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N FSC 340 Course Reader Professor Schneider F Table of contents Topk Last seniestefs oornplete study guide Macronutrient caiouiations Malnutrition Worid versus 118 Nutritional Guideiines Nutrient Density Target and class question Carbohydrates Trends in dietary intake astrointestn1a1tract Carbohydrate digestionfabsoirption Lipids Lipid digestiomaibsoirption Chyiomioron n1etaboiism Protein requirementsVegetarian diets Proteiri digestionabsorption Metabolism Energy NutrigeneticsNutrigenomics Pages 112 13 1433 3450 5152 5361 6263 6471 17275 769 8083 84 8586 8788 8897 98 99100 NFSC 240 Htunan llutrition This review sheet is to assist you in studying for the exam It does not replace studying your lecture notes Everything covered so far in lecture is fair game and anything in the textbook and course reader that pertain to the topics covered in class wili also be fair game introduction to Nutrition l 2 3 8 9 Food and nutrition define Macronutrients versus micronutrients describe and give examples Water list functions Fiber is it essential What is f1ber s role in health Phytochemicals what are they and What are their bene ts Describe nutrient density and energy density Distinguish between malnutrition in US and malnutrition in developing countries a Article Kennedy 2003 What are contributing factors to iron iodine and vitamin A de ciency What are consequences of these deficiencies b What are the leading causes what people die of each year of death in the United States today c Article Popkin 2006 Briefly describe nutrition transition related to degenerative disease See table 2 speci cally patterns 3 4 and 5 Outline the stages in the develotprnent of a nutrient deftiiciency what is the difference between a primary and secondary de ciency Nutritional assessment describe Nutritional Guidelines 1 2 3 Heaithy Perople 2020 a Describe the purpose and target audience of Healthy People 2020 Dietary Reference Intakes DRIS Ovtervitewhistory of RDAsDRIS How do the DRAS and DRIs differ in their endpoint of interest What is the intended goalpurpose of RDAsDRIS Describe the types of studies DRIs are based Dietary Reference Intakes DRl i De nitions we EAR Al UL RDA BER ii Are there any dramatic changes in recornmendations with the updated DR1s List any new nutrients iii What are the recommendations for percent of total calories from carbohydrate protein fat AMDR iv What about fiber What about activity Dietary Guidelines 2010 a What is the intent and goal of the guidelines what are they designed to do what population does it apply to b List the two fundamental shifts in from the 2005 to the 2010 Dietary Guidelines i Answer Use of the new Evidenced Based Library to assess the strength of the evidence as limited moderate or strong based on published research studies and the new focus on the environment at an instigator of dietary intake NF SC 240 Human Nutrition ii What factors contribute to dietary intake c Briefly describe the four major ndings as stated in the 2010 Dietary Guidelines List at least two speci c key recommendations from each category 4 Article Lupton 2005 how are the strength of the science between a foodsubstance and disease evaluated 5 MyPyramfd a List the six essential concepts of MyPyramid proportionality etc b Be familiar with the recommended amounts from each of the food groups for a 2000 kilocalorie diet 6 oz of grains etc c What is nutrient density Describe it 6 Article Painter 2005 Give a brief description of the various food group guides What the shape of the food guide and proportions for each food group for Canada China Mexico 7 Describe the Japanese food guide Carbohyd rates 1 Carbohydrate what is it What is the general formula 2 List the three monosaccharides Describe how they differ Examples of food sources 3 Polyol what is it Name a few Why are they used 4 List the three disaccharides Describe the bonding between the sugar units Food sources 5 Oligosaccharide what is it 6 List the polysaccharides what is arnylose amylopectin 7 Describe the bonding between the sugar units How does cellulose differ from starch 8 Trends in intake 9 Dietary Recommendations for carbohydrate 10 DRI a RDA 130 gday b 45 65 of total Kcalories c added sugars not to exceed 25 of total kcals d Adults under age 50 yrs Women 25 g ber men 38 g fiber l4 g1000 kcals l 1 Dietary Guidelines a 45 65 of total Kcalories b added sugars not to exceed 25 of total kcals c 14 g 1000 kcals l2 MyPyramid 2000 kcal diet a 6 oz of grains 1392 whole grain b 2 cups of fruit c 2 12 cups vegetables 13 Carbohydrates in the diet describe the general trend in complexi versus simple carbohydrate consumption in the US diet 1909present How are Americans doing compared with recommendations 14 List consequences of sugar intake and health l5 Article Liebman 2002 What are changes in carbohydrate intake in the US Dairy flour and cereal sweeteners fruits and vegetables NFSC 240 Human Nutrition Fiber 1 2 4 What is dietary liber functional fiber and total fiber DRl recommendations for total fiber intake Rich food sources What are the general physiological properties of nonavisconsnonfermentahle aka insoiuble fibers a Be familiar with each nonwiscous fiber cellulose hemicellulose lignan etc b What are they are composed of main constituents c Examples of food sources for each What are the general physiological properties of viscousfermentable aka soluble fibers a Be familiar with the viscous fibers pectin gums b What are they are composed of main constituents c Examples of food sources for each Article Marlett 2002 American Dietetic Association position paper on fiber and health a What is known about ber and gastrointestinal health b Fiber and cardiovascular disease what types of fiber is implicated and HOW does it work c Fiber and diabetes d Fiber and colon cancer If it works how does it work Digestion and absorption Chapter 3 ll 2 3 4 5 Digestion what is it Mouth a Describe the digestive processes taking place in the mouth b What is saliva composed of c What are the major electrolytes secreted d Salivary glands parotid submaxillary sublingual glands e Ceil types serous mucous cells what do they secrete fj What is the function of mucus Esophagus a Describe the 3 stages of swallowing b What is the function of the esophagus c What is peristalsis d Lower esophageal sphincter Stomach a List the functions of the stomach b List the gross anatomy of the stomach c Gastric gland cell typesachief parietal mucus endocrine what do each secrete d List types of gastric glands aw wliat are the primary secretions of each e Three phases of gastric secretions and what happens in each fj Describe roles of acetylcholinegastrinhistamine in HCL secretion g What two factors contribute to ulcer formation h Mechanical aspects of stomach i What is chyme Small intestine NF SC 240 Human Nutrition a What is the small intestines prirnrary fimction b List the gross anatomy of small intestine mesentery serosa muscles subrnucosa mucosa villi c Describe its microanatomy villus crypt enterocyte microyill i capillaries d Describe the layers that impede absorption nnstirred water layer glycoprotein coat lipid bilayer of cell membrane 6 Absorption a Absorption define it b List four fagtors that affect amount of nutrient absorbed c What are the two general ways that nutrients cross the intestinal cell membrane What are the differences between passive diffusion facilitated diffusion and active transport 7 Pancreas a Describe anatomy b Exocrine versus endocrine function and name the secretions of each 8 The Liven gall bladder a What are the functions b Describe gross anatomy c What is bile What is it composed of what is it needed for 9 The Large lntestine a Gross anatoniy b What is its function c What are feces 10 The Circulatory system a describe the general flow of Water and fatnsoluble nutrients l 1 Ehrenberg articlei Taste receptors Carbohydrate digestion and absorption Chapter 5 1 Be able to THOROUGHLY discuss the digestion and absorption of carbohydrates This includes roles of enzymes and hormones a Terms salivary amylase pancreatic amylase gastrin secreting CCK maltase glucoamylase isorrialtase also known as or dextrinase sucrase lactase maltose maltotriose dextrins sucrose lactose duodenal papilla 2 Be able to describe how glucose fructose and galactose are absorbed Lipids Chapter 6 l List the general functions of lipids 2 Lipid classification a Triglyceride i draw the general structure of a fatty acid ii What39sr the difference between saturated monounsaturated and polyunsaturated fatty acids know how to recognize and draw structures based on nomenclature eg 181 9 and omega 3 6 9 fatty acids iii draw the general struvctnre of a triglyceride examples of food sources rich in SPA MUFA PUFA 3 4 NFSC t 240 Human llutrition iv name the two essential fatty acids why are they essential what happens in a deficiency what important products are formed from each food sources of each type V recess versus cisfatty acid what is a trans FATE What are major food sources of trans FA Possible health implications Cholesterol structure and intportance functionimportant products formed food sources of cholesterol c Phospholipid Draw the general structure of a phospholipid importance of PLS functions d Glycolipid Dietary recommendations for fat consumption a DRDietary Guidelines i Al linoleic acid omega 6 1217 gday linolenic acid omega 3 ll16 eday ii 20 35 of total calories for all fats iii lt 300 mgday cholesterol b MyPyramid 2000 calories i Select lean meat poultry or fish eggs nuts seeds beans Beans are an excellent meat alternative that are low in fat ii Oils 6 teaspoons from many different plants and from fish ADA Report Position of the American Dietetic Association Fat Replacers a Describe the general trends in fat consumption and consumption patterns bl Lipid digestion and absorption 1 2 Be able to THOROUGHLY discuss the digestion and absorption of dietary fat This includes roles of enzymes and hormones a Terms lingual lipase gastric lipase CCK secretin bile colipase pancreatic lipase phospholipase MG fatty acids lytsophospholipid cholesterol esterase retinol esterase micelle What happens to the digestive products of fat once they are absorbed into the intestinal cell What39s a cliylcmicron How does it get to the general circulation Be able to describe the Ill lBf1b0lllSIl1 of a chylomicron after it enters the general circulation Protein Chapter 7 1 2 3 List some important products and functions of protein Structure a The amino acid draw out the basic structure what is meant by amphoteric i How are amino acids classified list names of essential amino acids b The peptide bond be able to draw out c Describe the primary secondary tertiary and quaternary structures of proteins Specific functions of AAS a what are the specific functions of methionine tryptophan and phenylalaninetyrosine 4 5 6 7 NFSC 240 Human Nutrition Protein Requireinent 8 Describe what is meant by protein tumover what are the sources of protein intake and protein losses b why do we need to eat protein c de ne N balance balance positive balance negative balance and give examples of each Be able to describe how protein RDA was determined using the N balance method be able to calculate protein RDA Protein quality a Chemical score AA score Biologic value BV Net protein utilization NPU PER Be prepared to solve problems Vegetarian Diets a common limiting amino acids in grains and legumes b What is an incomplete proteinquot what is meant by cotnbining proteins c nutritional pros and cons Lack and excess of protein a What are health consequences of lack of and excess of protein in the diet b chronic versus acute protein malnutrition C1 Protein digestion and absorption 1 2 Be able to THOROUGHLY discuss the digestion and absorption of dietary proteins Terms gastrin HCL pepsinogenpepsin secretin CCK eneterokinase trypsin chymotrypsin carboxypeptidase elastase luniinal phase brushborder phase cytosolic phase aminopeptidase carboxypeptidase dipeptidase tripeptidase a Describe how dietary protein is absorbed Cell metabolism 1 2 3 4 Overview of the cell a know basic function of the following organelles cell membrane nucleus endoplasmic reticulum golgi apparatus cytoplasm mitochondriia lysosonie Photosynthesis versus respiration what is it what are the products What is metabolism ATPwhat is it How is it used for energy Catabolic and Anabolic reactions a Describe the overview of metabolism big picture i What is oxidation and reduction What roles do the following nutrients play in the cell Water electrolytes protein lipids Carbohydrate metabolism l Regulation of Blood Glucose Levels normal glucose levels glucose tolerance hyperglycemia hypoglycemia a Blood Sugar Guidelines Fgasting Values lt 100 mgdl 100l25 mgdl 126 mgdl Normoglycecemia new value Preadiabetes Diabetes 2 3 47 NF SC 240 Human Nutrition 2hour Postprandial Values2 hours after 75 g glucose load lt 140 mgdl Normal l40 199 mgdl Pre diabetes 3 200 mgdl Diabetes b De ne glycogen glycogenesis glycogenolysis gluconegenesis glucagon c Be prepared to discuss the actions of the following hormones insulin glucagon epinephrine Carbohydrate breakdown for energr ATP a Glycolysis Fast anaerobic VEI39S1JS Slow aerobic metabolism of glucose What39s the difference what39s produced what39s the difference in ATlPs produced i List situations when fast metabolism would occur ii Where does it take place in cell iii Know general pathway Pyruvate oxidation outline it where does it take place know role of vitaminsVitamin eoenzyrnes what is a coenzyme Give examples KrrebsI TCA cycle know role of Vitamins know overall purpose of cycle ATP yieldturn of TCA and ATP yield from glucose total Electron transport chain know key reactions ATP yield from NADHH versus FADH2 be able to explain Why it is different e What is ATP count from glucose Glucose storage a Glyeogenesis what is it outline pathway b Glycogenolysis why does only liver yield glucose Glnooneogenesis a describe metabolic or dietary situations when this would occur what are the four major precursors outline general pathway where major precursors enter ll 0 d Lipid metabolism l 2 3 4 Why is triglyceride an important fuel source Where is fat stored in body Describe the regulation of triglyceride in the fat cell by lipoprotein lipase fat storage and horInone s ensitive lipase lipolysis know how hormones in uence these enzymes Lipid breakdown for ATP a How does fat get from fat cell to tissue for energy use b Fatty acid iozridation or Bsoxidation activation in cytosol transfer into mitochondria via carnitine know general pathway of fatty acid oxidation role of vitaminsi i TCA cycle role ofvitamins ATP yield ii relative ATP yield from a fatty acid VS glucose be able to count ATP yield if I give you a fatty acid eg how many ATPS are produced from l20 iii where does glycerol enter metabolic oxidation for ATP Ketogenesis what organ synthesizes them names of ketones when are ketones produced NFSC 240 Human Nutrition 1 know general pathway of synthesis use Good points and drawbacllts of ketones 5 Lipogenesis where when does lipogenesis take place a Fatty acid synthesis takes place in what part of liver cell know general pathway role of vitamins h Triglyceride synthesis How are triglycerides synthesiized activated form of glycerol activated form of FAS 6 Lipoproteins how are they categorized what is major lipid associated with each Be able to discuss the ycornp lete inetaholisln lot VLDL LDL and HDL iniplications of these lipoproteins to heart disease what are desirable lipid levels New Material Protein metabolzism l Protein Synthesis a Describe the player involved DNA RNA mRNA tRNA rRNA ribosomes energy b Transcription DNA E introns r exons 2 nal mRNA provide overview e Translation mRNA H protein provide overview 1 codon anticodon describe 4 steps 2 Protein breakdown a What are the 2 ways to rernove N from amino acids what role does B6 play in transamination lb Where do ketoacids of amino acids enter oxidative metabolism what three points c What is meant by glucogenic glycogenic versus ketogenic amino acid 3 Disposal of N Urea synthesis where does this take place39 outline general pathway where do Ns and C come from in urea 4 Nutrition genetics a Define nutrigenomicsnutrigenetics give an example b Key insight of human genome project Energy l Measures of Energy a Measurements of energy what is a kcal kjoule be prepared to do conversions i How do we measure food energy bomb calorimetry discuss it define gross digestible rnetaholizable energy of food what are the differences 2 Energy Balance a Energy balance negative balance positive balance give examples 3 Energy intake a Energy intallte diet how do we measure dietary energy 4 Energy output a Energy Expenditure BMR DIT activity i what is BMR Be familiIar with factors that in uence BMR what is DI39lquotfTEF What is TEE What is adaptive tliermogenesis NFSC 240 Human Nutrition ii How to measure cornponents of energy expenditure what is direct calorin1etry what is indirect calorimetry estimation equations Vitamins involved in energy metabolism ll Thiarnin a What is the free form versus coenzyme form b Give examples of the functions of thiamin i What happens in a thiamin deficiency What 2 hody systems does it affect What is meant by wet versus dry beriberi in the US what group is at high risk of at thiainin deficiency and whey c What is the DRI for rthiaminwhat are rich food sources Riboflavin a what is the free vitamin form name the two coenzymes i what39s the major overall function of rihoflavin give examples of specific functions ii What happens in a deficieincy What are the symptoms is de ciency cornrnon or rare b What is the DRI for riboflavinWhat are rich food sources Niacin a Name the 2 forms of niacin coenzyrnes i what39s the major overall function of niacin give specific examples of its function ii what is NADP used for iii what happens in a niacin deficiency b What is the DRI for niacin Whats a NEquot role of tryptophan what are rich food sources i Is niacin toxic use of niacin for treatment of hypercholesteroleniia What are the potential toxic side effects What is the UL Pantothenic Acid PA a Name the Vitamin and its 2 coenzymes b Functions give examples of pathways that use PA What is ACP used for c DRI for PA what is it Biotin a What is free vitamin i Functions Give examples of pathways that need biotin ii Deficiency of biotin common or rare what is avidin b DRI for biotin what is it Vitamin B6 a What are the 3 forms of B6 and how do they differ list coenzyme i Functions What is the primary function of B62 give other exainples of its function ii De ciency of B What happens What are the symptoms b What is the DRI for B5 relationship to protein what are rich food sources i is B6 toxic What happens What is the UL NFSC W 240 Human Nutrition Micronutrients and anemia 739 Folic Acid a What is the free form of folic acid What is the coenzyrne form what is the difference between Inonoglutamate and polygilutanlate forms b briefly describe digestion of folacin i Function of folacin whats the primary function list other functions what diseases are low levels of folate linked to 1 Deficiency of folic acid what happens What kind of anemia Why r other symptoms c DRI for folacinlitstt rich food sourcesWhat is the ULewhyquot Vitamin B12 What mineral does it contain Where do you find B12 Briefly describe digestion and absorption and transport of Big know roles of pepsinHCL R proteins intrinsic factor transcobalarnin Problems with digestionabsorption of B12 What is most connnon problern What is pernicious anemia Function of En What are the 3 functions oflB1g l What is B 339s relationship with folic acid What is homocysteinie g De ciency of B12 what happens What syrnptonrs are unique to Big h What is the DRI for B12Narne rich food sonrces What is a rnajorn1acrotrace Inicro mineral and give examples it b C d 6 fl Iron Where is iron found in the body What is heme and nonheme iron list factors which increase or decrease iron absorption describe roles of ferritin tceruloplasnlin transferrin what are the functions of iron what happens in a deficiency list the DRI and rich food sources a b Micronutrients as antLi oxidants 1 LIJ Vitamin C a Why are humans not able to make vitamin C b List the functions of vitamin C c Deficiency of vitamin C Q what happens d what is the llRl for srnokers name good food sources e why do people megadose List possible side effects UL wl1y Vitamins List some of the differences between water solubl e and fat soluble vitamins Vitamin A a Forms i retinoids list names and how they differ ii carotenoids what is most cornrnon form l how is 3carotene converted to active Vitamin Aquot where does this take place in what tissues 2 What are the biologically active forms of A b d 6 NFSC 240 Human Nutrition DigBS OIlAbSOI pti0IlfIIilEt i0ilSllll1I i how is quotvitamin A found in food 2 fonns how is Vitamin A digestedquot which form is digested ii what happens to vitamin A in the intestinal cell39 how is Vitamin A transported to the liver iii What happens to A in the liver how is A transported in the general circulation Functions i how does vitamin A function in Vision Be able to outline the visual cycle what happens in a defiiciency ii what happens to epithelial tissues in a deficiency iii growth what happens in a de ciency iv what is Vitamin A s role in immunity V reprzoduction what happens in a deficiency in animals vi vitamin A Becaroteneother carotenoids and cancerCHDcataracts macular degeneration for A REList rich food sources Toxicity of A when is it toxic UL at what dose what happens 4 Vitamin E 3 13 0 dl 6 what is the most comrnon form of E Functions of E In brief what39s a free radical What is the danger of free radicals i How does E function as an antioxidant De ciency of E what happens in a vitamin E deficienlcy Who is at risk why What is the DRI for E TElist rich food sources Toxicity of E Ul What happens Micronutrients and bone 5 Calcium a bl where is calcium found in body i Absorption of calcium what is bioavailaloilityi list factors which increase or decrease calcium absorption Regulation of serum calcium i What happens if serum calcium is too high too low 1 Describe what happens if serum calciurn increases or decreases know ii role of Vitamin D PTH calcitonin list the functions of calcium what happens in an acute versus chronic calcium deficiency i What is cortical VS cancellous bone ii List the risk factors associated with osteoporosis what is DRI and list rich food sourcesUL why 6 Vitamin D a h 0 how does the body synthesize D Be able to outline reactions role of shin liver and kidney what is active form of D Functions of D what are the 3 primary actions of D What happens in a vitamin D de ciency adults versus children NFSC 240 Human Nutrition 1 what is the NEW RDA1 What is the difference between the old Al and new RDA Value for vitamin iDt list rich food sources e Toxicity of D when is it toptic UL What happens Other micronutrients if time allows l Vitarrlin K n up iquot in oiK W ls Function 7 7 i K O O r I it 39 i c Decieny o 5 I I39g U quot It I 3 Vitamin article Vitamin D articles posted in unit 4 1 Articl e 2 is a report by the lnstitute of Medicine lOM What health outcome does the IOM base the new recommendation for vitamin D and calcium a List the other bene ts of Vitamin D described by the IOM report other than bone health i What was the conclusion reached by the IOM ii What is the signi cance of AI versus RDA Vitamin D was an Al and now it is an RDA Why b List limits to testing vitamin D in the blood Labeling regulation 1 NLEA what is it a List examples of exception of items that do NOT require a label b Be able to describe basic REQUIRED information on the current label c De ne Daily Values RDIS and DRVS know nutrients that have RDls and DRVS d Describe the two types of claims that can be made on food labels list some examples e What about restaurants 0 What about raw foods producemeatpoultrytish pg Proposed grading sysrteni and quali ed health claims Calculating kilocalories in food Kcallgram grams kcals kcaIlf0od A Carbohydrate Protein Fat V Alcohol Total Calculating percent of macronutrient in daily diet Assume intake of 1980 kcals in one day 290 grams of carbo11ydrate 60 grams of fat 70 grams of protein Gina iienned is a Consuitant in the Nutrition Pianningi assessment and ifiraiiitlatison Senriice ESPN at FM day tiitatntel is a Senior Officer ESiJ rand iraaasht Sheity is Chief oi ESiiii Z Z he most recent estimates 39 i from FAQ indicate that Sit Y X million people do not receive enough energy from 5W their diets to meet their needs The overwhelming majority of these people 799 million live in developing countries The global toll of affected deficiency is estimated to be even higher people by micronutrient and probably exceeds two billion Micronutrient deficiencies can exist in populations even where the food supply is adequate in terms of meeting energy requirements ln these situations people are not considered hungrtyquot in the classical sense but their diets may be grossly deficient in one or more micronutrients Blindness and goitre are two of the most visible external manifestations of micronutrient defi ciency and have helped to bring it into the limelight However they represent only a fraction of the problem and subclinical deficiencies afflict a much larger proportion of the population Today the consequences of subclinical better understood and monitored but they deficiency are becoming often go unnoticed within the community in spite of their insidious effects on immune systtem functioning growth and cognitive development it is for these reasons that micronutrient deficiencies have been referred to as quot hidden hunger Micronutrient deficiencies are most prevalent in areas where the diet lacks variety as is the case for many individuals in developing countries When people cannot afford to diversify their diets with adequate amounts of fruits vegetables or animalsource foods that contain large amounts of micronutrients deficiencies are inevitable ln addition a minimum amount of fat or vegetable oil is required in the diet for adequate absorption of the fatasoluble vitamins A D E and K Grave consequences including continued and sustained loss of productivity permanent mental dis ability blindness depressed immune system function and increased infant and maternal mortality can result from micronutrient deficiencies The heaviest toll from these dietary deficiencies is borne disproportionately by women and children Death and the disabilities caused by micronutrient deficiencies need not occur because there are several short and long term strategies that can be employed to prevent the development of these deficiencies Many actions can be undertaken by the communities them selves once they recognize and under stand the problem This article provides an overview of the global prevalence of micronutrient malnutrition and discusses approaches that may be used to address the situation while emphasizing the role of foodbased strategies favoured by FAO tilobai prevalence oi hiden hunger lvlicronutrients are the essential vitamins and minerals required by human beings to stimulate cellular growth and metabolism Nineteen vitamins and minerals are considered essential for physical and mental development immune system functioning and various metabolic processesl Deficiencies of tuber based diets FADXWIIO 2002 Situations of food insecurity where populations do not have enough to eat will also inevitably result in micro nutrient de ciency iron vitamin A and iodine deli ciencies are the three micronutrient deficiencies of greatest public health significance in the developing world iron aetleiency ianaernla Anaemia is defined as a reduction in the oxygen carrying capacity of red blood cells which occurs as a result either of decreased haemoglobin or of a reduction in the total number of red blood cells Le a decline in red blood cell mass Iron deficiency is the most common cause of anaemia although anaemia can also occur as a result of vitamin B13 or folate deficiencies con genital hereditary defects in red cells from reproductive blood losses or infection by malarial parasites or iron found in anirnal source foods such as meat poultry and fish has greater bioavailability than does non haem iron found in cereals pulses fruits and vegetables There are many dietary factors that can either inhibit or enhance absorption of non haem iron Iron absorption is inhibited by phytate found in whole grains seeds nuts and legumes and by the phenolic compounds tannins present in tea coffee and red wine By contrast iron absorption is enhanced when consumed with ascorbic acid present in many fruits and vegetables iron deficiency becomes more common when an individuals iron requirements are increased owing to physiological demands such as pregnancy menstrual loss or periods of growth or when iron is lost because of parasitic infections hookworrn or malaria As a consequence of these compounding factors people living in environments prone to infection from malaria and hookworm and whose habitual diet is high in phytate with few Wllieiri people cannot aifiord to diversify tlieir diets 9 anti adequate arnounts of irruits vegetables or enimal source foods that coritain large dl i39lDquottii il 2 of inicronutrien39ts deficiencies are inevitable iron iodine and vitamin A are the most of micronutrient health consequences Other mieronutrients have forms with widespread rnalnutrition public been shown to play a role in preventing specific disease conditions eg folic acid and calcium or in promoting growth leg zinc The global prevalence of zinc and folate deficiency has not yet been established but it is predicted to be significant as rnicronutrient deficiencies rarelyquot occur in isolation One reason is that deficiencies usually occur when the habitual diet lElClS diversity or is overly dependent on a single staple food as is the case with monotonous cereal or 1 Vitamins ii B4 Big C D E and K thiamine ribo iiavin niacin panrothenic acid and biotin folate and follc acid calcium iodine iron magnesium and zinc infestations of the gut by parasites such as hoolcworm The level of haemoglobin in the blood is the most commonly used indicator to screen for iron deficiency anaemia lDA and is thus the indicator for which there is the most data worldwide The true prevalence of iron deficiency in a population however will be larger than the level of clinically detectable iron deficiency anaemia WHO 2lUia because most individuals are likely to be iron deficient long before there is a detectable drop in blood haemoglobin levels Nutritional iron deficiency or habitual iron intake that is insuiiicient to cover requirements is the most common cause of iron deficiency FAUHNHO 2lll2 Dietary sources of iron are present in two forms haem and non haem iron Haem anirnalesource foods are more likely to become iron deficient IDA is considered as a micronutrient deficiency of public health significance not only because it is widespread with an estimated two billion persons affected worldwide but also because of its serious consequences in both adults and children IDA is more prevalent in women than in men and is also prevalent among children and the elderly IDA during pregnancy can result in serious consequences for both mother and baby lrondeficient women have a higher mortality risk during childbirth and an increased incidence of low39birth weight babies WHO 2002 Figure 1 illustrates the prevalence of IDA in pregnant women Southeast Asia shows the highest prevalence of anaemia in women 39 39 eaev ats39tect or son in basement elloaaeal 7 esoas es ta aseas an asset iievelopeatl countries including cotrntries with no data P a we gg pGe r with over 50 percent of pregnant women affected Mason et at 2001 ln addition to the effects of anaemia during pregnancy much more is now known of the deleterious effects of anaemia on the cognitive performance behaviour and physical growth of infants and children of preschool and school age WHO Zllfllal lDA in adults diminishes their stamina and work capacity by as much as ll l5 percent and it has been estimated that this deficiency provokes losses in gross domestic product of up to 15 percent FAO 2002 Iodine is an essential mineral required by the body to synthesize thyroid hormones the most important of which is thyroxine a rnetaboIism regjulating substance The iodine content of plant foods is heavily influenced by the presence of iodine in the soil or environment Seaweed concentrates iodine from seawater and therefore constitutes a rich source of this nutrient Seaweed and seafood in general are good dietary sources of iodine Eggs meat milk and cereals also contain small amounts of iodine Populations with little access to ocean fish or other marine products for example persons living in mountainous areas are the most likely to show iodine deficiencies resulting from a lack of natural dietary sources of iodine Clinical iodine deficiency is detected by the presence of goitre swelling of the ID 1 thyroid gland Subclinical iodine deficiency can be detected by measuring urinary iodine or assessing thyroid function Figure 2 shows the global prevalence of goitre The latest estimates indicate that 741 million people or l3 percent of the world39s population are affected by goitre WHO Zll lb As with lDA the true prevalence of iodine deficiency is even more widespread than the numbers of those affected with goitre would seem to indicate however there are no global estimates for prevalence of low urinary iodine which is the best subclinical indicator The most devastating consequence of iodine deficiency is reduced mental capacity Fifty million people worldwide are mentally handicapped as a result of iodine deficiency WHO 2302 According to one source it has been estimated that lll 000 children are born each year with irreversible brain damage because their mothers lacked iodine prior to and during pregnartcy lC ClDD 2002 l39laternal iodine deficiency can also lead to spontaneous abortions stillbirth and impaired foetal development In infancy and childhood this manifested by poor mental developrnent deficiency is and growth defects Persons living in with deficiency may show an intelligence communities endemic iodine quotient l35 points lower than persons from similar communities with adequate iodine supplies WHO Z lllbl iodine de ciency is the most preventable cause of brain clarnage and one of the easiest disorders to prevent it suffices to add small amounts of iodine to frequently consumed foods such as common table salt E quot e 3 i it lfitarniln t deficiency Vitamin A is required by all body tissues for normal growth and tissue repair The visual and immune systems are particularly dependent upon this vitamin for normal functioning Vitamin A in the form of retinol is present in a variety of foods including eggs milk and fish or in its precursor form as carotene in yellow fruits and vegetables green leafy vegetables and red palm oil Retinol forms of vitamin A are more readily absorbed by the body than carotene although the lioavailability of carotene can be enhanced by consuming dietary sources of fat at the