Nutrition: Science and Everyday Application

Nutrition: Science and

Everyday Application
V. 1.0

ALICE CALLAHAN, PHD; HEATHER LEONARD, MED, RDN; AND TAMBERLY

POWELL, MS, RDN
Nutrition: Science and Everyday Application by Alice Callahan, PhD; Heather Leonard, MEd, RDN; and Tamberly Powell,
MS, RDN is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where
otherwise noted.
 Contents

Introduction 1
About the Authors 3
Acknowledgements v
Updates Made to OER vi

UNIT 1 - DESIGNING A HEALTHY DIET

Introduction to Designing a Healthy Diet 9

Nutrition and Health 11

An Introduction to Molecules 17

Classification of Nutrients 22

Defining Nutrient Requirements: Dietary Reference Intakes 32

Understanding Food Labels 40

Tools for Achieving a Healthy Diet 50

UNIT 2 - NUTRITION SCIENCE AND INFORMATION LITERACY

Introduction to Nutrition Science and Information Literacy 69

The Scientific Method 71

Types of Research Studies and How To Interpret Them 77

Healthy Skepticism in Nutrition Science 84

Finding Accurate Sources of Nutrition Information 91

Who Can You Trust for Nutrition Information? 100

UNIT 3 - MOLECULES OF LIFE: PHOTOSYNTHESIS, DIGESTION, AND

METABOLISM

Introduction to Molecules of Life 109

Organization of Life 111

Photosynthesis and Metabolism 118

The Digestive System 125

Disorders of the GI Tract 134

Food Intolerances, Allergies, and Celiac Disease 140

UNIT 4- CARBOHYDRATES

Introduction to Carbohydrates 149

Types of Carbohydrates 152

Carbohydrate Food Sources and Guidelines for Intake 161

Digestion and Absorption of Carbohydrates 165

Glucose Regulation and Utilization in the Body 172

Fiber - Types, Food Sources, Health Benefits, and Whole Versus Refined 184
Grains

Sugar: Food Sources, Health Implications, and Label-Reading 194

Sugar Substitutes 205

UNIT 5- LIPIDS

Introduction to Lipids 213

The Functions of Fats 217

Lipid Types and Structures 222

Fatty Acid Types and Food Sources 229

Digestion and Absorption of Lipids 239

Lipid Transport, Storage, and Utilization 245

Lipid Recommendations and Heart Health 253

UNIT 6- PROTEIN

Introduction to Protein 263

Protein Structure 265

Protein Functions 276

Protein in Foods and Dietary Recommendations 283

Protein Digestion and Absorption 288

Health Consequences of Too Little and Too Much Dietary Protein 294

Protein Food Choices and Sustainability 299

UNIT 7- ENERGY BALANCE AND HEALTHY BODY WEIGHT

Introduction to Energy Balance 313

Energy Balance: Energy In, Energy Out—Yet Not As Simple As It Seems 316

Indicators of Health: BMI, Body Composition, and Metabolic Health 324

Overweight and Underweight—What are the Risks? 335

Obesity Epidemic: Causes and Solutions 344

Best Practices For Weight Management 355

UNIT 8 - VITAMINS AND MINERALS PART 1

Introduction to Vitamins and Minerals 369

Classification of Vitamins and Minerals 371

Sources of Vitamins and Minerals 378

Dietary Supplements 383

Vitamins and Minerals Involved In Fluid And Electrolyte Balance 391

Vitamins and Minerals as Antioxidants 400

Vitamins Important for Vision 412

UNIT 9 - VITAMINS AND MINERALS PART 2

Introduction to Vitamins and Minerals Part 2 421

Introduction to Bone Health 423

Calcium: Critical for Bones and Throughout the Body 429

Other Minerals Important to Bone Health 433

Vitamin D: Important to Bone Health and Beyond 439

Vitamins and Minerals Involved in Energy Metabolism 445

Vitamins and Minerals Involved in Blood Health 454

UNIT 10 — NUTRITION AND PHYSICAL ACTIVITY

Introduction to Nutrition and Physical Activity 463

Essential Elements and Benefits of Physical Fitness 465

Fuel Sources for Exercise 470

Nutrient Needs of Athletes 477

UNIT 11 — NUTRITION THROUGHOUT THE LIFESPAN

Introduction to Nutrition Throughout the Lifecycle 487

Nutrition in Pregnancy and Lactation 489

Nutrition in Early Infancy 502

Nutrition in Later Infancy and Toddlerhood 509

Raising Healthy Eaters 517

Nutrition in Adolescence 522

Nutrition in Older Adults 526

Glossary 533
Introduction

What comes to mind when you think of food? What does it mean to you?
Maybe it is this morning’s breakfast, essential fuel grabbed as you ran out the door to make it to
work or class on time.
Or perhaps it’s the smell of food cooking in your childhood kitchen, building anticipation for a meal
to be shared with family.
Maybe it is the feeling of soil crumbling between your fingers as you prepare a garden bed for the
first seeds of spring, each one a promise of fresh food for the months to come.
Or perhaps it is the thought of navigating your grocery cart down fluorescent-lit aisles at the
grocery store, wondering what to choose and how to stay within your budget.
Maybe you think of food as a collection of nutrients, tiny molecules that will nourish and energize
you, defend your health, and fuel your brain.
Or perhaps you think of the food traditions of your family’s culture, recipes shared for generation
upon generation, over decades of change.
Maybe you think primarily of feeding yourself. Or perhaps you’re already planning what to cook for
your large family tonight.
Maybe food is a collection of sweet memories for you. Or perhaps your relationship with food is
more complicated, one of struggle and control.

Maybe the meaning of food is bigger than you and your family. Perhaps you think of how to
best feed patients in a hospital, to nourish children in a school, or to get food to elderly shut-ins
1
2 TAMBERLY POWELL, MS, RDN

looking for a warm meal and a friendly face. Or maybe you think of how food production affects
the environment, workers, and communities. Perhaps you wonder how we’ll feed the world as the
population grows and the climate warms.
Food is all of these things and more. It is a basic human need that permeates every day of our lives.
The choices we make about food can affect something as small as the cells in our body and as large
as the environment around us. We can’t cover every facet of food in this book, but what we can do is
give you a foundation on which to understand the science of food and nutrition and how to apply it
in your everyday life.
We originally developed this book for our students in FN 225, our course in human nutrition at
Lane Community College in Eugene, Oregon. Our students come from all walks of life, and we know
they each carry their own meaning of food and come into our class with different goals. Many have
their sights on careers in the health professions, and others choose our class to be better-informed
as they feed themselves and their families.
We’re glad to share this book as an open educational resource, or OER, with students beyond our
college. In developing this OER, we leaned heavily on the previous work of other OER authors. In the
spirit of open education, we’ve built on the foundation that they provided, updating it and tailoring
the material to the needs of our students. In that same spirit, we’re sharing it so that others can
benefit and to help reduce costs for students.
This OER is divided into units that roughly correspond to one week of learning in our 10-week
course, with each unit comprising six to eight sections of information on the unit’s theme. When
possible, we’ve embedded videos to expand upon and enrich the content of the text. Each section of
the unit also includes self-check questions to test your comprehension as you read.
To students: We hope you enjoy reading and learning through this resource, and we wish you a
lifetime of eating well!

A NOTE TO EDUCATORS INTERESTED IN USING THIS RESOURCE:

As this is an OER, you are welcome to adopt this material and modify it as needed for your own teaching
needs. We welcome your feedback, suggestions, and corrections regarding the text. If you plan to use this OER,
we ask that you please contact Tamberly Powell at the address below, so that we can track where the resource is
being used and contact you if there are updates. Instructors may also contact us for access to ancillary materials
for each unit, including a guided notes document for student use and a question bank for instructor use.
Tamberly Powell, MS, RDN
Nutrition Coordinator, Lane Community College
Phone: 541-554-2196
Email: [email protected]

Image Credits:

Photo by Max D. Photography on Unsplash (license information)

About the Authors

ALICE CALLAHAN, PHD

Alice Callahan is a nutrition instructor at Lane

Community College and holds a PhD in Nutritional
Biology from the University of California, Davis. She is
also a health and science writer and the author of The
Science of Mom: A Research-Based Guide to Your Baby’s
First Year, published by Johns Hopkins University
Press. In both her teaching and writing, she focuses on
making science accessible and applicable to everyday
life. She is the mother of two children and enjoys
running, hiking, reading, and baking.

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4 TAMBERLY POWELL, MS, RDN

HEATHER LEONARD, MED, RDN

Heather Leonard is a registered dietitian nutritionist

with a master’s degree in Prevention Science. She is a
nutrition instructor at Lane Community College where
she loves helping students make connections between
nutrition and their personal lifestyles. She is currently
pursuing her PhD in Prevention Science at the
University of Oregon. She is the mother to three
children and enjoys exploring the outdoors through
trail running and ultramarathons.

TAMBERLY POWELL, MS, RDN

Tamberly Powell is a registered dietitian nutritionist with a master’s degree in Nutrition and
Foodservice Management. She is a nutrition faculty member and program coordinator for Health and
Nutrition at Lane Community College. She is passionate about saving students’ money by offering
low-cost or OER materials and engaging students through online learning. She enjoys being a mom
of two girls, staying active through outdoor recreation in the Pacific Northwest, playing tennis, and
reading a good book.
Acknowledgements

The creation of this OER resource was made possible by an Open Oregon Educational Resource
Grant, with additional grant support from Lane Community College. We are grateful for the
commitment of our college and Open Oregon to funding OER projects, ultimately making education
more accessible to all.
Portions of this Open Educational Resource text have been adapted from the following texts:

• An Introduction to Human Nutrition // CC BY-NC-SA 3.0

• University of Hawai’i at Mānoa Food Science and Human Nutrition Program. (2018). Human
Nutrition. // CC BY-NC-SA 4.0
• Lindshield, B. (2018). Kansas State University Human Nutrition (FNDH 400) Flexbook. NPP
eBooks. // CC BY-NC-SA 4.0
• Betts, J. G., Young, K. A., & Wise, J. A., et. al (2013, updated 2020). Anatomy and Physiology.
OpenStax // CC BY 4.0
• Clark, M. A., Douglas, M., & Choi, J. (2018). Biology 2e. OpenStax // CC BY 4.0

We extend our sincere gratitude to the authors of these texts, without which our project may have
been too daunting and time-consuming to complete. It is the spirit of sharing ideas and work in the
OER community that allows us to create resources that best serve our students.
Front cover photo of citrus by Edgar Castrejon on Unsplash (license information).

5
Updates Made to OER

Date Unit Page Update Made

1–
3/ Tools for
Designing a The section, “Dietary Guidelines for Americans,” was updated to reflect the 2020
20/ Achieving a
Healthy recommendations.
21 Healthy Diet
Diet

7 – Energy
The section, “Evidenced-Based Dietary Recommendations” was updated to reflect the
Balance
3/ Best Practices for 2020 recommendations.
and
20/ Weight Replaced Figure 7.26, “Dietary Intakes Compared to Recommendations” from the 2015
Healthy
21 Management Dietary Guidelines for Americans, with image from the 2020 Dietary Guidelines for
Body
Americans.
Weight

8– Vitamins and For Figure 8.10, replaced “Food category sources of sodium in the U.S. population, ages 2
3/ Vitamins Minerals ”
20/ and Involved in Fluid years and older, from the 2015 Dietary Guidelines for Americans, with “Top Sources
21 Minerals and Electrolyte and Average Intakes of Sodium: U.S. Population Ages 1 and Older” from Dietary
Part 1 Balance Guidelines for Americans, 2020-2025

6
UNIT 1 - DESIGNING A
HEALTHY DIET

7
 Introduction to Designing a Healthy Diet

What makes a diet “healthy”? What does the

word “healthy” even mean? Each of us might
picture something different when we think of a
healthy diet, and if you travel around the world,
you’ll find even more variation in how people
define this term.
Indeed, humans are incredibly flexible when it
comes to food. We are omnivores, and we can
survive and thrive on a wide variety of different
foods. The foods that nourish our bodies are
often the same foods that nourish our souls,
bringing us together with friends and family,
celebrating traditions and conjuring memories
of meals past.
We’ll begin our study of nutrition by zooming
in on nutrients—the molecules in food that
nourish us—to begin to understand what each
gives us. Then, we’ll zoom back out to consider
some tools for choosing foods that will together
provide us with all the nutrients we need.
Because whatever the deep and complex
meanings that food brings to our lives and our
culture, we also want to choose foods that will
enable us to be well, to fuel our activities, to
prevent disease, and to live long, healthy lives.

