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Summary
Healthy eating patterns in childhood and adolescence promote optimal childhood health, growth, and intellectual development; prevent immediate health problems, such as iron deficiency anemia, obesity, eating disorders, and dental caries; and may prevent long-term health problems, such as coronary heart disease, cancer, and stroke. School health programs can help children and adolescents attain full educational potential and good health by providing them with the skills, social support, and environmental reinforcement they need to adopt long-term, healthy eating behaviors.
This report summarizes strategies most likely to be effective in promoting healthy eating among school-age youths and provides nutrition education guidelines for a comprehensive school health program. These guidelines are based on a review of research, theory, and current practice, and they were developed by CDC in collaboration with experts from universities and from national, federal, and voluntary agencies.
The guidelines include recommendations on seven aspects of a school-based program to promote healthy eating: school policy on nutrition, a sequential, coordinated curriculum, appropriate instruction for students, integration of school food service and nutrition education, staff training, family and community involvement, and program evaluation.
INTRODUCTION
School-based programs can play an important role in promoting lifelong healthy eating. Because dietary factors 'contribute substantially to the burden of preventable illness and premature death in the United States,' the national health promotion and disease prevention objectives encourage schools to provide nutrition education from preschool through 12th grade (1). The U.S. Department of Agriculture's (USDA) Nutrition Education and Training (NET) Program urges 'nutrition education {to} be a major educational component of all child nutrition programs and offered in all schools, child care facilities, and summer sites' by the year 2000 (2). Because diet influences the potential for learning as well as health, an objective of the first national education goal is that children 'receive the nutrition and health care needed to arrive at school with healthy minds and bodies' (3).
The recommendations in this report are intended to help personnel and policymakers at the school, district, state, and national levels meet the national health objectives and education goals by implementing school-based nutrition education policies and programs. This report may also be useful to students, to parents, and to personnel in local and state health departments, community-based health and nutrition programs, pediatric clinics, and training institutions for teachers and public health professionals. These recommendations complement CDC guidelines for school health programs to prevent the spread of acquired immunodeficiency syndrome (AIDS) (4), to prevent tobacco use and addiction (5), and to promote physical activity (6).
In this report, nutrition education refers to a broad range of activities that promote healthy eating behaviors. The nutrition education guidelines focus largely on classroom instruction, but they are relevant to all components of a comprehensive school health program -- health education; a healthy environment; health services; counseling, psychological, and social services; integrated school and community efforts; physical education; nutrition services; and school-based health promotion for faculty and staff (7). Although the meals served by school food service programs are an important part of a school health program, this report does not provide specific recommendations related to purchasing and preparing food for school meals. Detailed information on this topic is available from many other publications (8-19) and information sources (see Appendix A). These guidelines also do not address the specific nutrition education and counseling needs of pregnant adolescents (20,21) or young persons with special needs (22-28).
These guidelines are based on a synthesis of research, theory, and current practice and are consistent with the principles of the national health education standards (29), the opportunity-to-learn standards for health education (29), the position papers of leading voluntary organizations involved in child nutrition (30), and the national action plan to improve the American diet (31). To develop these guidelines, CDC convened meetings of experts in nutrition education, reviewed published research, considered the recommendations of national policy documents (1,32-35), and consulted with experts from national, federal, and voluntary organizations.
EFFECTS OF DIET ON THE HEALTH, GROWTH, AND INTELLECTUAL DEVELOPMENT OF YOUNG PERSONS
School-based nutrition education can improve dietary practices that affect young persons' health, growth, and intellectual development. Immediate effects of unhealthy eating patterns include undernutrition, iron deficiency anemia, and overweight and obesity.
Undernutrition
Even moderate undernutrition can have lasting effects on children's cognitive development and school performance (36). Chronically undernourished children attain lower scores on standardized achievement tests, especially tests of language ability (37). When children are hungry or undernourished, they have difficulty resisting infection and therefore are more likely than other children to become sick, to miss school, and to fall behind in class (36,37); they are irritable and have difficulty concentrating, which can interfere with learning (38); and they have low energy, which can limit their physical activity (38). Some reports have estimated that millions of children in the United States experience hunger over the course of a year (39), but no scientific consensus currently exists on how to define or measure hunger (1).
Skipping breakfast can adversely affect children's performance in problem-solving tasks (40-42). A study of low-income elementary school students indicated that those who participated in the School Breakfast Program had greater improvements in standardized test scores and reduced rates of absence and tardiness than did children who qualified for the program but did not participate (43). Twelve percent of students reported skipping breakfast the day before one national survey was taken (44); 40% of 8th- and 10th-grade students in another study reported having eaten breakfast on less than or equal to 2 days the week before the survey (45). Strategies to encourage adequate nutrition among young persons include the following:
Promote participation in USDA food assistance programs (e.g., the School Breakfast Program and School Lunch Program, the Summer Food Service Program, and the Child and Adult Care Food Program).
Advise parents and guardians about community-based food supplementation programs (e.g., food stamps; local food pantries; and the Special Supplemental Nutrition Program for Women, Infants, and Children {WIC}).
Educate students and their families about the importance of eating breakfast.
Iron Deficiency Anemia
Iron deficiency anemia is the most common cause of anemia in the United States (33). Iron deficiency hampers the body's ability to produce hemoglobin, which is needed to carry oxygen in the blood. This deficiency can increase fatigue, shorten attention span, decrease work capacity, reduce resistance to infection, and impair intellectual performance (33,46). Among school-age youths, female adolescents are at greatest risk for iron deficiency. Approximately 1% of elementary school-age children and 2%-4% of adolescent girls ages 12-19 years show evidence of iron deficiency anemia (47). To prevent iron deficiency, children and adolescents should eat adequate amounts of foods high in iron and in vitamin C, which helps the body absorb iron efficiently (33).
Overweight and Obesity *
Overweight and obesity are increasing among children and adolescents in the United States (48-52). The prevalence of overweight among youths ages 6-17 years in the United States has more than doubled in the past 30 years; most of the increase has occurred since the late 1970s (52). Approximately 4.7 million, or 11%, of youths ages 6-17 years are seriously overweight (52). Obesity in young persons is related to elevated blood cholesterol levels (53-56) and high blood pressure (57-59), and some very obese youths suffer from immediate health problems (e.g., respiratory disorders, orthopedic conditions, and hyperinsulinemia) (60). Being overweight during childhood and adolescence has been associated with increased adult mortality (61,62). Furthermore, obese children and adolescents are often excluded from peer groups and discriminated against by adults, experience psychological stress, and have a poor body image and low self-esteem (63,64). Increased physical activity and appropriate caloric intake are recommended for preventing and reducing obesity (35). CDC's guidelines for school and community health programs to promote physical activity among youths address strategies for increasing physical activity among young persons (6).
Unsafe Weight-Loss Methods
Many young persons in the United States practice unsafe weight-loss methods. Deliberately restricting food intake over long periods can lead to poor growth and delayed sexual development (65). Data from one study indicated that the rate of smoking initiation is higher for adolescent girls who diet or who are concerned about their weight than for nondieters or girls having few weight concerns (66), and another study indicated that many white female high school students who smoke report using smoking to control their appetite and weight (67). Harmful weight loss practices have been reported among girls as young as 9 years old (68,69). Young persons involved in certain competitive sports and dancing are particularly at risk for unsafe weight control practices (70). A national survey of 8th- and 10th-grade students found that 32% skipped meals, 22% fasted, 7% used diet pills, 5% induced vomiting after meals, and 3% used laxatives to lose weight (45). Children and adolescents should learn about the dangers of unsafe weight-loss methods and about safe ways to maintain a healthy weight. The emphasis of society in the United States on thinness should be challenged, and young persons need to develop a healthy body image (71).
Eating Disorders
Eating disorders (e.g., anorexia nervosa and bulimia nervosa) are psychological disorders characterized by severe disturbances in eating behavior. Anorexia nervosa is characterized by a refusal to maintain a minimally normal body weight, and bulimia nervosa is characterized by repeated episodes of binge eating followed by compensatory behaviors such as self-induced vomiting (72). Eating disorders often start in adolescence, and greater than 90% of cases occur among females (72). Anorexia nervosa and bulimia nervosa affect as many as 3% of adolescent and young adult females, and the incidence of anorexia nervosa appears to have increased in recent decades (72). Compared with adolescents who have normal eating patterns, adolescents who have eating disorders tend to have lower self-esteem; a negative body image; and feelings of inadequacy, anxiety, social dysfunction, depression, and moodiness (73). Eating disorders can cause many severe complications, and mortality rates for these disorders are among the highest for any psychiatric disorder (74). Persons who have eating disorders should receive immediate medical and psychological treatment.
Dental Caries
Dental caries is perhaps the most prevalent of all diseases (1). It affects 50.1% of youths ages 5-17 years and 84.4% of youths age 17 years (75). More than 50 million hours of school time are lost annually because of dental problems or dental visits (76). Dental caries is a progressive disease, which, if left untreated, can result in acute infections, pain, costly treatment, and tooth loss. A strong link exists between sugar consumption and dental caries (33). To prevent dental caries, children and adolescents should drink fluoridated water, use fluoridated toothpaste, brush and floss their teeth regularly, have dental sealants applied to the pits and fissures of their teeth, and consume sugars in moderation (1).
EFFECTS OF CHILDHOOD EATING PATTERNS ON CHRONIC DISEASE RISKS OF ADULTS
Nutrition education also should focus on preventing children and adolescents from developing chronic diseases during adulthood. Some of the physiological processes that lead to diet-related chronic disease begin in childhood. For example, autopsy studies have demonstrated that early indicators of atherosclerosis (the hardening of the arteries that is the most common cause of coronary heart disease {CHD}) begin in youth (77-83) and are related to blood cholesterol levels in young persons (79,81-83). Unhealthy eating practices that contribute to chronic disease are established early in life; young persons having unhealthy eating habits tend to maintain these habits as they age (84). Thus, it is efficacious to teach persons healthy eating patterns when they are young; high-risk eating behaviors and physiological risk factors are difficult to change once they are established during youth.
Diet-related risk factors for cardiovascular disease (e.g., high blood cholesterol level, high blood pressure, and overweight) are common in youths in the United States (34,52,85-90). Compared with their peers, children and adolescents who have high blood cholesterol (34,91-96), have high blood pressure (97,98), or are obese (91,99-103) are more likely to have these risk factors during adulthood. Poor diet and inadequate physical activity together account for at least 300,000 deaths in the United States annually and are second only to tobacco use as the most prominent identifiable contributor to premature death (104). Interventions that promote healthy eating and physical activity behaviors during childhood and adolescence may not only prevent some of the leading causes of illness and death but also decrease direct health-care costs and improve quality of life.
Diet is a known risk factor for the development of the nation's three leading causes of death: CHD, cancer, and stroke (33). Other health problems of adulthood associated with diet are diabetes, high blood pressure, overweight, and osteoporosis.
Coronary Heart Disease
CHD kills more persons in the United States than any other disease does (1). Diet-related risk factors for CHD include high blood cholesterol, high blood pressure, and obesity. These risk factors can be reduced by consuming less fat (particularly saturated fat) and cholesterol and by increasing physical activity (105).
Cancer
One out of every five deaths in the United States is attributable to cancer (106). Dietary factors have been associated with several types of cancer, including colon, breast, and prostate (33). All cancer deaths in the United States might be reduced as much as 35% through dietary changes (107,108). The risk for some types of cancer may be reduced by maintaining a healthy weight; limiting consumption of fat, alcohol, and salt-cured, salt-pickled, or smoked foods; and eating more foods that protect the body against cancer (fruits, vegetables, whole grain cereals, and other high-fiber foods) (109). The National Cancer Institute advises eating at least five servings of fruits and vegetables each day (110).
Stroke
Cerebrovascular disease, or stroke, is the third leading cause of death in the United States and a major cause of illness and disability (111). The most important risk factor for stroke is high blood pressure, which often can be controlled or prevented by adopting a healthy diet and maintaining a healthy weight (112). The risk for stroke can be reduced by consuming less sodium, increasing physical activity, and maintaining a healthy body weight.
