acids. Twenty common amino acids arc incoq)orated into
the great variety of body proteins. Although the amino acids contain an amine (amino)
0
II
group (NH 2 ) and a carboxylic acid group (-C-OH ), each has a distincti\e structure
(Figure A-7). Proleins typically conrain many atoms, such as carbon, nirrogen, sulfur,
hydrogen, ,rnd oxygen.
The generic information found in DNA iJ1 the nucleus of the cell is the code book
for constructing a protein. The sequence of ami no acids in a protein fo llows the DNA
code for synrhesi.ling the protein. This protein can be made over and over again be-
cause of the code carried in the person's genes.
Nucleic Acids (DNA and RNA}

Nucleic acids indude DNA (deoxyribonucleic acid), RNA (ribonucleic .lCid), and the
subunits from which they arc fo rmed, caJled nucleotides. The nucleotide is nude of
three components: a 5-carbon pcntose sugar, a phosphate group, and a nitrogenous
base (Figure A-8). There are two kinds of nitrogenous base: puriaes (double ring) and
pyrimidines (single ring).
The sugar contained in Ri"IA is ribose. The pyrimidine bases in ribonucleic acids an:
uracil and cytosine, and the purine bases are guanine and adenine. RNA is a single
polynuclcoride str:1J1d, not a double strand like DNA.
DNA fo und in the nucleus of t he cell is the basis of the genetic code. The sugar in
DNA dcoxyribosc can be covalently bonded ro the purine bases adenine and guanine
and to tht: pyrimidine bases cytostne and thymine (figure A-9). These four types of
nucleotides can produce the long chain that makes up a single strand of D~A. The
DNA is a two stranded sugar phosphate chain rhat twists around in such a \\ .1y to form
a helix. The bases project into the center of the helix, forming a staircase strucwrc. The
two strands .ll'e held togerhc:r by hydrogen bonds (figure A- 10).
H NH2 NH2
"c=C-CH -CH <o
I I 2 II
~CH2-CH<~
H-N N C-OH ~-) C-OH
'er N
I H
H
Histidine (His) Tryptophan (Trp) Glycine (Gly)
(essentiaJ) (essential)
NH,, CH3 NH2

~ ~
2
CH3-S-CH2-CH2-CH< -
C-OII CHa
) ctt -CH2-CH <
C -OII
CH -CH<r
3
C-OH
Methionine (Met) Leucine (Leu) Alanine (Ala)
(essential) (essential)
Arginine (Arg) Lysine (Lys) Proline (Pro)

(essential) (essential)
0 0 NH2
II
HO-C-CH2 -CH2-CH
<NH2
~
II
HO- C- CH2 -CH
< NH2
0
II
HO -CH2-CH < ~
C-OH c-on
C-OH
Glutamic Acid (Glu) Aspartic Acid (Asp) Serine (Ser)
<~H2
O CH -CH<~
2 NH2
2 II
C- OH
PhenyJaJanine (Phe)
Cll:1-CH2>
CHa
CII
_
CH
Isolcucine (Ile)
(essential)
C-OH
II HOO-' CH 2 - CH
-
Tyrosine (Tyr)
< ~
C-OH
(essential)
0
II
H,N-C-CH,-CH
<NH2 0
Clla>
CH-CH
<~12
II
- • II
C-OH HO C-OH
Glutamine (Gin) Asparaginc (Asn) Threonine (Thr)
CII:i
CII3
> < CH -CIT
NII2
O
II
c -on
llS-CII2 -CII <
NII.,
~
C-OH
-
(essential)
Valine (Val) Cysteinc (Cys)

(essential)
Figure A·7 I The 20 common amino acids in foods.
(a) DNA always contains an equal number of purine and pyrimidine bases. And there
Phosphate is a relationship called complementary base pairing-adenine pairs only with thymine,
·~J--o~"
and guanine pairs only with cytosine. (ln RNA adenine pairs with uracil.)
Although there are only four bases, the number of sequences of bases is endless. The
total human genome consists of billions of base pairs making up about 35,000 genes.
The applications of this knowledge can lead to genetic screening for breast cancer and,
in the furure, are likely to help produce drugs ro rreat obesity and inborn errors of
metabolism.
Five-carbon During replication, the helix uncoils and separan.:s, so that each chain or strand
sugar
serves as a template for the synthesis of its complementary chain. This step is impor-
I
Nucleotide
tant for cell di\'ision. Each daughter cell recei\'eS DNA containing one strand of the
original molecule and one new strand.
(b) RNA, another nucleic acid, takes its instructions from DNA. There an: three rypes
Bases of Ri~A: ribosomal RNA, transfer RNA, and messenger RNA. RibosomaJ RNA forms
part of the structure of ribosomes in the cell; chis is where proteins arc synthesized.
Guanine
Messenger RNA contains the code for the synthesis of a specific protein transcribed
from DNA. Transfer RNA decodes the genetic message in Ri~A and assembles Lhe
amino acid!> for the protein .mcmbly line (sec Chapter 7 for details). The process is
Thymine called trans la ti on.
Cytosine
y-e0
Adenine
k Phosphate ,H
Figure A·8 I (a} The general structure of a ~ H, ~ N, ,fo----- --- -H - N\- c/H
nucleotide. (b} A polymer of nucleotides, or CH, C C- C // ~ /
J;;y
polynucleotide, is formed by sugar-phosphate
bonds between nucleotides.
~_;' N - H---------N"\ C-C
H /O
N=C C-N---....:
0 I N- H- --- -----0 0
H,C~
Deoxyrobose
H
Guanine
Thymine
Figure A · 9 I The four nitrogenous boses in deoxyribonucleic acid {DNA). Notice that
hydrogen bonds can form belween guanine and cytosine and belween thymine and
adenine.
Plgure A-1 0 I The double-helix structure of

DNA. The two strands ore held together by
hydrogen bonds between complementary
bases in eoch strand.
S-deoxyribose sugar
P-phosphate group
Important Chemical Reactions Related to the Study

of Nutrition
One of the most important properties of chemical compounds is the type of reactions
they undergo. Chemical reactions are responsible for vision, thinking, movement, and
everything dse that occurs in the human body.
In a chemical reaction, a compound or set of compounds (the reactants) is con -
verted into another compound or set of compounds (the products), accompanied by
the absorption or release of energy, which is typically heat in biological processes. In
effect, the reactants reshuftle their aroms to form products. Clearlr, then, no atoms
lose their identity during a chemical reaction, and no acorns are gained, lost, or con-
verted to another kind of atom during the course of chemical activity.
Chemists have grouped reactions according to their similarities in chemic.11 behav-
ior. Some of these reactions arc performed over and O\'er within each cell. Following
is a brief overview of some important reaction types.
Condensation Reactions
A condensation reaction occurs when two molecules join together to form a larger
molecule and water is released. The two-reactant molecules typically contain hydroxyl
groups, meaning that there are rwo OH groups. A simple example is the condensation
of glucose and gaJacrosc ro make lactose and water.
C 6H 110 6 + C 6H 120 6 ~ C 12H 220 11 + H 20
G lucose Ga lactose Lactose Water

One -OH group on the single sugar gains a proton and forms a water molecule .
The OH group on Lhc other single sugar loses a proton and forms a bond with the
other molecule- in exactly the same place that die water molecule leave~. Nore that
this is an overall description of what happens, not how it happens. In addition, keep in
mind that although ic is typical for bath molecules to contain an -OH group in a con-
densation reaction, it is not a requirement for the reaction. A condensation reaction
can occur where only one of the reactants contains an -0 H group.
Hydrolysis Reactions
any important compounds in cells ore
formed through condensation reactions, Hydrolysis reactions arc reactions that occtrr when water is added ro a compound. In
and the breakdown of many compounds into biological system~. hydrolysis reactions are very frequently the reverse of condensation
smaller fragments occurs via hydrolysis reactions. That is, \\'ater is added to a large molecule, which results in the formation of
reactions. two smaller molecules. This can be illustrated by the hydrolysis of lactose .
C 12H 220 u + H 20 -7 C6H 120 6 + C6 H 120 6
Lactose Water G lucose Galactose
n organic chemistry oxidation is the loss of

hydrogen (or gain of oxygen).
Oxidation and Reduction Reactions
n organic chemistry reduction is the gain of Oxidation-reduction (redox) reactions arc important in nutrition science bcc.1use they
hydrogen (or loss of oxygen). release energy from food during oxidation and synthesize carbohydrates, farry acids,
and other organic compounds during reduction. Redox reactions follow th ree rules:
l. No oxidarion reaction takes place without something being reduced ar che same
time, and no reduction takes place without something being oxidized.
2. Oxidation is the loss of electrons.
3. Reduction is the gain in electrons.
catalyst A compound that speeds reaction
roles but is not altered by the reaction.
A simple rec.fox reaction involving iron is as follows:
Fe3 • + c- ~ Fe 2 +
Energy of A biochemical redox reaction invol\'ing die coenzyme tonn of riboflavin occu~ as follows:
activation
+2H
~
• FAD~ FADH2
~
-2H
Chapters 4, l 0, and 12 prO\·ide more information about coenzymcs, cofactors, and
oxidation-reduction reactions.
Products Energy and Enzymatic Reactions

Enzymes are large proteins with varying amino acid composition that behave as or-
Course of the reaction in lime ganic catalysts. They are highly specific. Enzymes help a reaction to proceed by low-
Figure A · 1 1 I Enzymes and other catalysts ering the "enerro of acti\'ation" ~o that the reaction can go faster (Figure A-11 ).
accelerate chemical reactions by reducing the Enzymes lower chis energy barrier between the reactancs and the products. Some of
energy barrier lo the reactions. Reactant the enzyme reactions thar occur in the cell require cocnL.ymes (vitamins) at the acti,·c
molecules free in solution con react only if they sire to make the reaction go, whi:reas many others don't. Fortunately, an enzyme isn 'r
meet in just the right orientation and with consumed by rhe reaction, so it can be used over and over.
enough energy. An enzyme holds its substrate
molecules in the right orientation lo react and
exerts farces on them that cause chemical Common Chemical Structures
bonds to break and form. In this way, on
enzyme lowers the energy barrier that Most compounds in the body are composed of carbon, hydrogen, and oxygen, \\'ith car-
substrates must poss and, so, increases their bon often being the predominant atom. Some commonly encountered combinations of
reaction rates. atoms, called functional groups, have been given specific names because they .1ppear in
many molecules. You need to be fumiliar with them, for they arc the most important
foati.ires in many of our nutrients. The importanr ones were listed in Table A-5. You will
be using these names and sntdying these structures throughout rhis course.
The Drawing of Chemical Structures

Chemists have developed a shorthand notation for \\'riting chemical formulas, called
skeletal structures. l n skeletal structures, neither carbon aLOms nor the hydrogens
bonded to the carbon atoms are expressly shown. What arc shown are the bonds be-
tween the carbon atoms and the position of all atoms otht:r rhan carbon and hydro-
gen. Keep in mind that there are carbon atoms at the apices of e,·ery angle in the
structure (with the appropriate nwnber of hydrogens attached to the carbon ) and at
Lhc terminal end of the sticks. By way of illustration, look at ,, skeletal strucnire of
propane (CH 3 CH2 CH3 ).
The ad\'antagc of using skeletal structures is that it allows for a clear representation
of complex molecules without cluttering up the picture. This notation wi ll be used
lhroughour the text. It is handy when large strucrmes, such as fatty acids, have to be
represcnred.
CH2
I \
CH3 CH 3 ~
Propane Skeletal structure
of propane
'•
a en~ IX
DETAILED DEPICTIONS OF GLYCOLYSIS, CITRIC ACID
CYCLE, ELECTRON TRANSPORT CHAIN, CLASSES OF
EICOSANOIDS, AND HOMOCYSTEINE METABOLISM
The following illu5trations are provided to help you better visualize the changes in
chemical strucrun:s throughout the metabolic processes described. These figure~ re
fleet greater scientific detail than the more simplified versions in Chapter 4, Chapter 6,
and Chapter 10.
A-26
~!© ©J~i
Addition of phosphol'\Js
to glucose by ATP
odivotes the 6-corbon
glucose molecule. The
loter metobolism of
fructose 6-phosphote to
fructose 1-6 Q"= 6- ho• hom HO :H : OH ®
bisphosphate uses
another ATP.
CV c H2 - o -® H OH
- Fl'\J
_d._o_se-6-p
- ho-s-ph-ot--.
e ~HPH
@ H OH
p
OH H CH 2 - 0 - ®
CH2- 0 -® Fructose 1,6-bisphosphote ~
0 ®
I CH2 - 0- P
C= O _ _ _ _ _ _ __, @ 0 ~---------,
I
CHPH H H ~ OH The 6-corbon molecule,
: ~dose 1,6-bisphosphote,
Dihydroxyocelone phosphate 1 4 - - - -1 Glyceroldehyde 3- phosphote OH H is split into two 3-corbon
molecules: one is
H- C = O glyceroldehyde
I 3-phosphote, and the
H-C = OH other is eventually
(2)NAD I
® CH2-0-® converted into that
product as well.
(2) NAOH + H+ . - - - - @ 0
II
C - O f"\.. ®
I(2) 1,3-Bisphosphoglycerotel I
H- C - OH
Metabolism of each 1,3-
bisphosphoglycerate to 3-
I phosphoglycerate results
CH2-0 - ®
in the synthesis of ATP.
The conversion of each
pyruvote to lactate 0
allows a cell to recycle II
NADH + W bock to (2) 3-Phosphoglycerate C - OH
I
NAO This then allows H- C - OH
glycolysis to continue,
as NAO is needed.
® I
CH2-0-®
This latter pathway
occurs primarily in only 0
a few types of cells, (2) 2-Phosphoglycerate II
such as red blood cells, C-OH
I
and under anaerobic H- C - 0-®
conditions. Most I
NAOH + H+ is recycled CH20H
bock to NAO in the (2) Phosphoenolpyruvate Metabolism of each
mitochondria (using the phosphoenolpyruvate lo
electron transport 0 pyruvate results in the
chain) II
C-OH synthesis of another ATP.
I
C-Of"\.. ®
I
CH 2
0 Pyruvate can undergo

....__ ____.. - - - - - - - - -QD
1 2 1 Pyruvote II
C - OH further metabolism lo
0 I enter the citric acid cycle,
II C= O which occurs in the
C - OH I mitochondria.
I CH 3
OH- C - H
I
CH3
Figure 8 - \ l Detailed depiction of the individual chemical reactions lhol comprise glycolysis~lucose lo pyruvole. Glycolysis takes place in the cytosol of
the cell. The enzymes in the cytosol that participate at the following steps ore (l) hexokinase, (2) phosphohexose isamerase, (3) phosphofructokinose,
(4) aldolase, (5) phosphotriose isomerase, (6) glyceraldehyde-3-phosphate dehydrogenase, (7) phasphoglycerate kinase, (8) phosphoglycerote mulase,
(9) enalase, and (10) pyruvale kinase. Sometimes (11) lactate dehydrogenase is used to recycle NADH + W bock to NAD (anaerobic glycolysis). P1
represents a phosphate group.
A-27
A·28 Appendix B Detailed Depictions
0 0
CH3- C- C=OH Transition
IPyruvate Reaction
Pyruvole is first metabo·
lized lo ocetyl·CoA It is
NAD ocetyl·CoA thot actually
enters the citric acid cycle.
CoA In the process, NADH +
H+ is produced and C02
is lost.
The metobolism of molote
':R
lo oxoloocelote produces 0
II
NADH + H+, ond the CH3 - C 'V CaA
cycle returns to its starting
point, oxoloocelote.
9 ~ l Acetyl·CoA I
C- C-OH Twocarbonsfromacetyl-
1 0 CoA CoA combine with the 4·
CH 2- C-OH o carbon oxaloocetate lo
CH2- C- OH form the 6·carbon citrate.
9 NADH + H+
OH- CH- C-OH
I 9
NAD I.O xaloaceta te .j H20 I 0
HO- CH-C- OH
I 0
In the process o CoA
molecule is lost This is the
first step in the citric ocid
CHi- C- OH
/ IMala!. I ® (i)
CH 2- C-OH
I c._ I )\_o_______,
cycle.
/ " HO
2
~ HO
2
11
~ 2 - ~00
0 @ I 0
H- C-<'.- OH CH- C:- OH
o II II Q
HO - <'.-C- H CH- C- OH
Fumarate Cis·aconitate
The metabolism of Citric

succinote to fumarole
produces FADH 2 . Acid
Cycle
0
II
CHcC- OH
I 0
CH-C-OH
I 0
HO- CH- C-OH
lsocitrate
Metabolism of
succinyl-CoA lo
succinale produces
GTP. (This con then
be converted lo ATP.)
A CoA molecule is
lost. NADH + H+ Metabolism of isocitrate to
0 alpha·ketoglutorate
II produces NADH + H+
CH2- C- OH with the release of C02 .
I
CH20
I "
O= C-C-OH
Metabolism of alpha·
ketoglutorate to succinyl· _,... KetogIutarate
C02 ["'
CoA produces a second
NAOH + H+, with release
of a second C02 .
Figure B·2 I Detailed depiction of conversion of pyruvate to acetyl-CoA in the transition reaction and the individua l chemical reactions of the citric acid
cycle. Conversion of pyruvote to ocetyl-CoA uses on enzyme complex that includes pyruvote dehydrogenose. The enzymes used in the citric acid cycle at the
following steps ore 11 J citrate synthase, (2) aconitose, (3) oconitose, (4) isocitrote dehydrogenose, (5) alpha-ketoglutarote dehydrogenase, (6) succinate
thiokinose, (7) succinote dehydrogenase, (8) fumarose, and (9) malote dehydrogenose. CoA stands for coenzyme A, which is made from the vitamin
pantothenic acid (see Chapter 10 for the chemical structure). Note that the C02 molecules lost during one turn of the citric acid cycle are not those from the
carbons donated by acetyl-CoA Instead, the carbons ore broken off the portion of the citrate molecule derived from oxa loacetate.
www.mhhe.com/ wardlawpers7 A·29
Carrier
molecule ~ ·' -.
Outer
compartment ~ (i)ATP -< ATP '7
--r . ..J..
+ADP
NAO+
1. NADH or FADH 2 2. As the electrons are separated 3. The hydrogen ions diffuse back into 4. ATP is transported out of the
transfer their a
by coenzyme (CoQ) and move the inner compartment through special Inner compartment by a
electrons to the through the electron transport channels (ATP synthase) that couple carrier molecule that
electron transport chain, some of their energy is the hydrogen ion movement with the exchanges ATP for ADP. A
chain. used to pump hydrogen ions into production of ATP. The electrons, different carrier molecule
the outer compartment. hydrogen ions, and oxygen combine to moves phosphate into the
form water inner compartment.
Figure B-3 I Detailed depiction of the electron-transport chain. NADH + H and FADH 2 transfer their hydrogen ions and electrons to electron carriers
located on the inner mitochondrial membrane. The electrons and hydrogen ions combine w ith oxygen to form water (H,O). The energy yielded by the entire
process is used to generate ATP. Eoch NADH + W in lhe mitochondria releases enough energy to form the equivalent of 2.5 ATP, while each FADH 2 releases
enough energy to form the equivalent of 1.5 ATP.
Group 1 series Group 2 series

0 Group 3 series o
0 II II
~~-
~-OH ~--rn c::::::;::~
Di homo-gamma· Arochidonic acid Eicosapentaenoic acid
linolenic acid (C20:4, w-6) (C20:5, w-3)
Cydoo><ygonoi ~"""'""' Cydooxyg""'f \ l"•Y9""'" Cydooxygooo.; \ "''"'""'

Prostoglondin E1 Leukotriene AJ Thromboxone A2 Leukotriene Ai Thromboxane AJ Leukotriene A s
Prostaglandin F1 Leukotriene C3 Prostaglandin D2 Leukotriene B.i Prostoglandin 0 3 Leukotriene Bs
Thromboxane A i Leukotriene 0 3 Prostoglandin E2 Leukotriene C.i Prostoglondin E3 Leukotriene Cs
Prosloglondin 12 Leukotriene D..s Prostaglandin '3
(Prostocyclin 12) (Prostacyclin '31
Figure B·4 l Examples of eicosanoids from the three major groups. Th e parent fatty acid produces profound difference in how eicosanoids across the three
groups act In the body (e.g., thromboxane A 1 vs. Ai
vs. A 3).
A·30 Appendix B Detailed Depictions
I Dimethyl glycine J
Choline
Methionine ATP
One of two
M ethyl (-CH 3) donors 3 P;
S-adenosyl-
methionine (SAM)
Vitamin B- 12 coenzyme
Serine I (methylcobalamin)
S-adenosyl-
IGlycine I homocysteine
O ne of two Homocysteine
M ethyl ( - CH3 ) donors
Vitamin B-6
(PLP)
®
Vitamin B-6
(PLP)
Alpha -ketobutyrote
+ NH3
ICysteine I
CD With the aid of the vitamin B-12 coenzyme ® With the aid of vitamin B-6 coenzyme PLP, homocysteine
(methylcobolomin), the methyl group (- CH 3 ) is transferred is used to make the nonessentidl amino acid cysteine. The
from the folote coenzyme, methyl THFA, to homocysteine nonessential amino acid serine contributes port of its
to form methionine. Another important function of this carbon skeleton to homocysteine. This is another pathway
reaction is to make the resulting tetrahydrofolate coenzyme that helps control blood homocysteine concentration.
available to participate in DNA synthesis.
@ Either methyl telrahydrofolate or

@ Methionine can be converted to S-adenosyl-methionine
(SAM) with the addition of adenosine from ATP. The three
phosphate groups are removed . CZ:, Betaine is a donor of a methyl group to form methionine.
@ S-adenosyl-methionine is converted to S-adenosyl @ The betaine is derived from choline.

homocysteine by removal of the - CH 3, which is donated
to a variety of methyl group acceptors.
® Note that the serine-glycine reaction is reversible in
conjunction w ith THFA and methylene THFA. Here is
© S-adenosyl homocysteine is converted back to another example of vitamin B-6 in action as PLP.
homocysteine w ith the removal of adenosine.
In summary, the coenzymes of vitamin B- 12, folote, and
Overall, this cycle, especially step (j), helps control the vitamin B-6 , along with choline, work together as a team to
concen tration o f homocysteine in the blood. control the amount of homocysteine in the blood. The vitamin
riboAavin also participates (not shown).
Figure B· 5 I Detailed diagram of folote, vitamin B-12, vitamin B-6, and choline metabolism in relation to homocysteine metabolism. Note tha t step 9 (serine
-7glycine) is the ma jor source of methyl groups for this overall pathway.
•
a en HUMAN PHYSIOLOGY:
IX
A TOOL FOR UNDERSTANDING NUTRITION
This appendix explores the ,·arious systems in the body beyond the digestive system,
focusing specifically on how these systems relate to the study of human nutrition. This
focus will ser the stage for iJwestigacing the \'arious nutrients associated with human
nutrition. Before that process can begin, howe\·er, it is important ro review the
processes raking place in a human cell.
The Cell: Structure and Function

The cell is the basic structural and fonctional unit of life. Li,ing organisms arc made
of many diftercnc kinds of cells specialized to perform particular functions, and all cells
are deri\'ed from preexisting cells. In the human body, the trillions of cells all have cer-
tain basic characteristics that are a.like. All cells have compartments, particles, or fila-
ments that perform specialized functions; these structures are called organelles. There
are at least 15 different organelles, but this section discusses only eight. The numbers
preceding the names of the cell structures correspond to the structures illustrated in
Figure C -1.
1. Cell (Plasma) Membrane

There is an outside and inside to every ceU, as defined by the cell (plasma) membrane .
This membrane holds in the cellular contents and regu lates the direction and Aow of
substances into and our of the cell. Cell-to-cell communication also occurs by way of
this membrane. Some cells can even penetrate another cell membrane and so invade
that cell.
The cell membrane is a lipid bilayer (or double membrane ) of phospholipids with phospholipid Any of a class of fat-related
their'' acer-soluble (polar) heads fucing into the interior of the cell and out co the ex- substances that contain phosphorus, fatty acids,
terior of the cell. The water- in~oluble (nonpolar) tails are tucked into the interior of and a nitrogen-containing base. The
the cell membrane (Chapter 6 review~ phospholipids in derail and Appendix A re\'iews phospholipids ore an essential port of every
the concept of polar and nonpolar compounds). cell.
Cholesterol is a fur-soluble component of the membrane, so it is embedded within
the bilayer. This cholesterol provides rigidity and thus stability to the membrane.
There arc also various proteins embedded in the membrane. Proteins provide struc-
tural support, act as transport vehicles, and function as enzymes that affect chemical
processes within the membrane. Some proteins are open channels that allow water-
soluble substances to pass into and out of the cell. Proteins on the outside surface of
the membrane act as receptors, snagging essential substances the cell nee<ls and draw-
ing them into the cel l. O ther proteins act as gates, openi ng and closing to control the
flow of various particles into and out of the cell .
A-31
A·32 Appendix C Human Physiology: A Tool for Understanding Nutrition
Carbohydrate chains lar cell identity
I
External
Nonpolar region
of phospholipid
Peroxisome
Nuclear
envelope Nucleus Nucleolus
Figure C-1 I An animal cell. Almost all human cells contain these various organelles. Shown in
greater detail ore mitochondria and the cell membrane. Note: Not all cells hove microvilli. The nuclear
envelope encloses the nucleus. The centrioles participate in cell division.
In addition to the lipid and protein, the membrane also contains carbohydrates chat
glycocalyx Projections of proteins on the mark the exterior of the cell, called the glycocalyx. These carbohydrates are combined
microvilli; they contain enzymes to digest either with proteins or fats and provide a dcli\'ery service for sending messages ro rhe
protein and carbohydrate. cell's organelles. The scrucnircs also provide distinct identification for a cell. In addi-
organelles Comportments, particles, or tion, they detecc in\'aders and initiate defensi,•e actions. In sum, these carbohydratel>
filaments that perform specialized functions provide tags that are importam to cellular identity and interaction.
within a cell. Included within the cell membrane arc organ elles. They carry out vital roles in cell
fimctions. Some structures allow the cell to replicate itself, others provide energy, .rnd
others destroy the cell when it is worn out. Still other organelles produce and secrete
products destined for other cells.
www.mhhe.com/ wardlawpers7 A-33
2. Cytoplasm
The cytoplasm is the fluid material and organelles within the cell, not including the cytoplasm The fluid and organelles (except the
nucleus. (The cytosol is lhe fluid surrounding the organelles. ) A small amount of ATP nucleus) in a cell.
energy for use by the cell can be produced by glycolysis reactions char occur in the cy- cytosol The water-based phase of the
toplasm. This contributes co our survi,·aJ, because it is the key process in red blood cclJ cytoplasm; excludes organelles such as
energy metabolism; it is called anaerobic metabolism because it doesn't require oxygen. mitochondria.
mitochondria The main sites of energy

3. Mitochondria production in a cell. They also contain the
pathway for oxidizing fat for fuel, among other
Mitochondria arc sometimes called "'power plants," or the powerhouse of the cell.
metabolic pathways.
These org<tnellcs arc capable of converting the energy in our energy-yielding nutri<.:nts
(carbohydrate, protein, and fat) to a form that cells can use, again ATP. This is an .1cr-
obic process that uses the oxygen we inhale, and water, enzymes, and other com-
pounds (sec Chapter 4 for details). With the exception of red blood cells, all cells
contain mitochondria; only the size, shape, and numbers vary.
Mitochondria have a double membrane and this characteristic is key to overall m i-
cochondrial function. Within the inner membrane, the electron transport chain and
ATP synthesis cake place. In the inner matrix of the micochondria, the citric acid cycle,
B-oxidation of fatry <lcids, and the transition reaction involving pyruvate take place.
The biochemical pathways that operate in the mitochond1ial matrix arc also capable
of synthesizing cell components, such as the carbon skeletons needed to produce carbon skeleton What remains of an amino
amino acids. These will e\cnruaUy become cellular protein. acid after the amino group has been removed.
4. Cell Nucleus
The cell n ucleus is surrounded by its own double membrane. The nucleus controb .lC- cell nucleus An organelle bound by its own
rions that occur in the cell, using the hereditary material known as dcox} ribonucleic double membrane and containing
acid (DNA ). DNA is the "code book" that contains directions for making substances chromosomes, the genetic information for cell
the cell needs. It consists of genes on chro m osom es. This code book rem.tins in the protein synthesis.
nucleus of the cell, but conveys its information to other cell organelles by way of a sim- chromosome A single, large DNA molecule
ilar molecule called ribo nucleic acid (RNA). The RNA has the responsibilit)' of tran- and its associated proteins containing many
scribing the inform,nion of the DNA and moving out through pores in the nuclear genes; stores and transmits genetic information.
membrane to the cytoplasm. The RNA then carries the code co protein-synthesizing
ribonucleic acid (RNA) The single-stranded
sites called ri b osom es. There, the RNA code is translated into a spccilic protein (see
nucleic acid involved in the transcription of
Chapter 7 for details on protein synthesis). With the exception of the red blood cell , genetic information and translation of that
aU cclJs have one or more nuclei. information into protein structure.
The nucleoli arc areas within the nucleus of the cell containjng a combination or
protein and RNA. This is where RNA is produced for export to the cytoplasm. ribosomes Cytoplasmic particles that mediate
DNA has the secondary task of cell replication. DNA is a double-stranded molecule, the linking together of amino acids to form
and when the cell begins to di,idc, each strand is separated and an identical copy or proteins; attached to endoplasmic reticulum as
bound ribosomes, or suspended in cytoplasm
each is made. Thus, each new DNA molecule contains one new strand of DNA and
as free ribosomes.
one strand from the original DNA. ln this way, the genetic code is preser\'cd from one
cell generation to the next. The mitochondria contain their O\\·n DNA, so the} repro- nucleolus Center for production of ribosomes
duce themsch·es independently of the nucleus. within the cell nucleus.
The transport of prote111s, \'itamins, and other material from the C} toplasm to the
nucleus also occurs through pores in the nuclear membrane, as just mentioned . These
small molecules serve a \'ariety of functions, including rhc acrh·acion (or in.KtivaLion )
of certain parts of the DNA.
5. Endoplasmic Reticulum (ER) endoplasmic reticulum (ER) An organelle 1n the

cytoplasm composed of a network of canals
The outer membrane of the cell nucleus is continuous with a network of tubes called running through the cytoplasm. Rough ER
rhc end oplasmic reticulum (ER). The ER is found in two types: rough and smooth. contains ribosomes. Smooth ER contains no
The rough endoplasmic reticulum has 1ibosomcs bound co it, whereas the smooth ribosomes.
docs not. As noted earlier, ribosomes are the sires whe re proteim. arc synthesized.
A-34 Appendix C Human Physiology: A Tool for Understanding Nutrition
Many of these proteins play a central role in human nutricion. The smooth ER is in-
volved in lipid synthesis, detoxification of toxic substances, and calcium storage and re-
lease in the celJ.
6. Golgi Complex
Golgi complex The cell organelle near the The Golgi complex is a packaging site for proteins and lipids that are used in the cy-
nucleus that processes newly synthesized toplasm or exported from the cell. The Golgi complex consists of sacs within the cy-
protein for secretion or distribution lo other toplasm in which products of the rough endoplasmic reticulum are received,
organelles. processed, separated according to function and destinacion, and "packaged" in secre-
secretory vesicles Membrone-bound vesicles tory vesicles for secretion by the cell.
produced by the Golgi apparatus; contain
proteins and other compounds to be secreted
by the cell.
7. Lysosomes
L ysosomes are the cel l's digescive system. T hey are sacs that contain enzymes for the:
lysosome A cell organelle that contains
digestive enzymes for use inside the cell for digestion of foreign material. Sometimes known as "suicide bags," they arc rcsponsi
turnover of cell ports. ble for digesting worn-out or damaged cells. T hey carry our apopt osis, or pro-
grammed ceU death, which occurs naturnlly or is associated with illness or infections.
apoptosis A process that occurs over time in Certain cells that are associated wi th immunity contain many l)rsosomes.
which enzymes in a cell set off a series of
events that disable numerous cell functions, 8. Peroxisomes
eventually leading to cell death. Peroxisomes contain enzymes that detoxify harmful chemicals. H ydrogen peroxid e
(H 2 0 2 ) is formed as a result of such enzyme action. Peroxisomes contain a protecti\'e
peroxisome Cell organelle that uses oxygen to
enzyme called cnmlnse, which prevents excessive accumulation of hydrogen peroxide
remove hydrogens from compounds. This
produces hydrogen peroxide (H 20 2), which in the cell, which would be very damaging. Peroxisomes also play a minor role in me-
breaks down into 0 2 and H20. tabolizing one possible source of energy for cells-alcohol.
hydrogen peroxide Chemically, Hp2. The remainder of this appendix looks ac the body systems. Keep in mind that these
systems depend on the cell functions just discussed.
lntegumentary System
integumentary Hoving to do with the skin, T he first system to examine is the one you arc most familiar \Vith, the integumentar y
hair, glands, and nails; the largest organ in the system, which is made up of dissimilar clements, such as the skin, hair, various glandi.,
body. and nails. T he largest organ in the body, the ski n, consists of two principal layers, the
epidermis The outermost layer of the skin, epid er mis and the d ermis (figure C-2 ). The epidermis is the layer of skin composed
composed of epithelial layers. largely of dead cells, which arc used for protection from environmental pathogens, tox -
ins, injury, and water. 'vVe don't want to absorb water through the skin, nor do we want
dermis The second, or deep, layer of the skin, water to readily escape the bod)'·
under the epidermis. The dermis is a deeper and thicker layer of skin, with an extensive network of blood
decubitus ulcers Chronic ulcers (also coiled vessels, sweat glands, oil-secreting glands, ner\'C endings, and hair follicles. When peo-
bedsores) that appear in pressure areas of the ple are confined to bed for long periods or time, decubitus ulcers, also called bed-
skin over o body prominence. These sores sores, may develop because of restricted blood flow co the dermis. This lack of blood
develop when people ore confined lo bed or causes cells to die and open wounds co develop-a potentially life-threatening situa-
immobilized. tion. Adequate intakes of protein, \itamin A, vitamin C, and zinc intake may hclp pre
\ent this problem.
The appearance of the skin, hair, and n.lils is clinically important because it can in -
dicate nutritional deficiencies. For instance, hot, dry skin is an obvious sign of dch> -
dration due to inadequate "ater intake. (Other signs and symptoms of nutrient
deficiencies, as manifested by rhe skin, arc described in Chapters 5, 6, 7, 9 , 10, 11, and
12 as the functions of individual nurrients arc explained.)
The skin plays a vital role in temperature regulation. Heat produced by the body's
metabolic processes, especially the processes that occur in muscle, must be removed be-
fore cells are damaged. Heat is removed from the body through the skin. And when we
are cold, we warm ourselves by shiveri ng, because muscle contractions generate hc:n.
www.mhhe.com/wardlawpe rs7 A-35
Figure C·2 I Cross-section of the skin. This is