same time The efficiency in eesvalrac or ioonas asset as to 35l 39 339 iii to v25 A ale 0 eiansas 3 39 l O Developed cetantrses 39 mu quot including countries with no data Fl39 and carotenoids into the active form of the thought to be converting carotene other vitamin is now considerably poorer than previously assumed this topic is currently an active area of investigation Blindness resulting frorn vitamin A VAD has responsible for sensitizing communities deficiency been largely and raising international awareness of the devastating consequences of this deficiency WAD is still the leading cause of preventable blindness in children However clinical forms of the deficiency are now becoming less frequent and detection of subclinical deficiency is gaining more importance Mason et al 2Ull Optimal vitamin A status is necessary for the immune system to function normally Subclinical deficiency has been linlted to increased childhood illness and death lt is estimated that improving the vitamin A status of children would decrease overall child mortality rates by 25 percent measles death rates by 50 percent and death caused by diarrhoea by 40 percent UlllCEF 2002 Previously the most common indicators used to assess VAD were clinical signs affecting the eye Collectively known as xerophthalmia these range from relatively mild rever sible conditions to permanent blindness as a result of keratomalacia irreversible corneal damage Subclinical deficiency can be detected through measurement of serum retinol This indicator can be used to identify populations at risk from increased morbidity and mortality and can also be used to classify the severity of World Health Organization WHO recommends that the problem The l AD be regarded as a severe public health problem in populations where more than 20 percent of the children have serum retinol levels equal to or lower than 0 ttttltilfl WHO N96 Figure 3 shows the global prevalence of low serum retinol Sitter rnieronutrients Deficiencies of the micronutrients vitamin A iron and iodine are those considered to be of the greatest public health signi cance However much more is now being discovered about the vital role of other important nutrients for growth development immune system functioning and prevention of birth defects zinc and folate are two of these Zfrit Global attention to zinc deficiency has accelerated rapidly over the past 15 years However there is still no information about the prevalence of this deficiency although it is assumed to be widespread in areas lacking dietary diversity Zinc is an essential component in over 300 enzymes needed by the body for metabolism fFAU W39l39lD 2002 The best dietary sources of zinc are meat particularly organ meats and shell sh while eggs and dairy products are also relatively good sources of zinc The bioavailability of zinc is inhibited by phytate which is present in large amounts in cereals and legurnes Thus people whose diet contains only minor amounts of anirnal source foods including eesvetErict or var aastfo on y tow 39SEI 2tJ ivi 39 quotRET39iiIiCti 2 ease is to aides in re 1es G to i o 39 Beveioped countriesi rincltiding countries with no data dairy products with large amounts of staple grains and pulses will be at greater I l5l of zinc deficiency Research is emerging on the role of zinc deficiency and the impact of zinc supplementation on pregnancy outcomes for both mother and foetus and on the morbidity growth and neuro behavioural development of children The clearest indicator of zinc deficiency is stunted child growth there is evidence that zinc supplementation can improve the growth of stunted children Brown and Wuehler 2000 Some benefits in relation to incidence and prevalence of diarrhoea have also been noted with zinc supplementation Evidence linking zinc to improvement in pregnancy outcomes and cognitive development of children is not strong and more research is needed in these areas and Wuehler 2UflU39 Most importantly there is a need to develop Brown simple low cost methods for assessing the zinc status of individuals so that a better assessment of the global prevalence of zinc deficiency can be conducted Folate Folate is required for the synthesis of nucleic acids Deficiency can arise from insufficient dietary intake as well as rnalabsorption resulting from gastrointestinal disorders and secondary deficiencies of B5 and B12 or iron Stover and Garza 2002 Liver is considered to be the richest source of this nutrient folate is also present in a variety of vegetables Folate has received con siderable attention for its role in the prevention of foetal neural tube defect a condition associated with inadequate folate stores in early pregnancy Thus folate status before conception and during early pregnancy has become the focus of much of the discussion on this nutrient There is increased risk of foetal neural tube defects if the folate status of pregnant women shifts from adequate to poor FAOIWHCL 2002 It is for this reason that folate supplementation for women planning a pregnancy and during the first trimester has become a recommendation in many countries An important distinction to note with folate is that recommendations during early conception are designed to prevent deficiency and are recomrnended even for people whose folate status is considered adequate The supplementation strategy in this case focuses on prevention rather than correction of problems Even though there has not been a large effort to determine the global prevalence of folate deficiency the FAOl WHO Expert Con sultation on Human Vitannin and Mineral Requirements has recommended that further investigation he conducted into the relationship between folate deficiency and incidence of neural tube defects in developing countries FAOIWPIO ZUOZ Progress in controlling rnicrolnutrient de ciencies Micronutrient deficiencies remain a significant global public health concern Although sufficient to solve the problems of scientific ltnowledge is micronutrient deficiencies operational impediments prevent the implementation of solutions impediments include lack of political commitment and poor use of resources Underwood 1999 A recent report by the lldicronutrient lnitiative undertook a thorough analysis of trends in the prevalence of the three major This reductions in the prevalence of clinical cleficiencies analysis revealed VAD and significant improvements in goitre rate in countries with substantial iodization programmes such as Bolivia Cameroon Peru and Thailand but virtually no progress in the control of llDA Mason et al Zllfll However it is equally the difficulties important to note encountered in estimating the global reduction of rnicronutrient deficiencies owing to underestimation in past evaluations lack of comparable infor mation from one survey to another and improved detection skills in recent surveys WHO Efl lb Hunt and Quibria 1999 Mason er al 2901 The importance of collecting data on subclinical and process indicators is becoming increasingly evident Table 1 provides a list of clinical subclinical and process or programmatic indicators for vitamin A iron and iodine deficiencies Process indicators are being increasingly utilized to detect programmatic improve ments in control strategies and are frequently included in nationally representative surveys such as multiple cluster indicator surveys or demographic and health surveys When systematically collected these indicators can also be used to demonstrate progress and are often easier to collect than clinical and subclinical indicators innovative and multisectoral ap proaches to controlling micronutrient deficiencies have contributed to observed improvement in the global situation One of the more successful recent strategies in the control of VAD has been to link the distribution of vitamin A capsules to national immunization days The United Nations Children39s Fund UNICEF estimates that ll countries had vitamin A supplementation coverage rates of ill or more for the percent targeted population of children under five years of age in 1995 and by 1999 43 countries had reached this level of coverage UNICEF 2001 lo the case of iodine deficiencyi an estimated T2 percent of households in developing countries now use iodized salt compared to 20 percent a decade ago UNICEF Z l Strategiess to address lntcronutrlent rnalntitril tion Three addressing rnicronutrient malnutrition of the main strategies for are dietary diversification fortification including biofortification and sup plementation Most rnicronutrient defi ciencies can be effectively addressed through dietary diversification llortifi cation strategies are needed in areas where the traditional diet lacks a specific nutrient such as iodine Food based approaches to fulfilling rnicronutrient requirements have received strong support as a sustainable means of meeting the nutritional needs of population groups WHOfFAU lflil F3iOVvllIO ZUUZ These strategies are discussed in more detail below Suppiernentation Supplementation is a technical approach in which nutrients are delivered directly by means of syrup or pills Supplementation is most appropriate for targeted populations with a high list of deficiency or under special circumstances such as during pregnancy or in an acute food shortage Under normal circumstances supple mentation programmes are used only as a shortsterrn measure and are then replaced with longterni sustainable foocl based measures such as fortification and dietary quotTYPE it ilti i tiitl h lriiieiiriiie a Clinical SubcIinicall Serum retinal F recessf itIregrfarnmatit i2 Xeroptitha39lrnia and Bitets spots Percentage or presclieol children r39eeeiving vitamin A capsules t3EFiCti l ll39l i ifll39CRQiil3llquotlf RlElquottl fl l lil Serum ferri tin Haemoglobin haerrnatocrit Percentage of households tor 1surning adequately iotii2edI salt i iitSE Geitre visible or paipable Urina39ry incline Percentage of pregnant women receiving iron supplementation modification usually by increasing food diversity eiortiiication Fortification strategies utilize widely accessible commonly consumed foods to deliver one or more rnicronutrients The most widespread effort to date has been fortification of salt with iodine However many other foods may be used as vehicles for a variety of micronutrients Some of the more common combinations are wheat products cereal bread or pasta with one or more nutrients including calcium iron niacin ribo avin thiamine and zinc Milk can be fortified with vitamin D fruit and fruitjuices have been fortified with calcium and vitamin C Fish sauce and soy sauce are also recognized as good fortification vehicles and trials are under way to determine the efficacy of these foods as fortification tools Manner and Gallego 2002 Chen EDGE Successful employment of fortifi cation strategies requires centralized processing facilities mechanisms for quality control and social marlteting and public education strategies Nantel and Tontisirin 2002 Uauy et al 2002 The required infrastructure is often weak or laclung in developing countries WlllCh reduces the potential for the success of fortification measures Adequate income and marlteting channels are essential if these strategies are to succeed but the poor and nutritionally vulnerable are frequently less able to purchase fortified food products lvloreover infrastructure including roads and transportation systems is weak in many developing countries In order for fortification pro grammes to be successful these issues need to be acldressecl particularly in rural and remote areas where the majority of the populations at high risk live Eioi39ortiiieation Consumption of a wide variety of foods including those that contain an array of micronutrients is still seen as the best longterm sustainable solution to eradicate hidden hunger Along the path to achieving this goal biofortification may help to improve the health and welfare of many populations Blofortif ication or plant breeding for the specific purpose of enhancing the nutritional properties of crop varieties reflects the new application of an ancient technique For centuries farmers have bred crops to enhance specific traits such as improved yield drought tolerance or insect resistance Recently breeding trials have been undertalten for the specific purpose of enhancing the nutritional value of crops with the specific objective of improving human nutrition Gene rnarlzing techniques malte it possible for scientists to identify the specific plant genetic material that controls nutrient content so as to select the most beneficial ones for breeding purposes Using genes that contain nutritionally superior traits has enabled scientists to produce crop varieties with higher nutrient content There have been some reported successes including high protein maize high carotene sweet potato and cassava and 39iron enhanced rice TFFRT 2302 ietarp oiversiiieation Dietary diversity can be augmented by expanding the production processing marketing and consumption of a wide variety of foods In treating the problem of micronutrient deficiencies food based approaches that focus on improving overall dietary quality rather than merely delivering a single nutrient are particularly useful Several factors lend support to this increase bioavailability when nutrients are consumed simultaneously For example iron absorption is increased when it is combined with vitamin C FAQ 1997 New evidence about the protective role of phytochemicals and antioxidants continues to emerge These protective chemicals are easily obtained by consuming a wide variety of fruits and vegetables Scientific ltnovvledge linking nutrition and disease continues to evolve and eitpand implicating an even wider range of nutrients with a variety of roles in health rnaintenance Rickets a disease associated with vitamin D deficiency has now been connected to diets low in calcium Demonstrating the ezsisterice of dependent relationships heightens the importance of promoting foodhasecl approaclies that focus on achieving sustained improvements in the overall diet There are several low cost foodbased measures that can be promoted at the community level to improve micro nutrient status some of which are presented in Box l Culturally appropriate should be developed to help people identify con rlietary modifications crete actions that can improve both dietary supply and the absorption of micronutrients This information needs to be disseminated to the public through traditional information channels factors for success increased coiliaboraition and political comrnitrnent approach First there are complex Developing communities face multiple nutrient nutrient interactions that problems Therefore focusing on a single q 5 J i uwg xMv 7 Q srsraruesirriseiva a39 lt2 quotya 9 i39 ii D333 39 w 1V7 7 IvrvrnvVHF A vvarvn39nX39nvr ghinWwoecc u for order infants y o 3 Maomammqxm is Enc ouraging eitciusive breastfeeding upto sis rnolnthls of ageuancl centillleuvtifeasrtfeeding at identityinfgand promoting useor cu39ituraIly appropriate weaning foods rich in rnicronutrients ttlentiiyirifg and promoting use of traditional green leafy vegetables and traits to aria diversity to the diet a Preserving micrenutrients in fruits and quotvegetables by using solar drying or canning technologies 1 Promoting smallemale cornrrlunity gardens s Rearing small ilvestocit 1 Improving yearround supply or micrenuuient rich foods micronutrient deficiency or on a single strategy is not the most effective means to eliminate micronutrient deficiencies The problems often result from a wider set of factors including health care education sanitation water supply and housing Nantel and Tontisirin 2002 Comple mentary public health interventions that can help reduce micronutrient n 1al ch dhood immunization Sueciessful strategies are sanitation facilities and those that address all these issues in an integrated and coordinated faslnion Holistic strategies using a mixture of direct and indirect interventions and public health measures as well as education and awareness campaigns have proved to be the most successful in themselves are best suited to determine which corrective actions to employ to address their problleniis Collecting process indicators at this level can help direct community actions The role of government and government counter parts is to support these actions through political commitment training and the provision of lsasic services including nutrition include devvorming rnalaria prophylaxis improved water and Underwood Brovvn e tiieulenier 390 eds 2000 Zinc and human health Ottawa lvlicronutrient Initiative tters Ettiunrning 2003 lron forti cation of soy sauce in China Food Nutrition and rilgriiculture 32 pp TEu 82 rrno 100 Human nutrition in the developing world by M Latham Rome st eta 2002 State of Food lrtsecurity in the World 2002 Rome i ie0iiii internationai Life Sciences institute 190i Preventing micronutrient malnutrition a guide to foodhased approaches A manual for policy malrers and programme planners RomeiWashington DC FAOlllSl Fiitliiiivliiii 2002 Human vitamin and mineral requirements Report oi ajolnt FAQsWHO expert consultation Rome Hunt 339 to Quintin tut eds 1990 investing in child nutrition in Asia lvianlla Asian Development Bank i t tnternatio nai ouneiE tor the Controt of iodine eticiencg tsisorderi 2002 M30 fact card New Orleans lC39CIDD Communications Focal Point Tulane University School of Pulpic Health and tropical Medicine available at vvwvvtullaneeduiticeci aboutiddfhtrn accessed end lvlav 2003 insetsiationat Food Funny Research institute near 2002 Biofortification harnessing agricultural technology to improve the health of the poor available at vvvvvviipriorgfthemes grp06papers39tiloiortpdF accessed end May eeesi iliiannan ii at Geitego E 2002 lron fortification Country level experiences and lessons learned J Nutr 132 85638585 iii lason 13 lot illii taalrriive hi Se39tltsusarnari ls t eitctiiler pM with Gieiloei S iiienvveter id ilrnart lo iiliason it as Evioeirp I 2001 The rnicronutrient report current progress in the control of vitamin A iodine and iron de ciencies Ottovva l vlicronutrient lnitiativeflnternatlonal Development Research Center available at httpzilwvvwmicronutrientorgirameHTlv iL i39resourcetextipublicationsrnnreportpdt accessed end May 2003 liiiantel 0 at iquotootisirin itquot 2002 Policy and sustainability issues J Nutr 132 33938trIS reducing micronutrient I999 malnutrition attention to micronutrients Cornmunities Stoves 0 gr iarrrca 0 2002 Bringing individuality to public health recommendations J Nutr 132 2425524805 liauisi R irlertrarnpf E at Raddy 7 2002 Iron iortilicatlon of foods C ivercoming technical and practical barriers J Nutr quot132 84938525 iindemvood it 1990 Perspectives irorn micronutrlent malnutrition eliminationeradication programmes iiriquotl vl39WP Morbidity and Mortality Weekly Report 48 3242 United tensions tEl39riidren s Fund tiisii0 2001 Review of the achievements in the implementation and results of the World Declaration on the Survival Protection and illevelopment of Children and Plan of Action for lrnplementing the World Declaration on the Survival Protection and D39eveloprnent of Children in the T9905 Report of the Secretary General to the United Nations General Assembly 2th Special Session New York liiili0EP 2002 Vitamin A global initiative available at wwwuniceforgvitamina accessed end May 2003 itSZltiD the United States etpene3 for international iievelopmentl 1992 Economic rationale for investing in micronutrient prograrris A policy brief oased on new anal yses Washingtion DC United States Agency for international Development Bureau for Research and Development Office of Nutrition tlitamin pi Field Support Project iitiiii ieiorid Health rgeniaatioin 1996 indicators for assess ing vitamin A deficiency and their application in monitoring and evaluating intervention programmes WHONUTf9510 Geneva tamo 2001a iron de ciency anaemia Assessment prevention and control a guide for programme managers Geneva iiiiirit 2001 b Assessment of iodine de ciency disoro ers and monitoring their elimination a guide for programme rnanagers Second edition Geneva WtE0 2002 Turning the tide of malnutrition responding to the challenge of the 21st century available at wwvvvvhointi39nutl documentsnlhdbrochurepot accessed end lvlafv 2003Jr uiliitiliiiei 1905 Preparation and use of foodoased dietary guidelines Geneva 1 Tit 3 inraricctrt Jorr39runi of t39Irquotr39rr39orl nitrt39riticrrr Clornrnentary Global nutrition dynamics the world is shifting rapidly toward a diet linked with noncommunicable cliseasesl Barry M Popktrt ABSTRACT Global energy imbalances and related obesity levels are rapidly increasing The world is rapidly shifting from a dietary period in which the higherincome countries are dornirtatet l by pattems of degenerative diseases whereas the lower and middle income coun tries are dominated by receding t39amine I to one in which the world is increasingly being dorninated by degenerative diseases This article documents the high levels of overweight and obesity found across higher and lower incorne countries and the global shift of this bur den toward the poor and toward urban and rural populations Dietary changes appear to be shifting universally toward a diet dominated by higher intakes of animal and partially hydrogenated fats and lower intakes of ber Activity patterns at work at leisure during travel and in the home are equally shifting rapidly toward reduced energy expenditure Largescale decreases in food prices cg beet prices have increased access to supermarkets and the urbanization of both urban and rural areas is a key underlying factor Limited documen tation of the extent of the increased effects of the fast food and bottled soft drink industries on this nutrition shift is available but some examples of the heterogeneity of the underlying changes are pre sented The challenge to global health is clear Am J Clin Nutr 2IlUo84l28998 KEY WORDS Nutrition transition global obesity edible oils caloric sweeteners physical inactivity WHAT IS THE NUTRITION TlRANSITION Humankind has faced major shifts in dietary and physical activity patterns and body composition since Paleolithic man emerged on Earth Human diet and nutritional status have un dergone a sequence of major shifts among characteristic states de ned as broad patterns of food use and corresponding nutritionr elated disease Over the past 3 centuries the pace of dietary change appears to have accelerated to varying degrees in different regions of the world The concept of the nutrition tran sition focuses on large shifts in diet and activity patterns espe cially their structure and overall composition These changes are reflected in nutritional outcomes such as changes in average stature and body cornposition Furthermore dietary and activity pattern changes are paralleled by major changes in health status and by major demographic and socioeconomic changes 3 One needs to beconcemed with food supply which relates to agricultural systems and agricultural technology as well as with the factors that affect the demand for and use of food The latter include economic resources dentographic patterns and various cultural and ltnowledge factors associated with food choice dis ease patterns and sociologic considerations eg the role of women and liarnily structure Similarly equally important changes affect how we move work at home and in the market place and change our leisure activity patterns This shift toward increased obesity and noncommunicable diseases NCDS is only the latest pattern of this transition The 5 patterns of the nutrition transition are presented in Table I 1 The first pattern which is linked with hunter gather societies and is often called the Paleolithic pattern butcovers a longer period was one in which the diet was very healthy but inf39ectious dis eases and other natural causes resulted in a very short life span The second pattern when modern agriculture and a period of famine emerged was one in which nutritional status worsened lviost attention is focused on nutrition shifts in the last 3 patterns which are generally the ones represented by most of the global population today Figure 1 In pattern 3 famine begins to re cede as income rises ln pattern 4 changes in diet and activity patterns lead to the emergence of new diseases and increases disability In pattern 5 behavioral change begins to reverse the negative tendencies of the preceding patterns and enable a pro cess of successful aging 3 4 A range of factors including urbanization economic growth technical change and culture drives all the changes For convenience the patterns can be thought of as historical developments however earlier patterns are not restricted to the periods in which they first arose but continue to characterize certain geographic and socioeconomic subpopulations 1 From the University of North Carolina Chapel Hill NC 1 Supported by the National Institutes ofquot Health R01llD39l33 R01 HDEI4l339l5 R0l CAlD399831 R01CAl2ll52 RlllHDBDBSD and R01 PEDEBTOO 3 Reprints notavailable Address correspondence to BM Popkin Carolina Population Center University of North Carolina at Chapel Hill 123 West Franklin Street Chapel Hill NC 275 lo399 E mail poplinuncedu Received January 3 2006 Accepted for publicatl on March ll 2006 iii J Ciin Nairquot 20nss42saas Printed in usa to zone American Society for rtuuntmi 289 5003 gt Jaqtuatdlas uo an tuenaW t39J lllQAlU39 are13 elurojtjcg ta BJo39uols39awtM LLlClJl pepeogumocl i 39 quotquotT D r I I as rirrrern39crt Jorirrrol of Uquotrnt39crrl fvrrrrtr39rtrrt 290 TABLE 1 PClPKlN Characteristics of the 5 patterns of the nutrition transition Nutrition profile Diet Nulrttiottal status Economy Houseltold production lncorne and assets Dentographic profile Mortality and fertility lvlorbidity Age structttrc Residency patterns quotFood processing Pattern 1 collecting food Plants low t39at wild animals varied diet Robust lean population few nutritional de ciencies Huntergatherers Primitive onset of re Subsistence prtrrtitivc stone tools Low fertility high mortality low life expectancy Much infectious disease no epidemics Youn g population Rural low density Nonexistent quot39 MCH maternal and child health WHY THE CONCERN The shift from the receding famine pattern pattern 3 to one dominated by nutritionrelated NCDs has been very rapid in most Pattern 2 famine Cereals predominant diet less varied Chiildren and women suffer most from low fat intake nutritional deftciency diseases emerge stature declines Agriculture animal husbandry homentaliin g begin shift to rnonocultures Labor intensive primitive technology begins clay cooking vessels Subsistence few tools Age of lvlalthus high natural fertility short life expectancy high infant and maternal mortality Epidemics endemic disease plague smallpox polio tuberculosis deficiency disease begins starving common Youn g very few elderly Rural a few small crowded cities Food storage begins Transition profile Pattern 3 receding famine Fewer starchy staples more fruit vegetables animal protein low variety continues Continued lvICllquot nutrition problems many deficiencies disappear weaning diseases emerge stature grows Second agricultural revolution crop rotation fertilirer Industrial Revolution women join labor force Primitive water systerns clay stoves cooking technology advances Increases in income disparity and agricultural tool s industrialization Mortality declines slowly then rapidly fertility static then declines small cumulative population growth which later esplodes Tuberculosis smallpox infection parasitic disease polio wcanin g disease diarrhea retarded growth expand later decline Chiefly young shift to older population begins Chiefly rural move to cities increases international migration begins mcgacities develop Storage processes drying sailing begin canning and processing technologies emerge increases in food re ning and rnilling Pattern 4 degenerative disease More fat especially from animal products sugar processed foods less fiber Olztesity problems for elderly bone health etc many disabling conditions Fewer jobs with heavy physical activity service sector and mechanization household technology revolution Household technology nteehanizes and proliferales Rapid growth in income and income disparities technology proliferati on Life expectancy hits unique levels ages 6l U huge tlec1ine and fluctuations in fertility cg postwar baby boom Chronic disease related to diet and pollution heart disease can ccrl decline in infectious disease Rapid decline in fcrtililty rapid increase in proportion of elderly person Dispersal of urban population decrease in rural green space Nunterou s foods tzransforming technologies Pattern 5 behavioral change Fligherquality fats reduced refined carbohydrates more whole grains fruit vegetables Reduction in body fatquot and obesity irnprovernent in bone hcahh Service sector t39t let3l391ElfIlZtlll0l1 antl industrial robotiaation dominate increase in leisure csercise offsets sedentary jobs Significant reduction in food preparation costs as ti result of technologies change Decrease in quotincome growth increase in home and leisure technologies Life expectancy extends to ages ill and St y disabili39ty t39ree period increases Increases in health promotion preventive and therapeutic rapid decline in cardiovascular disease slower change in agespecific cancer profile lrtcreases in the proportion of elderly 75 yr of age Lower density cities rejuvenate increase in urbanization of rural areas encircling cities Technologies create foods and food constituent substitt1tes cg tnacronutrient sLtbsti39tutesr low and rniddle incorne economies moreover there is evidence of a speeding up of this transition in higherincome more eco nornically developed economics 5 Weight and height data are 6003 Al Jectwetdes U0 Cl39l Llll393 J3l ll millC39lUrl B11313 ElllIOllE39 to 5l039Ll3lB39MMM LllOll papeotuivtoj tart 3932 ii 1 13 i 393939 con Joaraoi ofCE39r et39clttl Ntrrririzrrt GLOBAL NUTRlTlON DYl lAMlCS pl K ledEino39Eoogallegeneiesin work leisure U and loud processungrmass media growth Ftanem 5 Behavioral Change PEIEEITI 42 Degenerative Disease Pattern 3 Receding Famine 39 Improved tat quality Increased fruit and vemrranlas F loduced rulined cartohydrate E Irrcruas ed whole grain iv Reduced E B iEhl t1quotrll39Ifi5ll1391 J Starc hyt loavvariely lowtat lughfiber toad Labormtenslva work and IEISIJF3 activities e Increased fat sugar processed foods Shift in technology at work and leisure activities MCH deficiencies Weaning disease Stunting Reduced body lain oss lrnpmved bone health V Obesity emerges Elena density problems Accelerated life expectancy shift to increased NFNED iner eased disability period FIGURE 1 Patterns of the nutrition transition 2 NR NCD nutrition related noncornrnunicable disease MCIi maternal and child health Extended Fealthzr aging Slow rnortalrty decline redwad MWNGD the nationally representative noncotnmunicable and nutritional measures most available in both high and lowincome countries These data provide some sense of the rate of change in obesity and of the rapidly changing faces of global obesity Obesity prevalence and trends N ationally representative data are presented tor a large num ber of countries in Figure EAt Only data for Africans blacks are presented for South Africa data from only 9 provinces are pre sented for China but these data mirror closely national levels and 1 Bivll 525 EJBMI a so as 35 MFlvlFMF39FIUlF I25rs lvll3tl 291 trends Essentially overweight and obesity levels are consis tently high in an array Oflligili139ltCDlll16 countries butthe levels are much lower in other European countries and several lower income countries eg Mexico Egyptt and South Africa have equally high levels of obesity among women Other very large countries eg China have obesity rates of gt20 for women and men What is potentially far more important are the rates of change in the prevalence of overweight and obesity in these countries as shown in Figure 2B A large number of lower and rniddleA income countries eg Mexico Thailand China and Indonesia are experiencing an annual increase in percentage points in overweight and obesity gt1 Only in the United Kingdom and Australia are such rates seen in higherincome countries Are these rates of change accelerating We rexplored the relative rates of change across the world for adults and children in a new study and have long term compa rable data for Brazil and the United States 5 Earlier changes in these 2 countries refer mostly to the mid 1970s the 1980s recent changes to the l990s and to the early 2000s In Brazil time trends indicate a deceleration in the combined overweight and obesity IEVEIS fOT adults however the increase in the combined overweight and obesity levels shows an acceleration for US adults Studies in China show patterns similar to those in Brazil The rate of change in the prevalence of overweight in FMF M F M F M F M F M quotUSA Australia UK Merice Brazil Morocco Egypt Salrica thetland China tnctonesia 19992dZl2 21300 2003 1999 2063 13931939 1993 1993 1998 2060 2000 GNP il3llP GNP GNP GNP GNP GNF sate 4630 1240 1290 date atsol 750 newness Et lvllzfto I25 EMi30 L55 139 A l M F M F M F F M USA Australia UK Mexico 391 999200 EllDE EH03 19331999 GtlF39 GNP GNP GNP 292to roots Elailtlll auto 4630 E Brazil 2033 GNP F M F M F M F Morocco Thailand China Indonesia 19 S1999 i9911996 zone 0 DD GNP GNP G NP GNP 39tE ll 2 Bill 750 640 FIGURE 2 Obesity patterns throughout the world A and increases in obesity among adults B in selected countries 2 US United States UK United Kingdom GNP gross national product per capita US S South 5003 gt rsqtuoideg U0E1lquot39 Lldell w ootu3 agun aims BllJl0llB its 5J0 LlJB39MMM won popeoumoc The trrrer39ie urr Jritrrnnl rfCliur cni r vtrr39rit39irirz 292 POPKIN Urban Women Marten lasso Brarai412a S Atriea l lilltll quotTurkey 13160 Narrtitaa at 1 in Peru man E olurrhis 2329 th Guamrat it50 Jordan E15963 Ra Dominl39top15o1 Kazakhstan 1 2331 I Harem nine entlvta penal Esmtiswl e China llDl quot1 Soto til niteie tlll K Ennbatiwa nan I a lJabelcialiIn l Ea roeroan El b Kyru3r239F39Iep159gtDj Z SEN tndia4aiCIl Ghana lti iill zsnunln tarsal s V P CAfriefant7lcpl31D Kenya SSH EantN350 iiigaria zeal H I p Eunrlziaa Fesoiiidtl quot HaJ39ti l D39r I Ligands 1250 39 T Madagascar EESICI PMZ 33t Malawi zeal Hitter E2943 Tanzarilahslil CI El 40 E0 8539 at Overvrelght so so lm ii Underweight Rural Women Mexico 4till Brant E3231 5 Mesa 933101 Turkey Eatti l Namibia pa in Paruiatla l caiumsiatananj I S N P T s as 39 Guatemalalt l I R I Jsrdasizssut 39 Umrr2nHnrp t D F Ia2alrhtainli29tj M Iitaroeeailtodj I I I Enl39rula tll UE9l Esinllsafll Bhinaiittti uteartvoirel oaj L 2irrsbabWsiB3tll Uzbekistan E3331 V Gavanenters 39 Krurt H sil a l senrgatsaoj lndia iampo C2trarlaliliidji N izmsiatissnj 39 H oArmsnHap1seo U itanyaia till aersn i5n1 h Iigeria29ttj B4ir9lnnFasnE9tl 3 Haulers Ugaada25Ul GD H Madagaaearl l39lai24D quot I naaialz ujz Niger net I Tanszriritaita0 P so at 43 212 it b 20 as St 30 at Underweight is Dve39r39iveight FIGURE 3 Prevalence ofoverweight BMI in kgfrnzl E 25 and underweight BilIl si l85 in women aged 2049 3 in 36 