Diabetes
Diabetes is the seventh leading cause of death in the United States (104). CHD is two to four times more common and stroke is two to six times more common in persons who have diabetes than in persons who do not have diabetes (113). Diabetes can lead to blindness, kidney disease, and nerve damage (113). Non-insulin-dependent diabetes mellitus, which affects approximately 90% of persons who have diabetes, is often associated with obesity (114). Maintaining a desirable body weight through physical activity and modest caloric restriction is important in preventing diabetes and controlling its complications (114).
High Blood Pressure
High blood pressure is a major cause of CHD, stroke, and kidney failure. About one in four adults in the United States has high blood pressure (115). Persons who have high blood pressure have three to four times the risk of developing CHD and as much as seven times the risk of stroke as do those who have normal blood pressure (116). Persons can reduce their risk for high blood pressure by consuming less sodium, increasing physical activity, and maintaining a healthy body weight. A diet high in potassium may help reduce the risk of high blood pressure (117).
Overweight
In the United States, about one in three adults is overweight (118), and these persons are at increased risk for CHD, some types of cancer, stroke, diabetes mellitus, high blood pressure, and gallbladder disease (33). Overall risk for premature death is increased by excess weight; the risk increases as severity of overweight increases (33). The best way to lose weight is to increase physical activity and control caloric intake, preferably by adopting a diet that is low in fat and high in vegetables, fruits, and grains (35).
Osteoporosis
Osteoporosis is a decrease in the amount of bone so severe that the bone fractures easily. About 1.3 million bone fractures, including many fatal hip fractures, occur per year in persons greater than or equal to 45 years of age (33). Low dietary calcium, a mineral essential for bone growth, may be associated with an increased risk for osteoporosis (33). For females especially, eating enough calcium is particularly important during childhood, adolescence, and young adulthood -- when bones approach their maximum density -- to reduce the risk for osteoporosis later in life (1,119- 122). Regular weight-bearing exercises also can help prevent osteoporosis (33).
GUIDELINES FOR HEALTHY EATING
To prevent certain diseases and to promote good health, persons greater than 2 years of age should follow the seven recommendations that constitute the Dietary Guidelines for Americans (35). These guidelines are developed by the USDA and USDHHS and are published every 5 years. They are based on extensive reviews of hundreds of studies conducted over many years and represent the best current advice that nutrition scientists can give. The guidelines are consistent with dietary recommendations made by major health promotion organizations, including the National Research Council (32), the National Cholesterol Education Program of the National Institutes of Health (34,105), the National Cancer Institute (109), the American Cancer Society (123), and the American Heart Association (124).
The principles contained in the Dietary Guidelines for Americans should be the primary focus of school-based nutrition education. By enabling young persons to adopt practices consistent with the guidelines, schools can help the nation meet its health objectives (1), which were designed to guide health promotion and disease prevention policy and programs at the federal, state, and local level throughout the 1990s. Objective 2.19 is to 'increase to at least 75 percent the proportion of the Nation's schools that provide nutrition education from preschool through 12th grade, preferably as part of quality school health education' (1). The six relevant dietary guidelines are (a) eat a variety of foods; (b) balance the food you eat with physical activity -- maintain or improve your weight; (c) choose a diet with plenty of grain products, vegetables, and fruits; (d) choose a diet low in fat, saturated fat, and cholesterol; (e) choose a diet moderate in sugars; and (f) choose a diet moderate in salt and sodium. (The seventh recommendation concerns adults and alcoholic beverages.) Enabling children and adolescents to follow these guidelines can help the nation achieve these national health objectives for the year 2000 (1): 2.3 Reduce overweight to a prevalence of less than or equal to 20%
among people aged 20 and older and less than or equal to 15% among adolescents aged 12 through 19. 2.5 Reduce average dietary fat intake to less than or equal to 30%
of calories and average saturated fat intake to less than or equal to 10% of calories among people aged two and older. 2.6 Increase complex carbohydrates and fiber-containing foods in
the diets of adults to five or more daily servings for vegetables (including legumes) and fruits and to six or more daily servings for grain products. 2.7 Increase to greater than or equal to 50% the proportion of
overweight people aged 12 and older who have adopted sound dietary practices combined with regular physical activity to attain an appropriate body weight. 2.8 Increase calcium intake so greater than or equal to 50% of
youth aged 12 through 24 and greater than or equal to 50% of pregnant and lactating women consume three or more servings daily of foods rich in calcium, and greater than or equal to 50% of people aged greater than or equal to 25 consume two or more servings daily. 2.9 Decrease salt and sodium intake so that greater than or equal
to 65% of home meal preparers prepare foods without adding salt, greater than or equal to 80% of people avoid using salt at the table, and greater than or equal to 40% of adults regularly purchase foods modified or lower in sodium.
The Food Guide Pyramid (Figure_1) was designed by the USDA and USDHHS to help persons follow the Dietary Guidelines for Americans. Schools can use the pyramid to illustrate the concepts of variety (eat different foods from among and within the food groups), moderation (limit the consumption of foods high in fat and added sugars), and proportionality (eat relatively greater amounts of foods from the groups that are lower in the pyramid: grains, vegetables, and fruits) (125). Other educational materials supplement the pyramid by listing low-fat choices within each food group (35).
EATING BEHAVIORS OF CHILDREN AND ADOLESCENTS IN THE UNITED STATES
Many young persons in the United States do not follow the recommendations of the Dietary Guidelines for Americans or the Food Guide Pyramid. On average, children and adolescents consume too much fat, saturated fat, and sodium and not enough fruits, vegetables, or calcium (44,126-129; CDC, unpublished data). Children and adolescents obtain 33%-35% of their calories from fat and 12%-13% from saturated fat (above the recommended levels of 30% and 10%, respectively) (44,128,129). Only 16% of children ages 6-11 years and 15% of adolescents ages 12-19 years meet the recommendation for total fat intake; only 9% of children and 7% of adolescents meet the recommendation for saturated fat intake (130). Almost one-half of 8th- and 10th-grade students eat three or more snacks a day, and most of these snacks are high in fat, sugar, or sodium (45).
Unpublished data from CDC's 1993 Youth Risk Behavior Survey indicated that, on the day before the survey, 41% of high school students in the United States ate no vegetables and 42% ate no fruits (127) (Appendix B). An analysis of a nationally representative sample of youths ages 2-18 years indicated that, over a 3-day period, the youths ate only 3.6 servings of fruits and vegetables daily and that fried potatoes accounted for a large proportion of the vegetables consumed, 20.4% of the youths ate the recommended five or more servings of fruits and vegetables daily, 50.8% ate fewer than one serving of fruit per day, and 29.3% ate fewer than one serving per day of vegetables that were not fried (131). Adolescent females eat considerably less calcium and iron than recommended by the Food and Nutrition Board of the National Research Council (126,129).
Children and adolescents appear to be familiar with the general relationship between nutrition and health but are less aware of the relationship between specific foods and health. For example, young persons understand the importance of limiting fat, cholesterol, and sodium in one's diet, but they do not know which foods are high in fat, cholesterol, sodium, or fiber (45,132,133). One study indicated that adolescents were well-informed about good nutrition and health but did not use their knowledge to make healthy food choices (134).
THE NEED FOR SCHOOL-BASED NUTRITION EDUCATION
Young persons need nutrition education to help them develop lifelong eating patterns consistent with the Dietary Guidelines for Americans and the Food Guide Pyramid. Schools are ideal settings for nutrition education for several reasons:
Schools can reach almost all children and adolescents.
Schools provide opportunities to practice healthy eating. More than one-half of youths in the United States eat one of their three major meals in school, and 1 in 10 children and adolescents eats two of three main meals in school (135).
Schools can teach students how to resist social pressures. Eating is a socially learned behavior that is influenced by social pressures. School-based programs can directly address peer pressure that discourages healthy eating and harness the power of peer pressure to reinforce healthy eating habits.
Skilled personnel are available. After appropriate training, teachers can use their instructional skills and food service personnel can contribute their expertise to nutrition education programs.
Evaluations suggest that school-based nutrition education can improve the eating behaviors of young persons (136-138).
School-based nutrition education is particularly important because today's children and adolescents frequently decide what to eat with little adult supervision (139). The increase in one-parent families or families having two working parents and the availability of convenience foods and fast-food restaurants inhibit parents' monitoring of their children's eating habits.
Young persons' food choices are influenced by television advertisements for low-nutritive foods. Young persons see about one food advertisement for every 5 minutes of Saturday morning children's shows (140). Most of the foods advertised during children's programming are high in fat, sugar, or sodium; practically no advertisements are for healthy foods such as fruits and vegetables (140-142). Studies have indicated that, compared with those who watch little television, children and adolescents who watch more television are more likely to have unhealthy eating habits and unhealthy conceptions about food (143), ask their parents to buy foods advertised on television (144), and eat more fat (145). Some studies of young persons have found that television watching is directly associated with obesity (146-149). Because youths in the United States spend, on average, more than 20 hours a week watching television (150) -- more time over the course of the year than they are in school (141) -- school-based programs should help counter the effect of television on young persons' eating habits.
Schools are a critical part of the social environment that shapes young persons' eating behaviors and can therefore play a large role in helping improve their diet. However, schools cannot achieve this goal on their own when the cultural milieu has a large influence on food-related beliefs, values, and practices (30,138). Families, food stores, restaurants, the food industry, religious institutions, community centers, government programs, and the mass media must also support the principles of the Dietary Guidelines for Americans. The USDA's Team Nutrition (see Appendix A) seeks to gain the support of many sectors of society for improving the diet of young persons by creating innovative public and private partnerships that promote healthy food choices through the media, schools, families, and community (151).
PROMOTING HEALTHY EATING THROUGH A COMPREHENSIVE SCHOOL HEALTH PROGRAM
In the school environment, classroom lessons alone might not be enough to effect lasting changes in students' eating behaviors (30); students also need access to healthy food and the support of persons around them (137). The influence of school goes beyond the classroom and includes normative messages from peers and adults regarding foods and eating patterns. Students are more likely to receive a strong, consistent message when healthy eating is promoted through a comprehensive school health program.
A comprehensive school health program empowers students with not only the knowledge, attitudes, and skills required to make positive health decisions but also the environment, motivation, services, and support necessary to develop and maintain healthy behaviors (152). A comprehensive school health program includes health education; a healthy environment; health services; counseling, psychological, and social services; integrated school and community efforts; physical education; nutrition services; and a school-based health program for faculty and staff (7). Each component can contribute to integrated efforts that promote healthy eating. For example, classroom lessons on nutrition can be supported by
schools providing appealing, low-fat, low-sodium foods in vending machines and at school meetings and events;
school counselors and nurses providing guidance on health and, if necessary, referrals for nutritional problems;
community organizations providing counseling or nutrition education campaigns;
physical education instructors helping students understand the relationship between nutrition and physical activity;
school food service personnel serving healthy, well-balanced meals in the cafeteria; and
school personnel acting as role models for healthy eating (153). The USDA is promoting health-enhancing changes in the food service component of the school health program by requiring schools to serve meals that comply with the Dietary Guidelines for Americans (154) and by providing technical support to schools through Team Nutrition (151).
RECOMMENDATIONS FOR SCHOOL HEALTH PROGRAMS PROMOTING HEALTHY EATING
Based on the available scientific literature, national nutrition policy documents, and current practice, these guidelines provide seven recommendations for ensuring a quality nutrition program within a comprehensive school health program. These recommendations address school policy on nutrition, a sequential, coordinated curriculum, appropriate and fun instruction for students, integration of school food service and nutrition education, staff training, family and community involvement, and program evaluation. Strategies that schools can use to achieve these recommendations are available (Appendix C). However, local school systems need to assess the nutrition needs and issues particular to their communities, and they need to work with key school- and community-based constituents, including students, to develop the most effective and relevant nutrition education plans for their communities. Vigorous, coordinated, and sustained support from communities, local and state education and health agencies, institutions of higher education, and national organizations also is necessary to ensure success (29).
Policy: Adopt a coordinated school nutrition policy that promotes healthy eating through classroom lessons and a supportive school environment.
Curriculum for nutrition education: Implement nutrition education from preschool through secondary school as part of a sequential, comprehensive school health education curriculum designed to help students adopt healthy eating behaviors.
Instruction for students: Provide nutrition education through developmentally appropriate, culturally relevant, fun, participatory activities that involve social learning strategies.