the major organ of the integumentary system.
Pore
~"'~ ..IJ~\~7- Basement

membrane
~~=-l;.!.--l-\.1--- Sebaceous
gland
...,~F-=:....,.--=-tJ~-+--11-- Arrector plli

muscle
4--1~:........::1,....;.-E---=--....u.-"--- Hair root
(keratinized
Dermis cells)
~4-'.,_,.:..:_;,.;---r;;..;......,.:I:-- Hair follicle
Eccrine
sweat gland
:;;.r..~t-;----'~'--==---'--- Region of
cell division
~::!:!:=:::::::::::::i;;~-- Dermal
blood
vessels
An impo rtant nutrie nt, vitamin D, can be obtained from our diet, but the skin can
also make it fro m a cho lesterol derivative located in the skin. There is mo re detail about
this process in C hapter 9.
T he swear glands produce perspiration , or sweat, which helps evaporate flu ids to
cool the body and excrete certain wastes. Mammary glands within the breasts arc mod-
ified swear glands designed to secre te milk to feed a newborn.
Skeletal System
Approxi mately 206 bones make up the skeletal system; this is the rigid framework to
which the soft tissues and organs of the body are attached. Each bone b an organ th~lt
participates in the overall functioning of the skeleton. Bones that make up the skull and
\'Crtebral column protect the brain and spinal cord from injury. Likewise, the rib cage hematopoiesis The producfon of blood cells.
protects the heart, lungs, liver, and spleen from external damage. Bones have attach- cortical bone Dense, compact bone that
ment sires for skeletal muscles, ligaments, and tendons. (Bones attached to muscles constitutes the outer surface and shatts of bone;
allow body mo"ement when muscles contract.) Blood cell formation, known as olso colled compocl bone. Cortical bone makes
bematopoiesis, takes place within the marrow of some bones. Bones also arc a store- up 75 to 80% of total bone moss.
house for minerals such as calcium, phosphorus, magnesiu m, sodium, and fluoride. trabecular bone The spongy, inner motrix of
Rather than being considered dried, dead tissues, bo nes arc metabolically active and bone found primarily in the spine, pelvis, and
constantly adapting to a changing environment. ends of bones; also coiled concellous bone.
Long bones, such as those found in tl1c arms and legs, consist o f rwo types of body Trobecular bone makes up 20 to 25% of total
tissue: cor tical and trabccular (Figure C-3). Cortical bone is hard and dense. It forms bone moss.
a pro tective shell on the exterior of the bone. Trabccular bone is fo und within the
Figure C· 3 l Diagram of o long bone. The

epiphysis, consisting of trabeculor bone, is
surrounded by o layer of cortical bone. The
epiphyseol line indicates that the bone hos
completed growth. The production of blood
cells occurs in the porous chambers of Trabecutar bone
trobeculor bone. The collagen material, the Cortical bone - - - -
structural material of bone, is observed by the
open Aop. The skeletal system provides o
reserve of calcium and phosphorus for day-to-
day needs when dietary intake is inadequate.
epiphysis The end of o long bone. The

epiphyseol plate-sometimes referred to os the cortical bone at the ends of long bones and in the vertebrae. The sha~ of the long
growth plate-is mode of cartilage and allows bones is a cylinder of cortical bone surrounding a central cavity containing the marrow
growth of the bone to occur. During childhood, (review Chapter 11 ).
the cartilage cells multiply and absorb calcium At the end of the long bone is the epipbysis, consisting of trabecular bone coven:d
to develop into bone.
by cortical bone. The epiphysis is strong and allows for the attachment of tendons and
epiphyseal plate A cartilage-like layer in the ligaments. Red bone marrow is made of rrabccular bone and is the source of red blood
long bone. It functions in linear growth. cells as well as white blood cells and platelets. In children, just behind the epiphysis is
the epiphyseal plate. This area of bone is responsible for linear growth. When linear
epiphyseol line A line that replaces the
growth is complete, an epiphyseal line replaces the plate.
epiphyseol plate when bone growth is
complete.
Bones are constructed from several types of cells under rhe influence of a variety of
growth factors. These factors stimulate the formation of collagen , a type of flexible
collagen The major protein of the material that protein matrix, which forms the basic shape of bone. Minerals-principally, calcium
holds together the various structures of the and phosphorus-are embedded in the matrix, which give the bone sb·ength.
body. H ydroxyapatite, the name of the calcium phosphorus salt deposited in the protein
hydroxyapatite A compound, composed matrix, constinites about 85% of minerals in bone and makes it possible for the bone
primarily of calcium and phosphate, that is to resist compression and bending.
deposited into the bone protein matrix to give Calcification (also called ossification) of bone varies from bone to bone, but most
bone strength and rigidity (Co 10(POJ60H 2). bones manire (arc ossified) by ages 17 to 25. However, some bones, such as the ster-
m11n (breast bone), may not complete growth un til age 30-plus years.
Bone is constantly remodeled throughout life. Formation and resorption of bone remodeling The constant building and
occm because of the continual activity of osteoblasts and osteoclasts. Osteoblasts are breakdown of bone throughout life.
bone-building cells and osteoclasts are bone resorbing cells. In the first 20 or so years
oflife, bone formation is greater than resorption. By age 50 or 60, resorption is greater resorption The loss of a substance by
than deposition and bone diseases are likely to occur. Exercise promotes bone deposi- physiologic or pathologic means.
tion, whereas a lack of exercise results in bone loss. osteoblasts Cells in bone that secrete mineral
Bone deposition (ossification) an d bone resorption (dissolution) also maintain and bone matrix.
homeostasis of calcium and phosphorus in tl:ie blood. T hree hormones control the
osteoclasts Bone cells that arise originally from
process: the vitamin D hormone (l,25(0H)i vitamin D or calcitrio l), calcitoni n, and
a type of white blood cell. Osteoclasls secrete
parathyroid hormone (PTH).
substances that lead to bone erosion. This
Other hormones are involved i11 bone maintenance, such as growtl1 hormone; thy-
erosion can set the stage for subsequent bone
roid hormones; sex hormones, especially estrogen; and adrenocorticoid hormones. In mineralization.
addition, vitamins A, K, and C perform important jobs in bone metabolism. More in-
formation about bones can be found in C hapters 9, 10, 11, md 14, which cover vita-
nuns, minerals, and exercise.
Muscular System
The functions of the muscular system are to provide movement and to generate body
heat. Most of the energy released by a muscle cell during physical exercise is in the
form of heat. Muscle fibers respond when stimulated by motor neurons (nerve cells) . muscle fiber Component cl a muscle cell.
A muscle cell converts the chemical energy in ATP in to tl1e mechanical energy of mus-
neuron The structural and functional unit cl the
cle contraction. nervous system, consisting al cell body,
There are three types of muscle tissue: smooth, cardiac, and skeletal. Smooth mus- dendrites, and axon.
cle fibers have a single nucleus and fimction in involLmtary movements within internal
organs. Cardiac muscle fiber is striated (striped) with a single nucleus. T he stripes in smooth muscle Muscle tissue under involuntary
muscle fibers are caused by tl1c arrangement of alternating dark and light contractile control; found in the GI tract, artery walls,
proteins (myosin and actin). This type of muscle performs tl1e involuntary rhytl:inuc respiratory passages, the urinary tract, and the
reproductive tract.
contractions of the heart. Skeletal muscle, also conrai11ing striated muscle fibers, bas sev-
eral nuclei and is involved in volw1t.'lry movements. Skeletal muscle is attached to bone cardiac muscle Muscle tissue that makes up the
by tendons. (Note that C hapter 14 also discusses some specific muscle fiber types.) walls cl the heart; produces rhythmical
involuntary contractions.
Skeletal Muscle skeletal muscle Muscle tissue responsible for

voluntary body movements.
Skeletal muscle fibers are actually long cells witl1 the same organelles that are found in
other cells. However, unlike most other cells, skeletal muscle cells possess an excellent myosin A thick filament protein that connects
supply of fuel in the form of glycogen, the body's storage form of the sugar glucose. with octin to cause a muscle contraction.
Skeletal muscles contra.er when stimulated by motor neurons. Motor neurons can actin A protein in muscle fiber that, together
stimulate several muscle fibers simultaneously. A single muscle fiber is not a very efficient with myosin, is responsible for contraction.
machine. The activation of numerous muscle fibers by multiple motor nemons results in
increased muscle strength as the number of fibers stimulated by new-ons increases. tendon Dense connective tissue that attaches a
muscle lo a bone.
Muscle Contractio.n
As pre,~iously mentioned, within muscle fibers are tl1e dark and light stripes called stri-
ations. Each muscle cell, when viewed in the electron microscope, contains subunits
called myofibrils. The myofibrils arc the source of the light and dark bands or stripes. myofibrils A bundle ol contractile fibers within
The importance of these sa·uctures is the presence of unique proteins, actin and myosin. a muscle cell.
The fu11ctior1ing structure of the myofibril is tl1e sarcomere, the contracting urtit.
sarcomere A portion al a muscle fiber that is
vVhen a muscle fiber is stimulated by a neuron to contract, one of tl1e first events to considered the functiona l unit of a myofibril.
occur is the release of large amounts of calcium from storage in the smooth endoplas-
mic reticulum (also called sarcoplasmic reticulum). This is the "on" switch. The pres- power stroke Movement of the thick filament
ence of calcium allows the two main proteins, myosin and actin, to get ready to slide alongside the thin filament in a musde cell,
into each other and set the power stroke in motion. Of course, energy is required to causing muscle con traction.
carry out tl1e muscle contraction. Here is where ATP plays the key role (Figmc C-4).
A·38 Appendix C Human Physiology: A Tool For Und erstanding Nutrition
0
1. Activation
An ATP molecule bound to the myosin
head is hydrolyzed to ADP and Pi. which
5. Actin and myosin separate remain bound to the myosin.
Binding of a new ATP molecule
causes myosin to release actin and
r
return to the "cocked" forward position,
ready to repeat the cycle.
2. Cross-bridge formation
Activated myosin is now able
to bind to the active site of an
actin monomer.
4. Second ATP binds

Myosin remains flexed
and bound to the actin until
another ATP molecule binds to it.
• 3. Power stroke
Myosin releases AD P and Pi. The
head flexes and pulls the thin
filament along the thick filament.
Figure C·4 I M uscle contraction. In Step 1, or activation, an ATP is bound to the myosin head
(purple) and is split into ADP and P;. Troponin and tropomyosin are proteins !hat participate in this
process. During Step 2, lhe activated myosin can now bind to the actin (the red beads). In Step 3, the
myosin head releases the ADP and Pi. The head flexes a nd pulls the thin filament along the !hick
filament. This is the power stroke. In Step 4 , the myosin remains bound lo th e aclin until another ATP
binds to the myosin. The new ATP causes the myosin to release the actin, so that it ca n gel ready for
another cycle, Step 5. Actin and myosin separate, which leads to muscle relaxation. The w hile dot in
th is figure is ca lcium, a nutrient required for muscle action.
Another ATP is needed to release the actiJ1 from the myosin. Th.is is the end ofd1e
contraction. As the muscle moves to the "off" position the calcium is transported back
co storage, the muscle fiber relaxes, and it gets ready for another contraction.
T he reason that muscle action occurs at all is due to the essential nutrienr calcium.
When the muscle is relaxed , there is very little calcium in the cytoplasm of the muscle
cell because calcium is in storage. However, when d1e muscle is ready to go co work,
as directed by d1e motor neuron, calcium is moved out of storage, which sets d1e srage
for d1e power sn-oke. And , when die contraction ends, the calcium is released from the
muscle fibers and goes back into storage.
Cardiac and Smooth Muscle

Cardiac muscle and smooth muscle, although similar in many ways to skeletal muscle
in their use of calciwn as an off/on switch, operate under involw1tary control.
In cardiac muscle, the stimulation occurs automatically by a group of muscle cells.
These cells initiate the heartbeat and set the heart rate under control of the brain and
the influence of certain hormones.
Smooth muscles are found in the lungs, blood vessels, GI u·act, and other internal
organs. In the GI tract, c:hey produce important conn·actions in peristalsis (see Chapter 3 unique feature of smooth muscle is its abil·
for details). ity to stretch. By the end of pregnancy, the
smooth muscle in the uterus con be stretched up
to eight times its prepregnont length.
Circulatory System
The circulatory system is made up of two separate systems: the cardiovascular system
and the lymphatic system. The cardiovascular system consists of the heart and blood
vessels. The lymphatic system consists of lymphatic vessels, lymph, and a number of
lymph tissues.
One organ vital to our existence is the heart, a four-ch::imbered pump that keeps
blood continuously circulating around the body. It takes about I minute for blood to
leave the heart, circulate t0 all tissues in the body, and return to c:he heart. When we
are exercising strenuously, the blood can circulate at a rate of six times per minute.
The cells that make up the tissues of the body need a constant supply of water, m.-y-
gen, and nutrienrs. In addition, the body needs ATP energy, which in turn comes from
the breakdown of energy nuu·ients within the cells. The blood carries oxygen from the
lLmgs to all organs in the body. The blood also carries nun·ients from rhe digestive tract
to all tissues and to srorage sires \Vhen mmieots are not needed immediately for en- erythrocyte A mature red blood cell. It has no
ergy, growth, or repair. Waste materials produced by cells must be removed by way of nucleus and a life span of about 120 days;
the skin, lungs, kidneys, and digestive tract. This, too, is a function of the cardiovas- contains hemoglobin, which transports oxygen
cular system. The delivery of hormones ro their target cells, the mai.ntenance of a con- and carbon dioxide.
stant body temperature, and the disu·ibution of white blood cells to protect against leukocyte A white blood cell.
invading pathogens are all performed by the blood and circulatory systems without our
ever being aware of any specific action. The circulatory system has chemical means to plasma The fluid, noncellular portion of the
circulating blood. This includes the blood serum
prevent excessive Joss of blood from damaged vessels. It uses the clotting process (see
plus all blood-clotting factors. In contrast, serum
Chapter 9). is the fluid that results ofter the blood is first
allowed to clot before being centrifuged; this
Blood Constituents does not contain the blood-clotting factors.
serum The portion of the blood Auid remaining
Red blood cells, known as erythrocytes, are carriers of oxygen to all tissues and play a
after (l) the blood is allowed to clot a nd (2) the
role in the return of carbon dioxide to the lungs. The white blood cells, known as red and white blood cells and other solid
leukocytes, function as part of the immune system. They protect the body from in - matter ore removed by centrifugation.
vading pathogens. T he blood is able to clot because of platelets and other clotting fac-
rors. The Liquid part of blood is known as plasm a. In contrast, serum is the fluid that atria The two upper chambers of the heart,
resul ts after the blood is first allowed ro clot before being cenn-ifuged; this will not which receive venous blood.
contain the blood-clotting factors. ventricles The two lower chambers of the
heart, which contain blood to be pumped from
the heart.
Heart Structure
aorta The major blood vessel of the body
The heart has two sides, left and right. The right side is closest to your right arm; like- leaving from the left ventricle.
wise, the left side is closest to your left arm. T he upper part of the heart has left and
right atria, which empty simultaneously into the lower part of the heart, the left and artery A blood vessel that carries blood away
right ventricles. from the heart.
Blood travels in blood vessels from the left side of the heart, through the aorta to capillary A microscopic blood vessel that
major arteries. Arteries become smaller and smaller nntil they are so tiny they are clas- connects on arteriole and a venule; the
sified as arterioles. The blood flows from the arterioles into microscopic, weblike functional unit of the circulatory system.
su·uctures called capillaries. Capillaries are just one cell layer ti-lick and have pores that
A·40 Appendix C Human Physiology: A Tool For Understanding Nutrition
vein A blood vessel that conveys blood to the allow oxygen, water, and other nutrients to leave the blood for smrounding celb and
hear!. thac allow waste and oLher products of cellular metabolism to enter the blood. There
are few cells in the body that aren't dose co a capillary. Larger blood vessels are not
systemic circuit The port of the circulatory porous, so blood cannot escape rhcsc \'esscls. Only in the capillaries can the blood di!.
system concerned with the flow of blood from charge and recm·er substances associated \\ith nearby cells.
the lett ventricle to the body and back to the As the blood exits the capillaries, ir flows into tiny venules, which enlarge and be-
right atrium.
come veins, returning the blood to the right side of the heart. The route from the kti
venule A tiny vessel that carries blood from the side of t he heart to the capillaries and then back to the right side of the hcan is calJcd
capillary too vein. the syst emic circuit of blood (Figures C-5, C-6 and C-7).
D Right side of the heart accepts

oxygen-depleted venous blood
that hos already circulated to
body cells
Lett side of the heart receives
oxygen·rich blood from the
lungs.
Blood is pumped out of right
side of the heart to lungs.
0 Oxygenated blood from the

lek side of the heart is
II Gos exchange tokes place in the destined for body cells.
lungs. Blood picks up oxygen
and releases carbon dioxide. J
Blood reaching the small
intestine supplies oxygen and
nutrients to cell; also picks up
nutrients from digestion of food.
Nutrient-rich venous blood

leaves the small intestine and
travels via a portal vein to liver.
Near the small intestine, lymph

vessels pick up fats. Lymph is
eventually returned to the blood.
When blood reaches the kidney,

waste products, excess nutrients,
and water are removed. The
removed substances are
excreted via urine. Filtered
blood returns bock into
circulation.
Capillaries
Figure C·5 I Blood circulation through the body. This figure shows the paths that blood tokes from the heart to the lungs (Steps 1-3), bock to the heart
(Step 4), and through the rest of the body {Steps 5-9). The red color indicates blood that is richer in oxygen; blue is for blood carrying more carbon dioxide.
Keep in mind that arteries a nd veins go to all parts of the body.
Figure C· 6 I Capillary ond lymph vessels. {a) Exchange of oxygen and nutrienls for carbon dioxide
and waste products occurs between the capillaries and lhe surrounding tissue cells. (b) Lymph vessels
ore also present in capillary beds, such as in lhe small intestine. Lymph vessels in the small intesline are
also called lacteals. Note lhol lhe lymph vessels ore blind-ended.
Lymphatic Figure C-7 1Lymph. As lymph moves lhrough

r~ capillaries the lymphatic system, it encounters lymph
~ nodes, containing immune cells that destroy
invading pathogens. Lymph also carries dietary
fat and fat-soluble nutrients from the digestive
Lymph tract to the blood, utilizing the thoracic duct.
node
Blood
flow
Lymph
node
~~X~C!~~~~l capillary
system1c
network
a.,.;===-"'-- Lymphatic
capillaries
A·41
The flow of blood through the circulatory system is measured by pressure in mil
limeters of mercury. The average arterial (anery) pressure is about 100 mm Hg,
whereas the average venous pressure is only 2 mm Hg. To guarantee return flo" back
to the heart, blood 1s moved thro ugh the veins by the contraction of skeletal muscle'>.
There are also valves in the veins that prevent a back.flow of blood.
Flow of Materials between Capillaries and Cells

As the blood flows from the arterioles into the capiUaries, the h)rdrostatic pressure gen
crated by the force of the heart's contraction causes fluid co flow into spaces around
extracellular Ruid (ECF) Fluid present outside the surrounding cells, called the extracellular fluid (ECF) (Figure C-8 ). Some of this
the cells; it includes introvosculor and interstitial fluid returns to the capillaries and some enters another nearby vessel called a lymphatic
fluids; represents about one-third of all body vessel.
fluid. Oxygen and nutrients leave the capillaries and enter the ECF and arc then de-
lymphatic vessel A vessel that carries lymph. livered to cells by one of the mechanisms mentioned in Chapter 3: passive and fa
ci litated diffusion, active transport, and pinocytosis. Cellular products plus waste
substances arc collected in the ECF and arc either released to t he capillaries that
connecr to the venules or channeled into the lymph vessels. Oxygen travels to the
cell by diffusing from the blood into the extracellu lar fluid and then in Lhrough
the cell membrane. Carbon dioxide exits the cell and goes to the blood in the same
way. This is one of two importam gas exchange activities in the body and is often
referred to as internal respiration.
The right atriwn of the heart receives dark red venous blood from the body, which
is then pumped into the right ventricle. The right ventricle pumps blood through the
puJmonary arteries ro the capillaries in the lungs. The lungs then return the freshh
oxygenated blood to the left atrium of the heart via the pulmonary veins. This route
pulmonary circulation The system of blood is known as pulmonary circuJation.
vessels from the right ventricle of the heart to As the blood moves through the pulmonary capiJlaries, carbon dioxide is re-
the lungs and bock to the lek atrium of the leased for expiration, and the inhaled oxygen is taken up by the blood. This is the
heart. other site for gas exchange in the body, often reforrcd to as external respiration .
The oxygenated blood ( now a bright red) in the atrium is pumped to the left vcn
trick. The blood is pumped out of the left ventricle and through the aorta to the
systemic circuit.
Figure C·8 I Distribution of body fluids. The lntracellular---i ..--------Extracellular- - - -- - - - - - ,

intracellular comportment contains fluid in the 27-30 L I 14-16.5 L
cell, which is free lo move into the extracellular Cell

compartment. The extracellular compartment
contains the fluid between the cell and the
capillary, called the interstitial fluid. The
extracellular fluid also includes the fluid within
blood and lymph vessels. This figure shows the
fluid (plasma) from the blood moving freely Interstitial Blood
between cells and capillaries through the fluid plasma
Cytoplasm volume volume
interstitial fluid.
~(§)!
11-13 L 3.0-3.5 L
Other Circulatory Systems

One specific capillary bed does not send blood back to the heart bur, rather, directs it to-
ward the liver. This is the portal system of the GI tract, composed of veins draining blood portal system A general term that describes
from the capillaries of the intestine and stomach. T hese veins empty into a large portal veins in the GI tract that convey blood from
vein, which acts as a direct pipeline to the liver. (The brain also has a portal system.) capillaries in the intestines and portions of the
T he heart also bas its own circulatory system. Coronary vessels supply blood to stomach to the liver.
meet cardiac needs. These arteries are particul:irly susceptible to damage by deposits of portal vein A large vein that leaves from the
cholesterol and other lipids in the artery wall. Th is accumulation of cholesterol can intestine and stomach and connects to the liver.
lead to coronary heart disease. T here is more about this disease in Chapter 6.
Lymphatic System
The lymphatic system is closely related to the immune system in that both provide us
with ddense against pathogenic invaders. As the lymphatic system col lects Auid from
tissues, it picks up microorganisms as well. The fluid passes through many lymph lymph node A small structure located along
nodes as it makes its way back to the bloodstream. [n the nodes is an abundant col - the course of the lymph vessels.
lection of white blood cells ready to detect pathogens in the lymph fl uid and quick.ly lymphocyte A class of white blood cells
destroy them. T he lymphatic system consists of lymph vessels, lymph fl uid , lymph involved in the immune system, generally
nodes, and lymphatic tissue, with its population of i1m11Lme cells. comprising about 25% of all white blood cells.
The interstitial or exu-acellular fluid (fluid smroLU1ding the cell) contains many com- There ore several types of lymphocytes with
ponents that are too large to pass th rough holes in the capiUa.ries, so tbey are blocked diverse functions, including antibody
from retmning directly to the bloodstream. Therefore, they take an indirect route via production, allergic reactions, graft rejections,
the lymphatic system back tO general circulation (review Figure C-7). tumor control, and regulation of the immune
Lymph also serves as the passageway by which fat-soluble nutrients are absorbed system.
from the GI tract and carried into the bloodstream. Lymph also contains bacteria, lymph The clear, plosmolike fluid that flows
viruses, cellular trash, and cancer cells on their way to invade some distant site. Lymph through lymph vessels.
generates immw1e cells, called lymphocytes, that combat these invaders (see the next
section on the in1mune system). lacteal A small lymphatic duct within a villus
At the terminal end of tbe capillaries, the fl uid released from the capillaries into the of the small intestine.
venu.les is less than the amount of flu id entering the capillaries from the arterioles. The lymph duct A large lymphatic vessel that
missing 15% of fluid represen ts the extracellular flu id that is returned tO the vascular empties lymph into the circulatory system.
system via t he lymphatic system. This fluid is subsequently delivered to the lymphatic
macrophage Any large mononuclear
system by way of specialized capillaries called lymph capillaries. Blood plasma and fluid
phagocytic cell that is found in the tissues and
in the tissues are constantly being interchanged. The fluid, which is now called lymph, is derived from o monocyte in the blood.
enters these porous vessels and consists of exu·acellulru· tluid and proteins too large to Besides functioning os important phagocytes,
squeeze back into the capillaries. macrophages secrete numerous cytokines and
In addition to microorganisms, the lymph contains absorbed dietary fat. The ab- act as antigen-presenting cells.
sorption of fats occurs only in tbe lacteals, which aJ~e lymphatic capillaries of the small
intestine, not tl1e portal vein. From tbe lacteals, lymph is d irected into larger vessels, T lymphocyte A type of white blood cell that
recognizes intracellular antigens (e.g., viral
called lymph ducts, and i5 moved toward the heart by the action of skeletal muscle
antigens in infected cells), fragments of which
contractions and other body movements.
move to the cell surface. T lymphocytes
As the lymph makes its way back to tbe heart, it encounters clusters of lymph nodes originate in the bone marrow but must mature
containing phagocytic cells, lymphocytes, and mobile macrophages, which help de- in the thymus gland.
stroy invading pathogens and fil ter the lymph. T lymphocyt es and B lymphocytes arc
found in these nodes and are major players in immunity (sec the scccion titled Immune Blymphocyte A type of white blood cell that
System). When you are ill and seek medical attention, do you ever wonder why your recognizes antigens (e.g., bacteria} present in
extracellular sites in the body and is
physician checks the lymph glands in your neck for swelling? Swelling means the lymph
responsible for antibody-mediated immunity. B
nodes are in combat against an invading pathogen.
lymphocytes originate and mature in the bone
The spleen, d1ymus gland, and tonsils are considered lymphoid organs. The spken morrow and are released into the blood and
contains phagocytes, which filter out foreign substances and destroy worn-out red lymph.
blood cells. The d1ymus gland is important in immw1ity during childhood. Tonsils
protect against invaders that are inhaled or eaten.
A-44 Appendix C Human Physiology: A Tool fo r Understanding Nutri tion
Eventually, the lymph empties into the thoracic d uct and the Light lymphatic duct,
then into veins that enter the right atrium of the heart, and finally into general cin.:u-
lation ( review Figure C-7). There is further discussion of transport oflipid substances
in the lymph system in Chapter 6.
Immune System
The cells that carry our immune functions are known collectively as the immune sys-
tem. U nlike other systems in the bod)', they do not exist as anatomically connected or-
gans, but rather as separate collections of cells throughout the body. They prO\'ide
ddense against invading pathogens-microorganisms, or substances capable of pro-
ducing disease. They discrimi nate becwccn "self'' and " nonsclf" They are very sensi -
tive indicators of the body's nutritional status. The most numerous of the immLmc
system cells cu·e the letLkocytes.
Our body const:mtly wages war against disease-producing microorganisms such as
bacteria, ,·iruses, fungi , and parasites; or substances capable of producing disease such as
antigen Any foreign substance, generally large toxins from snake venom; or allergens, which trigger allergic reactions via antigen re-
in size, that induces a stole of sensitivity and/or lease; or cancer cells (Figure C-9 ). T he most common invaders arc bacteria, which a.re
resistance to microbes or toxic substances ofter one-cell o rganisms with a cell wall in addition to a plasma membrane, and viru.~es, which
a log period; substance that stimulates o are nucleic acids surrounded by a protein coat. V irnses can't multiply by themselves be-
speci fic aspect of the immune system. cause they lack ribosomes for protein syntl1esis, so they survive by raking over a cdl and
instructing the host to produce the proteins and energy they need for survival.
Leukocytes and Macrophages

Leukocytes, also known as white blood cells, are produced in the bone marrow and
may undergo furrher development in tissues outside the marrow. T hey travd via the
blood and enter into tissues where they function. They are classified by their structure
and the affinity for certain types of dye. For example, the monocyte has a single,
prominent nucleus. Another type of immune cell takes up the red dye eosin and so is
called an eosinophil. There are five general types of leukocytes, which are listed in
Table C-1 along with a brief description of their functions.
Macrophages arc found in almost all tissues of the body. They are derived from one
kind of leukocyte, the monocyte. When a monocyte leaves tl1e blood and enters into a
Table C· 1 I Types and Functions of Leukocytes