Unit Learning Objectives

After completing this unit, you should be able to:

1. Define nutrition, food, and nutrients, and

describe how nutrition is related to health,
including risk of chronic disease.

2. Describe the different factors that impact food choices.

3. Understand the basic structure of molecules and that all nutrients are also chemical molecules.

4. Describe the 6 types of nutrients and the various ways they are classified.

5. Understand how the Dietary Reference Intakes (DRI) are determined, what each type of DRI value means, and how
they are used.

6. Use the information in a Nutrition Facts label to understand the nutritional qualities of a food.

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10 TAMBERLY POWELL, MS, RDN

7. Be familiar with several concepts that are helpful in planning a healthful diet, including adequacy, balance,
moderation, variety, nutrient density, and empty calories.

8. Be familiar with and able to use tools for planning a healthful diet, including MyPlate, Harvard Healthy Eating Plate,
and the Dietary Guidelines for Americans.

Image Credits:

Person cooking at a table photo by Markus Winkler on Unsplash (license information)

Nutrition and Health

WHAT IS NUTRITION?

Simply put, food is the plants and animals that we eat, and nutrition is how food affects the health
of the body. According to the Academy of Nutrition and Dietetics, “Food is essential—it provides
vital nutrients for survival, and helps the body function and stay healthy. Food is comprised of
macronutrients including protein, carbohydrate and fat that not only offer calories to fuel the body
and give it energy but play specific roles in maintaining health. Food also supplies micronutrients
(vitamins and minerals) and phytochemicals that don’t provide calories but serve a variety of critical
1
functions to ensure the body operates optimally.” (Phytochemicals
Phytochemicals are compounds found in plants
that give them their smell, taste, and color. They are not technically nutrients, but many have been
shown to affect human health.)

The study of nutrition goes beyond just a discussion of food and the nutrients needed by the
body. It includes how those nutrients are digested, absorbed, and used by the cells of the body. It
examines how food provides energy for daily activities and how our food intake and choices impact
body weight and risk for chronic diseases such as heart disease and type 2 diabetes. It also provides
insight on behavioral, social, and environmental factors that influence what, how, when, and why we
2
eat. Thus, nutrition is an important part of the overall discussion of health and wellness.

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12 TAMBERLY POWELL, MS, RDN

HOW NUTRITION AFFECTS HEALTH

The World Health Organization (WHO) defines health as “a state of complete physical, mental and
3
social well-being and not merely the absence of disease or infirmity.” The WHO recognizes nutrition
4
as a critical part of health and development, noting that better nutrition is related to:

• improved infant, child and maternal health

• stronger immune systems
• safer pregnancy and childbirth
• lower risk of non-communicable diseases (such as type 2 diabetes and cardiovascular
disease)
• greater longevity
• greater productivity, creating opportunities to break cycles of poverty and hunger

Malnutrition
Malnutrition, including both undernutrition and overnutrition, is a significant threat to human health.
In fact, nutrition is associated with four of the top ten leading causes of death in the United States,
5
including heart disease, cancer, diabetes, and stroke.

Figure 1.1. Age-adjusted death rates for the 10 leading causes of deaths: United States, 2016 and 2017
Nutrition can affect the health of the mind as well as the body. For example, some research
suggests that the foods people eat can influence their mood. A 2019 study of moderately-depressed
people aged 17 to 35 years old found that when half of them shifted towards a Mediterranean-
style eating pattern for 3 weeks—emphasizing more fruits and vegetables, whole grains, lean protein
sources, unsweetened dairy, fish, nuts and seeds, olive oil, and spices—their depression levels
decreased compared to participants who continued their usual eating habits. Some (but not all)
other studies have also found links between healthier diets and decreased risk of depression. It’s not
clear why this might be, but researchers speculate that decreased inflammation or changes in the
NUTRITION AND HEALTH 13

body’s microbiome caused by these dietary patterns may play a role in brain functioning and mental
6
health. This is an area that requires much more research, but as you’re thinking about dietary
choices, it’s worth thinking about how foods make you feel.
In addition to nutrition, health is affected by genetics, the environment, life cycle, and
lifestyle. One important facet of lifestyle is personal dietary habits. Dietary habits include what a
person eats, how much a person eats during a meal, how frequently meals are consumed, and how
often a person eats out. Other aspects of lifestyle include physical activity level, recreational drug use,
and sleeping patterns, all of which play a role in health and impact food choices and nutrition status.
Following a healthy lifestyle improves your overall health and well-being.

One or more interactive elements has been excluded from this version of the text. You can view them online here:

https://openoregon.pressbooks.pub/nutritionscience/?p=729#oembed-1

VIDEO: “Little Changes” by Patrick Mustain, Vimeo (May 22, 2014), 3:40 minutes.
14 TAMBERLY POWELL, MS, RDN

PERSONAL CHOICE: THE CHALLENGE OF CHOOSING FOODS

There are other factors besides environment and lifestyle that influence the foods you choose to eat.
Food itself can regulate your appetite and how you feel. Multiple studies have demonstrated that
some high-fiber foods and high-protein foods decrease appetite by slowing the digestive process and
prolonging the feeling of being full (also called satiety
satiety). Making food choices that maximize nutrient
intake and satiety can help manage how much you eat and how long before you eat again.
Food also has social, cultural, and religious significance, all of which impact the foods we
choose to eat. The social meanings of food affect what people eat, as well as how and when. Special
events in our lives—from birthdays to funerals—are commemorated with equally special foods.
Cultural influences and upbringing can also shape an individual’s food habits. Being aware of these
factors can help people make healthier food choices, and still honor the traditions and ties they hold
dear.

Factors that Drive Food Choices

A number of other factors affect the dietary choices individuals make, including:

• Taste, texture, and appearance. Individuals have a wide range of taste preferences,
which influence their food choices. For example, some people dislike milk and others hate
raw vegetables. Foods that may be unappealing at first to some people, like vegetables or
tofu, can often be adapted to meet most taste preferences, and people can learn to like
foods over time with repeated exposures.
• Economics. Access to fresh fruits and vegetables may be limited, particularly for those who
live in economically disadvantaged or remote areas, where affordable food options are
limited to convenience stores and fast food.
• Early food experiences. People who were not exposed to different foods as children, or
who were forced to swallow every last bite of overcooked vegetables, may make limited
 NUTRITION AND HEALTH 15

food choices or experience food aversions as adults. On the other hand, those exposed to a
variety of foods in the setting of pleasant family meals, are more likely to maintain those
same eating habits in adulthood.
• Habits. It’s common to establish eating routines, which can work both for and against
optimal health. Habitually grabbing a fast food sandwich for breakfast can seem
convenient, but might not offer substantial nutrition. Yet getting in the habit of drinking an
ample amount of water each day can yield multiple benefits.
• Culture. The culture in which one grows up affects how one sees food in daily life and on
special occasions.
• Geography. Where a person lives influences food choices. For instance, people who live in
Midwestern US states have less access to seafood than those living along the coasts.
• Advertising. The media greatly influences food choices by persuading consumers to eat
certain foods.
• Social factors. Any school lunchroom observer can testify to the impact of peer pressure
on eating habits, and this influence lasts through adulthood. People make food choices
based on how they see others and want others to see them. For example, individuals who
are surrounded by others who consume fast food are more likely to do the same.
• Health concerns. Some people have food allergies or intolerances and need to avoid
certain foods. Others may have developed health issues which require them to follow a low
salt diet. In addition, people who have never worried about their weight have a very
different approach to eating than those who have long struggled to change their weight.
• Emotions. There is a wide range in how emotional issues affect eating habits. Food can be
a source of comfort, such as the taste of a favorite dish from childhood. Or, for people with
a history of disordered eating, it may also be a source of anxiety. When faced with a great
deal of stress, some people tend to overeat, while others find it hard to eat at all.
• Green food/Sustainability choices. Based on a growing understanding of diet as a public
and personal issue, more and more people are starting to make food choices based on
their environmental impact. Realizing that their food choices help shape the world, many
individuals are opting for a vegetarian diet, or, if they do eat animal products, striving to
consider animal welfare and sustainability in their choices. Purchasing local and organic
food products and items grown through sustainable products can help to shrink the
environmental impact of one’s food choices.

Self-Check

An interactive H5P element has been excluded from this version of the text. You can view it online here:

https://openoregon.pressbooks.pub/nutritionscience/?p=729#h5p-25

Attributions:

• University of Hawai‘i at Mānoa Food Science and Human Nutrition Program, “Introduction,”
CC BY-NC 4.0
16 TAMBERLY POWELL, MS, RDN

References:

1
• Academy of Nutrition and Dietetics. (2019). How to Explain Basic Nutrition Concepts.
Retrieved December 18, 2019, from https://www.eatrightpro.org/practice/practice-
resources/international-nutrition-pilot-project/how-to-explain-basic-nutrition-concepts
2
• Medline Plus. (2019). Definitions of Health Terms. Retrieved from https://medlineplus.gov/
definitions/nutritiondefinitions.html
3
• World Health Organization. (n.d.) Constitution. Retrieved from https://www.who.int/about/
who-we-are/constitution
4
• World Health Organization. (2018, February 22). Nutrition. Retrieved from
https://www.who.int/news-room/facts-in-pictures/detail/nutrition
5
• Centers for Disease Control and Prevention. (2017, March 17). Leading Causes of Death.
Retrieved from https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
6
• Aubrey, A. & Chatterjee, R. (2019, October 19). Changing Your Diet Can Help Tamp Down
Depression, Boost Mood. Retrieved from https://www.npr.org/sections/thesalt/2019/10/09/
768665411/changing-your-diet-can-help-tamp-down-depression-boost-mood

Image Credits:

• Macroshot of vegetables photo by Dan Gold on Unsplash (license information)

• Figure 1.1. “Leading Causes of Death in the U.S.” by Centers for Disease Control and
Prevention is in the Public Domain
• Best friends photo by Thought Catalog on Unsplash (license information)
• Family meal photo by National Cancer Institute on Unsplash (license information)
An Introduction to Molecules

In order to understand the chemical structure of nutrients and how they function in the body
and provide energy to cells of the body, you must first understand the basic chemical structure of
molecules. Nutrients are chemical molecules that are found in foods and required by our bodies to
maintain life and support growth and health. On this page, we’ll zoom in to understand how atoms
bond together to form these chemical molecules.

THE ATOM

Matter is anything that has mass and takes up space. All living and nonliving things are composed
of matter. Atoms are the fundamental unit of matter. The chair you are sitting in is made of atoms.
The food you ate for lunch was built from atoms. Even the air you breathe is made of atoms. An
atom is the smallest unit of an element, just like a blade is the smallest unit of grass. An element
is made entirely from one specific type of atom. There are more than 100 elements that make up
the world we live in, however hydrogen, carbon, nitrogen, and oxygen make up the bulk of all living
things. Many elements are found in the foods we eat and all of them are found on the Periodic Table
of Elements.

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18 TAMBERLY POWELL, MS, RDN

Figure 1.2. The Periodic Table of Elements. Note the four elements circled in blue (hydrogen, carbon,
nitrogen, and oxygen). These four elements make up the bulk of all living things.
Atoms are unimaginably small. Even within a single microscopic cell, there is room for not just
billions, but trillions or even hundreds of trillions of atoms. The atoms themselves are made of
even smaller particles called protons
protons, neutrons
neutrons, and electrons
electrons. Protons and neutrons are found in the
nucleus (center) of the atom, while electrons are found outside the nucleus in regions called shells.
Protons have a positive charge, neutrons have no charge, and electrons are negatively charged.
Because protons and neutrons are contained in the dense nucleus of the atom, the nucleus has a
positive charge. And since opposites attract, electrons are attracted to this nucleus and move around
it in an electron cloud surrounding the nucleus. This attraction keeps the atom together, much like
the force of gravity keeps the moon in orbit around Earth.
AN INTRODUCTION TO MOLECULES 19

Figure 1.3. Diagram of a lithium atom, showing the placement of protons, neutrons, and electrons.
Protons and neutrons are found in the nucleus (center) of the atom. Electrons are found outside the
nucleus.