Integration of school food service and nutrition education: Coordinate school food service with nutrition education and with other components of the comprehensive school health program to reinforce messages on healthy eating.
Training for school staff: Provide staff involved in nutrition education with adequate preservice and ongoing in-service training that focuses on teaching strategies for behavioral change.
Family and community involvement: Involve family members and the community in supporting and reinforcing nutrition education.
Program evaluation: Regularly evaluate the effectiveness of the school health program in promoting healthy eating, and change the program as appropriate to increase its effectiveness.
Recommendation 1. Policy: Adopt a coordinated school nutrition policy that promotes healthy eating through classroom lessons and a supportive school environment.
Rationale for the Policy
A coordinated school nutrition policy, particularly as part of an overall school health policy, provides the framework for implementing the other six recommendations and ensures that students receive nutrition education messages that are reinforced throughout the school environment. For example, such a policy would address nutrition education classes; school lunch and breakfast; classroom snacks and parties; use of food to reward or discipline; and food sold in vending machines, at school stores, snack bars, sporting events, and special activities, and as part of fundraising activities. The school environment can powerfully influence students' attitudes, preferences, and behaviors related to food (137). Without a coordinated nutrition policy, schools risk negating the health lessons delivered in the classroom and cafeteria by allowing actions that discourage healthy eating behaviors.
Developing the Policy
A school nutrition policy should be a brief document that incorporates input from all relevant constituents of the school community: students, teachers, coaches, staff, administrators, food service personnel, nurses, counselors, public health professionals, and parents. The policy should meet local needs and be adapted to the health concerns, food preferences, and dietary practices of different ethnic and socioeconomic groups. Technical assistance for assessing nutrition education needs is available through the state NET Program (155). Schools might consider using one or more of the following techniques to assess their particular needs:
Interview nutrition professionals to learn more about local eating habits and to identify materials and services available for youths and adults. Schools might interview representatives from the school food service program; the state NET Program; the nutrition unit within the State Department of Health; the district or state school health coordinator; the local WIC program and Cooperative Extension nutrition education program; the state or local chapters of the American Cancer Society, American Dietetic Association, and the American Heart Association; nutrition councils or coalitions; university research programs; organizations with special insights into the particular nutrition education needs of cultural and ethnic minorities; or businesses that offer nutrition-related services or food products.
Interview food service staff about students' eating practices in the school cafeteria.
Observe the school cafeteria, the teachers' lunchroom, and other areas in the school where food is available.
Review nutrition curricula used by teachers.
Survey teachers to determine how nutrition is taught, whether teachers use food for reward or punishment, and the level of interest of teachers in nutrition or wellness programs for themselves.
Survey students to determine their dietary preferences and what types of healthy changes in school food they most want.
The policy plan should include means of obtaining follow-up input from all parties and means of revising the plan as needed. Student involvement is critical to the success of a nutrition policy. A nutrition advisory committee or a nutrition subcommittee of the school health advisory council having student members can develop and promulgate a coordinated school nutrition policy. Technical assistance in forming a school nutrition advisory committee is available from the American School Food Service Association (Appendix A). Successful implementation of a nutrition policy also requires the active support of school and district educational leadership.
Content of the Policy
The written policy should describe the importance of the nutrition component within the comprehensive school health program. This section can briefly describe the role of good nutrition in promoting childhood growth, health, and learning; discuss the role of child and adolescent nutrition in reducing the risk for chronic diseases of adulthood; identify the importance of establishing a school environment that supports healthy eating choices by young persons; and generate support for the policy by identifying how improvements in student nutrition can satisfy the needs of different constituents of the school community (e.g., students, teachers, and food service personnel). An optimal policy on nutrition should publicly commit the school to providing adequate time for a curriculum on nutrition, serving healthy and appealing foods at school, developing food-use guidelines for teachers, supporting healthy school meals, and establishing links with nutrition service providers.
Curriculum. Adequate time should be allocated for nutrition education throughout the preschool, primary, and secondary school years as part of a sequential, comprehensive school health education program. In addition, teachers should be adequately trained to teach nutrition and be provided with ongoing in-service training.
Healthy ** and appealing foods. Healthy and appealing foods should be available in meals, a la carte items in the cafeteria, snack bars, and vending machines (Exhibit 1) (Table_1); as classroom snacks; and at special events, athletic competitions, staff meetings, and parents' association meetings. In addition, schools should discourage the sale of foods high in fat, sodium, and added sugars (e.g., candy, fried chips, and soda) on school grounds and as part of fundraising activities. Although selling low-nutritive foods may provide revenue for school programs, such sales tell students that it is acceptable to compromise health for financial reasons (158). The school thereby risks contradicting the messages on healthy eating given in class. If schools contract with food service management companies to supply meals, the contractors should be required to serve appealing, low-fat, low-sodium meals that comply with the standards of the Dietary Guidelines for Americans.
Food use guidelines for teachers. Schools should discourage teachers from using food for disciplining or rewarding students. Some teachers give students low-nutritive foods, such as candy, as a reward for good behavior, and punish misbehaving students by denying a low-nutritive treat (159). These practices reinforce students' preferences for low-nutritive foods and contradict what is taught during nutrition education. Schools should recommend that both teachers and parents serve healthy party snacks and treats (160).
Support for healthy school meals. Starting with the 1996-1997 school year, schools will be required to serve meals that comply with the standards of the Dietary Guidelines for Americans (154). To encourage students to participate in school meal programs and to make healthy choices in cafeterias, schools can use marketing-style incentives and promotions (13,14,135,161); use healthy school meals as examples in class; educate parents about the value of healthy school meals; involve students and parents in planning meals; and have teachers, administrators, and parents eat in the cafeteria and speak favorably about the healthy meals available there. Students should also be given adequate time and space to eat meals in a pleasant and safe environment (162).
Links with nutrition service providers. Schools should establish links with qualified public health and nutrition professionals who can provide screening, referral, and counseling for nutritional problems (30,163); inform families about supplemental nutrition services available in the community, such as WIC (164), food stamps, local food pantries, the Summer Food Service Program, and the Child and Adult Care Food Program; and implement nutrition education and health promotion activities for school faculty, other staff, school board members, and parents. These links can help prevent and resolve nutritional problems that can impair a student's capacity to learn, demonstrate the value placed on good nutrition for the entire school community, and help adults serve as role models for school-age youths.
Recommendation 2. Curriculum for nutrition education: Implement nutrition education from preschool through secondary school as part of a sequential, comprehensive school health education curriculum designed to help students adopt healthy eating behaviors.
Nutrition Education as Part of a Comprehensive School Health Education Program
Nutrition education should be part of a comprehensive health education curriculum that focuses on understanding the relationship between personal behavior and health. This curriculum should give students the knowledge and skills they need to be 'health literate,' as delineated by the national health education standards (29) (Exhibit 2) (Table_2). The comprehensive health education approach is important to nutrition education because
unhealthy eating behaviors may be interrelated with other health risk factors (e.g., cigarette smoking and sedentary lifestyle) (165),
nutrition education shares many of the key goals of other health education content areas (e.g., raising the value placed on health, taking responsibility for one's health, and increasing confidence in one's ability to make health-enhancing behavioral changes), and
state-of-the-art nutrition education uses many of the social learning behavioral change techniques used in other health education domains. Therefore, nutrition education activities can reinforce, and be reinforced by, activities that address other health education topics as well as health in general.
Linking nutrition and physical activity is particularly important because of the rising proportion of overweight youths in the United States. Nutrition education lessons should stress the importance of combining regular physical activity with sound nutrition as part of an overall healthy lifestyle. Physical education classes, in turn, should include guidance in food selection (6).
Sequential Lessons and Adequate Time
Students who receive more lessons on nutrition have more positive behavioral changes than students who have fewer lessons (166,167). To achieve stable, positive changes in students' eating behaviors, adequate time should be allocated for nutrition education lessons. The curriculum should be sequential from preschool through secondary school; attention should be paid to scope and sequence. When designing the curriculum, schools should assess and address their students' needs and concerns. A curriculum targeted to a limited number of behaviors might make the most effective use of a scarce instructional time available for nutrition education (136).
To maximize classroom time, nutrition education can be integrated into the lesson plans of other school subjects; for example, math lessons could analyze nutrient intake or reading lessons could feature texts on nutrition (168). Little research on the integrated approach has been conducted (137), but embedding information on nutrition in other courses probably reinforces the goals of nutrition education. However, the exclusive use of an integrative approach might sacrifice key elements of an effective nutrition education program (e.g., adequate time, focusing on behaviors and skill-building, attention to scope and sequence, and adequate teacher preparation) (137). Therefore, integration into other courses can complement but should not replace sequential nutrition education lessons within a comprehensive school health education curriculum. Classroom time can be maximized also by having nutrition education lessons use skills learned in other classes (e.g., math or language arts) (169-171).
Organizations and agencies can supply information on specific nutrition education curricula and materials (Appendix A). The USDA's NET Program provides technical assistance in school-based nutrition education (2,172). The Food and Nutrition Information Center of USDA's National Agricultural Library provides information on nutrition education evaluation and resources and serves as a national depository and lending library for NET materials. Nutritionists at some organizations can also answer specific nutrition content questions (Appendix A).
Focusing on Promoting Healthy Eating Behaviors
The primary goal of nutrition education should be to help young persons adopt eating behaviors that will promote health and reduce risk for disease. Knowing how and why to eat healthily is important, but knowledge alone does not enable young persons to adopt healthy eating behaviors (137). Cognitive-focused curricula on nutrition education typically result in gains in knowledge but usually have little effect on behavior (173-178).
Behaviorally based education encourages specific healthy eating behaviors (e.g., eating less fat and sodium and eating more fruits and vegetables) (136,179); however, it does not detail the technical and scientific knowledge on which dietary recommendations are based and, therefore, might not fulfill science education requirements (180). The strategies listed in Appendix C can be used as central concepts in a behaviorally based nutrition education program.
Several programs using a behavioral approach have achieved significant (p less than 0.05), positive changes in students' eating behaviors (167,181-190). Compared with students in control schools, students in some behaviorally based health and nutrition education programs had significant (p less than 0.05), favorable changes in serum cholesterol levels (167,188,191), blood pressure level (167,191), and body mass index (184). Although most of the behaviorally oriented programs did not achieve all their behavioral aims -- perhaps because of the limited amount of curriculum time (136) -- current scientific knowledge indicates that a focus on behavior is a key determinant in the success of nutrition education programs (136-138).
Recommendation 3. Instruction for students: Provide nutrition education through developmentally appropriate, culturally relevant, fun, participatory activities that involve social learning strategies.
Developmentally Appropriate and Culturally Relevant Activities
Different educational strategies should be used for young persons at different stages of cognitive development. Regardless of the amount and quality of teaching they receive, young elementary schoolchildren might not fully understand abstract concepts (e.g., the nutrient content of foods or the classification of foods into groups) (192-194). Nutrition education for young children should focus on concrete experiences (e.g., increasing exposure to many healthy foods and building skills in choosing healthy foods) (169).
More abstract associations between nutrition and health become appropriate as children approach middle school. By this age, children can understand and act on the connection between eating behaviors and health (137,194). Nutrition education for middle and high school students should focus on helping students assess their own eating behaviors and set goals for improving their food selection (138,195). Lessons for older children should emphasize personal responsibility, decision-making skills, and resisting negative social pressures (183,185,187,189).
Nutrition education presents opportunities for young persons to learn about and experience cultural diversity related to food and eating. Students from different cultural groups have different health concerns, eating patterns, food preferences, and food-related habits and attitudes. These differences need to be considered when designing lesson plans or discussing food choices. Nutrition education can succeed only when students believe it is relevant to their lives.
Active Learning and an Emphasis on Fun
The context in which students learn about healthy eating behaviors and the feelings students associate with healthy foods are key factors in determining their receptivity to nutrition education. Students are more likely to adopt healthy eating behaviors when
they learn about these behaviors through fun, participatory activities rather than through lectures (138,196,197);
lessons emphasize the positive, appealing aspects of healthy eating patterns rather than the negative consequences of unhealthy eating patterns;
the benefits of healthy eating behaviors are presented in the context of what is already important to the students; and
the students have repeated opportunities to taste foods that are low in fat, sodium, and added sugars and high in vitamins, minerals, and fiber during their lessons. ***
Computer-based lessons on nutrition can also be effective (198), especially when teacher time is limited or when student self-assessment is appropriate. Interactive, highly entertaining, and well-designed computer programs are now available to help young persons learn healthy food selection skills and assess their own diets (199,200). Computer-based lessons allow students to move at their own pace and can capture their attention.