Leukocyte Function
Neutrophil Phagocytizes bacteria. Forms highly toxic compounds that destroy
bacteria.
Eosinophil Phagocytizes antigen-antibody complex, allergy-causing antigens,
inflammatory chemicals. Attacks parasites, such os worms.
Basophil Secretes histamine, a vasodilotor, thus increasing blood flow to tissues.
Secretes heparin, which prevents blood clotting.
Lymphocytes Natural killer cells attack cells infected with viruses or that hove turned
cancerous. B lymphocytes present antigens and activate other cells of
the immune system. Con become plasma cells that secrete antibodies.
Serve as memory cells in humoral immunity. T lymphocytes destroy
foreign cells, regulate the immune response, and serve as memory cells
in cellular immunity.
Monocytes Differentiate into numerous types of macrophages. Macrophages
phagocytize pathogens, dead neutrophils, and cellular debris. They
present antigens and activate other cells of the immune system.
Foreign invaders: the body is constantly bombarded

by invading organisms, such as viruses, bacteria,
ond other microorganisms.
CD Scavenger cells, such as
~
. . ·•·
neutrophils, arrive early
o0 o_£) o 0 o at the site of invasion, but
survive only o few days.
0 0 v--- 0 0 0 .. :
0 OO 0 _,,,, ...
Macrophages engulf 0 0 0 0 The complement system's
foreign matter and
signal other immune
Q) 0 0 0 .... , @ circulating proteins attach
to microbial invaders,
cells, such as T cells,
to attack invaders. ~ 0 0 Q '•' > contributing to their
destruction.
~ _./ o o oo
/ 0 0 0 lof.ot.d "II w;th
Q @@ Macrophages QQ Q QQ QQ~,n...ic;~(j)
~~o~.eontigens
display antigens
derived from Q (Qj
e
digestion of
ingested invaders. Q (!) Antibodies bind
Q \ These activate
T helper cells. '{
to invaders, either
destroying them Killer Tcell
T cells ~ .n \. or making them
~ ~ more vulnerable
,;, y to mocrophoges @ Killer T cells
f' and complement form from T
Q · .". ~.· y proteins. cytotoxic cells
I:'\ Q • and then destroy
U infected cells.
@ ~ ~ Plasma cell
Bcells @
T helper cells multiply Bcells divide and form

and help activate B cells plasma cells, which
and macrophages. produce anti bodies. Some Band T cells
become memory cells,
which con quickly
mount o defense if the
some foreign invader
attacks again.
Figure C-9 I Biological warfare. The body commands a wide assortment of defenders to reduce the
danger of infection and help guard against repeat microbial infections. The ultimate target of all
immune response is on antigen, commonly o foreign protein from o bacterium or other microbe.
tissue, it is transformed into a macrophage. At birth, the baby is already supplied \\ith
macrophages, which continue to develop throughout life. They are strategically lo-
cated throughout the body to phagocytize foreign material. mast cell fosue cell that releases histamine and
Mast cells are produced in the bone marrow and found in almost all tissues and or- other chemicals involved in inAommotion.
gans. They release histamine and Lhc other chemicals that are involved in inflammation.
cytokine A protein secreled by o cell that
Other participants in the immune system are cytokines, a complicated group of
regulates the activity of neighboring cells.
protein messengers that arc produced by va1ious cells throughout the body. They reg·
ulate the host cells' fu nction and growth.
There are two types of immunity: nonspecific, or namral, immunity and specific, or
acquired, immunity. The nonspecific immunity protects against foreign invaders with
out having to recognize the specific appearance of the invaders, whereas specific im-
munity is acquired.
Nonspecific Immunity
nonspecific immunity Defenses that stop the Nonspecific immunity is an array of mechanisms that are present at birth and do not
invasion of pathogens; requires no previous require any activation. They are barriers such as the skin and the mucous memb ranes
encounter with a pathogen. of the GI tract, reproducL1,·e sysLem, mi nary tract, and respiratory u-acr. The mucus
mucous membranes Membranes that line produced by these tissues traps invaders. Internally, other forms of nonspecific immu -
possogeways open to the exterior environment; nity include phagocytic cells, wh ich can swallow bacteria and other harmful substances
also called mucosoe. and ultimately destroy them. Acid produced by the stomach ( HCl) can destroy in -
gested pathogens. Inflammation is a local response to infection or injury. The purpose
mucus A thick fluid secreted by glands
is to destroy or inactivate foreig n invaders and begin the process of repair. Fever is abo
throughout the body. It contains a compound
an internal defense mechanism. ft seems to aid in the recovery process by reducing the
tha t hos both a carbohydrate and a protein
nature. It acts as both a lubricant and a means amount of iron in the blood, which in turn reduces bacterial activity. Fever also s1.:cms
of protection for cells. to be associated with an incrc,\se in interferons. Viral infections are subject to short·
term control by this group of proteins released by infected cells. Interferons are re·
interferons A group of proteins released by ceiving a lot of attention today as potent \\'capons against cancers, hepatitis C, and
virus-infected cells that bind lo other cells, other diseases.
stimulating synthesis of antiviral proteins that in
turn inhibit viral multiplication.
Specific Immunity
specific immunity The function of lymphocytes
directed at specific antigens. Specific immunity im olving the lymphOC) tes is directed ar specific molecules. When
1
nonspecific immunological defCnscs fail to halt an invasion by pathogens or by toxim

antibody-mediated immunity Specific immunity
provided by B lymphocytes; also known as
produced by pathogens, another mechanism comes into action. This mechanbm i'
humorol immunity. based on the action of antibodies, lymphocytes, and other cells of the immune system
and is known as antibod y-mediated immunity, or humoral immunity.
antibodies Blood proteins that inactivate Recall that antigens are molecules that are generally large in size and foreign co the
foreign proteins found in the body. This helps body. A given molecule can have a number of antigenic determinant sites that sLimu·
prevent and con trol infections. late the production of ,·arious ,tntibodics. When we successfully fight off an in\'adcr,
immunoglobulins Proteins found in the blood chemicals called antibodies have been in action. Antibodies are highly specific protein:.
that ore responsible for antibody-mediated produced by B lymphoC)'tC!S in response to antigens. Antigens are detected as danger·
immunity and that bind specifically to antigen; ous in truders. They arc detected because the immune system can identify molecules
also called antibodies. lmmunoglobulins ore that arc "sclf''- thcy belong to 1uc pcrsonall)' -from "nonselI'' molecules. (Recal l th<H
produced by certain white blood cells in one role of the carbohydrates found on the cell membrane is to identify "sdf. " )
response lo a foreign substance (antigen) in the The lymphocytes that produce antibodies, designated B lymphocytes, arc produced
bloodstream. in the bone marrow. These B lymphocytes wage war against bacterial intCctions as well
plasma cells A form of B lymphocytes that as some \'iral infections and even a fe" parasites. B l}'mphocytes (or B ceUs ) and anti
produce about 2000 antibodies per second. bodies, also known as immunoglobulins, come in five major classifications. These
bind to the antigen on the invader and begin a process of attack. This antibod\'
memory cells B lymphocytes that remain oher
antigen interaction soon produces plasma cells, which results in the production of
on infection lo convey long-lasting or
permanent immunity.
more antibody proteins to continue the attack. A person can produce as many differ
enc antibodies as there arc exposures ro specific antigens. It is estimated that there arc
complement A series of blood proteins that l 00 million trillion antibod~ molecules per person, representing a few million specie-.
participate in a complex reaction cascade of antigens.
following stimulation by on onligen<intibody Memory cells arc then produced by B cells and pro\'ide acti,·e immwlity. Once you
complex on the surface of a bacterial cell. have been exposed to an antigen, you develop active im111w1iry. Obviously, this is the
Various activated complement proteins con
basis of vaccinations; an inactivated pathogen is injected and the body devdops im
enhance phogocytosis, contribute to
inflammation, and destroy bacteria.
muuity to that pathogen.
The blood also contaim a group of proteins called complement proteins.
Complement proteins arc released into the area of infection and attach to the target
pathogen to be destroyed. The antibody-antigen combination does not cause the de-
struction of the pathogenic invaders, but it docs identify them so that they can be at
tacked by nonspecific immune processes such as the complement proteins.
www.mhhe.com/ wardlawpers7 A·47
Complement proteins attach to the pathogenic invader and drill holes in its membrane,
thus leading to its destruction. (The hole in the wall allows water to flow into the cell,
causing the cell ro burst.)
T lymphocytes (T cells) directly attack and destroy specific cells, which are identi-
fied by specific antigens on the cell surface. T lymphocytes produce cell-mediated cell-mediated immunity A process in which T
immunity because they actually are in contact with the enemy cell. T cells must be first lymphocytes come in actual contact with the
activated in the thymus gland. invading cells in order lo destroy them.
The acrual T lymphocytes that are killers are known as cytotoxic T cells. They rec- cytotoxic T cells Type of T cells that interact
ognize the infected cell and attach themselves through a CDS receptor. There are also with the infected host cell through special
helper T cells. They attach to an infected cell through the CD4 receptor. They pro- receptor sites on the T cell surface.
mote phagocytic activity. Together the cytotoxic and helper T cells bind to the infected
helper T cells Type of T cells that interact with
cell and lead to the cell's destruction. You may have heard of CD4 cells because they
macrophages and secrete substances to signal
are markers for AIDS. When the disease progresses, the CD4 coLLnt decreases as the
an invading pathogen; stimulates B
virus attacks helper T cells (and macrophages). lymphocytes to proliferate.
Most of the information concerning the relationship of nutrition to immunity
comes from studies in poor countries of the developing world, where children die of
infectious diseases secondary to malnutJ.ition. Protein-energy malnutrition deficiencies
of vitamins and minerals and an inadequate intake of certain fatty acids seriously alter
immune function. There is more information about how individual nutrients make it
possible to support an immune response in Chapters 9 through 12.
Allergies are types of immLme responses. One type of allergic response is almost im -
mediate. The symptoms are produced by B lymphocytes exposed to an allergen, as
demonstrated by a numy nose, red eyes, and itchy skin (dermatitis). The culprit is
hist amine, an altered form of the common amino acid histidine. T his type of immune histamine A breakdown product of the amino
response can be u·eated by antihistan'line drugs. Allergies are further discussed with acid histidine that stimulates acid secretion by
eicosanoids in Chapter 6 and adolescenr nutrition in Chapter 17. the stomach and has other effects on the body,
Delayed hypersensitivity, an abnormal T cell response, can occur as late as 72 homs such as contraction of smooth muscles,
increased nasal secretions, relaxation of blood
after exposLLre. The best known example of this type of immune response is contact
vessels, and changes in constriction of airways.
dermatitis caused by coming in contact with poison ivy, poison oak, or poison sumac.
A final rype of immunity is known as autoimmunity. Here the immune system fails
to recognize "self~" thinking a normal cell is an antigen. The immune system then goes
on the attack by activating T lymphocytes ;rnd the production of antibodies by B lym -
phocytes, which kills the cell. In other words, the defense mechanisms are confused
and attack the body rather than invaders. There arc at least 40 autoimmune diseases.
Some well-known examples include rheumatoid arthritis, type 1 diabetes, and multiple
sclerosis.
Respiratory System
In order to produce sufficient energy to meet body needs, there must be m,·ygen pres-
ent to help convert food energy into ATP. When oxygen is supplied to the tissues, car-
alveoli, alveolus The basic functional units of
bon dioxide is produced and removed from the body by the combined actions of the
the lungs.
cardio\'ascular and respiratory systems.
The organs of the respiratory system are the nose, pharynx, larynx, u·achea, bronchi, pharynx The organ of the digestive tract and
and lungs. Respiration refers to breathing and to the exchange of gases between the respiratory tract located al the back of the oral
blood and other tissues. The respiratory u-act features the alveoli (plmal ) in the ltu1gs. and nasal cavities.
These are tiny structures where one form of gas exchange takes place, described previ- larynx The structure located between the
ously as e"'1:ernal respiration (Figure C-10). The alveolus (singular), the basic functional pharynx and trachea that contains the vocal
unit of respiration, <lilows m.·ygen to be recovered from in.haled air and loads it onto red cords.
blood cells for transport to target tissues throughout the body. Simultaneously, carbon
dioxide in the blood is released into the lungs and ultimately exhaled into the air. trachea The airway leading from the larynx to
the bronchi.
Air reaches the lungs from the nasal cavity and t he mouth by first passing tlu·ough
d1e pharynx to the lar ynx. T he larynx is open to the trachea during breathing but bronchial tree The bronchi and the branches
closes during swallowing. The trach ea is a tu be that connects the larynx to the tha t stem out to bronchioles.
bronchial t ree. The bronchial tree is located in tbe llmgs a.nd looks like a tree wid1
;...;...--------Soft palate
Tr- - - - - -- - - Pharynx
•- ' + - - - -- - - ' - - - Epiglottis
_ _ _ _......;._ _ _ Esophagus
Left primary
bronchus Conducting zone Respiratory zone
Trachea
Primary
bronchus
Figure C· 1 0 I Anatomy of the respiratory system. Air enters through th e nose and mouth and is
conducted into bronchioles of the lungs. Gos exchange occurs in the alveoli.
branches. The branches on this tree get smaller and smaller the farther out thc::y go from
bronchioles The smallest division of the the tree trunk (the trachea) into lung tissue LmtiJ finally they rum into bronchioles, the
bronchi. location of the pulmonary alveoli.
The distance across the alveoli is two cells thick; one cell for the alveoli plus one cell
for the pulmonary capillaries. Gas exchange allows C02 and 0 2 to diffuse easily bc-
rweeo the blood and lungs. There is an estimated 300 million aJveoU in the lungs, pro-
viding a tremendous sw·face area for the diffusion of gases.
Another aspect of respiration is the discharge of water through the lungs. This
process is obvious on a cold day when the breath we exhale turns to ice cr ystals, and
we can see vapor fo rming around the mouth and nose. Of course, such water Joss is
much more extensive during hot, hwnid weather when the body loses heat via the
lungs.
Nervous System
The nervous system is a regulatory system controlling a variety of body functions. 1t
homeostasis A series of adjustments that
can detect changes occurring in various organs and talce corrective action when needed
prevent change in the internal environment in to maintain the constancy of the internal environment, homeostasis. The nervous sys-
the body. tem regulates activities that occur almost instantaneously, such as muscle contractions
and perception of danger.
central nervous system (CNS) The brain and The nervous system consists of the central nervous system (CNS) and the pe-
spinal cord portions of the nervous system. riphe1·al ne1·vous system (PNS). The central nervous system contains the brain and
peripheral nervous system (PNS) The nerves of spinal cord . The peripheral nervous system, with its nerves coming from the central
the central nervous system that lie outside the nervous system, branch out to aU organs of the body.
brain and spinal cord. The basic structural and functional unit of the nervous system is the neuron- a cell
that responds m electrical and chemical signals, conducts electrical impulses, and
(a) Figure C-11 I (a) An illustration of a neuron

or nerve cell, showing the cell body with
dendrites and the axon. The axon releases the
neurotransmitters. (b) How a neuron looks
under o light microscope.
Myelin /
sheath
'?-.....__--~-~
~1------- Axon - - ---<
dendrite A relatively short, highly branched

Axon
terminal nerve cell process that carries electrical activity
lo the main body of the nerve cell.
axon The port of a nerve cell that conducts

releases chemical regulators (Figure C-11 ). Nemons allow us to perceive what is oc- impulses away from the main body of the cell.
curring in our environment, engage in learning, store vital information in memory, and
control the body's voluntary actions. Incoming information tO the body depends on nerve A bundle of nerve cells outside the
central nervous system.
sensory receptors, such as visual, auditory, smell, and tactile receprors.
New·ons can't produce new cells, although some can regenerate parts of their sa-uc- neuroglia (glial cells) Specialized support cells
rures. Loss of nerve tissue causes loss of important functions. A spinal cord inj ury is of the central nervous system.
likely tO cause permanent paralysis.
neurotransmitter A compound mode by a
N euroglia (glial cells) protect neurons and aid in their function. They are fu r more
nerve cell that allows for communication
abtmdant than nemons. For example, one group of neuroglia wraps nerves in a pro - between it ond other cells.
tective myelin sheath, a job associated with vitamin B-12 (review Figure C-11 ). This
sheath acts Like an insulating material, isolating one nerve conduction pathway from synapse The space between the end of one
the others. Another group of neuroglia phagoC)rtizes pathogens and disposes of cellu- nerve cell and the beginning of another nerve
lar debris in the CNS. cell.
Each neuron contains a cell body with a nucleus and rough endoplasmic reticulum, dopamine A type of neurotransmitter in the
dendrites, and an axon. Information (electrical or chemical stimuli) enters the cell central nervous system that leads to feel ings of
through the dendrites and/or the cell body, and the output of elecuicaJ impulses leaves euphoria, among other functions; it is also used
by way of the axon. lo form norepinephrine, another
By now, you may be wondering about the term ner11e. A n erve is a bundle of axons neurotransmitter molecule.
located outside the CNS. Nerves contain axons of both sensory and motor neurons.
norepinephrine A neurotransmitter released
Axons end close to, or may be in physical contact with, the next neLtron. In most from nerve endings, ond a hormone produced
cases, however, the electrical signal at the end of the axon is converted to a chemical by the adrenal gland in times of stress.
signal called a new·otran smitter that is released into the gap (Figure C-12 ). The trans-
mission from neuron to neuron or from neuron to muscle cell is by way of these neu- acetylcholine A neurotransmitter released from
rotransmitters. The space between one neuron and the next is known as a synapse. nerve endings.
Neurotransmirrcrs that bridge the gap are derived from common nutrients fou nd in serotonin A neurotransmitter synthesized from
foods (review Chapter 11 for more details). There are a variety of neurotransmitters- the amino acid tryptophan that affects mood
dopamine, norepinephrine, acetylcholine, and serotonin are just a few. (sense of calmness), behavior, and appetite
The body's fight or fl ight mechanism-the ability to survi,•e a threat-depends on and induces sleep.
the adren ergic effect provided by adrenergic neurons secreti ng epinephrine and nor-
epinephrine A hormone produced by th e
epinephrine. The adrcnergic effect stimulates the heart to beat faste r, constricts blood adrenal gland in times of stress. It may also
vessels to raise blood pressure, increases breathing, and promotes the breakdown of hove neurotransmitter functions, such as in the
glycogen in the liver. These changes are essential to survival, because they make it pos- brain.
sible to provide plenty of glucose, our basic muscle fuel, instantly when there is an
emergency and muscles need ro respond qu ickly. C holinergic effects usually produce adrenergic Relating to the actions of
epinephrine and norepinephrine.
the opposite response of adrenergic effects.
The brain has a tremendous metabolic rate; the blood that it requires accounts for cholinergic Relating to the actions of
20% of the total cardiac output. This translates into 750 ml of blood per minute being acetylcholine.
pumped through the brain, yielding a steady supply of O.l\}'gen and glucose. Any
A·SO Appendix C Human Physiology: A Tool for Understanding Nutrition
Figure C· 1 2 l Transmission of the message , - -- - - Neurotransmitter

from one neuron to another neuron or other cell
relies on neurotransmitters. Vesicles containing - - - - Synaptic vesicle
neurotransmitters fuse with the membrane of the
neuron, and the neurotransmitter is released ~ Presynaptic membrane
into the synapse. The neurotransmitter then / ~ of a neuron
binds to the receptors on the nearby neuron (or ]-synapse
cell}. In this way, the message is sent from one
neuron to another, or to the cell that ultimately • - - Postsynaptic membrane
\ 1 of another neuron or
performs the action directed by the message.
~ nearbycell
Receptor
imerruption in me supply of d1ese two substances is life-th reatening. The brain also
generates waste materials that are prompdy removed by this high blood flow rate.
All the various structures that make up the ne rvous system are related to a person's
nutritional status. For example, most of me axons of the CNS and PNS ;ire covered bv
myelin. Vitamin 13-12 plays a key role in me formation of myelin. .
T he transmission of information tlu·ough the nervous system depends o n nutrients
obtained from the diet: calcium, sodium , and potassium. The soditm1 io n (Na+)
(mostly extracellular) and the potassium ion (K+ ) (mostly intracellular) located on ei-
d1er side of the axon membrane exchange places as tl1ey flow through ion channels in
response to electrical stimulation. This is how an electrical signal is transmitted. They
are later pumped back to tl1eir previous location.
Calcium allows t11e rele;ise of neurotransmitters from t11e axon of a neuron . As we
have seen, t11e neurou·ansmitter carries the signaJ to the next neuro n as it jumps t11e
synapse. Fortunately, a calcium-deficient diet will never have a major effect 011 nerve
transmission; the body can always find enough calcium to keep the nervous system
functioning. There are, hovvever, rare instances when a deficiency of calcium causes
he most important nutrient for continued ef- tetany. (More about tetany appears in Chapter 11.)
ficient brain function is carbohydrate in the Other nutrients required for the nervous system a.re various amino acids. One amino
form of glucose. Should the diet foil to deliver acid we obtain from dietar y protein, tryptophan, is converted to serotonin by neurons.
enough carbohydrate that can form glucose, the This neurotransmitter has a variety of behavioral effects. Varying the amount of dietary
body will synthesize it in sufficient amounts to tryptophan controls t11e amount of serotonin produced by new·ons. The amino acid
provide for the needs of the brain. Alternately, tyrosine can be conver ted to dopmnine and norepinephrine.
the brain will use an alternative fuel called ke- The GI tract has its own separate nervous system. The sighr o r smeli of food , or
tone bodies, but this is not healthy for the body one's emotions, can signal muscle celJs and glands co prepare the way for food and turn
over the long term {review Chapter 4). on digestive processes (Chapter 3 has more details).
Endocrine System and Hormones

Endocrine glands secrete regulatory substances, hormones, into t11e blood for distri-
bution to target tissues o r organs. The endocrine gland that secretes a hormo ne is re-
sponding to the need to restore homeostasis. This section is by no means a complete
exploration of all the body's hormones bur concentrates on those that affect nutrition
(Figure C-13).
Some hormones control metabolic functions, such as appetite, and me transporr of
substances through cell membranes. Others control growth, and still others are re-
sponsible for sex and reproduction . Of all d1ese hormones, some arc described as
"local," in that they function in the immediate vicinity of d1eir production. There are
also many interrelationships bel:\veen ho rmones and the nervous system. For example,
the adrenal gland and the pituitary gland respond to neural sti muli.
Some hormones from the pituitary gland control the secretion oF ocher endocrine
glands. And, as mentioned in the previous section, a substance such as norepineph1ine
secreted as a nemotransmitter can act as a hormone.
www.mhhe.com/wardlaw pe rs7 A· S 1
Figure C· 1 3 I The major endocrine glands.
Pituitary
c2)~ \
Note the location of some of the endocrine
glands. These glands secrete a variety of
hormones.
gland "" { • ~
~ Hypothalamus
Thyroid - - - --
gland
Adrenal - - -:--:-.:ii
gland
Pancreas --+.Y~!'tr1~~
Creek
Chemical Classification of Hormones

steroids A group of hormones and related
General hormones are classified according to chemical categories: steroids, glycopro- compounds that ore derivatives of cholesterol.
teins, polypeptides, and amines.
Steroid hormones are lipid substances synthesized from cholesterol (Table C-2). glycoprotein A protein containing a
The glycoproteins are long chains of amino acids (100 or more) bound to carbohy- carbohydrate group.
drate (Table C-3). Follicle-stimu lating hormone (FSH ), lureinizing hormone (LH), polypeptide Fifty to 2000 or more amino acids
thyroid -stimulating hormone (TSII), and several other pituitary hormones are such bonded together.
hormones and arc referred to as tropic hormones because they Himulacc the secre-
amines Con refer to hormones mode of one or
tion of another hormone and usually stimulate the growth of the .\Ssociated gland.
a few amino acids.
For cx.1mpk, TSH stimulates the production of the thyroid hormone. Another group
of hormonl!s are polrpeptidc chains made of fewer than I 00 amino acids per chain tropic hormone A hormone that stimulates the
(Table C-4). Amines arc hormones srnthesi.led from chc amino acids tyrosine and secretion of another secreting gland.
cryptophan (Table C-5 ).
Table C·2 I Steroid Hormones

Hormone Gland Target Effect Role in Nutrition
Testosterone Testes, adrenal glands Reproductive organs Reproduction, secondary Muscle growth
sexual development
Estrogens, progesterone Ovaries, adrenal glands Reproductive organs Reproduction, secondary Maintenance of bone
sexual characteristics
Cortisol Adrenal glands Liver Glucocorticoid activity Metabolism of protein,
carbohydrate, fat
Aldosterone Adrenal glands Kidney Minerakorticoid activity Electrolyte balance
A·52 Appendix. C Human Physiology: A Tool for Understanding Nutrition
Table C-3 I Glycoprotein Hormones

FSH, LH, TSH Pituitary gland Variety of organs Stimulation of target organ None directly
lo produce its own hormone
Table C-4 I Polypeptide Hormones

Antidiuretic hormone Pituitary gland Kidney Water retention, Maintenance of proper
vasoconstriction blood volume
Proloctin !tropic hormone) Pituitary gland Mammary gland Milk production; in males, Nourishment of newborn
indirect enhancement of
testosterone secretions
Oxytocin Pituitary gland Uterus and mammary Contraction of uterus, Milk production
glands mammary secretions
Insulin Pancreas fat and muscle cells Decreased blood glucose Storage of glucose as
concentration glycogen, increased fat
storage, increased amino
acid uptake by cells
Glucagon Pancreas liver Increased blood glucose Release of glucose from
concentration liver stores, increased
fat mobilization
ACTH Pituitary gland Adrenal glands Secretion of Secretion of adrenal cortical
(odrenocorlicotropic glucocorticoids hormones
hormone)
Growth hormone Pituitary gland Most cells Promotion of amino acid Promotion of protein synthe-
(tropic hormone) uptake by cells sis and growth, increased
fat utilization for energy
Parathyroid hormone Parathyroid glands Intestinal tract, kidneys Increased blood calcium Release of calcium from
bone into blood
Calcitonin Thyroid gland Bone Inhibition of breakdown Reduced blood calcium
of bone, stimulation of concentration
calcium excretion by
kidneys
leptin No gland, just adipose Hypothalamus Targeting of satiety center Decreased appetite
tissue
Table C-5 I Amine Hormones

Epinephrine, Adrenal glands Heart, blood vessels, Increased metabolic rote Release of glucose into the
norepinephrine* brain, lungs blood, fat mobilization
Thyroid hormones Thyroid gland Most organs Increased oxygen Protein synthesis, increased
consumption, growth, brain metabolic rote
development, development
of CNS in fetus
Melatonin Pineal gland Specific neurons Maintenance of body Scavenging of atoms and
(circadian) rhythms, sleep molecules that ore highly
reactive and dangerous
0
Norepinephrine ofw functions os o neurotransmitter, depending on location in lhe body Epinephrine is suspected of doing the some, such as in the broin.
There arc also special hormones that regulate the digestive trace. These are discussed
in Chapter 3.
Interesting Features of Hormones

The steroid and thyroid hormones can be taken in pill form because they arc not di-
gested in the GI tract; thus, they can be absorbed into the body in their active state.
All the other hormones are deactivated when taken by mouth because their biological
acti,·icy is destroyed by digestive enzymes. That is why the hormone insulin must be
taken by injection to bypass the digestive tract. n most coses, o single gland secretes o single
Some hormones must undergo chemical changes before they C<\11 tltnction. For ex- hormone, but in o few coses, o gland secretes
ample, 'itamin D synthesized in the skin and/ or obtained from food is converted to more than one hormone. In addition, sometimes
an active hormone by the kidneys and liver. o hormone is produced by more than one
gland.
Neural and Endocrine Regulation
Whether a chemical is acting as a hormone or a neurotransmicter, the target cell must
han: a receptor protein to combine with it. This causes a change in the target cell
(Chapter 3 pro,1des a fuller discussion of this concept}. This al~o means that there
must be a mechanism to turn off the action. Hormones are subject to control by an
off switch. For example, when the blood glucose concentration has been returned to
normal by the action of the hormone insulin, insulin production is nirned off. If it
were not, the person would experience decreasing glucose concentrations until the
concentration dropped so low that the person wou ld go into shock and die.
Urinary System
The urinary system is composed of rwo kidneys located on the back of the abdominal
wall, one on each side of the vertebral column (Figure C-14 }. Each is connected ro the
urinaq bladder by a ureter. The bladder is emptied by way of the urethra. ureter A tube thol lronsports urine from the
E,1ch bean-shaped kidney has an outer section called the cortex and an inner section kidney to the urinary bladder.
called the medulla. The medulla is composed of cone-sluped pyramid structures,
urethra The tube that transports urine from the
which empty waste materials into a funnel-shaped rube ending in the ureter. Ureters urinary bladder to the outside of the body.
carry urine from the kidneys to the bladder for tempor~u·y storage. Blood flows
through the kidneys at a rate of about 120 ml/minute.
Kidney Functions
The kidneys regulate the composition of the blood (plasma ) and the interstitial fluid, ogether with the lungs, the kidneys maintain
known together as the extracellular fluid. This regulation is accomplished by filtering the pH of the blood.
the blood and forming urine, which is basically the filtrate. As a result of kidney action
and the formation of urine, the ,·olume of blood plasma is controlled, and blood pres-
sure is maintained. The kidneys remove metabolic waste and foreign chemicals from
the blood, and they maintain a certain concentration of electrolytes ~uch as Na+, K+,
and HC0 3 - (bicarbonate) in the plasma. The kidneys constantly monitor the compo-
sition of the blood and produce hormones to maintain homeostasis. For example, the
kidneys produce the hormone erythropoietin, which is responsible for the synthesis erythropoietin A hormone secreted mostly by
of red blood cells. The kidneys convert a form of vitamin D into its active hormone the kidneys that enhances red blood cell
form. During times of fasting, the kidneys can produce glucose from amino acids. synthesis and stimulates red blood cell release
from bone morrow.
Kidney Structure nephron The functional unit of the kidney.
Each kidney is enclosed in a fatty, fibrous sack that protect!> it from external physical
damage. Examined microscopicall)', the functional w1it of the kidney, the nephron, is
disclosed. Nephrons extend through the renal cortex and the renal medulla. There arc
A·S4 Appendix C Human Physiology: A Tool for Understanding Nutrition
vein
Fat deposit
9"!:.-..,.-----~ urinary
bladder
To urinary
bladder
(a) (b)
Figure C· 14 I Organs of the urinory system. (a) The urinory system of the female. The mole's urinary
system is the some, except thol lhe urethra extends through the penis. (b) A cross section of the kidney.
The kidneys ore bean-shaped organs located on either side of the spinal column and filter waste from
the blood, which is then stored in the bladder os urine. The kidneys ore connected to the urinary
bladder by ureters. The outer section of the kidney is the cortex, the inner section is the medulla. The
functional unit of the kidney, the nephron, loops through the cortex and medulla, and the fluid that Rows
through these tiny structures is separated so that the waste is removed from the blood into collecting
ducts and drains into the renal pelvis. Thus the urine exits by way of the ureter lo the bladder. The
remaining fluid is returned lo the circula tory system to maintain the normal composi tion of the blood.
more than 1 million nephrons per kidney. The nephron consists of smaU n1bulcs allied
glomerulus The capillaries in the kidney that \\'ith small blood "essels. The tiny capillary filtration unit, the glomeruJus, is held in a
filter waste products from the blood. small capsule (Bo" man's capsule). The glomerulus filters large amounts of fluid from
the blood, rcmo' ing the dissolved waste and excess Au id to form urine, which leaves
by way of the tubules. The remaining Auid is returned to the blood.
T his ingenious mechanism consi:antly adjusts the compositio n of the blood . ln
doing so the essential components are recovered and returned ro general circulation,
waste products and excess water are removed, and unneeded nutrients (ones in which
storage compartments are full or there are no storage facilities ) are flushed away by the
urine.
Reproductive System
Reproduction is a fundamental property of all living things. We die, but our genes li\·e
on in our progcn~. In humans, both O\'a and sperm, called gametes (sex cells), contain
23 chromosomes. The fertilized egg conrajns 46 chromosomes (23 from each parent)
and is programmed Lo produce a new human. At conception, the instructions for the
developing embryo arc all present. Through the actions of the fema le reproductive
organs, supported by hormonal secretions, a human is produced about 40 weeks after

conception, providing that essential nutrients are present and no genetic detects are en-
countered. Tbe most precarious time during pregnancy is during Lbc development of
the embryo (the first 13 weeks), when a woman is least Ukely to know she is pregnant.
The male reproductive organs consist of the scrontm (containing the testes), the
penis, the urethra, the seminal vesicles, and the prostate. The fema le reproductive or-
gans consist of the ovaries, uterus, and vagina (review Figure C-14).
In addition to reproduction, the se~ hormones stimulate bone growth and the clo-
sure of the epiphyseal plate, thus causing the cessation of bone growth. Estrogens pro-
tect against bone loss. The sex hormone testosterone stimulates protein synthesis, such
as musde growth and bone growth.
Puberty, or the onset of adult sex life, takes place during early adolescence.
Menarche, the term used to describe the onset of mensu·uacion, occurs usually be- menarche The onset of menstruation.
tween the ages of 11 and 16 in fi::nules. In the male, sexual maturation occurs some- Menarche usually occurs around age 13, 2 or
what later and is initiated by hormonaJ secretions from the brain. 3 years otter the first signs of puberty start to
The female reproductive system is discussed in Chapter 16 in more detail. appear.
•
a en IX
DIETARY ADVICE FOR CANADIANS
The information in chis appendix includes ad\'ice on dietary patterns as well as regula-
Recommended Nutrient Intake (RNI) The tions that apply to food labeling. Previous RNis for nutrients have been replaced by
Canadian version of RDA published in 1990. the Dietary Reterence Intakes (DRis) that apply to Canadian and U.S. citizens. These
are listed on the inside cover. Both Canadian and American scientists worked on the
various DRI commirrees, coming up with a set of harmonized D ietary Reference
Intakes for both counrries.
Summary of the Nutrition Recommendations

for Canadians
The latest NULrition Recommendations of the Scie ntific Review Commfrtec of the Office
xcellent World Wide Web resources for
of Nuoition Policy and Promotion suggest that the Canadian diet shou ld supply:
Canadians ore Health Canada (www.
hc-sc.gc.ca), Dietitians of Canada (www. • essential nutrients in the amounts specified in the updated Recommenc.kd Nutrient
dietitians.ca), and the Notional Institute of Intakes (RNJs);
Nutrition (www.nin.ca). • sufficient energy to maintain a healthy weight when balanced with physical acri,·it)
(energy intakes for adults should not be lower than 1800 kilocalories in order to
meet RNis);
• no more than 30% of energy as fat and no more than 10% of energy as saturated fat;
• at least 55% energy as carbohydrates;
• less sodium than is now used;
• no more than 5% of energy as alcohol, or 2 drinks per day (\Yhjchever is less), with
no alcohol during pregnancy;
• no more caffeine than the equh•alent of four regular cups of coffee per day; and
• water containing no less than 1 mg/litre of Auoridc.
Tn essence, sugge11ted actions toward healthful eating as listed in Canada's Guidelines
for Healthy Eating include the following:
• Enjoy a \ 'AlUETY of foods.
• Emphasize cereals, breads, other grain products, \'egetables, and fruit.
• Choose lower-fut dairy products, leaner meats, and foods prepared with little or no fut.
• Achieve and maintain a healthful body weight by enjoying regular physical activit)
and healthy eating.
• Limit salt, alcohol, and caffeine.
The Cnnndin11 Food Guide is a guide to help Canadians make wise food choices
(Figure D-1 ). The rainbO\\ side of the Food Guide places foods into four groups: grain
products; vegetables and fruit; milk products; and meat and meat alternati,·es. The
rainbow includes information about the types of foods to choose from each food group
for healthy e~1ting.
A-56
www.mhhe.com/wardlawpe rs7 A-5 7
Health and Welfare Sante et Bien-etre social
••• Canada Canada
Enjoy a variety
of foods from each
group every day.
Choose lower-
fat foods Y050ui!1
2.2}
more often.
I 0.1%
r
I
Grain Products Vegetables & Fruit Milk Products Meat & Alternatives
Choose whole-grain Choose dark green and Choose lower-fat milk Choose leaner meats,
and enriched orange vegetables and products more often. poultry and fish, as well
products more orange fruit more often. as dried peas, beans, and
often. lentils more often.
Canada
Figure D-1 I Canadian Food Guide to Healthy Eating.
A·58 Appendix D Dietary Advice for Canadians
Different People Need Different Amounts of Food

The amount of food you need every day from the four food groups and other
foods depends on your age, body size, activity level, whether you are male or
female and if you are pregnant or breastfeeding. That's why the Food Guide
gives a lower and higher number of servings for each food group. For example,
young children can choose the lower number of servings, while male teenagers
TO HEALTHY EATING can go to the higher number. Most other people can choose servings some-
FOR PEOPLE FOUR YEARS ANO OVER
where in between.
Grain 1 Serving 2 Servings
Products
Ho1Cerea1
5-12
SERVINGS PER DAY Cold Cereal
~
175ml
\q ~! . )
3/4 cup
1 Slice
\.2, 30g
1 Serving
Fresh. Frozen or
Cenned Vegelables Salad Juice
0< Fru11
125 ml
..;
1/2cup
12Sml
1 Medium Size Vege1able or Fruil 1/2 cup
Milk 1 Servin
Products Other
Cheese
SERVINGS PER DAY Foods
Qf-4-9"""' H
Y-11-llyurr J-4
.......................
-H
3• x 1·x 1• 2 SJoces
.,
175g
Taste and enjoyment
••
SOg SOg
250ml can also come from
-•·H 314 cup
IJ>
1 cup
other foods and
beverages that are
not part of the four
1 Servin
food groups. Some of
these foods are
Fish Beans
higher in fat or
t25·250ml Calories, so use these
foods in moderation.
113-213 Can ~
50-100 g 1009
Meat. Poollry or Fish .._) Peanut

50·100 g 113 cup Butter
1·2 Egg 30 ml or 2 tbsp
Enjoy rating wrll, bring actitle, and jPelmg good about yourself. T hat \
Cl M1114ster of Supply and Services canada 1992 C.tt No H39-252 / 1992E No changes permitted Repont permission not required
ISBN 0·662· t 9648· 1
Figure D-1 I Canadian Food Guide to Healthy Eating.