MOLECULES AND COVALENT BONDING

Atoms combine to form a larger and more complex entity called a molecule. Molecules are composed
of two or more atoms held together by chemical bonds.
The electrons of an atom contain energy. This energy is stored within the charge and movement
of electrons and the bonds that atoms make with one another. However, this energy is not always
stable, depending on the number of electrons within an atom. Atoms are more stable when their
electrons orbit in pairs. An atom with an odd number of electrons must have an unpaired electron.
In most cases, these unpaired electrons are used to create chemical bonds. A chemical bond is the
attractive force between atoms and contains energy. By bonding, electrons find pairs, and atoms
become part of a molecule.
The most stable situation for an atom is to have its outer shell completely filled with
electrons. It is not easy to explain why this is true, but it’s a rule of thumb that predicts how atoms
will react with each other. The first electron shell of an atom is considered full (or stable) when
it contains two electrons, and the second and third shells are full (stable) with eight electrons.
Atoms tend to bond to other atoms in such a way that both atoms have filled outer shells as a result
of the interaction. While some elements may be able to hold more electrons in their third shell, most
of the important elements in biology (e.g. hydrogen, carbon, nitrogen, and oxygen) are considered
stable with eight electrons in this outer shell.
Instead of transferring their electrons completely, atoms typically remain in very close
contact and share electrons so that their outer shells are filled. In essence, a shared electron
is counted “twice” and participates in a larger shell that joins the two atoms. A single pair of shared
electrons makes a single covalent bond. Atoms can also share two pairs of electrons (in a double
20 TAMBERLY POWELL, MS, RDN

bond). This sharing of electrons is called a covalent bond

bond. Covalent bonds are the strongest, most
stable types of chemical bonds in the biological world.
One example of covalent bonding to form a molecule is the formation of methane, a colorless and
flammable gas that results from burning gasoline or fossil fuels (Fig. 1.4). One carbon atom and four
hydrogen atoms react to form methane. The outer shell of carbon has four electrons, so carbon can
share an electron with four other atoms (which will then give carbon a full outer shell of 8 electrons).
Hydrogen has a single electron in its outermost shell and can share this electron with one other
atom. The carbon atom forms a covalent bond with four hydrogen atoms to form a molecule of
methane. In a methane molecule, carbon effectively has a “full” second shell (eight electrons) and
each hydrogen has a “full” first shell (two electrons). Each hydrogen requires one covalent bond to fill
its first shell. Each carbon requires four covalent bonds to fill its second shell.

Figure 1.4. A molecule of methane. Carbon and hydrogen react to form methane by sharing electrons
through a covalent bond.
In food and in components of the human body, energy resides in the chemical bonds of specific
molecules. Bond formation and bond breaking are chemical reactions that involve the movement
of electrons between atoms. These chemical reactions occur continuously in the body. When the
chemical bonds of nutrients in the foods we eat are broken, energy is released. That energy is
used by cells of the body to perform daily functions and tasks such as breathing, walking up a flight
of steps, and studying for a test.

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VIDEO: “Free Fatty Acids and Triglycerides” by Doctor Klioze, YouTube (June 16, 2013), 6:13 minutes.
 AN INTRODUCTION TO MOLECULES 21

BIOLOGICAL MACROMOLECULES

As we noted earlier, atoms are the building blocks of all matter. Biological macromolecules are formed
when atoms of carbon, hydrogen, oxygen, and nitrogen bond with each other in unique and varied
ways. Biological macromolecules are the raw materials used to build living organisms. They are
special molecules that contain carbon atoms covalently bonded with hydrogen atoms.
There are three classes of biological
macromolecules (or macronutrients
macronutrients) that we will
study in this course: carbohydrates, lipids,
proteins. These macronutrients are probably
already familiar to you, because they make up
the nutrients you ingest every time you eat. In
this way, you provide your cells with the building
materials and energy necessary to sustain life.
The next section will take a closer look at these
important macronutrients and the role they play
in our diet and in providing energy to cells.

Self-Check

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Attributions:

• “Introduction to Biology” by Open Learning Initiative is licensed under CC BY-NC-SA 4.0

• University of Hawai‘i at Mānoa Food Science and Human Nutrition Program, “The Atom,” CC
BY-NC 4.0

Images:

• “Lemons and Vitamin C” by Heather Leonard, CC BY-NC 4.0, edited from photo by Lauren
Mancke on Unsplash (license information) and “Ascorbic Acid” by Yikrazuul in the Public
Domain.
• Figure 1.2 “Periodic Table of Elements” by Heather Leonard, CC BY-NC 4.0, edited from
photo by “Periodic Table of Elements” by PubChem, U.S. National Library of Medicine is in
the Public Domain
• Figure 1.3. “Diagram of an Atom” from “Introduction to Biology” by Open Learning Initiative
is licensed under CC BY-NC-SA 4.0
• Figure 1.4. “Formation of Methane” from “Introduction to Biology” by Open Learning
Initiative is licensed under CC BY-NC-SA 4.0
• Person eating a burger photo by Szabo Viktor on Unsplash (license information)
Classification of Nutrients

Food is one of life’s greatest pleasures. It offers amazing flavors, aromas, and textures. Food also
provides our body with essential nutrients and non-nutrients like phytochemicals, both of which are
vital to health. This section will discuss the six classes of nutrients and how these nutrients can be
classified.

WHAT ARE NUTRIENTS?

Nutrients are chemical substances found in food that are required by the body to provide energy, give
the body structure, and help regulate chemical processes. There are six classes of nutrients:
1. carbohydrates
2. lipids
3. proteins
4. water
5. vitamins
6. minerals
Nutrients can be further classified as either macronutrients or micronutrients and either organic or
inorganic
inorganic, as well as whether or not they provide energy to the body (energy-yielding
energy-yielding). We’ll discuss
these different ways of classifying nutrients in the following sections.

MACRONUTRIENTS

Nutrients that are needed in large amounts are called macronutrients

macronutrients. There are three classes of
macronutrients: carbohydrates, lipids, and proteins. Water is also a macronutrient in the sense that
you require a large amount of it, but unlike the other macronutrients, it does not yield energy.se that
you require a large amount of it, but unlike the other macronut

22
CLASSIFICATION OF NUTRIENTS 23

Figure 1.5. Macronutrients include proteins, carbohydrates, lipids, and water. This figure illustrates each
nutrient’s chemical structure and examples of food sources.

Carbohydrates

Carbohydrates are molecules composed of carbon, hydrogen, and oxygen. The major food sources of
carbohydrates are grains, dairy products, fruits, legumes, and starchy vegetables, like potatoes. Non-
starchy vegetables, like carrots, also contain carbohydrates, but in lesser quantities.
Carbohydrates are broadly classified into two groups based on their chemical structure: simple
carbohydrates (often called simple sugars) and complex carbohydrates, which include fiber, starch,
and glycogen. Carbohydrates are a major fuel source for all cells of the body, and certain cells, like
cells of the central nervous system and red blood cells, rely solely on carbohydrates for energy.

Lipids

Lipids are also a family of molecules composed of carbon, hydrogen, and oxygen, but unlike
carbohydrates, they are insoluble in water. Lipids are found predominantly in butter, oils, meats,
dairy products, nuts and seeds, and in many processed foods. The three main types of lipids
are triglycerides, phospholipids, and sterols. The main job of lipids is to provide or store energy.
In addition to energy storage, lipids serve as major components of cell membranes, surround
and protect organs, provide insulation to aid in temperature regulation, and regulate many other
functions in the body.

Proteins

Proteins are large molecules composed of chains of amino acids, which are simple subunits made
of carbon, oxygen, hydrogen, and nitrogen. Food sources of proteins include meats, dairy products,
seafood, and a variety of plant-based foods, like beans, nuts, and seeds. The word protein comes
from a Greek word meaning “of primary importance,” which is an apt description of these
macronutrients as they are also known as the “workhorses” of life. Proteins provide structure to
24 TAMBERLY POWELL, MS, RDN

bones, muscles, and skin, and they play a role in conducting most of the chemical reactions occurring
in the body. Scientists estimate that more than 100,000 different proteins exist within the human
body. Proteins can also provide energy, though this is a relatively minor function, as carbohydrates
and fat are preferred energy sources.

Water

There is one other nutrient that we must have in large quantities: water water. Water does not contain
carbon but is composed of two hydrogens and one oxygen per molecule of water. More than 60
percent of your total body weight is water. Without it, nothing could be transported in or out of the
body, chemical reactions would not occur, organs would not be cushioned, and body temperature
would fluctuate widely. On average, an adult consumes just over two liters of water per day from
food and drink combined. Since water is so critical for life’s basic processes, we can only survive a few
days without it, making it one of the most vital nutrients.

MICRONUTRIENTS

Micronutrients are nutrients required by the body in smaller amounts, but they’re still essential
for carrying out bodily functions. Micronutrients include all of the essential minerals and vitamins.
There are 16 essential minerals and 13 essential vitamins (Table 1.1 and Table 1.2). In contrast to
carbohydrates, lipids, and proteins, micronutrients are not a source of energy, but they assist in
the process of energy metabolism as cofactors or components of enzymes (known as coenzymes).
Enzymes are proteins that catalyze (or accelerate) chemical reactions in the body; they’re involved
in all aspects of body functions, including producing energy, digesting nutrients, and building
macromolecules.

Minerals

Minerals are inorganic substances that are classified depending on how much the body requires.
Trace minerals
minerals, such as molybdenum, selenium, zinc, iron, and iodine, are only required in amounts
of a few milligrams or less per day. Major minerals
minerals, such as calcium, magnesium, potassium, sodium,
and phosphorus, are required in amounts of hundreds of milligrams or more per day. Many minerals
are critical for enzyme function, and others are used to maintain fluid balance, build bone tissue,
synthesize hormones, transmit nerve impulses, contract and relax muscles, and protect against
harmful free radicals in the body. To give you an appreciation of the many functions of minerals, the
table below has a complete list of all the minerals and their major functions. (Note: There is no need
to memorize these minerals and functions at this point in the course.)
CLASSIFICATION OF NUTRIENTS 25

Major Minerals Major Function

Sodium Fluid balance, nerve transmission, muscle contraction

Chloride Fluid balance, stomach acid production

Potassium Fluid balance, nerve transmission, muscle contraction

Calcium Bone and teeth health maintenance, nerve transmission, muscle contraction, blood clotting

Phosphorus Bone and teeth health maintenance, acid-base balance

Magnesium Protein production, nerve transmission, muscle contraction

Sulfur Protein production

Trace Minerals Function

Iron Carries oxygen, assists in energy production

Zinc Protein and DNA production, wound healing, growth, immune system function

Iodine Thyroid hormone production, growth, metabolism

Selenium Antioxidant

Copper Coenzyme, iron metabolism

Manganese Coenzyme

Fluoride Bone and teeth health maintenance, tooth decay prevention

Chromium Assists insulin in glucose metabolism

Molybdenum Coenzyme

Table 1.1. Minerals and their major functions

Vitamins

Vitamins are organic nutrients that are categorized based on their solubility in water. The water-
soluble vitamins are vitamin C and all of the B vitamins. The fat-soluble vitamins are vitamins A, D, E,
and K. Vitamins are required to perform many functions in the body, such as making red blood cells,
synthesizing bone tissue, and playing a role in normal vision, nervous system function, and immune
function. To give you an appreciation of the many functions of vitamins, the table below lists the 13
essential vitamins and their major functions. (Note: There is no need to memorize these vitamins and
functions at this point in the course.)
26 TAMBERLY POWELL, MS, RDN

Water-Soluble Vitamins Major Functions

Thiamin (B1) Coenzyme, energy metabolism assistance

Riboflavin (B2 ) Coenzyme, energy metabolism assistance

Niacin (B3) Coenzyme, energy metabolism assistance

Pantothenic acid (B5) Coenzyme, energy metabolism assistance

Pyridoxine (B6) Coenzyme, energy metabolism assistance

Biotin (B7) Coenzyme, amino acid and fatty acid metabolism

Folate (B9) Coenzyme, essential for growth

Cobalamin (B12) Coenzyme, red blood cell synthesis

C (ascorbic acid) Collagen synthesis, antioxidant

Fat-Soluble Vitamins Major Functions

A Vision, reproduction, immune system function

D Bone and teeth health maintenance, immune system function

E Antioxidant, cell membrane protection

K Bone and teeth health maintenance, blood clotting

Table 1.2. Vitamins and their major functions

As you might suspect based on the major functions of vitamins listed above, vitamin deficiencies
can cause severe health problems and even death. For example, a deficiency in niacin causes a
disease called pellagra, which was common in the early twentieth century in some parts of the United
States. The common signs and symptoms of pellagra are known as the “4D’s—diarrhea, dermatitis,
dementia, and death.” Until scientists discovered that better diets relieved the signs and symptoms
of pellagra, many people with the disease ended up hospitalized and in asylums awaiting death. The
following video gives an overview of pellagra and how its cure was discovered through a change in
diet.