developing countries ranked in brackets by per capita gross national income US Reprinted with permission 19 Dom Dominican Rep Republicr C Central 3 South China accelerated from lt05 in 19801990 to l399 and 09 in 1997 2U0390 tor men and women 139espectively 6 preliminary data for 2004 indicate that these changes are still accelerating In the dietary area we have documented longi tudinally that income elasticity or the proportioin of food purchases with a l increase in income has accelerated at an increasing rate in the past 15 y 7 8 Obesity is universally found in urban and rural areas In an article published in this Journal we provided nationally representative data for women aged 2049y rt 148 579 from 1992 to 2000 in 36 countries 9The article presents data on both underweight and overweight plus obesity status in loweincomc and transitional countries The summary shown in Figure 3 provides a clear picture of these differential patterns overweight plus obesity exceeded underweight in most countries Countries with high income and urbanization levels not only had high absolute levels of overweight plus obesity but they also had small urbanrural differences in overweight and very high ratios of overweight plus obesity to underweight In more developed countries overweight among women with a low socioeconomic status was high in both rural 318 and urban 51 settings Even many poor countries where underweight persists as a significant problemghad fairly high levels of overweight in rural area 9 Adult obesity appears to precede child obesity We recently explored this question using nationally represen tative data from 6 countries and nationwide representative data from a seventh country all measured at least twice during the 198520U4 period 5 This study used the single body mass index kgmg cutoff of392539 overweight plus obesity whereas the International Obesity Task Force seas and agespecific body mass index cutoffs for children are equivalent to 25 at 18 y of age It is not possible to compare prevalences between the standards used for children and adults however this analysis focuses on rates of change in these prevalences that can be compared Absolute rates of increase in overweight plus obesity tended to be higher among adults than among children in most countries muoh higher in the 2 low income countries ie China and Indo nesia and moderately higher in Brazil and in 2 of the 3 high income countries is the United Kingdom and the United States The only country where overweight plus obesity increased more among children than adults was Australia However relative rates of increase in overweight indicate faster increases in over weight arnong children in Brazil and in the 3 highincome coun tries As a result the relative excess of overweight among adults seen initially in all countries increased in China Indonesia and Russia but decreased in Australia Brazil the United Kingdom and the United States Although patterns indicate that there will he an increasing global obesity problem among children to match the adult prob tern other equally disturbing data on adultonset diabetes are emerging not only from the United States but also globally lit the United States many scholars are pointing to a large and important increase in adult onset diabetes among adolescents a phenomenon previously unseen 1013 tn the developing world the mean and median ages for adultonset diabetes have been lower than in the United States which possibly points to similar global problems in the future l4 15 5003 ii J9qLU3Cl3 S U0 q UltBylaw G LlfquotlLll p 31913 E39ilJ0ECI JE 5i0quotUClB39hMi5 A llliOJ p3pE0LlMD39 P39 quotHa Fee 7 in r is quotDma ha39 3quot lquot u 5 19 39 39 3939 E 39F39 393 as I ts quotA gag it We we 5 e wt quot7quot 3 v 3quot 5 M if Q 13 I 39lt GLOBAL NUTRITION DYNAMICS 293 40 isatl Total Fat 35 p p 1952 total Fat 1 so E 35 p 62 Animal39Fai 5 2 39 V 39 issu aaimalrai E 2 5 quot r I iQ90 39egatableFal 53 v I 10 1962 vegetable Fat 5 A p D PX I I 39 1quotquot L n 39 I quot I ti coon Mina wanna sous inane tame niece GNP per capita in constant l 993 LIB 39s FIGURE 4 Relation between the perzzentage of energy intake from fat and the per capita gross national product GNP in i962 and 1990 Reprinted with permission 8 WHAT ARE THE KEY DIETARY DIMENSIONS Globally our diet is becoming increasingly energydense and sweeter At the same time higherfiber foods are being replaced by processed versions There is enormous variability in eating patterns globally but the broad themes seem to be retained in most countries Eating pattern shifts in particular seem to be specific to dif ferent regions and sets of countries 16 In the higher income countries increased portion sizes awayfromhome food intake and snacking are eating pattern shifts that accontpany these changes 1720 Water and milk appear to be replaced by ca lorically sweetened beverages quotI 8 2l Dozens of studies doc ument these shifts in the United States but few studies document these same shifts in other higherincome countries where con cern for these shifts is greatest 22 Much less documentation exists for lowerincome countries and there scents to be more heterogeneity in terms of the shifts to awayfromhome food intake lo For instance awayfromhome food intake and snacking are as high in the Philippines as in the United States but is rare in Russia and China The global shifts in the energy density of the diet are equally difficult to document One can document large increases in the consumption of edible oils and animalsource foods for selected countries 7 23 with the help of wellcollected repeated 2fl h recall measures of dietary intake However in general most research has focused on the use of food disappearance data from the Food and Agricultural Organization With these data which are not as accurate in picking up smaller shifts in consumption and wastage 24 it is possible to see that the shifts in edible oil intake are universal In one set of analyses that compared edible oil intake patterns in the l96Us with those in the 19905 based on food lisappearance data large increases in edible oil available for intake were shown particularly for lower income countries 8 25 The crude picture of the increased intake of vegetable fats edible oils is being seen globally as shown in Figure 4 How ever average daily intakes in a country such as China where we measured intakes with recall and direct measures of household consumption were much higher For example individual adults in China with gt3Cl of energy intake from fat increased from El 5 to 44 between 1989 and 2000 Animabsource food changes are equally dramatic particu larly in selected countries 26 In China we documented very large increases in anirnal source food intake 23 27 Egg poul try beef and pork consumption have increased rapidly in China and milk intake has recently begun to rise Today the average Chinese adult consumes 1300 kcalld of pork poultry beef mutton fish eggs and dairy foods As we showed elsewhere the structure of consumption shifts in China is such that for each additional increase in income adults proportionally increase their intake of animahsource foods 7 S 2 Concurrent shifts are occurring in the use of caloric sweeten ers Only a few countries have published studies of the trends concerning the specific foods in which caloric sweeteners are found the United States and South Africa are 2 of these countries I8 2831 In the United States calorically sweetened bever ages eg soft drinks and fruit drinks account for gt50 of the increase in added caloric sweeteners in the past several decades the foods responsible for caloric stweetenerintakein South Africa are much more varied than in the United States 18 28 31 Elsewhere we used food disappearance data to document the worldwide increase in caloric sweeteners to the diet We showed that as national income gross national product GNP per cap ita and the proportion of the population residing in urban areas increased sugar intake also increased 28 This relation is shown in Figure 5 with countries grouped by GNP in 1962 The changes are larger for lower and middleincome countries Ur banization and national income per capita are correlated highly in the developing countries that have access to processed foods higher in sugar Urbanization is also linked with greater access to modern mass media to better transportation systems and to larger modem supermarkets dominated by multinational corpo rations 32 33 Although increases in per capita income have occurred in most cases hand in hand with iirbanization per capita income plays a powerful separate role in food consump tion decisions particularly in relation to the consumption of more processed foods The studies on fiber intake and other changes toward pro cessed foodstuffs are much more incomplete Because the issue of reduced fiber intake in the Western diet was first discussed as a rnajorhealth concern there have been few systematic studies of shifts in fiber intake throughout the world However important historical case studies have documented these shifts for selected population groups and countries 34 35 Specific shifts in diet 5033 gt Jequiaidag uo qgn tuieuew 03Ll e lU39 eieig BlUJDlBQ 1e dioquotuolewwith Loon popeountog lbCL vI Q quotM quotha quot22 it E quot39u 39J H4 3 as Q quotquot 39up 3 if runquot 39ulie e 139vi 3935 3 F 3quotn M Hil Q re at quote 294 POPKIN 13 C19 5 1 I 19562 E EDGE 30839 r to 5 11 155 T00 Kcalstcapitarday added sugar Lowest End lowest tlrd lowest J 4th lowest If higresr t13NP eapita groupings of countries in was FIGURE 5 Relation between changes in the per capita gross national product GNP US and caloric sweetener intake Reprinted with permission 28 from coarse grains to refined grains in a few countries have also been documented 36 Similarly studies of fruit and vegetable intakes indicate de creased intakes in many countries and regions ofthe world but again this trend has not been systematically studied 21 25 37 Fruit and vegetable intakes remain very high in selected coun tries eg Spain Greece and South Korea 38 40 WHAT ARE KEY PlIYSI39CAt ACTIVITY SHIFTS National or largescale monitoring of overall physical activity patterns did not exist before the late 1990s except in a few rare f3tCl pllDIlS 4l 43 In general research on physical activity and its changes in the world has focused mainly on the role of leisure activities particularly television viewing 4446 In China re search has shown that shifts in the types of occupations levels of activity at each occupation and shifts in the mode of transpor tation from active to more passive are potentially very impor tant 43 4739 48 Limited research on shifts in more common daytoday activities linked with home production and other forms of movement has been conducted by Levine et al 49 50 This research suggests that major shifts in this area are linked with the use of more modern technologies in the workplace in the shopping arena and at home The picture of overall shifts in activity their causes and their consequences are still incomplete Typically scholars examine changes in each element of physical activity We are yet to see studies of joint shifts in all activity components to enable us to begin to understand I what the past shifts have been 2 what potentially future shifts are the most important and 3 how to use this knowledge to guide policies on increasing activity in a more coherent manner WHAT ARE THE MAJOR UNDERLYING GLOBAL FORCES Globalization Globaliaation with its focus on freer movement of capital technology goods and services has had profound effects on lifestyles that are linked with diet activity and subsequent im balances that have led to the obesity epidemic Although many researchers have placed the global food production marketing and distribution sectors including soft drink fast food and other multinational food companies at the center of blame for these changes there are other profound and equally responsible factors that must be understood to enact effective public policy to ad dress them 5 1 These other factors include I worldwide shifts in the trade of technology innovations that affect energy expen ditures during leisure transportation and work 2 globalization of modern food processing marketing and distribution tech niques most frequently linked with westernization of the world s diet 3 vast expansion of the global mass media and 4 other changes that constitute the rubric of the effects resulting from an increased opening of our world economy 52 53 One of the central shifts has occurred in the global food sys tem which is related to the marketing and sales of food The fresh wet or open public market is disappearing as the major source of supply for food in the developing world These markets are being replaced in some countries by multinational regional and local large supermarkets supermarkets that are usually part of larger chains cg Carrefour or Walmant or by local domestic chains patterned to function and look like these global chains in other countries such as South African and China Increasingly we are finding hypermarkets very large megastores as the major force driving shifts in food expenditures in a country or region For example in Latin America the supermarkets share of all retail food sales increased from l5 in 1990 to 60 by 2000 32 For comparison 803939i of retail food sales in the United States in 2000 occurred in superrnarkcts In one decade the role of supermarkets in Latin Arrierica has expanded by an amount equivalent to that which occurred over about a half century in the United States 54 Supermarket use has spread across both large and small countries from capital cities to rural villages and from upper and middleclass families to the working class 55 This same process is also occurring at varying rates and different stages in Asia Eastern Europe and Africa Many factors are responsible for this food system phenome non 56 Consumer demand for processed and safer foods is on the rise in developing countries Additionally as countries mod ernize the opportunity co st of women s time has grown building a market for timesaving prepared foods has become more im portant Transportation and access to technology eg refrigera tors has also played a role in the demand for and access to supermarkets Other factors include the liberalization of direct foreign investment trade liberalization and the saturation of Western markets that has pushed growing companies into other 5003 gt Jeqtuaidag uo or uieuaw oogugstun eieig Bllll0jilE3 is 5l0 IU3lB39MMM Luci pepeojuiviog we re quotM quot149 39 an e E r s 5 J 39 7 E a NJ 5quotvs quotquot39 7393 1 E er 5 3 39J 5 it 339 39393 1512 iquotw GLOBAL NllTRlTlON DYNAMlCS 295 E00 500 4 l 300 l99 US 39 EDD 100 39quot 100 kg Pool in U I u 39 1 F 39 n t rr 39 I I U 72 8082 9092 2020 FIGURE 6 Real world prices in l99ll US 55 over the years l97l l 972 I980i982 and 19901992 and projected estimates in 2020 Unpublished figure used with permission from Delgado et al 58 MT metric tons locales Furthermore improvements in the logistics and procure ment systems used by the supermarkets have allowed them to cornpet39e on cost with the more typical outlets in developing countries ie the small momand potp stores and wet markets fresh or open public markets for fruit vegetables and all other products Supermarkets are large providers of processed higherfat addedsugar and saltladen foods in developing countries but they have also been the purveyors of some good For eaampe supermarkets were 1 instrumental in the development of ultra heat treatment hightemperature pasteurized milk which gives milk a long shelf life and provides a safe source of milk for all income groups and 2 were key players in establishing food safety standards 57 Most importantly supermarkets have solved the problem of keeping animalsource products chilled and in many instances have brought hi gherquality produce to the urban consumer throughout the year Global agricultural policies Global agricultural policies have a builtin longterm focus on creating cheaper grains and animalsource foods The relation between these policies and the shift in livestock and other animal sourcc food intakes is documented by Delgado et al 26 58 One clear outcome has been a dramatic decline in the real price of beef and related products The huge decline in the global cost of too kg beef to 2ll of its initial costs over a 4decade period is presented in Figure 6 Global mass media Global mass media access has shifted in an equally impressive manner Minimal research has been conducted on how the in creased global access has affected dietary and physical activity behavior but it is clear from the extent of global food advertising growth that it is important For instance television viewership in China has more than tripled over a decade 95975 of all house holds had working television sets during the l99tls Moreover television programming has shifted from political and educa tional offerings prepared by the national or provincial govern ments to modern Chinese Asian and Western programming For example in the 9 provinces and 22739 communities monitored by the China Health and blutrition Survey no Hong Kong Phoenix cable or satellite television was available until 1993 in 2004 10 of these communities were watching these Western pro grammed channels and viewing is expected to accelerate greatly At the same time advertising contenthas shifted to more modern marketing The effects of such changes in television programming are found throughout the developing world The effect of such shifts in television access and programming are not understood Television and other media penetration has been complete for several decades in Europe the United States and other higher income countries which has made it difficult for studies to un ravel the exact causal effects of television viewing on nutrition related behaviors 44 DO COCACOLA AND MCDNALIIl S HAVE ANY RESPONSIBILITY Some researchers believe that the fast food sector and soft drink industry in the United States have led to the decline in the quality of diets throughout the developing world 51 59 The growth of American food companies has certainly spread across the globe CocaCola products are sold in gt200 countries and gt50 of McDonald s sales are made outside the United States Many other examples can be found to show that the numbers of MCDOt131tl S Pizza Hut and Kentucky Fried Chicken restaurants are growing rapidly across the globe Most interesting is the number of local restaurants and chains that have attempted to copy these American fast food rnodels even to the point of serving the same dishes and being equally hygienic and effi cient 60 Much research has been conducted on the effect of fast food restaurant patronization on current dietary patterns in the United States but little research has been conducted in the rest of the world 19 20 61 62 One 4country comparison of fast food intakes and other elements of modern food intake was undertaken for China the Philippines Russia and the United States by using comparable 24h recall data 63 This study examined away fromhome food intake overall and fast food and soft drink in takes among children and adolescents The results indicate very low levels of awayfrorn home food intake in Russia and China but equally high intakes in the Philippines and the United States lntake of fast foods and soft drinks in the Philippines was less than onefifth that in the United States and was miniscule in China and Russia 63 THE ECONOMIC COSTS OF THIS TRANSITION ARE HUGE In the United States and other higherincome countries sev eral analyses of the health costs and other effects of this shift toward higher obesity have been conducted For instance Wolfe and Colditz 64 65 have undertaken several studies of this topic using a costaccounting perspective Finklestein et at 6668 followed a more behavioral approach and examined how obesity affects medical expenditures In developing countries far less has been done to study this issue In one set of studies on the economic costs in India and China it was shown that these costs are rapidly increasing and represent a serious component of their GNP 37 69 in fact itis possible that these economic effects of the shift toward the degenerative disease stage of the nutrition transition will overwhelm the health system of China and slow its economic growth 70 6003 ii JE3qLll9Cl9S U0 Cl39 IUBlJElW ootugngun B lfE3913 BlLlJOllE3 1398 5lCI U3 lBquotMMM LUOJJ p3pEOlll39tl39t0j The lnscrr ccut Jonrrerri rifiilltrricrrf Ntrr39rirrftrrt 296 P0PKIN DO WE HAVE ANY POSITIVE MODELS AT THE NATIONAL OR REGIONAL LEVEL Few countries or regions have made signililcant program and policy changes that have resulted in positive shifts in dietary patterns and in considerable decreases in nutritionrelated NCDs Finland is one example that pointedly shows how intersectoral collaboration with one responsible national agency as the focal point can be very effective Fl in Finland national price policy and foodlabeling policies were combined with nutrition educa tion programs and the enlistnient of voluntary organizations to tackle this effort 72 73 Brazil is the only country with limited evidence of a decrease in obesity in one region T4 75 This decrease in obesity pre ceded a series of major initiatives in Brazil to further the decrease in obesity among women with a high socioeconomic status and to possibly slow the decline in other populations 76 78 Bra zilquots initiative to improve dietary patterns began as a coordinated and systematic initiative that included many important legisla tive and regulatory policies and changes to the national school feeding program 76 This effort appears to have slowed con siderably under the new president South Korea has long promoted the consumption of a tradi tional diet ie one rich in vegetables and low in fatin lieu of the type of dietary shifts found in other middleincome countries 39 40 For many decades the government has advised against modern Western cuisine and has provided intensive training to newly married women about the preparation of traditional dishes The results of these efforts have been lower obesity levels and lower intakes of energy from fat than would be expected given the high income level of this country and much higher intakes of vegetables than observed in other Asian countries 39 40 DIS CUBSION This commentary on the global shifts in the patterns of the nutrition transition addresses a broad range of socioeconomic and demographic shifts that have resulted in rapid changes in the diets and physical activity levels of most regions of the world The available data seem to indicate that most of the changes have involved reductions in fiber and whole grain intakes increases in refined carbohydrate intakes particularly in sweeteners and increases in intakes of animal and partially hydrogenated fats The shifts in activity patterns appear to have been equally rapid but are more poorly documented Although nutritionists and other health professionals might view these diet changes specifically the shifts toward higher intakes of animal and partially hydrogenated fats and lower in takes of fiber to be negative there has also been a shift toward a more diverse and pleasurable diet The activity patterns also represent a shift away from onerous difficult laborintensive activities Thus although these shifts in diet and physical activ ities are desirable in many ways they are associated with many onerous nutritional and health effects It is this paradox and complexity that make it difficult to arrest the negative aspects of the nutrition transition Since the development ofthe wheel and fire humankind has attempted to reduce the effort involved with activities both at home and away from the home Our striving to increase the tastefulness of the diet has been equally important Fat and sugar are 2 of the more pleasurable elements of the diet in terms of taste preferences Obesity results from the interaction of genetic susceptibility factors and modifiable environmental factors with genetic vari ations in uencing a person s susceptibility to environrnental fac tors We still have a remarkably weak global database for truly understanding these changes Few countries put energy into monitoring or studying these dynamics at the national or regional level Extensive documentation on micronutrient deficiencies and proteinenergy irnalnutrition is available however remark ably little data exists about largescale dietary and physical ac tivity patterns despite evidence that there are more overweight or obese than underweight or rnalnourished persons in the world this disparity is growing rapidly Our challenge is to devise ways to improve the lives of our citizens ie to I provide more varied and tasteful diets 2 pro vide less burdensome work 3 prevent obesity type 2 diabetes and other aspects of the metabolic syndrome and 4 prevent a vast array ofcancers linked with unhealthful dietary and activity patterns However the data indicate that few countries have tackled these issues at the national level Milio 72 73 studied these issues systematically and showed that little effort has been undertaken globally nationally or regionally to address them Lowerincome countries are only beginning to discuss and con sider options for dealing with obesity Concerns for poverty and hunger dominate the attention of the public and politicians and it is difficult to get foundations and governments to focus on NCDS We must also realize that these problems coexist in many countries and our solutions must not adversely affect the under nourished 79 81 At the same time we must begin to develop an array of largescale options that national governments can implement to address these issues 82 As with any other epi demic we must focus much of our energy on environmental solutions 0 l We thank Frances L Dancy for administrative assistance quotTom Swasey for graphics support William Shapbell for editing assistance and Du Shufa and Ningqui Hon for research assistance The author had no conflict of interest REFERENCES l Popkin E Nutritional patterns and transitions Popul Dev Rev l993l9 l3E 5 l39 2 Popkin BM An overview on the nutrition transition and its health im plications the Bellagio meeting Public Health Nutr 2Dll239593lU3 3 lvlanton KG Soldo BJ Dynamics ofhealth changes in the oldest old new perspectives and evidence lvlilbank Mern Fund Q Health Soc 1985 395339 20685 4 Crimmins EM Saito Y lngegneri D Changes in life expectancy and disability free life expectancy in the United States Popul Dev Rev 1989 l5235 6 5 Popkin BM Conde W Hon N Monteiro C Why the lag globally in obesity trends for children as compared to adults Obesity in press 6 Wang H De 5 Zhai F Popkin BM Trends in the distribution of body mass index among Chinese adults aged 20 45 years 1989 to 2000 ln t J Obes Relat Metab Disord in press T Du S lvlrotz TA Zhai F Popkin BM Rapid income growth adversely affects diet quality in China particularly for the poor Soc Sci Med 2UD lr3959l5I5 l5 8 Gun X Mroz TA Popkin BM Zhai F Structural changes in the impact of income on food consumption in China I939 93 Econ Dev Cultural Change 20tl437393 6D 9 Mlendez MA Monteiro Carlos A Popkin BM Overweight exceeds underweight among women in most developing countries Am J Clin Nutr 2JlJ53114 21 10 Lipton RB Drum M Burnct D et al Obesity at the onset ofdiabetes in an ethnically diverse population of children what does it mean for epidcmiologists and clinicians Pediatrics 2ttl5ll5quote553 6ll ll Saaddine lB Fagot Campagna A Rolka D et al Disttibution of 5002 gt J39aCLUBldBS 110 on niepew oogugalum oieig eluiolnegj in 6J039lJ3B39MMM tuol1pepeoiuvog The taterz39cttu Iour39artl ttfitliinicrti hquotttt 39r39t iftlJt39i 13 14 20 21 22 24 25 26 27 28 29 311 31 32 33 37 38 GLOBAL NUTRITION DYNAMICS HbA l cl levels for children and young adults in the US Third National Health and Nutrition Examination Survey Diabetes Care 2002 25ll32630 Clinton Smith J The current epidemic of childhood obesity and its implications for future coronary heart disease Pediatr Clin North Am 2UU4511fFl39995 it Hale DE Type 2 diabetes and diabetes risk factors in children and adolescents Clin Cornerstone 2tU46l301 Zimrnet PZ McCarty DJ de Courten MP The global epidemiology of rtoninsulindependent diabetes mellitus and the metabolic syndrome 1 Diabetes Complications l99l 1 11603 King H Aubert RE lierman WH Global burden of diabetes 1995 2025 prevalence numerical estimates and projections Diabetes Care l998211439l431 Adair LS Popkin BM Are child eating patterns being transformed globally Obes Res 2U39t5l3 128199 Jahns L Siega Riz AM Popltin BM The increasing prevalence of snacking among US children from 19 to 1995 J Pediatr 2Uil13S 4933 Nielsen SJ Popkin BM Changes in beverage intalte between 19 and 2001 Am J Prev Med 2004272U5 ltl Nielsen SJquot Popltin BM Patterns and trends in food portion sizes 197 1998 JAMA 2UU3289450 3 Nielsen SJ Siega Riz AM Popitin BM Trends in food locations and sources among adolescents and young adults Prev Med 2tl0235 10 13 Cavadini C SiegaBiz AM Popltin Blvi US adolescent food intake trends from 1965 to 1996 West I Med 200017337883 Cutnmins SC McKay t lvtacintyre S McDonald39s restaurants and neighborhood deprivation in Scotland and England Am J Prev Med 2005293tl810 Du 5 Lu B Zhai F Popkin BM A new stage of the nutrition transition in China Public Health Nutr 20025 169T4 Crane NT Lewis Cl Yetley EA Do time trends in food supply levels of macronutrients reflect survey estimates of tnacronuttient intake Am 1 Public Health 19Ei2328626 Drewnowsld A Popltin BM The nutrition tratisition new trends in the global diet Nutr Rev 199iquot553143 Delgado CL Rising consumption of meat and milk in developing coun tries has created a new food revolution J Nutr 2UU3l33suppl3Eitl7S IDS Popltin BM Du 3 Dynamics of the nutrition transi tion toward the animal foods sector in China and its implications a worried perspective 1 Nutr 2003l33suppl3S98S9065 P390pllI t BM Nielsen S The sweetening of the world s diet Obes Res 2l39Cl3 1 l 1 3253 2 Bray GA Nielsen SJ Popkin BM Consumption of highfructose corn syrup in beverages may play a role in the epidemic of obesity Am J Clin Nutr 2Utl47953739 l 3 Steyn NP Nel lli Casey A Secondary data analyses of dietary surveys undertaken in South Africa to determine usual food consumption of the population Public Health Nutr 2t3396t53 l44 Steyn NP Mfyburgb NG Nel JH Evidence to support a foodbased dietary guideline on sugar consumption in South Africa Bull World Health Organ 2ltl33 t59s eos Re fd ft T Berdegue J A The rapid rise of supermarltets in Latin Amer ica challenges and opportunities for development Dev Policy Rev 20D22IIl339i391quotS8 Reardon T Timrner P Berdegue l The rapid rise of supermarkets in developing countries induced organizational institutional and techno logical change in agrifood systems J7 Agric Dev Econ 20U41lL6883 Trovvell IiC Burltett DP eds Western diseases their emergence and prevention Cambridge MA Harvard University Press l98l Hughes RE Jones A Welsh diet for Britain BM 19791 l 145 Popltin BM Keyou G Zhai F Guo X Ma H Zohoori N The nutrition transition in China a crosssectional analysis Eurl Clin Nutr l9934 i39 33346 Popkin B Horton S Kim S The nutrition transition and prevention of dietrelated chronic diseases in Asia and the Pacific Food Nutr Bull 200 l 22 158 Morento LA Salria A Popkin BM The nutrition transition in Spain a European Mediterraneatt country Eurl Clin Nutr 2Ul2559921003 39 40 41 42 441 45 46 47quot 48 49 50 51 52 53 59 60 61 I52 63 64 65 297 Lee M1 Popltin BM Kim S The unique aspects of the nutrition transi tion in South Korea the retention of healthful elements in their tradi tional diet Public Health Niutr 2tltl25l97203 Kim 5 Moon S Popltin BM The nutrition transition in South Korea Am it Clin Nutr 2ltlUl4it 53 Tudor Locite C Ainsworth BE Adair LS Du S Popltin BM Physical activity and inactivity in Chinese schoolaged youth the China Health and Nutrition Survey Int J Obes Rclat Nietab Disord 2tlll3quot239i ltl 93 El TudorLocke C Net39i39Ll Ainsvvorth BE Addy CL Popitin Blvl Omis sion of active Commuting to school and the prevalence of children39s healthrelated physical activity levels the Russian Longitudinal Moni toring Study Child Care Health Dev 2l02 2S5lT39 l2 Bell AC G3 K P litltin Blvll Weight gain and its predictors in Chinese adults Int J Obes Relat ivietab Disord 2001 2 539ltl i986 Contrnit39tee on Food Marketing and the Diets of Children and Youth Food marketing to children and youth threat or opportunity Washing ton DC National Academy Press 2005 Dietz Wli GDt39ttt1allte1 31 Prcventing obesity in children and adoles cents Annu Rev Public Health 2DDI392233739 53 Gortnialter Sl Must A Sobol AM Peterson K Colditz GA Dietz WH Television viewing as a cause of increasing obesity among children in the United States l93986 l99 l39 Arch Pcdiatr Adolesc Med l99615t 356E2 Bell AC Ge K Popltin Btvt The road to obesity or the path to prevention rnotorized transportation and obesity in China Obes Res 2lD2ia3v2 T39 83 Paerataltul S Popltin BM Keyotl Ci AdairlS Stevens 1 Changes in diet and physical activity affect the body mass index of Chinese adults tntl Ctbes Relat tvletab Disord l9982242t 31 Levine JA Lanningham Fostcr Llvl lvlc rady SK et al lnterindividual variation in posture allocation possible role in hulnan obesity Science 2lIlt530T5846 LanninghamFoster L Nysse Ll Levine JA Labor saved calories lost the energetic impact of domestic labor savir1g devices Obes Res 2003 39l39lll7881 Brownell K Horgan K Food fight The inside story of the food industry America s obesity crisis and what we can do about it New Yorit NY Contemporary Books 2004 Mendez MA Popkin B Globalization urbanization and nutritional change in the developing world J Agric Dev Econ serial onlinel 2005 122041 Popkin Bit391 Technology transport globalization and the nutrition tran sition Food Policy in press Reardon T Titnnter CP Barrett CB Berdegue lA The rise of super markets in Africa Asia and Latin Atnerica Am 1 Agric Econ 2lt385 1 1406 HLI D Re td n T Rozelle S Tirnrner P Wang H The emergence of supermarkets with Chinese characteristics challenges and opportunities for China s agricultural development Dev Policy Rev 2UD42255786 Wilkinson 1 The food processing industry globalization and developing countries J Agric Dev Econ serial online 2lIl04l18 45201 Balsevich F Berdegue lA Flores L Mainville D Reardon T Super markets and produce quality and safety standards in Latin America Arnll Agric Econ 2Ut39l3351 391454 Delgado CL Rosegrant M Steinfield H Ehui S Courbois C Livestock to 2020 the next food revolution Washington DC International Food Policy Research institute l 999 Lobstein T Baur L Uauy R Obesity in children anti young people a crisis in public health Obes Rev Ztltl l549 Watson 1 Golden arches east McDonald39s in East Asia Stanford CA Stanford University Press 199 French SA Story M NeurnarkSztainer D Fulkerson JA Hannah P Fast food restaurant use among adolescents associations with nutrient intake food choices and behavioral and psychosocial variables Int Obes Retat Metab Disord 2tlt125 1 82333 Jeffery RW French SA Epidemic obesity in the United States