Social Learning Techniques
Most of the nutrition education programs that have resulted in behavioral change have used teaching strategies based on social learning theory (195,201-205). In such lessons, increasing student knowledge is only one of many objectives. Social learning instruction also emphasizes
raising the value students place on good health and nutrition and identifying the benefits of adopting healthy eating patterns, including short-term benefits that are important to young persons (e.g., physical appearance, sense of personal control and independence, and capacity for physical activities);
giving students repeated opportunities to taste healthy foods, including foods they have not yet tasted;
working with parents, school personnel, public health professionals, and others to overcome barriers to healthy eating;
using influential role models, including peers, to demonstrate healthy eating practices;
providing incentives (e.g., verbal praise and small prizes) to reinforce messages;
helping students develop practical skills for and self-confidence in planning meals, preparing foods, reading food labels, and making healthy food choices through observation and hands-on practice;
enabling students to critically analyze sociocultural influences, including advertising, on food selection, to resist negative social pressures, and to develop social support for healthy eating; and
helping students analyze their own eating patterns, set realistic goals for changes in their eating behaviors, monitor their progress in reaching those goals, and reward themselves for achieving their goals. Nutrition education strategies include social learning techniques (Appendix C).
Recommendation 4. Integration of school food service and nutrition education: Coordinate school food service with nutrition education and with other components of the comprehensive school health program to reinforce messages on healthy eating.
The school cafeteria provides a place for students to practice healthy eating. This experience should be coordinated with classroom lessons to allow students to apply critical thinking skills taught in the classroom (2,8,9,11-15,18,169,178,206). School food service personnel can
visit classrooms and explain how they make sure meals meet the standards of the Dietary Guidelines for Americans,
invite classes to visit the cafeteria kitchen and learn how to prepare healthy foods,
involve students in planning the school menu and preparing recipes,
offer foods that reinforce classroom lessons (e.g., whole wheat rolls to reinforce a lesson on dietary fiber),
post in the cafeteria posters and fliers on nutrition, and
display nutrition information about available foods and give students opportunities to practice food analysis and selection skills learned in the classroom.
In addition, classroom teaching can complement the goals of the school food service. For example, teachers can help food service managers by teaching students about the importance of nutritious school meals and getting feedback from students on new menu items developed to meet the goals set by USDA's School Meals Initiatives for Healthy Children (154).
To ensure consistent nutrition messages from the school, food service personnel should work closely with those responsible for other components of the school health program. For example, the personnel can
help develop and implement school policies that make healthful foods available;
educate parents about the value of school meals (e.g., put health messages in monthly menus sent home to parents or make periodic presentations at parents' association meetings) (11,13);
help schools access and assess community public health and nutrition services; and
keep classroom teachers, physical education teachers, coaches, counselors, health-service providers, and other staff informed about the importance of healthy school meals.
Recommendation 5. Training for school staff: Provide staff involved in nutrition education with adequate preservice and ongoing in-service training that focuses on teaching strategies for behavioral change.
Training in nutrition and health education can increase the extent to which teachers implement a curriculum (207-209), which in turn affects the likelihood that students' eating behaviors will change (167,207). All elementary school teachers as well as secondary school teachers in disciplines such as home economics, family and consumer sciences, language arts, physical education, and science should receive nutrition education training. State NET Programs can provide technical assistance for training teachers in nutrition education (Appendix A).
Training should address content and teaching strategies. Because classroom teachers often need more help with innovative nutrition teaching techniques than with content (195,210), training should focus on giving teachers the skills they need to use the nonlecture, active learning methods discussed previously (195). Training programs are most effective if they
are designed to meet the specific needs of the teachers and are based on the teachers' level of nutrition knowledge and experience with the suggested teaching strategies,
model behavioral change techniques and give teachers practice in using them,
involve multiple sessions spaced across time so that teachers can try out the newly learned techniques in their classrooms and report on their experiences to the training group, and
provide posttraining sessions so that teachers can share experiences with their peers (211,212).
Teachers should understand the importance of fully implementing the selected curriculum and become familiar with its underlying theory and concepts. Training should also help teachers assess and improve their own eating practices and make them aware of the behavioral messages they give as role models (213).
Continuing education activities in nutrition education should be offered to food service personnel so this staff can reinforce classroom instruction through the school meal program and help shape the school's nutrition policy. State NET Programs and the National Food Service Management Institute provide technical assistance and training seminars for school nutrition professionals (see Appendix A). Administrative support is also critical to implementing a new program (214). Training for school administrators can help gain their support for nutrition education. Health promotion services for all school staff can positively affect their eating behaviors and their effectiveness in teaching healthy eating behaviors (180,215,216).
Recommendation 6. Family and community involvement: Involve family members and the community in supporting and reinforcing nutrition education.
The attitudes and behaviors of parents and caretakers directly influence children's and adolescents' choice of foods (217,218). Parents control most of the food choices available at home, so changing parents' eating behaviors may be one of the most effective ways to change their children's eating behaviors. Involving parents in a nutrition education curriculum at the elementary school level can enhance the eating behaviors of both the students (181,219-221) and the parents (181,219,222). Although parental involvement can enhance the effects of nutrition education programs at the elementary school level, it is not known whether involving parents at the secondary school level helps improve the students' eating behaviors. For older youths, self-assessment (185,189,198) and peer educators (187) might be more influential than parental involvement (137).
Parents are usually more receptive to activities that can be done at home than to those that require their attendance at the school (223,224). To involve parents and other family members in nutrition education, schools can
send nutrition education materials and cafeteria menus home with students,
ask parents to send healthy snacks to school,
invite parents and other family members to periodically eat with their children in the cafeteria,
invite families to attend exhibitions of student nutrition projects or health fairs (217),
offer nutrition education workshops and screening services, and
assign nutrition education homework that students can do with their families (e.g., reading and interpreting food labels, reading nutrition-related newsletters, and preparing healthy recipes).
Through school health advisory councils or through direct contact with community organizations, schools can engage community resources and services to respond to the nutritional needs of students (225,226). Schools can also participate in community-based nutrition education campaigns sponsored by public health agencies or voluntary organizations. Students are most likely to adopt healthy eating behaviors if they receive consistent messages through multiple channels (e.g., home, school, community, and the media) and from multiple sources (e.g., parents, peers, teachers, health professionals, and the media) (225).
Recommendation 7. Program evaluation: Regularly evaluate the effectiveness of the school health program in promoting healthy eating, and change the program as appropriate to increase its effectiveness.
Policymakers should regularly review the effectiveness of the school nutrition program. All groups affected by the program should have the opportunity to provide input. Assessment of nutrition programs and policies should include whether
a comprehensive school nutrition policy exists and is implemented as written;
nutrition education is provided throughout the preschool, primary, and secondary school years as part of comprehensive school health education;
teachers deliver nutrition education through developmentally appropriate, culturally relevant, fun, participatory activities that involve social learning strategies;
teachers and school food service personnel have undertaken joint project planning and action;
teachers have received curriculum-specific training; and
families and community organizations are involved in nutrition education.
Schools might also consider measuring the effects of their programs and policies on self-reported eating behaviors; key variables that influence behavior, such as knowledge, attitudes, self-confidence, and behavioral intentions; and in-school eating behaviors that are easy to assess, such as participation in school food service programs and the number of students choosing healthy alternatives in the cafeteria (e.g., salad bars or low-fat milk).
Schools can consult with the state NET Program or with evaluation specialists at universities, school districts, or the state departments of education or health to identify methods and materials for evaluating the effectiveness of their program (227,228). Valid evaluations can increase parent and community support for school programs, help schools reward teachers for exceptional work, and support grant applications for enhancing school health programs.
CONCLUSION
To ensure a healthy future for our children, school-based nutrition education programs must become a national priority. These programs should be part of comprehensive school health programs and reach students from preschool through secondary school. School leaders, community leaders, and parents must commit to implementing and sustaining nutrition education programs within the schools. Such support is crucial to promoting healthy eating behaviors.
The seven recommendations for school-based nutrition education presented in this report provide the framework for establishing such programs. By adopting these recommendations, schools can help ensure that all school-age youths attain their full educational potential and good health.
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Kalina BB, Philipps CA, Minns HV. The NET Program: a ten-year perspective. J Nutr Educ 1989;21(1):38-42.
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Byrd-Bredbenner C, Shannon B, Hsu L, Smith DH. A nutrition education curriculum for senior high home economics students: its effect on students' knowledge, attitudes, and behaviors. J Nutr Educ 1988;20(6):341-6.
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Connell DB, Turner RR, Mason EF. Summary of findings of the School Health Education Evaluation: health promotion effectiveness, implementation, and costs. J Sch Health 1985;55(8):316-21.
Olson CM, Devine CM, Frongillo EA Jr. Dissemination and use of a school-based nutrition education program for secondary school students. J Sch Health 1993;63(8):343-8.
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Crockett SJ, Mullis RM, Perry CL. Parent nutrition education: a conceptual model. J Sch Health 1988;58(2):53-7.
Hearn MD, Bigelow C, Nader PR, et al. Involving families in cardiovascular health promotion: the CATCH Feasibility Study. J Health Educ 1992;23(1):22-31.
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Perry CL, Luepker RV, Murray DM, et al. Parent involvement with children's health promotion: the Minnesota Home Team. Am J Public Health 1988;78(9):1156-60.
Crockett SJ, Mullis R, Perry CL, Luepker RV. Parent education in youth-directed nutrition interventions. Prev Med 1989;18:475-91.
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Perry CL, Crockett SJ, Pirie P. Influencing parental health behavior: implications of community assessments. Health Educ 1987;18(5):68-77.
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Stone EJ, McGraw SA, Osganian SK, Elder JP, eds. Process evaluation in the multicenter Child and Adolescent Trial for Cardiovascular Health (CATCH). Health Educ Q 1994;(suppl 2):S1- S142.
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* Obesity refers to an excess of total body fat. Body fat content is usually estimated by one of two techniques, measuring skinfold thickness or computing the ratio of body weight to height. Researchers who use weight-to-height ratios tend to use the term 'overweight' instead of 'obesity.' Although weight-to-height ratios correlate highly with body fat, they do not distinguish between body fat and lean body tissue: excess fat tissue is generally assumed to account for the additional weight, but excess weight can also include lean body mass or a large body frame (33).
** As defined by the U.S. Food and Drug Administration (156,157) in its food label regulations, a 'healthy' food must be low in fat (less than or equal to 3 g per serving), be low in saturated fat (less than or equal to 1 g per serving), contain limited amounts of cholesterol (less than or equal to 60 mg per serving for a single-item food), and contain limited amounts of salt (less than or equal to 480 mg per serving until 1998, when the criterion for a single-item food will decrease to less than or equal to 360 mg per serving). In addition, single-item foods that are not raw fruits or vegetables must provide greater than or equal to 10% of the daily value of one or more of the following nutrients: vitamin A, vitamin C, iron, calcium, protein, and fiber. Criteria for products that include more than one type of food (e.g., macaroni and cheese) vary depending on the food.
*** When serving food, teachers must use hygienic food handling practices and consider possible food allergies and religious prohibitions; the food service director can help in this area.
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**Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov.Page converted: 09/19/98
Nutrition is the science that interprets the interaction of nutrients and other substances in food in relation to maintenance, growth, reproduction, health and disease of an organism. It includes food intake, absorption, assimilation, biosynthesis, catabolism, and excretion.[1]
The diet of an organism is what it eats, which is largely determined by the availability and palatability of foods. For humans, a healthy diet includes preparation of food and storage methods that preserve nutrients from oxidation, heat or leaching, and that reduces risk of foodborne illnesses.