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VIDEO: “Pellagra video” by Teresa Johnson, YouTube (June 20, 2012), 5:49 minutes.
CLASSIFICATION OF NUTRIENTS 27

ENERGY-YIELDING NUTRIENTS

The macronutrients—carbohydrate, protein, and fat—are the only nutrients that provide
energy to the body. The energy from macronutrients comes from their chemical bonds. This
chemical energy is converted into cellular energy that can be utilized to perform work, allowing cells
to conduct their basic functions. Although vitamins also have energy in their chemical bonds,
our bodies do not make the enzymes to break these bonds and release this energy. (This is
fortunate, as we need vitamins for their specific functions, and breaking them down to use for energy
would be a waste.)
Food energy is measured in kilocalories (kcals). A kilocalorie is the amount of energy needed to
raise 1 kilogram of water by 1 degree Celsius. The kilocalories stored in food can be determined by
putting the food into a bomb calorimeter and measuring the energy output (energy = heat produced).

Figure 1.6. A Bomb calorimeter

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28 TAMBERLY POWELL, MS, RDN

VIDEO: “Bomb Calorimetry” by David Read, YouTube (September 16, 2008), 2:19 minutes.

In the US, the kilocalorie (kcal) is the most commonly used unit of energy and is often just referred
to as a calorie. Strictly speaking, a kcal is 1000 calories. In nutrition, the term calories almost always
refers to kcals. Sometimes the kcal is indicated by capitalizing calories as “Calories.” For the sake of
simplicity, we’ll use the terms “calories” and “kilocalories” interchangeably in this book.
Below is a list of energy sources in the diet from lowest to highest calories per gram (a gram
is about the weight of a paperclip). Notice the addition of alcohol. Although alcohol does provide
energy, it isn’t a nutrient, because it isn’t required as a source of nourishment to the body.
Energy Sources (kcal/g)

• Carbohydrates 4
• Protein 4
• Alcohol 7
• Lipids 9

Carbohydrates and proteins provide 4 calories per gram, and fats provide 9 calories per gram. Fat is
the most energy-dense nutrient, because it provides the most calories per gram (more than double
carbohydrates and protein).
CLASSIFICATION OF NUTRIENTS 29

When you look at the Nutrition Facts panel on a food label,

you’ll see that it lists calories, as well as grams of total fat, total
carbohydrates, and protein per serving. From these values,
you can estimate the amount of calories coming from the
different macronutrients.
Looking at the values in the Nutrition Facts label, you can
convert grams into calories by doing the following calculations:

• 8 grams of fat x 9 kcal/g = 72 kcals

• 37 grams of carbohydrate x 4 kcal/g = 148 kcals
• 3 grams of protein x 4 kcal/g = 12 kcals

You can double check your math by adding the calories per
serving provided from fat, carbohydrate, and protein (232
calories for the example above). This number should come
close to the total calories per serving listed on the Nutrition
Facts. It will not always match up exactly (like in the example
above) due to rounding.

ORGANIC AND INORGANIC NUTRIENTS

So far, we’ve categorized nutrients as macronutrients or

micronutrients and based on whether or not they’re energy-
yielding. There is one more way to categorize nutrients:
organic or inorganic. When you think of the word “organic,”
you might think of how foods are produced (with or without
synthetic fertilizers and pesticides), but in this case we are
referring to the chemical structure of a nutrient.

Organic Nutrients

The organic nutrients include the macronutrients Figure 1.7. Nutrition Facts
(carbohydrate, protein, and fat) and vitamins. An organic
nutrient contains both carbon and hydrogen. Organic
nutrients can be made by living organisms and are complex, made up of many elements (carbon,
hydrogen, oxygen, and sometimes nitrogen) bonded together. In a sense, they are “alive,” and
therefore can be destroyed or broken down.
Vitamin E (shown below) is an organic molecule, because it contains both carbon and hydrogen
atoms. Vitamin E is synthesized by plants and can be destroyed by heat during cooking.

Figure 1.8. Chemical structure of Vitamin E

 30 TAMBERLY POWELL, MS, RDN

Inorganic Nutrients

Inorganic nutrients include both water and minerals. Inorganic nutrients do not contain both
carbon and hydrogen, and they are not created or destroyed. Minerals can’t be destroyed, so they
are the ash left when a food is burned to completion. Minerals are also not digested or broken down,
as they are already in their simplest form. They are absorbed as-is, then shuttled around the body
for their different functions, and then excreted.

Summary

The different categories of nutrients are summarized in the following table.

Classification Nutrient

Macronutrient Carbohydrate, protein, lipids, water

Micronutrient Vitamins, minerals

Energy-Yielding Carbohydrate, protein, fat

Organic Carbohydrate, protein, lipids, vitamins

Inorganic Minerals, water

Table 1.3. Summary of nutrient classifications

Self-Check

An interactive H5P element has been excluded from this version of the text. You can view it online here:

https://openoregon.pressbooks.pub/nutritionscience/?p=748#h5p-27

Attributions:

• University of Hawai‘i at Mānoa Food Science and Human Nutrition Program, “Introduction,”
CC BY-NC 4.0

Images:

• Figure 1.5. “Macronutrients” from University of Hawai‘i at Mānoa Food Science and Human
Nutrition Program, “Introduction,” CC BY-NC 4.0
• Table 1.1. “Minerals and major functions” from University of Hawai‘i at Mānoa Food Science
and Human Nutrition Program, “Introduction,” CC BY-NC 4.0
CLASSIFICATION OF NUTRIENTS 31

• Table 1.2. “Vitamins and major functions” University of Hawai‘i at Mānoa Food Science and
Human Nutrition Program, “Introduction,” CC BY-NC 4.0
• Figure 1.6. “Bomb Calorimeter Diagram” by Lisdavid89 is licensed under CC BY-SA 3.0
• Figure 1.7. “FDA Nutrition Facts Label” by USDA Food and Drug Administration is in the
Public Domain
• Figure 1.8. “Vitamin E” by Annabel is licensed under CC BY-SA 3.0
• Table 1.3. “Summary of classification of nutrients” by Tamberly Powell is licensed under CC
BY-NC-SA 4.0
Defining Nutrient Requirements: Dietary
Reference Intakes

How do we know how much of a given nutrient people should eat, or how much is too much? For this
information, we can turn to the Dietary Reference Intakes (DRI)
(DRI)—a set of recommendations developed
by the National Academies of Sciences, Engineering, and Medicine to describe the amounts of specific
nutrients and energy that people should consume in order to stay healthy. They are developed
by groups of nutrition scientists, who together evaluate the research to determine how much of a
nutrient is required to prevent deficiencies and chronic disease, as well as how much is excessive and
could cause toxicity. The DRI standards are specific to people living in the United States and Canada,
and they’re meant to be used by people who are generally healthy, because those with specific health
conditions may have different nutrient requirements.
The DRI standards can be divided into two main categories:

• Recommendations for energy intake – How many calories are required, and how much
energy should proportionately come from carbohydrate, fat, and protein?
• Recommendations for nutrient intake – How much of each nutrient should be
consumed, and how much is excessive?

We’ll discuss each of these categories, and then we’ll discuss some of the ways that the DRI standards
are used. Be prepared to learn a lot of acronyms!

DRI RECOMMENDATIONS FOR ENERGY INTAKE

The DRIs include two types of recommendations related to energy intake:

1. Estimated Energy Requirement (EER). The EER is an estimate of how many calories a
person needs to consume, on average, each day to stay healthy, based on their age, sex,
height, weight, and physical activity level. For adults, the EER is meant to be a caloric intake that
maintains energy balance, meaning that it won’t cause weight loss or gain. For children, the EER
includes the energy needed for normal growth. For pregnant or lactating women, it includes energy
needed for development of the fetus and other pregnancy requirements or for milk production.
Different EER values were also developed for different physical activity levels, because greater
1
physical activity requires more energy. The EER should be considered a “ballpark” estimate of a
person’s caloric needs. As we’ll learn later in the term, the way that people process and utilize energy
is highly variable, and two people can have the same sex, weight, height, and level of physical activity
but different caloric needs.

32
DEFINING NUTRIENT REQUIREMENTS: DIETARY REFERENCE INTAKES 33

2. Acceptable Macronutrient Distribution Ranges (AMDR)

(AMDR). The AMDR is the calculated range of how
much energy from carbohydrate, fat, and protein is recommended for a healthy diet. People
who do not meet the AMDR may have increased risk of developing health complications—although
these are also ballpark recommendations, not absolute requirements for health. Keep in mind that
the percentage of daily caloric intake from the three energy-yielding macronutrients will add up to
100 percent, so the proportion of each influences the other two. For example, someone consuming
a very low carbohydrate diet, with just 5 to 10 percent of calories coming from carbohydrates would
not only fall short of the AMDR for carbohydrate but also exceed the recommended amounts of fat
and/or protein, because the rest of daily calories must come from these macronutrients. The AMDR
recommendations are based on balancing carbohydrate, fat, and protein to allow for adequate
amounts of all three, and they are wide enough ranges that many different types of diets can fit
within them.

Figure 1.9. Acceptable Macronutrient Distribution Ranges (AMDR) for the three energy-yielding
macronutrients.
34 TAMBERLY POWELL, MS, RDN

DAILY RECOMMENDATIONS FOR NUTRIENT INTAKE

There are four different types of DRI values used to describe recommendations for intake of
individual nutrients:

• Estimated Average Requirements (EAR)

• Recommended Dietary Allowances (RDA)
• Adequate Intakes (AI)
• Tolerable Upper Intake Levels (UL)

DRI values are summarized in tables to make it easy to find a specific value for a person based on
their life stage and sex. For example, part of a table of EAR values for macronutrients and vitamins is
shown below.

This page from the National Institutes of Health Office of Dietary Supplements provides links to DRI
reports and tables: Nutrient Recommendations: Dietary Reference Intakes (DRI)
Let’s look at how each of these DRI values is determined, what they mean, and how they are used.

Estimated Average Requirement

The Estimated Average Requirement (EAR) is the amount of a nutrient that meets the requirements
of 50 percent of people within a group of the same life stage and sex. The requirements of
half of the group will fall below the EAR, and the requirements of the other half will be above it. To
understand the EAR, it’s important to recognize that individuals have different nutrient requirements,
depending on many factors beyond our life stage and sex (differences in genetics, metabolism, body
DEFINING NUTRIENT REQUIREMENTS: DIETARY REFERENCE INTAKES 35

weight, and physical activity, for example), and the EAR is like the midpoint in the range of different
individual requirements.
To develop the EAR, a committee of scientists evaluates the research on that nutrient and chooses
a specific bodily function as a criterion on which to base it. For example, the EAR for calcium is set
using a criterion of maximizing bone health, because this is quantitatively one of the most important
functions of calcium, and the effects of different levels of calcium intake on bone health can be
measured. Thus, the EAR for calcium is set at a point that will meet the needs, with respect to bone
health, of half of the population.
The EAR for a given nutrient is shown in the graph below, with the individual requirement on the
x-axis. Imagine this graph is depicting individual calcium requirements. The people on the left side
of the graph have lower calcium requirements, and the people on the right side of the graph have
higher calcium requirements. If everyone was eating the EAR for calcium, half would be getting
enough calcium and half would not. Therefore, it wouldn’t be wise to recommend that everyone only
consume the EAR, because about half of the population would fall short in calcium if this was set as
the recommendation. EAR values are most important because they are used to calculate the
Recommended Daily Allowance (RDA) values, which are commonly used as population-wide
recommendations for nutrient intake.

Figure 1.10. EAR and RDA relative to individual requirements for a given nutrient.

Recommended Daily Allowances

Once the EAR of a nutrient has been established, the Recommended Daily Allowances (RDA) value
can be mathematically determined. While the EAR is set at a point that meets the needs of half
the population, RDA values are set to meet the needs of the vast majority (97 to 98 percent)
of the target healthy population. You can see this in the graph above. The RDA is a better
recommendation for the population, because we can assume that if a person is consuming the RDA
of a given nutrient, they are most likely meeting their nutritional needs for that nutrient.
This also explains why the RDA is not the same thing as an individual nutritional requirement.
You may be consuming less than the RDA for calcium, but this does not automatically mean that
36 TAMBERLY POWELL, MS, RDN

your body is deficient in calcium and that you’ll definitely end up with osteoporosis, because your
individual calcium requirement may be less than the RDA. However, since you probably don’t know
your individual calcium requirement, the RDA is a good target amount for consumption, and the
more your intake drops below the RDA, the greater your risk of later developing osteoporosis. The
RDA is meant as a recommendation, and meeting the RDA means it is very likely that you are meeting
your actual requirement for that nutrient.
It’s interesting to compare and contrast the EER (for energy or calorie intake) and the RDA (for
nutrient intake). In practice, both types of recommendations serve as a daily target for intake.
However, the EER is set to meet the average caloric needs of a person, while the RDA is set to meet
the needs of the vast majority of the population. Imagine if the EER was set to ensure that it met the
caloric needs of the vast majority of a population. It would end up being a dramatic overestimate
of caloric needs for most people. If everyone actually followed this recommendation, the majority
of them would consume far more calories than they actually needed, resulting in weight gain. For
nutrients, we have more flexibility in our intake, because we have ways of storing or metabolizing
and excreting excess nutrients, so consuming somewhat more than our body needs is just fine.