are fast foods and television viewing contributing Am J Public Health 1998 S82 iquoti39 St Popkitl B Adair lt Are child eating patterns being transformed globally Obes Res 2tltl51312iil 3999 WolfAlVl Colditz G Current estitnates of the economic costs of obesity in the United States Ob 3953 Q r h 5 quotquot39d1 5 quot1quot 5 rs quotW t E quotstir 3 am E3 quotquot ea 5239 P Wu Ab ist F 3 9 an eca 3 is iquot 1 298 66 67 68 as F0 T1 72 7393 Finkelstein EA Piebelkorn IC Wang G National medical spending attributable to overweight and obesity how much and who s paying Health Aff Millwoodl 2003Suppl Web Exclt1sivesW3 2l9 26 Pinkelstzein EA Fiebelkorn IC Wang G Statelevel estimates of annual medical expenditures attributable to obesity Obes Res 2U43939l 2211824 Pinkelstein EA Rubin Cl Kosa KM Economic causes and conse quences of obesity Annu Rev Public Health 2053926239 51 P pkltl BM 1Iorton S Kim S Mahal A Shuigao J Trends in diet nutritional status and dietrelated noncommunicable diseases in China and India the economic costs of the nutrition transition NutrRev 2001 593799CI Popkin B Kim S Rusev E D11 5 Zizza C Measuring the full economic costs of diet physical activity and obesity39 relatecl chronic diseases Obes Rev in press Puska P Pirjo P Uusitalo U In uencing public nutrition for non comrnunicable disease prevention from community intervention to na tional jprogramtne experiences from Finland Public Health Ntttr 2002 5245 5l Milio N Making healthy public policy developing the science by learn ing the art an ecologic framework for policy studies Health Promot quotI 918812226344 Milio N Nutrition policy for food rich countries a strategic analysis Baltimore MD The Johns Hopkins University Press l99l PO PKIN TF4 75 T6 T7 78 T9 80 8 82 Monteiro CA PA Benicio MH Condo Wl Popkin BM Shifting obe sity trends in Brazil Eur J Clin Nutr 200D5433912 6 Monteiro CA Conde 3 Poplcin BM Is obesity replacing or adding to undernutrition Evidence from different social classes in Brazil Public liealth Nutr 2tJU251IC5 l2 Coitinho D Monteiro CA Poplqin BM What Brazil is doing to promote healthy diets and active lifestyles Public Health Nutr 2JU25263 7 Matsutlo V Mats title 5 Andrade D et al Promotion of physical activity in a developing country the Agita Sao Paulo experience Public Health Nutr 2l25253 6l Matsudo V The Agile Sao Paulo experience in promoting physical activity West Indian Med J 20D251suppl43 50 D0391llt CM Adair LS Bentley M Monteiro C Popltin BM The dual burden household and the nutrition transition parmiox Int J Obes Relat Metab Disord 200529 l29 36 Deal C Adair L Bentley M Fengying Z Popltin B The underweightf overweight household an exploration of liousehold sociodemographic and dietary factors in China Public Health Nutr 2U0252l5 2l Garrett J l Ruel MT Stunted child overweigiht39 mother pairs prevalence and association with economic development and urbanization Food Nutr Bull 2lJU5262 9 21 P Iladdad L What can food policy do to redirect the diet transition Food Nutr Bull 20l5262fi8 40 5003 IL J8qlll8ICl3S 110 Elm LllBJ9tl 0DjlL lJ 81913 BLlJO E 1153 lG39UCliE39NUquotI39M UJDJJ D lpeOllM0 f39 Tar iouariat or NUTRITION Symposium Nutrient Disease Relatlionshlips Closing the Scientific Knowledge Gap Determining the Strength of the Relationship Between a Food Food Cornponent or Dietary Supplement ingredient and Reduced Risk Joanne R Lu ptont D of a Disease or Health Related Condition Faculty of Nutrition Texas Addi University College Station TX 77843 ABSTllACTi lEV3lLl3l39llOlquotl of the strength of the science between a foodisu39bstance and a disease is not unique to the FDA and their re39riewl or petitions tor health claims although this is the focus of the symposium Deterrnilniing the strength of the science linking a food isubstance to a reduced risk of disease is also an important part of the process used to set the Dietary Reference Intake values lDFils and the Dietary Gluidelines for Americans It involves using an evidencebased system An appreciation of how erridencebased systems work and how research studies attempting to show the relationship between a foodsubstance and a disease are evaluated should lead to the design of better studies Better studies in turn will result in multiple benefits J Nutr 135 3404342 2005 KEY WORDS suhstanceidiseasle relationships evio ence based systems I health claims Although doe focus of this symposium is on etraluating the suength of the science between a foodlsubstance and decreased risk of a disease or healtheelated condition in support of a health claim which is regulated by the FDA determining the suength of diet disease relationships is not unique to the FDA The lnstitute of Medicine National Academy of Sciences evaluated the sIre1 1gth of the science between nutrients and disease or health related conch tions in setting the Dietargr Reference Intakes DRls3 1 The Dietary Guidelines Advisory Committees evaluate the strength of the science linking foods and nutrients to reduced risk of disease to make informed recommendations on guidelines for Americans 2 4 The American Dietetic Association evaluates the strength of the science linking a diet recommendation to an improvement in health 56 The overall goal of this paper is to show how the strength of the science between a f itutrientisubstance and a disease or hcaltharelated condition can be determined using an evidertcerbased review system The focus is on the evaluation of health claims as a specific use of an evidencc bascd system 1 Presented as parl of the symposium utrient Disease Ftelationships Closing the Scientific Knowledge Gapquot given at the 2Clot Experimental Biology meeting on April 1399 2004 Washington DC The symposium was sponsored by the American Society for Nutritional Sciences and supported in part by McNeil Nutritionals The proceedings are published as a supplement to The Joumai lofhiutrition This supple ment is the responslbility oi the Guest Editors to whom the Editor of The Journal of Nutntion has delegated supenrlsion of both technical conforrnity to the published regulations of quotThe Journal of Nutn39rion and general oversight of the scientific merit of each article The opinions expressed in this publication are those of the authors and are not attributable to the sponsors orthe publisher editor or editorial board of The Journai of Nutniion The Gumt Editors tor the symposium publication are Leila G Salclan ha Scientific Consultant Alexandria VA and Mary Ann Johnson Department of Foods and Nutrition Uniirersltgr of Georgia Athens GA 2 To whom correspondence should be addressed Email dluptontamuedu 3 abbreviations used Al adequate intalte CHD coronary heart disease DFil Dietary Reference Intake EAR Estimated Average Requirement RDA Recommended Dietary Allowance FiNl Recommended Nutrient Intake SSA Significant Scientiiicngreernent U012321663905 300 2005 American Sticrettr for Nutritional Sciences 340 The need to assess the strength of the relationship between to nutrient and or disease National nuuition policy requires an ongoing assessment of how foodnutrient intake affects human health Such information is needed to establish DRIS the Dietary Guidelines and to determine what health claims may be put on food labels In addition a Varietyquot of professional organizations with a focus on dietldisease relationships leg the American Dietetic Association the American Heart As sociation the American Diabetes Associalion evaluate these rela tionships to establish best practice guidelines for their members The NIH may detcnnine the strength of these dietidisease relationships in considering whether to support major clinical intervention trials testing the effect of a foodisubstance on decreased risk of a disease A few speci c examples follow The Dietary Reference Intake process The DRI process expands on and replaces the series of reports called Recom mended Dietary Allowances RDASJ published in the United States and Recommended Nutrient lntakes RNls in Canada 1 Die major differences between the DRI reports and the previous RDA reports are that DRI values can be established with decreased risk of chronic disease as an endpoint rather than the previous endpoint of protecting against deficiency diseases see the original concept paper for cstahlishing the DRIS 7l ln addition food substances not traditionally considered to be nu trients can be reviewed for possible assignment of a DRI value if sufficient data exist to warrant the evaluation 739 This means that for establishing each DRI value an assessment must be made of the strength of the relationship between intake of the food substance and decreased risk of chronic disease If strong data exist it would be possible to assign an EAR value Estimated Average Requirement The EAR can then be used to calculate an RDA For example an EAR and an RDA exist for protein based on the amount required to maintain nitrogen balance 8 xz 3993 ihl f U0 jR UJBEJBW 03Lljjhlu 31945 EiLlJ0j 3 Q i39E l 5JO39U0JTlU39Ul U101 DBDEUIUMOG r THE JOURNAL or Ntrrarrrou J STRENGTH OF SlJEST ANCElDlSrEASE REiATlONSHll3S if sui cient evidence exists but it is not as strong as that required to establish an EAR then an Al adequate intake value might be assigned An example of such an assignment is the Al for ber which is based on decreased rislt of coronary heart disease k if insu cierrt evidence exists to establish either an EAR or 6 Al then no DRI value for intake is assigned Thus the Dhl process is used to evaluate the strength of the relationship between a nutrient or other substance and decreased rislc of disease The process of establishing the Dietary Guidelines The Dietary Guidelines for Americans are the cornerstone of federal nutrition policy and nutrition education activities They are issued jointly by the USDA and the Department of Health and Human Services and are updated every 5 y The National Nu trition Monitoring and Related Research Act of i990 requires the Secretaries of Agriculture and Health and Human Services to publish jointly every 5 y a report entitled the Dietary Guidelines For Americans 10 The report must contain nutritional and dietary information and guidelines for the general public and be based on the preponderance of scienti c and medical ltnowledge current at the time oi publication ill To determine what the guidelines should be the guidelines advisory comrnittee must evaluate the strength of the relationship between a food or nutrient and decreased risk of a disease andfor the promotion oi human health For example the strength of the relationship of whole grain intalce to reduced rislt of heart disease andfor diabetes may be weighed to determine whether whole grains should be recommended over re ned grains Assigning an actual value for intallte recommendations requires doseresponse data Professional societies and their evaluation of dietdisease relationships A number of professional societies issue practice guidelines based on an analysis of the strength of the relationship between diet and disease For example the American Dietetic Association scienti cally evaluates the diet disease relationship in support of their evidencebased dietetics practice 56 Dietitians can consult the evidencevbased reviews to evaluate the strength of the relationship between a particular diet intervention and an outcome that will be beneiicial to health eg lowering choles terol modulating blood glucose levels 56 Based on the strength of the relationship they can strongly recommend a diet intervention or ii the data are less compelling suggest but not strongly recommend a diet intervention Similarly the American Diabetes Association uses an evidencebased review to determine its clinical practice guidelines 11 The FDA and their evaluation of health claims The health claims that are authorized by the WDA and appear on food labels are about the relationship between a substance and a disease They were authorized in l99O by the Nutrition labeling and Education Act 12 and apply to both conventional foods and dietary supplements The highest level of evidence behind a loodsubstance and reduced risk of a disease would meet the Signi cant Scienti c Agreement SSA standard B More recently a Task Force appointed by Mark B McClellan Commissioner oi Food and Drugs was man dated to determine the best way to evaluate the strength of the science behind potential health claims for which the science was not as suong as that required for SSA health claims 14 Their report issued in July 2003 is the basis For much of the information in the following section l4 Evidencebased systems the common mechanism for evaluating the strength of the relationship between a food substance and the rislt of a disease The common mechanism for evaluating the strength of the relationship between a ioodisubstance and the risk of a disease is the use of an evidencebased rating system which is a science based systematic evaluation of the strength of the evidence be 341 hind a statement ln the case oi the DRI process the statement will recommend the amount oi a nutrient that should be con sumed to promote health the amount will be based on a partic ular endpoint described and evaluated in the text ln the case of the Dietary Ciuidelines the statement will be a guideline to help Americans eat healthier diets with scienti c documentation for the guidelines provided in the Guidelines Advisory Committee Report ln the case of health claims the statement would rate the strength of the evidence behind a proposed substanceidisease relationship for use on the food label Ftlthough evidenceabased reviews differ from each other most have the same essential components For an excellent analysis of existing evidencebased systems and their evaluation see West et al 15 Applying an evidencebased system to quali ed health claims As noted above ii the strength of the relationship between a substance and a disease is very high then it will meet the SSA standard for health claims 1213 However if the science be hind the claim is not well enough established to meet the SSA standard then qualifying language is required for the food label and the claim is termed a quali ed health claim The type of qualifying language will depend on the strength of the relation ship that is the weaker the relationship the stronger the qualw ifying language it therefore becomes necessary to have a method to determine the strength of the relationship The Food and Drug Administration uses an evidencevbased system to rank the strength of the science so that the appropriate qualifying language can be used for a health claim A general outline of their evi dencebased approach can be iound in FDA guidelines 16 and is discussed below Clari ciation of the questionlstatement to be evaluated The rst general step in the evaluation of a potential health claim is a critical lOOllt at the proposed claim statement itself This usually takes the form of Substance X reduces the rislc oi disease Y in name the population This means that the substance has to be clearly de ned ll the disease has to be de ned and the target population must be de ned This is important because it determines which studies are relevant and which are not in support of the claim if the proposed health claim was for a substance reducing the risk of prostate cancer in older men then the most pertinent studies would test the substance itself in older men and determine whether there was a reduced incidence of their acquiring prostate cancer Studies that used a mixture of substance X with other potentially active substances would not be rated as high because it would be dii cult to separate out the effects of the subject of the claim from other substances Ii the substance were tested in men who already had prostate cancer the study would not be as highly rated because the claim is to reduce the risk of acquiring the disease not ameliorating the disease in people who already have it Amelioration of a disease is considered to be a drug effect not the reflect of a food If the substance were tested in adolescent males rather than older men it would not be as relevant Collection of all relevant studies A study that would be considered of primary importance in support of a health claim would be a human study done in a nondiseased population The study would be designed to determine directly the relationship between the subject of the proposed claim and the t iSl reduction of the disease itseli or an accepted surrogate marlter for the disease or health relatedcondition it would use accepted study designs and statistical methods to evaluate the data Human studies always rate higher than animal or in vitro studies Primary data are rated higher than review articles or metaeanalyses Although nonhuman studies can be used as bacltground iniorrrration they fE Q3 tinr U0 Cquot LllE lJ3L j O3l quot lU 31613 BLU0llilEQ IE JD39UD iJlTiU39Ul UJOJJ PBDEDELJMOC y THE JOURNAL or NUTRITION 3342 would not be considered primary studies in support of a health claim As noted above the study must be conducted in a non diseased population and cannot be used to mitigate an existing disease If the claim is for substance X then the studies with the greatest relevance would test substance X39 not a food that contains substance K For example if the claim is for n3 fatty acids then the substance to be tested is n3 fatty acids not sh A mixture or cocktail containing substance X and other sub stances is not a direct test nor is an extract containing other bioactive components along with substance X Evaluation of the quality of a study The ranlting of various study designs is based on minimizing bias with random ized clinical trials relceiving the highest score followed by pro spective cohort studies Casescontrol studies and crosssectional studies are tanked lower than either randomized clinical trials or prospective cohort studies lf one is not testing the relationship between the substance and risllt reduction of the disease then an accepted surrogate marker is required This marlcer must be genE erally accepted as a surrogate marllter particularly with the FDA and NIH For example decreasing LDL cholesterol is considered an appropriate marker for reducing the risk of coronary heart disease CHD but other surrogate markets for decreased risk or CIll such as reductions in C reactive protein or homocysteine levels may not be Appropriate statistical tests are important and inappropriate use of statistical methods can downgrade a study A case in point is the use of paired t tests for multiple endpoints For epidemiologic studies lcnown confounders have to be taken into consideration Selection of the study population is very impor tant particularly that the population be healthy people who do not yet have the disease of interest Studies conducted in popur lations that differ from the US population in important ways eg evidence of malnutrition or very different rates of disease are not as relevant as populations similar to those in the United States Before and after studies in I group are not valued as highly as a control and intervention group because the Former do not account for extemal factors over time Similarly key differences between the control and test groups with respect to gender Blvil or smoking for example would downgrade a study The inter vention in a clinical trial must be of sufficient length to establish the relationship and the food or substance provided for the intervention must be adequately characterized in addition if the intervention affects the rest of the diet eg substitution of i type of Fat for a different type of fat or Fat at the expense of carbohy drate then the rest of the diet must also be characterizecl Re porting on how the intervention diet aiiected energy intake and weight gain is important because body weight may be an inde pendent risk factor for certain diseases Rating of the strength of the entire body of earidenlce In an evidencebased system each primary study becomes part of the overall rating of the strength of the evidence The overall quality of the studies combined with the quantity total number of subjects relevance to the US population and bene t and consistency of the findings are all taken into consideration The end result of using the evidencebased ranlting system is a state ment linldng a substance to a diseasehealth relared condition with a ranlcing related to the scienti c evidence behind that statement There is a clear and transparent demonstration of which research studies were evaluated to provide the ranking and evidence tables showing the rigor of the evaluation Trained scientists should come to similar conclusions using the same database it should be noted however that science is an evolving process and the strength of the evidence must be reevaluated over time A review of how well dietdisease associations stand SYiviPOSlUivi the test of time can be found in the institute of Medicine publication 18 Summary and conclusions National nutrition policy requires the constant evaluation and reevaluation of the strength of the relationship between a food substance and reduced tislt of a disease There is increasing use of evidencobased systems to determine the strength of this relation ship and such systems are used by the National Academy of Science for determining Dietary Reference Intakes the Dietary Guidelines Advisory Comtnittee for making recommendations on the guidclines for Americans professional societies and the FDA for evaluating health claims With respect to health claims the objective is that by using and refining an evidencebased system to clarify the strength of the science behind the claim consumers will be able to make healthier food choices based on sound science ACKNOVJLEDGMENTS The author aclcnowledgcs the input of the following individuals at the FDA ClBAN For their contribution in helping to frame the original evidencebased guideline for quali ed health claims Kath leen Ellwood Claudine Cavanaugh Craig Rowlands Christine Taye lot Paula Trumbo and Elizabeth Yetley LITERATURE C ITED 1 Institute oi lvledlcine 2002 Introduction lo dietary reference intakes In Dietary Reference intakes Energy Carbohydrate Fiber Fat Fatty acids Cholesterol Protein and Amino Acllds pp 11 13914 The National Academies Press Washington DC 2 lvlcivlurry K Y 2003 Setting dietary guidelines the US process J Am Diet Assoc 103 511816 3 Dietary Guidelines Advisory Committee of Agriculture Washington DC 4 Cooper J aziotlrin S H 2003 An svidonce basedapproacl1lotha development of national dietary guidelines J Am Diet Assoc 103 S22S239 5 lir1yers E lP1ritche1t E 8 Johnson E Q anal Evidence guides vs protocols whats the difference J Am Diet Assoc 101 10851090 6 Splett P 2000 Developing and v39alidating EvldlenceEaseci Guides for Practice A Tool Kit for iljlsistics Profssslonals The lamerican Dietetic Association Chicago lL 7 lnstiiuis of Medicine llsatli How Should the Recommended Dietary Allowances be Revised National Academy Press Washington DC 8 lnstituts of ivledilcine 2002 Protein and Amino Acids in Dietary Refer sncs intakes Energy Carbohydrate Fiber Fat Fatty Acids Cholesterol Protein and Amino Acids pp 101 101 13Tl1e National Academies Press Washington DC 9 institute of Medicine 2002 Dietary functional and total fiber In Dietary Reference Intakes Energy Carbohydrate Fiber Flat Fatty Acids Cholesterol Pro tein and Amino Acids pp l T4 The National Academies Press Washingion DC 10 National Nutrition lvloniloring and Related Research Act of 1990 Public Law 445 section 301 101st Congress 2nd session October 22 11 Clinical lPractlce Recommendations Dnilne American Diabetes Associa lion htipi39vrwwdiabetesorgfor 39l1ealtl1profssslonals andsoleniistsi cprjsp ac cessecl July 3 2004 12 Nutrition Laloellng Educailon Act NLEA 1090 Public Law 101535 13 Guidance for industry Signiiicant Scientific Agreement in the Review of Health Claims for Conventional Foods and Dietary Supplernsnts online FDA Food and Drug Adlminisiratlon hitpz39i39wwwcl sanfclagov dmse ssaguidshtml accessed July 3 2004 14 Consumer Health lnfonnaiion for Better Nutrition quotinitiative Task Force Final Fisporl on39line FDA htlpwwwcfsanfdagow dlmsa nuftftocl1tml accessed July 32004 15 West 8 King V Carey T 8 lohr K N lvlclioy N Sutton 8 F 3 Lux L 2002 Systems to Hate the Strength of Scientific Evidence Evidence Fiaporl Technology Assessment no 4 AHllCl Agency for llsalthcare Research and Quality Publication bio 02E01o Fiockvllle MD 16 Gulclancs for Industry and FDA interim Evidencebased Ranking Sys tem for Scientific Data Ionline FDA initpn www1 dagovbbsfiopicsr39NEWS 2003fNEW00923ntm l accessed July 3 2004 1 Office of Federal Register 2004 Code ofFscleraJ Regulations Food and Drugs 21 CFR 10114 ajl2 US Government Printing Office Washington DC 1 B lnstliuls of lvledicins 2002 Evolution of Evidence for Selected Nutrient and Disease Relationships Committee on Examination of tna Evolving Science for Dietary Supplements National Academy Press Washington DC 1990 Report US Department 1990 B003 EBZ ii lquot U0 ql Ul9 BIN 39339l39lSiquot U39 91918 EUJ0Jl3933 19 5J0quotU 0llJ3 The Vision Mission and Goals of Healthy People 2020 The vision mission and overarching goals provide structure and guidance for achieving the Healthy People 2020 objectives While general in nature they offer speci c important areas of emphasis where action must be taken if the United States is to achieve better health by the year 2020 Developed under the leadership of the Federal lnteragency Workgroup Flw the Healthy People 202039 framiework is the product of an exhausltive collaborative process among the US Department of Health and Human Services HHS and other federal agencies public stakeholders and the advisory committee s 5 if in t 39 r E 1 Vision A society in which all people live long healthy lives NiSi0n Healthy People 2020 strives to Identify rlationwilde health improvement priorities increase public awareness and understancling of the determinants of health disease and disability and the opporlzunities for progress a Provide measurable objectives and goals that are applicable at the national state and local levels a Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge and n Identify critical research evaluation and data collection needs Overarching Goals u Attain high quality longer lives free of preventable disease disability injury and premature death a Achieve health equity eliminate disparities and improve the health of all groups o Create social and physical environments that promote good health for all 3 Promote quality of life healthy development and healthy behaviors across all life stages wwwhealthypeoplegov Questions and Answers on the 2010 Dietary Guidelines for Americans Why did the 2010 Dietary Guidelines Advitsory Committee DGAC use an eviidence based systematic review methodology Evidencenbased systematic review is considered the state of the art method for objectively synthesizing research findings to support practice guideline and policy recommendations The transparent systematic review method used by the USDA Nutrition Evidence Library ensures government compliance with the Quality of information Act which mandates that Federal agencies ensure the quality objectivity utiiity and integrity of the information used to form Federal guidance What are the major themes of the 2010 DGAC Report The DGAC considers the obesity epidemic to be the greatest threat to public health in this century Each section of the Report was developed in a way that addressed the challenges of obesity Another major theme was a focus on children throughout the Report The Report included four major action steps for the American public 1 Reduce the incidence and prevalence of overweight and obesity of the US population by reducing overall calorie intake and increasing physical activity 2 Shift food intake patterns to a diet that emphasizes vegetables cooked dry beans and peas fruits whole grains nuts and seeds In addition increase the intake of seafood and fat free and low fat milk and milk products and consume only moderate amounts of lean meats poultry and eggs 3 Significantly reduce intake of foods containing added sugars and solid fats because these dietary components contribute excess calories and few if any nutrients in addition reduce sodium intake and lower intake of refined grains that are coupled with added sugar solid fat and sodium 4 Meet the 2008 Physical A ctivity Guidelintes for Americans What is new in the 2010 DGAC Report Two new chapters were included Tire Total Diet considers various health promoting dietary patterns and Translating and integrating the Evidence addresses the broader environmental and social change needed to support healthy eating A exible approach to a total diet was encouraged incorporating individual tastes and food preferences into the Reportquots individual recommenclations for a dietary pattern that is acceptable without exceeding calorie needs in addition I Eating behaviors were addressed e g breakfast snacking fast food and the association of screen time with increased body weight was assessed I Recommendations to increase consumption of plant foods vegetables cooked dry beans and peas fruits whole grains and nuts and seeds were included a Seafood consumption of 8 oz two servings per week was encouraged The Report noted that the benefits of consuming seafood far outweigh the risks even for pregnant women Content What is the makeup and overall scope of the DGA 201039 The DGA includes 23 key recomrne1 1dations for all Americans and six recommendations for specific population groups it is organized into six chapters that follow the four main findings from the DGAC s translationfintegjration chapter identified in the section on 2010 DGAC Report content major themes The overall scope of the DGA reflects the association of poor diet and physical activity with major causes of morbidity and mortality including but not limited to obesity Recommendations were based on conclusion statements from the DGAC Report taking the strength of the evidence into consideration What are the major themes of the DGA 2010 The two major themes are balancing calories to manage body weight and focusing on nutrient dense foods and beverages Balancing calories to manage body weight includes the concepts of controlling total calorie intake to manage body weight increasing physical activity and avoiding inactivity Focusing on nutrient dense foods and beverages includes the concepts of eating vegetables fruits whole grains fatafree or low fat dairy products and seafood more often and eating foods and beverages high in solid fats major sources of saturated and trans fats and added sugars less often and reducing sodium intake What is different in the 2010 DGA from the 2005 DGA The overarching differences include emphases on managing body weight through at life stages and on proper nutrition for children throughout Also research on eating patterns is incorporated for the first time and the eating patterns presented now include vegetarian adaptations Chapter 6 of the 2010 DGA a new section acknowledges the influence of the broader food and physical activity environment on Americans daily food beverage and physical activity choices This section calls for improvements to the environment via Systematic and coordinated efforts among all sectors of influence Additional differences include I The 2390l0 Key Recommendations for food group intake are directional rather than providing the precise quantitative amounts that should be consumed as were included as examples in 2005 Although the 20l 0 Key Recommendations do not specify quantities an entire chapter Chapter 5 and several appendices discuss eating patterns that include specific quantities Inclusion of a Key Recommendation for increasing seafood intake 0 Eating behaviors are addressed eg breakfast snacking fast food and the association of screen time with increased body weight was assessed Speci c foods that should be limited because they are substantial sources of sodium saturated fat cholesterol trans fat and added sugars are identified o Reduce daily sodium intake to less than 2300 mg and further reduce intake to 1500 mg among persons who are 51 and older and those of any age who are African American or have hypertension diabetes or chronic kidney disease Thel500 mg recommendation applies to about half of the US population including children and the majority of adults There is a focus on nutrients of public health Concem potassium dietary fiber calcium and vitamin D rather than on nutrients with intakes below recommended levels A new appendix table includes key consumer behaviors and potential strategies for professionals to use in implementing the Dietary Gur39delines New guidance for alcohol consumption by breastfeeding women is included 39 VltW39xoo39Mooinxn0Qgfoooxvid5amp539nq39cZpo6quot O639JiQ quotH quot39 gnrzwvv WW 5r yu M c P j ru n w xeooooiwcoocootr mum quot l fissisiis 4e I A Brief History of USDA Food Guides 1915 to 19305 quotFood for Young Children and quotHow to Select Food 0 Established guidance based on food groups and household measures I Focus was on protective foodis 19405 A Guide to Good Eating Basic Seven a Foundation diet for nutrient adequacy a Included daily number of servings needed from each of seven food groups 0 Lacked speci c serving sizes 0 Considered complex 1956 to 19705 Food for Fitness A Daily Food Guide Basic Four Foundation diet approach goals for nutrient adequacv Speci ed amounts from four food groups 0 Did not include guidance on appropriate fats sugars and caorie intake 1979 Hassle Free Daily Food Guide I Developed after the 1977 Dietary Goals for the United States vvere released 0 Based on the Basic Four but also included a lth group to highlight the need to moderate intake of fats sweets and alcohol 1984 Food Wheel A Pattern for Daily Food Choices 4 I 9 Total diet approachlncluded goals for both nutrient adequacy and E 3l l quot moderation 0 Five food groups and amounts fquotorrned the basis forthe Food Guide Pyramid I Daily amounts of food provided at three calorie levels I First illustrated for a Red Cross nutritilon course as a food wheel 1992 Food Guide Pyramid FJLL393ii5 5mpe1 Her W Total diet approach goals for both nutrient adequacy and moderation quotquot quot quot d E Developed using consumer research to bring awareness to the new food quot i39iquotquot ampv391 W l39ea1ui39v Fol 3 mass patterns m lE 0 illustration focused on concepts of variety moderation and proportion ma quot quot 395 i9 5 5 T39I Fruit mrp o Included visualization of added fats and sugars throughout five food H quot v 39 39 groups and in the tip I Included range for daily amounts of food across three calorie levels 2005 l39VlyPyramid Food Guidance System 0 Introduced aiong with updating of Food Guide Pyramid food patterns for the 2005 Dietory Guidelines for Americans including daily amounts of food at 12 calorie levels I Continued pyramid concept based on consumer research but simpli ed illustration Detailed information provided on website 39 lVlyPyramidgov I Added a band for oils and the concept of physical activity 0sm I p Idgov arses TO A HEALTH39lER you I Illustration Could be usedl to describe concepts of variety moderation and proportion 2011 lVlyPlate