In humans, an unhealthy diet can cause deficiency-related diseases such as blindness, anemia, scurvy, preterm birth, stillbirth and cretinism,[2] or nutrient excess health-threatening conditions such as obesity[3][4] and metabolic syndrome;[5] and such common chronic systemic diseases as cardiovascular disease,[6]diabetes,[7][8] and osteoporosis.[9][10][11] Undernutrition can lead to wasting in acute cases, and the stunting of marasmus in chronic cases of malnutrition.[2]
- 1History of human nutrition
- 2Nutrients
- 2.1Macronutrients
- 2.1.1Carbohydrates
- 2.2Micronutrients
- 2.2.1Minerals
- 2.1Macronutrients
- 7Advice and guidance
- 9Malnutrition
- 11Outline of nutrition
- 11.4Fats
- 11.11Professions
History of human nutrition[edit]
Antiquity[edit]
The first recorded dietary advice, carved into a Babylonian stone tablet in about 2500 BC, cautioned those with pain inside to avoid eating onions for three days. Scurvy, later found to be a vitamin C deficiency, was first described in 1500 BC in the Ebers Papyrus.[12]
According to Walter Gratzer, the study of nutrition probably began during the 6th century BC. In China, the concept of qi developed, a spirit or 'wind' similar to what Western Europeans later called pneuma.[13] Food was classified into 'hot' (for example, meats, blood, ginger, and hot spices) and 'cold' (green vegetables) in China, India, Malaya, and Persia.[14]Humours developed perhaps first in China alongside qi.[13] Ho the Physician concluded that diseases are caused by deficiencies of elements (Wu Xing: fire, water, earth, wood, and metal), and he classified diseases as well as prescribed diets.[14] About the same time in Italy, Alcmaeon of Croton (a Greek) wrote of the importance of equilibrium between what goes in and what goes out, and warned that imbalance would result in disease marked by obesity or emaciation.[15]
The first recorded nutritional experiment with human subjects is found in the Bible's Book of Daniel. Daniel and his friends were captured by the king of Babylon during an invasion of Israel. Selected as court servants, they were to share in the king's fine foods and wine. But they objected, preferring vegetables (pulses) and water in accordance with their Jewish dietary restrictions. The king's chief steward reluctantly agreed to a trial. Daniel and his friends received their diet for ten days and were then compared to the king's men. Appearing healthier, they were allowed to continue with their diet.[16][17]
Around 475 BC, Anaxagoras stated that food is absorbed by the human body and, therefore, contains 'homeomerics' (generative components), suggesting the existence of nutrients.[18] Around 400 BC, Hippocrates, who recognized and was concerned with obesity, which may have been common in southern Europe at the time,[15] said, 'Let food be your medicine and medicine be your food.'[19] The works that are still attributed to him, Corpus Hippocraticum, called for moderation and emphasized exercise.[15]
Salt, pepper and other spices were prescribed for various ailments in various preparations for example mixed with vinegar. In the 2nd century BC, Cato the Elder believed that cabbage (or the urine of cabbage-eaters) could cure digestive diseases, ulcers, warts, and intoxication. Living about the turn of the millennium, Aulus Celsus, an ancient Roman doctor, believed in 'strong' and 'weak' foods (bread for example was strong, as were older animals and vegetables).[20]
Galen to Lind[edit]
One mustn't overlook the doctrines of Galen: In use from his life in the 1st century AD until the 17th century, it was heresy to disagree with him for 1500 years.[21] Galen was physician to gladiators in Pergamon, and in Rome, physician to Marcus Aurelius and the three emperors who succeeded him.[22] Most of Galen's teachings were gathered and enhanced in the late 11th century by Benedictine monks at the School of Salerno in Regimen sanitatis Salernitanum, which still had users in the 17th century.[23] Galen believed in the bodily humours of Hippocrates, and he taught that pneuma is the source of life. Four elements (earth, air, fire and water) combine into 'complexion', which combines into states (the four temperaments: sanguine, phlegmatic, choleric, and melancholic). The states are made up of pairs of attributes (hot and moist, cold and moist, hot and dry, and cold and dry), which are made of four humours: blood, phlegm, green (or yellow) bile, and black bile (the bodily form of the elements). Galen thought that for a person to have gout, kidney stones, or arthritis was scandalous, which Gratzer likens to Samuel Butler's Erehwon (1872) where sickness is a crime.[21]
In the 1500s, Paracelsus was probably the first to criticize Galen publicly.[21] Also in the 16th century, scientist and artist Leonardo da Vinci compared metabolism to a burning candle. Leonardo did not publish his works on this subject, but he was not afraid of thinking for himself and he definitely disagreed with Galen.[14] Ultimately, 16th century works of Andreas Vesalius, sometimes called the father of modern human anatomy, overturned Galen's ideas.[25] He was followed by piercing thought amalgamated with the era's mysticism and religion sometimes fueled by the mechanics of Newton and Galileo. Jan Baptist van Helmont, who discovered several gases such as carbon dioxide, performed the first quantitative experiment. Robert Boyle advanced chemistry. Sanctorius measured body weight. Physician Herman Boerhaave modeled the digestive process. Physiologist Albrecht von Haller worked out the difference between nerves and muscles.[26]
Sometimes forgotten during his life, James Lind, a physician in the British navy, performed the first scientific nutrition experiment in 1747. Lind discovered that lime juice saved sailors that had been at sea for years from scurvy, a deadly and painful bleeding disorder. Between 1500 and 1800, an estimated two million sailors had died of scurvy.[27] The discovery was ignored for forty years, after which British sailors became known as 'limeys.'[28] The essential vitamin C within citrus fruits would not be identified by scientists until 1932.[27]
Lavoisier and modern science[edit]
Around 1770, Antoine Lavoisier discovered the details of metabolism, demonstrating that the oxidation of food is the source of body heat. Called the most fundamental chemical discovery of the 18th century,[30] Lavoisier discovered the principle of conservation of mass. His ideas made the phlogiston theory of combustion obsolete.[31]
In 1790, George Fordyce recognized calcium as necessary for the survival of fowl. In the early 19th century, the elements carbon, nitrogen, hydrogen, and oxygen were recognized as the primary components of food, and methods to measure their proportions were developed.[32]
In 1816, François Magendie discovered that dogs fed only carbohydrates (sugar), fat (olive oil), and water died evidently of starvation, but dogs also fed protein survived, identifying protein as an essential dietary component.[33]William Prout in 1827 was the first person to divide foods into carbohydrates, fat, and protein.[34] During the 19th century, Jean-Baptiste Dumas and Justus von Liebig quarrelled over their shared belief that animals get their protein directly from plants (animal and plant protein are the same and that humans do not create organic compounds).[35] With a reputation as the leading organic chemist of his day but with no credentials in animal physiology,[36] Liebig grew rich making food extracts like beef bouillon and infant formula that were later found to be of questionable nutritious value.[37] In the 1860s, Claude Bernard discovered that body fat can be synthesized from carbohydrate and protein, showing that the energy in blood glucose can be stored as fat or as glycogen.[38]
In the early 1880s, Kanehiro Takaki observed that Japanese sailors (whose diets consisted almost entirely of white rice) developed beriberi (or endemic neuritis, a disease causing heart problems and paralysis), but British sailors and Japanese naval officers did not. Adding various types of vegetables and meats to the diets of Japanese sailors prevented the disease, (not because of the increased protein as Takaki supposed but because it introduced a few parts per million of thiamine to the diet, later understood as a cure[39]).
In 1896, Eugen Baumann observed iodine in thyroid glands. In 1897, Christiaan Eijkman worked with natives of Java, who also suffered from beriberi. Eijkman observed that chickens fed the native diet of white rice developed the symptoms of beriberi but remained healthy when fed unprocessed brown rice with the outer bran intact. His assistant, Gerrit Grijns correctly identified and described the anti-beriberi substance in rice. Eijkman cured the natives by feeding them brown rice, discovering that food can cure disease. Over two decades later, nutritionists learned that the outer rice bran contains vitamin B1, also known as thiamine.
From 1900 to the present[edit]
In the early 20th century, Carl von Voit and Max Rubner independently measured caloric energy expenditure in different species of animals, applying principles of physics in nutrition. In 1906, Edith G. Willcock and Frederick Hopkins showed that the amino acid tryptophan aids the well-being of mice but it did not assure their growth.[40] In the middle of twelve years of attempts to isolate them,[41] Hopkins said in a 1906 lecture that 'unsuspected dietetic factors,' other than calories, protein, and minerals, are needed to prevent deficiency diseases.[42] In 1907, Stephen M. Babcock and Edwin B. Hart started the cow feeding, single-grain experiment, which took nearly four years to complete.
| Vitamin | Year Isolated[43] |
|---|---|
| Thiamin | 1926 |
| Vitamin C | 1926 |
| Vitamin A | 1939 |
| Vitamin D | 1931 |
| Vitamin E | 1936 |
| Niacin | 1937 |
| Biotin | 1939 |
| Vitamin K | 1939 |
| Pantothenic acid | 1939 |
| Folate | 1939 |
| Riboflavin | 1933 |
| Vitamin B6 | 1936 |
In 1912, Casimir Funk coined the term vitamin, a vital factor in the diet, from the words 'vital' and 'amine,' because these unknown substances preventing scurvy, beriberi, and pellagra, were thought then to be derived from ammonia. The vitamins were studied in the first half of the 20th century.
In 1913, Elmer McCollum and Marguerite Davis discovered the first vitamin, fat-soluble vitamin A, then water-soluble vitamin B (in 1915; now known to be a complex of several water-soluble vitamins) and named vitamin C as the then-unknown substance preventing scurvy. Lafayette Mendel and Thomas Osborne also performed pioneering work on vitamins A and B. In 1919, Sir Edward Mellanby incorrectly identified rickets as a vitamin A deficiency because he could cure it in dogs with cod liver oil.[45] In 1922, McCollum destroyed the vitamin A in cod liver oil, but found that it still cured rickets.[45] Also in 1922, H.M. Evans and L.S. Bishop discover vitamin E as essential for rat pregnancy, originally calling it 'food factor X' until 1925.
In 1925, Hart discovered that trace amounts of copper are necessary for iron absorption. In 1927, Adolf Otto Reinhold Windaus synthesized vitamin D, and was awarded the Nobel Prize in Chemistry in 1928. In 1928, Albert Szent-Györgyi isolated ascorbic acid, and in 1932 proved that it is vitamin C by preventing scurvy. In 1935, he synthesized it, and in 1937, he won a Nobel Prize for his efforts. Szent-Györgyi concurrently elucidated much of the citric acid cycle.
In the 1930s, William Cumming Rose identified essential amino acids, necessary protein components that the body cannot synthesize. In 1935, Underwood and Marston independently discovered the necessity of cobalt. In 1936, Eugene Floyd DuBois showed that work and school performance are related to caloric intake. In 1938, Erhard Fernholz discovered the chemical structure of vitamin E and then he tragically disappeared.[46][47] It was synthesised the same year by Paul Karrer.[46]
In 1940, rationing in the United Kingdom during and after World War II took place according to nutritional principles drawn up by Elsie Widdowson and others. In 1941, the first Recommended Dietary Allowances (RDAs) were established by the National Research Council.
In 1992, The U.S. Department of Agriculture introduced the Food Guide Pyramid.[48] This replaced the Four Food Groups (1956-1992) and was superseded by the concept of MyPlate (2011–present).
Nutrients[edit]
The list of nutrients that people are known to require is, in the words of Marion Nestle, 'almost certainly incomplete'.[49] As of 2014, nutrients are thought to be of two types: macronutrients which are needed in relatively large amounts, and micronutrients which are needed in smaller quantities.[50] A type of carbohydrate, dietary fiber, i.e. non-digestible material such as cellulose, is required,[51] for both mechanical and biochemical reasons, although the exact reasons remain unclear. Some nutrients can be stored - the fat-soluble vitamins - while others are required more or less continuously. Poor health can be caused by a lack of required nutrients, or for some vitamins and minerals, too much of a required nutrient.