Adequate Intake

When there is insufficient scientific evidence to set an EAR and RDA for the entire population, then
the National Academies committee can decide to set an Adequate Intake (AI) level instead. The AI is
based on observing healthy people and seeing how much of the nutrient in question they are
consuming. An AI is less precise than an RDA, but in the absence of an RDA, the AI is our best guess
of how much of a given nutrient is needed. If there is not an RDA for a nutrient, than the AI is used as
the nutrient-intake goal.
For example, there has not been sufficient scientific research into the exact nutritional requirements
for infants. Consequently, all of the DRI values for infants are AIs derived from nutrient values in
human breast milk. For older babies and young children, AI values are derived from human milk
coupled with data on adults. The AI is meant for a healthy target group and is not meant to be
sufficient for certain at-risk groups, such as premature infants.

Tolerable Upper Intake Levels

Consuming inadequate amount of nutrients can cause health problems, and we use the RDA or
AI values as targets to ensure that we’re getting enough. However, consuming too much of many
nutrients can also cause health problems. This is where the Tolerable Upper Intake Level (UL) is helpful.
ULs indicate the highest level of continuous intake of a particular nutrient that may be taken
without causing health problems.
It’s rare to find amounts of a nutrient exceeding the UL in a balanced diet based on whole foods.
However, a person who consumes dietary supplements, foods fortified with high levels of additional
nutrients (protein bars, for example) or a diet based on only a few foods, might exceed the UL, and
this could cause problems with nutrient toxicity. If you’re selecting a supplement, be sure to choose
one that does not exceed the UL for any nutrient, unless this is under specific instructions from your
doctor or a registered dietitian.
When a nutrient does not have any known issue if taken in excessive doses, it is not assigned a UL.
However, if a nutrient does not have a UL, that doesn’t necessarily mean that it is safe to consume
in large amounts—only that there isn’t currently evidence that large amounts will cause problems.
Science is an ongoing process, and the toxicity of many nutrients hasn’t yet been studied.

Putting It All Together

The graph below summarizes the meaning of the 4 DRI values for nutrient intake.
DEFINING NUTRIENT REQUIREMENTS: DIETARY REFERENCE INTAKES 37

Figure 1.11. DRI values for nutrient intake. The EAR, RDA, AI, and UL are shown relative to the observed
level of intake and risk of inadequacy and adverse effects.
This graph shows the risks of nutrient inadequacy and nutrient excess as we move from a low
intake of a nutrient to a high intake. Starting on the left side of the graph, you can see that when
you have a very low intake of a nutrient, your risk of nutrient deficiency is high. As your nutrient
intake increases, the chances that you will be deficient in that nutrient decrease. The point at which
50 percent of the population meets their nutrient needs is the EAR, and the point at which 97 to 98
percent of the population meets their needs is the RDA. The UL is the highest level at which you can
consume a nutrient without it being too much. As nutrient intake increases beyond the UL, the risk of
health problems resulting from that nutrient increases. The AI is shown to exist somewhere between
the EAR and UL, as it’s an amount of the nutrient known to maintain health.
Note that there is a wide margin between the RDA and UL, showing that a person might safely
eat much more than the RDA for a given nutrient without concerns of nutrient toxicity. However, be
aware that the margin of safety varies depending on the nutrient. For example, fat-soluble vitamins
have a smaller margin of safety between the RDA and the UL than water-soluble vitamins, meaning
that it’s easier to consume toxic levels of fat-soluble vitamins.
 38 TAMBERLY POWELL, MS, RDN

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VIDEO: “Dietary Reference Intakes,” Maurie Luetkemeier (September 16, 2015), 7 minutes. This video reviews
the different types of DRI values and what they mean.

HOW THE DRIS ARE USED

Individuals can use the DRIs to help assess and plan their diets. Keep in mind that the values
established have been devised with an ample safety margin and should be used as guidance for
optimal intakes. Also, the values are meant to assess and plan the average intake over time; that is,
you don’t need to meet these recommendations every single day—meeting them over several days
is sufficient.
The DRIs are also used by professionals, government agencies, and the food industry. Here are
2
some examples of their applications :

• Health professionals. Registered dietitians and other nutrition professionals use the DRIs
to provide dietary counseling and education and to plan menus for institutions, such as
hospitals, long-term care, prisons.
• Development of dietary guidelines. These include the U.S. Dietary Guidelines for
Americans, MyPlate, and Canada’s Food Guide. In each case, developers ensure that their
advice will help people meet the DRI standards.
• Nutrition labeling. The DRIs help to inform Nutrition Facts labels on foods and
Supplement Facts on supplement labels.
• Assistance programs. School meals, WIC, SNAP, Child and Adult Care, and Administration
on Aging programs must ensure that their programs align with the DRI.
• Nutrition monitoring research. Data from surveys of what people in the U.S. and Canada
eat are compared with the DRIs to monitor national nutritional health.
• Military. The military uses the DRIs as a reference to ensure nutrient needs are met for the
armed forces, to plan meals, and to procure military rations.
• Food and supplement industries. In the development of healthy food and safe
supplement products, these industries should refer to the DRI.

Self-Check
 DEFINING NUTRIENT REQUIREMENTS: DIETARY REFERENCE INTAKES 39

An interactive H5P element has been excluded from this version of the text. You can view it online here:
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Attributions:

• University of Hawai‘i at Mānoa Food Science and Human Nutrition Program, “Understand
Daily Reference Intakes,” CC BY-NC 4.0.

References:

1
• Institute of Medicine, Food and Nutrition Board. (2005). Dietary Reference Intakes for Energy,
Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients).
Washington, D.C.: The National Academies Press.
2
• The National Academies of Sciences, Engineering, and Medicine. Dietary Reference Intakes
Tables and Application. Retrieved December 11, 2019, from Health and Medicine Division
website: http://nationalacademies.org/hmd/Activities/Nutrition/SummaryDRIs/DRI-
Tables.aspx

Image Credits:

• “People eating a meal around a table” by Priscilla Du Preez is in the Public Domain
• Figure 1.9. “Acceptable Macronutrient Distribution Ranges (AMDR)” by Alice Callahan is
licensed under CC BY 4.0.
• Figure 1.10. “EAR and RDA relative to individual requirements for a given nutrient” by Alice
Callahan is licensed under CC BY 4.0; edited from “Fig 8.43, Kansas State University Human
Nutrition Flexbook” by Brian Lindshield is licensed under CC BY-NC-SA 4.0, with the addition
of “small people 7 clip art” by Public Domain Clip Art in the Public Domain.
• Figure 1.11. DRI values for nutrient intake. “Fig 8.44, Kansas State University Human
Nutrition Flexbook” by Brian Lindshield is licensed under CC BY-NC-SA 4.0
Understanding Food Labels

Not so long ago, food choices were limited to what could be grown or raised, hunted or gathered.
Today, grocery stores offer seemingly infinite choices in foods, with entire aisles dedicated to
breakfast cereals and cases filled with a multitude of different yogurts. Faced with so many choices,
how can we decide? Taste matters, of course. But if a healthy diet is your goal, so does nutrition. Food
labels are our window into the nutritional value of a given food. Let’s examine what we can learn
from food labels and how reading them can help us make smart choices to contribute to a healthy
diet.

The U.S. Food and Drug Administration (FDA) requires food manufacturers to accurately label
foods so that consumers can be informed about their contents. There are 5 types of information
1.2
required by the FDA on every food label, except for fresh produce and seafood :

1. Statement of identity (what type of food is it?)

2. Net contents of the package (how much is in there?)
3. Name and address of manufacturer (where was it produced?)
4. Ingredients list (what ingredients are included in the food?)
5. Nutrition information (what is the amount of nutrients included in a serving of food?)

40
UNDERSTANDING FOOD LABELS 41

Figure 1.12. The 5 required types of information on a food label.

The statement of identity and net contents of the package tell you what type of food you’re
purchasing and how much is in the package. The name and address of the manufacturer are
important if there’s a food recall due to an outbreak of foodborne illness or other contamination
issue. Given the size of our food system and the fact that one manufacturer may make products
packaged under multiple brand names, being able to trace a food’s origin is critical.
The last two types of required information—the ingredients list and the nutrition information—are
a bit more complex and provide valuable information to consumers, so let’s look more closely at each
of these parts of a food label.
42 TAMBERLY POWELL, MS, RDN

INGREDIENTS LIST

The ingredients list includes all ingredients,

listed from most predominant to least
predominant (by weight) in the product. For
example, in the corn muffin mix label to the
right, the most prevalent ingredient is enriched
unbleached flour (with ingredients in the flour
then listed in parentheses), followed by sugar,
cornmeal, salt, and then a few other ingredients.
This order of ingredients comes in handy
when judging the nutritional value of a
product. For example, in the ingredients list for
the corn muffin mix shown at right, it’s
interesting to note that it contains more sugar
than cornmeal! The ingredients list can also help
you determine whether a bread contains more
whole grain flour than refined flour. Or, if you’re
choosing a breakfast cereal and the first
ingredient is sugar, that’s a red flag that it’s more
of a dessert than part of a nutritious breakfast.
By law, food manufacturers must also list
major allergens, which include milk, egg,
fish, crustacean shellfish, tree nuts, wheat,
2
peanuts, and soybeans. Allergens may be listed in a separate statement, as on the corn muffin mix
label, which lists “Contains: Wheat” on the label. Alternatively, allergens can be listed in parentheses
within the ingredient list, such as “lecithin (soy).” Some labels include an optional “may contain” or
“made in shared equipment with…” statement that lists additional allergens that could be present,
not as ingredients in the food, but in trace amounts from equipment contamination. For people with
food allergies, having this information clearly and accurately displayed on food packages is vital for
their safety.

THE NUTRITION FACTS PANEL

If you want to learn about the nutritional value of a food, the Nutrition Facts panel is where you’ll find
this information. It’s very useful for comparing products and for identifying foods that will be more
or less valuable in meeting your nutritional goals. For example, if you’re trying to watch your intake
of added sugar or saturated fat, or you’re trying to incorporate more dietary sources of calcium and
vitamin D, the Nutrition Facts panel is a valuable tool. There are 4 main parts of a Nutrition Facts
panel, shown in the figure below. The colors are added to highlight different sections of a label;
Nutrition Facts are printed in black and white.
UNDERSTANDING FOOD LABELS 43

Figure 1.13. The four main sections of a Nutrition Facts label, highlighted in color.

1. Serving size information

It’s fitting that serving size information is first on the Nutrition Facts panel, because all of the
information that follows is based on it. The serving size of the food is the amount that is
customarily eaten at one time, and all of the nutrition information on the label is based on
1
one serving of the food. This section of the label also states the number of servings per container.
It’s important to note that you might not always eat one serving of a food; sometimes you might
eat half of a serving, and sometimes you might eat two or more servings in one sitting. For example,
if the label above is for a breakfast cereal, you might easily consume 1 ⅓ cups of cereal for breakfast.
If you’re interested in how many calories or nutrients you’re consuming, you would need to double
the nutrition values to accurately represent your breakfast, since the serving size is only ⅔ cup.

2. Calorie information

This section simply states the number of calories, or the amount of energy, provided in one serving
of the food. Again, if you consume more or less than the serving size, you’ll need to take that into
consideration when estimating the calories you’re consuming.
44 TAMBERLY POWELL, MS, RDN

3. Nutrient amounts

The Nutrition Facts panel must list the amounts of these nutrients: total fat, saturated fat, trans fat,
cholesterol, sodium, total carbohydrate, dietary fiber, sugars, added sugars, protein, calcium, vitamin
1
D, iron, and potassium.
Manufacturers may also choose to add several other optional nutrients or nutritional information:
calories from saturated fat, polyunsaturated fat, monounsaturated fat, soluble and insoluble fiber,
sugar alcohol, other carbohydrate, and other vitamins and minerals.