introduced along with updating of USDA food patterns for the 2070 Dietary Guioleiines for Americans 6 Different shape to help grab consumers attention with a new visual cue 0 Icon that serves as a reminder for healthy eating not intended to provide speci c messages E i i a visual is linked to food and is a famliiar mealtime symbol in consiurners gsi minds as identified through testing p B 0 quotquotlV1Yquot continues the Personalization al iliroach from MiP rramid Pc kc For more information 6 Welsh S Davis C Shaw A A brief history of food guides in the United States Nutrition Todoy NovemberDecember 1992611 0 Welsh S Davis C Shaw A Development of the Food Guide Pyramid Nutrition Today NovemberDecember 19921223 0 Haven J Burns A Britten P Davis C Developing the Consumer Interface for the lv39yPyramid Food Guidance System iournoi of Nutrition Education and Behavior 2006 38 51245135 Center for Nutritilon Poiicy and Promotion June 2011 P F 39s 39139 Fti 3quot23quotts 239Q egtw39 5i6 JT 395 quott39gt39 E f8quotf 39 f quot 139 quot quot quot n va e valt sawxva95 a wev24nquot 39sz9stT 139 E wewar r39N 39A9s r 9 sQso s vxvt39 iquot quotv Qrquot 39e wrwmmea9 39vM we agt39vsl0 39 39 romoooovoorwvtiruck 3mEmi 3ses2 ze 39 quot quot P f9quot quotf W 393 f335 iquoti i quot 2 quot quot 9 of MCC2 f f39Fquot 39 Y39X39fY393I6 1 VQ 139393 3T3 EquotCY E39P 31quot 39 v o S 39t9quot 9396 239quot V aD 2 Wu J f 42 o3J H W owM w ww x w quot39 quot39 t 39 9 Mtreatv 01 H 5di39t5n 6 vihv zoksairtri maMxE i n 32st Aa5a6cltv2a v as 35aamp32a39339mHmH S 39 quot mmwmemmemi KI mtquot393 Al It iquot quot391Cquoti639939fr 6lIUxuei I39 h394AR390 f33RD 73 5mI5Ga39 ocmm sm m f mm39 quot 39 L amp339oat u5 mum 5339a mama Emma 33 an m tam mFmn2u mmm lt T onoEEn ncm T Gon oEZ Em mmacmo m T T Ea8mltoEmEmnmaTmT P gtm mmEmSToE mm xmu gumm mmm B mmom mo mEoEm ucm mus 9 mg m m Em mmTmm m5 mmmmm m cm cmmmmm me 5 gsmzm m oTmmmommm aumnmaman 5 Tmmm Emm mbmmmm Em Em m mgtmmnmE B Tmqmmm mEm mc mm Eat Emcmn 30gt mm 53 1 lt 9 mm mBT ax T emu mmEgtm E5 mmmmmmzm m mmoTTm mm a 3 ummmmzmocm m EmEmgtonE Tmmm EEmgtP nE m5 m 39 quot 3939g mmTm 50 BE E cmm muoom mmm E wOE ms mmmm no mkmum mEE m Bmm mzmm Em Emmmm mmum mEE mEEmEmu muoom E mnmmmm mmmm TnS mmiotmc mam mto moE mmUmmm mm ET m mTmm mmmmmm mmbum E mmmm Eow mm 6 BE 53 mmoom Tom mvcmmm mmmm mmmmc ms 93 3 EOHETQ Em nEm mop comm mm msEmm my 3 umHmmmTTnmm m mmmmmoE nomu m ai Mmm Bow 5 xm T comm umumm Em mmzem m Em mmmom E5 mmmTmmmT mF mTo mam EETmSn m5 5 mmzmmm DOE m m5 mEmmmEmT mmmmn ToTTmu m m5 3 u MOQEAm m bmmgt wmampgt T bgtEm momba mu E mmcmtmnEm m mo TmmmEE m mm Em mEEu commmm m5 3 5 mcax m 52E 3 mmm mmm mm mr vmm0 mcm mmmmm mE E ummcmmmmmmm m 5304 bgtuu mmtonoE mumxm mo TmmmT mmmm m E2 T 2m mzmm Em m ugt mi Em comm Em mmoocm Eaogm omTmn Tm woo mE gtD mmmmmzm m m mm mmcmn mama moom ms 5 mEE3 mcmmmmczm m5 3 Egtorm m bmTomtomm nmu uaaE omn mmnTEmmmTm mmm unExm m5 mo mtmm m uEU mTF xmn bmgtm m mm mm B mam mmgozmm meme Esmmc TmvmE 9 mmTEmou mEm B mmgomgtmu cmmn mm mTnEm mm B Ummmmmmu cmmg mm mTaExm me bgtTBm EmoTETn tam mcnmm b mmc S gumoamm um mcommma m mmNonEmm UEmL m at gment aim 25 EmgtngtE no aE3wlt Foo Intake Pattems The suggested amounts oi food to consume from the basic food groups subgroups and oils to meet recommended nutrient intakes at 12 different calorie levels Nutrient and energy contributions tram each group are calculated according to the nutrien39t dense iorrns of ioods in each group 1eg lean meats and lattree rniI39llti The table also shows the discretionary calorie allowance that can be accommodated within each calorie level in addition to the suggested amounts of nutrientdense forms of foods in each group Daily Amount of Food From Each Group Calorie Levelquot 1000 1200 1400 1000 1800 2000 2 2200 l 2400 20002 1 2800 3000 1 3200 i Fruits 1 cup 1 cup 15 cups 15 cups 15 cups 2 cups 2 cups 2 cups 2 cups 25 cups 2 25 cups 25 cups Vegetables 1 cup 15 cups 15 cups 2 2 cups 25 cups 25 cups 3 cups 3 cups I 35 cups 35 cups 4 cups 4 cups Grains 3 ozeq 4 ozeeq 5 o ed 5 died 6 oz eq 5 oz eg breed 8 ozeeq 0 ozeq 10 ozeq 10 been 10 o eq pM and Beanss 1 2 seed 3 oz ed 4 oz eq 5 ozeq W oz eq 55 ozeq 6 oeeq 55 been 65 o eq 7 ozed 7 oz eg 7 area Miik 2 cups 5 2 cups 2 cups H I 3 cups I 3 cups 3cups 3 cups 3 cups 3 cups 3 cups 3 cups 3 cups Oils 3 tsp 4 tsp 4 tsp 5 tsp 5 tsp o tsp 6 tsp 7 m 8 tsp 8 tsp 10Htsp 11 tsp Discretionary Z 2 p calorie allowances 165 171 171 132 195 267 23990 362 410 426 512 8418 1 Calorie Levels are set across a wide range to accommodate the needs of di erent individuals The attached table Estimated Daily Caiorie Needs can be used to help assign individuals to the toad intake pattern at a particular calorie level 2 Fruit Group includes all lresh lrozen canned and dried fruits and fruit juices In general 1 cup of fruit or 100 fruit juice or 112 cup oi dried iruit can be considered as 1 cup irorn the fruit group 3 Vegetable Group includes all fresh frozen canned and dried vegetables and vegetable iuices in general 1 cup of raw or cooked vegetaoies or vegetable iuice or 2 cups of raw ieaty greens can be considered as 391 cup from the vegetable group Vegetable Subgroup Amounts are Per Week 22 Calorie Level 1000 1200 1400 1600 1800 2000 2200 2400 2600 2800 5 3000 3200 Dark green veg 1 cfwk 15 cfwic 15 cfwk 2 cwk 3 cwk 3 cfwk 3 cfwk 3 cfwk 3 cfwk 3 cfwk 3 cfwk 3 cfwk Orange veg 5 cfwk 1 cfwl 1 clwk 15 c1 wllt 2 cfwk 2 cfwk 2 cfwk 2 cfwk 25 cwk 25 cfwlz 25 cfwk 25 cfwk Legumes 5 cfwk 1 cfwk 1 cwk 25 cfwlc 3 cwk 3 ciwk 3 cwk 3 cwk 35 cfwir 35 cfwk 35 cfwk 35 cfwk Starchy veg 15 cfwk 25 cfwk 25 cl wk 25 cfwk 3 cfwk 3 cwk B cwk 6 cfwk 7 cfwk 39 cwk 9 cfwk 9 cfwk Other veg 135 cwk 45 cfwk 45 c wk 55 cfwk 65 cfwk 65 cfwk 7 cwk 7 cwk 35 cwk 85 cfwk 10 cfwk 10 cfwk 4 Grains Group includes all foods rnade horn wheat rice oats cornmeal barley such as bread pasta oatrneal breakfast cereais tortillas and grits in general 1 slice of bread 1 cup of ready to eat cereal or 12 cup of coollted rice pasta or cooked cereal can be considered as 1 ounce equivalent from the grains group At least half of all grains consumed should be whole grains 5 Meat 81 Beans Group in general 1 ounce of lean meat poultry or fish 1 egg 1 Tbsp peanut butter 14 cup cooked dry beans or 122 ounce of nuts or seeds can be considered as 1 ounce equivalent ironi the meat and beans group 6 Milk Group includes all tluid milk products and foods made irom milk that retain their calcium content such as yogurt and cheese Foods made from milk that have little to no calcium such as cream cheese cream and hutter are not part oi the group Most milk group choices should be fatfree or lowfat In general t cup of milk or yogurt t 12 ounces of natural cheese or 2 ounces ot processed cheese can be considered as 1 cup from the milk group 7 Oils include fats from many different plants and from sh that are liquid at room temperature such as canola corn oliye soybean and sunflower oil Some ioods are naturally high in oils tike nuts olives some fish and avocados Foods that are mainly oil incltrde mayonnaise certain salad dressings and soft margarine 8 Discretionary Calorie Allowance is the remaining arnount of calories in a food intakes pattern atter accounting for the calories needed tor all road gr0ups usih g forms at foods that are tatafree or towlat and with no added sugars Estimated Daily Calorie Needs To determine which food intake pattern to use for an i39ndi39vidual the fol39low39ing chart gives an estimate of individual calorie needs The calorie range for each agesex group is based on physical activity teyel from sedentary to active calorie Range s Sedentary means a liiestyle that includes only the Fh39ldrequot sedentary 1 quot Acme light physical activity associated with typ39ical 23 years 1000 1400 dayT20quotday life Females T Active means a lifestyle that includes physical activity equivalent to walking more than 3 miles 8 Yea 1300 5 W00 per day at 3 to 4 miles per hour in addition to 943 L600 mquotquot 2200 the light physical activity associated with typical 1448 1800 a 2400 LdaytOday ma l9 3O 2000 1 2400 3150 A 1800 2200 51 L600 i 2200 Males res years l 1400 n 2000 913 1800 2600 l418 2200 i 3200 1930 2400 1I 33000 3i 50 2200 3000 51 2000 in 2800 tlS Department of Agriculture Center tor Nutrition Policy and Promotion April 2005 CUWOUHi IiiIDIIIIUCIQOUCIIiiIIiIiIlilIIII OliIiQiClh l ip l EEMMENTMHY V IIIOIIIICIUCIUI3039iilii lilll lllililiitiQIClPiitiIDDIGQIIIUII clJIII l39iSIli M international f d lli tinns pictorial JAMES PAINTER PhD RD JEEHlquotUN BS YEONKl 7JNG LEE PhD he number of countries developing or revising their own food guide illustrations has been increasing To devise foodguidance systems appropriate for each nation many countries have applied research regarding their national food supply food consumption pattern nutrition status and nutritional standards for the development of their individual food guides l 5 For instance the US Food Guide Pyramid is firmly based on United States Department of Agrlculture s USDA research on the types of food Americans consume the nutrient composition of those foods and their relation to the individuals nutrient needs 6 In some food guides the pres ence of indigenous foods and a particular dietary pattern resulting from diii erent geographical conditions and cultural heritages have also been considered CT 8 It is well known that various cultures have different food availabilities food preferences dietary patterns and cultural de nitions of foods 7 B In a review paper Cronin stated that different food guidance systems may be appropriate for veg etarians ethnic groups and others with distinct and varying food preferences or dietary needs j Simopoulos also stated that universal dietary recommendations are not applicable and that to be effective food guides must incorporate the unique dietary Components of speci c populations 10 Therefore considering the disparities in food intake of populations food availability and the nutrition status between countries one J Pointer is on ossistortt professor JaHi13rth is rt graduate situcteut and YK Lee is an assistant professor in the Department ofF ood Science and Human Nutrition University ofliltuots at Urbouo hampoign Gorresponciirtg author James Pointer PhD RD Assistant Professor Department ofFood Science and Human Ntttrittmt University ofllltnois at Urbano v hoampotgvt 905 S Goodicta Urbano IL 61801 0 A jposnteruiuc ealu would expect the food guide graphics of various countries to differ in their recommendations This study was conducted to introduce the official food guide pictorial representations designed by various countries and to examine the differences p their recommendations through a comparison The national food guide illustrations of Australia Canada China Germany Korea Mexico the Philip pines Portugal Puerto Rico Sweden the UK and the US were reviewed The comparison focused mainly on the food group ings and the recommended quantities for food groups However this study was limited by data collection The number of food guides used in this comparison may represent only a small percentage of the countries that have official food guides While the authors attempted to collect food guide illustrations from 20 countries it is important to note that there are countries which do not have official food guide illustrations such as Japan and in addition there are C0llI l tries that have adopted the US Food Guide Pyramid as their own of cial guide We were unable to obtain oillcial food guides for countries in South America which will x the application of our findings METHODS OF COMPARISON Clf cial food guide pictorial representations for 12 countries along with additional dietaryrelated information were col lected via Internet searches interviews with developers and a thorough review of current literature on the subject Food guides were compared according to the food categori zation and quantitative recoruruendations for each food group The comparison of rec omrnended quantities for each food group was conducted based on inionnation in the food guide brochure For Gerrnany information regarding the recom mended quantities was obtained from a phone interview with the German Nutrition Society by the authors June 2001 Journal of THE AMERICAN DIETETIC A830CLATION I 483 CIOICUIICIIUUUOIOOD9IQCCCCCDCUIDOlICCbiOU39lUiIiiitlil i iild ilil T BIIMMENTMW CI IOI IDQ flCf 39IQ 39IOUHIQD CQIl Q Cr uC 39ICC Q g Great Britain Austra ia rd iit39 iH Iinimic 39quot Pl fhi I El IIKII ANU CW1 35 25 mass as IBREFESIE 100 HIRE Es l SGRJEI H I 5039100E 1 i 5 3950E Ema cam 39 T 739 6an swam h ttvuuww t Steuuamag 2 11 4 an 5 quot w m 3939 Si 31 533 39 H mg China FIG I Vatr et39239es of shapes and 313295 of vaxrious 7wI139L07zs f0od gu39ide pyramids 484 I April 2002 Volume 102 Number 4 iiCWUCUUICUVIOIIQIIQIiUIIU9I39lCOIIIIIillulll39lIIiI39iIIiCI39DIIIIiillj 0tn IIQiIrooooiiootdtltotolDIcotsioiqcgoqpsonpupqopggqgnugnaqnauou CIIMPHEHTHHY F lRi39 F091339 PYRRHJD vquot hnr u ax 39 v suu Lo A m A pa A la1 6 J I quotH1 HE E p F i i i JHEE 311 WIEEI Eatiyast enough FmE ms 8 Animat toads Eaarls 3 Nuts quot7mv Eat mod39aatey 39 E quot39 391 quot 5 Mr 1an 39e s1 aaa 9s eanr aam aaarwmaaim L vegembles 8 t 0 a FmR5 5a quot quot9 A Rmaaeather 3 9 am am quot 2 il t 53 mii ii3quoti i fa ii 3 Vii ff 5lail mt 1 quotH 3 V35 5 F39lt 3 F ii n i tH39Rl39I39EQ I IREeSEARGH 3 lTUIE 39 Eepartirnmzt of and T DOST Gmnpmxnd Biot ar11 raguig iluieiro Manila 3amp3 3 r 39 393 1 um PIquotw39quoti39rJp i 205 mm q m 3 3 39 39 tum 6 swzgzagram quotCrm c39e Fe 1 Lc 1 rt 5 FIG I cominued4 Varieties of shapes and sizes of various ncm1ons fooc g1Lic e pyramids Jrjumal of THE AMERICAN DIETETIC ASSOCIATION 485 IIIII IIi IIIIii39IiiI39CIQIIIIIIICCCUIIUIIIIIIIOIDCIICIOUQIIQOCIOIIDIICU QUI3939I 393939C CCICC 3939Qquot 3939 BHMMENTAHV pX I I I I I H I 39 ii iIa1 aeaf sii a39aa n Jjiiaiaggirmsehwiahur aliniiaadnaalliashmreutk 3 quotquotquot39FN39 uanaqn r i 3 mm39ampsumquots39 p 39 V J 39 Faumxnmmmmwm tnimyaav z H P I 0b Lquottn 21911 Sratc3 quotu ed 39n FIG I continued Varieties ofshapes and sizes ofvariozcs ncm3mzs fnod guide pyramids 486 J April 2002 Volume 102 Number 4 IQllIllIIllQIIIIUCQICCIOIIIIIIIIUCIOiliiiiiiilIIiIOQQQQIIIQIIOIIUIIUIICI SHAPES OF FOOD GUIDE ILLUSTRATIONS PYFIAMID CIRGLE PAGDDA RAINBOW AND PLATE Before comparing the actual recornmendations the diverse shapes of these international food guide illustrations should be examined Previous research indicates that the food guide gure should be effective in conveying the message ofmodera tion and proportionality ll l2 The USDA conducted an extensive research and consumer survey to decide the design of a national food guide illustration for this country A wheel bowl pie chart and shopping cart were considered however the pyramid was the form that proved to be the easiest to understand l2 While the Philippines adopted the pyramid as a frame for their national food guide Korea and China chose a pagoda shape Most of the European countries on the other hand have selected a circular form 10 Other unique food guide forms include the rainbow shape of Ganada s Food Guide for Healthy Eating and the plate form of The Balance of Good Health from the UK The Dish of Well Eating of Mexico Figure 1 demonstrates the variety of shapes FOOD GROUPWG Despite the wide spectrum of shapes representing lood guides from around the globe these guides use very similar methods in presenting their concepts of the ideal dietary pattern Each of these guides gives consumers a selection of recommended food choices food groups as well as a recommended daily amounts consumers should ingest to maintain optimum health Figure 1 shows a remarkable similarity in the basic food groupings of international food guide illustrations The groups include grains vegetables fruits meat and dairy prod ucts and fats and sugar Despite the differences in indigenous foods of each culture along with the differences in the cultural definitions of food and what constitutes a usual dietary pat tern the fundamental classification of foods was similar in all countries Minor differences in food categorization were observed in the fat and sugar group the vegetable and fruit group and the milk and dairy product group The existence of additional groups along with the categorization of foods such as beans nuts and potatoes also contributed to these differences While most of the countries group fat and sugar as a single category food guides for China Sweden Germany and Portugal do not include sugar in the group The Chinese Nutrition Society has stated that there is no recommendation related to sugar intalce in their pagoda because the current consumption of sugar by the Chinese is rather low 18 Moreover in some food guides such as the Mexican food guide the fat and sugar group is not included at all in an electronic correspondence with the authors April 2001 Hector Bourges MD PhD the director of Nutrition in National lnstitute of Medical Science and Nutri tion offered an explanation for this omission It is not included in the food guide since we do not try to say that it is part of the diet and since it is an ingredient rather than foodquot The fat and sugar group in the iood guides for Canada and Australia is included in a brochure accompanying the mus trated guide as well as in the corner of the guide Fruits and vegetables were grouped together in the food guides for Canada the UK China Korea Portugal and Mexico while each of each oiquot these groups appear as independent groups in the other guides The Philippines is the only country lacldng the PPe and dairy group in their food guide Since Filipinos are not milk drinkers EUMMEJTHHY IOllialllil llliIlivilHD0003U CDC liiilOQQIOHIGHl39Ci CquotIICIC39iiCCCCOlII and mill is not traditionally part of their diet it is incorporated with the major protein group 7 Mexico on the other hand grouped it with other foods of origin An additional food group exists in the Sweden and German Food Circles Sweden separated potatoes and root vegetables from the essential vegetable group in a phone interview March 2001 with the authors Lena Bergstorn a nutritionist in the Sweden National Food Administration said that pota toes and root vegetables are regarded as the base food which provides the foundation for a nutritious and inexpensive diet and can remain approximately the same from day to day it is recommended that they should be supplemented with other vegetables which are considered foods that vary from day to day and between seasons Interestingly Germany is the only country that contains a uid group in its food guide A separate group for beverages exists to ensure enough daily consumption of fluids Although not classifying uid as an independent group Puerto Rico includes water in both their illustration and recommendations They include water due to their tropical climate8 Most countries grouped potatoes in the vegetable group However Korea the UK Portugal Germany and Mexico categorized them into the grain group The UK placed them within the grain group yet included other root crops such as turnips and parsnips within the fruit and vegetable group 2 Likewise countries have made different decisions regarding the classi cation of beans and legumes While beans and legumes are usually in the rueat group due to their high protein content Sweden Germany and Australia put them into the vegetable group as they considered their high vitamin mineral and dietary ber contents in the case of the US Food Guide Pyrarnid legumes including kidney beans and cl iclpeas are classi ed within the vegetable group while drybeans and nuts are grouped with meat poultry and sh The Chinese Pagoda on the other hand placed them into the milk and dairy products group Nuts are also classified in different ways Unlike the US Puerto Rico and Australia where the protein content in nuts is valued Korea placed them into the fat and oil group because of their high fat content 3 QUA lTlTA39TWE FIECUMMENDATIONS For each category of food these guides have either recoms mended specific quantities or offered general advice empha sizing suggested portions in a daily diet Figure 1 shows that the Philippines Portugal Mexico Germany and Sweden avoid taking the quantitative approach in their recommendations In the Philippines the quantitative recommendation was per ceived to be a stumbling block rather than a helpful aid since nutritionists thought people would have a hard time interpret ing serving portions T as a result the Filipino Pyramid Food Guide uses easy to comprehend action words implying the proportion and frequency instead of using specific amounts in their recomrnendatirons The Portuguese Food Wheel defined the approximate pro portions of food weight for only live food groups 14 The proportion of each food category in a daily diet is expressed in a percentage Sweden on the other hand prioritizes the variety in its recomrnendation They simply recommend that individuals choose irorn all seven groups of food during a day The remainder of the food guide graphics made quantitative recommendations based on various units such as serving sizes Journal of THE AMERIGAN DIETETIC ASSOCIATION I 43quot llIiiiliiiliii9ii ii IIICCiIFlquotI1FICI39iiI100 ir Cxl a ji jljjnQiijjgggrggq g g gggg4 ggQi39TiTT I TiI lquotquotl39iTiti39i EBMMEHTHHY USHAIIE Cnnsdsls Food Australian Food The Home Chinese Korean Food German Food Guide i Gui c to Healthy Guide to of Good 39 Food Guide Pagoda Nutrition Pyramid 6 Eating 15 Healthy Eating Health of UK Guide 3 Circle V 16 17 Pagoda i T P T 13 T Grain 6ll servings 512 servings 3ll samples More than 5 300S flg 45 250350 g of portions i based on brad day or a a serving a sample a portion row a serving 23025 03 of 1 slice ofbrwi 1 slice of brad 2 slices of bread 3 bread T weight 3 slices lT00g cooked rice 1 ounce of cereal S g ocrml 1 M3 cup of B g cereal of bread day or A cup of cooked quot5 cup of coolocd cereal g riceinot 903 256gSlil g of rice or pasta rice or poem 1 cup of cooked speci c if T 2 11 lg cooked potatomi day T T T T 39Iioeorp2sm cook ordry T rice T T Vegetable 35 servings 29 samples 4005003 2003 cooked T based on amp 1003 row a serving a mmjple raw T amp 7395 3 of salad 1 cup of row i 1 cup of salad weight I day leafy vegetable vegetables I g raw 1 cup of other xi oup75g of legumes I vegetables cooked vegetable month cooked or raw TA cup of 39 Vsge hle lice A TT T T T Fruit 24 T 15 samples 71002003 E v 300g day A 39 Mininurn two a serving in sample portions rm 9 medium apple 1 medium apple fruits banana or i banana or orange orange A cup of fruit 56 cup of cooked juice A c 33 s i T j i T T T Vegetable 5ll servizngs More tlian 5 o 67 servings amp portions Fruit a serving a serving l meoium a portion T T g raw vegmbic or nit 100150g fruit 39 vegetable V cup of 39BSi1 or 1093 quotfruit canned vegetable Hz cup of juice or uit T GllTIDfjl1iE3fTr T T T T Milk 23 servings 24 servings 25 samples 23 portions l rnl l serving 3934 liter of low milk amp fat milk or 903 a serving a serving a sample 39 s potions Eesrn 53933 3 serving of low fox 1 cup ofmilk 1 cup of milk 1 11p25U39l39nii of 190 ml milk l cup ofrnillc cheese day 11 ounces of 2 slices5Gg of milk 303 cheese 2 slices 4Ug cheese cheese 2 slices Mg of of cheese T cheese T T Meet 23 servings 23 servings 2 somplw 23 portions 5010 45 servings 1503003 of raw meat sh week or a serving a o mrnple a portion amp5l0g a serving E ll6003 of 23 ounces of 50lfl g meal 65ifi g cooked 60 35g meat sh 5 603 of raw mean week or cooked mat not speci c 0 p i rim not speci c if 25503 meat 3 cm week poultry or sh row of p p 93 cup of cooked raw or cooked 1150g egg cup of cooked 12 eggs dry beans dry beans 2 small eggs Fat SE Lirnited WA NfA 03 portions 253 ts Limited Laws than 40g T Sugsr a portion and oils day 305 cake A TT Fluid NIAF NaquotA NM Na39A NfA T NM T More than I 56 liter dayquot NM Not Avsilable FIG 2 The comgcorzisori of recommended qisoraririesfor each food group in intsrieotionoijood guide depictions 488 TX April 2002 Volume 102 Number 4 COIl lIIIiDi iIlii iiifICOINIGIIIIHICIEIOICIUGIIIl iQiUICOO i portion sizes sample sizes and grams Figure 2 reveals the comparison of recommended quantities for each food group in international food guide depictions Although Gerrnany does not give specific amounts for each group it provides example information as listed in Figure 2 The Korean and Chinese Food Guide Pagodas recommend smalleri number of servings for the V group For the remainder of the food groups the total intake suggested for each food group did not show significant differences among countries ifboth the number of servings and serving sizes are considered the core reoomrnerldation for individuals to consume large amounts oi grains vegetables and fruits with moderate intake lot meet milk and dairy products was consistent in all the international food guide llllustrations included in this study Korea for instance recommended a relatively small number of servings for the grain group yet has a sendng size nearly three times that of others making the actual recommendation similar to that of others Likewise because of the smaller serving sizes for the meat group Korea recommended a larger number of servings in its food guide Whether or not quantitative recommendations were pre sented most of the countries consistently recommended a greater consumption of the grain vegetable and fruit groups with a lower intake of the meat milk and dairy groups PPii Tl i3f iElllSi ls This study reveals the fact that there are differences in the shapes of food guide illustrations and food grouping However the core recommendation for iridividuals to consume large amounts of grains vegetables and fruits with moderate intake of meat milk and dairy products was consistent in all the international food guide illustrations included in this study This is important considering the prevalence of the high pro tein diet in the American culture None of the countries 3 iIMfN39 39l39l IUQQUQOCIIIIOIQUQCUWVCCUQilliDIIIIIiiIDCQCUIIODIIOIOIIICOIHIOIOHD examined to date recommend a high protein diet as a healthy eating pattern for their population This information should be considered when counseling clients that are confused about whether to consume a high protein or high complex carhohye drate diet although experts in the field have suggested that recom mendations may vary because of the differences in dietary patterns and cultures it is perhaps more beneiicial to consider the similarities in these recommendations Whil e the indi vidual food recommendations iraijr between countries the recommended food patterns emphasising high carbohydrate foods are similar Dietitians Working with diverse cultural groups in this coun try might find it helpful to use the US Food Guide Pyrarnid as a food choice guide in addition to emphasizing cultural foods References 1 Davis CA Britten F Myers EF Past present and tuture ol the food guide pyramid JAM Diel Assoo 2001 i l1393l B81e885 2 Gat snb39 r39 SJ Hunt F Rayner M The National Food Guide development of dietetic criteria and nutritional chajracteristlcs J Hum Norr ieret 1995 85 323334 3 Korean quotN utrltlon Society Heoommended ietarjrA owanoes for Koreans 7th Fievlsion Seoul Korea dungsang Publishing 3000 4 Health Canada web site Guiding Canadians toward healthy eating national nutrition leadership Available at httpflwwwhc scgcca39 hppbj nutritionI background him Accessed June 16 2DO l 5 Australian department oi health 8 aging Web site Austraiian Guide to nsatthy sao39ng baolrpround information for nuirmon educators Availabl e at 39httplwwwhealt39hgovzaur pubhlthi stralegf food guide materialshtm Ac cessed June 16 2cm 6 Food Guide Pyramid A Guide to Daily Food noloes Washington DC US Department of lgriculture Human Nutrition Information Service 1992 Home and Garden Bulletin No 232 7 Orloeta S3 The Filipino Pyramid Food Guide Nutrition Today 1993 335 210215 8 Maoolisrsorl Sanchez AE A food guide pyramid lor Puerto Rico Nuiridon Today 1998 335 198209 9 Cronin FJ Fleilections on loocl guides and guidance systems Nutrition Today 1998 335185133 10 Simopoulos AP The Mediterranean Food Guide Nutritious Today 1995 3OIf2 54Bi 11 Hunt P Rayner M Gatsnoyquot S A national food guide tor the UK Background and development J Hum Nurr Dieter 1995 85 3151322 12 Nestle M ln defense oiihe USDA Food Guide Pyramid Numrlion Today 1998 335 189192 13 Dietary guidelines and the Food Guide Pagoda The Chinese Nutrition Society J Am Dr39etAssoo 2000 1008 8BB 38739 14 GraAa P Dietary guidelines and food nutrient intakes in Portugal Bro Nutr 1999 Biisuppl 2 3998103 1 5 Canada s Food Guide to healthy eating Ottawa Onlario Health Canada 1992 il3S252391992E lSEN U6622196481 If Minister of Public Works and Government Services Canada 199 16 Australlan guide to healthy eating Canberra Australia Commonwealth department of health and aged cars 1998 25052485 1 T The Balance of Good Health U K Health Education Authority 1994 lSBN 0 521 0252 1 The authors wish to ooicrtowiedge and thdnitfoiiowing peoptefor their corstrihuttons to this study Special thanks to Dr Hector Bourges MD PhDfor has constant assistance regordtng the graphic and rnforoaotion rotated to the Mexico Food Thomas to Ms Lerrm Bergstrom Ms Celeste Tcrschooo Ms Letiioto White and Ms Pom Beoitlegrfor the iraforuadttois and r3tiustrations for the Sweden Food Garcia the Filipino Pyramid Food Guide the Australian Guide to Heoithy Editing and the UK s Balance of Good Health Dr Pedro Gradefor the depiction ofPortugdl1Foooi Wheel and nutritionists in the Germrrn Nutrition Sootictyfor their comments about the G9quotI iquot2 1t Nutrition Carole Journal of THE AMERICAN DIETE TIC ASSOCIATION I 439 de Spinning Top Japan Espi i 592 M 113 mi 11maMI1na neml an mi 0a 0a y h h y Pmh N g 2 3quot 5bo v6ooiouowovotoo u 2w g F 2 h I39 39 39 if E E 1 0i 0i mm4mlt momgt a 255 m4 mmmo4 w mnlttm mm mam Lw sm p Emma mo mmmmmu mzwzmu E353 W r 393 E mEmu Emaoy mgtoE mlt E05 rzmzmo rzmmz Take a moment and describe the intended urpose for Healthy People 2020 Dietary Reference lntakes Dietary Guidelines for Americans 2010 and MyPZare39 Describe the target population for each nutritional guideline How might these guidelines be used In other words who are the intended populations Structural formulas of hexuses Hexoses differ from each other because their H and 01I groups are arranged differently about the earboii atoms Glucose and galaetose both have aldehyde groups and are called afdosesg fructose has a ketone group and is called ketose 1 Describe the difference between a triose pentuse and hexese 2 Which hexeses are uldehydes Aldehyde a I I I O I I I I O I O I I I I I I I o 0 o o O OI I I I Z O O I I I Glucose Aldehyde 4 lill I I I O I O I I I O I I I I I I f Q I I I Galaetose I O I Fructose iiiinIIUIQU39iIUl QQiA IHUICDDUGEiiiiDiIhI qzljDiI llli iij l llgjgpgjQCCQ Position of the American Dietetic implications of dietary fiber ABBTBMEF Dietary fiber consists of the structural and storage polysac charides and lignin in plants that are not digested in the human stomach and small intestine A wealth of information supports the American Dietetic Association position that the public should consume adequate amounts of dietary fiber from a variety of plant foods Recommended intakes 2035 gfday for healthy adults and age plus 5 g day for children are not being met because intakes of good sources of dietary flb er fruits vegetables vvhole and high ber grain products and legumes are low Consumption of dietary fibers that are viscous lowers blood cholesterol levels and helps to normalize blood glucose and insulin levels making these kinds of fibers part of the dietary plans to treat cardiovascular disease and type 2 diabetes Fibers that are incompletely or slowly fermented by microflora in the large intestine promote I10139II1a113 3ll0I1 and are integral compo nents of diet plans to treat constipation and prevent the development of diverticulosis and diverticulitis A diet adequate in bencontaining foods is also usually rich in nucronutrients and nonnutritive ingredients that have additional health benefits It is unclear why several recently published clinical trials with dietary ber intervention failed to show a reduction in colon polyps Nonetheless a fiber rich diet is associated with a quotlower risk of colon cancer A fiberrich meal is processed more slowly which promotes earlier satiety and is frequently less calorically dense and lower in fat and added sugars All of these characteristics are features of a dietary pattern to treat and prevent obesity Appropriate kinds and amounts of dietary fiber for the critically ill and the very old have not been clearly delineated both may need nonfood sources of fiber Many factors confound observations of gastrointestinal function in the critically ill and the kinds of ber that would promote normal small and large intestinal function are usually not in a form suitable for the critically ill Maintenance of body vveight in the inactive older adult is accomplished in part by decreasing food intake Even with a fiberric h diet a supplement may be needed to bring fiber intakes into a range adequate to prevent constipation By increasing variety in the daily food pattern the dietetics professional can help most healthy children and adults achieve adequate dietary fiber intakes HM HEPHBIS IOIIllIOIOIIC0IOUiiOiIIIII UOCUCIllii SUIHUIODIIOIOIICDOKIQIIIDCIIIIICIii lMTlRODUCTl0N Dietary fiber has demonstrated benefits for health mainte nance and disease prevention and as a component of medical nutrition therapy Except in certain therapeutic situations dietary fiber should be obtained through consumption of foods in addition to fiber minimally processed fruits vegetables legumes and whole and highfiber grain products provide micronutrients and nonnutritive ingredients that are essential components of healthful diets Plant foods also may contain other nonnutritive components eg antioiddants phyloes trogensj that have implications for health A fiberrich diet is lower in energr density often has a lower fat content is larger in volume and is richer in micronutrients all of vvhich have bene cial health effects By encouraging people to eat ber rich plant foods the dietetics professional can have a signifi cant impact on the prevention and treatment of obesity car diovascular disease and type 2 diabetes as Well as constipa tion iF39DSlTlON STATEMENT It is the position of the American Dietetic association ADA that the public should consume adequate amounts of dietary fiber from a variety of plant foods DIETARY FIBER Recommended Fiber intakes Through the Life Cycle Recommendations for adult dietary fiber intake generally fall in the range of 20 to 35 gday 1 Others have recommended dietary fiber intakes based on energy intake 10 to 13 g of dietary fiber per 1000 kcal Nutrition facts labels use 25 g dietary fiber per day for a 2000 kcalday diet or 30 gfday for a 250 0 kcal day diet as goals for American intake Attempts have been made to define recommended dietary fiber intakes for children and adolvescenlzs Although based on limited clinical data the recommendation for children older than 2 years is to increase dietary fiber intake to an amount equal to or greater than their age