The bar side of the Food Guide helps Canadians decide how mm:h they need from
each group C\'ery day. The guide gives a range for the number of ser\'ings for each food
group, since different people need different amounts of food. The Food Guide also
shows serving si:tcs for different foods.
The bar side of the Food Guide also tells how other foods that are nor part of the four
tood groups can ha,·e a role in heald1y eating. Because somt: of these "other foods" arc
higher in fur or calories, the Food Guide reconunends using d1ese foods in moderation.
Nutrition Labels
The former Canadian Nurrition Label is shown here. Consumers ha,·e now started to
see more information about the nutritional value of most prepackaged food under new
labeling requirements that were published on January l, 2003. The new regulations
require most food labels to carry :i mandatory Nutrition Fact.nablc listing Calorics and
13 key nutrients.
HOW TO READ THE FORMER CANADIAN NUTRITION LABEL
+ Nutrition information is expressed per

suggested serving. The serving size will
vary according to food type and brand.
Consider this fact when comparing foods.
Gives the calorie content

LASAGNA
{Call Nutrition Information
•
per 275 g serving
Indicates the quantity of ( 1 cup/250 ml)
naturally occurring and
added sugars as well as Energy 275 Cal
dietary fibre 1140 kJ
Protein 19 g
Indicates the level of Fat 7 g
sodium from salt and a ll Polyunsatu rates 0.8 g
other sources Monounsaturates 1.9 g
Satu rates 2.5 g
Vitamins and minerals Cholesterol 46 mg
are expressed as a Carbohydrate 3A g
percentage of the highest Starch 29 g
recommended amount Sugars 5 g
Dietary Fibre 0.2 g
Sodium 850 mg
millilitres:
Potassium 675 mg
5 ml = 1 teaspoon
Percentage of Recommended
kilojoules: Daily Intake
metric unit of energy
1 Col = 4. 18kJ Thiamine 20%
Riboflavin 19%
I grams: 28 g = 1 ounce Niacin
Calcium
18%
12%
Iron 28%
The New Canadian Nutrition Label
As noted on page A-59 , nc" regulations publi~hcd on January 1, 2003, niJkc nutri-
tion labeling mandato ry on most food labels using a new format. The regulations also
update requirement~ for nutrient content claims and permit, for the first ti1rn: in
Canada, diet-related health clai ms for foods .
How to Read the Latest Canadian Nutrition Label
The Regulations provide for the optional Daily Value is a comparison standard
declaration of the number of Calories comprised of
both from fat and from saturates plus (o) vitamin or mineral amounts referred
Irons. Recommendations on the % of to in the definition of a recommended
Calories from fat apply to the total diet doily intake for that vitamin or mineral
I
rather than to an ind ividual food. (b) nutrient amounts referred to in the
\
Therefore, inclusion of the % of Calories definition of reference standard for
from fat in the Nutrition Facts table may that nutrient
be confusing and is not permitted. Nutrition Facts
Per 1 cup (26_4g)
The Nutrition Facts table provides

Amount
""- % Daily Value'
~0%
Calories 260
information on saturated and Irons fatty
Fat 13g
acids which hove been shown lo raise
serum cholesterol levels. The declaration Saturated Fat 3g
2~
""
of the other groups of fatty acids, mono· + Trans Fat 2g Serving size is stipulated for
unsaturates, omega-3 and omego-6 Cholesterol 30mg various foods.
polyunsatura tes, is optional unless claims Sodium 660mg 28%
ore made, in which case all three must --
Carbohy drate 31 g 10%
be declared.
Fibre Og 0%
--
Sugars 5g
Potassium is not included as a mandatory
Protein 5g The amount of vitamins and minerals
nutrient of the Nutrition Facts table
because it is not considered to be a Vitamin A 4% Vitamin C 2% ~
is expressed as a percentage of the
nutrient of general public health Calcium 15% Iron 4% Daily Value per serving of slated size.
importance. The declaration of potassium,
however, is mandatory when a claim is
mode for the sodium or salt content of a
food which contains on added potassium
salt.
There is also .1 C.rnadi.rn Nutrition Label for children under two years of age
Nutrition Facts
Per 1 jar (126 ml)
Amount
Calories 110
Fat Og
Sodium 10mg
Carbohydrate 27g
Fibre 4g
Sugars 18g
Protein Og
0
e OaHy Value
Vitamin A 6% Vitamin C 45%

Calcium 2% Iron 2%
A-60
www.mhhe.com/wardlaw pers7 A·61
Recommended Daily Intakes and Reference Standards

Belo\\ are the Recommend ed Daily Intakes and Reference Standards used on
Nutrition Labels for persons 2 years of age and older. *H
Dietary Constituent Amount Dietary Constituent Amount

Fol 65 g Folocin 220 µ.g
The sum of soturoled fatty Vilomin B12 2 µ.g
acids and Irons fatty acids 20 g Pontothenic acid or
Cholesterol 300 mg pontothenole 7 mg
Carbohydrate 300g Vitamin K SO mg
Fibre 25 g Biotin 30 µ.g
Sodium 2400 mg Calcium 1100 mg
Chloride 3400 µ.g Phosphorus 1100 mg
Potassium 3500 mg Magnesium 250 mg
Vitamin A 1000 RE Iron 14 mg
Vitamin D 5 µ.g Zinc 9 mg
Vitamin E 10 mg Iodide 160 µ.g
Vitamin C 60 mg Selenium 50 µ.g
Thiamin, thiamine or vitamin B1 1.3 mg Copper 2mg
Riboflavin or vitamin B2 1.6 mg Manganese 2 mg
Niacin 23 NE Chromium 120 µ.g
Vitamin B6 1.8 mg Molybdenum 15 µg
·RE =retinol equivolents

INE = niocin equivalenll
!Together these conshtute !he Daily Values used on !he new Canadian Nutrition label Nole !hot Reference Standards are bolded.
Approved Nutrient Content Claims

Below is a sample of approved nutrient content claims for food labels.
E nergy
• Free of eneJlJ.V: The food provides less than 5 Calorics or 21 kilojoules per reference
amount and serving of stated size.
• Lon' i11 energy: The food provides 40 Calories or 167 kilojoules or less per reference
• Reduced iu cnCJ;gy: The food is processed, formulated, reformulated or otherwise
modified so that it pro\'ides at least 25% less energy per reference amot111t of a sim-
ilar food.
• Lower in energy: The food provides at least 25% less energy per reference amount
of a similar food.
• So111·ce of enc1;gy: The food pro\'ides at least 100 Calories or 420 kilojoules per ref-
erence amount and ser\'ing of stated size.
• J101·c mcrg.\ The food prmides at least 25% more energy. totalling al least 100
1
:
more Calories or 420 more kilojoules per reference amount of a similar food.
Protein
• Low in p1·otci11: The food contains no more than l g of protein per 100 g of the
food.
• So1ffce of protei11: The food has a protein raring of20 or more, as determined by of-
ficial method F0-1, Determi111rtio11 of Protein Rnting, October 15, 1981, (a) per
reasonable daily intake; or (b) per 30 g combined with 125 mL of milk, if the food
is a breakfast cereal.
• £'1:celle11t so1wce of protein: The food has a protein rating of 40 or more, JS deter·
mined by official method FO- l, Dctcrminntion of Protein Rating, October 15,
1981, (n) per reasonable daily intake; or (b) per 30 g combined with 125 mL ot
milk, if the food is a break.fast cereal.
• More protei11: The food (n ) has a prorein rating of20 or more, as determined b~ of-
ficial method F0-1, Dctcrmi11ntio11 of Protein Rating, October 15, 1981, (i) per
reasonable daily intake, or (ii) per 30 g combined with 125 mL of milk, if the food
is a breakfast cereal; and ( b) contains at least 25% more protein, totalling ,11 lea~t
7 g more, per reasonable daily intake compared ro the reference food of the ~.m1e
food group or the similar reference food.
Fat
• Free offrtt: The food contains less than 0.5 g of far per reference amount and sctY·
ing of stated size.
• Low in fat: The food contains 3 g or less of fat per reference amount and sen·ing or
stated size and, if the re Ference amount is 30 g or 30 mL or less, per 50 g.
• Reduced in fat: T he food is prot.:csscd, formulated, reformulated or otherwise mod -
[fied so that it contains at least 25% less fat than the reference amount of :.i simil,1r
food.
• Lower i11 fat: The food contains at least 25% less fat per reference amount of the
food, than the rcfcrent.:e amounc of the reference food of the same food group.
• 100% fn.t-frce: The food (a) contains less rh:.in 0.5 g of fat per 100 g; ( b) conrJ111\
no added fat.
• No added fat: ( l ) The food concains no added fats or oils set out in Di'i~ion 9, or
added butter or ghce, or ingrcdicncs rhar contain added fats or oils, or butter or
ghee.
• F1-ee of saturated fatt)' acids: The food concains less than 0.2 g saturated fat!') Jci1.h
and less than 0.2 g tm11s fatty ,icids per reforence amounc and serving of stated 'i1e
• Low in snturnted fatty ncids: ( l ) The food contains 2 g or less of saturatl!d fatty acid~
and tm11s fatty •lcid~ combined per reference amount and serving of stated 1-iLc.:.
(2) The food provides 15% or less energy from the sum of s:.iturated fatty acids :md
tl"ans fatty acids.
• Reduced in saturated fatty rtcids: The food is processed, formulated, reformulated
or otherwise modi fled, without increasing the content of ti'ans fatty acids, so that it
contains at least 25% less saturated fatty acids per reference amount of the food than
the reference amount of the simi lar reference food.
• Lower in saturated fatty acids: The food contains at least 25% less saturated fatt~
acids and the content of trnns fatty adds is not higher per reference amount of the
food, than the reference amount of the reference food of the same food group.
• Free of trans fatty acids: The food contains less than 0 .2 g of trans fatty acids per ref·
erence amount and serving of seated size.
• Reduced in trans fatty acids: The food is processed, formulated, reformulated or
otherwise modified, without increasing the content of saturated fatty acids, so that
it contains at least 25% less tm11s faery acids per reference amount of the food than
the reference amount of the similar reference food.
• Lmver in trans fatty acids: The food contains at least 25% Jess trans fat!')' acids and
the content of saturated faery acids is not higher per reference amount of the food
compared to the reference amounr of a similar food.
• Sotffce of omega-3 pol.v1111srit11mted fntt)• acids: The food contains 0.3 g or more of
omega-3 polyunsaturated fatty acids per reference amounc and serving or st::iccd
size.
• Source of omega-6 po(1•1msat11rrited fntty ncids: The food contains 2 g or more of
omega-6 pol)runsaturaced fauy acids per reference amount and serving of seated
size.
www.mhhe.com/wardlaw pe rs7 A -63
Cholesterol
• F1u of c/Joluterol: The food contains less than 2 mg of cholesterol per reference
amow1t and scn·ing of stared size.
• Lon• i11 c/Joluterol: The food conrains 20 mg or less of cholesterol per reference
amount and sen·ing of scared size (if the reference amount is 30 g or 30 mL or less,
per 50 g. )
• Reduced i11 c/Jolcsw·o/: The food is processed, formulated, rcformubtcd or otherwise
modified so that ic contains at le.1st 25% less cholesterol per reference amount of a
similar food.
• Lo1J1L'1' i11 c/Jolem.·1·01: The food contains ac lease 25% less cholesterol per reforcnce
amount of a similar food.
Sodium or SaJt
• F1·cc of sodium 01· snit: The food contains less than 5 mg of sodium per rdcrence
• Low in sodium or snit: The:: food contains 140 mg or less of sodium per rdcrcnce
• Reduced iu sodi11111 or snit: (1) T he food is processed, formulated, reformulated or
otherwise modified so that it contains at least 25% less sodium per rdcrencc amount
of a similar food .
• Lower i11 sodium or snit: The food contains at least 25% less sodium per reforence
amount of the food.
• No added sodium or snit: The food contains no added salt, other sodium sa.lcs, or in-
gredients that contain sodium that functional!}' substitute for added saJt.
• Light~Y salted: The food contains at least 50% less added sodium than the sodium
added co a similar reforence food.
Sugars
• Free of s11.gars: The food contains less than 0.5 mg of sugars per reference amount
and serving of stared size.
• Reduced i11 sugars: The food is processed, form ulated, reformulated or otherwise
modified so that it contains at least 25% less sugars, totalling at least 5 g less per ref-
erence amow1t of the food.
• Lower in sugars: T he food contains at least 25% less sugars, totalling at least 5 g less
per reference amount of the food.
• No added sugars: (1) The food contains no added sugars, no ingredients containing
added sugars or ingredients that contain sugars that functionally substitute for
added sugars.
Fibre
• Source offibre: ( 1) The food contains 2 g or more (a) of fibre per reference amount
and serving of seated size, if no fibre or fibre source is identified in the statement or
claim; or ( b) of each identified fibre or fibre from an identified fibre source per ref-
erence amount and senfog of stated size, if a fibre or fibre source is identified in the
statement or claim.
• Hi._q/1 sow·cc offibre: The food contains 4 g or more (a ) of fibre per reference amount
and serving of stated size, if no fibre or fibre source is identified in the statement or
claim; or ( b) of each identified fibre or fibre from an identified fibre source per rct:
erence amount and serving of stated size, if a fibre or fibre source is identified in the
statement or claim.
• Very high source o.fflb1'1:: The food contains 6 g or more (a) of fibre per reference
amount and serving of stated size, if no fibre or fibre somce is identified in the state-
ment or claim; or ( b) of each identified fibre or fibre from an identified fibre source
per reforence amount and sen ing of stated size, if a fibre or fibre sow-cc is identi-
fied in the statement or claim.
• M~ore fibre; The food contains at least 25% more fibre, totalling at least 1 g more, if
no fibre or fibre source is identified in the statement or claim, or at least 25% more
of an identified fibre or fibre from an identified fibre source, totalling at least l g.
more, if a fibre or fibre source is identified in the statement or claim compared to
reference amow1t of a similar food.
L ight and Lean
• Light i11 energy 01· fnt: The food meets the conditions set out for the subject "re
duced in energy" or "reduced in fut."
• Lean: T he food (a) is meat or poulrry t hat has not been ground , a marine or fresh
water animal or a product of any of rhese; and ( b) contains 10% o r less far.
• Extra lean: T he food (a) is meat or poultry that has not been ground , a marine or
fresh water <mimal or a product of any of these; and (b) contains 7 .5% or less fat.
Approved Health Claims for Nutrition Labels

If a manufacturer follows specific gu idelines addressing both the nutrients noted in the
claim as well as guidelines pertaini ng to other nutrients in a food, the following he.11th
claims can be made.
• A healthy diet containing foods high in potassium and low in sodium may reduce
the risk of high blood pressure, a risk factor for stroke and heart disease.
• A healthy diet with adequate calcium and vitamin D, and regular physical acti\ ity,
help to achie,·e strong bones and may reduce the risk of osteoporosis.
• A healthy diet lo\\ in santratcd and trans fats may reduce the risk of heart disease.
• A healthy diet rich in a \'a1iery of vegetables and fruit may help reduce che ril!k of
some types of cancer.
• Foods ' 'ery IO\\ in starch and termentable sugars can make the following health
claims:
• vVon't cause ca\'ities;
• does not promote tooth decay;
• does not promote dental caries; or
• is non-cariogenic.
•
a en IX
THE EXCHANGE SYSTEM:
A HELPFUL MENU-PLANNING TOOL
The Exchange System is a valuable tool tor roughly estimating the energy, protein, Exchange System A system for clossifying
carbohydrate, and fut comenr of a food or meal. This tool organizes many details of foods into numerous lists bosed on the foods'
the nutrient composition of foods into a manageable framework. B)' using the macronutrient composition ond establishing
exchange System, you can plan daily menus to fall roughly within specific percentages serving sizes, so that one serving of each food
of macronutrients without having to look up or memori1e the nutrient values of nu- on a list contains the some amount of
corbohydrote, protein, fat, ond energy content
merous foods, so the time ~·ou spend now becoming familiar with the Exchange
System will pay dividends in the future.
In the Exchange System, individual foods are placed into three bro,1d groups: car-
bohydrate, meat and meat substitutes, and far. Within these groups an: lists that con-
tain foods of similar macronutrient composition: \'a1ious types of milk, fruits,
vegetables, starch, other carbohydrates, meat and meat ~ubstitutes, and fat . These lists
arc designed so that n·hen the proper serving size is observed, each food on a list pro-
vides about the same amount of carbohydrate, protein, fat, and energy. This equality
allows the exchange of foods on each list, hence the term £-.:change System.
The Exchange System was originally developed for planning diabetic diets. Diabetes
is easier to control if the person's diet has about the same composition day ati:er day.
ff a certain number of exchanges from each of the va1ious lisrs is eaten each day, that exchange The serving size of o food on o
regularity is easier to achieve. However, bcc.wsc the Exchange System provides a quick specific exchange list.
way to estimate rhe energy, carbohydrate, prorein , and fat conrcnt in any food or meal,
it is a valuable menu-planning cool.
Becoming Familiar with the Exchange System

To use the Exchange System, you must know which foods arc on each list and the serv-
ing sizes for each food.
Table E-1 gi\·es the ser\'ing sizes for foods on each exchange list a!. \\ell as the car
bohydrate, protein, fat, and energy content per exchange. Note that the meat and milk
lists are divided into subclasses, which vary in fat content and, he nce, in the amount of
energy they provide. Foods on the meat and fat lists contain essentially no carbohy-
drate; those on rhe fruit and fat Lists lack appreciable amounts of protein; <llld those on
the vegetable, fruir, and other carbohydrates lists contain essentially no fat. You need
to srudy Table E- 1 and Figure E-1 to become familiar with the exchange lisrs, the sizes
of the exchanges (that is, serving sizes) on each list, and the amounts or carbohydrate,
protein, fat, and energy per exchange.
Before you can turn a group of exchanges into a daily meal plan, you must be aware
of which foods are on each exchange list (Figure E- l ). The entire U.S. Exchange
System is presented in Appendix F, which you should consult frequently while explor-
ing the system to discover its various peculiarities. For example, t11e starch list includes
A-65
A·66 Appendix E The Exchange System: A Helpful Menu-Planning Tool
Table E· 1 I Nutrient Composition of Exchange System lists (2003 Edition)
Household Carbohydrate Protein Fat Energy

Groups/Lists Meosures• (g) (g) (g) (kcal)
Carbohydrate Group
Storch 1 slice, 3/4 cup row, 15 3 1 or lesst 80
or 1/2 cup cooked
fruit 1 small/ medium piece 15 60
Milk 1 cup
Fol-free/very low-fat 12 8 0-3t 90
Reduced-fat 12 8 5 120
Whole 12 8 8 150
Other carbohydrates Vories 15 Vories Vories Vories
Nonstorchy vegetables 1 cup row or
l /2 cup cooked 5 2 25
Meot and Meot Substitutes Group 1 oz
Very lean 7 0-1 35
Leon 7 3 55
Medium-fat 7 5 75
High-fat 7 8 100
Fat Group 1 tsp 5 45
•Just on estimate; see exchange lists for actual amounts.
ICokuloted as 1 g for purposes of energy contribution
Reproduclion of rhe exchange lis1s 1n whole or in port, without permission of The American Dietetic ksociolion or rhe Amertcon Diabetes Association Inc. 1s a violation of federal low. This material hos
been modified from Exchange lists For Meal Planning, which is rhe basis of o meal planning system designed by o committee of 1he American Diabetes Association and The Amencon Dietehc
Association While designed pnmorily for people with diabetes and others who must follow special diets, the exchange lists ore based on principles of good nutrition that apply 10 everyone. Copynght
IC 2003 by the American Diabetes Association and the American Dietetic Association.
Starch exchange choices Meat and meat substitutes exchange choices Vegetable exchange choices
Fruit exchange choices Milk exchange choices Fot exchange choices
Figure E· 1 I Foods arranged according to the Exchange System lists.

nor only bread, dry cereal, cooked cereal, rice, and pasta, but also baked beans, corn
on the cob, and potatoes. T hese foods arc not identical to those composing the grain
group in MyPyrarnid. The Exchange System is not concerned with the 01igin ofa food,
whether animal or \'egetable. It is primarily concerned with the macronutrients carbo-
hydrate, protein, and fat in each food on a specific list. For example, the carbohydrate
composition of potatoes resembles that of bread more than that of broccoli, although
pmatoes are Yegctablcs. In addition, sc\'eral foods on the meat and meat substitutes list
arc not meats. The list of other carbohydrates includes jam, angel food cake, fat-fTee
frozen yogurt, and foods such as frosted cake that count .1s both other carbohydrate
exchanges and fut exchanges. Bacon appears in the fat list rather than the high -fat meat
category.
Free foods (essentially calorie-free ) include bouillon, diet soda, coffee, tea, dill pick-
les, and ' 'inegar as well as herbs and spices. J\lost vegetables, such as cabbage, celery,
mushrooms, lettuce, and zucchini, also can be considered free foods; their minimal en-
ergy contribution need not cou nt in the calculations when they are eaten in modera-
tion ( 1 to 2 servings per meal or snack).
Using the Exchange System to Develop Daily Menus

Use the Exchange System to plan a 1-day menu. Target an energy content of 2000
kcal, with 55% derived from carbohydrates (1100 kcal), 15% from protein (300 kcal),
and 30% from fat (600 kcal). These specifications can be translated into 2 low-fat milk
exch.rnges, 3 vegetable exchanges, 5 fruit exchanges, 11 starch exchanges, 4 lean meat
exchanges, and 6 far exchanges (Table E-2 ). Note that this example is only one of
man}' possible combinations; the Exchange System offers greJt flexibility.
Table E-3 arbitrarily separates these exchanges into breakfast, lunch, dinner, and a
snack. Breakfast includes 1 reduced-fat milk exchange, 2 fruit exchanges, 2 starch ex-
changes, and 1 fat exchange. Thjs total corresponds to 3/4 cup of a ready-to-eat
breakfast cereal, 1 cup of reduced-fat milk, 1 slice of bread with l tsp margarine, and
1 cup of orange juice.
Lunch consists of 2 fat exchanges, 4 starch exchanges, 1 \'egetable exchange,
1 reduced-fat milk exchange, and 2 fruit exchanges. This total translates into one slice
of bacon with 1 teaspoon mayonnaise on two slices of bread, with tomato-in other
words, a bacon and tomaro sandwich. You can also add knuce to the sandwich.
Lcm1cc can be considered a free vegetable choice. Add Lo thi!> meal a 9 -inch banana
( I exchange = l small banana), 1 cup of reduced-fat milk, and 6 graham crackers
(2 1/2 inches by 2 1/2 inches). Later, add a snack of 3/ 4 oz of pretzels for another
srarch exchange.
Table E-2 I Possible Exchange Pa tterns That Yield 55% of Energy as

Carbohydrate, 30% as Fat, and 15% as Protein for Energy Intakes Greater
Than 2000 kcal
kcal/Doy
Exchange List 1200· 1600' 2000 2400 2800 3200 3600
Milk (reduced-fol) 2 2 2 2 2 2 2
Vegetable 3 3 3 4 4 4 4
Fruit 3 4 5 6 8 9 9
Starch 5 8 11 13 15 18 21
Meat (lean) 4 4 4 5 6 7 8
Fat 2 4 6 8 10 11 13
This is just one r.el of options More meol could be included ii less milk were used, for exomple
·energy intokes of 1200 and 1600 kcol contain 20% of energy os protein and 50% energy as corbohydrote to allow for greeter
flexibility in diet planning.
A-68 Appendix E The Exchange System: A Helpful Menu-Planning Tool
Table E-3 I Sample l-Doy 2000 kcal Menu Based on the Exchange System Pion*
Breakfast
1 reduced-fat milk exchange 1 cup reduced-fat milk (some on cereal)
2 fruit exchanges 1 cup orange juice
2 starch exchanges 3/4 cup ready-to-eat breakfast cereal, 1 piece whole-wheat
toast
1 fat exchange 1 tsp sott margarine on toast
Lunch
4 starch exchanges 2 slices whole-wheat bread, 6 graham crackers
(2 1/2 inches by 2 1/2 inches)
2 fat exchanges 1 slice bacon, 1 tsp mayonnaise
1 vegetable exchange 1 sliced tomato
2 fruit exchanges 1 banana (9 inches)
1 reduced-fat milk exchange 1 cup reduced-fat milk
Snack
1 starch exchange 3/4 oz pretzels
Dinner
4 lean meat exchanges 4 oz lean steak (well trimmed)
2 starch exchanges 1 medium baked potato
1 fol exchange 1 tsp sott margarine
2 vegetable exchanges 1 cup cooked broccoli
1 fruit exchange 1 kiwi fruit
Coffee (if desired)
Snack
2 starch exchanges 1 bagel
2 fat exchanges 2 tbsp regular cream cheese
'The target pion was o 2000 kcal energy intake, with 553 from carbohydrate, 15% lrom p1otein, and 30% from lot Computer
analysis indicates that this menu yielded 2040 kcal, with 53% from carbohydrate, 16% from ptotein, and 31 % from fol-in close
agreement with the IOrgeted goals.
Dinner consists of 4 lean me:u exchanges, 1 fruit exchange, 2 vegctJblc exchanges,

fat exchange, nnd 2 starch exchangcs. T his total corrcsponds to a 4-oz broiled steak
(meat only, no bone), 1 mcdiu m bakcd potato ( 1 cxchangc = 1 small baked potato )
with 1 tsp or margarine, l cup of broccoli, and 1 kiwi fruiL Coffee (if desired ) is nor
counted, because it contaim. no appreciable cnerg}.
Finally, you can ha\ e a snack containing 2 starch exchanges and 2 fat exchanges.
This total transl.Hes into 1 bagel '' ith 2 tbsp of regular cream cheese.
This 1·da}' menu is on ly one of many thar arc possible with the exchange li:.ts. Apple
juice could n:place the orange juice; two :-ipplcs cou ld bc exchanged for the banana.
The choices Jre endless. Notice that an exchange dict is much easier co p!Jn if you use
indi,·idual foods, as was done here; however, the Exchange System rabies list some
combination foods to help you (sec Appendix F). Using combination foods, such as
pizza or bsagna, however, makes it more difficLtlt to calculate the number of exchanges
in a sen1ing. For instance, lasagn•l typically has meat exchanges, vegetable exchanges,
and starch exchanges. With practice, you will be ablc to rnckle such complex foods
(Figure E-2). For now, using individual foods makes learning the Exchange System
much easier. Finally, you mighr want to prove to yourself that the food choices listed
in Table E·3 really meet the exchange plan. This demonstration will give you practice
turning exchanges into acrual food servings.
www.mhhe.com/ wardlawpe rs7 A-69
Figure E·2 I Record the Exchange System

Total Exchanges Exchanges Consumed at Each Meal pattern you hove chosen in the left column.
Exchange to Be Consumed
Then distribute the exchanges throughout the
List Dally Breakfast Lunch Dinner
day, noting the food to be used and the serving
size.
MILK
VEGETABLE
FRUIT
STARCH
MEAT AND
SUBSTITUTES
FAT
•
a en IX
EXCHANGE SYSTEM LISTS*
Milk Exchange List

Fat-Free and Low-Fat Milk
(12 g carbohydrate, 8 g protein, 0-3 g fat, 90 kcal)
1 cup fat-free,~%, and 1% milk and buttermilk
~cup powdered (fat-free dry, before adding liquid )
~cup canned, ernporated fat-free milk
l cup buttermilk made from far-free or low-fat milk
1 cup soy m ilk (low-fat or fat-free )
%cup (6 oz) yogurt made from fat-free milk (plain, Lu1Aavorcd)
~c up (6 oz) yogurt, fut-free, Aavored, sweetened with nonnutritivc S\vccccncr and fructose
Reduced-Fat Milk
( 12 g carbohydrate, 8 g protein, 5 g fat, 120 kcal )
1 cup 2% milk
1 cup soy milk
X cup yogurt plain, low-fut (added milk solids)
l cup sweet acidophilus milk
Whole Milk
(12 g carbohydrate, 8 g protein, 8 g fol, 150 kcal)
1 cup whole milk
~c up evaporated whole milk
1 cup goat's milk
l cup kefir
1 cup yogurr, plain (made from whole milk)
*T he exchange lists are the b.1~is of a meal planning system designed by a committee of the Amcnc.m Diabetes Association and the Americ:m D1ctertc As\1..:1.irion.
While drngncd primarily fbr people IVith diabetes and oLhcrs who mu~t folio" ~rcc1.1l diet~, the cxch.111g.: list~ are ba~cd on prindplcs of good nutrition th.ll appl)
to everyone. Copyright© 2003 by the Amcri c~ n Diabetes Association .1nd th\: Amtrican Dietetic Asmci.1tion.
A-70
Vegetable Exchange List

(5 g carbohydrate, 2 g protein, 0 g fat, 25 kcal )
1 vegetable exchange equals:
~ cup cooked vegetables or vegetable juice
1 cup ra\\' \'egerables
artichoke cucumber peppers (all varieties)
artichoke hearcs eggplant radishes
asparagus green onions or scallions salad greens (all varieties)
beans (green, wax, Italian) greens (e.g., collard) sauerkraut
bean sprouts kohlrabi spinach
beers leeks squash (summer)
broccoli mixed \'egerables (without corn, romato (fresh, canned, sauce)
brussels sprouts peas, or pasta) romato/vegctable juice
cabbage mushrooms turnips
carrots okra water chest.nuts
cauliflower onions watercress
celery pea pods zucchini
Fruit Exchange List

Fruit
( 15 g carbohydrate, 0 g protein, 0 g fat, 60 kcal )
1 fruit exchange equals:
l (4 oz) apple, unpeeled (small) 1 (4 oz) peach, fresh (medi um)
4 rings apple, dried Mcup peaches, canned
Mcup applesauce (unsweetened) ~ (4 oz) pear, fresh
4 ( 5 ~ oz) apricots, fresh ~ cup pear, canned
8 halves apricots, dried X cup pineapple, fresh
~ cup apricots, canned ~ cup pineapple, canned
l (4 oz) banana (small} 2 ( 5 oz) p lums (smaU)
~ cup blackberries M cup plums, canned
11
cup blueberries 3 plums, dried (prunes)
!.s melon ( 11 oz ) cantaloupe (small ) 2 tbsp raisins
1 cup cubes cantaloupe l cup raspberries
12 (3 oz) cherries rn cups strawberries (raw, whole)
~ cup cherries, canned 2 (8 oz} tangerines (small)
3 dates 1 slice ( 13 ~ oz) watermelon (or rn cups cubes )
2 ( 3Moz) figs, fresh (large )
rn figs, dried
Fruit Juice
M cup fruit cocktai l
M ( 11 oz) grapefruit (large ) ~ cup apple juice/cider
;i: cup grapefruit sections, canned ~ cup cranberry juice cocktail
17 ( 3 oz) grapes (small ) 1 cup cranberry juice cocktail,
l ~lice (10 oz) honeydew melon (or 1 cup cubes) reduced-calorie
1 (3Moz) kiwi ~ cu p fruit juice blends, 100% juice
}: cup mandarin orange sections ~ cup grape juice
~( S M oz) mango (or l1 cup} Mcup grapefruit juice
I ( 5 oz ) nectarine (small ) Mcup orange juice
I (6Jfoz) orange (small ) M cup pineapple juice
~ (8 oz) papaya (or 1 cup cubes) !{ cup prune juice
A-72 Appendix F Exchange System Lists
Starch Exchange List