4. Percent Daily Values

The Daily Value (DV) is an approximate recommendation for daily intake for a nutrient, developed by
the FDA for use on food labels so that consumers can see how much of a nutrient is provided by a
serving of a food relative to about how much they need each day. The DV is similar to the RDA or AI,
except that because it’s used on food labels, it needs to be a simplified recommendation, with just
3
one value rather than several for different age groups and sex, as found in the DRI.
Most DVs are based on amounts for people age 4 years through adult, though there are DVs
established for infants, toddlers, and pregnant and lactating women, and you’ll see those used on
food products specifically developed for those groups. Most of the time, the DV for a nutrient is the
highest RDA or AI for the group it’s intended for.
The value printed on the Nutrition Facts panel is the percent DV, which tells you how much one
serving of the food contributes towards meeting the daily requirement for that nutrient.
4
The FDA uses the following definitions for interpreting the %DV on food labels:

• 5%DV or less means the food is low in a nutrient.

• 10% to 19%DV means the food is a “good source” of a nutrient.
• 20%DV or greater means the food is high in a nutrient.

The DV is not as precise as the RDA, so while the %DV is useful for comparing food products
or making quick judgements about the nutritional value of a food, it’s better to use the RDA if
you’re looking for your individual nutrient requirements.

Putting the Nutrition Facts panel to work for you

How you use the Nutrition Facts on food labels depends on your dietary goals. If you’re trying to
reduce your saturated fat intake, you’ll want to pay close attention to the %DV for saturated fat and
try to choose foods with less than 5% DV for saturated fat. If you’re watching your caloric intake, you’ll
want to pay attention to the calorie information. Regardless, always start by checking the serving size
and comparing it to the amount you usually consume.
As an example of smart label reading, take a look at the two soup labels below. First, think about
how much soup you would usually consume. There are two servings per can, but would you eat the
entire can or just half of it? Many people would eat the whole can, and if that’s you, you would want
to double all of the calorie and nutrient information. Both soups provide 160 calories per one-cup
serving, or 320 calories for the entire can.
UNDERSTANDING FOOD LABELS 45

Figure 1.14. Comparison of Nutrition Facts for a regular vegetable soup, and reduced sodium vegetable
soup.
Next, take a look at the sodium. Most Americans consume too much sodium, and this can increase
the risk of developing high blood pressure. The regular soup has 680 mg or 28% of the DV for sodium.
If you eat the entire can, that becomes 1360 mg or 56% DV. That’s a lot of sodium. You can see how
the reduced sodium soup might be the wiser choice here.
46 TAMBERLY POWELL, MS, RDN

One or more interactive elements has been excluded from this version of the text. You can view them online here:
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VIDEO: “Reading Food Labels,” by Cincinnati Children’s, YouTube (May 9, 2019), 2:56 minutes.

WHAT’S THAT CLAIM?

In addition to the FDA-required information on food labels, it’s common for them to be peppered
with claims about the nutrient content of the food and the purported health benefits of eating it.
These claims are marketing tools for food manufacturers, and they’re regulated by the FDA in an
effort to ensure that they give the consumer accurate, science-based information about the food.
Let’s look at the different types of claims that you’ll find on food packages.

Nutrient Claims

Nutrient claims provide straight-forward information about the level of a nutrient or calories in the
food, such as “fat-free,” “low calorie,” or “reduced sodium.” Nutrient claims are regulated by the FDA,
with very specific requirements for each one. For example, a food with a “low sodium” claim must
have 140 mg of sodium or less per serving, whereas a food with a “reduced sodium” claim must have
at least 25 percent less sodium than the standard product. You’ll see claims that a food is “high in,”
“rich in,” and “excellent source of” a nutrient, all of which mean that a serving of the food contains
1
20% DV or more. A “good source of” claim contains 10-19% DV of the nutrient.
UNDERSTANDING FOOD LABELS 47

Figure 1.15. Examples of food packaging with nutrient claims. Can you spot them?

Health Claims

Health claims are statements on food packaging that link the food or a component in the food to
reducing the risk of a disease. Health claims can be “authorized” or “qualified.” Authorized health
5
claims have stronger scientific evidence to back them than qualified health claims.
As an example of an authorized health claim, a food that is low in sodium (per the FDA’s definition
of less than 140 mg per serving) can include the following claim on their packaging: “Diets low in
1
sodium may reduce the risk of high blood pressure, a disease associated with many factors.”
For an authorized health claim to be approved by the FDA, the agency says “there must be
significant scientific agreement (SSA) among qualified experts that the claim is supported by the
totality of publicly available scientific evidence for a substance/disease relationship. The SSA
standard is intended to be a strong standard that provides a high level of confidence in the validity
5
of the substance/disease relationship.” In other words, the FDA requires a great deal of evidence
before allowing food manufacturers to claim that their products can reduce the risk of a disease.
As is evident in the low sodium claim, they also require careful language, such as “may reduce” (not
definitely!) and “a disease associated with many factors” (as in, there are many other factors besides
sodium that influence blood pressure, so a low sodium diet isn’t a guaranteed way to prevent high
blood pressure).
Qualified health claims have some evidence to support them, but not as much, so there’s less
certainty that these claims are true. The FDA reviews the evidence for a qualified claim and
determines how it should be worded to convey the level of scientific certainty for it. Here’s an
example of a qualified health claim: “Scientific evidence suggests but does not prove that eating 1.5
ounces per day of most nuts [such as name of specific nut] as part of a diet low in saturated fat and
cholesterol may reduce the risk of heart disease.”

Figure 1.16. Examples of food packaging with authorized health claims. Can you spot them?
 48 TAMBERLY POWELL, MS, RDN

Structure-Function Claims

Health claims are very specific and precise in their language, and they convey the level of scientific
certainty supporting them. In contrast, structure-function claims are intentionally vague statements
about nutrients playing some role in health processes. Examples of structure-function claims are
“calcium builds strong bones” and “fiber maintains bowel regularity.” Note that these statements
make no claims to prevent osteoporosis or treat constipation, because structure-function claims are
6
not allowed to say that a food or nutrient will treat, cure, or prevent any disease. They’re allowed
by the FDA, but not specifically approved or regulated, as long as their language stays within those
rules.

Figure 1.17. Examples of food and supplement packaging with structure-function claims. Can you spot
them?
Structure-function claims were originally designed to be used on dietary supplements, but they can
also be used on foods, and they’re usually found on foods that are fortified with specific nutrients.
They are marketing language, and because nutrients are involved in so many processes, they really
don’t mean much.
As you look at food labels, pay attention to what’s shown on the front of the package compared
with the back and side of the package. Nutrient and health claims are usually placed strategically
on the front of the package, in large, colorful displays with other marketing messages, designed to
sell you the product. But for consumers trying to decide which product to buy, you’ll find the most
useful information by turning the package around to read the Nutrition Facts panel and ingredients
list. These parts of the label may appear more mundane, but if you understand how to read them,
you’ll find that they’re rich in information.

Self-Check
 UNDERSTANDING FOOD LABELS 49

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References:

1
• U.S. Food and Drug Administration. (2013, January). A Food Labeling Guide: Guidance for
Industry. Retrieved January 2, 2020, from FDA website: https://www.fda.gov/regulatory-
information/search-fda-guidance-documents/guidance-industry-food-labeling-guide
2
• U.S. Food and Drug Administration. (2019, December 11). Food Labeling & Nutrition.
Retrieved December 18, 2019, from FDA website: http://www.fda.gov/food/food-labeling-
nutrition
3
• National Institutes of Health, Office of Dietary Supplements. (n.d.). Daily Values (DVs).
Retrieved December 22, 2019, from https://ods.od.nih.gov/HealthInformation/
dailyvalues.aspx
4
• U.S. Food and Drug Administration. (2019, September 5). New and Improved Nutrition
Facts Label. Retrieved January 2, 2020, from FDA website: http://www.fda.gov/food/
nutrition-education-resources-materials/new-and-improved-nutrition-facts-label
5
• U.S. Food and Drug Administration. (2018). Questions and Answers on Health Claims in
Food Labeling. FDA. Retrieved from http://www.fda.gov/food/food-labeling-nutrition/
questions-and-answers-health-claims-food-labeling
6
• U.S. Food and Drug Administration. (2018). Structure/Function Claims. FDA. Retrieved from
http://www.fda.gov/food/food-labeling-nutrition/structurefunction-claims

Image Credits:

• Grocery aisle photo by NeONBRAND on Unsplash (license information)

• Figure 1.12. “The 5 required types of information on a food label” by Alice Callahan is
licensed under CC BY-NC 4.0
• “Corn muffin ingredient list” by Alice Callahan is licensed under CC BY-NC 4.0
• Figure 1.13. Part of a nutrition fact label by Alice Callahan, CC BY 4.0, edited from “Nutrition
Facts Label” by C.D.C. is in the Public Domain
• Figure 1.14. “Soup label comparison” by U.S.D.A. ChooseMyPlate is in the Public Domain
• Figure 1.15. “Examples of food packaging with nutrient claims” by Alice Callahan is licensed
under CC BY-NC 4.0
• Figure 1.16. “Examples of food packaging with authorized health claims” by Alice Callahan is
licensed under CC BY-NC 4.0
• Figure 1.17. “Examples of food packaging with structure-function claims” by Alice Callahan
is licensed under CC BY-NC 4.0
Tools for Achieving a Healthy Diet

Good nutrition means eating the right foods, in the right amounts, to receive enough (but not too
much) of the essential nutrients so that the body can remain free from disease, grow properly, work
effectively, and feel its best. The phrase “you are what you eat” refers to the fact that the food you eat
has cumulative effects on the body. And many of the nutrients obtained from food do become a part
of us. For example, the protein and calcium found in milk can be used in the formation of bone. The
foods we eat also impact how we feel—both today and in the future. Below we will discuss the key
components of a healthy diet that will help prevent chronic disease (like heart disease and diabetes),
maintain a healthy weight, and promote overall health.

ACHIEVING A HEALTHY DIET

Achieving a healthy diet is a matter of balancing the quality and quantity of food that you eat to
provide an appropriate combination of energy and nutrients. There are four key characteristics that
make up a healthful diet:

1. Adequacy
2. Balance
3. Moderation
4. Variety

Adequacy

A diet is adequate when it provides sufficient amounts of calories and each essential nutrient, as
well as fiber. Most Americans report not getting enough fruit, vegetables, whole grains or dairy,
which may mean falling short in the essential vitamins and minerals found in these food groups, like
1
Vitamin C, potassium, and calcium, as well as fiber.

Balance

A balanced diet means eating a combination of foods from the different food groups, and because
these food groups provide different nutrients, a balanced diet is likely to be adequate in nutrients.
For example, vegetables are an important source of potassium, dietary fiber, folate, vitamin A, and
vitamin C, whereas grains provide B vitamins (thiamin, riboflavin, niacin, and folate) and minerals
(iron, magnesium, and selenium). No one food is more important than the other. It is the
combination of all the different food groups (fruit, vegetables, grains, dairy, protein and fats/oils) that
will ensure an adequate diet.

50
TOOLS FOR ACHIEVING A HEALTHY DIET 51

Moderation

Moderation means not eating to the extremes, neither too much nor too little of any one food or
nutrient. Moderation means that small portions of higher-calorie, lower-nutrient foods like chips and
candy can fit within a healthy diet. Including these types of foods can make healthy eating more
enjoyable and also more sustainable. When eating becomes too extreme—where many foods are
forbidden—this eating pattern is often short-lived until forbidden foods are overeaten. Too many
2
food rules can lead to a cycle of restriction-deprivation-overeating-guilt. For sustainable, long-term
health benefits, it is important to give yourself permission to eat all foods.
52 TAMBERLY POWELL, MS, RDN

Variety

Variety refers to consuming different foods within each of the food groups on a regular basis. Eating
a varied diet helps to ensure that you consume adequate amounts of all essential nutrients required
for health. One of the major drawbacks of a monotonous diet is the risk of consuming too much of
some nutrients and not enough of others. Trying new foods can also be a source of pleasure—you
never know what foods you might like until you try them.

DIETARY GUIDELINES FOR AMERICANS

The Dietary Guidelines are published and revised every five years jointly by the U.S. Department of
3
Agriculture (USDA) and Health and Human Services (HHS) as a guide to healthy eating for Americans.