plus 5 gfday and to achieve intakes of 25 to 35 g day after age 20 years 2 No published studies have defined desirable fiber intakes for ihfants and children younger than 2 years Until there is more information about the effects of dietary fiber in the very young a rational approach would be to introduce a variety of fruits vegetables and easily digested Jourrial of THE AMERICAN DIETETIG ASSOClATlON 2 993 hillIUUUIt lil liliililtiii iii IiiUllilliiqii lt ni nbipi yt g cereals as solid foods are brought into the diet Specific recom mendations for the elderly have not been published although a safe recommendation would encourage intakes of l0 to l3 g dietary fiber per lUOU kcal All recommendations need to re cogniae the importance of adequate fluid intake and caution should be used when recommending fiber to those with gas trointestinal diseases including constipation Dietary ber intake continues to be at less than recom mended levels in the United States with usual intakes averag ing only id to 15 gfday 3 When asked about their perceptions of their dietary fiber intake 73 of individuals with a mean fiber intake below 20 gday think the amount of fiber they consume is about right 3 Many popular American foods contain little dietary fiber Servings of commonly consumed grains fruits and vegetables contain only 1 to 3 g of dietary fiber 4 Legumes and highfiber bread and cereal products supply more dietary fiber but are not commonly consumed quotDefinition and Sources of Fiber A variety of de nitions of dietary fiber exist globally 5 Some are based primarily upon analytical methods used to isolate and quantify dietary fiber whereas others are physiologically based Dietary fiber is prhnarily the storage and cell wall polysaccharides of plants that cannot be hydrolyzed by luirnan digestive enzymes Lignin which is a complex molecule of polyphenylpropane units and present only in small amounts in the human diet is also usually included as a component of dietary ber 5 p n For labeling the dietary ber content of food products within the United States dietary fiber is defined as the material isolated by analytical methods approved by the Association of Official Analytical Chemists 5 A variety of lowmolecular carbohydrates that are being developed and increasingly used in food processing are not digested by human digestive enzymes sugar alcohols such as sorbitol and l tol polydeictroses and various fructo and galactoolie gosaccliarides These small polymers and ollgosaccharildes are not measured by the AOAGJapproved methods for measur ing dietary fiber but methods specific for each material are being approved byAOnC to measure for these compounds 5 Resistant starch the sum of starch and starchdegradation products not digested in the small intestine 6 contributes to the pool of microbial substrate or dietary fiber reaching the large intestine Legumes are a primary source of resistant starch with as much as 35 of legume starch escaping diges tion T Small amounts of resistant starch are produced by the processing and baking of cereal and grain products The amount of resistant starch in atypical Western diet is not known and meaningful tables of the resistant starch content of foods are not available Because of the availability of new manufactured materials that behave like dietary fiber either analytically or physioIogi cally and the globalization of food markets there is renewed interest in having a single physiologically founded clefnilion of dietary fiber Two are receiving attention in North America The definition developed by the American Association of Cereal Chemists is Dietary fiber is the edible parts of plants or analogous carbohydrates that are resistant to digestion and absorption in the human small intestine with complete or partial fermentation in the large intestine Dietary fiber in cludes polysaccharides oligosaccharides lignin and associ ated plants substances Dietary fibers promote beneficial physi ological effects including laxation andfor blood cholesterol attenuation andfor blood glucose attenuationquot 8 994 July 2002 Volume 102 Number 7 lm REPIJHTS Vll l lifllDQDIQCOIIUIIIIICUIIICQIUIibtiIiiI diiiliiiii ilpniiliyq The other definition for North America has been proposed by a panel assembled by the Food and Nutrition Board 539 as part of the federally mandated evaluation of Dietary Reference Intakes The Panel on the Definition of Dietary Fiber proposed two new definitions Dietary Fiberquot and quotAdded Fiberquot Die etary Fiber consists of nondigestible carbohydrates and lignin that are intrinsic and intact in plants Added Fiber consists of isolated nondigestibl e carbohydrates that have bene cial physiP ologiical effects in humans Total Fiber is the sum of Dietary Fiber and added Fiber The intent of these proposed definitions is to recognize the physiological actions of fiber and its demonstrable health effects and to reduce the emphasis on dietary fiber as a constituent of food requiring quantification 5 Benefits of Adequate Fiber Intake Dietary ber and blood cholesterol levels Several dietary fiber sources lower blood cliolesterol levels specifically that fraction transported by low density lipoproteins LDL 9 Fibers that lower blood cholesterol levels include foods such as apples barley beans and other legumes fruits and vegetables oatmeal oat bran and rice hulls and purified sources such as beet fiber guar gum karaya gum konjac rnannan locust bean gum pectin psyllium seed husk soy polysaccharide and xanthan gum 9 Two of these fibers namely beta glucan in cats and psyllium husk have been sufficiently studied for the FDA to authorize a health claim that foods meeting speci c compositional requirements and containing 395 g or 1 g of soluble fiber per serving respectively can reduce the risk of heart disease 10 Consequently these two dietary bers are specifically included in the most recent National Cholesterol Education Program Ainerican Heart Association guidelines 1 1 The mechanism by which these ber sources lower blood cholesterol levels has been the focus of many investigations and characteristics such as solubility in water viscosity fermentability and the kinds and amounts of protein and tocotrienols have been explored as possible bases for this physiological effect 12 The one characteristic common to all cholesterollowering fibers is viscosity l2 Indeed when a soluble fiber that is not viscous is evaluated or the fiber is treated to reduce viscosity sufficiently the cl1o1esterollower ability is lost 1315 As components in foods are digested and absorbed from the small intestine fiber becomes a major component inthe gut lumen makingthe viscosity evident This viscosity interferes with bile acid absorption from the ileum 1647 In response LDL cholesterol is removed from the blood and converted into bile acids by the liver to replace the bile acids lost in the stool Some evidence also indicates that changes in the composition of the bile acid pool accompanying ingestion of some viscous bers dampen cholesterol synthesis l f 18 Because endogenous synthesis accounts for about threequarters of total body cholesterol pool slowing synthe sis as do the statin drugs could have a favorable impact on blood cholesterol concentrations increasing soluble fiber in take by consuming a wide variety of foods may 19 or may not 2 B have a hypocholesterolemic effect this variable effective ness may depend on the composition of the rest of the diet Dietary fiber and normal laxation Many fiber sources including cereal brans psyllium seed husk methylcellulose and a muted highfiber diet increase stool weight thereby ilCQ39IquotU39ii iCIiiliI illll fi iiIllQCBIOIICOOIIOI IquotIIIAIIIIIIIIIIIIIIICIIIII Table HM HEPBHTS U309 Iii IIquot iC 55I39D939QGilliIIIIIIIlillliil9iiiOiIP II39OlhIijQlj Q Elietary fiber content or foods gfserving Food Groups Food Serving Size Total Dietary Fiber Fruits Apple large wiskin 1 apple 37 Banana 1 banana 26 Figs dried 2 figs 46 Orange 1 orange 3 1 Peach canned 1l392 1 3 Pear 1 pear 40 Prunes dried 5 30 Raisins 1 miniature box 14 g 06 Strawberries raw 1 cup sliced 3 8 Vegetables Beans kidney canned 1f2 cup 45 Broccoli raw U2 cup 13 Brussels sprouts cooked 1 f2 cup 20 Carrots raw U2 cup 16 Celery raw U2 our 10 Lentils Cooked H2 cup 78 Lettuce iceberg 1 cup sliredded 08 Peas green canned 1J2 cup 35 Peas split cooked 1 2 cup 61 Potatoes boilecl 12 cup 16 Spinach cooked 1 cup 22 Grains Bread white wheat 1 slice 06 Bread whole wheat 1 slice 19 Cheerios 1 cup 26 Crackers graham 2 squares 04 Cream of Whetat 1 cup 29 Oat bran muffin 1 muffin 26 Oatmeal cooked 3f4 cup 30 Raisin bran 1 cup 75 Rice brown cooked 1 cup 35 Rye crispbread 1 wafer 1 Shredded wheat 2 biscuits 50 Wheat bran flakes 314 cup 46 other Apple pie 1 piece 19 Chocolate cake 1 slice 18 Mr Goodloar 1 bar 1 Nuts mixed dry roast 1 oz 26 Yellow cake 1 slice 02 Source USDA Nutrient Database for Standard Reference Release 14 promoting norrnal laxalzion 21 Stool weight continues to increase as ber intake increases 2022 but the added fiber tends to normalize defecation frequency to one bowel Inove t ment daily and gastrointestinal transit time to 2 to 4 days 23 The increase in stool weight is caused by the presence of the fiber by the water that the fiber holds and by partial ferrnen tation of the fiber which increases the amount of bacteria in stool 2425 if the fiber is fully and rapidly fermented in the large bowel as are most soluble ber sources there is no increase in stool weight 21 it is a common but erroneous belief that the increased Weight is due primarily to water The moisture content of human stool is 70 to 75 and this does not change when more fiber is consumed 2 6 In other words fiber in the colon is not more effective at holding water in the lurnen than the other components of stool The one known exception is psylliuni seed husk which does increase the concentration of stool Water to approximately 80 27 Dietary fiber digestion and satiety While emphasis has been quotplaced on specific effects that can be detected as statis tically significant when a particular ber source is consumed dietary fiber has many subtle less easily quantifiable effects that are beneficial This is particularly true for fiber provided by foods A fiberrich meal is processed more slowly and nutrient absorption occurs over a greater time period 28 Further a diet of foods providing adequate fiber is usually less energy dense and larger in volume than a lots fiber diet which may limit spontaneous intalze of energy 29 This larger mass of food takes longer to eat and its presence in the stomach may bring a feeling of satiety sooner although this feeling of Journal of THE MXERIKCAN DIETETIC ASSOCIATION I 995 IliitiiiIDlilntuqdiviiiDwiiitiii itoldtuoiuhojIubtdnihqttbnttui q fullness is short term A diet of a wide variety of fib ercontains E foods also is usually richer in rnicronutrients When viscous fibers are isolated and thereby concentrated their effects on digestion are frequently easier to detect when these types of fibers are added to a diet the rate of glucose appearance in the blood is slowed and insulin secretion is subsequently reduced 303l These beneficial effects on blood glucose and insulin concentrations are most evident in individuals with diabetes mellitus in healthy individuals the rapid insulin secretion that causes rapid removal of glucose from the blood frequently makes it impossible to detect a difference between blood glucose concentrations during a test meal with and without a fiber supplement ther roles in health There is observational evidence that fiber may protect against duodenal ulcers 32 and cancer in the gastric carclia region 33 Animal experiments suggest that the type and amount of fiber consumed may affect intes tinal immune function 3435 but human studies are lacking As a result of fiber serving as a substrate for bacteria in the large bowel changes in intestinal bacterial populations espe cially with the consumption of large amounts of purified homogenous bers cg fructooligosaccl1arides arabinogalacb ans have been reported 36 Some human data suggest that iructooiigosaccharides may increase calcium absorption 3738 Soluble versus insoluble dietary fiber There has been a trend to assign specific physiological effects either to soluble or insoluble bers This approach makes it difficult to evaluate the effects of fiber provided by mined diets Dietary fiber provided by mixed diets is twothirds to threequarters in soluble although the exact distribution between soluble and insoluble is very dependent on the method of analysis 39 Further some fibers are placed in one category or another when in fact they may have major benefits attributable to both soluble and insoluble bers psylliurn seed husk oats and oat bran are examples Both of these ber sources increase stool weight and improve laxation as well as lower blood cholesterol levels 1dl74fl4l lt is also apparent that all soluble fibers are not hypocholesterolenuc agents but rather only those that are viscous The disparities between the amounts of soluble and insoluble fiber that are measured chemically and their physiological effects has led a National Academy of Sciences Panel to recommend that the terms soluble fibers and in soluble fibersquot gradually be eliminated and replaced by specific beneficial physiological effects of a fiber 5 Other components in bercontaining foods There is substantial scientific evidence suggesting that vegetables fruits and whole grains reduce risk of chronic diseases including cancer and heart disease 424i3l In epidemiologic studies it is often easier to count servings of whole foods than translate information on food frequency questionnaires to nutrient in takes Additionally recent studies suggest that whole foods offer more protection against chronic diseases than dietary fiber antioxidants or other biologically active components in foods Thus associations between dietary fiber and disease identified through epidemiologic studies may actually be re flections of a synergy among dietary fiber and these associate substances or of an effect of only the associated materials This suggests that the addition of puri ed dietary fiber to foodstuffs is less likely to be beneficial as opposed to changing 996 I July 2002 Voliirne M2 Number I AM HEPHRTS nmnoopionooptoooaoeoocqolnanamonopoiiiuonuouuuagguqqugupggqgggggug American diets to include vvhole foods high in dietary fiber The concept of synergy among components in whole foods and the attendant overall healthfulness of a varied diet are important aspects of any dietary counseling Disease Flisk Reduction and quotTherapeutic Uses of Fiber A lot of what is known about the benefits of a higher fiber diet comes from epidemiological studies Sometimes there are disparities between epidemiological and metabolic studies One possible source of discrepancy is the time of collection of diet information since the food supply and food habits change continuously especially in response to the National Labeling and Education Act Foods in current databases may not be reflective of what was consumed more than a decade ago this is particularly true for data for dietary fiber in foods that have been gathered largely in the past i5 years Fortunately there are now fewer differences among methods of determination of total dietary fiber in US foods so that current fiber databases are improved over those that were available previously and are reasonably useful for epidemiological diet studies now in contrast the division of total fiber between soluble and insoluble remains very method dependent The proportion of the total fiber that is soluble varies by two to threefold across major methods of analysis meaning that there is the same CXl3El l1 of variation among the values for insoluble fiber 39 Thus the use of databases to differentiate the effects of soluble versus insoluble fiber with disease could produce statistically quotsignificant relationships particularly when values from one decade of time are applied to intake data collected during a different decade Finally people eat diets and it is possible that the use of isolated frequently singleiiber sources in metabolic studies is not representative of a mixed highfiber diet Prevention and management of diabetes mel litus Considerable experimental evidence demonstrates that the addition of viscous dietary fibers slows gastric emptying rates digestion and the absorption of glucose to benefit immediate postprandial glucose metabolism 44 and long term glucose control 4546 in individuals with diabetes mel litus The long term ingestion of 50 g of dietary fiber per day for 24 weeks significantly improved glycemic control and reduced the number of hypoglycemic events in individuals with type 1 diabetes 4748 Among pregnant women with type 1 diabetes mellitus a higher fiber intake was associated with lower daily insulin requirements 49 Studies with indi viduals with type 2 noninsulindependent diabetes suggest that high fiber intakes diminish insulin demand 5051 39I wo cohort studies found that fiber from cereals but not from fruits and vegetables had an inverse independent relationship with risk of noninsulindependent diabetes 5253 The mechanisms whereby fiber may affect insulin require ments or insulin sensitivity are not clear In rats and dogs higher fiber intakes especially of fermentable fibers increases expression of the gut derived proglucagon gene and secretion of proglucagonderived peptides including glucagon lillte pep tidel GLP1 5455 GLPl has been shown to reduce gastric emptying rates promote glucose uptake and disposal in peripheral tissues enhance insulindependent glucose dis posal inhibit glucagon secretion and reduce hepatic glucose output in animals and humans 56 The multiple effects of GLP1 may reduce the amount of exogenous insulin required by individuals with impaired glucose metabolism when con suming a high ber diet IQUDIIIIUCIIIOOC I U I IlU39IWUDICD1MIUQQOCUCCUCCEi liQiiIIIilili Prevention and management of oardiovas cular disease The primary bene t of including dietary fiber as part of the medical nutrition therapy to treat cardiovascular disease is a consequence of fiberfs effects on blood cholesterol levels Thus hypocholesterolemic fibers are those that are viscous The secondary benefits of a higher fiber diet to treat cardiovas cular disease may include lower energy fat and simple sugar contents all of which would be effective treatments for the obesity and hypertriglyceridenda also associated with cardio vascular disease Antioxidants found in some cereal brans and associated germ also may have health bene ts Prevention and management of constipation The mecha nisms by which dietary fiber promotes normal laxation are the bases for recomrnending fiber to treat and prevent constipa tion The large intestine responds to the larger and softer mass of residue produced by a higher fiber di et by contracting which moves the contents towards excretion Fiber in mixed diets legumes and whole and highfiber grain products are particu larly effective promoters of normal laxation A fiber supple ment may be needed when food intake is low as is the case among inactive elderly one of the cereal brans psyllium seed huslt or methylcellulose is frequently used in these cases iPrevention and management ofdiverticnlosis Movement of material through the colon is stimulated in part by the presence of residue v the lumen When chronic insufficient built accompanying a low fiber diet occurs in the colon the colon responds with stronger contractions in order to propel the smaller mass distally This chronic increased force leads to the creation of diverticula which are herneations of the mu cosa layer through weak regions around blood vessels in the colon niusculature Adequate intake of vdietarii Fiber prevents the formation of diverticula by providing adequate bulk in the colon so that less forceful contractions are needed to propel it distally A highfiber diet is standard therapy for diverticular disease of the colon Formed diverticula will not be resolved by a diet adequate in fiber but the built provided by such a diet d prevent the formation of additional diverticula lower the pressure in the lumen and reduce the chances that one of the existing diverticula will burst or become in amed Generally small seeds or h39usilts that may not be fully digested in the upper gastrointestinal tract are eliminated from a highfiber diet for a patient with diverticulosis as a precaution against having these small pieces of residue become lodged within a diverticu lum Flelatlonship between dietary fiber and cancer Large bowel cancer Extensive epideiniolog39c evidence sup ports the theory that dietary fiber may protect against large bowel cancer Correlation studies that compare colorectal cancer incidence or mortality rates among countries with estimates of national dietary fiber consumption suggest that ber in the diet may protect against colon cancer Data col lectcd from 20 populationsin 12 countries showed that average stool weight varied from 72 to 470 gfday and was inversely related to colon cancer rislr57Wl 1en results of 13 case control studies of colorectal cancer rates and dietary practices were pooled the authors concluded that the results provided sub stantive evidence that consumption of fiberrich foods is in versely related to risks of both colon and rectal cancers 58 IllIilllllllilIQIIIIIIIIIIDIIiirialinInIntiginnliiouiuiudtbtwiiqgaanaag The authors estimated that the risk of colorectal cancer in the US population could be redu ced by about 81 with an average increase in fiber intalte from food sources of about 13 gfday Three intervention studies do not support the protective properties of dietary ber against colon cancer 5961 The studies found no significant effect of high fiber intakes on the recurrence of colorectal adenornas Each paper describes a wellplanned dietary intervention to determine whether high fiber food consumption could lower colorectal cancer risk as measured by a change in colorectal adenomas a precursor of most largebowel cancers Several reasons have been given for the failure to demonstrate a benefit Perhaps the fiber inter ventions were not long enough the fiber dose was not high enough the recurrence of adenoma is not an appropriate measure of fibers effectiveness in preventing colon cancer or these individuals had already optimized their diets since the fiber intake by the low fiber control subjects exceeded that of the American population 5960 Yet the results from the studies are clear increasing dietary fiber consumption over 3 years did not alter the recurrence of adenomas Despite the inconsistency in the results of fiber and colon cancer studies the scientific consensus is that there is enough evidence that dietary fiber protects against colon cancer that health profes sionals should be prornoting increased consumption of dietary fiber 62 Breast cancer Limited epidenu ologic evidence has been pub lished on ber intake and human breast cancer rislr Since the fat and fiber contents of the diet are generally inversely related it is difficult to separate the independent effects of these nutrients and most research has focused on the fat and breast cancer hypothesis International comparisons show an inverse correlation between breast cancer death rates and the consumption of llber rich foods 53 an interesting exception to the highefat diet hypothesis in breast cancer was observed in Finland where intake of both fat and fiber is high and the breast cancer mortality rate is considerably lower than in the United States and other Western countries where the typical diet is high in fat 64 The large amount of fiber in the rural Finnish diet may modify the breast cancer risk associated with a lu7gh fat diet A pooled analysis of 12 casecontrol studies of dietary fac tors and risk of breast cancer found that high dietary fiber intake was associated with reduced risk of breast cancer 65 Dietary fiber intake also has been linked to lower risk of benign proliferative epithelial disorders of the breast 66 Not all studies find a relationship between dietary fiber intake and breast cancer incidence including a US prospective cohort study 67 A pooled analysis of eight prospective cohort studies of breast cancer found that fruit and vegetable con sumption during adulthood was not significantly associated with reduced breast cancer risk 68 A large casecontrol study reported protective effects with high intake of cereals and grains vegetables and beans 69 Role of fiber in critical illness and use in enteral formu las No 1 ecommendations exist for fiber intake in several disease states or for patients in long term care facilities Two types of enteral formulas that contain dietary fiber are cur rently marketed blenderiaed formulas made from whole foods and formulas supplemented with purified fiber sources Puri fled fiber sources used in enteral products include oat pea hydrolysed guar gum and sugar beet bers as well as others Journal of THE AMERICAN DTETETIC ASSTOCIATION Q9 aitunvnuinnl iIiiIiiDblIiiIIIrvlirillQisiaiinilsOip tjlioqsybdnQ9cgogaogogid Some formulas use a mixture of fiber sources A recent addi tion to enteral formulas is fructooligosaccharides FOSs which are shortchain oligosaccharides usually 2 to ill monosaccharide units that are not digested in the upper digestive tract and therefore have some of the same physi ologic effects as soluble lquot1ber36 FOSs are rapidly fermented by intestinal bacteria that produce short chain fatty acids SOFA which stimulate water and electrolyte absorption and should aid in the treatment of diarrhea FOSs are a preferred substrate for bifidobacteria but are not used by potentially pathogenic bacteria thus helping to maintain and restore the balance of healthy gut ora and they are not isolated by the currently accepted method for dietary fiber so they cannot technically be called dietary fiber 5 The newly proposed definitions of dietary ber if implernented should allow a label claim for FOSS as an added fiber 5 The original rationale for adding dietary ber to enteral formulas was to normalize bowel function Dietary fiber is usually promoted as a preventive against constipation for the normal healthy population Enteral formulas containing fiber are also used in the acutescare setting to prevent diarrhea associated with tube feeding Bowel function is affected by more than fiber level and there is much individual variation in the amount of fiber needed for optimal bowel function Studies on the biologic effects of enteral formulas containing fiber are few and even less information is av39ailable from patients The addition of soy polysaccharide to an enteral formula signi cantly increased stool weights of healthy male adults 70 whereas no differences in stool weight or stool frequency were observed in one study when soy polysaccharide was added to the enteral formula of patients in a longterm care facility 7 l However 089 another study of the same population that was one year in length soy polysaccharide ber did signi cantly in crease daily stool frequency weight and moisture 72 Thus existing clinical studies do not uniformly support the assertion that the addition of dietary fiber to an enteral formula improves bowel function Dietary fiber is thought to normalize bowel function in healthy subjects and there is anecdotal evidence of reduction of diarrhea in patients receiving fiber containing formulas No convincing data have been published to document that flberacontaining enteral formulas prevent diarrhea in tubefed patients T3 Unfortunately there are no standard accepted ways of defining diarrhea The reported incidence of diarrhea in tubefed patients ranges from 2 to 63 Stool frequency stool consistency and stool quantity are the three features of bowel elimination usually used to define diarrhea in addition to fiber oral agents such as sorbitol and magnesium have been suggested as important intake variables affecting stool consis tency Dietary fiber may improve fecal incontinence Patients with fecal incontinence who consumed dietary fiber as psylv lium or gum arabic had signi cantly fewer incontinent stools than with placebo treatment T4 improvements in fecal incontinence or stool consistency did not appear to be related to unfermented dietary fiber The results of some lclinical studies with dietary fiber have been disappointing although the model proposed that fiber is fermented by anaerobicintestinal bac tone that generate SCFss which serve as energr sources for colonic mucosal cells is probably correct 75 To study the physiologic effects of dietary llber especially in a sick population is extremely difficult Most studies have been too short measurements are semiquantitative and dietary fiber and SOFA levels were 993 I July 2002 Volume 102 Number 7 mm HEPDHTS IlI39I Iil39ii3939UIll li liill39WquotUGOItnilonQvlii ililiIIiiiiiiililllliuivhl frequently not measured It is not clear that results from vitro fermentation studies have direct application in vivo Despite the laclvc of cornpelling clinical data dietary fiber is the treatment of choice for many bowel disorders Potential negative effects of dietary ber Potential nega tive effects of dietary fiber include reduced absorption of vitamins minerals proteins and calories It is unlilcely that healthy adults who consurne fiber in amounts within the recommended ranges will have problems with nutrient absorp tion however dietary fiber r econunendations of 25 gday may not be appropriate for children and the elderly since so little research has been conducted in these populations Generally39 dietary fiber in recommended amounts is thought to normalize transit time and should help when either consti pation or diarrhea is present however case histories have reported diarrhea when excessive amounts of dietary fiber are consumed U6 so it is difficult to individualize fiber intake based on bowel function measures Thus stool consistency cannot be used as a benchmark of appropriate dietary fiber intake lntestinal obstruction caused by a cecal beaoar was reported in a seriously ill rnalel given fiberecontainirlg tube feedings and who was also receiving intestinal motility sup pressing medications 39339 The bezoar resulted in mesenteric hemorrhage Fennentation of dietary ber by anaerobic bacteria in the large intestine produces gas including hydrogen methane and carbon dioxide which may be related to complaints of distention or flatulence When dietary fiber is increased fluid intalte should be also and fiber should be increased gradually to allow the gastrointestinal tract time to adapt Further normal lanatlon may be achieved with smaller amounts of dietary fiber and the smallest dose that results in normal laitation should be accepted Fiberenriched enteral formulas may cause blockages in smallbore feeding tubes This is most problematic with gums and other viscous fibers Formulas containing fiber tend to be more expensive than standard formulas making them a diffi cult choice in the absence of compelling clinical data Few data have been published on the effectiveness of fibercontaining formulas in the long term setting and less expensive and more effective laxation aids are available Researchbased reconunendations about which patients are good candidates for fibervcontaining enteral formulas cannot be made Tubeafed patients with constipation or diarrhea who are known to have otherwise healthy gastrointestinal tracts should be considered candidates for fibencontaining enteral forrnulas Because of the potential protective role of ber against diverticulosis colon cancer diabetes and heart dis ease a liber enriched enteral formula may be indicated for patients in long term enteral feeding Fibencontaining enteral formulas may work be tter for certain patients and they should be used if they produce positive results Clinicians should be cautious in prescribing fibercontaining enteral products Be cause of the wide individual variability of responses to dietary fiber and the potential problems with large closes the smallest dose of dietary ber that gives the desired result should always be used CONCLUSIONS Chronic insuf cient intalte of dietary fiber represents a chal lenge for the dietetics professional that can be met with enthusiastic recommendations fora healthy dietary pattern 54 quotDquotU 9lIUDGil90 CUQ99IIIICIOIiI39II39Qi39Q lIQOQ39II li Iitl liig ICQDIGquot Modest increases in intakes of fruits vegetables 1egumes and wholes and high ber grain pro ducts would bring the majoriity of the North American adult population close to the recom mended range of dietary ber intake of 20535 giday in addi tion a higher fiber intake provid ed by foods is likely to be less caloricalijr dense and lower in fat and added sugar The benefits of so ch a varied dietary plan cannot be Werasmpbnsized Many of the diseases of public health slgniffcance obesity cardio vascular dis ease type 2 diabetes as Well as the less prevalent but no less significant diseases of colonic diverticulosis and constipation can be prevented or treated by increasing the atnounts and yanietives of t39iber containing foods Promotion of such a food plan by the die tetics professional and implementa tion by the adult population should increase ber intakes of children References 1 Pllch 5 Physiological Effects and Health Conseouences of Dietary Fiber Bethesda MD Life Sciences Besearch Office Federation of American Societies for Experimental Biology 198 2 Williams CL Bollella flit Wynder ELL A new recommendation for dietary fiber intalte in childbood Ped39iatn39cs 1995QBf3 Suppl 83985988 3 Alaimo K McDowell MA Brlefel BB Bischcf AM Caughman CB Lorie Cid Johnson CL Dietary intalre of vitamins minerals ano fiber ofpersons ages 2 months and over in the United States Third National ileaitn and Nutrition Examination Suryay Phase 1 1988i99 l Advance Data from Vital and Health Statistics No 258 Hyattsyille MD National Center for Health Statis tics 4 MarlellJA Cheung TF Database and quick methods of assessing typical dietary fiber intakes using data for 228 commonly consumed foods J Am Diet Assoc 1i9979113Q1 1481 151 5 Dietary Reference in taires Proposed Definition of Dietary Fiber Washing ton DC National Academyquot Press 2UD116ti B Asp N G llutrltionalclassification and analysis of food carbohydrates Am J Cil39n Aiutr 19e459SupplB39sSI3B1S 7 Marlett JA Longacre MJ Comparisons of in yitro and in viyo measures of resistant starch in selected grain products Cereal Chem 1996736388 8 The Definition of Dietary Fiber Cereal Foods World 2fJDf39I4B l l2l2Q 9 Marion JA Dietary fiber and cardiovascular disease In Cho SS Dreher ML eds Handbook ofDietary Fiber New fork Marcel Deltker inc 2UD11391 30 1b US Food and Drug Administration Health Claims Soluble fiber from certain foods and risk of heart diseases Code of Federal Ffeguiations 2DOl211D1B l 11 Expert Panel on Detection Evaluation and Treatment of High Blood Cholesterol in Adults 2001 Executive Summary of the Third Heport of the National Cholesterol Education Program NCEP Expert Panel on Detection Eyaluation and Treatment of High Blood Cholesterol in Adults Adult Treat ment Panel ill JAM l 28524ElE 2ltlQ 12 MarIettJA Sites and mechanisms for