Macronutrients[edit]
The macronutrients are carbohydrates, fiber, fats, protein, and water.[50]The macronutrients (excluding fiber and water) provide structural material (amino acids from which proteins are built, and lipids from which cell membranes and some signaling molecules are built) and energy. Some of the structural material can be used to generate energy internally, and in either case it is measured in Joules or kilocalories (often called 'Calories' and written with a capital C to distinguish them from little 'c' calories). Carbohydrates and proteins provide 17 kJ approximately (4 kcal) of energy per gram, while fats provide 37 kJ (9 kcal) per gram,[52] though the net energy from either depends on such factors as absorption and digestive effort, which vary substantially from instance to instance. Vitamins, minerals, fiber, and water do not provide energy, but are required for other reasons.
Molecules of carbohydrates and fats consist of carbon, hydrogen, and oxygen atoms. Carbohydrates range from simple monosaccharides (glucose, fructose and galactose) to complex polysaccharides (starch). Fats are triglycerides, made of assorted fatty acidmonomers bound to a glycerol backbone. Some fatty acids, but not all, are essential in the diet: they cannot be synthesized in the body. Protein molecules contain nitrogen atoms in addition to carbon, oxygen, and hydrogen. The fundamental components of protein are nitrogen-containing amino acids, some of which are essential in the sense that humans cannot make them internally. Some of the amino acids are convertible (with the expenditure of energy) to glucose and can be used for energy production, just as ordinary glucose, in a process known as gluconeogenesis. By breaking down existing protein, the carbon skeleton of the various amino acids can be metabolized to intermediates in cellular respiration; the remaining ammonia is discarded primarily as urea in urine.
Carbohydrates[edit]
Carbohydrates may be classified as monosaccharides, disaccharides, or polysaccharides depending on the number of monomer (sugar) units they contain. They constitute a large part of foods such as rice, noodles, bread, and other grain-based products, also potatoes , yams, beans, fruits, fruit juices and vegetables.Monosaccharides, disaccharides, and polysaccharides contain one, two, and three or more sugar units, respectively. Polysaccharides are often referred to as complex carbohydrates because they are typically long, multiple branched chains of sugar units.
Traditionally, simple carbohydrates are believed to be absorbed quickly, and therefore to raise blood-glucose levels more rapidly than complex carbohydrates. This, however, is not accurate.[53][54][55][56] Some simple carbohydrates (e.g., fructose) follow different metabolic pathways (e.g., fructolysis) that result in only a partial catabolism to glucose, while, in essence, many complex carbohydrates may be digested at the same rate as simple carbohydrates.[57] The World Health Organization (WHO) recommends that added sugars should represent no more than 10% of total energy intake.[58]
Fiber[edit]
Dietary fiber is a carbohydrate that is incompletely absorbed in humans and in some animals. Like all carbohydrates, when it is metabolized it can produce four Calories (kilocalories) of energy per gram. However, in most circumstances it accounts for less than that because of its limited absorption and digestibility. Dietary fiber consists mainly of cellulose, a large carbohydrate polymer which is indigestible as humans do not have the required enzymes to disassemble it. There are two subcategories: soluble and insoluble fiber. Whole grains, fruits (especially plums, prunes, and figs), and vegetables are good sources of dietary fiber. There are many health benefits of a high-fiber diet. Dietary fiber helps reduce the chance of gastrointestinal problems such as constipation and diarrhea by increasing the weight and size of stool and softening it. Insoluble fiber, found in whole wheat flour, nuts and vegetables, especially stimulates peristalsis – the rhythmic muscular contractions of the intestines, which move digest along the digestive tract. Soluble fiber, found in oats, peas, beans, and many fruits, dissolves in water in the intestinal tract to produce a gel that slows the movement of food through the intestines. This may help lower blood glucose levels because it can slow the absorption of sugar. Additionally, fiber, perhaps especially that from whole grains, is thought to possibly help lessen insulin spikes, and therefore reduce the risk of type 2 diabetes. The link between increased fiber consumption and a decreased risk of colorectal cancer is still uncertain.
Fat[edit]
A molecule of dietary fat typically consists of several fatty acids (containing long chains of carbon and hydrogen atoms), bonded to a glycerol. They are typically found as triglycerides (three fatty acids attached to one glycerol backbone). Fats may be classified as saturated or unsaturated depending on the detailed structure of the fatty acids involved. Saturated fats have all of the carbon atoms in their fatty acid chains bonded to hydrogen atoms, whereas unsaturated fats have some of these carbon atoms double-bonded, so their molecules have relatively fewer hydrogen atoms than a saturated fatty acid of the same length. Unsaturated fats may be further classified as monounsaturated (one double-bond) or polyunsaturated (many double-bonds). Furthermore, depending on the location of the double-bond in the fatty acid chain, unsaturated fatty acids are classified as omega-3 or omega-6 fatty acids. Trans fats are a type of unsaturated fat with trans-isomer bonds; these are rare in nature and in foods from natural sources; they are typically created in an industrial process called (partial) hydrogenation. There are nine kilocalories in each gram of fat. Fatty acids such as conjugated linoleic acid, catalpic acid, eleostearic acid and punicic acid, in addition to providing energy, represent potent immune modulatory molecules.
Saturated fats (typically from animal sources) have been a staple in many world cultures for millennia. Unsaturated fats (e. g., vegetable oil) are considered healthier, while trans fats are to be avoided. Saturated and some trans fats are typically solid at room temperature (such as butter or lard), while unsaturated fats are typically liquids (such as olive oil or flaxseed oil). Trans fats are very rare in nature, and have been shown to be highly detrimental to human health, but have properties useful in the food processing industry, such as rancidity resistance.[59]
Essential fatty acids[edit]
Most fatty acids are non-essential, meaning the body can produce them as needed, generally from other fatty acids and always by expending energy to do so. However, in humans, at least two fatty acids are essential and must be included in the diet. An appropriate balance of essential fatty acids—omega-3 and omega-6 fatty acids—seems also important for health, although definitive experimental demonstration has been elusive. Both of these 'omega' long-chain polyunsaturated fatty acids are substrates for a class of eicosanoids known as prostaglandins, which have roles throughout the human body. They are hormones, in some respects. The omega-3 eicosapentaenoic acid (EPA), which can be made in the human body from the omega-3 essential fatty acid alpha-linolenic acid (ALA), or taken in through marine food sources, serves as a building block for series 3 prostaglandins (e.g., weakly inflammatory PGE3). The omega-6 dihomo-gamma-linolenic acid (DGLA) serves as a building block for series 1 prostaglandins (e.g. anti-inflammatory PGE1), whereas arachidonic acid (AA) serves as a building block for series 2 prostaglandins (e.g. pro-inflammatory PGE 2). Both DGLA and AA can be made from the omega-6 linoleic acid (LA) in the human body, or can be taken in directly through food. An appropriately balanced intake of omega-3 and omega-6 partly determines the relative production of different prostaglandins, which is one reason why a balance between omega-3 and omega-6 is believed important for cardiovascular health. In industrialized societies, people typically consume large amounts of processed vegetable oils, which have reduced amounts of the essential fatty acids along with too much of omega-6 fatty acids relative to omega-3 fatty acids.
The conversion rate of omega-6 DGLA to AA largely determines the production of the prostaglandins PGE1 and PGE2. Omega-3 EPA prevents AA from being released from membranes, thereby skewing prostaglandin balance away from pro-inflammatory PGE2 (made from AA) toward anti-inflammatory PGE1 (made from DGLA). Moreover, the conversion (desaturation) of DGLA to AA is controlled by the enzyme delta-5-desaturase, which in turn is controlled by hormones such as insulin (up-regulation) and glucagon (down-regulation). The amount and type of carbohydrates consumed, along with some types of amino acid, can influence processes involving insulin, glucagon, and other hormones; therefore, the ratio of omega-3 versus omega-6 has wide effects on general health, and specific effects on immune function and inflammation, and mitosis (i.e., cell division).
Protein[edit]
Proteins are structural materials in much of the animal body (e.g. muscles, skin, and hair). They also form the enzymes that control chemical reactions throughout the body. Each protein molecule is composed of amino acids, which are characterized by inclusion of nitrogen and sometimes sulphur (these components are responsible for the distinctive smell of burning protein, such as the keratin in hair). The body requires amino acids to produce new proteins (protein retention) and to replace damaged proteins (maintenance). As there is no protein or amino acid storage provision, amino acids must be present in the diet. Excess amino acids are discarded, typically in the urine. For all animals, some amino acids are essential (an animal cannot produce them internally) and some are non-essential (the animal can produce them from other nitrogen-containing compounds). About twenty amino acids are found in the human body, and about ten of these are essential and, therefore, must be included in the diet. A diet that contains adequate amounts of amino acids (especially those that are essential) is particularly important in some situations: during early development and maturation, pregnancy, lactation, or injury (a burn, for instance). A complete protein source contains all the essential amino acids; an incomplete protein source lacks one or more of the essential amino acids.
It is possible with protein combinations of two incomplete protein sources (e.g., rice and beans) to make a complete protein source, and characteristic combinations are the basis of distinct cultural cooking traditions. However, complementary sources of protein do not need to be eaten at the same meal to be used together by the body.[60] Excess amino acids from protein can be converted into glucose and used for fuel through a process called gluconeogenesis.
Water[edit]
Water is excreted from the body in multiple forms; including urine and feces, sweating, and by water vapour in the exhaled breath. Therefore, it is necessary to adequately rehydrate to replace lost fluids.
Early recommendations for the quantity of water required for maintenance of good health suggested that 6–8 glasses of water daily is the minimum to maintain proper hydration.[61] However the notion that a person should consume eight glasses of water per day cannot be traced to a credible scientific source.[62] The original water intake recommendation in 1945 by the Food and Nutrition Board of the National Research Council read: 'An ordinary standard for diverse persons is 1 milliliter for each calorie of food. Most of this quantity is contained in prepared foods.'[63] More recent comparisons of well-known recommendations on fluid intake have revealed large discrepancies in the volumes of water we need to consume for good health.[64] Therefore, to help standardize guidelines, recommendations for water consumption are included in two recent European Food Safety Authority (EFSA) documents (2010): (i) Food-based dietary guidelines and (ii) Dietary reference values for water or adequate daily intakes (ADI).[65] These specifications were provided by calculating adequate intakes from measured intakes in populations of individuals with “desirable osmolarity values of urine and desirable water volumes per energy unit consumed.”[65]
For healthful hydration, the current EFSA guidelines recommend total water intakes of 2.0 L/day for adult females and 2.5 L/day for adult males. These reference values include water from drinking water, other beverages, and from food. About 80% of our daily water requirement comes from the beverages we drink, with the remaining 20% coming from food.[66] Water content varies depending on the type of food consumed, with fruit and vegetables containing more than cereals, for example.[67] These values are estimated using country-specific food balance sheets published by the Food and Agriculture Organisation of the United Nations.[67]
The EFSA panel also determined intakes for different populations. Recommended intake volumes in the elderly are the same as for adults as despite lower energy consumption, the water requirement of this group is increased due to a reduction in renal concentrating capacity.[65]Pregnant and breastfeeding women require additional fluids to stay hydrated. The EFSA panel proposes that pregnant women should consume the same volume of water as non-pregnant women, plus an increase in proportion to the higher energy requirement, equal to 300 mL/day.[65] To compensate for additional fluid output, breastfeeding women require an additional 700 mL/day above the recommended intake values for non-lactating women. Dehydration and over-hydration - too little and too much water, respectively - can have harmful consequences. Drinking too much water is one of the possible causes of hyponatremia, i.e., low serum sodium.[65][68]
Alcohol (ethanol)[edit]
Pure ethanol provides 7 calories per gram. For distilled spirits, a standard serving in the United States is 1.5 fluid ounces, which at 40% ethanol (80 proof), would be 14 grams and 98 calories.[69] Wine and beer contain a similar range of ethanol for servings of 5 ounces and 12 ounces, respectively, but these beverages also contain non-ethanol calories. A 5 ounce serving of wine contains 100 to 130 calories. A 12 ounce serving of beer contains 95 to 200 calories.[70] According to the U.S. Department of Agriculture, based on NHANES 2013-2014 surveys, women ages 20 and up consume on average 6.8 grams/day and men consume on average 15.5 grams/day.[71] Ignoring the non-alcohol contribution of those beverages, the average ethanol calorie contributions are 48 and 108 cal/day. Alcoholic beverages are considered empty calorie foods because other than calories, these contribute no essential nutrients.