Purpose

The purpose of the Dietary Guidelines is to give Americans evidence-based information on what
to eat and drink to promote health and prevent chronic disease. Public health agencies, health
care providers, and educational institutions all rely on Dietary Guidelines recommendations and
3
strategies. These agencies use the Dietary Guidelines to:

• Form the basis of federal nutrition policy and programs such as WIC and SNAP
• Help guide local, state, and national health promotion and disease prevention initiatives
• Inform various organizations and industries (for example, products developed and
marketed by the food and beverage industry)

Process

Before HHS and the USDA release the new Dietary Guidelines, they assemble an Advisory Committee.
This committee is composed of nationally recognized nutrition and medical researchers, academics,
and practitioners. The Advisory Committee develops an Advisory Report that synthesizes current
scientific and medical evidence in nutrition, which will then advise the federal government in the
development of the new edition of the Dietary Guidelines.
The public also has opportunities to get involved in the development of these guidelines. The
Advisory Committee holds a series of public meetings for hearing oral comments from the public,
and the public also has opportunities to provide written comments to the Advisory Committee
throughout the course of its work. After the Advisory Report is complete, the public has opportunities
to respond with written comments and provide oral testimony at a public meeting.

2020-2025 Dietary Guidelines

The major topic areas of the Dietary Guidelines are:

1. Follow a healthy dietary pattern at every life stage.

2. Customize and enjoy nutrient-dense food and beverage choices to reflect personal
preferences, cultural traditions, and budgetary considerations.
3. Focus on meeting food group needs with nutrient-dense foods and beverages, and stay
within calorie limits.
4. Limit foods and beverages higher in added sugars, saturated fat, and sodium, and limit
alcoholic beverages.
TOOLS FOR ACHIEVING A HEALTHY DIET 53

Several nutrients are of special public health concern, including dietary fiber, calcium, potassium,
and vitamin D. Inadequate intake of these nutrients is common among Americans and is associated
with greater risk of chronic disease. People can increase their intake of these nutrients by shifting
towards eating more vegetables, fruits, whole grains, dairy products, and beans. The Dietary
Guidelines thus encourage the following nutrient-dense food choices:

• Vegetables, including a variety of dark green, red and orange, legumes (beans and peas),
starchy and other vegetables
• Fruits, especially whole fruits
• Grains, at least half of which are whole grains
• Dairy, including fat-free or low-fat milk, yogurt, and cheese, and/or fortified soy beverages
and yogurt
• Protein foods, including seafood (8 or more ounces per week), lean meats and poultry,
eggs, legumes (beans, peas, lentils), soy products, and nuts and seeds
• Oils, including those from plants, such as canola, corn, olive, peanut, safflower, soybean,
and sunflower oils, and those present in whole foods such as nuts, seeds, seafood, olives,
and avocados.

The DGA explains that most of an individual’s daily caloric intake—about 85%—must be made
up of nutrient-dense foods in order to meet nutrient requirements, leaving about 15% of calories
available for other uses. Yet many Americans consume too much of foods with added sugars and
saturated fat, in addition to excessive amounts of sodium and alcohol. Consuming too much of
these dietary components is associated with development of chronic disease over time and can add
calories without providing much in the way of beneficial nutrients. Therefore, the DGA recommends
limiting the following:

• Added sugars – Consume less than 10 percent of calories per day from added sugars
starting at age 2. (Avoid foods and beverages with added sugars for those younger than
age 2.)
• Saturated fat – Consume less than 10 percent of calories per day from saturated fat
starting at age 2.
• Sodium – Consume less than 2,300 milligrams (mg) per day of sodium – and even less for
children younger than age 14.
54 TAMBERLY POWELL, MS, RDN

• Alcoholic beverages – If alcohol is consumed, it should be consumed only in moderation

(up to one drink per day for women and up to two drinks per day for men). Drinking less is
better for health than drinking more.

The United States is not the only country that develops nutritional guidelines. The Food and
Agriculture Organization of the United Nations has a website where you can search for dietary
guidelines for different countries, such as Sweden’s guidelines, illustrated below.

Figure 1.18. “Sweden’s one-minute advice” by Food and Agriculture Organization of the United Nations
(FAO)
TOOLS FOR ACHIEVING A HEALTHY DIET 55

The Swedish National Food Agency also has a great resource, “Find Your Way To Eat Greener, Not
Too Much and Be Active” on how to put these guidelines into practice.
One way the USDA and other federal agencies implement the Dietary Guidelines is through
MyPlate, which we will discuss next.

MyPlate (USDA Food Guide)

For many years, the U.S. government has been encouraging Americans to develop healthful dietary
habits. For example, the food pyramid was introduced in 1992 as the symbol of healthy eating
patterns for all Americans.

Figure 1.19. The food pyramid in 1992.

In 2005, the food pyramid was replaced with MyPyramid.

56 TAMBERLY POWELL, MS, RDN

Figure 1.20. MyPyramid, introduced in 2005.

However, many felt this new pyramid was difficult to understand, so in 2011, the pyramid was
replaced with MyPlate.
TOOLS FOR ACHIEVING A HEALTHY DIET 57

Figure 1.21. MyPlate, introduced in 2011.

MyPlate is a food guide to help Americans achieve the goals of the Dietary Guidelines for
Americans. For most people this means eating MORE:

• whole grains
• fruits
• vegetables (especially dark green vegetables and red and orange vegetables)
• legumes
• seafood (to replace some meals of meat and poultry)
• low-fat dairy

And LESS:

• refined grains
• added sugars
• solid fats: saturated fats, trans fats, and cholesterol
• sodium

Foods are grouped into 5 different groups based on their nutrient content. The following table
summarizes the different food groups, examples of foods that fall within each group, and nutrients
provided for each food group.
58 TAMBERLY POWELL, MS, RDN

Food Group Example of Foods Nutrients Provided

Whole grains: brown rice, oats, whole wheat bread, cereal

and pasta, popcorn. Refined grains: typically tortillas,
dietary fiber, several B vitamins (thiamin, riboflavin,
couscous, noodles, naan, pancakes (although sometimes
niacin, and folate), and minerals (iron, magnesium,
these products can be whole grains too). For more foods
and selenium)
and what counts as a cup check out: The Grain Group Food
Gallery.

Dark green vegetables- broccoli, kale, and spinach. Red and

orange vegetables- bell peppers, carrots and tomatoes.
Starchy vegetables- corn, peas and potatoes. Beans and
potassium, dietary fiber, folate, vitamin A, and
Peas- hummus, lentils and black beans. Other vegetables-
vitamin C
asparagus, avocado, zucchini. For more foods and what
counts as a cup check out: The Vegetable Group Food
Gallery.

Fresh berries, melons, and other fruit as well as 100% fruit

juice. Fruits can also be canned, frozen, or dried, and may
potassium, dietary fiber, vitamin C, and folate
be whole, cut-up, or pureed. For more foods and what
counts as a cup check out: The Fruit Group Food Gallery.

Meats, poultry, seafood, beans and peas, eggs, nuts and

protein, B vitamins (niacin, thiamin, riboflavin, and
seeds. For more foods and what counts as a cup check out:
B6), vitamin E, iron, zinc, and magnesium
The Protein Group Food Gallery.

Milk, yogurt, cheese and calcium-fortified soy milk. Foods

such as cream cheese, cream, and butter, are not part of
the Dairy Group as they have little/no calcium (they count as calcium, potassium, vitamin D, and protein
a fat). For more foods and what counts as a cup check
out: The Dairy Group Food Gallery.

Table 1.4. A summary of MyPlate food groups, examples of foods that fall within each group, and nutrients
provided for each food group.

This graphic summarizes serving sizes for each of the food groups:
TOOLS FOR ACHIEVING A HEALTHY DIET 59

Figure 1.22. Cup- and ounce-equivalents for different food groups within MyPlate.
Planning a healthy diet using the MyPlate approach is not difficult:

• Fill half of your plate with a variety of fruits and vegetables, including red, orange, and
dark green vegetables and fruits, such as kale, collard greens, tomatoes, sweet potatoes,
broccoli, apples, oranges, grapes, bananas, blueberries, and strawberries in main and side
dishes. Vary your choices to get the benefit of as many different vegetables and fruits as
you can. One hundred percent fruit juice is also an acceptable choice as long as only half
your fruit intake is replaced with juice.
• Fill a quarter of your plate with grains. Half of your daily grain intake should be whole
grains such as 100 percent whole-grain cereals, breads, crackers, rice, and pasta.
Read the ingredients list on food labels carefully to determine if a food is comprised of
whole grains. We will discuss how to identify whole grains in more detail in later units.
• Select a variety of protein foods to improve nutrient intake and promote health
benefits. Each week, be sure to include a nice array of protein sources in your diet, such as
nuts, seeds, beans, legumes, poultry, soy, and seafood. The recommended consumption
amount for seafood for adults is two 4-ounce servings per week. When choosing meat,
select lean cuts.
60 TAMBERLY POWELL, MS, RDN

• If you enjoy drinking milk or eating dairy products, such as cheese and yogurt,
choose low-fat or nonfat products. Low-fat and nonfat products contain the same
amount of calcium and other essential nutrients as whole-milk products, but with much
less fat and calories. Calcium, an important mineral for your body, is also found in lactose-
free dairy products and fortified plant-based beverages, like soy milk. You can also get
calcium from vegetables and other fortified foods and beverages.
• Oils are also important in your diet as they contain valuable essential fatty acids. Oils like
canola oil also contain more healthful unsaturated fats compared to solid fats like
butter. You can also get oils from whole foods like fish, avocados, and unsalted nuts and
seeds. Although oils are essential for health, they do contain about 120 calories per
tablespoon, so moderation is important.

Some people have criticized the Dietary Guidelines for Americans and MyPlate for being influenced
by political and economic interests, as the meat and dairy industries and large food companies
have a powerful lobbying presence that may override scientific consensus. When the 2020-2025
Dietary Guidelines were released in December of 2020, for example, they were criticized for failing to
address sustainability, climate change, and the potential benefits of eating less meat and processed
foods. In addition, although the 2020 Advisory Committee, made up of nutrition science experts,
recommended stricter limits on added sugars and alcohol consumption, the final version of the
Guidelines ignored these recommendations and stuck with the same advice about sugar and alcohol
4
given in the 2015 version of the Guidelines.
Another guide for creating healthy, balanced meals comes from Harvard’s School of Public Health.
The Healthy Eating Plate (HEP) is based on the best available science and is not influenced by political
or commercial pressures from food industry lobbyists.
TOOLS FOR ACHIEVING A HEALTHY DIET 61

Figure 1.23. Harvard’s Healthy Eating Plate.

The message of the HEP is similar to MyPlate in that the focus is on diet quality—encouraging
nutrient-dense whole grains, fruits, vegetables, and beans. However, there are a few key differences
between MyPlate and HEP. For example, MyPlate recommends 3 cups of dairy a day, whereas HEP
recommends limiting dairy to 1-2 cups per day, and instead encourages non-dairy sources of calcium
like collards, bok choy, fortified soy milk, and baked beans.
The HEP encourages protein sources from fish, poultry, beans or nuts, and it encourages
consumers to limit red meat and avoid processed meat,since these foods raise the risk of heart
5
disease, diabetes, and colon cancer. MyPlate, however, does not mention that red and processed
meat should be limited.

Nutrient Density and Empty Calories

MyPlate encourages people to take a balanced approach and to eat a variety of nutrient-dense, whole
foods. To help people control calories and prevent weight gain, the USDA promotes the concept of
nutrient density and empty calories. Nutrient density is a measure of the nutrients that we’re usually
trying to consume more of—vitamins, minerals, fiber and protein—per calorie of food, coupled with
little or no solid fats, added sugars, refined starches, and sodium. For example, in the screenshot
below, a 90 percent lean 3-ounce ground beef patty is considered more nutrient-dense than a 75
percent lean patty. In the 90 percent lean patty, for 184 calories you get protein, iron, and other
needed nutrients. On the other hand, the 75 percent lean patty has 236 calories, but the extra 52
calories add only solid fats and no other appreciable nutrients.
62 TAMBERLY POWELL, MS, RDN

Figure 1.24. Examples of the calories found in nutrient-dense food choices compared with calories found
in less nutrient-dense forms of these foods.
All vegetables, fruits, whole grains, seafood, eggs, beans and peas, unsalted nuts and seeds, fat-
free and low-fat dairy products, and lean meats and poultry—when prepared with little or no added
solid fats, and sugars—are nutrient-dense foods.
Foods become less nutrient dense when they containempty empty calories
calories—calories from solid fats and/
or added sugars. Solid fats and added sugars add calories to a food but don’t provide other nutrients.
Foods with empty calories have fewer nutrients per calorie; therefore, they are less nutrient dense.
Examples of foods HIGH in empty calories:

• doughnuts, cakes, cookies

• sweetened cereals and yogurt
• sweetened beverages
• high-fat meats
• fried foods
• alcohol

Examples of nutrient-dense foods:

• whole grains like brown rice, whole wheat bread and pasta, barley, and oatmeal
• plain, nonfat milk and yogurt
• beans, nuts, and seeds
• lean meats
• whole, fresh fruits and vegetables

You can choose more nutrient-dense foods by making small modifications to your current eating
pattern. Examples include preparing foods with less fat by baking versus frying, purchasing items like
cereals and fruits with less added sugar, and focusing on eating foods in their natural state versus
adding a lot of extra fat, sugar and sodium.
TOOLS FOR ACHIEVING A HEALTHY DIET 63

Figure 1.25. Typical versus nutrient-dense foods.