(15 g carbohydrate, 3 g protein, 0-1 g fat, 80 kcal)
l starch exchange equals:
Bread
~ ( l oz) bagel Mcup plantain
2 slices ( rn oz) bread, reduced-calorie !-' cup or
1 slice ( 1 oz) bread, white, whole-wheat, Mmedium ( 3 oz) potato, boiled
pumpernickel, or i·ye ~ large (3 oz) potato, baked with skin
4 ( ~ oz) bread sticks, crisp, 4 inch X Minch Mcup potato, mashed
~ English muffin 1 cup squash, winter (acorn, butternm,
~ (1 oz) hot dog o r hamburger bun pumpkin)
x naan, 8 inch X 2 inch Mcup yam, sweet potato, plain
1 pancake, 4 inch across X X inch thick
M pita, 6 inches across
Crackers and Snacks
1 slice ( 1 oz) raisin bread, unfrosted
1 ( 1 oz) roll, plain (small ) 8 animal crackers
1 tortilla, corn, 6 inches across 3 graham crackers, 2M-inch squ.m.:
1 tortilla, flour, 6 inches across x oz matzoh
~ tortilla, flour, l 0 inches across 4 slices mclba coast
1 waffle, 4 inches square or across, 24 oyster crackers
reduced -fat 3 cups popcorn (popped, no fat added or
low-fat microwave)
%oz pretzels
Cereals and Grains
2 rice cakes, 4 inches across
~ cup bran cereal 6 saltine-type crackers
Mcup bulgur 15- 20 (% oz) snack chips, fat-free {torrilla,
Mcup cereal, cooked potaro)
X cup cereal, unsweetened, ready-ro-cac 2- 5 (~ oz ) whok-\\'heat crackers, no
3 tbsp cornmeal (dry) fat added
~cup couscous
3 tbsp flour (dry)
Dried Beans, Peas, and Lentils
Xcup granola, low-fat
X cup Grape-Nuts (Counts as l starch exchange plus l very Jean meat exchange )
Mcup g rits
!& cup beans and peas (garbanzo,
Mcup kasha
pinto, kidney, white, split,
Mcup millet
black-eyed )
~ cup muesli
;~ cup lima beans
Mcup oats
~ cup lentils
~ cup pasta
3 tbsp miso
rn cups puffed cereal
~cup rice, white or brown
Mcup Shredded Wheat Starchy Foods Prepared with fat
Mcup sugar-frosted cereal
(Counts as l starch exchange plus 1 fat exchange)
3 tbsp wheat germ
biscuit, 2M inches across
:6 cup cho\\' mcin noodJes
Starchy Vegetables l (2 oz) corn bread, 2-inch cube
~ cup baked beans 6 crackers, round burrer n ·pe
~ cup corn l cup croutons
M( 5 oz) corn on che cob (large) 1 cup (2 oz) French-fried potatoes (O\'en-bakcd)
1 cup mixed vegetables with corn, (sec also the fast-foods list)
peas, or pasta l4 cup granola
Mcup peas, green Xcup hummus
www.mhhe.com/ wardlawpers7 A· 73
Starchy Foods Prepared with Fat (continued)

·~ ( l oz ) muffin, 5 oz h cup sruffmg, bread (prepared )
3 cups popcorn, microw:l\'ed 2 taco shell, 6 inches across
3 sandwich crackers, cheese or pcanur 1 waffle, 4 -inch square or across
buLter tilling 4-6 (l oz) whole-wheat crackers, fat added
9- 13 (?.: oz) snack chips (pot.no, tortilla)
Other Carbohydrates Exchange List

One exchange equals 15 g carbohydrate, or 1 starch, or I fruit, or 1 milk.
Exchanges per Serving
)l~ thcake (about 2 oz) angel food cake, unfrosted 2 carbohydrates
2 -inch square (about 1 oz ) brownie, unfrosted (small) 1 carbohydrntc, 1 fat
2 -inch square (abou t 1 oz) ca kc, unfrosted 1 carbohydrate, l fat
2 -inch square (about 2 oz) cake, frosted 2 carbohydrates, l fat
2 cookies, fat-free (small ) 1 carbohydrate
2 (about 1S oz ) cookies or sandwich cookies \\ith creme filling (small) l carbohydrate, 1 fat
4 cup cranberry sauce, jellied 1!1 carbohydrates
1 (:ibout 2 oz) cupcake, frosted (small) 2 carbohydrates, l fat
l ( JM oz) doughnut, plain cake ( medium ) rn carbohydrates, 2 fats
3 ... inches across (2 oz ) doughnuts, glazed 2 carbohydrates, 2 fats
I bar ( rn oz ) Ener~, sport or breakfast bru· 2 carbohydrates, 1 far
1 bar (2 oz) Energy, sport or breakfast bar 3 carbohydrates, 1 fat
~ cup (3 ~ oz) fruit cobbler 3 carbohyd rates, l fat
1 bar ( 3 oz) fruiL juice bars, frozen, 100% juice 1 carbohydrate
l roll (% oz) fruit snacks, che\\} (pureed fruir concentrate ) l carbohydrate
l tbsp honey 1 carbohydrate
1 tbsp sug:ir 1 carbohydrate
l ~ tbsp fruit spread, l 00% fru it l carbohydrate
~ rnp gelatin, reguJar 1 carbohydrate
3 gingersnaps 1 carbohydrate
1 bar ( 1 oz ) granola or snack bar (regular and IO\\ -fat) rn carbohydrates
l.: cup ice cream, low-fat 1!1 carbohydrates
~ cup ice cream 1 carbohydrate, 2 fats
~ cup ice cream, light 1 carbohydrate, 1 fat
~ cup ice cream, fat-fret:, no sugar added 1 carbohydrate
l tbsp jam or jell), regul.lr 1 carbohydrate
1 cup milk, chocolate, whole 2 carbohydrates, 1 fat
J<. pie pie, fruit, 2 crust.'> (8 inches acro~s) 3 carbohydrates, 2 fats
Ji: pie pie, pump kin or cusrard ( 8 inches <Kross) 2 carbohydrates, 2 fats
~ cup pudding, regular (made with reduced-fat milk) 2 carbohydrates
~ cup pudding, sugar-free (made with fat-free milk) 1 carbohydrate
1 can (10- 1 l oz ) reduccd-c:ilorie me JI replaccmt:nt (shake) rn carbohydrates, 0- 1 fat
l cup rice milk, low-faL or fat-free, plain 1 carbohydrate
1 cup riet: milk, low-faL, flavored 1~ carbohydrates
Y. cup salad dressing, fat free 1 carbohydrate
~ cup sherbet, sorbet 2 carbohydrates
'· cup spaghetti or pasta sauce, canned 1 carbohydrate, 1 fat
1 cup (8 oz) sports drinks 1 carbohydrate
l tbsp sugar 1 carbohydrate
I ( 2~ oz) sweet roll or Danish 2 ~ carbohydrates, 2 fats
2 tbsp syrup, light 1 carbohydrace
J tbsp syrup, regular 1 carbohydrate
5 vanilla wafers 1 carbohydrate, 1 fat
~ cup yogurt, frozen, fat-free 1 carbohydrate
l cup yogurt, low-fat'' ith fruit 3 carbohydrates, 0-1 fat
A·7 4 Appendix F Exchange System lists
Meat and Meat Substitutes Exchange List

Very Lean Meat and Substitutes List
(0 g carbohydrate, 7 g protein, 0- 1 g fat, and 35 kcal )
One very lean meat exchange equals:
Poultry Other
l oz chicken o r turkey (white meat, no skin), l oz processed sandwich meats with 1 g or less fat
Cornish hen ( no skin) per oz, such as ddi thin, shaved me:us, chipped
Fish beef, turke), ham
1 oz fresh or frozen cod, flounder, haddock, halibut, 2 egg whites
trout; runa, fresh or canned in water lt: cup egg substitute, plain
Sh ellfis h 1 oz hot dogs with l g or less fat per oz
l 07 clam s, crab, lo bster, scallops, shrimp, l oz kid ney ( hig h in cholesterol)
imitatio n shellfish l oz sausage with 1 g o r less fat per o z
Gaine
1 O.l duck or pheasant (no skin ), venison, buffalo, Counts as one very lean meat and one st.uch
ostrich exchange:
Cheese with 1 g or less fat per oz
l4 cup fat-free or low-fat cartage chee!.e ~ cup dried beans, pea~ , lentils (cooked )
l oz fat-free cheese
Lean Meat and Substitutes List

(0 g carbohydrate, 7 g protein, 3 g fac, and 55 kcal)
One lean meat exchange equals:
Beef Fish
1 oz USD A Select o r Choice grades of lean beef l oz herring (uncreamed o r smo ked )
trimmed of fat, such as ro und, sirloin, and flank 6 oysters (medium )
steak; tenderloin; roast (rib, chuck, rump); steak 1 oz salmon (fresh o r canned ), catfish
(T-bone, porterhouse, cubed ), ground round 2 sardines (canned, medimn )
Pork l oz tuna (canned in oil , drained )
1 oz lean pork, such as fres h ham ; canned, cured, or Game
bo iled ham; Canadian bacon; tenderlo in , center l oz goose (no skin ), rabbit
loin chop C heese
Lamb xClip 4 .5%- fat cottage cheese
1 oz roast, chop, leg 2 tbsp grated Parmesan
Veal 1 oz cheeses with 3 g or less fat per oz
1 oz lean chop, roast Other
Poultry rn oz hot dogs with 3 g or less far per oz
l oz chicke n, tu rkey (dark meat, no skin), chicken l oz processed sandwich meat with 3 g or lc s~ far per
white meat (with skin ), do mestic duck o r goose oz, such as turkey pastrami o r kiel basa
(well drained of fat, no skin) 1 oz liver, heart (high in cholesterol)
Medium-Fat Meat and Substitutes List

(0 g carbohydrate, 7 g protein, 5 g fat, and 75 kcal)
One medium-fat meat exchange equals:
Beef Lamb
l oz most beef products (ground beef~ 1 oz rib roast, grou nd
meatloaf, corned beef, short ribs, prime grades VeaJ
of meat trimmed of fat, such as 1 oz cutlet (ground or cubed, unbreadcd )
prime rib) P o ultry
Pol'k 1 oz chicken dark meat (with skin), ground turkey or
l oz top lo in , chop, Bosto n butt, cutlet ground chicken, fi·ied chicken (with skin )
Fish Other
] oz any fried fish product 1 egg (high in cholesterol, limit to 3 per \\'eek)
Cheese (with 5 g or less fat per oz) 1 oz sausage with 5 g o r less fat per oz
1 oz feta X cup tempeh
l oz mozzarella 4oz (~ cup ) rofu
4cup (2 oz) ricotta
High-Fat Meat and Substitutes List

(0 g carbohydrate, 7 g protein, 8 g fat, and I 00 kcal )
One high-fat meat exchange equals:
Pork Other
l oz spareribs, ground pork, pork sausage 1 oz processed sandwich meats with 8 g or less fat per
Cheese oz, such as bologna, pimento loaf, salami
l oz all regular cheeses, such as American, chedd.1r, 1 oz sausage, such as bratwurst, Italian, knockwurst,
Monterey Jack, Swiss Polish, smoked
hot dog ( turkey or chicken) ( 10 per pollt1d )
3 slices bacon (20 slices per pound)
Counts as one high -fat meat plus one fat exchange:

1 hot dog (beef, pork, or combination )
( l 0 per pound )
Fat Exchange List
Monounsaturated Fats List
(5 g fat and 45 kcal )
One exchange equals:
2 tbsp ( I oz) a\'Ocado (meruum ) 6 nuts mixed (50% peanuts)

1 tsp oil ( canola, olive, peanut) I 0 nuls peanuts
olives: 4 halves pecans
8 ripe, black (large) Mtbsp peanul butter, smooth or crunchy
10 green, stuffed (large) l tbsp sesame seeds
6 nuts almonds, cashews 2 tsp tahini or sesame paste
Polyunsaturated Fats List

(5 g fut and 45 kcal )
margarine: salad d ressing:
l tsp stick, rub, or squeeze l tbsp regular
1 tbsp lower-fat ( 30 to 50% ,·egetablc oil) 2 tbsp reduced-fat
mayonnaise: Miracle vVhip Salad Dressing:
l tsp regular 2 tsp regular
l tbsp reduced -fat l tbsp reduced-fat
4 halves nuts, walnuts, English 1 tbsp seeds: pumpkin, sunflower
I tsp oil (corn, sa.ffiower, soybean )
Saturated Fats List

( 5 g fat .md 45 kcal )
1 slice bacon, cooked (20 slices per pound ) butter:
1 rsp bacon, grease l rsp stick
2 tsp whipped
l tbsp red uccd-fa r
A-76 Appendix F Exchange System Lists
2 tbsp (M oz) chitterlings, boi led sour cream:

cream cheese: 2 tbsp regular
1 tbsp (M oz) regular 3 tbsp reduced-fat
2 tbsp (1 oz) reduced-fat
1 tsp shortening or lard
Free Foods List

A ft·ce food is any food or drink that conrains less than 20 kcal or less than 5 g of carbohydrate pc:r st~rving. Foods wirh a serving si1e
listed should be limited LO Lhree servings per da>'· Food~ listed without a serving size an be eaten as often as }'OU like.
Fat-Free or Reduced-Fat Foods

L tbsp (!1 oz) cream cheese, fat-free I tbsp salad dressing, fut-free
1 tbsp creamers, nondairy, liquid nonstick cooking spray
2 tsp creamers, nondairy, powdered 1 tbsp salad dressing, for-free or low fat, Italian
1 tbsp mayonnaise, fat-free 2 tbsp salad dressing, fat-free, kllian
1 tsp mayonnaise, reduced-fur l tbsp sour crean1, fac -free, reduced-fat
4 tbsp margarine, fat-free l rbsp whipped topping, regular
I tsp margarine, reduced-fut 2 tbsp whipped topping, light or fut free
I tbsp Miracle Whip, fut-free
1 tsp ~1iracle Whip, reduced-far nonstick
cooking spray
Sugar-Free Foods
l candy candy, hard, sugar-free 2 tsp jam or jeUy, light
gelatin dessert, sugar-free sugar substitutes*
gelatin, u nflavored 2 tbsp syrup, sugar-Ii-cc
gum, sugar-free
Drinks
bouillon, broth, consomm<! coftee
boui llon or broth, low-sodi um diet soft drinks, sugar-free
carbonated or mineral water drink mixes, sugar-free
club soda tea
I tbsp cocoa powder, lL11swecccned tonic water, sugar-free
Condiments
I tbsp catsup 2 slices pickles, sweet (bread and butter)
horseradish x 01 pickles, sweet (gherkin )
lemon juice ~ cup salsa
lime juke 1 tbsp soy sauce, regular or light
mustard l tbsp t:ico sauce
l tbsp pickle relish vincg:ir
l~ pickles, dill (medium) 2 tbsp yogurt
•:-.ugar subsrirmc~. altcrnati\·es, or rcpl.1ccmenrs that arc .1ppro\ cd h} tlw him.I Jilli Drug Admi1ti.strntion ( FDA) are safe ro u~c . Common brand names include :
bqual (asparramc )
Spknda (sucr.ilo~c )
Sprinkle Sweet b.1ccharin )
Sweet One ( .m:~ulfame K )
Sweet- I 0 I s.1cd1arin )
Sugar T\\;n (\,tcch.mn )
Sweet 'N Low (s.icclurin l
Seasonings
fla\'oring extracts spice~
garlic Tabasco or hot pepper sauce
herbs, fresh or dried wine, used in cooking
pirnenro Worcestershire sauce
Combination Foods List

E n trees Exchanges per Serving
l cup (8 oz) runa noodle casserole, lasagna, spaghetti with 2 carbohydrates, 2 medium -fat meats
mearballs, chili with beam, macaroni and cheese
2 cups (16 oz ) chow mein (without noodles or rice ) 1 carbohydrate, 2 lean meats
~ cup (3Moz ) runa or chicken salad ll carboh)rdrate, 2 lean meats, 1 far
F rozen Enrrees and M eals
generally 14-17 oz dinner-type meal 3 carbohrdratcs, 3 medium-far meats, 3 fars
3 oz meatless burger, soy-based ~ carbohydrate, 2 lean meats
3 oz meatless burger, vegetable and srarch-ba~ed 1 carbohydrate, 1 lean meat
V. of 12-inch ( 6 oz) pizza, cheese, thin crust 2 carbohydrates, 2 medium-fat meats, l fat
X of 12-inch (6 oz) pizza, meat topping, thin crust 2 carbohydrates, 2 medium -fut meats, 2 faLs
l (7 oz) pot pie 2 ~ carbohydrates, l medium -fat meat, 3 fat~
8-11 oz emree or meal witl1 less than 340 kcal 2- 3 carbohydrates, 1-2 lean meats
Soups
1 cup bean l carbohydrate, 1 very lean mear
1 cup (8 oz) cream (made with water) l carbohydrate, l fat
6 oz prepared instant l carbohydrate
8 oz prepared instant with beans/lentil:, 2 ~ carbohydrates, l \'cry lean meat
M cup (4 oz) split pea (made with water) 1 carbohydrate
1 cup (8 oz) tomato (made with water) 1 carbohydrate
1 cup (8 oz) vegetable beef, chicken noodle, or otl1er broth-type I carbohydrate
Fast-Foods
Exchanges per Serving
l (5-7 oz) burritos with beef 3 carbohydrates, 1 medium-fut meat, l fat
6 chicken nuggets l carbohydrate, 2 medium-fat meats, l fat
leach chicken breast and wing, breaded and fried l carbohydrate, 4 medium-fat meats, 2 fats
l chicken sandwich, grilled 2 carbohydrates, 3 \'Cry lean meats
6 ( 5 oz ) chicken wings, hot 1 carbohydrate, 3 medium-fat meats, 4 fats
1 fish sandwich/tartar sauce 3 carbohydrates, l medium-fat meat, 3 fats
l medium serving (5 oz) French fries 4 carbohydrates, 4 fats
1 hambrnger ( regular) 2 carbohydrates, 2 medium-fat meats
1 hamburger ( l.1rge) 2 carbohydrates, 3 medium-fut meats, l fat
1 hot dog with bun 1 carbohydrate, 1 high-fat meat, l fat
l individual pan pizza 5 carbohydrates, 3 medium-fat meats, 3 fats
X 12-inch (about 6 oz) pizza, cheese, thin crust 2~ carbohydrates, 2 medilm1 -faL meats
)4 12-inch (about 6 oz) pizza, meat, thin crust 2 ~ carbohydrates, 2 medium-fat meats, l fat
l (5 oz) soft-serYe cone (small) 2 ~ carbohydrates, 1 fat
l sub ( 6 inches) submarine sandwich 3 carbohydrates, 1 ,·egetable, 2 medium-fat
meats, 1 fat
l (3-3ll oz) taco, hard or soft shell 1 carbohydrate, J medium-fat meat, l fat
•
a en IX
DIETARY INTAKE AND ENERGY
EXPENDITURE ASSESSMENT
Although it may seem O\'erwhclming at first, it is actually very easy to track the foods
you eat. One tip is to record foods and be\'erages consumed as soon as pos5ible after
the acmal time of consumption.
I. FilJ in the food record form that folJows. This appendix contains a blank
copy (see the completed example in Table G-1 ). T hen, to esti mate the nutrient values
of the foods you arc eati11g, consult food labels and the food composition table in this
book (AppendiA N ), or use the nutrition software package a\'ailablc with rhis book. If
these resources do not have the serving size you need, adjust the value. ff you drink 1
cup of orange juice, for example, but a table has \'alues only for I cup, hake all ,-alucs
before you record them. Then, consider pooling all che same food to Sa\'c time; if you
drink a cup of 1% milk tlu·ec times throughout the day, enter )'Our milk consumption
only once as 3 cups. As you record your intake for use on t11e nurricm <lnalysis form
that follows, consider the following tips:
• Measure and record t11e amounts of foods eaten in portion sizes of cups, teaspoons,
tablespoons, ounces, slices, or inches (or con\'ert metric units to these units).
• Record brand names of all food products, such as "Quick Quaker Oats."
• .Measure and record all t11ose little extras, such as gravies, salad dressings, taco
sauces, pickles, jelly, sugar, catsup, and margarine.
• For beverages
-List t11e type of milk, such as whole, skim, 1%, evaporated, chocolate, or recon·
stituted dry.
-Indicate "hether fruit juice is fresh, frozen, or canned.
-Indicate type for other beverages, sucb as fruit dJ·i.nk, fruit-flavored drink, Kool·
Aid, and hot chocolate made with water or milk.
• For fruits
-Indicate whether fresh, frozen, di-ied, or canned .
-If\\'holc, record number eaten and size with approximate measurements (such as
l apple- 3 in. in diameter).
-Indicate whether processed in water, light S)'rup, or hea,·y syrup.
• For vegerabks
-Indicate whether fresh, frozen, d ried, or canned.
-Record as portion of cup, teaspoon, or tabkspoon, or as pieces (such as carror
sticks--4 in. long, ~ in . d1ick).
-Record preparation method.
• For cereals
-Record cooked cereals in portions of tablespoon or cup (a level measurement
after cooking).
-Record dry cereal in le\'el portions of tablespoon or cup.
A-78
www.mhhe .com/wardlawpers7 A-79
- If margarine, milk, sugar, fruit, or something else is added, measure and record
amow1t and type.
• For breads
- Indicate whether whole wheat, rye, white, and so on.
- Measure and record number and size of portion (biscuit- 2 in. across, l in . thick;
slice of homemade rye bread-3 in. by 4 in., %in. thick).
- Sand\s,ilches: list n.ll ingredients (lettuce, mayonnaise, tomato, and so on).
• For meat, fish, poultry, and cheese
- Give size (length, width, thickness) in inches or weight in ounces after cooking for
meat, fish, and poultry (such as cooked hamburger patty- 3 in . across, ~ in. thick).
- Gi"e size (length, width, thickness) in inches or weight in ounces for cheese.
- Record measurements only for the cooked, edible part- without bone o r fat that
is lefr on the plate.
- Describe how meat, pouJrry, or fish was prepared.
• For eggs
- Record as soft or hard cooked, fried, scrambled, poached, or omelet.
- If milk, butter, or drippings are used, specify kinds and amount.
• For desserts
- List commercial brand or "'homemade" or "bakery" under brand.
- Purchased candies, cookies, and cakes: specif)• kind and size.
- i\lcasure and record portion size of cakes, pies, and cookies by specifying thick-
ness, diameter, and width or length, depending on the item.
Minutes M Reason
TIme Spent Eating ors· Activity While Eating Place of Eating Food and Quantity Others Present for Choice
·M or S: Meal or snack
IH: Degree of hunger jO = none; 3 moximum)
A-80 Appendix G Dietary Intake and Energy Expenditure Assessment
Table G·1 One Day's Food Record-This Activity Can Help You Understand More about Your Food Habits
Minutes M Ht Reason
TI me Spent Eating ors· (0-3) Activity While Eating Place of Eating Food and Quantity Others Present for Choice
7·10 A.M. 15 M 2 Standing, fixing lunch Kitchen orange juice, 1 cup Health
Crispix, 1 cup Habit
Reduced-lat milk, ~ cup Heolth
Sugar, 2 tsp Taste
Black coffee Habit
10:00A.M. 4 s 1 Sitting, toking notes Classroom Diet cola, 12 oz Closs Weight control
12:15 P.M. 40 M 2 Sitting, talking Student union Chicken sandwich Friends Toste
with lettuce and
mayonnaise
(3 oz chicken,
2 slices of bread,
2 tsp mayonnaise)
Pear, 1 medium Health
Reduced-fat milk, 1 cup Health
2:30 P.M. JO s Sitting, studying Library Regular cola, 12 oz Friend Hunger
6:30 P.M. 35 M 3 Sitting, talking Kitchen Pork chop, 1 Boyfriend Convenience
Baked potato, 1 Health
Margarine, 2 tbsp Toste
Lettuce and tomato Health
salad, 1~ cups
Ranch dressing, 2 tbsp Toste
Peas,~ cup Health
Whole milk, l cup Hobit
Cherry pie, l small piece Taste
Ice tea, 12 oz Health
9:10 P.M. 10 s 2 Sitting, studying Living room Apple, l Weight control
Gloss mineral wafer, 1 Weight control
•Mor S: Meof or snock
IH, Degreeof hunger (0 .. none; 3 =moximum)
II. Now complete the nutrient analysis form as s hown, using your food
record. A blank copy of this form is printed in this appendix for your use. Note that
the diet analysis software available with this book will create such a ta bk for you if vou
simply enter all food eaten.
A·82 Appendix G Dietary Intake and Energy Expenditure Assessment
Nutrient Analysis Form (Sa mple)
-
..E
a;
1
~
·~
c ..§..
0 c
:>
Name CJ _g
Egg bagel, 3 5 in. diameter 180 7.45 34.7 0.748 1.00 0.286 0.400 0.171 44.0 20.0 2.10
Jelly 1 tbsp 49.0 0.018 12.7 0.018 0.005 0.005 0.005 2.00 0.120
Orange juice, prepared
fresh or frozen l \4 cups 165 2.52 40.2 1.49 0.210 0.037 0.045 0.025 33.0 0.411
Cheeseburger, McDonald's 2 636 30.2 57.0 0.460 32.0 12.2 2.18 13.3 80.0 338 5.68
French fries, McDonald's 1 order 220 3.00 26.1 4. 19 11.5 4.37 0.570 4.61 8.57 9. 10 0.605
Colo beverage, regular rn cups 151 38.5 9.00 0.120
Pork loin chop, broiled, leon 4 oz 261 36.2 11.9 5.35 1.43 4.09 112 5.67 1.04
Baked potato with skin 220 4.65 51.0 3.90 0.200 0.004 0.087 0.052 20.0 2.75
Peas, frozen, cooked l4 cup 63.0 4.12 11.4 3.61 0.220 0.019 0.103 0.039 19.0 1.25
Margarine, regular or soh,
80% fat 20g 143 0.160 0.100 16.1 5.70 6.92 2.76 5.29
Iceberg lettuce, chopped 2 cups 14.6 1.13 2.34 1.68 0.212 0.008 0.112 0.028 21.2 0.560
French dressing 2 oz 300 0.318 3.63 0.431 32.0 14.2 12.4 4.94 7.10 0.227
Reduced fat milk 1 cup 121 8.12 11.7 4.78 1.35 0.170 2.92 22.0 297 0.120
Graham crackers 2 60.0 1.04 10.8 1.40 1.46 0.600 0.400 0.400 6.00 0.367
Totals 2584 99.0 300 17.9 112 44.1 24.8 33.4 266 792 15.4
RDA or related nutrient standard* 2900 58 130 38 1000 8
'?"o of nutrient needs 89 170 230 47 79 193
Abbreviations: g =groms, mg milligrams, µg = micrograms
'Values from inside cover. The values listed ore for a mole age 19 yeors. Note that number of kcol is just a rough estimate. II is better to base energy needs on actual energy output
lin RAE units. Table values generally ore in RE units today because the food values have not been updated lo reflect the latest vitamin A standards RAE equal RE lor foods with preformed vitamin A,
such os f0< the pork chop, but RAE are only abaul half the RE listed f0< foods with provitamin A corotenoids, such os for the peas (see Chapter 9 for details)
I Amounts refer lo actuol lolale content rather !hon dietary lolate equivalents IDFE) This diffe<ence is important to consider ii the food contains added synthetic folic acid as part ol enrichment 0< l0<tilico-
11on Any such lolic acid is absorbed about twice as much os the folote present noturolly in foods So the Iola! contribution of folote in the food in comporoson lo human needs will be greole< than if aft
the folote wos naturally in the food product. Nufrienl analysis tobles have yet to be updated to reffed the dietary folole equivalents of products (see Chapter I 0 10< more detoils).
Nutrient Analysis Form (Sample) cont'd
m m m
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18.0 61.0 65.0 300 0.612 7.00 1.80 2.58 0.197 2.40 0.030 16.3 0.065
0.720 1.00 16.0 4.00 0.200 0.7 10 0.016 0.002 0.005 0.036 0.005 2.00
36.0 60.0 711 3.00 0.192 28.5 145 0.714 0.300 0.060 0.750 0.165 163
45.8 4 10 314 1460 5.20 134 4. 10 0.560 0.600 0.480 8.66 0.230 42.0 1.82
26.7 101 564 109 0.320 5.00 12.5 0.203 0.122 0.020 2.26 0.218 19.0 0.027
3.00 46.0 4.00 15.0 0.049
34 .0 277 476 88.2 2.54 3.15 0.454 0405 1.30 0.350 6.28 0.535 6.77 0.839
55 .0 115 844 16.0 0.650 26.1 0.100 0.216 0.067 3.32 0.701 22.2
23.0 72.0 134 70.0 0.750 53.4 7.90 0.400 0.226 0.140 1.18 0.090 46.9
0.467 4.06 7.54 216 0.04 1 199 0.028 2.19 0.002 0.006 0.004 0.002 0.2 11 0.0 17
10. l 22.4 177 10. 1 0.246 37.0 4.36 0. 120 0.052 0 034 0.210 0.044 62.8
5.81 3.63 7.03 666 0.045 0.023 15.9 0.006
33.0 232 377 122 0.963 140 2.32 0.080 0.095 0.403 0.210 0.105 12.0 0 888
6.00 20.0 36.0 86.0 0.113 0.020 0.030 0.600 0.011 1.80
298 1425 3732 3165 11.7 607 204 22.5 5.52 1.79 25.9 2.14 395 3 65
400 700 4700 1500 11 900t 90 15 1.2 1.3 16 1.3 400* 2.4
75 204 80 210 106 67 226 150 450 138 162 160 99 152
Nutrient Analysis Form
3
3
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Totals
RDA or related nutrient standard*
% of nutrient needs
' Values from onside cover Note that number of kcols is just o rough eslimole. II is bener lo base energy needs on actual energy output
'Use RAE values, even though food table is based on RE units.
IUse DFE values, even though the food is based on total folote content, irrespective of natural or synthetic source.
Nutrient Analysis Form cont'd
a; 17> ~
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A·86 Appendix G Dietary Intake and Energy Expenditure Assessment
III. Complete the following table as you summarize your dietary intake.
Percentage of kcal from Protein, Fat, Carbohydrate, and Alcohol

Intake
Protein (P): _ g/day X 4 kcal/g (P) _ kcal/day
Fat (F): _ g/day x 9 kcal/g (F) _ kcal/day
Carbohydrate (C) : _ g/day X 4 kcal/g (C) _ kcal/day
Alcohol (A): (A) __ kcal/day*
Total kcal (T]/day (T] _ kcal/day
Percentage of kcal from protein:
1!L_ x 100 = %
(T]
Percentage of kcal from fat:

tB_ xlOO = %
(T)
Percentage of kcal from carbohydrate:
!fl_ x 100 = _ %
(T)
Percentage of kcal from alcohol:
(A) x 100 = %
(T)
NOTE: The four percentages con totol 99, 100, or I0 l, depending on lhe way in which figures were rounded off earlier.
*To calculate how many kcal in a beverage are from alcohol, look up lhe beverage in Appendix N. Determine how many kcal ore
from carbohydrate (muhiply corbohydrole grams limes 4), fol (fat grams limes 9), and protein (protein grams times 4). The remaining
kcal ore from alcohol.
IV. Use the table on the following page to again record your food intake for
one day, placing each food item in the correct category of MyPyramid, with the
correct number of servings (see pages 58-59 in Chapter 2). Note that a food such
as roast \.vith soft margarine conu·ibutes to two categories-namely, to the grain group
and ro th~ oils group. You can expect that many food choices will contLibute to more
than one group. Indicate the number of servings from the My Pyramid that each food
vields.
Indicate the Number of Servings from MyPyromid That Each Food Yields
Food or Beverage Amount Eaten Milk Meat & Beans Fruits Vegetables Grains Oils
Group totals
Recommended servings
Shortages in
numbers of servings
V. Evaluation. Are there weaknesses suggested in yow- nutrient intake that corre-
spond to missing servings in MyP)rntmid? Consider replacing the missing servings ro
improve your nutrient intake.
VI. For the same day you keep your food record also keep a 24-hour record
of yoW' activities. Include sleeping, sitting, and walking as well as the obvious forms
of exercise. Calculate your energy expenditure for these activities using Table 13-6 in
Chapter 13 or the software available with this book. Try to substitute a similar activity
if your particular activity is not listed. Calculate the total kcal you used for the day.
Following is an example of an activity record and a blank form for your use. Ask your
profossor whether you are to turn in the form or the activity printout from the
software.
Weight (kg)*: 70 kg
Energy Cost
Column 1 Column 2 Column 3
Time (Minutes): kcal/kg/hr (Column 1 x (Column 2 x
Activity Convert to Hours (from Table 13·6) Time) Weight in kg)
Brisk walking (60 min) l hr 4.4 (x 1) = 4.4 (x 70) = 308
'lb/2.2
Weig ht (kg)*:
Energy Cost
Column 1 Column 2 Column 3
Time (Minutes): kcal/kg/hr (Column 1 X (Column 2 x
Activity Convert to Hours (from Table 13·6) Time) Weight in kg)
Total kcal used (add all items listed in column 3)