Micronutrients[edit]
The micronutrients are minerals, vitamins, and others.[50]
Renal Nutrition Games For High School Students
Minerals[edit]
Dietary minerals are inorganicchemical elements required by living organisms,[72] other than the four elements carbon, hydrogen, nitrogen, and oxygen that are present in nearly all organic molecules. The term 'mineral' is archaic, since the intent is to describe simply the less common elements in the diet. Some are heavier than the four just mentioned, including several metals, which often occur as ions in the body. Some dietitians recommend that these be supplied from foods in which they occur naturally, or at least as complex compounds, or sometimes even from natural inorganic sources (such as calcium carbonate from ground oyster shells). Some minerals are absorbed much more readily in the ionic forms found in such sources. On the other hand, minerals are often artificially added to the diet as supplements; the most famous is likely iodine in iodized salt which prevents goiter.
Macrominerals[edit]
Many elements are essential nutrients called dietary minerals. Some have roles as cofactors, while others are electrolytes.[73] Elements with recommended dietary allowance (RDA) greater than 150 mg/day are, in alphabetical order:
- Calcium, a common electrolyte, but also needed structurally (for muscle and digestive system health, bone strength, some forms neutralize acidity, provides signaling ions for nerve and membrane functions)
- Chloride; electrolyte; see sodium, below
- Magnesium, required for processing ATP and related reactions (builds bone, facilitates peristalsis)
- Phosphorus, required component of bones; essential for energy processing[74]
- Potassium, an electrolyte (heart and nerve functions)
- Sodium, an electrolyte; common in food and manufactured beverages, typically as sodium chloride. Excessive sodium consumption can deplete calcium and magnesium,[75] leading to high blood pressure.
Trace minerals[edit]
Many elements are required in trace amounts, usually because they play a catalytic role in enzymes.[76] Some trace mineral elements (RDA < 200 mg/day) are, in alphabetical order:
- Cobalt required for biosynthesis of vitamin B12 family of coenzymes. Animals cannot biosynthesize B12, and must obtain this cobalt-containing vitamin in their diet.
- Copper required component of many redox enzymes, including cytochrome c oxidase
- Chromium required for sugar metabolism
- Iodine required not only for the biosynthesis of thyroxine but also — it is presumed — for other important organs as breast, stomach, salivary glands, thymus, etc. (see Extrathyroidal iodine); for this reason iodine is needed in larger quantities than others in this list, and sometimes classified with the macrominerals
- Iron required for many enzymes, and for hemoglobin and some other proteins
- Manganese (processing of oxygen)
- Molybdenum required for xanthine oxidase and related oxidases
- Selenium required for peroxidase (antioxidant proteins)
- Zinc required for several enzymes such as carboxypeptidase, liver alcohol dehydrogenase, and carbonic anhydrase
Vitamins[edit]
Vitamins are essential nutrients,[72] necessary in the diet for good health. (Vitamin D is an exception, as it can be synthesized in the skin in the presence of UVB radiation, and many animal species can synthesize vitamin C.) Vitamin deficiencies may result in disease conditions, including goitre, scurvy, osteoporosis, impaired immune system, disorders of cell metabolism, certain forms of cancer, symptoms of premature aging, and poor psychological health, among many others.[77] Excess levels of some vitamins are also dangerous to health. The Food and Nutrition Board of the Institute of Medicine has established Tolerable Upper Intake Levels (ULs) for seven vitamins.[78]
Phytochemicals[edit]
Phytochemicals such as polyphenols are compounds produced naturally in plants (phyto means 'plant' in Greek). In general, the term identifies compounds that are prevalent in plant foods, but are not proven to be essential for human nutrition, as of 2018. There is no conclusive evidence in humans that polyphenols or other non-nutrient compounds from plants confer health benefits, mainly because these compounds have poor bioavailability, i,e., following ingestion, they are digested into smaller metabolites with unknown functions, then are rapidly eliminated from the body.[79][80]
While initial studies sought to reveal if dietary supplements might promote health, one meta-analysis concluded that supplementation with antioxidant vitamins A and E and beta-carotene did not convey any benefits, and may increase risk of death.[81] Vitamin C and selenium supplements did not impact mortality rate. Health effects of non-nutrient phytochemicals such as polyphenols were not assessed in this review.[82]
Intestinal bacterial flora[edit]
Animal intestines contain a large population of gut flora. In humans, the four dominant phyla are Firmicutes, Bacteroidetes, Actinobacteria, and Proteobacteria.[83] They are essential to digestion and are also affected by food that is consumed. Bacteria in the large intestine perform many important functions for humans, including breaking down and aiding in the absorption of fermentable fiber, stimulating cell growth, repressing the growth of harmful bacteria, training the immune system to respond only to pathogens, producing vitamin B12, and defending against some infectious diseases.[84] 'Probiotics' refers to the idea of deliberately consuming live bacteria in an attempt to change the bacterial population in the large intestine, to the health benefit of the host human or animal. 'Prebiotic (nutrition)' refers to the idea that consuming a bacterial energy source such as soluble fiber could support the population of health-beneficial bacteria in the large intestine. There is not yet a scientific consensus as to health benefits accruing from probiotics or prebiotics.
Animal nutrition[edit]
Carnivore and herbivore diets are contrasting, with basic nitrogen and carbon proportions vary for their particular foods. Many herbivores rely on bacterial fermentation to create digestible nutrients from indigestible plant cellulose, while obligate carnivores must eat animal meats to obtain certain vitamins or nutrients their bodies cannot otherwise synthesize.[85]
Plant nutrition[edit]
Plant nutrition is the study of the chemical elements that are necessary for plant growth.[86] There are several principles that apply to plant nutrition. Some elements are directly involved in plant metabolism. However, this principle does not account for the so-called beneficial elements, whose presence, while not required, has clear positive effects on plant growth.
A nutrient that is able to limit plant growth according to Liebig's law of the minimum is considered an essential plant nutrient if the plant cannot complete its full life cycle without it. There are 16 essential plant soil nutrients, besides the three major elemental nutrients carbon and oxygen that are obtained by photosynthetic plants from carbon dioxide in air, and hydrogen, which is obtained from water.
Plants uptake essential elements from the soil through their roots and from the air (consisting of mainly nitrogen and oxygen) through their leaves. Green plants obtain their carbohydrate supply from the carbon dioxide in the air by the process of photosynthesis. Carbon and oxygen are absorbed from the air, while other nutrients are absorbed from the soil. Nutrient uptake in the soil is achieved by cation exchange, wherein root hairs pump hydrogen ions (H+) into the soil through proton pumps. These hydrogen ions displace cations attached to negatively charged soil particles so that the cations are available for uptake by the root. In the leaves, stomata open to take in carbon dioxide and expel oxygen. The carbon dioxide molecules are used as the carbon source in photosynthesis.
Although nitrogen is plentiful in the Earth's atmosphere, very few plants can use this directly. Most plants, therefore, require nitrogen compounds to be present in the soil in which they grow. This is made possible by the fact that largely inert atmospheric nitrogen is changed in a nitrogen fixation process to biologically usable forms in the soil by bacteria.[87]
Plant nutrition is a difficult subject to understand completely, partially because of the variation between different plants and even between different species or individuals of a given clone. Elements present at low levels may cause deficiency symptoms, and toxicity is possible at levels that are too high. Furthermore, deficiency of one element may present as symptoms of toxicity from another element, and vice versa.
Advice and guidance[edit]
Government policies[edit]
Canada's Food Guide is an example of a government-run nutrition program. Produced by Health Canada, the guide advises food quantities, provides education on balanced nutrition, and promotes physical activity in accordance with government-mandated nutrient needs. Like other nutrition programs around the world, Canada's Food Guide divides nutrition into four main food groups: vegetables and fruit, grain products, milk and alternatives, and meat and alternatives.[88] Unlike its American counterpart, the Canadian guide references and provides alternative to meat and dairy, which can be attributed to the growing vegan and vegetarian movements.
In the US, nutritional standards and recommendations are established jointly by the US Department of Agriculture and US Department of Health and Human Services and these recommendations are published as the Dietary Guidelines for Americans. Dietary and physical activity guidelines from the USDA are presented in the concept of MyPlate, which superseded the food pyramid, which replaced the Four Food Groups. The Senate committee currently responsible for oversight of the USDA is the Agriculture, Nutrition and Forestry Committee. Committee hearings are often televised on C-SPAN. The U.S. Department of Health and Human Services provides a sample week-long menu that fulfills the nutritional recommendations of the government.[89]
Government programs[edit]
Governmental organisations have been working on nutrition literacy interventions in non-primary health care settings to address the nutrition information problem in the U.S. Some programs include:
The Family Nutrition Program (FNP) is a free nutrition education program serving low-income adults around the U.S. This program is funded by the Food Nutrition Service’s (FNS) branch of the United States Department of Agriculture (USDA) usually through a local state academic institution that runs the program. The FNP has developed a series of tools to help families participating in the Food Stamp Program stretch their food dollar and form healthful eating habits including nutrition education.[90]
Expanded Food and Nutrition Education Program (ENFEP) is a unique program that currently operates in all 50 states and in American Samoa, Guam, Micronesia, Northern Marianas, Puerto Rico, and the Virgin Islands. It is designed to assist limited-resource audiences in acquiring the knowledge, skills, attitudes, and changed behavior necessary for nutritionally sound diets, and to contribute to their personal development and the improvement of the total family diet and nutritional well-being.
An example of a state initiative to promote nutrition literacy is Smart Bodies, a public-private partnership between the state’s largest university system and largest health insurer, Louisiana State Agricultural Center and Blue Cross and Blue Shield of Louisiana Foundation. Launched in 2005, this program promotes lifelong healthful eating patterns and physically active lifestyles for children and their families. It is an interactive educational program designed to help prevent childhood obesity through classroom activities that teach children healthful eating habits and physical exercise.
Education[edit]
Nutrition is taught in schools in many countries. In England and Wales, the Personal and Social Education and Food Technology curricula include nutrition, stressing the importance of a balanced diet and teaching how to read nutrition labels on packaging. In many schools, a Nutrition class will fall within the Family and Consumer Science or Health departments. In some American schools, students are required to take a certain number of FCS or Health related classes. Nutrition is offered at many schools, and, if it is not a class of its own, nutrition is included in other FCS or Health classes such as: Life Skills, Independent Living, Single Survival, Freshmen Connection, Health etc. In many Nutrition classes, students learn about the food groups, the food pyramid, Daily Recommended Allowances, calories, vitamins, minerals, malnutrition, physical activity, healthful food choices, portion sizes, and how to live a healthy life.
A 1985, US National Research Council report entitled Nutrition Education in US Medical Schools concluded that nutrition education in medical schools was inadequate.[91] Only 20% of the schools surveyed taught nutrition as a separate, required course. A 2006 survey found that this number had risen to 30%.[92] Membership by physicians in leading professional nutrition societies such as the American Society for Nutrition has generally declined from the 1990s.[93]
Professional organizations[edit]
In the US, Registered dietitian nutritionists (RDs or RDNs)[94] are health professionals qualified to provide safe, evidence-based dietary advice which includes a review of what is eaten, a thorough review of nutritional health, and a personalized nutritional treatment plan through dieting. They also provide preventive and therapeutic programs at work places, schools and similar institutions. Certified Clinical Nutritionists or CCNs, are trained health professionals who also offer dietary advice on the role of nutrition in chronic disease, including possible prevention or remediation by addressing nutritional deficiencies before resorting to drugs.[95] Government regulation especially in terms of licensing, is currently less universal for the CCN than that of RD or RDN. Another advanced Nutrition Professional is a Certified Nutrition Specialist or CNS. These Board Certified Nutritionists typically specialize in obesity and chronic disease. In order to become board certified, potential CNS candidate must pass an examination, much like Registered Dieticians. This exam covers specific domains within the health sphere including; Clinical Intervention and Human Health.[96]
Nutrition literacy[edit]
The findings of the 2003 National Assessment of Adult Literacy (NAAL) provide a basis upon which to frame the nutrition literacy problem in the U.S. NAAL introduced the first ever measure of 'the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions' – an objective of Healthy People 2010[97] and of which nutrition literacy might be considered an important subset. On a scale of below basic, basic, intermediate and proficient, NAAL found 13 percent of adult Americans have proficient health literacy, 44% have intermediate literacy, 29 percent have basic literacy and 14 percent have below basic health literacy. The study found that health literacy increases with education and people living below the level of poverty have lower health literacy than those above it.