the h39ypocholesterolemic actions of soluble dietary fiber sources ln lltritcheystlty D Bonlield C eds DietaryFfber in Health and Disease New fork NY Plenum Press 1991D9121 13 Anderson SA Fisher lltD Talbot Jlyl eds Evaiuaticn of the Health Aspects of Using Partially Hydroiyzeo Guer Gum as a Food ingredient Bethesda lv lD Federation of American Societies for Experlrnentail Biology 39l9931bl 14 Lie 5 Hallmans G Sandberg A8 Sundberg B Amen P Andersson ll Oat Bglucan increases bile acid excretion and a flber rich barley fraction increases cholesterol excretion in ileostomy subjects Am J Ciin A ctr 1995E23912451251 15 Davidson MH Dugan LD Stocki J Dicklin MP1 llrlalti KC Colette F Cotter Fl McLeod lvl lloersten K it lonwiscosity solublefiber fruitjuioe supplement fails to lower cholesterol in hypercholesterolemic men and women J Nutr l993 l28 lEi271932 15 Eyerson GT Doggy BF McKinley C Story JA Effects of psyllium hydrophilic rnucilloid on LDlcholesterol and bile acldsynlhesis in hypercho lesterolernic men J Lipid Res 1992331183 11Q2 17 Marlett JA Hosig KB Vollendorl NW Shinnicic FL llaack V81 Story JA Mechanism of serum cholesterolquot reduction by oat bran Hepafoiopry 19B42D145Cl145 1B Hillman LC Peters SG Fisher CA Pornare EW Effects of fibre compo HDH HEPUHTS 39MoiaouivilcsonatacocoonsnowhoinninuntoononinnounsoIninnccanhnoouloo nents pectin cellulose and lighin on bile salt metabolism and biliary lipid composition in man Gut l9862E9BE 19 Jenltins DJ Woleysr39 Tllrl Flao AV lllegele BA llilltchelll SJ Flanson TP Bcctor DL Spadafora PJ Jenkins At lvlehling C Effect of blood lipids of very high intakes offiber in diets low in saturated fat and cholesterol N Englti Med l939933292128 20 Haaclc VS Chesters JG tfollendorf NW Story JA Marlett JA Increasing amounts of dietary fiber provided by foods normali239es physiologic response of the large bowel without altering calcium balance ortecal steroid excretion Am J Ciin Nutr 1ssssae1ss22 21 Cummings JH The effect of dietary fiber on fecal weight and composi tion in Spiller GA ed CBC iianolbcoir of Dietary Fiber in Human Aiutrifr39on 2nd ed Bcca Flaton FL CFlC Press 19932Ei3 349 22 Southgate DAT DurninJ li GA Calorie conversion factors An experimen tal reassessmenl of the factors used in the calculation of the energy value of human diets Brl39Nutr 197U245 l535 23 Harvey BF Pomare EW Heston KW Effects of increased dietary fibre on intestinal transit time tanclet 193112l812180 24 Stephen AIM Cummings JH Mechanism of action of dietary fibre in the human colon Nature 19B02842832B4 25 Kurosawa S llaaclr VB Marlett JA Plant residue and bacteria as bases for increased stool weight accompanying consumption of higher dietaryfiber diets J Am Coll Nutr ECDDquotlB42B 433 26 Eastwood MA Brydon lr1iGTadess ellt Effect officer on colon function In Spiller GA iltayquotPlllr1 eds lliedicai39Aspects ofDietaryFlber New fork NY Plenum Press 1 ssor 2s 2 Prynne CJ Southgate DAT The effects of a supplement of dietary fibre on faecal excretion by human subjects Br J Nufr 1Eli399414B5503 28 Jenkins DJA Woleyar 39TMS Jenkins AL Taylor HH Dietary fiber gas trointestinal endocrine and rhetabolic effects Iente carbohydrate In lfahourry GV Kritcheyslsy D eds Dietary Fiber Basic and Clinical flspecis New Yorlt NY Plenum Press 1988269BU 29 Rolls BJ Bell EA Castellanos VH Chow M Pelkman CL Thorwarl ML Energy density but not fat content of foods affected energy intake in lean and obese women Am J Clin Nutr 199QSQ39863Bil 3d Jenkins DJA Jenkins AL Woleyer TMS liulrsan V Bao Alf Thompson LU Josse es Dietary fiber carbohydrate metabolism and diabetes In Kritclheysky D Bonfleld C eds Dietary39Fiber in Health and Disease 81 Paul MN Egan Press l9B51 3145 31 Anderson JW Akanji AD Treatment of diabetes with high fiber diets In Spiller GA ed DietaryFfberin Humenhiulrition 2nd ed Boca Baton FL CBC Press 1BB3443 4Vl39l 32 Aldooriwl1 Gioyarlnuccl EL Stampfer MJ Flimm EB 39tlii39ng AL Willett WC Prospective study of diet and the risk of duodenal ulcer in men Am J Epidernroi 199 145142ED 33 Terry P Lagegren J Ye W Wollr A Nyren D Inverse association between intake of cereal fiber and risk of gastric cardia cancer Gastrcenteroiogy 2D0112D3873El1 34 Field CJ Mcburney llill Massimlno S llayek MG Sunyold GD The fermentable fiber content of the diet alters the function and composition of canine gut associated lymphoid tissue Vet irnmunoi Pathoi 1QQ9392325 315 35 Lim BO remade llt Nonaka M llturamoto Y Hung P Eugene lrrl Dietary fibers modulate lndices of intestinal immune function in rats J fiotr 199 l23939B53BB7 36 Boberlroid M Slayin JLi Nondigestible oligosaccharides Crit Rev Food Science fliutr Etltltl 401481 4BO 3 Coudray C BellahgerJ CastigliaDelavaud C liermolrellyl Bayssignufer 39139 Effect of soluble or partly soluble dietary fibre supplementation on absorp tion and balance ofcalcium magnesium iron and zinc in healthy young men Eur J Ciin Nutr 1Q9395l 33953Ell3 38 Van den lleuvel E Muys T van lDDlltiltLll39f39I W Schaafsma G Dllgolructose stimulates calcium absorption in adolescents Am J Clin Nutr 199969544 548 39 lVlarettJA Soluble dietary fiber workshop in liritcheyslry D Bonfielcl C eds Dietary Fiber in Health and Disease New York NY Plenum Press l9Q 3l 1313 40 Hoslg KB Shlnniclc PL Johnson MD Story JA Marlelt JA Comparison IQUIIQQIIUICCIIIOCIDII IIiiBDGOIQIIIIiIIiIlilIIIiIIIIC39DDiIICIII39II39III psyliium on glucose and serum lipid responses in men with type 2 diabetes and hypercholesteroiemia Ant J Ciin iiiutr 199970455473 45 Vuksan v Jenkins DJA Spadafora P SievenpiperJL Owen H 39v39iclgen E Brighenti Fquot Jesse B Leiter LA BruceThompson C llltonjac mannan glucomannan improves glycemia and other associated risk factors for coronary heart disease in type 2 diabetes A randomized controlled meta bolic trial Diabetes Care 199922913919 45 Chandalia fvl Garg A Lutjohann D von Bergmann K Grundy Sivi Brinkley LJ Beneficial effects of high dietary fiber intake in patients with type 2 diabetes mellitus N Engi J Med 290034213921398 4 Buyken AE Toeller ivt l leitkarnp G iiitelli F Stehle P Scherbaum WA Fuller JH and the ElJBODfAB IDDM Complications Study Group Relation of fibre intake to HbA and the prevalence of severe ketoacidosis and severe hypoglycemia Diabetoiogia 199S4391 BB2S9i39l 49 Giacco FT Parillo tvl Fliveliese AA Lasoreiia G Giacco A D39Episcopo L Fiiccardi G Longrlerm dietary treatment with increased amounts of fiberrich lowglycemic index natural foods improves blood glucose control and re duces the number of hypoglycemic events in type 1 diabetic patients Diabetes Dare 2CiDD2314S11456 49 lltalkwarf HJ Bell FiC Khoury JC Gouge AL fvliodovnik ivl quotDietary fiber intakes and insulin reoiuirements in pregnant women with type 1 diabetes J Am Diet Assoc 2DD1 iCl13O53110 St Simpson HCFi39 Simpson F iW Lously 8 Carter FiD Geekie ivf llockaday TDB A high carbohydrate leguminous fiber diet improves all aspects of diabetic control Lancer 19B1i115 51 Beviilese A Hiccardi G Giacco A Pacioni D Genovese S fviattioli F Mancini ivi Effect of dietary fiber on glucose control and serum llipoprotein in diabetic patients Lancet 39l9BOii3944739 45D 52 Salmeron J lvlanson JE Stampier lvlJ Coiditz GA Wing AL Wiliett WC Dietary liber giycernic load and risk of noninsulindependent diabetes mellitus in women JAMA 199392i 7472477 53 Salmeron J Ascherio A Flirnm EB Colditz GA Speigelman D Jenkins DJ Stampfer MJ Wing AL Willelt WC Dietary liber glycemic load and risk of NIDDM in men Diabetes Care 1992D545559 54 Beimer FlA lvicBurney Mi Dietaryfiber moduatesintestinal proglucagon mHNA and postprandial secretion of GLP 1 and insulin in rats Endocrinoi 19399B39l3739483956 55 lvlassiminoSP fvlcBurneylv ll Field CJ iihomsonABFi Pospisil L Keelan ltil Hayek MG Sunvold GD Fermentable fiber increases GLP1 secretion and improves glucose homeostasis despite increased intestinal glucose trans port capacity in healthy dogs J Nutr 199S12B1Y8f31193 55 D39Alessio D Glucagonlike peptide 1 GLP1 in diabetes and aging J AntiAging Med 2DOl l3S293373 57 Cummings JiI Bingham SA Ileaton llltW Eastwood MA Fecal weight colon cancer risk and dietary intake of nonstarch polysaccharides dietary fiber Gastroenteroiogyaf9921IEi31F931799 53 Howe GB Benito E Castelleto B Cornee J Esteve J Gallagher RP Iscovich Jlvil Dengso J liltaaks Ft Kune GA Dietary intake of fiber and decreased risk of cancers of the colon and rectum Evidence from the combined analysis of 13 casecontrol studies J Natl Cancer inst 19928 i1BS1996 ADA Position adopted by the House of Delegates on October 18 1987 and reaffirmed on September l2 1992 on September 6 1996 and on June 22 2000 This position will be in effect until December 31 209 ADA authorizes republication of the position statementfsupport paper in its entiirety provided full and proper credit is given Requests to use portions of the position must be directed to ADA Headquarters at 8D ii39839i 7 1690 ext 4835 or ppaperseatn ghtorg Recognition is given to the following for their contributions Authors Judith A Marlett PhD RD University ofwisconsin Madis on Madison WI Michael I McBurne3r PhD Kellogg Company Battle Creek Ml Joanne l Slavin PhD RD University of Minnesota St Paul MN 1090 i July 2002 Jollurne lfl2 Number T AM REPDHTB 1goqggggg ggsg osionauguuguunq 1iovonannucancoinosoogaooutto 59 Schatzkin A Lanza E Corie D Lance P iber F Cann B Sl 1llltB M Weissfelld J Burt B Cooper MR lquotltikendall JW Cahill J and the Polyp Prevention Trial StudyGroup Lack of effect of a lowfat highfiber diet on the recurrence of colorectal adenomas N Engl J Med 290934211491155 E9 Alberts DS ivfarinez ME Kor DL GuillenRodriguez Marshall lFl Van Leeuwen JB Field lvlE Ritenbaugh C ifargas PA Bhattacharyya AB Earnest DL Sarnplirier RE and the Phoenix Colon Cancer Prevention Physicians ivetwor Lacir of effect of a highfiber cereal supplement on the recurrence of colorectal acienomas N EngiJMed 200032411561162 61 BonithonKopp C Kronborg D Giacosa A Bath U Faivre J for the European Cancer Prevention Organisation Study Group Calcium and fibre supplementation in prevention of colorectal adenoma recurrence a random ized intervenlion trial Lancet 290035613901396 62 Kim Yl AGA technical review Impact of dietary fiber on colon cancer occurrence Gastroenteroi 20001181235li25T 63 Prentice BL Future possibilities in the prevention of breast cancer fat and fiber and breast cancer research Breast Cancer Res 2UDO22S8239S E4 Adlercreutz H Evolution nutrition intestinal microflora and prevention of cancer a hypothesis Proc Soc Exp Bio Med 199821 724391 245 B5 Howe GFi Hirohata T llislop 39l39G Iscovich Jlvl Kalsouyanni K Lubin F lvlarubini E lvlodan B Flohan T Dietary factors and risk of breast cancer Combined analysis of 12 casecontrol studies JiiariCancerinst 1l99DEi25S1 569 BE Baghursl PA Rohan TE Dietary fiber and risk of benign proiiferative epithelial disorders of the breast int J Cancer 1995E33r4Eli485 6 Willett WC Hunter DJ Stampfer ivlJ Coldiz G Manson JE Spiegelman D FiosnerB Hennekens CH Speizer FE Dietary fat and fiberin relationto risk of breast cancer An 9year followup JAMA 3919922SS2U3l 2D44 BB SmithWarne39r SA Spiegelman D Yaun SS Adami H0 Beeson WL van den lBirandt PA Folson AR Fraser GE Freudenseim JL Goldbohrn i3iA Graham 8 Miller AB Potter JD Bohan TE Speizer FE Toniolo P Willett li39iiC Walk A ZeleniuohJaclquotte A Hunter DJ intake of fruits and vegetables and risk or breast cancer a pooled ar iaysls of cohort studies JAMA 2Dti1285f59W6 E9 Potischman N Swanson CA Coates FlJ Gammon MD Brogan DB Curtin J Brinton LA intake of food groups and associated n39iicronutrients in relation to risk of earlystage breast cancer into Cancer 1999B23939315321 TD Slavin JL Nelson NL McNamara EA Cashmere K Bowel function of healthy men consuming liquid diets with and without dietary iiber J Parenter Enterai Nutr 1985931l if321 7391 Fischer ivf Adkins W Hall L lvlarietl JA The effects of dietary fibre in a liquid diet on bowel function of mentally retarded individuals J ivient efic Res 19S53929339i393391 3392 Liebl BH Fischer MH van Calcar SC lvlarleil JA Dietary fiber and long term large bowel response in enteraily nourished nonambuiatory profoundly retarded youth JPEN 1990143T13S T3 Bliss DZ Guenter PA Settle HG Defining and reporting diarrhea in tubefed patientswvltat a mess Am J Ciin Nutr 1992S575339r3959 74 Bliss DZ Jung HJ Savik ilt Lowry A Lefvloine M Jensen L Werner C Schaffer ii Supplementation with dietary fiber improves fecal incontinence Nurs Fies 2CiO15D2CI3213 Y5 Scheppacih Wlvl Bartram llP Experimental evidence for and clinical implications of fiber and artificial enteral nutrition Nutrition 19939399405 76 Saibil F Diarrhea due to fiber overload N39EngiJ ivfed 1999320599 7 Cooper SG Tracey EJ Small bowel obstruction caused by oat bran bezoar N Engl J Med 199932011491149 Reviewers Carol Chang MA RD MiamiDade County Public Schools lvliami FL Nancy Emenaker PhD RD Columbia University New York NY Debra lndorato RD Approach Nutrition and Fitness Chesapeake VA 1 Julie Miller Jones PhD RD The College of St Catherine St Paul MN Cirrtcololgy Nutrition dietetic practice group Carol Frantrnann MS RD The University of Texas MD Cancer Center Houston TX Lynn Magnuson RD Saint Joseph39s Hospital of Atlanta Atlanta GA Julie A Meddles RD The Ohio State University Hospitals East Columbus OH Angela Pahl RD Spectrum Health Grand Rapids lvli Members oftiieassociction Positions Committee Wonirgroup Sonja C onnor MS RD Ch The Changing American Diet BY BONNIE LIEB1VIAI J What are Americaits eatiitg Are we DX iDW39BI39d5 tregemria diets or inciuiging in mare steak Are we gettisrtg fat an fatafrae ice cream cake and cookies or rewarding cntt39 seiares with fatladen cheesecake ic cream and pastries Are we eating more fruits and Vegatabla DI more fI39EI tCh fries Since t1 1EE I391j7 39D s u US Department of P9 139L SbEE I1 tracking the amount of food ava able fur Amexicaits to eat The nt11391 vA hers nvetwatiziiate what we acmaiiy swaiiow sime some food itever gets said some spoils and some gets left on our plate But t1teyquotre valid far yeartoyear ctmpari a1ts Every few years we use that dam to size up the American diet The quotyaclesquot look not just at what we39re eating but whether wequotre moving in the right direc on IEiei39e s our latest rep tart card Beverages D In 19 Basia became the most popular American beverage EI 39d it never looked back We now 0 rnughly 50 gallons of sodi per person per year And that dcm5nquott irtclutde the eight gallons of uncaibrmateti soda that masquerades as fruit Of the healthier beverages mil1lt frtlit juice and bottled water r y Waterquot is clearly ciimbimg The bottom line The softdtjililc in dustry keeps lling our everlarger cups with its highcalorie sugar water and we keep drinking as though there were 13910 bath room scale to get on tomorrow V A Report Card Ga ons per person per year 1 1u39 1n 10 qu gq u a 59 Cg cc 4939 i 0n mp g Beer Dairy PEt 0du cts D We39re eating only siightly less ice R than we dict 19quot390 And most of it is as fatty as it was SE1 years ago except for Ben E e1 I395r 5 and Ii agen Dazs which are eevelt fattier Pounds per person per year towFat Cmam As for cheese The s1lt3r s the limit We eat more than twice as mmit as we did in 1970 Gtease has new pa5sed beef as out nuJnbei39 one source cf saturated fat Pizza and ciiieesw burgers started the mend back in the 1959s But now cheese is everywhere 1311 your ta05 and naclws your soups and salads yuur rice and potatoes your chicken and anti your arteries Flour 8 Cereal B We3952 ea ng more ame than we did in the 19705 in the 135 our mearts wheat Some goat int3 breads bagels pasta and pancakes some aids up in cakes ctctkies Cinnabotts doughnuts and other sweets Pounds par person per year 1413 13 T 3 I T 3 White 15 What tment Fiour nu Px SW Are all those caxins making us fat You bet they are e along with a ne fat protein aind alcoh l we scarf down And only a tin fracs tion at the wheat our is quotwholegrain the Ircimii that may help lower the risk of heart diS ease and iabetes Added Fats 8 Oils B The big trends sets aradeiis are clear Sillce 19 we39ve been eating slightly less butter and margarine more shortening and much Inore oil Paunds pcr parmn per year Tetel Added I ms 5horLenJng Shortening bu er end some mergarina have setnzrated or trans fat which citgs arteries Oils don39t But all fats have ca1cm39esend that39s one thing we don39t need more of Seme people blame America 3 nbesity epidemic on e lowfat diet see Big Fat Lies Novembsr 2002 Can you find the 1sw f39at diet on this graph Sweeteners F We now produce 152 pounds sf addedsug are each year for every man womet1 arid child in America That39s 25 percent more than in 19D Soft drirtlcs account for a 39l u39rdl of our W MT called quotfrLit S supply another ten percent while con des cakes end other Ewes baked goods coniribum 14 PEICEEHZ 5K you Mrs Fields and Cixmaben Cenc13r breakfast cereais and ice cream each chip in about ve percent Does me tiny dip in 2000 signal the end sf our runaway sweet tooth Smy N Pounds per parses per year we 39 0 K SugarCernyrupetcI we 5 140 Article 1 The Changing Amesrican Diet Meet Poultry 82 Seafood B Beef end perk were neck ar1dneck for the first hsIf ef the Z lth cenfury But in the 19505 beef sense a steep climb that peaked in the e39s39Ld19 s Chiclcen39s growth keeps C1i1Ck ing along But we still eat far more red meat 111 peuhds per person than pcmler and sea food 873 pounds each year g Pmme39 per person per year 3 g A 7 8 my rah E V sw V 39 Iquotquot5 50 3E Pork us 7 V 67 39 39 quotff quotsquotquotquot39er quot39 quot sf C3 7 HH 39 Na 39 Chicken 5 L2 J E r 7 N Hm ssnrmsh T p 5 jui m f A N 39 7 V ft g nniw 46 Fruits 3 Vegetables A We e eating more ixim ancivegetables we did 30 years ago On the upswing are bell peppers bmccsli sewers cucum t39 eIs mush moms erulens spiruech squash and tometees but not brussels sprouts cabbage celery or sweet pctetoa Also rising ems bananas grapes mangos melons papayes peers pineapples and strawbercies but not apples eprico cl1e39 ties grapefruit oranges peaches cuplums We s ll dcn t eat enough fruits and vegembles but at least were moving in the right direction Pounds per person per year am 3 Tsmtsms 5 E 95eE1 is 39 I T p pr L V39 E quot 39iquot39v v jg K 9quot quotK 225 wk r quot39 39 n quotEa 4 quotHis Tots Vegetables E Em Eexcept otatazc E 39 Mi1k C Whole mill is down that39s goad Se is as c1uced fat 2 percent milk also ggodj But lowfat 1 percent and slcim fatfree aren39t replacing the fettier m ks And we shill more than twice as much of the ewe fsttisg milks than their two iowvfat ceusins I t3a fons per pperscn per year Heather Isms Demfsc helped cempiis the information for this article Seurce Economic Reseerch Service US Depertmsnf of Agriculture To access the USDA s per capers food consumption detsbsse areline go to eiwzsesusdagsedafsj odconssmption From Nutrition Action HesEb esEer December 2002 by Bennie Liebmasl opyright ED 2002 by 39i39he Center for Science in the Pub ic Interest Reproduced with permis5ien of The Center for Science in the Public Interest in the format Textbook via Copyright CJearance Cer1er 3 I O Namm Without using your text label the parts of the GI tract Fig 131 Major regions of the stomach juhiuq 4 0q Tcm a u4 LJ IQ Wsr hitJ H 113 um w 0 2iLmmWa w p fn wTrwmaWWmLuuunJuw r I m rmw munx T 1AvX1a U J u 31 nu Trmsni n m F 3 Pyloric sphincter D ccanal U Q E fl E d r a C EsDphagusT Duudenum K1 Pyl Pyloric regiun 1 nm cmg 0 S math 1 Smaif frbi7r Castricpits T ax 1h aaaa d K ai wa1 EAT 1 quotquot k k r II I IquotI1gtCD L157 cells Parietal Cells pepsinogen Muscle e I 5 ubmucasa r Micrnvilli on Capillaries epithelial cells Vein Lymphatic 0 M i mLlscle quot A rfnanr y39 re5saI E smmnth 31 3 i 5 Mt P H39 v r39i1r3t3i par tirm 3quot C833 ai 39em3939a 1E T N inmt5 ms fV Oumde Gf CE m Wa r3t u E seia taWe5 mro amaj gut Gftha Cei Ptariz 421 quotzamazLrz aquotyquotfE39 r 1ji1 quotliZW sEI gQ SfE i t wa er ltiLaTE 39 SL tlitafi H 335 hraLg Em m rTuEme1sE A 0iigoacchiaridamp side cfrairw v 9 GJW rfd Glam e r 39nwe6 ip lnteg mi pmt2ei 13 Phcshol39EpEd Pe herai membram prstein iiLhart 1 T aa 3FaCc39 the meer1ae iz3 st3bifi 39g39a 1tJ V reqmgzleiws rresa39 a 39anEamp Ir 1side cf CeEl u gW s Wadswngthf Cangaga EaarVrxErg Fig 13 p 3 Table 54 I DAILY SECFIEEWON OF INTESTINAL JUICEIS Daily Volume ml pH Samiva 6070 Gastric secre on 1035 Pancreatic secretion 8083 Bile 78 Small Intestinal secretion 1800 75 A 80 Brunne s gland secration 200 8039 Large intestinal secretion 20 7580 Total 6700 Vega center 01 maduila m Cephalic phase uiavag rs T T Pararsyrnpatha m excite Fund Secretory 0 j M papsinand aaid pmdu1inn t m j fiber Afferent Vague Z T A P j G sntdgphase nP P f 39ELmaIranruu5 flb f mink Local nerve xx T sacretury re exes plgxug i 2VagaIIfaIlaxes Pf T T d V 3Gaslrm stimuiatunn quot T Circulatoryquot system ilntastinal phase 1 Nervous mechanisms 2 39Hunnunal machanisrna Te smclll infes ne Figure 33 p 69 Mesenfery 1H hW5 ar M5 V445 Serosa Longimdinc musc e Circular muscle A submuw r Mucosm Wardlcxw 8 Inset Perspectives in Nutri on 1990 Times MirrorMosby Co ege Publishing i39quotquot39F 7 0 T Serosa 1E 39 H L f V a gt V r 139 quot 39J Longitudinal muscle 15 P Q Subrnucosa N E T Meissnefs N nerve plexus quotVquot 3 Epithe ial T lining ril 7 Muscuiaris 39 39 rnucosae 39 39 e 9 1 939 gt 7 n 3 quotP 3 J I A L Myenteric nerve plexus Mk H K 4 1 gin V 39 quot 391 I T a I 39 in cquot3 IA3939l o 39 T Lnquot Mucasaf gland Submucosai gland Mesentery Figure 522 Typicaf drosssection of the gut Unstirred water layer Unsiirred water layer Cytoeolit compartmebt of Intestinal lumen ovedying microviiii intestinal epiliielial oails r i Biia salt m ioaitas or vesicles Figure ri e2 the role at lode salt mieelles in ove39r coiniog the difmsionl barrier associated with the unstirred water iayer in the absence of bite salts I eniy39 a limited number of lipid molecules difftise tlwrottgli the tmstirred water layer to be taken up aczross the brasi1bolrder membrane of the enterocytes in the presence of bite salts r 239t more lipid melectuzies can be clainrared to the bruisleborder membrane by bite salt micelles importance of giyrcoproteias quotThe brush border membrane corltains many embedded glycoproteins that extend from the membrane into the lumen The carbohydrate side chains ofthese membrane glycoprote39ins makes up a glycocaliyx next to the brush border membrane itself this glycocalyx acts to trap water and to form an quotquot39unstirred water layer near the absorptive surface Many of these glycoproteins are digestive enzymes Stipanuk MH Biochemical physiological molecular aspects of human nutrition 2 ed Saunders Elseuieir 2006 Carbohydrate digestion Mouth and esophagus Most digestible carbohydrates are polysaccharides and dissachharides The mouth releases salivary oramylase The enzyme only hydrolyzes on l 4 glycosidic bonds in starch amylose and amylopectin and maltose producing a few free glucoses in the mouth Furtlrer digestion of starch occurs in the esophagus resulting primarily in ulimit dextrins and some glucose maltose and maltotriose maltose 005 rnaltotriose 3500 oelirnit dextrins Part ofa glycogen or starch rnolecule Structure of a branched starch molecule and the action of uamylase The circles represent glucose monorners The black circles show glucose units linked by u l6 linkages at the branch points The at l6 links and terminal ol 4 bonds cannot be cleaved by oramylase Stomach Food in stomach or thought of food increases gastrin by G cells resulting in the increase of HCl by parietal cells Mechanical digestion mixes food with gastric acid forming chyme cr Amylase continues digestion until denatured by HCl Intestinal lumen Majority of digestion occurs in the small intestine Mechanical continues When chyme enters the duodenum secretin stimulates the release of NaHCO3 and CCK stimulates the release of pancreatic amylase l ancreatic o amylase is released into the upper duodenum Chemical digestion takes place entirely in the upper small intestine Amylase I maltose and maltotriose n amy39lase further digests maltose and maltotriose to glucose at a much slower rate Amylopectin orlimit dextrins maltose and glucose Digestion at the brush border Enzymes found on the brush boarder are responsible for digestion of carbohydrates to absorbable free rnonosaccl larldes These enzymes include rnaltase sucrose lactose glucoarnylase and lsomaltase also called oedlextrinaese Maltase hydrolyzes the n 4 glycosidic bonds of maltose Suerase cleaves o39l 2 glyvcosidic bonds of sucrose lLac tase cleaves 3l 4 glycosidic bonds of lactose Glucoarnylase cleaves nl4 glycosidic bonds of maltotriosesr and olirnit dextrins releasing glucoses at the end one at a time lsomaltase cleaves the nl 6 glyoosidic branching points of ctlimit dextrins Maltase Maltese 9 glucose glucose Glucoarnylase lsomaltase o dextrlnase rnaltase 3 5 glucose units 29 glucoses Gr2c0amyZase cleaves c glucosels or end I or or rinse ct 4 4 Isomaltase alphas dextrinasej breaks or 36 bronchfnggprs Sucrase Sucrose 9 glucose s fructose Lactose Lactose 9 galactose glucose maltase glucosarnylase isornaltase or dextrinase Q unit sucrase complex End products of digestion are glucose fructose and galactose Monosaccharide absorption Lumen capillary GLUT5 c GLUT2 SGLTT1 tr Nat A 2 Na ATP AMP 1 Na tK t AT39Pasle lg 1 or I galactose intercelluilar space a Schernatic representation of hexose absorption in the human intestine Fructose is absorbed into the intestinal cell via facilitative diffusion requires GLLJT5 transporter no energy is required The rate of fructose absorption is slower than glucose or galactose In contrast glucose and galactose are absorbed through active transport Two sodium atoms are preloaded onto SGLT1 then one glucose or one galactose may bond to the transporter After absorption into the intestinal cell sodium is pumped out via llaquot39lltquot ATIFlase that converts ATP to AMP Facilitative transpo rt of GLUT5 and GlUT2 require the sugars to go down the concentration gradient Glucose and Galactose absorption SGLUT 1 binds two lquotla and then one glu or gala 2 Glu or gala absorption is driven by low intracellular concentration of Na 3i This is active transport because ATP is converted to AMP when pumping l la out of the intestinal cell through LNallt ATPase The Na is pumped into the interstitial space 4 GLUT2 facilitative diffusion moves gluc or gala to capillary following the concentration gradient 5 The concentration of gluc and gala is low in the capillary Fructose absorption 1 Fructose enters the intestinai cell through tacijlitartiwe via GLUTE This is due to the lower concentration of fructose in the ceii 2 Fructose absorption is at a much slower rate than glucose St galactose absorption 3 Facilitative transport is used to move fiructose out of the intestinal ceil and into the capillaries via GLUT2 Again fructose is mowing down the concentratiion gradient Common name of fatty Name by numbers acid indicating components Saturated fatty acids F0mic 1 Acetic 20 Priopiionic 3 0 Butyric 40 Valerie 50 Caprioie 60 Caprylic 80 Capric 100 Laurie 120 Myristic 1 40 Palmitic 1460 Stearic 180 Lignoceric 200 Unsaturated fatty acids Labelilqg COOH end Labeiing CH3 end Palmitoleic 161 A9 07 Oleic 181 A9 09 Vaccenic 181 A11 co Linoleie 182 A912 06 01 Linolenic 183 A91215 033 Arachidonic 204 A581 114 036 Eicosapentameic acie 204 A581 11417 033 Docosahexaenoic acid 226 A4T731 0L1 3316319 133 Please note that 033 can also be designated as I13 etc m e Q I m t2 It Ia tJW3 I v4 Fw I imam um I39 U f x no2 u MI mm L I aA a Omega6 fatty acid metabolism linoleic acid 182 n6 Dihomoylinolenic acid T eicosanoids 203 n6 4l ArachidonicAA rgt eicosanoids 204 n6 Linoleic acid and orlinolenic acid are precursors to longer PUFA need for cell membranes Additionally they are converted to eicossnoids Functions of too PUFAs include the 1 orn1atio11 of phospholipids used for signal transduction sphingolipids skin water barrier and eicoisanoids I16 Eicosanoids have many functions blood coagulation inflarnniation modulate vascular resistance contractionrelaxation and blood pressure Omega3 fatty acid metabolism d lir1oleni c acid 183 n3 ElCOSaD l itaElquotl0lC acid EPA fr eicesanoids 205 n 3 Dowsahiexaehoilc acid DHA igt docosanoids 226 n3 Purported functions of omega 3 fatty acids to Make up large portion of fatty acids in membranes of brain and retina Believed to be required for neurological de39uelepment and visual acuity 0 Required for norrnail growth and development 0 May he related to preventiontreatment of heart disease arthritis or Cernpetes with n6 arachidonic acid incerperratioh into membranes thus less arachidonic acid available to make n6 ElCOSilquotiOidS 0 n3 eicosinoids are ahtithrornbotic and arlti inflammatery 0 n3 docosaneids are antiiinflaimmat0ry Lipid digestion and absorption Mouth and stomach Grinding and churning releases hydrophobic substances from food Triglycerides TG these are the major fat foulnd in food 1 50 gday on average Phospholipids PL about 2 of fat in food Cholesterol ester CE about 300400 mgday Fatsoluble Vitamins vitamins A D E K Lipid droplets are created by stomach peristalsis and exiting through the pyloric valve Enzymatic hydrolysis a small amount of short chain fatty acids SCFA and medium chain fatty acids MCFA may be released from TG via lingual lipase an enzyme release from lingual serous glands at back of tongue and gastric lipasel These enzymes play a stronger role in the digestion of lipid in young infants Duoclen u m Presence offat stimulates release of cholecystokinin CCK and secretin from the intestinal rnucosal cells into the Vascular system Secretion stimulates the release of sodium bicarbonate from the pancreas CCK stimulate the release of the lipolytic enzymes from the pancreas and stimulates the gallbladder to contract and release bile Bile is synthesized by the liver and stored in the gallbladder Bile salts hydrophilic side out coat the lipid droplets thus emulsifying them and preventing formation of larger droplets tat droplet emulslflcation 0 p bile salt 1 mRemukmn dmpbm Emulsification of fats by bile salts and lecithin greatly increases the surface area available to the fatesdigesting enzymes Lecithin is a phopholipid aka phosphatidylcholine round in large quanitities in cell membranes litid content in recess cotttinues throuhout 1l3l3l1lIttIII1 witl1l aduall dBClquot39ampSil f Duodenurrl cont The pancreas releases the lipolytic enzymes and coalipase and they enter the ClL10d6I1ill1 I1 via the sphincter of Oddi Colipase is not really an enzyme but a small protein that penetrates the hile salt layer thus opening it tip so that the lipolytic enzymes can access the ester bonds of triglycerides phospholipids and cholesterol esters Enzymatic hydrolysis these are all esterases S39ubstrate enz me Q1 JiZl11Ct Pancreatic lipase Triglyceride morioglyceride 2 fatty acids major glycerol 3 fatty acids minor Phospholipase A2 Phospholipid i it lysophospholipid fatty acid Cholesterol esterase Cholesterol ester it cholesterol fatty acid Retinol esterase Vitamin A ester vitamin A fatty acid MiceIle formation Excess bile salts and bile acids released from the shrinking lipid droplet from micelles Micelles are small packs of bile salts that have hydrophobic and hydrophilic properties and the polar products of hydrolysis monoglycerides fatty acids cholesterol lysophospholipids etc penetrate these small packs of bile salts and arrange themselves so their hydrophobic portion is on the inside and their polar groups stick out This is a mixed rnicelle Structure of mixed micelles i it iiiiii ii 39 bile acid cholesterol free fatty acid 3 phospholipid i 2rinorioglyceride The mixed micelle can pass through the uustirred water layer and glycoprotein coat because of the hydrophilic properties of bile The mixed micelle disaggregates at the mucosal surface The digestive products of fat monoglycerides fatty acids cholesterol fat soluble Vitamins etc diffuse into the mucosa cell Lysophospholipid is hydrolyzed by membrane phosphatases to glycerol or monoglycerol phosphate and choline or ethanolamine and these products diffuse in Bile salts migrate back to the lumen for additional emulsifying and micelle formation see next pass ileum Bile salts are absorbed by active transport and returned to the liver via the portal vein This process is called quotquot enterohepat39ic circulation of bile salts Events within the enterocyte Water soluble component like short chain fatty acids SCFA and glycerol diffuse into capillary blood gt portal vein gt liver There they can be metabolized into products that can be stored or transported to other tissues Monoglycerides MG and most of the cholesterol are reesterifred with long chain fatty acids into triglycerides and cholesterol ester These fat droplets including the fatsoluble vitamins are covered with a protein coating and reesterified phospholipid is inserted in the protein covering These coated particles are known as the lipoprotein called chylomic39rons Chylomicrons are excreated out of the enterocyte into the intercellular tlluid and diffuse into a small lymphatic collecting duct called a lacteal The chylomicrons travel through progressively larger lymph V6SS lS to the thoracic duct that empties into the subclavian vein Chylrnicrons are then carried to peripheral tissues such as muscle and adipose Unstlrrecl water layer W Unsiirred water tayer Cytosoiiic totripartment of intestinal iumeu overiying microvtlii tinlestinat epithelial cells 1 if i W Bite salt micelias or t yesmtss t 3 d 2 Figure it 2 39t39he role ot bile sail rmceites in overcoming the diffusion trarrier associatett with the unstirretl water jiayer in the absence of bile salts LL only a limited nttiriber oi lipid momcules diffuse through the uristirted water layer to be talaett up across the b39l LISl1vlJOl t it39l memlrratio of the eaterocytes in the presence of bile salts t2 more iipid rnoiecuies can he deiiivereti to the brusti i39norder membrane by bile salt micelles Absorption at Brush Border g 1 0120 or less SCFAs MCFAs 3 SCFAsIMC Glycerol Gnycemn Capiliaries Re esterify WIG 739 MG 1 Covered with 1 TG L FA5 i0 FAS gt1012 C long Lysphosphoiipid yP FA e PL 39 Fat soluble vt E in Vit A 3 FA 9 VitA ester Cholesterol diffusion mmsmmz uumnmmco E mm nmu new mmmmmgt too mEm 96 mumucsm mu mm oum co mmmmixm m E mm9gtuoom wgt mmm Tmgt Egt B 3 Eu mumltlt mommoxw U5 naoma u CCw Eu msocmmoxw mmmmxuma Eu up 9 0 wk E H DE mmmm 3 gt9mu Lmgtmn 28 mo Eogtru Recummended grams g of pmlzein per kg 0 body weight far various athletes V 0fA 11ete V T T Suggesjted ProtcinRequiEiiient T Rcg1 arExcrciser 08 12gkg Endumncc Athlete 12 14 l Sr1EngthA1h1ete 1 18 gfkg A Comparisnn 0f PmIein Requirements for the New athlete Regular Exerciser and Atllglete Cate go A T Weight Pmtcin R oriimenda on Nor1 athletc 72 kg 3 08 g pmtcinkg 39 53 g of protein Regular exerciser 72 kg 4 10 g protein cg 2 72 g of pmtcin Endurance athlete 72 kg 1 L2 g pmtein cg 86 g ofprotehi 1 Strangth athlete 72 kg at 17 g prominfkg 2 122 g of pmtein Types of Vegeta ams Type Foods Eliminated fmm the Diet Vegan Meat fish poulny eggs pmducts and animal products such as honey and gala n Lactovegeta