'lb/2.2
•
a en IX
FATIY ACIDS, INCLUDING OMEGA-3
FATIY ACIDS, IN FOODS
Chain Length, Number, and Site of Double Bonds for Common Fatty Acids
Common Nome of Fatty Acid Number of Carbon Atoms and Number and
Site of Double Bond(s), Counting from Methyl
End (-CH 3) if Appropriate
Saturated Fatty Acids (No Double Bonds)
Formic 1
Acetic 2
Propionic 3
Butyric 4
Valerie 5
Coproic 6
Coprylic 8
Copric 10
Lourie 12
Myristic 14
Polmitic 16
Steoric 18
Unsaturated Fatty Acids
Oleic 18:1 (9-10) w-9
linoleic 18:2 (6-7, 9-10) w-6
Alpho-linolenic 18:3 (3-4, 6-7, 9-10) w-3
Arochidonic 20:4 (6-7, 9-10, 12-13, 15-16) w-6
Eicosopentoenoic 20:5 (3-4, 6-7, 9-10, 12-13, 15-16) w-3
Docosohexoenoic 22:6 (3-4, 6-7, 9-10, 12-13, 15-16, 18-19) w-3
A· 89
A-90 Appendix H Fatty Acids, Including Omega-3 Fatty Acids, in Foods
Fatty Acid Composition of Selected Foods*

Fatty Acidt
So tu roted Unsaturated
C18:1 C18:2 C18:3 C20:5 C22:6
Food Item C12:0 C12:0 14:0 C16:0 C18:0 w-9 w-6 w·3 w-3 w·3
Alpha·
Lourie Myristic Polmitic Steoric Oleic Linoleic linolenic
Fats and Oils Acid Acid Acid Acid Acid Acid Acid EPM OHM
Beef !allow 0.90 3.70 24.9 18.9 36.0 3.1 0.60
Butter 7.0 2.20 8.10 21.3 9.8 20.4 l.8 1.20
Cocoa butter 0.10 25.4 33 .2 32.6 2.8 0.10
Corn oil 11.0 2.0 25.0 58.0 0.70
Cottonseed oil 0.80 22.7 2.3 17.0 51.5 0.20
lard 0.1 0.20 1.30 23 15.2 40.9 9.7 1.10
Olive oil 11.0 2.5 72.5 7.5 0.60
Palm kernel oil 7 47.00 16.40 8.1 2.8 11.4 1.6
Palm oil 0.10 l.00 43.5 4.3 36.6 9. 1 0.20
Safflower oil 4.2 1.9 14.4 74.6
Shortenings 0.2 0.10 l.60 23.0 15.2 41.0 9.7 1.10
Margarine, slick 0.20 9.7 6.0 36.0 24.3 1.10
Margarine, tub 0.100 8.7 5.0 37.3 24.6 l.10
Conole oil 4.0 18 56.0 20.3 9.30
Soybean oil 14.0 4.0 29.0 45.0 3.00
Coconut oil 14.0 45.00 17.00 8.2 3.0 6.0 l.8
Peanut oil 0.100 9.5 2.2 44.8 32.0
Cod liver oil 3.6 10.6 2.8 20.6 0.9 0.9 6 .9 11.0
Menhaden oil 8.0 15.1 3.8 14.6 2.2 1.5 13.2 4.9
Meat, Fish, and Poultry
Beef, lean only, uncooked 0 .04 0.50 4.0 2.1 6.5 0.4 0.16
Chicken, white meat, cooked 0.03 0.01 2.1 0.7 3.5 2.1 0.10 0.01 0.05
Salmon, coho, cooked 0.18 0.8 0.3 1.7 0.2 0.40 0.40 1 40
Tuna, lighl, canned in water 0.02 0.2 0.1 0.1 0.02 0.05 0.20
Nuts ond Seeds
Walnuts 4.4 1.6 8.8 38 9
Flaxseeds l.8 1.4 6.9 4.3 18.1
From USDA Nutrient Database far Standard Reference, Release I 3.
·Only major fatty acids are presented
lAlf values represent grams per 100 g edible portion.
•EPA eicosopentoenoic acid } . h . f d
1IS 011 OHy OCI S
DHA docosohexoenoic acid
•
a en IX
THE 1983 METROPOLITAN LIFE
INSURANCE COMPANY HEIGHT-WEIGHT
TABLE AND DETERMINATION OF FRAME SIZE
1983 Metropolitan Life Insurance Company Height-Weight Table*t

Women Men
Height Frame Height Frame
Ft. In. Small Medium Large Ft. In. Small Medium Large
4 10 102-111 109-121 118-131 5 2 128- 134 131-141 138-150
4 11 103- 113 l l l-1 23 120-134 5 3 130-136 133-143 140-153
5 0 104-115 113-126 122-137 5 4 132- 138 135-1 45 142-156
5 1 106-118 115-129 125-140 5 5 134-140 137-1 48 144-160
5 2 108-121 118-132 128-143 5 6 136-142 139-151 146-164
5 3 111-124 121-135 131 -1 47 5 7 138-1 45 142- 154 149-1 68
5 4 114-127 124-1 38 134-151 5 8 140- 148 145-1 57 152-172
5 5 117- 130 127-141 137- 155 5 9 142- 151 148-160 155-176
5 6 120-133 130-144 140-159 5 10 144- 154 151-1 63 158-1 80
5 7 123-1 36 133-147 143-163 5 11 146-157 154- 166 161-184
5 8 126-139 136-150 146-167 6 0 149- 160 157-170 164-188
5 9 129-1 42 139-153 149-170 6 l 152- 164 160- 174 168-192
5 10 132-145 142-156 152-173 6 2 155-168 164-178 172-197
5 11 135-148 145-159 155-1 76 6 3 158-172 167-182 176- 202
6 0 138-151 148- 162 158-179 6 4 162- 176 171-1 87 181-207
Reprinted courtesy of Metropoliton Life lnsuronce Compony, Stotislicol Bulletin.
Permission granted courtesy of Metropolitan life Insurance Compony, Slolisticol Bulletin.
·sased on a weight-height mortality study conducted by the Society of Actuaries and the Association of Life lnsuronce Medical Directors of America, Metropolitan Life Insurance Medical Directors of
America, Metropolitan life Insurance Company, revised 1983.
!Weights ot oges 25 to 59 based on lowest mortality. Height Includes 1-in. heel. Weight for women includes 3 lb for indoor clothing. Weight for men includes 5 lb for indoor clothing.
A-91
A-92 Appendix I The 1983 Metropolitan life Insurance Company Height-Weight Tobie and Determination of Frame Size
Using the Metropolitan Life Insurance Table

to Estimate Healthy Weight
The i\letropolitan Life Insurance table is a common method for estimating he.1lrh)
weight. The table lists for Jn) height the weight that is associated with a maximum hti:
span. The table docs not tell the healthiest weight for a li\'ing person; it simpl) lists rhi:
weight associated \\'ith longc,·iry.
Criticisms of this table stem from the inclusion of some people and the exclusion of
others. For example, only policyholders of lite insurance are included. In .i.ddirion ,
smokers are included, bur anyone over chc age of 60 is excluded. Weight is mc.1surcd
o nly at the time of purchase or insurance, and there is no follow-up. All these factors
contribute to rhe fact rluc this table is ro be used only as a ro ug h screen ing tool ; nm
meeting the exact recommendations sho uld not be cause for alarm .
To (fo gnose overweig ht or obesity using the table, calculate the pen.:enrage of the
Metropolitan Life l nsurnncc t.1blc weig ht. Use the mid point o f a weig ht range for .1
specific he ig ht.
(Cu rrent \\'l. wt. from table ) OO
1
Weig ht from table X
Example:
140 120
- - - - X I 00
120
= 17% O\'er standard
O verweight can be defined as weighing at least 10% more than the weight li!>tcd on
the table. Obesity weighs in at 20% more than that listed on the table. MorcO\cr, Lim
measure of obesity comes in degrees. Whereas mild obesity carries little health risk, sc
vere obesity raises overall health risk twcl\'efold.
D egrees of Obesity
% over H ea lt hy Bod y Weig ht Form of O besity
20-40% Mild
41-99% Moderate
Severe
Determining Frame Size

Method 1
Height is recorded without shoes.
Wrist circumference is measured just beyond the bony (styloid ) process at the "mt
joint on the right arm, using ,1 rape measure.
The following formul.1 is med:
._ Height (cm )
1
- \Vrist circumforence (cm)
Frame size can be determined .1s follows:t
Males Fem ales
1· > 10.4 small r > 11 small
1· = 9.6- 10.4 medium r = 10.1- 11 medium
1· < 9 .6 large 1· < 10.l large
ti=rom Gram JP: Hrmrl/1dok 1~('111t11/ p111·r1urml 1111rri111111. Phibcklphi.1: WH Saunders, 1980.
www.mhhe.com/wardlaw pers7 A-93
Method 2
The patient's right arm is extended forward, perpendicular to the bod~ , with the arm
bent so the angle at the elbow forms 90 degrees, with the fingers pointing up and the
palm turned away from the body. The greatest breadth across the elbow joint is mea-
sured with ,1 sliding caliper along the axis of the upper arm, on the two prominent
bones on either side ofrhe elbow. This measurement is recorded as the clbo\\ breadth.
The following tables give elbo'' breadth measurements for medium-framed men and
women of various heights. Measurements lower than those listed indicate a small frame
size; higher measurements indicate a large frame size.
Ment Women
Height in Height in
1" Heels Elbow Breadth 1" Heels Elbow Breadth
5'2"-5 '3" 2 ~2~" 4' 10"-4'1 l " 2Y.-2W
5'4"-5'7" 2~2~·· 5'0"- 5'3" 2V.-2W'
5'8"- 5' 1I" 2~-3" 5'4"-5'7" 2%-2%"
6'0"-6' 3" 2~-3 V." 5'8"- 5' 1l " 2 %-2~"
6 '4" and over 2~t:· 6'0" and over 2h-2W

•
a en IX
NUTRITION CALCULATIONS
Conversions arc mathematical techniq ues that are useful to express the same quamiry
in different measurements. This section will walk you step by step through a fe\\ basic
conversions that are important to understand when studying bw11an nun·ition.
Begin with 2.2 pounds and 1 kilogram; they are equivalent. Each reprcscnrs rhc
same weight but is expressed in different units. Relow is the conversion facror ro
change pounds to kilograms and kilograms to pounds.
2.2 lb 1 kg
or
l kg 2.2 lb
Because these facrors equal I, they can be multiplied by a number without chang·
ing the measurcmem value. This allows the units to be changed.
Herc arc some examples or problems that arc commonly seen when srudying
nutrition.
Example 1: Convert the weigh t or 150 lb to kg.
Seep 1: Choose the conversion factor in wh ich the unit you are sc::eking is on top.
l kg
2.2 lb
Step 2: Multiply 150 pounds by the factor
1
150 J.b x kg = l SO kg = 59 kg
2.2 J.b 2.2
Example 2: Con\'ert l / 2 cup LO .m approximate number of milliliters for use in a
recipe.
Step 1: The conversion factor is
l cup 240ml
or
240 ml l cup
Step 2: Multipl) 1/ 2 cup by the conversion factor.
240 ml
1
/ 2 .cttl5 X = 120ml
l CttJ5
Example 3: Suppose that for one day in your diet }'OU consumed 290 g of carbohydrate,
60 g of fat, 70 g of protein , and 15 g of akohol. Calculate d1e energy in take for d1c da)
as well as the percentage of carbohydrate, fat, protein, and alcohol in d1e day's dicL
A·94
Step I: Calculate the total energy intake. Begin by multiplying the grams of car-
bohydrate, fat, protein, and alcohol by the number of kcal that each gram ~rields.
4 kcal
Carbolwdrate:
.
290 t>
c1 X - - = 1160 kcal
g
9 kcal
Fat: 60 g x - .g- = 540 kcal
4 kcal
Protein: 70 g X - -
.g
= 280 kcal
7 kcal
Alcohol: 15 g X - - = 105 kcal
g
Step 2: Add all the values together for total energy intake.
1160 + 540 + 280 + 105 = 2085 total kca l
Step 3: Calculate the percentage of total carbohydrate by multiplying the grams of
carbohydrate by the energy yield and total energy factor.
4
290 o1 X ke;rl X lOOo/t = 56% carboh,.rdrate
t> g 2085 keat
Step 4: Calculate the percentage of coral fut by multiplying the grams of fat by the
energy yield .rnd total energy factor.
9~ 100%
60 g x -- x = 26% fat
g 2085 keat
Step 5: Calculate the percentage of total protein by multiplying the gr.1ms of pro-
tein by the energy yield and total energy factor.
4 keat 100% ~
70 g X - - X = 13 /t protein
g 2085 keat
Step 6: Calculate the percentage of rotal alcohol by multiplying the grams of alco-
hol by the energy yield and total energy factor.
15 g x
7
~ X lOO% = 5% alcohol
.g 2085 ke<rt
Example 4: How many grams of saturated fat are contained in a 3-oz hamburger? A
5-oz hamburger contains 8.5 g of saturated fat.
Step 1: The com·ersion factor for grams of sanirated fat is
8.5 g sarurated fat
5-oz hamburger
Step 2: ?.lultiply 3-oz hamburger by the con\'ersion factor.
8.5 g saturated fat 3 X 8.5 g 25.5
3 = oz l~a1~~bm g<:r X = =
5-!lZ hamb01gi:r 5 5
= 5 g of saturated fat
Conversions are also useful when you are working with nutrient units. Two com
mon units you will encounter are sodium and folate. The com·ersion factor to change
milligrams of sodium to milligrams of salt, and milligrams of salt to milligrams of
sodium is
A·96 Appendix J Nutrition Calculations
1000 mg sodium 2SOO mg salr

or
2SOO mg salt I 000 mg sodium
To converr microgr.ims of synthetic folate in supplements and enriched foods ro
Dietary Folacc Equivalents (micrograms DFE), use this conversion factor:
l µ.g synthetic folic acid 1.7 µ.g DFE
or
1.7 µ.g DFE l µ.g synthetic folic acid
For naturally occurring folate, assign each microgram of food folace a value of l mi -
crogram DFE:
1 µg food folatc 1 µ.g DFE
or
1 µg DFE l µ.g food fo lace
Example 5: A frozen pepperoni pizza contains 2200 mg of salt. How much sodium i'
in the pizza?
Step 1: Choose tht: conversion factor with the unit you are seeking on cop.
lOOO mg sodium
2SOO mg salt
Step 2: l\lultiply 2200 mg of salt by the conversion factor.
1000 mg sodium
2200 ~ X _ - - = 880 mg of sodium
2 ::i 00 ~
Example 6: If a ready-co-cat brcakfust cereal contains 200 µ.g of synrhetic folic ,Kid ,
how many µ.g of folatc in the product arc in DFE units?
Step 1: Choose the conver~ion facror \\'ith the unfr you are seeking on top.
1.7 µg DFE
I µ.g synthetic folic acid
Stt:p 2: Multiply 200 µg of synthetic folic acid by the conversion factor.
1.7 µ.g DFE
200 .µ g symhetie folic .tdc:t X ... . c . ·-ot
l I' g synt1~eee rohc ac1u
= 340 µ.g DFE
Example 7: An orange has SO µg of food folate. How ma ny µ.g of folare in DFE docs
the orange contain?
Step 1: Choose the conversion factor with the unit you arc seeking on top.
1 µg DFE
I µg food folate
Step 2: Mukiply SO µg of food fobte by the conversion factor.
l µg DFE
50 µ.g foed folJrc x = 50 µ.g DFE
l µ.g feed fol,m:
•
a en IX
SOURCES OF
NUTRITION INFORMATION
Consider the following reliable soun.:el> of food and nutrition information:
Journals That Regularly Cover Diabetes Cnre jourunl of Food Technology

Nutrition Topics Disense-n-Jfo11t/J /NCI (fournnl of the Nntio11nl Cancer
Amcric1111 F11111i~v Pbysici1111 * FASEB ]011mnl lustitute)
A111eticn11 Jo11rnrrl ofC/i11icn,/ N11tritio11 FDA Co11su111c1·* ]oumnl of N11tritio11
A11w·icnn ]011runl of Epidemiology Food Chemical To.-.:ico/o'"f'f.l' ]oumnl of Nutritional Educntion *
A111cricrrn ]01m1al of Medicine Food Engi11ceri11g Journal of Nuti·ition for the Elderly
Amcrfrrw Jo11mal of Nursi11g Gast1·oentemlo._r1y f ourual of Pediatrics
A111cricn11 fmffnal of Obstetrics Ge1·iatrics Lancet
and Gy11ccology Gut Mayo Clinic Proceedings
Amcricn11 ]oumal of Ph_vsiology H11ma11 Nutrition: Applied Nutritio11 Mcdicim· C:r Science in Sp01·ts a11d E\-crcise
A111ericn11 Joumal of Public Hcalt/J Human Nutritio11: Cli11icnl Nutritio11 Nnt1n-c
Americnn Scientist Jo1m111J 1>f t/Je A111cricn11 College of T/Jc Nell' E11gland ]ottmal of Medicine
A1111rrh of Intemnl Medicine Nutritio11,. Nu tl'i tio11
A111111nl Rel'ie1J1s of111.cdicim joumnl of t/Je A111cricn11 Dietetic Nutrition Re11iews
Au1111nl Revic1J1s of N11tritio11 Associntio11,. Nutrition Today*
Archi11cs t{Disense in Childhood Journal o.fthc A111erirn11 Geriat1·ic Society Pcdirrtrics
Arc/Ji11cs of illternnl Medicine JAMA (Journal oft/Jc A mcrirnn Medical The Physicin11 and Sports Meriici11c
Britis/J Journal of N11trition Association) Postgrad urtte Medicine*
BAJ] (B,.itish Medical Journal) Journal of Applied Pl;ysio/o~ffY Proceedings of tbe Nutrition Society
Cnuci:r joumal of the Cn11ndin11 Dietetic Science
Cn11cer Rcscnrc/J Associ11tio11 * Scic11ce News•
Circulntio11 journal of Cli11icnl b11•cstigatio11 Scimtijic America11 *
Dinbt'tcs f ournal of Food Scn•icc
The majority of these jomnals arc available in college and university libraries or in a
specialty library on campus, such as one designated for health services or home eco-
nomics. As indicated, a few journals will be filed under their abbreviations rather than
d1e first word in their full name. A reference librarian can help rou locate any of these
sources. The journals with an asterisk ( *) arc ones you may find especially interesting
and use fol because of the number of nutrition articles presented each month or the less
technical nature of the presentation.
A·97
A-98 Appendix K Sources of Nutrition Information
Magazines for the Consumer That Cover Nutrition Topics

Men's Health Good Housckccpi11g Pnri:ms
Better Homes and Gardens Health Self
Textbooks and Other Sources for Food aud N11tritio11 News American Cancer Society
Advanced Study of Nutrition Topics National Cattlemen's Beef Association 90 Park Ave.
444 Michigan Ave. New York, NY 10016
Groff TL, Gropper SS: AdJ1rmcctf /m111r111 Chicago, IL 60611 www.cancer.org
nut1·itio11 am( metabolism. Belmont, (free )
CA: Wadsworth, 2005. American CoUege of Spores Medicine
www.beef.org
International Life Sciences In!.titute: P.O. Box 1440
Present knoivlcdge in nim·itiou. 8th ed. Harvard Medicnl School Hcn.lt/J Letter Indianapolis, IN 46204
Washingron DC: T he Nutrition Department of Cominuing Education www.acsm.org
Foundation, 2001. 25 Shattuck St. American Dental Association
Mahan LK, Escott-Stump S: Krause's Boston, MA 021 15 2 11 E. Chicago Ave.
food, 1111tritio11, a11d diet therapy. 1 lth www.hms.harvard.edu/news/ Chicago, IL 60611
ed. Philadelphia: W.B. Saunders, index.html www.ada.org
2004. Mnyo Clinic Henlt/1 Letter American Diabetes Association
Murray RK and others: Harper's bio- P.O. Box 53889 2 Park Ave.
clmnistr_v. 26th ed. New York: Boulder, CO 80322,3889 Ne\\ York, NY 10016
McGraw-Hill, 2003. www.mayoheal h org cVWW.diabetes.org
Schils ME, and others: Modern nut1·itio11
in /Jcrr lt/J nn d disease. l 0th ed. National Co1111cil Agnimt Health Fmttd American Dietetic Association
Philadelphia: Lippincott, 2006. Newsletter (NCAT IF) 120 S. Riverside Plaza
Stipanuk 1\tlH: Biochemical 1md P.O. Box 1276 Su ite 2000
p/~ysiologicaL aspects of human Loma Linda, CA 92354 Chicago, IL 60606
nutrititm. Philadelphia: W.B. www.ncahf.org www.eatright.org
Saunders, 2000. Nutrition Actio11 Ht'a/t/Jlcttcr Ame1ica11 Geriattics Society
1875 Connecticut Ave. 770 Lexington Ave.
Washington, DC 20009-5728 Suite 400
N ewsletters That Cover Nutrition Nm York, t\TY 10021
www.cspinet.org
Issues on a Regular Basis "' NW.americangeriatrics.org
Nutrition Fonm1
American Institute for Cancer Research American Heart Association
George Stickley Co.
Newsletter 7272 Greenville Ave.
210 Washington Square
American Institute for Cancer Research Da llas, TX 75231
Philadelphia, PA 19 106
(AICR) 1759 RSt. N .W. Washingwn, www.americanheart.org
www.quackwatch.com
DC 20009 American Medical Association
www.aicr.org T1~ftsUuil>ersity Dia 6- N11t1·ition Lettu· Nutrition Information Section
P.O. Box 420235 535 N. Dearborn Sc.
Dnir)' Co1mciL Digest Palm Coast, FL 32142
National Dairy Council Chicago, IL 60610
www.healthlett"r u 'fs .edu ~,., ama·assn.org
10255 \Vest Higgins Road, Suire 900
Rosemont, TL 60018 UniJJcrsity of Califontia at Berkeley American Public Health Association
www.nationaldairycouncil.org Wellness Letter 1015 Fifteenth St. N.W.
P.O. Box 420148 Washington, DC 20005
Nutrition Close- Up Palm Coast, FL 32142 www.apha.org
Egg Nutrition Center magazines.enew ... com/ magazines/
1819 H St. N.W., No. 510 vcbw American Society for C linical Nutrition
Washington, DC 20009 9650 Rockville Pike
(free ) Professional Organizations with Bethesda, i\ilD 20014
www.enc·online.org a Commitment ta Nutrition Issues ...,. w fa~eb.org/ ajcn
Envfronmcntal Nutrition American Academ~ of Pediatrics American Society for Nutrition.11 Science~
52 Riverside Dr. P.O. Box 1034 9650 RockviJk Pike
New York, NY 10024 Evanston, TL 60204 Bethesda, MD 20014
www.environmentalnutrition.com www.aap.org www.asns.org
The Canadian Diabetes Association Professional or lay Organizations local Resources for Advice on
15 Toronto St. Concerned with Nurrition Issues Nutrition Issues
Suite 1001 Bread for the World Institute Registered dietitians (R. D .s or in Canada
Toronto, Omario MSC 2E3 Canada 50 F Street, N.\V., Suite 500 also RDNs) in health care, city,
www.diabetes.ca Washington, DC 20001 counry, or state agencies as well as in
www.bread .or:J private practice
The Canadian Dietetic Association
Cooperati\'c extension agents in county
480 Universiry Ave. California Counci l Against Health Fraud,
extension offices
Suite 60 1 Inc.
Nutrition facu lty affiliated with
Toronto, Onrario MSG 1V2 Canada P.O. Box 1276
departmenrs of food and
www.dietitians.ca Loma Linda, CA 92354
nutrition, home economics, and
" 'W'N.nc h .o ·g
fhc Canadian Socicry for Nutritional dietetics
Sciences Children's Foundation
1420 New York Ave. N.W. Government Agencies Concerned
Deparonent of Foods and Nutrition
Suite 800 with Nutrition Issues or That
Universiry of Manitoba
Washington, DC 20005 Distribute Nutrition Information
Winnipeg, Manitoba, R3T 2N2 Canada
www hc-sc.gc.ca 'Ww.childr"nfoundation.com United States
The Consumer [nformation
Emironmental Working Group (EWG ) Food Research and Action Center
Center
1718 Connecticut Ave., N.W. Suite 600 (FRAC)
Departmenr 609K
Washington, DC 20009 1875 Connecticur Ave. N.W. #540
Pueblo, CO 81009
www.ewg.org Washington, DC 20009
www.pueblo.gsa.gov
www.frac.org
food and Nutrition Board Food an<l Drug Administration (FDA)
Institute for Food and Development
National Research Council 5600 fishers Lane
Narional Academy of Sciences Policy Rockville, f\ID 20852
1885 Mission Sr. www.fda.gov
2101 Constitution Ave. N.W.
San Francisco, CA 94 l 03
Washington, DC 20418
www.foodfirst.org Food and Nutrition Information and
www.nas.edu
Education Resources Center
La Leche League International, Inc. National Library of Congress
lnstiwte of Food Technologies
9616 Minneapolis Ave. Belts' illc, MD 20705
22 l N. LaSaUe St.
Franklin Park, IL 60131 www.nal.usda.gov
Chicago, IL 60601
~.la echeleague.org
www. ·ft.org Human Nutrition Research Di,·ision
i\1arch of Dimes Birth Defects Agricu ltural Research Cenrer
National Council on the Aging
Foundation Beltsville, MD 20705
1828 L St. N.W.
(National Headquarters) www.usda.gov
1275 Mamaroneck Ave.
vww.ncoa.org National Center for Health Statistics
White Plains, ~ry 10605
'WW.mvdi e ... org 3700 East-West
National Institute of Nutrition Hyattsville, MD 20782
1335 Carling A\'t;:. National \VIC Association (NWA) www.cdc.govI nchs
Suite 210 2001 S Street, N.W., Suite 580
Ottawa, Ontario KlZ OL2 Canada National Heart, Lung, and Blood
www.nin.ca/En/home.html Institute
www.nwica.org
9000 Rock\·illc Pike, Building 31,
National Osteoporosis Foundation Overeaters Anonymous (OA) Room 4A21
1150 Se,·enteenth St. N.W., Suite 500 2190 190th St. Bethesda, MD 20892
Washington, DC 20036 Torrance, CA 90504 www.nhlbi.nih.gov
www.nof.org W'NW.overeat1.:rsanonymous.org
National [nsritute on Aging
Society for N u rrition Education 0 xfam America Information Office
7150 Winton Drive Suite 300 26 West SL Building 31, Room 5C35
Indianapolis, IN 46268 Bosron, MA 02111 Bethesda, MD 2 0205
W'r w .sne.org "W'W.oxfama ica.org www.nih.govI nia
A· 100 Appendix K Sources of N utrition Information
Office of Cancer Communications World Health Organization (WHO ) Idaho Potato Commission
National Cancer Instin1te 1211 Geneva 27 P.O. Box 1968
Building 31, Room 10Al8 Switzerland Boise, ID 83701
90 Rock\,ille Pike www.who.org www.idahopotatoes.com
Bethesda, MD 20205
www.nci.nih.gov Trade Organizations and Kellogg Company
Companies That Distribute Department of Home Economics
l\lyPyramid Nutrition Information Ser\'icei.
USDA, Center for Nutrition Policy
Ame1ican Institute ol' Baking Battle Creek, Ml 49016
and Promotion
P.O. Box 1148 www.kellog.com
www.mypyramid.gov
USDA, Agriculrnr<ll Research Service Manhattan, KS 66502
Kraft General Foods
www.aibonline.o rg
6505 Belcrest Rd., Room 344 Three Lakes Dr.
Hyatmille, MD 20782 American !v1eat Institute Northfield, IL 60093
www.usda.gov P.O. Box 3556 www.kraftfoods.com
USDA, Food Safety & Inspection
www.meatami.com Mead Johnson Nutritionals
Service
Beech-Nut NutriLion Corporation 2404 Pennsylvania Ave.
Room U80 South, 14th and
Booth 1414 Evansville, IN 47721
Independence Ave. S.W.
Checkerboard Square www.meadjohnson.com
www.usda.gov St. Louis, MO 63164
www.beech·nut.com/ index.htm N.1tional Dair~' Council
U.S. Govcrnmenr Priming Office l 0255 W. Higgins Rd.
The Supcrintendent of Documents Best Foods Rosemont, IL 60018-4233
Washington, DC 20402 Consumer Sen1ce Dcpartmenr www.nationaldairycoun.o rg
www.gpo.gov Di,'ision of CPC International
International Plaza The 1ucraSweet Keko
Canndn Englewood Cliffs, NJ 07632 Company
Canadian Food Inspection Agency www.bestfoods.com 1751 Lake Cook Rd.
59 Camelot Dr.
Campbell Soup Co. Deerfield, IL 60015
Nepean, Ontario KlA OY9
Food Sen1ce Products Division www.nutrasweetkelco.com/
www.inspection.gc.ca
Campbell Plaza default.htm
Heakb and Welfare Canada Camden, NJ 08103
Canadian Government Publish ing Center www.campbe llsoups.com Pillsbttr)' Company
Minister of Supply and Services 1177 Pillsbury Building
The Dannon Company, Inc.
Ottawa, Ontario Kl A OS9 608 S<.:cond Ave. S.
120 White Plains Rd.
www.hc-sc.gc.ca M inneapolis, MN 55402
Tarrytown, NY 10591-5536
Nutrition Programs www.pillsbury.com
www.dannon.com
446 Jeanne Mance Building Del Monre Foods Ross Laboratories
Tunney's Pasture One Market Plaza Director of Profi::ssional
Onawa, Onrario Kl A l B4 San Francisco, CA 94105 Services
www.hc-sc.gc.ca www.de lmonte-international.com 625 Cleveland Ave.
Nutrition Services General Mills Columbus, OH 43216
P.O. Box 488 P.O. Box 1113 www.ross.com
Halifax, Nova Scotia B3J 3R8 Minneapoli:., MN 55440
www.fns.usda.gov www.generalmills.com Sunkist Growers, Inc.
14130 Rin:rside Dr.
United Nntiow Gerber Products Co. Sherman Oaks, CA 91423
Food and Agriculture Organization (rOA) 445 State St. www.sunkist.com/ index.html
North American Regional Office Fremont, MI 49413
1001 22nd St. N.W. www.gerber.com Vitamin Nutrition Informarion Sen ice
Washington , DC 20437 H.J. Heinz (VNIS )
or Consumer Relations Hoffo1ann-LaRoche
Via della Terma di Caracella P.O. Box 57 340 Kingsland A,·e.
0100 Rome, Italy Pittsburgh, PA 15230 Nutley, NJ 07110
www.fao.org www.heinzbaby.com www.roche usa.com
•
a en IX
ENGLISH-METRIC CONVERSIONS
AND METRIC AND HOUSEHOLD UNITS
Metric-English Conversions Volume

English (USA) Metric
length cubic inch = 16.39 cc
cubic foot = 0.03 m3
English (USA) Metric = 0.765 m 3
cubic yard
inch ( in.) = 2.54 cm, 25 .4 mm te.1 spoon (tsp ) = 5 ml
foot (ft) = 0.30 m , 30.48 cm cablc:.poon ( tb~p ) = 15 ml
y:ird (yd) = 0.91 m, 91.4 cm lluid ounce = 0.03 liter (30 m l)*
mile (stallltc ) (5280 ft ) = l.61 km, 1609 m cup (c) = 237 ml
mile (nautical ) pine (pc) = 0.47 lirer
(6077 ft, l.15 starute mi) = 1.85 km, 1850 m quart (qt ) ~ 0.95 liter
gallon (gal ) = 3.79 liters
Metric English (USA)
millimeter (mm ) = 0.039 in (thickness of a dime) Metric English (USA)
centimeter (cm) = 0.39 in milliliter (ml) = 0.03 oz
1m:ter (m ) = 3.28 ft, 39.37 in liter ( L) = 2.12 pc
kilometer ( km ) = 0.62 mi, 1091 yd, 3273 ft liter = 1.06 qt
liter = 0.27 gal
Weight
English (USA) Metric
grain = 64.80 mg Metric and Other Common Units
ounce ( 01) = 28.35 g
pound (lb) = 453.60 g, 0.45 kg
ton (short- 2000 lb) = 0.91 metric ton (907 kg) Unit/Abbreviation Other Equivalent Measure
milligram/mg lfooo of a gram
Metric English (USA) microgram/µg l{ooo.ooo of a gram
milligram (mg) = 0.002 grain (0.000035 oz) decilircr/ dl Ila of a licer (about ~ c.:up)
gram (g) = 0.04 oz ( 1128 of an oz) milliliter/ ml ~au• of a liter ( 5 ml is about 1 t~p )
kilogram (kg ) = 35.27 oz, 2.20 lb international Unir/ IU Crude measure of vitamin
metric ton ( l 000 kg) = 1.10 cons acrivicy generally based on
growth rate seen in animals
I lircr + 1000 • I mtlhhtcr or l robic ccnnmcta 110 -' btcrJ

I lirer + 1.000,000 • I m1crolircr ( 10·• tircrl
·~01c: I ml = l cc
A- 101
A· 102 Appendix L English-Metric Conversions and Metric and Household Units
Fahrenheit-Cel sius Conversion Scale Household Units