Another study examining the health and nutrition literacy status of residents of the lower Mississippi Delta found that 52 percent of participants had a high likelihood of limited literacy skills.[98] While a precise comparison between the NAAL and Delta studies is difficult, primarily because of methodological differences, Zoellner et al. suggest that health literacy rates in the Mississippi Delta region are different from the U.S. general population and that they help establish the scope of the problem of health literacy among adults in the Delta region. For example, only 12 percent of study participants identified the My Pyramid graphic two years after it had been launched by the USDA. The study also found significant relationships between nutrition literacy and income level and nutrition literacy and educational attainment[98] further delineating priorities for the region.
These statistics point to the complexities surrounding the lack of health/nutrition literacy and reveal the degree to which they are embedded in the social structure and interconnected with other problems. Among these problems are the lack of information about food choices, a lack of understanding of nutritional information and its application to individual circumstances, limited or difficult access to healthful foods, and a range of cultural influences and socioeconomic constraints such as low levels of education and high levels of poverty that decrease opportunities for healthful eating and living.
The links between low health literacy and poor health outcomes has been widely documented[99] and there is evidence that some interventions to improve health literacy have produced successful results in the primary care setting. More must be done to further our understanding of nutrition literacy specific interventions in non-primary care settings[98] in order to achieve better health outcomes.
Nutrition Games For High School
Malnutrition[edit]
According to WHO, malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients. The term malnutrition addresses 3 broad groups of conditions: undernutrition, which includes wasting (low weight-for-height), stunting (low height-for-age) and underweight (low weight-for-age); micronutrient-related malnutrition, which includes micronutrient deficiencies or insuficiencies (a lack of important vitamins and minerals) or micronutrient excess; and overweight, obesity and diet-related noncommunicable diseases (such as heart disease, stroke, diabetes and some cancers).[100] In Mali, the International Crops Research Institute for the Semi-Arid Tropics (ICRISAT) and the Aga Khan Foundation trained women's groups to make equinut, a healthy and nutritional version of the traditional recipe di-dèguè (comprising peanut paste, honey and millet or rice flour). The aim was to boost nutrition and livelihoods by producing a product that women could make and sell, and which would be accepted by the local community because of its local heritage.[101]
Insufficient[edit]
The U.S. Food and Nutrition Board sets Estimated Average Requirements (EARs) and Recommended Dietary Allowances (RDAs) for vitamins and minerals. EARs and RDAs are part of Dietary Reference Intakes.[102] The DRI documents describe nutrient deficiency signs and symptoms.
Excessive[edit]
The U.S. Food and Nutrition Board sets Tolerable Upper Intake Levels (known as ULs) for vitamins and minerals when evidence is sufficient. ULs are set a safe fraction below amounts shown to cause health problems. ULs are part of Dietary Reference Intakes.[102] The European Food Safety Authority also reviews the same safety questions and set its own ULs.[103]
Unbalanced[edit]
When too much of one or more nutrients is present in the diet to the exclusion of the proper amount of other nutrients, the diet is said to be unbalanced. High calorie food ingredients such as vegetable oils, sugar and alcohol are referred to as 'empty calories' because they displace from the diet foods that also contain protein, vitamins, minerals and fiber.[104]
Illnesses caused by deficient nutrient consumption[edit]
| Nutrients | Deficiency | Excess |
|---|---|---|
| Macronutrients | ||
| Calories | Starvation, marasmus | Obesity, diabetes mellitus, cardiovascular disease |
| Simple carbohydrates | None | Obesity, diabetes mellitus, cardiovascular disease |
| Complex carbohydrates | None | Obesity, cardiovascular disease (high glycemic index foods) |
| Protein | Kwashiorkor | Rabbit starvation |
| Saturated fat | Low testosterone levels, vitamin deficiencies. | Obesity, cardiovascular disease |
| Trans fat | None | Obesity, cardiovascular disease |
| Unsaturated fat | Fat-soluble vitamin deficiency | Obesity, cardiovascular disease |
| Micronutrients | ||
| Vitamin A | Xerophthalmia and night blindness | Hypervitaminosis A (cirrhosis, hair loss) |
| Vitamin B1 | Beri-Beri | ? |
| Vitamin B2 | Skin and corneal lesions | ? |
| Niacin | Pellagra | Dyspepsia, cardiac arrhythmias, birth defects |
| Biotin | Biotin deficiency | Reproductive and teratogenic effects |
| Vitamin B12 | Pernicious anemia | ? |
| Vitamin C | Scurvy | Diarrhea causing dehydration |
| Vitamin D | Rickets, Hypovitaminosis D | Hypervitaminosis D (dehydration, vomiting, constipation) |
| Vitamin E | Neurological disease | Hypervitaminosis E (anticoagulant: excessive bleeding) |
| Vitamin K | Hemorrhage | Liver damage |
| Omega-3 fats | Cardiovascular Disease | Bleeding, Hemorrhages, Hemorrhagic stroke, reduced glycemic control among diabetics |
| Omega-6 fats | None | Cardiovascular Disease, Cancer |
| Cholesterol | None | Cardiovascular Disease |
| Macrominerals | ||
| Calcium | Osteoporosis, tetany, carpopedal spasm, laryngospasm, cardiac arrhythmias | Fatigue, depression, confusion, nausea, vomiting, constipation, pancreatitis, increased urination, kidney stones |
| Magnesium | Hypertension | Weakness, nausea, vomiting, impaired breathing, and hypotension |
| Potassium | Hypokalemia, cardiac arrhythmias | Hyperkalemia, palpitations |
| Sodium | Hyponatremia | Hypernatremia, hypertension |
| Trace minerals | ||
| Iron | Anemia | Cirrhosis, Hereditary hemochromatosis, heart disease |
| Iodine | Goiter, hypothyroidism | Iodine toxicity (goiter, hypothyroidism) |
Mental agility[edit]
Health and nutrition appear to have close links with overall educational success.[105]
Mental disorders[edit]
Nutritional supplement treatment may be appropriate for major depression, bipolar disorder, schizophrenia, and obsessive compulsive disorder, the four most common mental disorders in developed countries.[106] Supplements under study for possible effects on mood elevation and stabilization include eicosapentaenoic acid and docosahexaenoic acid, which are omega-3 fatty acids in fish oil.[107]
Processed foods[edit]
Since the Industrial Revolution some two hundred years ago, the food processing industry has invented many technologies that both help keep foods fresh longer and alter the fresh state of food as they appear in nature. Cooling is the primary technology used to maintain freshness, whereas many more technologies have been invented to allow foods to last longer without becoming spoiled. These latter technologies include pasteurisation, autoclavation, drying, salting, and separation of various components, all of which appearing to alter the original nutritional contents of food. Pasteurisation and autoclavation (heating techniques) have no doubt improved the safety of many common foods, preventing epidemics of bacterial infection. But some of the (new) food processing technologies have downfalls as well.
Modern separation techniques such as milling, centrifugation, and pressing have enabled concentration of particular components of food, yielding flour, oils, juices, and so on, and even separate fatty acids, amino acids, vitamins, and minerals. Inevitably, such large-scale concentration changes the nutritional content of food, saving certain nutrients while removing others. Heating techniques may also reduce food's content of many heat-labile nutrients such as certain vitamins and phytochemicals, and possibly other yet-to-be-discovered substances.[108] Because of reduced nutritional value, processed foods are often 'enriched' or 'fortified' with some of the most critical nutrients (usually certain vitamins) that were lost during processing. Nonetheless, processed foods tend to have an inferior nutritional profile compared to whole, fresh foods, regarding content of both sugar and high GI starches, potassium/sodium, vitamins, fiber, and of intact, unoxidized (essential) fatty acids. In addition,processed foods often contain potentially harmful substances such as oxidized fats and trans fatty acids.
A dramatic example of the effect of food processing on a population's health is the history of epidemics of beri-beri in people subsisting on polished rice. Removing the outer layer of rice by polishing it removes with it the essential vitamin thiamine, causing beri-beri. Another example is the development of scurvy among infants in the late 19th century in the United States. It turned out that the vast majority of sufferers were being fed milk that had been heat-treated (as suggested by Pasteur) to control bacterial disease. Pasteurisation was effective against bacteria, but it destroyed the vitamin C.
As mentioned, lifestyle- and obesity-related diseases are becoming increasingly prevalent all around the world. There is little doubt that the increasingly widespread application of some modern food processing technologies has contributed to this development. The food processing industry is a major part of modern economy, and as such it is influential in political decisions (e.g., nutritional recommendations, agricultural subsidising). In any known profit-driven economy, health considerations are hardly a priority; effective production of cheap foods with a long shelf-life is more the trend. In general, whole, fresh foods have a relatively short shelf-life and are less profitable to produce and sell than are more processed foods. Thus, the consumer is left with the choice between more expensive, but nutritionally superior, whole, fresh foods, and cheap, usually nutritionally inferior, processed foods. Because processed foods are often cheaper, more convenient (in both purchasing, storage, and preparation), and more available, the consumption of nutritionally inferior foods has been increasing throughout the world along with many nutrition-related health complications.
Outline of nutrition[edit]
Academic publishing[edit]
Biology[edit]
Dangers of poor nutrition[edit]
- Deficiency
- Obesity
Fats[edit]
Saturated fats[edit]
Monounsaturated fats[edit]
Polyunsaturated fats[edit]
- Omega-3 fatty acid
- Eicosapentaenoic acid (EPA) – an essential fatty acid
- Docosapentaenoic acid (DPA)
- Docosahexaenoic acid (DHA) – an essential fatty acid
Food[edit]
Healthy diet[edit]
Lists[edit]
Nutrients[edit]
- Dietary minerals
- Fat
- Protein
- Vitamins
Organic acids[edit]
Organizations[edit]
Professions[edit]
Amino acids[edit]
Standard amino acids
- Isoleucine (branched chain amino acid)
- Leucine (branched chain amino acid)
- Valine (branched chain amino acid)
Other amino acids
Tools[edit]
See also[edit]
Notes and references[edit]
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- ^Metabolic syndrome – PubMed Health. Ncbi.nlm.nih.gov. Retrieved on 2011-10-17.
- ^Omega-3 fatty acids. Umm.edu (5 October 2011). Retrieved on 2011-10-17.
- ^What I need to know about Eating and Diabetes – National Diabetes Information Clearinghouse. Diabetes.niddk.nih.gov. Retrieved on 2011-10-17.
- ^Diabetes Diet and Food Tips: Eating to Prevent and Control DiabetesArchived 20 May 2011 at the Wayback Machine. Helpguide.org. Retrieved on 2011-10-17.
- ^Osteoporosis & Vitamin D: Deficiency, How Much, Benefits, and More. Webmd.com (7 July 2005). Retrieved on 2011-10-17.
- ^Dietary Supplement Fact Sheet: Vitamin D. Ods.od.nih.gov. Retrieved on 2011-10-17.
- ^Brody, Jane E. (19 March 1998). 'Osteoporosis Linked to Vitamin D Deficiency'. The New York Times. Archived from the original on 9 March 2008.
- ^Payne-Palacio, June R.; Canter, Deborah D. (2014). The Profession of Dietetics. Jones & Bartlett Learning. pp. 3–4. ISBN978-1-284-02608-5.
- ^ abGratzer 2005, p. 40.
- ^ abcGratzer 2005, p. 41.
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- ^Gratzer 2005, p. 38.
- ^Gratzer 2005, p. 39.
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- ^Carpenter 1994, p. 220.
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Bibliography[edit]
- Carpenter, Kenneth J. (1994). Protein and Energy: A Study of Changing Ideas in Nutrition. Cambridge University Press. ISBN978-0-521-45209-0.
- Curley, S., and Mark (1990). The Natural Guide to Good Health, Lafayette, Louisiana, Supreme Publishing
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External links[edit]
| Wikimedia Commons has media related to Nutrition. |
- Diet, Nutrition and the prevention of chronic diseases by a Joint WHO/FAO Expert consultation (2003)
- UN Standing Committee on Nutrition – In English, French and Portuguese