an Meat fish poultry gs Ovavegetanlan Meat sh poultry dairy products Lacto ovovegetarian Meat sh pouluy St391iveget3ri3n Malt bmirrr1ndP ltrm1H arrmmnr of poultry andor fish I E Limiting Essential Amine Acids in Plant Proteins Plant sprmein LL Limitinmminn Acids Legumas beans peas1em s Mc onine ufyptophan Grains Lysine isolcucine ueonine Nutsfseeds Lysine isoleucinc Nutrients At Risk for the Vegetarian Nutrient Vitamin D vimmin B12 calmm Cnmyii tifs and Rich Plant Food Sources D de ciency results in xickcts Vulnerable popula oans include and children While Vitanlin D may be synthesized by your from the sun food soumas include ford cd foods such as ceztgls somn k and rice J Vitamin B12 de ciency mm m in a type of anamia ca ed macmcyljc anemia Vu narable populations inc1ude vegan mothers and their breastfed infaxxts Snurces ofBu12 include for w cereals soym k meataI1alDE1 1cs and nutritional casL T J Iron de citrmcy IBSUHS in a type of called nrzicrocy c ancxnia Vulncrablc papulatiorns include infants mm and females during reproductive periods Sources sf imn include beans whole enriched and for ed and dried fruit Vitamin C also enhances imn absorp on if CDI1SIlII16ddl1LIil391E the same meal as V J i Calciuxn is needed for proper n and has been lir ccd with osteoporosis Vulnerable popula cms include infants chi1dxen and teens and women Sources 01 calcium include broccoli kale greens spinach forti ed fwcls p soy producm Protein Digestion and Absorption Mouth and stomach Grinding and churning mechanical digestion of food There are no salivary protein digestive enzymes Gastrin stimulates the release of HCl from the parietal cells HCL has 2 roles 1 HCl denatnres the 3din1ensiona1 shape of food protein and thereby aids in digestion 2 HCl activates pepsinogin to pepsin Chief cells secret pepsinogin Pepsin is a protein digestive enzyme that cleaves large polypeptides into smaller polypeptides beginning the process of digestion Small intestine The presence of food in the small intestine stimulates the release of secretin Secretin stimulates the pancrease to release bicarbonate and pancreatic proteolytic enzymes The pancreatic proteolytic enzymes are released in their inactive form zymogen form enterojkinase Q Q p Chymotrypsinogen I T 5 Chyrnotrypsin V Procarhoxypeptidase ux Carboxypeptidase Proelastase P Elastase Enterokinase a small intestinal enzyme starts the process of activating the inactive protein digestive enzymes Enterokinase activates Once trypsin is formed it activates all the other inactive protein digestive enzymes There are three phases to intestinal digestion and absorption of protein 1 luminal phase 2 brush border phase 3 cytosolic phase 1 Luniinal phase This phase involved digestion by the activated pancreatic protein digestive enzymes typsin chyrnotrypsin etc During this phase the polypeptides are digested into single amino acids dipeptides tripeptides and oligopeptides containing up to eight amino acids pancreatic enzymes Polypeptides 5 Single AAS Dipeptides 3 8 AAS 2 Brush border phase The brushborder phase involves the digestion of peptides by the brushborder enzyrnes and the absorption of the end products of single amino acids dipeptides tripeptides Dipemsg Enterocyte Am tidase Digestion amp Absorption at Brush Border Absorption of free amino acids dipeptides and tripeptides occurs by active transport Dipeptides and tripeptides are absorbed more efficiently than single arnino acids due to competition for carriers There are four types of carriers for single amino acid absorption into the intestinal cell 4 carriers for single amino acids 1 nentral amino acids 2 acidic amino acids 3 basic amino acids 4 proline and glycine 3 Cytosolic Phase The last phase of protein digestion and absorption occurs in the cytosol ofenterocytes Any dipeptides and tripeptides that were absorbed are cleaved into single amino acids Only single amino acids enter the capillaries to e carried by the way of the portal vein to the liver Enterocyte Dipeptides 3 a 8 AAS e W mp i a G 0 p 0 0 0 p 3quot 39 quot39 Ports vein Digestion amp1 bsor ptiorI I I idol aiitin Cytosol Lwer at Brush Border AAAAAA Overview of Metabolism Reduced fuels Glucose FAS glycerol Cskeletons of AAs 02 Metabolic 0xidaticm Glycolysis TCA Cycle lA oxidation AA oxidation C02 H20 Duel regulation of triglyceride in fat cell via lipoprotein lipase LPL and hormoneasensitive lipase HSL Chloicro 9 k 6 I n 1 gt 3 Glycerol 3 Fatty acids Q TG is composed of a 3 carbon backbone and 3 fatty acid chains Insulin upregulates Lipoprotein Llipase LPL Insulin stimulates the deposition of fat TG into fat cells GluegonEpi11epherine stimulate Hormone Sensitive Lipase HSL These hormones stirnulate lipolysis TG are removed from fat cells Fatty Acid Oxidation 1 Lipolysis and delivery of fatty acid to tissue 2 Oxidation of fat for energy 1 lipedysis and delivery of fatty acid to tissues Most common tissue is the muscle F I I TG blood Muscle 139polvsis Q TG Glycerol 3 Q3 1 was 39 z imited fatty acid aIburquotmr391 I Fattir acid used for energy CD2 H20 ATP A 2 Fatty acid oxidation to make ATP a fatty acid must be activated in eytosol COA fatty acid fatty acid COA AT 9 P Pi costs 2 ATP b Transport of fatty aeyl COA from cytosoi into mitochondria Via C I I 1itii iE Cytoplasmin Mite membrane llrmer matrix FAECOA camitine V eFACOA Carr1itiane FA CoA CQASH aesume fatty acid is palmitic acid C breakdown of fatty acid into 2earben fragments aeetyi COA palrnitir acidCOA i60 FAD it FADHg i P 8 aeetyi Co A Fatty acid oxidation Beta Oxidatiori NAD lt lt lt lt NADHE j d Acetyi C0A s enter the Kreb s Cycle erg paimitic acid can yield 106 ATPquots versus only 3032 ATP per gluonsee E4 cu G E U 0 G 9 w REm V 3 um cumuc mmmmmoo 30 mo S9gt o Emonmmbgt wuumo wmwgtmum Eoomm To3wmou wmwgtwm 8u 06 25 oU Am 26 M mmwu o 6 m8Bmgt Ketogenesis in the Liver Large amounts of fatty acids and low amount of Carbohydrates ie starvatiovn uncontrolled diabetes prolonged exercise T1 FAS some AAS 1 fatty acid doxidation spontaneous TTAce1yI COA in acetoacetate 1 3hydroxybutyrate The ketone bodies acetoeoetate and B hydroxybutyI39e te I acetone Lipogvenesis 1 Synthesis 0f fatty acids liver ontyt 2 Synthesis of triglycerides t fatty aeid synthesis acetyl COA gt fatty acid Excess Am Gtucose Ace39tyl COA Alcnhon Partially oxidized quot Fatty Acid Synthase Aeylt Carrier Protein ACP I tfitami nszl H 0 Pantothente eidt u i Fatty Acid Paltmitic Acid 160 ssetm P P Niacin NADPH2 W1 1 aim 1i I p 2 Synthesis of triglycerides need to activate fatty acids by adding COA G i I t P f t d C 9 sycero gt g ycero N a t act DA e V V quot 0 C CHZWCH3 lC OH O 0 P Fatty acid CoA O quotU 700 0 O 0 ooacquota Fatty acidCOA p CUA Ee FA E3 FA C FA triglyceride Table 2 CharaCteri cs and functions of the plasma Elipoproteihs characterfs39tt39s cfasses of pqprotefns a chytomfcmn VLDL Di t D HDJ detnsftyg gm mI lt35 951006 10064019 1 01 91 963 L063 I 2 0 etectrophorelic nrigin preB pre ta E B at mogbifity Urigin intestine ver and En rtrcLtlatIon secondairy to catalmiism Intestine of other poproteins Fiver ver War rtd intestine fphysiotogical rote transportpf tra spart of LDL major rev rse dietary endogenpus precursor chtIesterdl chol este7m trfghrcertde trigiyceide transport tran pon V lipoprotetr1 39 relative U 9 negatively atherogenitzity correlated with atheroscie asi 5 Composition triglyceride 90 EL 40 10 S chofesterol 5 12 30 50 2039 phosphotipid 3 IE 20 3915 23 prcmteltn 2 W 10 25 50 major apolipoprotetns A4 B1 00 84 DD S1 00 AI AW CW E AIf B48 CM CI CW CH E CW ax f FIGURE 3gt8 Eamb cainrimeter A food substa tn the ignition wires and piaced i 1 u er severai atmospheres of D p was nce is attached rs re chamber Jrassure The ex osively The V V sgmpie is than ignited and bu pi 39 39 V A V stirrer distributes the heats combustion uni 39 forirnly thr ot1 bout the water surrounding the IE V her he tharrnometar detects the heat re 39 I13 QUE Wilt BBBBB BI quot V V 39 saunas Based rm M Klaiizer 1961 Grass Er39 r393VaJr K cal3 CHo 2 Is 1Drne39n 555quot Df 5 577 gt S erw Vain quot IL V a I B 4 O QRL0 13130 qsl3 T 1 CHD 490 4 m Ece5 Pquot quotM Ito Fad 90 4 n1 Se V q mL l aJaoIa 1bifner j H39w 6reV ct1u1 C i 3 39 93 E 3d c 7fEL y Amgt113 nutrition science metabolism diet design and develop ment dietary supplements nutritional genomics food sci ence critical thinking and research study design execu tion and analysis including statistical analysis Additionally a social science base must be laid counseling skills relating to diet exercise other lifestyle choices and genetic counseling will be essential with competency in psychology bioethics and public policyn1aking desirable Many dietetics professionals specializing in the practice of nutritional genomics will also need to develop business skills such as those needed for operating and strategically developing a pro table business leg accounting nance and legal aspects marketing and selling and managing personnel The American Dietetic Association can share in this monumental task by considering Ways to support the growth of the field and the evolution of skills needed for functioning in myriad practice venues Although it is unl tely such a breadth of expertise can be acquired during the undergraduate years alone uni versity educators should incorporate genetic concepts and an evidencebased approach to the scienti c disciplines into their teachings wherever possible Additionally fos tering a lifelong approach to learning is essential partic ularly in a eld that is constantly evolving Students should be encouraged from the beginning of their aca demic tenure to assume responsibility for their career preparation and for developing independent study sltills that will serve them Well throughout their careers To assume the leadership roles envisioned for dietetics professionals within nutritional genomics graduatelevel study is required Further such study must be multidis ciplinary Research projects that foster collaboration with investigators in geneticsrelated elds outside dietetics should be encouraged For those planning to develop life style counseling practices that focus on nutritional genomics an advanced practice credential that combines graduate study a supervised practicum and a certi ca tion exam is highly desirable A list of suggested re Glossary sources for further study is listed in ll39igur e ii A recent article by Skipper 28 compares the needs of emerging dietetics professionals to those of advanced registered nurse practitioners Such an approach should be consid ered as the next step in preparing dietetics professionals to assume a more vital role within health care The Amer ican Dietetic Association can play a key role in facilitat ing such an evolution of today s dietetics professionals lllcuvcLusIuNl The farreaching potential for nutritional genomics is the prevention of dietrelated disease It is highly likely that during the next decade the nutritional supplement and functional food industries will experience robust growth in response to advances in nutritional genoinics research and its applications Parallel to this growth will be im pressive progress in understanding the speci c in uence of certain food components on metabolic pathways and their role in health and disease It will become increas ingly less expensive to generate genetic information about individual persons and such data are likely to rede ne the current concept of preventive medicine Die tetics professionals have the potential to harness this information and in uence health promotion and disease prevention on a global scale For these reasons the die tetics profession has an exciting opportunity that iiquot seized and properly executed could enhance the scientific foundation of clinical practice increase the therapeutic value of interactions with clients and substantially im prove the economic status oiquot practitioners The future of dietetics is unquestionably intertwined with nutritional genomics The authors thanl Philip R Reilly MD J D for helpful input and Jill Shaman MS RD ELS for scienti c Writ ing assistance in the development of certain sections of the article Glossary of nutritional genomics termsa 2931 2iJll3 American Dietetic Association Used with permission Allele Cytokine DNA sequencing Gene Gene expression Genelic counseling also called a carrier One of the variant lonns of a gene at a particular locus or location on a chromosome Different alleles produce variation in inherited characteristics such as hair color or blood type lo a person one form of the allele the dominant one may he expressed more than anoilher lonn the recessive one A protein or peptide that is outside the cell and serves as a communication signal to cells Examples are lnlerleukins intenerons and tumor necrosis factors that facilitate lhe inflammatory response The process by which the exacl order of the base pairs in a segment oi DNA is determined A segment of DNA that contains the information necessary to make a prolein The process of convezrling the information encoded in the DNA into RNA mend mile and rnhlnl most genes are transcribed into molds and ultimately into a prolein product A shortterm educational counseling process lor persons and families who have an inherited disease or who are at risk lor such a disease Genetic counseling provides persons with information about their condillon and helps them make informed decisions The sum total of all the genetic information in an organism its lnstruclion pools ihe blueprint that directs the The genetic makeup of a person as opposed to the phenotype which is lhe physiological manifestation of the Genetics The study of inherllance patterns of specific trails Genome development and functioning of human beings and other organisms Genomlcs The study of genes and their function Genotype genotype and its expression Heterozygolelhelerozygous Possessing two diilerent lorms of a parlicular gene one inherited hum each parent a heterozygous person is 596 Flpril 2005 Volume lll Number cl Glossary Glossary of nutritional genotnics terrnsa 2931 continued 3 llydroxy 3ivielhyl GlutaryICon HMGCon reductase Homozygotelhomorygous Human Genome Project Locusrloci ltiletaboomefmetaholomics l il39lonogenic hlultitactorial Multigenilc llutrigenetics Nutrigenomics llutritional genomics ilhenotype Polygenic Polymorphism Proteom efproteomics Signal transduction Single gene disorder Single nucleotide polymorphism Still Trait Transcriptomeitranscriptomics Key enzyme in the synthesis of cholesterol and a target or the static class or cholesterollowering drugs Possessing two identical forms oi a particular gene one inherited trorri each parent no international research protect to map each human gene and to completely sequence quothuman Dhlh the goals oi the project have expanded overtime to sequencing the genomes of other organisms and to identifying the products of human genes and their functions The actual physical position or a gene or marker on a chromosome a kind of address tor the gene The metabolome is the sum total of all the rnetabelites in an organism rnetabolomics is concerned with the identification or each metabolic pathway its metabolic products and their role in the organisms tunction A characteristic only influenced by iniormation from a single gene A pattern of inherited characteristics such as physical traits or diseases that results item the interaction oi genes and the environment it characteristic resulting from information contained in more than one gene The study of the mechanisrns by which bioactive dietary components communicate with the genetic material and how genetic variation affects the interaction between these bioactive dietary components and the health and disease potential pi a person Concerned with the effects or bioactive dietary components on the genome proteome the sum total of alt proteins and metabolome the sum or all metabolites at a global population level The study of how dietary and other liiestyle choices influence the iunction or living beings at the molecular cellular organismal and population levels includes nutrigenetics and nutrigenomics The observable traits or characteristics of an organism such as hair color or weight or the presence or absence of a disease Phenotypic traits are not necessarily genetic Characteristic resulting from the combined action of alleles of more than one gene eg heart disease diabetes and some cancers Such characteristics are inherited but they depend on the simultaneous presence of several alleles which typically results in hereditary patterns that are more complex than those of single gene traits A common variation among persons in the sequence of DNA technically a locus is polymorphic when two or more of the alleles at this locus are present in gt1 oi the population A proteome is the sum total of all proteins coded for in an organisms genetic material proteomics is the study or the full set of proteins encoded by a genome their identity and iunction Process by which chemical or physical messages are communicated between the surface of a cell and its interior in a step wise manner that results in a response by the cell no inherited condition caused by a mutant allele at a single locus in the hits such a trait is monogenic eg Duchenne muscular dystrophy and sickle cell disease a genetic variation caused by a change in a single DNA nucleotide most oi the variation among persons is due to SilPs the number of ditierent SNPs in the human population are thought to be in the millions SNP is pronounced quotshipquot A characteristic associated with a gene that can be guantified or described such as eye color flower color height intelligence or the presence of an enzyme A trahscriptome is the sum total of all the transcribed messenger RNA in an organism transcriptornics is the study or the full complement of activated genes menus or transcripts in a particular tissue at a particular time heprihted from ij2QilC3 Btltiiinmerican Dietetic association Used with permission References 1 Ordovas J Genediet interaction and plasma lipid American College of Cardiology Annual Scienti c Session Bethesda MD American College of C3ardiol responses to dietary intervention Biochern Soc Trans 2002306873 Ordovas J Corolla D Serkaleni D Dietary fat intake detetanines the effect of a common polytnorphisin in the hepatic lipase gene promoter on highdensity lipopro tein metabolism Circulation 200210623152321 Chasnoan DI Posada D Subrahmanyan L Cook NR Stanton VP Ridlster PM Pliarinacogenetic study of statin thterapy and cholesterol reduction JAMA 200429128212827 Offenhacher S Beck JD Panliow J Chatnhless L Bray M Couper D Martha PM Huttzner K Rogue J Duff GW Association of coronary heart disease with interleukin 1 gene variants in the Atherosclerosis Risk in Comntunities Study In Proceedings of The ogy 2004 Ahstract No 1028166 Ridker PM Clinical application of Careactiire protein for cardiovascular disease detection and prevention Circulation 2UU3lU7363v369 Endres S Ghorhani R Kelley VE Georgilis K Lon neinann G van der Meer J W Cannon J G Rogers l S Klernpner MS Weber PC Schaefer EJ Wolfi SM Dinarello CA The effect of dietary supplementation with 113 polyunsaturated fatty acids on the synthesis of interleukin1 and tumors necrosis factor by motio nuclear cells N Engl J Med 198932t3I265 271 Murray CA Clements l yiP Lynch E Interleukin1 induces lipid peroxidation and meinlorane changes in rat hippocarnpus An agerelated study Gerontology l99945136142 April 2005 0 Journal of the J lMERltlhh DEl39El39lC ASSUCliltTlDN 59 Cynthia P Goody PhD PD LB Iowa fty Iowa C arlier this year DeBusk and col 0 0V leagues presented a tltougltt pro toning research review in the journal of the American Dietetic Association about nutdtioiial genotnics 1 imagine as Dehuslt does its appll cation to dieterics practice and in our case diabetes educationtl1e registered dietitian RD or nutritional genornics practidoner continues to see clients with family histories of type 1 typei or gestational diabetes reviews their la boratorjr results and analyzes their genetic profiles for lifesty1e re1atved genes Based on the patient s dietaijr intalte lifestyle factors and genes con verge the provides individualized medical nutriinonal therapy llxINTquot to 39presi ent or delay the onset of diabetes This case appears routine and rnanagt ahle but as genebased mechanisms evolve and as more diet and gene interactions are identified clients will want to understand and rnaxirnize their genetic potential and minimize their rislt of disease The future of distance and nutritional genomicfs will involve the development of nutrition recom rnendations based on individualized genetic responses to dietary intakes To recognize the potential impact of nutri tional genornics on dietdisease pI39E Jo11 tion it is important to understand its fundamentals current existence and practice application considerations FUNHEMENTALE The successful completion of the Human Genorne Project in April 2003 by the National Human Genome Research quotinstitute tlie Depart1neut of Energy and the international Human Genotne Sequeucirlg lionsortitun result ed in a highquality version of the human sequence essentially an insttuc2 ticn guide about how to construct a human Being 2 IIowever gene media fication in humans is neither technical 13 feasible not ethically admitted 3 Researcliers and practitioners will use genornics information to recornrnend individual behavior changes This is expected to contribute more effective disease prevention and treatrnent The Human Genome Project and subsequent projects reveal that although all huinans are 999 identlv cal the 01 difference produces sig nificant trait varlal gtilltr A subset of these differences is purely cosmetic skin and hair color The challenge to researchers and scientists now is to determine how to read the contents of all diese pages and then uittlerstand hotat the parts work together and to discover the genetic basis for health and the pathology of human disease Genome research will eventually assist i with the development of highly effec tive diagnostic tools aid in the uucler standing of the health needs of people based on their iindividual genetic cons position and facilitate the design of new and highly effecrnre treatments for disease With a price tag of 27 billion the Human Genome Project will likely pay for itself many tirnes over considering that genomebased research willllplay an important role in seeding biotech nology and the pharma and nutraceu tical industries as well as offer major health improvements Using health his tory inforn1ation in cornhinatlon with the data from each person s g39enonie practitioners will have a greater role and stronger position in preventive medicine Researchers speculate that genome data will explain and predict the risks of future illness and speed the discovery of genes related to common illnesses such as asthma cancer dia betes and heart disease ln addition understanding the human genome will he a powerfill resource for studying the genetic factors contributing to variation in response to environmental influ ences susceptihilitr to infection and the effectiveness of medications and vaccines Healtllacare professionals will work with inditiiduals to focus on efforts related to lifestyle factors espe cially diet that are most lilaely to affect an individual s healtli One of the key discoueries Erom the ltlunian Genome Project was the identi fication of individual differences in gene sequences that resulted in a differ ential response to environrnenral fac tors such as diet These genetic sequencing differences known as single nucleotide polymorpliisms lSNl s pro nounced snips are similar to recipe substitutions Each gene is a recipe for a certain protein or group of pro teins tha t regulates function or struc ture in the body ll Some SNPs tnodi fy the recipe so that either a different quaritity of the protein 0ki produced or the protein tnolecule structure is altered ill The discovery of SIll s leads to the development of the lsroad scientific dis cipline lcnown as nutritional genomics it includes both nutrigenetics and nutrigenomics all g The science ofnntrtioiortnl genorrrics is the study of how dietary and other lifesnrle choices influence the function of living lElll at the molecular cellular organ and population levels S llutrigenetics is the rstudy of mechanisms by which bioactive dietary cornponents communicate v the genedc material and how genetic variation affects the interaction between the t etarjt compo nems and the health and disease poten rial of a person 53 The goal of riuuige N nodes is to generate recommendations K regarding the risks and bene tsquot of specif ic dien or dietary components to the individual Namigenomics focuses on G the effects of hioactive dietary cornpo 54 dents on the genome proteorne the sum total of all proteins and rnetaholorne the sum of all metabolites at a global population level 5ln p6 GURREIUT EHISTEWCE Preliminary worlt with nutritional Next Stop continued on page F8 Reprinted with permission from the Diabetes Care and Education Dietetic Practice Group of the Academy Ol NU U l tion and Dietst ics Goody C Knowing More about Nuttitio naIi Genomlcs Newsflash 20D5265l7 39l 9 Hsus ash 18 Next 5LquotEp fr urns page 1739 genomlcs began in cardiovascular dis ease CVD When addressing the fac tors associated with the leading con ten1porary dictrelated disease and cause of deach researchers and practi tioners have typically focused on modi fying the environnient and client behavior Ordovas and colleagues liavc suggested that interactions exist between dietary factors genetic vari ants and CVD biocliemical markers 6 3939 Qjrdovas noted that individuals carrying the apoE4 allele at the APSE gene lowered their plasma cholesterol levels when they consumed a lowfat low cholesterol diet 6 This idea also applies to other types of cholesterol The effect of polyunsaturated fatty acids PUFAJ intaltc on EELcholes terol HDLC is modulated by the A allele on the APOA1 genetic polyrnorv phisrn I17 in other words persons with low levels of HDLC and carriers of the A allele may benefit from diets high in PU1 As These studies allude to end ing the debate on the approach of rec ornrnending a lowfat lowcholesterol diet for the entire population versus the thought that some populations that consume high intakes of unsaturated fats have low rates of CVD and other clironic diseases 68 As our understanding of diabetes continues to unfold in the context of the Hurnan Genome Project we should expect to see an increasing body of lit erature on this topic In particular the role of genetic factors in type 2 dia betesquot has been shown in farnily twin 39 and Pints Indian studies 9 Although the evidence supports a genetic etiology for diabetes identifying the responsible genetic factors is more difficult 391 Gail To date genetic linlcs to type 2 diabetes have been found on chromo somes 20 3912 and 1 10 Despite these promising findings Ordovas cautions Nutrigcnoinics has established proof of concept demon strating that this approach may work in preventing chronic disease or achiev ing safer or more efficacious therapies but there is no such thing as a silver bullet for the complex and n1ultifactor ial traits associated with CZVD diabetes and other illnesses 4 Eurtlier these findings suggest that future dietary guidelines and recommendations offered to clients will be more person alized Clinical recommendations although not yet available will hare to be placed in the content of con1prehen L sivo T Nutritional gcnotnics investigatxes how specifio nutrients impact health the relationship between those dietary substances and the genome and the resulting clinical manifcstatlous of the relationship As this discipline ernerges the scope of our practice in distance and diabetes education will eitpandpnd require careful and thoughtful applica tion 39 PHACTIEE APPLIBATIDN C 39NSl39 EFt39 TIHNS The evolution of nutritional gcnornics in cotnbinatiori with nutrigcnetics and nuttigenornics will provide the neces sary scientific evidencebased informa tion so that more individualized specif ic nutrition counseling may be providw ed to patierits To guide our practice we must consider the conceptual tenets of and ethical issues associated with nutritional genontics 39 The Center of Excellence for Nutritional Gcnotnics University of California Davis established five guid ing tenets for nutritional genornics 13 1 In specific instances and in certain individuals diet is a serious risk Fac tor for a number of diseases 2 Common dietary chemicals directly or indirectly act on the hurnau genome altering gene expression or structure 3 The degree to which diet influences the balance between health and dis ease states may depend on an indi viduals genetic cornposition 4 Sonic dlCt39 mOd11la1oCl genes are likely to play a role in the onset incidence progression of or severity of chronic diseases 5 Based on nutritional requirements and status as well as genotype dietary intervention can be used to prevent mitigate or cure chronic dis39 case These tenets appear stralghtiorWard but tire relationship between diet and genes is complex When considering a chronic disease such as diabetes it is rnost likely the result of man variants oi genes and ienviroiunental factors Extensive information Will be required before decisions regarding client care are warranted Tire purpose of identifying diet and gene interactions is to present or reduce the risk of disease in doing so useful dietary changes are made for avoiding nutritionrelated diseases However new research designetl to help people create customized diets on the basis of their genetic makeup loaf areatre nurnerous ethical challenges with serious irnplicatioos for the scientific and medical conirnunities As more is learned about individual genetic susceptibiliw to disease infor rnation from genetic tests may become increasingly attractiquotre mpecially to outside parties that may profit from it A concern exists that employers or insurers could use genetic inforruation to the unfair disadvantage of some peo ple One of the most important issues is whether private generic inforrnation should be treated as confidential in nature and not communicated to others without consent Personal medical information usually rernains private but genetic tests may be relevant to biological relatives Physicians and other health care providers may face situations in wbicli they must choose between patient confidentiality and prodding potcntially useful informa tion to other family ntlembers While the purpose of food nutrition and gene interactions is to prevent and reduce the risk of disease through the implenlentation of useful dietarfr modi fications for clients ethical responsibili ty must also be emphasized The collec tion storageand use of genetic infor mation will be a hot topic in the future at this stage of research and develop ment scientific progress is outstripping the public s ability to make informed choices about the regulations related to ethics and privacy Thus practitioners have an obligation to Inaintain high standards of care and practice The fol lotring questions are offered as a curso 3937 Otdovas JM Corolla D Cupples LA ell al Polyunsaturated fatty acids rt starting point for assisting lRDs B the formulation of a nutritional quot 39 i i 1 i genornics ethicsbased practice i p what type of genomics inforrnation should be avaiIable to liealthv i care providers as well as toclients and their family nieinbetsi V 21 Who should have access to nutritional genomicquot information who Sh should not and how should i139npI39DpEIquot access be prevented 1 l 3 How should nutritional genornics information be delivered to N clie 113 39 39339quot W 39 4 How can potential nutritional genotnitsqelatedminequities es n iedi 39 I atcd 39 A p 5 Witich nutritional genort1ics issues should be tegtllated Award Safeguarding and monitoring the use of geneticquot information will be i 39 wI39nne r5 a daunting task However this powerful information and its successful translation to clients for disease prevention and management is a tremendous opporrunitjr that if properlsr implemented would enhance clinical practice and clients health outcomes Distinguishcd Service Award Sponsored by LifeScan EIANE REHDEE ND CUE Summ gy l Creative utrition Edncatiot1 Award Sponsored by Eli Lilly and Company The expansion of nutri1ionalquotgenon1ics into dietetics practice is inuni T GAHUL BRUNZELL RD LB GEE nent Witl1 a continued focus on how specific nutriettts impact health and the relationsliip between dietary intake and gcneticsRDs especially those in diabetes care and education are uniquely positioned to influ ence clients and the healtlucare process When considering tl1eorigi11s of Publicatiozns Award Sponsored by DCE nutritional genornics and its pragmatic applications R135 are well on I JquotqcKiE BQUQHEEI M51 ED CHE their way to facilitating desirable health and nutrition outcomes BEAEM nesenemcss Diabetes Educator of the Year Award 1 De uslt RM Fogarty CI Qrclovas EM Korntnan KS Nutritional 7 Sponsored by Diabetic Cooking rnapgazine genomics in practice wliere do we begin I Am Diet Assoc P ITl B GEIL MS RD FADA GEE 2o051054i5 89498 2 Collins FE Green ED Guttrnaclier P Guycr United States N Hon 0131 Member AW National Human Genome Research lI1St1t 11l 39E A vision for the iutute of S 5 ed b DEE gcnornics researth Nature 2IZ0342239835 8439 Poll 01quot quotYip p p p 3 Giuttrnacher AB Collins F3 Welcome to the genomic era N Engl HENRIDIrquot aI39Em l M5 Med 2003 34999698 4 Ordovas JM Mooser V Nutrigcnotnics and nutrigenetics Curr Opiwt Leglslaitrlie Actlvll Y Lipidol 2Cl0413i10l 1U8 j Sponsored by IDCE 5 DeBusk Genetics The Nutrition Contraction Chicage lll American Dietetic Association ZW3 6 Ordovas JM Genedietiinteraction and plasma lipid responses to dietary 9 Ed catio al stipends inteirvrention Biocbetn Soc Trans 2D0230 6373 LEDNJLDA MEDDNEBH FH3 BDE Sponsored by Idealtlr Management Resources modulate the effects of the APOA1 GA polymorphism on II DLcholes i nUTH39BEAn39 Ms Hg EDE Bc m terol concentrations in a sexwspecific I I1ar1ner the Frantingilam Studs Am I Ufd y JUTUHU PHD ster ee esesses we tnntrnsw i ii Grin Nun 2002 5384 6 l IADINE ennurssrerm me nor mm c 8 Ha PB The Mediterraneandiiet and mortalitje olive oil and beyond N p 55 Engi Medquot 2oe334s25s5 259s 1 A t t 9 Ravussin E Bogardus C Energy balance and weight regulation genetics i SGHAHLQ NUNES MS RD BEE versus environment Br Nitr 20DD83 Sie320 10 Cox N Calpain 10 and genetics of type 2 diabetes Curt Diseases 1 Speaker Shple ds Rap 2e0221ss 19e SPURS Wd bl DEE 11 Mercado MM McLenitl1an jc Silver Sliuldincr AR Genetics of JAMIE R0521EH 5390 SEE insulin resistance Cmr Diabetes Rep 200232 8395 ggmggg FARKEQI g Q55 12 Gloyn AL The search for type 2 J TEE RYANETUREKI RD SHE diabetes genes Aging Res Rem 2003211112 V p l p 13 Center for Excellence for Nutritional Genornics at the University of JDAW E E5 HHquotquotjquot RD LB CUE California at Davis Nntr genomics Available at p CHRISTINE HUHLE RD LON DUE littpnutrigenornicsuctlaviseclu Accessed July 11 2005 i i nlri1El s1atwnH s2se1al
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