<f •c
230 110
3 teaspoons = 1 tablespoon
220
4 tablespoons = J( cup
212 F 210 100 HJO' C 5 ~ tablespoons = Ji cup
200
8 tablespoons = Mcup
190
90 ]o~ tablespoons = ~cup
16 tablespoons = l cup
180
170
80 1 tablespoon = M fluid ounce
160 70
l cup = 8 fluid ounces
150
1 cup = Mpinr
140 60
2 cups = 1 pint
130 4 cups = 1 quart
120 50 2 pints = l quart
110 4 quarcs = l gallon
40
98°F 100 37•c
90
30
80
70 20
60
50 10
40
32 F 30 0 oc
20
10 10
0
- 20
-10
20 - 30
To cOn\'Crt cempcrnturc scales:
30 Fahrenheit to Celsius °C = (°F - 32 ) X 5/ 9
- 40 - 40 Celsius ro Fahrenheit °F = 9 /5 (0 C) + 32
A·102
•
IX
ESTIMATED AVERAGE REQUIREMENTS
FOR NUTRIENTS
A-103
A-104 Appendix M Estimated Average Requirements for Nutrients
Estimated Average Energy Requirements Set by the Food and Nutrition Board, Institute of Medicine, National Academies
Life Stage CHO PROT Vitamin A Vitamin C Vitamin E Thiamin Riboflavin Niacin Vitamin 8·6
Group (g/dl (g/kg/dl (µg/dl (mg/di (mg/di (mg/di (mg/di (mg/di (mg/d)
Children
1-3 y 100 0.88 210 13 5 .4 .4 5 .4
4-8 y 100 0.76 275 22 6 .5 .5 6 .5
Moles
9-13 y 100 0.76 445 39 9 .7 .8 9 .8
14-18 y 100 0.73 630 63 12 1.0 1.1 12 1.1
19-30 y 100 0.66 625 75 12 1.0 1.1 12 1. 1
31-50 y 100 0.66 625 75 12 1.0 1. 1 12 1.1
51-70 y 100 0.66 625 75 12 1.0 1.1 12 1.4
> 70 y 100 0.66 625 75 12 1.0 1.1 12 1.4
Females
9-13 y 100 0.76 420 39 9 .7 .8 9 .8
14- 18 y 100 0.71 485 56 12 .9 .9 11 1.0
19-30 y 100 0.66 500 60 12 .9 .9 11 1. l
31-50 y 100 0.66 500 60 12 .9 .9 11 1.1
51-70 y 100 0.66 500 60 12 .9 .9 11 1.3
> 70 y 100 0.66 500 60 12 .9 .9 11 1.3
Pregnancy
s 18y 135 0.88 530 66 12 1.2 1.2 14 1.6
19-30 y 135 0.88 550 70 12 1.2 1.2 14 1.6
31-50 y 135 0.88 550 70 12 1.2 1.2 14 1.6
Lactation
s 18 y 160 1.05 880 96 16 1.2 1.3 13 l .7
19-30 y 160 1.05 900 100 16 1.2 1.3 13 l .7
31-50 y 160 1.05 900 100 16 1.2 1.3 13 1.7
NOTE: This information taken from the various ORI reports (see www.nop.edu).
www.mhhe.co m/wa rdlaw pers7 A- 1 OS
Folate Vitamin 8-12 Copper Iodine Iron Magnesium Molybdenum Phosphorus Selenium Zinc
(µg/d) (~19/d) {µg/d) (µg/d) (mg/d) (mg/di (µg/dl (mg/di (µg/d) (mg/d)
120 .7 260 65 3.0 65 13 380 17 2.2

160 1.0 340 65 4.1 110 17 405 23 4
250 1.5 540 73 5.9 200 26 1055 35 7

330 2.0 685 95 7.7 340 33 1055 45 8.5
320 2.0 700 95 6 330 34 580 45 9.4
320 2.0 700 95 6 350 34 580 45 9.4
320 2.0 700 95 6 350 34 580 45 9.4
320 2.0 700 95 6 350 34 580 45 94
250 1.5 540 73 5.7 200 26 1055 35 7

330 2.0 685 95 7.9 300 33 1055 45 7.5
320 2.0 700 95 8.1 255 34 580 45 6.8
320 2.0 700 95 8.1 265 34 580 45 6.8
320 2.0 700 95 5 265 34 580 45 6.8
320 2.0 700 95 5 265 34 580 45 6.8
520 2.2 785 160 23 355 40 1055 49 10.5

520 2.2 800 160 22 290 40 580 49 9.5
520 2.2 800 160 22 300 40 580 49 9.5
450 2.4 985 209 7 300 50 1055 59 11.6

450 2.4 1000 209 6.5 255 50 580 59 10.4
450 2.4 1000 209 6.5 265 50 580 59 10.4
•
a en IX
FOOD COMPOSITION TABLE
The folio\\ ing table of nutrient values of foods represents a small portion of the
database found in the NutritionCalc Plus 2.0 dier analysis program a\'ailablc from
tllcGraw-Hill. The nutrient data in the software and in this appendiA comes from
the ESHA Research database. Some nutrient or food component values for some
foods are not included in the database because no accurate data values exist. The
nutrient or component may in fact be present in the food, but insunicicnt labora-
tory analyses have been performed to establish an accurate value. These missing val-
ues are indicated by a - (dash ) in the appropriate nutrient columns.
Name-brand foods often have missing values because manufucturcrs arc only re-
quired ro analyt.c for nutrients that must appear on Nutrition Facts labels and only co
the level of accuracy required by the nutrition labeling regulations. All missing nutri-
ent or food component values arc clearly marked in the table . You arc encouraged to
refer to the NutritionCak Plus 2.0 technical support website (mhhc com/support )
for links to nutrient data sites provided by food manufactmers and res1auranrs nor
found in this appendix.
A·106
www.mhhe.com/ wardlawpers7 A- 107
The following is a list of abbreviations used in the Food Composition Table:
Abbreviation Key
Unit/ Amt = Unit Amount Iron (mg) = Iron
Wt (g ) = Weight in grams J\lagn (mg) = i\lagnesium
Energy ( kcal ) = kilocalories Phos ( mg) = Phosphorus
Prot (g ) = Protein Pota (mg) = Potassium
Carb (g) = Carbohydrate Sodi ( mg) = Sodium
Fiber (g ) = Dietary fiber Zinc (mg) = Zinc
Fat (g ) = Total fat Wat(%) =Water
Sat (g ) = Saturated fat Ako (g) = Alcohol
Mono (g) = Monounsaturatcd fat Caff (g) = Caffeine
Poly (g) = Polyunsaturated fat
Chol (mg) = Cholesterol g = gram
Vit A ( RE) = Vitamin A mg = milligram
ThiJ (mg) = Thiamin µg = microgram
Ribo (mg) = Ribofla\'in mg AT = milligrams of alpha
Niac (mg NE)= Niacin tocopheral
Vit B-6 (mg) = Vitamin B 6 mg NE = milligrams or
Niacin
Vit B-12 (µg ) = Vitamin B 12 Equivalents
Fol (µg ) = Folate oz= ounce
Vit C (mg) = Vitamin C lb = pound
Vit D ( lU ) = Vitamin D Tbs = tablespoon
Vit E (mg AT)= Vit.1min E tsp = teaspoon
Cal ( mg) = Calcium
A-108 Appendix N Food Composition Table
PAGE KEY: A-108 Beverage and Beverage Mixes A-110 Other Beverages A- I I 0 Beverages, Alcoholic A- 11 2 Candies and Confed1ons, Gum A-1 16 Cereals, Breakfast Type
A- 120 Cheese and Cheese Substitutes A- 122 Dairy Products and Substitutes A-124 Desserts A-1 30 Dessert Toppings A-130 Eggs, Substitutes. and Egg Dishes A- J 32 Ethnic Foods
A-136 Fast Foods/Restaurants A-1 SO Fats, Oils, Margarines, Shortenings, and Substitutes A-150 Fish, Seafood, and Shellfish A-152 Food Additives
A-152 Fruit, Vegetable. or Blended Juices A- I 54 Grains. Flours, and fractions A-154 Grain Products. Prepared and Baked Goods
Food Unit/ Wt Energy Prot Carb Fiber Fat Sat Mono Poly Chol VitA
Code Name Amt {g) (kcal) {g) (g) (g) {g) (g) (g) (g) (mg) (RE)
BEVERAGE AND BEVERAGE MIXES
Carbonated Drinks
4794 Lemonade, end, Country Time 1 cup 247 90 0 23 0 0 0.0 0.0 0.0 0
20055 Soda, 7 Up 1 cup 240 100 0 26 0 0 0.0 0.0 0.0 0 0
20207 Soda, 7 Up, diet 1 cup 240 0 0 0 0 0 0.0 0.0 0.0 0 0
20006 Soda, club 1 cup 237 0 0 0 0 0 0.0 0.0 0.0 0 0
20147 Soda, Coca Cola/Coke 1 cup 246 103 0 27 0 0 0.0 0.0 0.0 0 0
443 Soda, cola, caff free 12 fl-oz 372 156 0 40 0 0 0.0 0.0 0.0 0 0
4796 Soda. Dr Pepper 1 cup 246 100 0 27 0 0 0.0 0.0 0.0 0
4797 Soda. Dr Pepper, diet 1 cup 246 0 0 0 0 0 0.0 0.0 0.0 0
20530 Soda. fruit punch 1 cup 251 117 0 32 0 0 0.0 0.0 0.0 0
20031 Soda, grape 1 cup 248 107 0 28 0 0 0.0 0.0 0.0 0 0
20032 Soda. lemon lime 1 cup 246 98 0 26 0 0 0.0 0.0 0.0 0 0
20271 Soda. Mountain Dew 1 cup 240 113 0 31 0 0 0.0 0.0 0.0 0 0
20272 Soda. Mountain Dew. diet 1 cup 240 0 0 0 0 0 0.0 0.0 0.0 0 0
20161 Soda, Mr Pibb 1 cup 249 97 0 26 0 0 0.0 0.0 0.0 0 0
20029 Soda, orange 1 cup 248 119 0 31 0 0 0.0 0.0 0.0 0 0
20166 Soda, Pepsi 1 cup 240 100 0 27 0 0 0.0 0.0 0.0 0 0
20167 Soda, Pepsi, diet 1 cup 240 0 0 0 0 0 0.0 0.0 0.0 0 0
20009 Soda. root beer 1 cup 246 101 0 26 0 0 0.0 0.0 0.0 0 0
20454 Soda, root beer, diet, w/nutrasweet 1 cup 240 0 0 0 0 0 0.0 0.0 0.0 0
20163 Soda, Sprite I cup 249 95 0 26 0 0 0.0 0.0 0.0 0 0
4815 Soda, Squirt 1 cup 246 100 0 27 0 0 0.0 0.0 0.0 0
Coffee and Substitutes

20312 Coffee Substitute, inst, dry 1 tsp 3 10 0 3 0 0.0 0.0 0.0 0 0
20592 Coffee. cappucC1no, w/lowfat milk, tall 1 5 cup 244 110 8 11 0 4 2.5 15 80
20639 Coffee. cappuccino. w/whole milk. tall 1 5 cup 244 140 7 11 0 7 4.5 30 60
20439 Coffee, espresso, prep at restaurant 1 cup 237 5 0 0 0 0 0.2 0.0 0.2 0 0
20659 Coffee, latte, iced, w/lowtat milk, tall 1.5 cup 392 90 7 10 0 3 2.0 15 60
20023 Coffee, reg, inst, prep wtwater I cup 238 5 0 1 0 0 0.0 0.0 0.0 0 0
Dairy Mixed Drinks and Mixes

44 Drink, carob, prep f/dry mix w/milk 1 cup 256 192 8 22 8 4.6 2.0 0.5 26 69
14 Drmk, chocolate, dry mix 2.5 tsp 22 75 20 1 1 0.4 0.2 0.0 0 0
40 Dnnk. strawberry, dry mix 2.5 tsp 22 BS 0 22 0 0 0.0 0.0 0.0 0 0
12 Hot Cocoa. dry mil\ 3 tsp 28 113 2 24 0.7 0.4 0.0 2 0
48 Hot Cocoa, prep f/dry mix w/water 1 cup 275 151 2 32 2 0.9 0.5 0.0 3
62057 Instant Breakfast. French vanilla. dry mix, pkt 1 ea 36 130 4 27 0 0 0.0 0.0 0.0 3 350
1O1 Instant Breakfast, prep w/1 % milk 1 cup 281 233 15 36 0 3 1.8 14 469
25 Instant Breakfast. prep wt2% milk, pwd 1 cup 281 253 15 36 0 5 3. 1 24 469
26 Instant Breakfast, prep w/whole milk 1 cup 281 280 15 36 0 9 5.3 38 630
30 Malted Milk. chocolate, dry mix 3 tsp 21 79 18 0.5 0.2 0.1 0
www.mhhe.com/ wardlawpers7 A· 109
PAGE KEY: A-158 Granola Bars. Cereal Bars, Diet Bars. Scones, and Tarts A-158 Meals and Dishes A-162 Meats A-168 Nuts, Seeds, and Products A-170 Poultry
A-172 Sa1ad Dressings, Dips, and Mayonnaise A-172 Salads A· 174 Sandwiches A-176 Sauces and Gravies A-176 Snack Foods-Chips, Pretzels, Popcorn
A· 178 Soups, Stews, and Chilis A· 180 Spices, Flavors, and Seasonings A-182 Sports Bars and Drinks A· 182 Supplemental foods and formulas
A·184 Sweeteners and Sweet Subst1tu1es A· 184 Vegetables and Legumes A-198 Weight Loss Bars and Drinks A-200 Miscellaneous
Thia Ribo Niac Vit 86 Vit 812 Fol Vit C Vit D Vit E Cal Iron Magn Phos Pata Sodi Zinc Wat Alco Caff
(mg) (mg) (mg NE) (mg) {µg) (µg) (mg) (IU) (mg An (mg) (mg) (mg) (mg) (mg) (mg) (mg) (%) (g) (g)
0.0 90 91 0.00 000

000 0.0 45 50 89 0.00 000
0.00 0.00 0.00 0.00 0.0 35 100 000 000
0.00 0.00 0.00 000 0.00 0.0 00 0.0 12 0.01 24 0 5 50 0.2 100 0.00 0.00
0.00 0.00 0.00 000 0.00 0.0 00 0.0 0.0 0.07 2.5 36 2 5 00 89 0.00 30 67
0.00 0.00 0.00 0.00 0.00 0.0 0.0 0.0 11 O.D7 37 48 4 15 0.0 89 0 00 0.00
0.0 35 89 0.00 27.20
0.0 35 0.00 27 20
00 0 0.00 0 13 10 0.00 000
0.00 0.00 0.00 0.00 000 0.0 00 0.0 7 0 20 2.5 0 2 37 0.2 89 0 00 0.00
000 0.00 0.03 0.00 000 0.0 0.0 0.0 s 0 17 2.5 0 2 27 0.1 90 0.00 0.00
0.00 0.0 0 0.00 0 47 87 0.00 36.66
000 00 0 000 0 23 100 000 3666
000 000 0.00 000 000 0.0 0.0 0.0 00 29 14 7 90 0.00 2700
0.00 0.00 0.00 000 000 00 0.0 0.0 12 0.15 25 2 5 30 0.2 88 0.00 0.00
000 0.0 0 0.00 35 23 88 000 24.67

0.00 00 0 0.00 27 5 23 0.00 24.00
0.00 000 000 0.00 000 0.0 0.0 00 12 0.11 2.5 0 2 32 02 89 0.00 000
0.00 30 100 0.00 000
0.0 0 0 23 89 0 00 0.00
00 15 89 000 000
0.0 0 0.00 0 0 000 0.00

2.4 250 0 00 110 0.00 90.00
2.4 250 0.00 105 0.00 90.00
0.00 041 12.34 0.00 0.00 2.4 0.5 0.0 5 0.31 189.6 17 273 33 01 98 0 00 502.44
1.2 250 0.00 100 0.00 90.00
0.00 0.00 056 0.00 0.00 0.0 0.0 0.0 10 0 10 72 7 72 0.0 99 0.00 61 97
0.10 0.44 0.34 0.10 1.08 12.8 0.0 0.1 251 0.63 25.6 205 335 118 0.9 84 0.00 000
000 0.02 0.10 000 0.00 1.5 0.2 0.0 8 0.68 21 2 28 128 45 0.3 1 0.00 7 78
000 001 0.01 000 000 00 01 0.0 0.0 010 0.2 1 1 8 0.0 0 0.00 0.00
0.02 0.15 0.17 0.02 037 0.0 0.5 0.2 40 034 235 89 202 143 0.4 2 0.00 5.09
0.03 0.20 0 21 0.03 0.49 0.0 0.5 0.2 60 0.46 33.0 118 269 195 0.6 86 0.00 5.48
0 30 0.14 500 0.40 0.60 99.7 27.0 00 6.8 250 4.50 79 7 100 249 95 3.0 0.00 000
0.40 0.47 548 0.52 1.53 117.7 30.9 100.0 5.4 406 486 1185 392 731 267 4.1 79 0.00 000
0.40 0.47 S.48 052 150 117.7 30.9 1000 5.5 403 4 86 118 5 390 726 264 41 78 0.00 000
040 046 5.46 0 51 1 so 117.7 30.7 100.0 5.5 396 4.86 117.1 386 721 262 41 77 0.00 000
0.03 0.03 041 002 0.03 10.7 0.3 10 00 13 047 14.7 37 130 53 02 000 7 76
A- 110 Appendix N Food Composition Table
PAGE KEY: A-108 Beverage and Beverage Mixes A-110 Other Beverages A-110 Beverages, Alcoholic A-1 12 Candies and Confecuons, Gum A-116 Cereals, Breakfast Type
A-120 Cheese and Cheese Substitutes A-122 Dairy Products and Substitutes A- i 24 Desserts A-130 Dessert Toppings A-130 Eggs, Substitutes, and Egg Dishes A-132 Ethnic Foods
A-136 Fast Foods/Restaurants A-150 Fats, Oils, Margarines, Shortenings, and Substitutes A-150 Fish, Seafood, and Shellfish A-152 Food Additives
A-152 Fruit, Vegetable, or Blended Juices A-154 Grains, Flours. and Fractions A-1 54 Grain Products, Prepared and Baked Goods
Code Name Amt (g) (kcal) (g) (g} (g) (g) (g) (g) (g} (mg) (RE)
Fruit Flavored Drinks
20004 Drink, breakfast, orange, prep f/pwd I cup 248 122 0 31 0 0 0.0 0.0 0.0 0 191
20385 Dnnk, cherry, swtnd, prep 8 fl-oz 254 60 o 16 0 0 0.0 0.0 0.0 0 0
20737 Dnnk, fruit punch 8 fl-oz 252 110 0 29 0 0.0 0.0 0.0 0
20176 Dnnk, fruit punch, non carbonated 12 fl-oz 360 200 0 so 0 0 0.0 0.0 0.0 0
20761 Drink, Island Punch 1 cup 252 110 0 27 0 0.0 0.0 0.0 0
20045 Drink, lemonade, prep f/pwd 1 cup 266 112 0 29 0 0 0.0 0.0 0.0 0 0
20746 Drink, pink lemonade B fl-oz 252 110 0 26 0 0.0 0.0 0.0 0
20123 Juice Drink, citrus fruit, calc fort 1 cup 240 112 28 0 0 0.0 0.0 0.0 0
20744 Juice Dnnk, raspberry peach 1 cup 252 120 0 29 0 0.0 0.0 0.0 0
793 Juice, apple 8 fl-oz 236 110 0 29 0 0 0.0 0.0 0.0 0
1853 Ju1Ce, grape 8 fl-oz 236 150 0 38 0 0 0.0 0.0 0.0 0
794 JUice, grapefruit 811-oz 236 120 0 29 0 0 0.0 0.0 0.0 0
1854 Juice, orange 8 fl-oz 236 120 0 29 0 0 0.0 0.0 0.0 0
3128 Juice, prune, end 1 cup 256 182 2 45 3 0 0.0 0.1 0.0 0
6504 Juice, tomato, end 1 cup 243 50 10 2 0 0.0 0.0 0.0 0 100
6507 Juice, vegetable, end 1 cup 243 50 2 10 2 0 0.0 0.0 0.0 0 400
OTHER BEVERAGES
38405 Drink, atole, cornmeal 1 cup 245 206 4 40 1 4 2.2 1.1 0.3 14 33
38362 Drink, horchata de arroz, nee beverage. Mexican 1 cup 245 100 0 25 0 0 0.0 0.0 0.0 0 0
20589 Drink, sugar cane, Puerto Rico 1 cup 240 164 0 42 0 0 0.0 0.0 a.a a 0
Teas
20495 Tea. bag 1 ea 2 0 0 0 0 0 0.0 o.a 0.0 0 0
20014 Tea, brewed w/tap water 1 cup 237 2 0 1 0 0 0.0 0.0 0.0 0 0
20538 Tea, Cool Drink, can/btl 1 cup 248 82 0 22 0 0 0.0 0.0 0.0 0 0
20681 Tea, green, sweetened, btl 1 cup 252 100 0 25 0 0.0 0.0 0.0 0
20894 Tea, herbal, Cranberry Cove. brewed 1 cup 237 0 0 0 0 0 0.0 0.0 0.0 0 0
20853 Tea, herbal. Echinacea Complete Care, brewed 1 cup 237 0 0 0 0 0 0.0 0.0 0.0 0 0
20899 Tea, herbal, Sleepyt1me, brewed 1 cup 237 0 0 0 0 0 0.0 0.0 0.0 0 0
30451 Tea, iced, 100%, inst, pwd 2 tsp I 0 0 0 0 0 0.0 0.0 0.0 0 0
20724 Tea, iced. w/lemonade 8 fl-oz 252 110 0 28 0 0 0.0 0.0 0.0 0
Water
20051 Water, btld 1 cup 237 0 0 0 0 0 0.0 0.0 0.0 0 0
20041 Water, municipal 1 cup 237 0 0 0 0 0 0.0 0.0 0.0 0 0
BEVERAGES, ALCOHOLIC
34066 Beer, amber ale 12 fl-oz 356 169 2 14 0 0.0 0.0 0.0 0
22500 Beer. can/btl, 12 fl oz 12 fl-oz 356 139 11 0 0 0.0 0.0 0.0 0 0
34053 Beer, Light 12 fl-oz 353 105 5 0 0 0.0 0.0 0.0 0
22685 Beer, non alcoholic, Near 12 fl-oz 356 32 5 0 0 0.0 0.0 0.0 0 0
22671 Bourbon, 80 proof 1 fl-oz 28 64 0 0 0 0 0.0 0.0 0.0 0 0
22513 Brandy, 80 proof 1 fl-oz 28 64 0 0 0 0 0.0 0.0 0.0 0 0

22514 Gin, 80 proof 1 fl-oz 28 64 0 0 0 0 0.0 0.0 0.0 0 0
22547 Liqueur. Amaretto, 1 shot 1 ea 30 106 0 13 0 0 0.0 0.0 0.0 0 0
34052 Malt Beverage, Zima 12 fl-oz 353 185 0 21 0 0 0.0 0.0 0.0 0
22555 Mixed Drink, Bacardi cocktail 1 ea 63 117 0 6 0 0 0.0 0.0 0.0 0 0
PAGE KEY: A-158 Granola Bars, Cereal Bars, Diet Bars, Scones, and Tarts A-15B Meals and Dishes A· 162 Meats A· 168 Nuts, Seeds, and Products A· 170 Poultry
A-172 Salad Dressings, Dips, and Mayonnaise A· 172 Salads A-174 Sandwiches A-176 Sauces and Gravies A-176 Snack Foods-Chips. Pretzels. Popcorn
A-178 Soups, Stews, and Ch ilis A-180 Spices, Flavors, and Seasonings A-182 Sports Bars and Drinks A-1 82 Supplemental Foods and Formulas
A-184 Sweeteners and Sweet Substitutes A-184 Vegetables and Legumes A-198 Weight Loss Bars and Drinks A-200 Miscellaneous
Thia Ribo Niac Vit 86 Vit 812 Fol Vit C Vit D Vit E Cal Iron Magn Phos Pota So di Zinc Wat Alco Catt
(mg) (mg) (mg NE) (mg) (µg) (µg) (mg) (IU) (mg AT) (mg) (mg) (mg) (mg) (mg) (mg) (mg) (%) (g) (g)
0.00 0.21 2.53 0.25 0.00 0.0 73.2 0.0 126 0.01 2.5 47 60 10 0.0 87 0.00 0.00
0.00 6.0 0 0.00 0 0 0 94 0.00 0.00
0.0 10 88 0.00 0.00
0.00 65.0 0 0 45 0.00 0.00
10 89 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.0 34.0 0.0 29 0.05 2.7 3 3 19 0.1 89 0.00 0.00
0.0 10 90 000 0.00
0.05 0.02 0.31 0.05 0.00 5.2 79.8 0.0 01 316 0.2 1 16.7 20 196 4 0.1 88 0.00 000
0.0 10 88 0.00 0.00
10 88 000 0.00
10 84 0.00 0.00
0 87 0.00 0.00
o 0.00 0.00
0.03 0.18 200 0.56 0.00 0.0 10.5 03 31 3.01 35.8 64 707 10 0.5 81 0.00 0.00
72.0 20 072 430 750 94 0.00 0.00
60.0 40 0.72 520 620 94 0.00 0.00
0. 12 0.23 0.81 0.07 0.36 6.4 0.9 0.1 140 0.67 24.2 117 185 55 0.6 80 0.00 0.00
0.00 0.00 0. 14 0.00 0.00 0.4 0. 1 0.0 12 0.34 35 5 6 7 0.1 89 0.00 0.00
0.07 0.03 0.05 0.00 0.00 0.0 0.0 0.0 12 2.25 8.0 5 39 42 0.2 81 0.00 0.00
0.0 0 0.00 25 0 0.00 SS.DO

000 0.02 ooo 0.00 0.00 11.8 0.0 0.0 0 0.05 71 2 88 7 0.0 100 0.00 47.36
0.0 0 0.00 73 38 33 0.00 11.00
0.0 10 90 0.00 18.00
0.0 o 0.00 30 0 100 0.00 0.00
35.0 0 0.00 0 7.5 100 0.00 0.00
0.0 0 0.00 30 0 100 0.00 0.00
0.0 o 0.00 45 0 0.00 40.00
0.0 10 89 0.00 18.00
0.00 0.00 0.00 0.00 0.00 0.0 0.0 0.0 2 0.01 2.4 0 0 2 0.0 100 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.0 0.0 0.0 5 0.00 2.4 0 0 5 0.0 100 0.00 0.00
44 18.65 0.00
0.01 0.09 1.83 0.15 0.07 21.4 00 00 14 007 21.4 50 96 14 0.0 93 12.82 0.00
0.03 0.03 1.40 11 59 11 98 14. 11 0.00
0.01 0.09 1.61 0. 18 0.07 21 .4 0.0 0.0 25 0.03 32.1 110 89 18 0.0 98 1.07 0.00
0.00 0.00 0.00 0.00 0.00 0.0 0.0 0.0 0 0.00 00 0 0.0 67 9.28 0.00
0.00 0.00 0.00 0.00 0.00 0.0 0.0 0.0 0 0.00 0.0 0 0.0 67 9.28 0.00
0.00 0.00 0.00 0.00 0.00 0.0 0.0 0.0 0 0.00 0.0 1 0 0.0 67 9.28 000
0.00 0.00 0.01 0.00 0.00 0.0 0.0 0.0 00 0 0.01 0.5 4 2 00 30 7 73 0.00
0.03 0 .03 0.87 38 51 20 16.94 0.00
0.00 0.00 0.02 0.00 0.00 1.2 1.0 0.0 0.0 2 0.05 12 3 12 11 0.0 68 13.72 0.00
A-112 Appendix N Food Composition Table
PAGE KEY: A· 108 Beverage and Beverage Mixes A-11 OOther Beverages A· 110 Beverages, Alcoholic A· 112 Candies and Confections, Gum A-116 Cereals, Breakfast Type
A· 120 Cheese and Cheese Substitutes A· 122 Dairy Products and Substitutes A· 124 Desserts A· 130 Dessert Toppings A· 130 Eggs, Substitutes. and Egg Dishes A· 132 EthnJC Foods
A· 136 Fast Foods/Restaurants A·150 Fats. Oils, Margarines, Shortenings, and Substitutes A· 150 Fish, Seafood, and Shellfish A· 152 Food Additives
A-152 Fru1l, Vegetable, or Blended Juices A-154 Grains, Flours, and Fractions A·154 Grain Products, Prepared and Baked Goods
Code Name Amt (g) (kcal) (g) (g) (g) (g) (g) (g) {g) (mg) (RE)
34057 Mixed Drink, bloody mary. prep I/recipe 1 ea 209 46 7 0 0.0 0 117
22538 Mixed Drink, daiquiri, 6.8 fl oz can 1 ea 207 259 0 33 0 0 0.0 0.0 0.0 0 0
34058 Mixed Drink, gin & tonic, prep I/recipe 1 ea 232 160 0 8 0 0 0.0 0.0 0.0 0 0
22556 Mixed Drink, high ball I ea 160 105 0 0 0 0 0.0 0.0 0.0 0 0
22569 Mixed Drink, Irish coffee, 1fl oz 1 ea 26 26 0 0 08 0.4 0.0 5 15
22568 Mixed Dnnk, Long Island iced tea 1 ea 125 119 0 9 0 0 00 00 00 0 0
22566 Mixed Dnnk, Mai Tai 1 ea 126 305 0 29 0 0 0.0 0.0 0.1 0 0
22557 Mixed Drink, margarita 1 ea 77 170 0 11 0 0 0.0 0.0 0.0 0 0
22571 Mixed Drink, Mexican eggnog/rompope 4 fl-oz 122 203 5 19 0 7 2.8 23 0.7 184 102
22561 Mixed Dnnk, p1na colada 1 ea 141 245 32 0 3 2.3 0.1 0.0 0 0
22683 Mixed Dnnk, suewdnver cocktail 1 ea 213 182 18 0 0 0.0 0.0 0.0 0 14
22567 Mixed Drink, tequila sunrise 1 ea 172 189 1 15 0 0 0.0 0.0 0.0 0 17
22534 Mixed Dnnk, whiskey sour mix, btld 4 fl-oz 124 108 0 26 0 0 0.0 0.0 0.0 0 0
22593 Rum, 80 proof I fl·OZ 28 64 0 0 0 0 0.0 0.0 0.0 0 0
22515 Tequila, 80 proof 1 fl-oz 28 64 0 0 0 0 0.0 0.0 0.0 0 0
22594 Vodka, 80 proof 1 fl-oz 28 64 0 0 0 0 0.0 0.0 0.0 0 0
22670 Whiskey, 80 proof 1 fl-oz 28 64 0 0 0 0 0.0 0.0 0.0 0 0
22577 Wine, all table types 6 fl·OZ 177 136 0 6 0 0 0.0 0.0 0.0 0 0
22608 Wine, cooking, red 1 fl-oz 30 20 0 3 0 0 0.0 0.0 0.0 0 0
22609 Wine, cooking, white 1 fl-oz 30 20 0 3 0 0 0.0 0.0 0.0 0 0
22681 Wine, cooler 1 cup 227 113 0 13 0 0 0,0 0.0 0.0 0 0
22509 Wine, dry, sherry 1 n-oz 29 20 0 0 0 0.0 0.0 0.0 0 0
20076 Wine, non alcoholic 4 fl-oz 116 1 0 0 0.0 0.0 0.0 0 0
22501 Wine, red 6 fl-oz 177 127 0 3 0 0 0.0 0.0 0.0 0 0
22600 Wine, rice, Japanese 1 fl-oz 29 39 0 1 0 0 0.0 0.0 0.0 0 0
22511 Wine, Sweet Vermouth 1 fl-oz 30 46 0 4 0 0.0 0.0 0.0 0 0
CANDIES AND CONFECTIONS, GUM
23017 Baking Chips, milk chocolate 1.5 oz 43 228 3 25 1 13 6.1 5.6 0.3 10 21
90704 Candy Bar, 3 Musketeers, 0.8 oz bar 1 ea 23 94 1 17 0 3 1.5 1.0 0.1 2 3
23125 Candy Bar, 5th Avenue, 2 oz bar 1 ea 57 273 5 36 2 14 3.8 6.0 1.9 3 8
23049 Candy Bar, Almond Joy, 1 7 oz 1 ea 48 231 2 29 2 13 8.5 2.5 0.6 2 4
90678 Candy Bar, Baby Ruth. 1.2 oz bar 1 ea 34 158 2 21 I 9 4.2 2.2 11 1
90653 Candy Bar, Butterfinger, 1.6 oz bar 1 ea 45 216 3 33 9 4.6 2.2 1.1 0 0
23116 Candy Bar. Caramello, 1.6 oz bar 1 ea 45 210 3 29 10 5.8 24 03 12 28
23118 Candy Bar. carob, 3 oz bar 1 ea 85 459 7 48 3 27 24.7 0.4 0.3 3 0
23099 Candy Bar. crisped rice, chocolate chip, 1 oz bar 1 ea 28 115 1 21 1 4 1.5 11 10 0 100
4196 Candy Bar. dark chocolate. 1.5 oz bar 0.5 ea 42 230 2 25 4 14 9.0 3 0
4198 Candy Bar. dark chocolate, wlalmonds, 1.5 oz bar 0.5 ea 42 230 3 23 4 15 8.0 3 0
91519 Candy Bar, Heath, bites 15 pee 39 207 2 25 12 6.1 3.4 1.0 7 18
23060 Candy Bar, Kf\ Kat. 1.5 oz bar 1 ea 43 220 3 27 0 11 7.6 25 0.4 5 10
23061 Candy Bar, Krackel, 1.5 oz bar 1 ea 43 218 3 27 11 6.8 2.7 0.2 5 9
23037 Candy Bar, Mars almond, 1. 76 oz bar I ea so 234 4 31 12 3.6 5.3 2.0 8 8
92633 Candy Bar. milk chocolate, 0.6 oz bar I ea 17 90 10 0 5 3.5 5 0

90687 Candy Bar, Milky Way, 1.9 oz bar I ea 54 228 2 39 1 9 4.2 3.2 0.3 8 10
23035 Candy Bar, Mounds, 1.9 oz bar 1 ea 54 262 2 32 2 14 11.1 02 0.1 0
23062 Candy Bar, Mr. Goodbar, 1.75 oz bar 1 ea 50 267 5 27 2 16 7.0 41 2.2 5 17
23133 Candy Bar, Nestle Crunch, 1.4 oz bar 1 ea 40 207 2 26 10 6.0 34 0.3 5 6
www.mhhe.com/wardlawpers7 A- 113
PAGE KEV: A· 158 Granola Bars. Cereal Bars, Diet Bars. Scones, and Tarts A· 158 Meals and Dishes A· 162 Meats A· 168 Nuts, Seeds. and Products A· 170 Poultry
A· 172 Salad Dressings, Dips, and Mayonnaise A· 172 Salads A· 174 Sandwiches A·176 Sauces and Gravies A-176 Snack Foods-Chips, Pretzels, Popcorn
A· 178 Soups, Stews. and Chilis A· 180 Spices. Flavors, and Seasonings A-182 Sports Bars and Drinks A· 182 Supplemental Foods and Formulas
A-184 Sweeteners and Sweet Substitutes A· 184 Vegetables and Legumes A· 198 Weight loss Bars and Drinks A-200 Miscellaneous
Thia Ribo Niac Vit 86 Vit 812 Fol Vit C Vit D Vit E Cal Iron Magn Phos Pota Sodi Zinc Wat Alco Caff
(mg) (mg) (mg NE) (mg) (µg) (µg) (mg} (IU) (mg An (mg} (mg} (mg) (mg) (mg) (mg) (mg) (%) (g) (g)
0.00 0.00 0.03 0.00 0.00 2.4 23.6 0.0 0.0 19 1.07 2.2 4 52 558 0.0 94 1.38 0.00
0.00 0.00 0.02 0.00 0.00 21 2.7 0.0 0.0 0 0.01 2.1 4 23 83 0.1 75 19.90 0.00
0.00 0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.0 3 0.03 0.9 2 7 0.1 88 18.56 0.00
0.00 0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.0 6 0.02 1.2 2 3 25 0. 1 90 15.09 0.00
0.00 0.00 0.03 0.00 0.00 0.1 0.0 1.8 0.0 3 0.00 1.1 3 12 2 0.0 86 1.63
0.00 0.00 0.02 0.00 0.00 1.3 3.2 0.0 0.0 4 0.05 1.8 12 14 6 0.0 83 12.14 0.00
0.00 0.00 0.05 0.00 0.00 1.2 1.0 0.0 0.0 3 0.09 2.4 6 24 11 0.1 54 27.56 0.00
0.00 0.00 0.03 0.00 0.00 1.2 1.0 0.0 0.0 2 0.05 1.4 4 15 4 0.0 62 18.50 0.00
0.03 0.20 0.07 0.07 0.55 18.0 0.6 43.7 0.5 106 0.54 11.1 136 125 42 0.7 69 7.48 0.00
0.03 0.02 0.17 0.05 0.00 16.5 6.9 0.0 0. 1 11 0.27 10.6 10 100 9 0.2 65 13.89 0.00
0.14 0.02 0.34 0.07 0.00 74.9 66.5 0.0 0.3 15 0. 18 17 I 29 326 2 0.1 83 15.10 000
0.07 0.02 0.33 0.09 0.00 18.2 33.3 0.0 0. 1 10 0.46 11.7 17 179 7 0.1 80 18.68 0.00
0.01 0.00 0.00 0.00 0.00 0.0 3.3 0.0 2 0.14 1.2 7 35 126 0.1 78 0.00 0.00
0.00 0.00 0.00 000 0.00 0.0 0.0 0.0 0 0.02 0.0 0 0.0 67 9.28 0.00
0.00 0.00 0.00 0.00 0.00 0.0 0.0 0.0 0 0.00 0.0 0 0.0 67 9.28 0.00
0.00 0.00 0.00 0.00 0.00 0.0 0.0 0.0 0 0.00 0.0 0 0 0.0 67 9.28 0.00
0.00 0.00 0.00 0.00 0.00 0.0 0.0 0.0 0 0.00 0.0 1 0 0.0 67 9.28 0.00
0.00 0.02 0.12 0.03 0.01 1.8 0.0 0.0 14 0.62 15.9 23 149 11 0. 1 87 16.45 0.00
0.30 0.30 0.30 0.00 0.3 2 0.30 4 24 180 88 3.59 0.00
0.30 0.30 0.30 0.00 0.3 2 0.30 4 26 180 88 3.59 0.00
0.00 0.01 0.10 0.02 0.00 2.7 41 0.0 0.0 13 0.62 11 .9 15 102 19 0. 1 90 8.81 0.00
0.00 0.00 0.01 0.00 0.00 0.3 0.0 0.0 2 0.11 2.9 4 26 2 0.0 89 2.72 0.00
0.00 0.00 0.11 0.01 0.00 1.2 0.0 0.0 10 0.46 11 .6 17 102 8 0.1 98 0.00 0.00
0.00 0.05 0.14 0.05 0.01 3.5 0.0 0.0 14 0.75 23.0 25 198 9 0.2 88 16.45 0.00
0.00 0.00 0.00 0.00 0.00 0.0 0.0 0.0 1 0.02 1.7 2 7 1 0.0 78 4.69 0.00
0.00 0.00 0.05 0.00 0.00 0.1 0.0 0.0 2 0.07 2.7 3 28 3 0.0 72 4.59 0.00
0.05 0.12 0.15 0.01 0.25 5. 1 0.0 0.9 80 1.00 26.8 88 158 34 0.9 2 0 00 8.51
0.00 0.02 0.05 000 0.03 0.0 0.1 0.2 19 0.17 6.6 21 30 44 0.1 6 0.00 1 80
0.07 0.05 2.21 0.05 0.10 20.4 0.2 15 41 0.68 35.2 80 197 128 0.6 2 0.00 2.83
0.00 0.07 0.23 0.02 0.05 0.3 0.0 31 0.61 318 54 122 68 0.4 8 0.00
0.02 0.02 0.94 0.0 1 0.00 10.5 0.0 0. 6 15 0.23 24.8 47 121 73 0.4 5 0.00 1.36
0.05 0.02 1.39 0.05 0.00 15.0 0.0 0.8 16 0.34 37.6 61 179 97 0.5 1 0.00 2-26
0.01 0.18 0.51 0.01 0.28 0.8 0.0 0. 1 97 0.49 19. 1 68 155 55 0.4 7 0.00 1 80
0.09 0.15 0.87 0.10 0.85 17.9 0.4 1.0 258 1.10 30.6 107 538 91 3.0 2 0.00 0.00
0.15 0.17 2.00 0.20 0.00 39.7 0.0 0.0 6 1.78 13.6 38 48 79 0.2 7 0.00
0.0 0 108 0 0.00
0.0 20 1.08 0 0.00
0.00 0.03 0.03 0.00 0.4 0.3 0.0 34 0.30 2.3 28 82 96 0.0 0.00 0.00
0.05 0.09 0.20 0.00 0.23 6.0 0.0 0. 1 53 0.43 15.7 57 98 23 0.0 2 0.00 5.94
0.01 0.07 0.10 0.01 0.25 2.6 0.3 0.0 67 0.44 5.5 52 138 83 0.2 0.00
O.Q1 0.15 0.46 0.02 0.18 4.5 0.3 3.9 84 0.55 36.0 117 162 85 0.6 4 0.00 2.00
0.0 32 o.14 15 5 0.00 3.96
0.01 0 11 0.18 0.02 0.17 3.2 0.5 0.7 70 0.40 18.3 78 130 129 0.4 6 0.00 4.30
0.00 0.00 0.00 0.00 0.00 0.0 0.4 0. 1 11 1.12 0.0 0 173 78 0.0 9 0.00 9.15
0.07 0.07 l.71 0.02 0.15 18.9 0.4 1.6 55 0.68 23.3 81 195 20 0.5 0 0.00 8.93
0.12 0.21 157 0.15 0.15 31.4 01 0.4 67 0.20 23.0 80 137 53 0.6 0.00 9.52
A· 114 Appendix N Food Composition Table
PAGE KEY: A· 108 Beverage and Beverage Mixes A·l 1OOther Beverages A-1 10 Beverages. Alcoholic A-11 2 Candies and Confections, Gum A· 116 Cereals, Breakfast Type
A· 120 Cheese and Cheese Substitutes A-122 Dairy Products and Substitutes A· 124 Desserts A-130 Dessert Toppings A-130 Eggs, Substitutes, and Egg Dishes A· 132 Ethnic Foods
A-136 Fast Foods/Restaurants A-1 SO Fats, Oils, Margarines, Shortenings, and Substitutes A- 1SO Fish. Seafood. and Shellfish A-152 Food Additives
A· 152 Fruit, Vegetable. or Blended Juices A-154 Grams. Flours, and Fractions A-154 Grain Products, Prepared and Baked Goods
Food Unit/ Wt Energy Prot Carb Fiber Fat Sat Mono Poly Chol Vit A
Code Name Amt (g) (kcal) (g) (g) (g) (g) (g) (g) (g) (mg) (RE)
92654 Candy Bar. Payday, snack size, 0. 7 oz bar 1 ea 20 90 2 10 5 0.5 0
23137 Candy Bar, peanut, 1.4 oz bar 1 ea 40 207 6 19 2 13 1.9 6.6 4.2 0 0
915 13 Candy Bar. Reese's Nutrageous, 0.6 oz bar 2 ea 34 176 4 18 11 3.0 4.3 2.8 1 2
23036 Candy Bar, Skor. toffee bar, 1.4 oz bar 1 ea 40 212 1 24 13 7.5 3.7 0.5 21 57
23040
23146
Candy Bar, Snickers, 2 oz bar
Candy Bar. Symphony, milk chocolate, 1.5 oz bar

1 ea
1 ea
"
43
265
226
5
4
37
25
11
13
4.2
7.8
4.7
3.4
1.5
0.3
B
10
22
20
90705 Candy Bar. Tw1x. caramel, 2.06 oz two bar pkg 1 ea 58 291 3 38 1 14 5.2 7.8 0.5 3 15
92221 Candy Bar, Twix, chocolate fudge cookie bar, 3.6 oz bar 1 ea 100 550 7 56 3 33 5.0 14.3 12.5 6 11
23151 Candy Bar. Whatchamacallit, 1.7 oz bar 1 ea 48 238 4 30 11 8.2 1.8 0.4 6 19
92658 Candy Bar, Zero, 0.6 oz bar 1 ea 17 70 12 2 1.5 0
23085 Candy, Almond Roca 1 pee II 48 7 0 2 1.1 0.6 0.2 1 2
4148 Candy, Bit 0 Honey, Nestle 6 pee 40 160 32 0 2.0 0 .8 0.2 0 0
92707 Candy, caramel, Sugar Daddy. lrg 1 ea 48 200 43 0 2 1.0 0 0
23015 Candy, caramels 1 pee 10 39 0 8 0 1 0.7 0.1 0.0 1 0
92374 Candy, cotton 2.1 oz 60 220 3 56 0 0.0 0.0 0.0 0
23078 Candy, fondant, chocolate cvrd 2 pee 28 102 22 0 3 1.5 0.9 0.1 a
92647 Candy, Good N Plenty. snack size box 1 ea 17 60 0 14 0 0 0.0 0.0 0.0 0 0
23409 Candy, gumdrops 1.5 oz 43 168 0 42 0 a 0.0 o.a 0.0 0 0
23412 Candy, gummy worms. pees 10 pee 74 293 0 73 0 0 0.0 0.0 0.0 0 0
23031 Candy, hard, all flvrs 1 pee 6 24 0 6 0 a 0.0 0.0 0.0 0 0
92653 Candy, hard, lollipop 1 ea 17 60 0 16 0 0 0.0 a.o 0.0 0 0
23472 Candy, Jawbreakers, Everlasting Gobstoppers,
Willy Wonka 6 pee 16 59 0 15 0 0.0 0.0 0.0
23033 Candy, jellybeans, sml 1a pee 11 41 0 1a 0 0 0.0 a.o 0,0 0 a
23063 Candy, Kisses, milk chocolate 6 pee 28 145 2 17 1 9 5.2 2.8 0.3 6 16
52154 Candy, licorice, black, vines/ropes 4 pee 40 140 1 33 0 0 a.o a.o 0.0 0 0
52155 Candy, licorice, red, vines/ropes 4 pee 40 140 34 0 0 a.o 0.0 0.0 0 0
92644 Candy. malt choc, Whoppers 9 ea 20 90 15 0 4 3.0 0 a
23047 Candy, milk chocolate peanut 1.5 oz 43 219 4 26 11 4.4 4.7 1.8 4 11
92642 Candy, Milk Duds 7 ea 21 9a 15 0 4 1.0 0
23193 Candy, mints. After Eight 5 pee 41 147 31 6 3.4 1.8 0.2 0
23225 Candy, mints, peppermint, Breath Saver 1 pee 2 10 a 2 0 0 0.0 0.0 o.a 0
92657 Candy, Nibs, licorice 9 ea 12 35 0 9 0 0.0 0.0 0.0 0 0
92201 Candy, nougat, a.5 oz pee 1 ea 14 56 0 13 a 0 0.2 0.0 a.o 0 a
23021 Candy, peanuts, milk chocolate cvrd 1.5 oz 43 221 6 21 2 14 6.2 5.5 1.8 4 14
23088 Candy, peanuts. yogurt cvrd 1.5 oz 43 23a 6 18 2 16 6.9 4.8 3. 1 0 0
90803 Candy, pralines, prep f/recipe 1 pee 40 174 22 1 10 2.7 10 30
23517 Candy, raisins, chocolate cvrd 35 pee 40 160 1 27 2 7 4.0 a 2
23089 Candy, raisins, yogurt cvrd 1.5 oz 43 167 2 31 s 43 0. 1 0. 1 0 0
92643 Candy, Sixlets 6 ea 38 170 1 29 0 7 5.0 0 0
23485 Candy, Skittles, original bite size candies, 2.17 oz pkg 1 ea 62 249 0 56 0 3 0.5 1.8 0. 1 0 0
23144 Candy, Starburst, fruit chews 1 pee 5 20 0 4 0 0 a.1 0.2 0.2 Q 0
92705 Candy, Sugar Babies 30 ea 44 180 0 41 0 2 a.a 0 0
4149 Candy. SweeTarts, reg 8 pee 15 60 0 14 0 0 0.0 o.a 0 .0 0 0
9a806 Candy, taffy, prep f/reope 1 pee 34 99 17 a 3 1.0 4
92769 Candy, Tootsie Roll 6 pee 40 155 35 0 0.4 0.8 0.1 0
www.mhhe.com/wardlawpers7 A-11 S
PAGE KEY: A· 158 Granola Bars, Cereal Bars, Diet Bars, Scones, and Tarts A· 158 Meals and Dishes A-162 Meats A· 168 Nuts, Seeds, and Products A· 170 Poultry
A·172 Salad Dressings, Dips, and Mayonnaise A-172 Salads A-174 Sandwiches A-176 Sauces and Gravies A-176 Snack Foods-<:hips, Pretzels, Popcorn
A· 178 Soups, Stews, and Chihs A· 180 Spices. Flavors, and Seasonings A· 182 Sports Bars and Drinks A· 182 Supplemental Foods and Formulas
A· 184 Sweeteners and Sweet Substitutes A· 184 Vegetables and Legumes A· 198 Weight Loss Bars and Drinks A·200 Miscellaneous
Thia Ribo Niac Vit 86 Vit 812 Fol Vit C Vit 0 Vit E Cal Iron Magn Phos Pota Sodi Zinc Wat Alco Caff
(mg} (mg) (mg NE) (mg} (µg} (µg} (mg) (IU) (mg An (mg) (mg) (mg) (mg) (mg) (mg) (mg) (%} (g) (g}
65 13 0.00 000
0.03 0.05 3.14 0.05 0.00 29.8 0.0 1.6 31 0.37 437 122 162 62 16 2 000 0.00
0.05 0.02 1.77 0.02 19.0 0.2 0.4 23 0.41 23.1 60 124 48 0.4 2 000
0.00 0.03 0.05 000 0.10 1.2 0.2 0.0 52 0.23 4.0 24 61 126 0. 1 2 0.00
0.02 0.07 2.03 005 0.09 15.3 0.0 0.9 60 0.68 40.8 108 183 129 1.4 6 0.00 4.53
0.03 0.15 0.14 0.01 0.17 0.9 0.0 0.1 107 0.38 23 4 88 186 43 0.5 0.00 2806
0.07 0.10 0.43 0.00 0 17 11.1 0.2 I. 1 53 0.46 18.7 64 110 113 0.6 4 0.00 1 75
0.14 0.20 1 11 0.03 0.33 9.0 1.0 2.7 130 1.30 46.0 147 309 266 0.9 2 0.00 10.00
0.05 0. 10 11 9 0 01 018 8.7 0.4 0.6 57 0.54 13.5 67 146 144 0.2 3 0.00 4 82
35 0.00
0.00 001 0.15 0.00 0.00 3.3 0.0 0.2 16 0.10 49 19 34 20 0.1 5 0.00
0.00 0.10 0.01 0.00 0.07 16 0.0 0.4 20 0.11 2.8 18 50 120 0.1 8 0.00 0.00
0.0 20 0.00 65 0.00 000
0.00 0.02 0.02 0.00 0.00 0.5 01 0.3 14 0.00 17 12 22 25 00 8 0.00 0.00
0 0.00 000
000 0.01 015 0.00 0.00 0.3 0.0 01 5 0.43 17.6 27 47 7 0.1 8 000 1. 12
0.0 0 011 40 0.00 0.00
0.00 0.00 0.00 0.00 000 0.0 0.0 00 0 .17 04 0 2 19 0.0 000 000
0.00 0.00 000 0.00 000 00 00 0.0 0.30 0.7 1 4 33 00 0.00 000
0.00 000 0.00 000 0.00 00 00 0.0 0 001 02 0 0 2 0.0 0.00 0.00
0.0 0 0.00 10 5 0.00 0.00
1 8 0.00 000
000 000 000 000 0.00 0.0 0.0 00 0 0.00 0.2 0 4 6 0.0 6 0.00 000
0.01 0.09 0.09 0.00 0.10 2.3 0.1 0.4 54 0.38 17 0 61 109 23 0.4 1 0.00 6.96
0.0 0 000 60 15 0.00 0.00
0.0 0 0.00 20 12 0.00 0.00

0.0 40 018 65 0.00
0.03 0.07 1 74 0.03 O.D7 16 2 0.2 1.1 43 0.49 32.3 99 148 20 1.0 2 0.00 4.67
40 6 0.00
O.Dl 001 011 0.00 0.00 0.4 0.0 02 9 0.62 18.5 23 69 5 0.2 6 0.00 8 19
0 0 0 0.00 0.00
0.0 0 000 60 25 0.00 000
0.00 O.Ql 0.07 0.00 0.00 0.7 0.0 0.4 4 0.07 4.5 8 15 5 0.1 2 0.00 000
0.05 007 1.80 0.09 0.18 34 0.0 15 44 0.56 408 90 213 17 1.0 2 000 9.35
0.14 0.09 2.48 O.Q7 0.18 49.9 0.1 23 64 0.93 35.0 113 202 24 0.8 4 0.00 0.00
0.05 0.02 0.11 0.01 0.02 2.5 0.2 4.8 0.4 20 0.34 13 4 33 67 40 0.4 17 0.00 000
1.0 16 3.00 40 10 0.00
0.05 0.07 0.33 0.07 0.12 3.9 0.9 0.6 48 0.56 10.3 55 236 19 0.2 10 000 000
0.0 40 000 55 0.00
0.00 000 0.00 000 000 0.0 41.2 0.3 0 0.00 0.6 6 10 0.0 4 000 0.00
000 000 000 0.00 000 0.0 2.6 0.0 0 0.00 0.1 0 0 3 0.0 7 000 000
0.0 20 0.00 40 0.00 0.00
0.0 0 0.00 0 0.00 0.00
0.00 0.01 0.\0 0.00 0.00 1.3 0.0 1.0 0.6 9 O.Dl 91 16 19 152 0.1 34 0.00 000
O.Ql 0.02 007 0.00 0.00 3.6 0.0 0.3 14 0.3 1 8.8 23 46 18 0.2 7 0 00 2.79
A· 116 Appendix N Food Composition Tobie
PAGE KEY: A- I 08 Beverage and Beverage Mixes A- 110 Other Beverages A-110 Beverages. Alcoholic A-112 Candies and Confections, Gum A· 116 Cereals, Breakfast Type
A· 120 Cheese and Cheese Substitutes A-122 Dairy Products and Substitutes A· 124 Desserts A-130 Dessert Toppings A· 130 Eggs, Substitutes, and Egg Dishes A-132 Ethnic Foods
A· 136 Fast Foods/Restaurants A· 150 Fats, Oils, Margarines. Shortenings, and Substitutes A-150 Fish, Seafood, and Shellfish A· 1S2 Food Additives
A-152 Fruit, Vegetable, or Blended Juices A-154 Grains. Flours. and Fractions A· 154 Grain Products, Prepared and Baked Goods
Code Name Amt (g) (kcal) (g) (g) (g) (g) (g) (g) (g) (mg) (RE)
4144 Candy, Treasures, peanut butter 4 pee 43 240 3 22 1 16 70 5 0
4143 Candy, Treasures, w/caramel 3 pee 35 170 22 0 9 5.0 5 0
23082 Chewing Gum, stick 1 pee 3 7 0 2 0 0 0.0 0.0 0.0 0 0
23369 Fruit leather, cherry 1 oz 28 105 0 23 0 2 0.7 0.9 0.0 0
91256 Fudge, plain 1.5 oz 43 188 0 27 0 9 6.0 II 10
23007 Marshmallows 4 ea 29 92 23 0 0 0.0 0.0 0.0 0 0
92226 Snack, crisped rice, peanut butter, 3.6 oz bar 1 ea 100 443 6 71 2 16 53 60 30 3 250
CEREALS, BREAKFAST TYPE

Cereals, Cooked and Dry
40055 Cereal, hot. breakfast pilaf, ckd 0.5 cup 140 170 6 30 6 3 0 0
40179 Cereal, hot, Cream Of Rice, ckd w/water & salt 1 cup 244 127 2 28 0 0 00 0.1 0.1 0 0
38497 Cereal, hot, Fanna, enrich, prep wfwater & salt 1 cup 233 119 4 26 0 00 0.1 0.0 0 0
40186 Cereal. hot. Maltex, ckd w/water & salt 1 cup 249 189 6 39 2 1 0.2 0.1 0.4 0 0
40239 Cereal, hot. Maypo, ckd w/water & salt 1 cup 240 170 6 32 5 2 0.4 0.6 0.5 0 701
40138 Cereal, hot, mult1grain, ckd 1 cup 246 202 7 40 4 2 0.3 0.5 I. I 0 116
38500 Cereal. hot, oat bran, prep w/water & salt I cup 219 94 4 16 4 2 0.4 0.7 0.8 0 4
40072 Cereal. hot, oatmeal, plain, inst, fort, prep w/water 0.75 cup 177 97 4 17 3 2 03 0.5 0.6 0 285
40190 Cereal, hot. Roman Meal, plain, ckd w/water &salt 1 cup 241 147 7 33 8 0.1 0.1 0.4 0 0
40188 Cereal. hot. wheat, plain, ckd wfwater & salt 1 cup 240 122 4 26 0 00 0.1 0.0 0 0
40191 Cereal, hot, Wheatena, ckd w/watef &salt 1 cup 243 143 5 29 5 1 0.2 0.2 0.6 0 1
40089 Grits, corn, inst, plain, prep w/water I/pkt 1 ea 137 93 2 21 0 0.0 0.0 0.1 0 0
38455 Grits. corn, white, dry 0.25 cup 42 150 3 33 1 0 0.0 0.0 0.0 0 20
38571 Grits, hominy, yellow, quick, dry 0.25 cup 37 125 3 29 2 0.2 0.2 0.3 0 21
Cereals, Ready To Eat
54234 Cereal, 100% Bran 0.33 cup 29 83 4 23 8 01 0 150
40095 Cereal. All-Bran 0.5 cup 30 78 4 22 9 0.2 0.1 0.6 0 158
40258 Cereal, Alpha-Bits, 1 1 oz svg 1 ea 32 130 3 27 00 0 150
40098 Cereal. Apple Jacks I cup 30 117 27 0I 0.2 0.3 0 42
40278 Cereal, Banana Nut Crunch 1 cup 59 249 5 44 4 6 0.8 0 150
40394 Cereal, Basic 4 1 cup 55 202 4 42 3 3 0.4 1.0 1.1 0 118

61203 Cereal, bran flakes 0.75 cup 30 96 3 24 5 01 0.1 0.3 0 225
40032 Cereal, Cap'N Crunch o 75 cup 27 108 1 23 2 04 0.3 0.2 0 4
40297 Cereal. Cheerios 1 cup 30 111 4 22 4 2 0.4 0.6 0.2 0 150
40325 Cereal, Chex, corn 1 cup 30 11 2 2 26 1 0 0.1 0.1 0.1 0 140
40333 Cereal, Chex, rice 125 cup 31 117 2 27 0 0 0. 1 0.1 0.1 0 155
40335 Cereal, Chex, wheat 1 cup 30 104 3 24 3 0.1 0. 1 0.2 0 90
40414 Cereal, Cinnamon Grahams 0.75 cup 30 113 2 26 1 0.2 0.3 0.3 0 150
40126 Cereal, Cinnamon Toast Crunch 0.75 cup 30 127 2 24 3 0.5 1.5 1.0 0 150
61272 Cereal, Coco Roos, chocolate 0.75 cup 30 122 26 0.3 0.6 0.1 0 397
40102 Cereal, Cocoa Krisp1es 0.75 cup 31 118 2 27 1 0.6 0. 1 0.1 0 153
40257 Cereal, Cocoa Pebbles 0 75 cup 29 115 25 0 11 0 150
40425 Cereal, Cocoa Puffs I cup 30 117 26 02 0.5 0.2 0 0
40103 Cereal, Complete Oat Bran Rakes 0.75 cup 30 105 3 23 4 02 0.5 0.3 0 235
40324 Cereal, Cookie Crasp 1 cup 30 117 26 0 0.2 0.4 0.2 0 145
61214 Cereal, corn flakes, plain 1 cup 28 101 2 24 1 0 0.0 0.0 0.0 0 216
40206 Cereal, Corn Pops 1 cup 31 118 28 0 0 01 0.1 0.1 0 144
PAGE KEY: A-158 Granola Bars, Cereal Bars, Diet Bars. Scones. and Tarts A-158 Meals and Dishes A-162 Meats A-168 Nuts. Seeds, and Products A-170 Poultry
A-172 Salad Dressings. Dips, and Mayonnaise A-172 Salads A-174 Sandwiches A-176 Sauces and Gravies A-176 Snack Foods-Chips, Pretzels, Popcorn
A-178 Soups, Stews, and Chilis A-180 Spices. Flavors, and Seasonings A-182 Sports Bars and Drinks A-182 Supplemental Foods and Formulas
A-184 Sweeteners and Sweet Substitutes A-184 Vegetables and Legumes A-198 Weight Loss Bars and Drinks A-200 Miscellaneous
Thia Ribo Niac Vit 86 Vit 812 Fol Vit C VitD Vit E Cal Iron Magn Phos Po ta Sodi Zinc Wat Alco Catt
(mg) (mg) (mg NE) (mg) {µg) (µg) (mg) (IU) (mg AT) (mg) (mg) (mg) (mg) (mg) (mg) (mg) (%) (g) (g)
0.0 40 0.36 80 0.00
0.0 40 0.00 60 0.00
0.00 0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.0 0 0.00 00 0 0 0 0.0 3 0.00 0.00
0.00 0.00 0.00 7 0.07 46 56 0.00 0.00
0.0 0 0.18 42 0.00 0.00
0.00 0.00 o.oi 0.00 0.00 0.3 0.0 0.0 1 O.Q7 0.6 2 1 23 0.0 16 0.00 0.00
0.43 0.44 6.go 0.52 119.0 14.9 344 5.17 28.0 102 185 406 0.5 4 0.00 0.00
0.0 20 1.44 15 0.00 0.00

0.00 0.00 0.98 O.D7 0.00 7.3 0.0 0.0 0.0 7 0.49 7.3 41 49 422 0.4 88 0.00 0.00
0.15 0.10 1.80 0.01 0.00 53.6 0.0 0.0 0.0 9 11.00 7.0 30 33 128 0.2 87 0.00 0.00
0.25 0.10 2.36 0.07 0.00 29.9 0.0 0.0 1.1 21 1.78 57.3 177 266 189 1.9 81 0.00 0.00
0.70 0.79 9.35 0.93 2.77 12.0 28.3 0.0 0.2 130 8.38 52 8 247 211 259 15 83 0.00 000
0.38 0.46 4.42 0.46 0.00 17.2 0.0 0.0 3.4 69 5.40 66.4 184 138 2 0.9 79 0.00 0.00
0.25 0.07 0.20 0.02 0.00 11.0 0.0 0.0 0.1 24 2.11 65.7 180 151 101 u 89 000 0.00
0.25 0.31 3.59 0 37 0.00 76. l 0.0 00 0.2 99 7.67 40.7 96 94 80 0.8 86 0.00 0.00
0.23 0.11 3.

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SEVENTH EDITION

!SBN-13 971Hl- 07-282750-7

Publisher: Co/111 H Wlmrtlq

Library of Congress Cataloging-in-Publication Data

Wardian, Gordon 1\1

QPl-ll .W3H 2007

PART TWO THE ENERGY-YIELDING NUTRIENTS AND ALCOHOL 149

PART THREE THE VITAMINS AND MINERALS 295

P. RT FOUR ENERGY BALANCE AND IMBALANCE 465

PART FIVE NUTRITION APPLICATIONS IN THE LIFE CYCLE 581

PART SIX PUTIING NUTRITION KNOWLEDGE INTO PRACTICE 689

Supplement Tour xxix

PART ONE NUTRITION BASICS 1

2 The Basis of a Healthy Diet 37

Chapter Objectives 38 Goslroinlestinol Hormones- A Key lo Orchestrating Digestion 90

Protein Metabolism 134 Fasting and Feasting 141

PART TWO THE ENERGY-YIELDING NUTRIENTS

Nutrition Focus Binge Drinking 287 Annotated References 291

PART THREE THE VITAMINS AND MINERALS 295

1 0 The Water-Soluble Vitamins 335

RiboRavin 341 Vitamin C 365

Chloride (Cl) 398 Iron in Foods 432

Silicon {Si) 452

PART FOUR ENERGY BALANCE AND IMBALANCE 465

I 4 Nutrition for Fitness and Sports 51 5

Designing a Fitness Program 518 15 Eating Disorders: Anorexia Nervosa,

PART FIVE NUTRITION APPLICATIONS IN THE LIFE CYCLE 581

PART SIX PUTTING NUTRITION KNOWLEDGE INTO

20 Undernutrition Throughout the World 729

Undernutrition in the United States 737 Appendixes A-1

Jeffrey S. Hampl, Ph.D., R.D., teaches coursework in public health nutrition in

Special Acknowledgments Catherine Jen, Wayne State University

JefTrcy S. Hamp! Ph.D., R.D.

Thoughtfully Crafted New illustrations

Energy Vitamin 8-6 Homocysteine

Vitamin A Vitamin 8·6

N!ilhlt!'ll! dolrn1 we..

Porotid salivary gland

A Personalized Approach to Nutrition

Latest Dietary Guidelines

Illustrations, Photos, and Tables

• Basic unit is glucose

Red blood cell

l• I A diluw so ~tlo n wlOI •

NBC News Nutrition

•• High Fiber Diets and Colon Cancer

•• Cholesterol Lowering Drugs

'.( / • Pet Sf H·~ 11 "'' '~ ooaooHM.wuol•w

Perspecb vea In Nucrttlon. 7fe

current 1.1u 9nm111ntt

F •W•w.-.np.Kttw4...!!,Hutrrn•n Mk•noft Inlet Mt bpk11e1

Please contact your local McGra\\ - Hill

CHAPTER OUTLINE CASE SCENARIO:

Peer Review of Experimental Results • Follow-up

Nutrition and Your Health

What Actually Is Nutrition?

Fur a substance to be considered essential, thn:c chan.lcteristics are needed:

Why Study Nutrition?

Table 1·1 I Ten Leading Causes of Death in the United States

Table 1 ·2 I Glossary Terms to Aid Your Introductio n to N utrition