Keep in mind that empty calories are not always a bad thing. In fact, empty calories can help
promote eating more nutrient-dense foods. Adding a little fat and/or sugar to nutrient-dense foods
can add flavor, making the food more enjoyable. A teaspoon of sugar in oatmeal, or a teaspoon of
butter on steamed veggies is a great way to include empty calories. In these cases, the calories come
packaged with other nutrients (since they are added to whole foods), whereas the empty calories in
soda come with no other nutrients, only added sugar.
 64 TAMBERLY POWELL, MS, RDN

Self-Check

An interactive H5P element has been excluded from this version of the text. You can view it online here:

https://openoregon.pressbooks.pub/nutritionscience/?p=843#h5p-30

Attributions:

• University of Hawai‘i at Mānoa Food Science and Human Nutrition Program, “Achieving a
Healthy Diet,” CC BY-NC 4.0
• “Recommendations for Optimal Heath,” section 2.5 from the book An Introduction to
Nutrition (v. 1.0), CC BY-NC-SA 3.0

References:

1
• U.S. Department of Agriculture and U.S. Department of Health and Human Services.
(2020). Dietary Guidelines for Americans, 2020-2025, 9th Edition. Retrieved from
https://www.dietaryguidelines.gov/
2
• Rumsey, A. (2018, Janurary 8) Why Eating Fewer Calories Won’t Help You Lose Weight. U.S.
News. Retrieved from https://health.usnews.com/health-news/blogs/eat-run/articles/
2018-01-08/why-eating-fewer-calories-wont-help-you-lose-weight
3
• Office of Disease Prevention and Health Promotion. (2020). About the Dietary Guidelines.
Retrieved from https://health.gov/our-work/food-nutrition/about-dietary-guidelines
4
• Rabin, R. C. (2020, December 29). U.S. Diet Guidelines Sidestep Scientific Advice to Cut
Sugar and Alcohol. The New York Times. https://www.nytimes.com/2020/12/29/health/
dietary-guidelines-alcohol-sugar.html
5
• Harvard’s School of Public Health, The Nutrition Source. (2019). Healthy Eating Plate vs.
USDA’s MyPlate. Retrieved from https://www.hsph.harvard.edu/nutritionsource/healthy-
eating-plate-vs-usda-myplate/

Images:

• “Four Days of Bento” by Blairwang is licensed under CC BY 2.0

• “Colours of Health” by Alex Promois is licensed under CC BY-NC 2.0
• “Fresh Berries” by Cookbookman17 is licensed under CC BY 2.0
• Figure 1.18. “Sweden’s one-minute advice” by Food and Agriculture Organization of the
United Nations (FAO) is licensed under CC BY 3.0
• Figure 1.19. “The original food pyramid” from the USDA is in the Public Domain
• Figure 1.20. “Mypyramid” from the USDA is in the Public Domain
• Figure 1.21. “MyPlate” from the USDA is in the Public Domain
TOOLS FOR ACHIEVING A HEALTHY DIET 65

• “Food Group Buttons” from the USDA is in the Public Domain

• Table 1.4. “MyPlate Summary” by Tamberly Powell is licensed under CC BY-NC-SA 4.0;
information in the table is from ChooseMyPlate is in the Public Domain
• Figure 1.22. “Cup- and ounce-equivalents” by the Dietary Guidelines for Americans, Figure
1.1, is in the Public Domain
• “Lentil Quinoa Soup” by Tasha is licensed under CC BY 2.0
• Figure 1.23. “Harvard’s Healthy Eating Guide” Copyright © 2011, Harvard University. Health,
www.thenutritionsource.org, and Harvard Health Publications, www.health.harvard.edu.
• Figure 1.24. “Examples of the calories in food choices that are not in nutrient dense forms
and the calories in nutrient dense forms of these foods” by The Dietary Guidelines for
Americans 2010, Figure 2.2, is in the Public Domain
• Figure 1.25. “Typical versus nutrient-dense foods” by the Dietary Guidelines for Americans,
Figure 2.8, is in the Public Domain
UNIT 2 - NUTRITION SCIENCE
AND INFORMATION LITERACY

67
Introduction to Nutrition Science and Information
Literacy

If you follow nutrition science in the media for long enough, you’ll start to see recurring themes.
You’ll see stories in the news about many of our favorite foods—like eggs, butter, coffee, and
chocolate—that seem to flip-flop about whether these foods are good or bad for us. You’ll notice
seemingly eternal debates about whether dietary fat and carbohydrates are valuable macronutrients
or villians. You’ll watch as particular diets come in and out of fashion—and then back into fashion
another decade or two later. And you’ll see countless click-baity stories about the health benefits of
eating so-called superfoods, or the dangers of eating others.

Even if you don’t pay much attention to nutrition science in the news, you’ll hear a ton of conflicting
opinions and information just by talking to the people around you. Maybe your best friend has
gone gluten-free, your dad is on a keto diet, and your coworker swears the Whole 30 diet has been
life-changing. They’re all trying to convince you to join them in their latest diets, but your head is
swimming. They can’t all be right, and you don’t want to just follow the latest fad. You want to find
accurate information that’s based on solid scientific evidence. How can you identify it in a sea of
conflicting and overwhelming information? Who can you trust?
It can be hard to filter through it all, especially when it’s attached to strong opinions, emotions, and
69
 70 TAMBERLY POWELL, MS, RDN

people trying to sell their product or point-of-view. And yet, we all need to make choices about what
to eat, at the very least for ourselves, and often for others. You may have the responsibility of feeding
family members in different stages of life, with different needs and preferences. And if you work
in the health professions, you may have patients or clients who look to you as a source of reliable
information about nutrition. Of course, the problem of conflicting and overwhelming information is
not unique to nutrition; you’ll find the same issue in many other health-related fields, and beyond.
Now, more than ever, it’s essential to develop skills in information literacy
literacy, including the ability to
find information, evaluate whether it is accurate and useful, and apply it effectively. The purpose of
this unit is to develop and hone your skills in information literacy as it applies to nutrition. You’ll learn
about the scientific method, because it forms the foundation of how we know what we know about
nutrition. You’ll learn about the different types of research studies and each of their advantages and
limitations. We’ll discuss various sources of information, such as scholarly and popular sources, how
each of them can be useful in different ways, and how to evaluate them. We’ll also discuss careers in
nutrition and the different types of skills that you’ll find among nutrition experts.

Unit Learning Objectives

After completing this unit, you should be able to:

1. Identify the sequential steps of the scientific method, and understand the importance of reporting research
results in peer-reviewed journals.

2. Describe the different types of research studies used in nutrition, including the quality of evidence, advantages,
and limitations of each.

3. Be aware of some of the limitations of nutrition research, including the challenges of studying complex dietary
patterns and the influence of industry funding.

4. Understand differences between scholarly (peer-reviewed) and popular sources for nutrition information.

5. Evaluate sources of nutrition information and distinguish between credible sources and junk science.

6. Identify the qualifications of nutrition professionals and career opportunities in the field of nutrition.

Image Credits:

Photo by Brooke Cagle on Unsplash (license information)

The Scientific Method

Similar to the method by which a police detective investigates a crime, nutritional scientists discover
the health effects of food and nutrients by first making an observation and posing a question that
they’d like to answer. Then they formulate a hypothesis, test their hypothesis through experiments,
and finally interpret the results. After analyzing additional evidence from multiple sources, they may
form a conclusion on whether the food suspect fits the claim. This organized process of inquiry used
in forensic science, nutritional science, and every other science is called the scientific method
method.
The basis of what we know about nutrition is derived from research, and the scientific method
underlies how research is conducted. The steps of the scientific method include:
1. Observation/Question: The researcher first makes an observation and comes up with a
research question to investigate.
2. Hypothesis: The researcher formulates a hypothesis, or educated guess, that would explain the
observation or question and that can be tested through scientific experiments.
3. Experiment: The researcher designs and conducts an experiment. A good design takes into
account what has been done previously. Thus, before beginning a new study, the researcher
undertakes a thorough review of published research in order to ensure that their work advances the
field.
4. Analysis: The researcher collects and analyzes data that will either support or refute the
hypothesis. If the hypothesis is not supported, researchers create a new hypothesis and conduct a
new experiment. If the hypothesis is supported, researchers will design additional experiments to try
to replicate the findings or to test them in different ways.
5. Conclusion: After multiple experiments consistently support a hypothesis, researchers can offer
a conclusion or theory.

71
72 TAMBERLY POWELL, MS, RDN

Figure 2.1. The scientific method is a cyclical process, because it always leads to new observations and
questions.
Through the scientific method, our knowledge of science builds continuously over time. No one
study is enough to fully explain any one phenomenon, particularly in an area as complex as nutrition.
Even experiments that go exactly as expected lead us to new questions to investigate. Science is
also filled with surprises, both big and small. Experiments may not yield the results that we expect,
but that can lead to new and important questions. And because scientists are human, they can
make mistakes along the way or fail to acknowledge or test an important variable, which is why it’s
important that experiments be repeated and evaluated by other researchers along the way.
The history of nutrition is full of fascinating examples of the scientific method at work, such
as the discovery that iodine is a nutrient. This story of scientific discovery began in 1811, when
French chemist Bernard Courtois was isolating a substance called saltpeter, an ingredient needed to
make gunpowder to be used by Napoleon’s army. Part of his isolation procedure involved burning
seaweed. When he did this, he observed the release of an intense violet vapor, which crystallized
when he exposed it to a cold surface. He sent the violet crystals to an expert on gases, Joseph
Gay-Lussac, who identified the crystal as a new element. It was named iodine, the Greek word for
violet. The following scientific record is some of what took place in order to conclude that iodine is a
1,2
nutrient.
Observation: Eating seaweed is a cure for goiter, an enlargement of the thyroid gland in the neck.
THE SCIENTIFIC METHOD 73

Figure 2.2. Large goiter in a woman from Bern, Switzerland.

Hypothesis: In 1813, Swiss physician Jean-Francois Coindet hypothesized that seaweed contained
iodine and that he could use iodine instead of seaweed to treat his patients.
Experimental test: Coindet administered iodine tincture orally to his patients with goiter.
Interpret results: Coindet’s iodine treatment was successful in treating patients with goiter.
Gathering more evidence: Many other physicians contributed to the research on iodine
deficiency and goiter.
Hypothesis: In 1851, French chemist Chatin proposed that the low iodine content in food and
water of certain areas far away from the ocean were the primary cause of goiter and renounced the
theory that goiter was the result of poor hygiene. (Physicians at the time also blamed drunkenness,
dampness, and contaminated water as causes of goiter.)
Experimental test: In the late 1860s, authorities in several French villages began giving out iodine
tablets and salt in an effort to treat goiter.
Interpret results: The program was effective, and 80 percent of goitrous children were cured.
74 TAMBERLY POWELL, MS, RDN

However, adults did not always respond well to the treatment, and because men with goiter were
exempted from service in the French military, some people were opposed to treating it. Some
scientists also insisted that goiter was caused by infectious disease, so iodine wasn’t yet accepted as
a means of preventing it.
Hypothesis: In 1918, Swiss doctor Bayard proposed iodizing salt as a good way to treat areas
endemic with goiter.
Experimental test: Iodized salt was transported by mules to a small village at the base of the
Matterhorn, where more than 75 percent of school children were goitrous. It was given to families to
use for six months.
Results: The iodized salt was beneficial in treating goiter in this remote population.
Experimental test: Physician David Marine conducted the first U.S. experiment of treating goiter
with iodized salt in Akron, Ohio.
Results: This study conducted on over 4,000 school children found that iodized salt prevented
goiter.
Conclusions: Seven other studies similar to Marine’s were conducted in Italy and Switzerland that
also demonstrated the effectiveness of iodized salt in treating goiter. In 1924, U.S. public health
officials initiated the program of iodizing salt and started eliminating the scourge of goiterism. Today,
more than 70 percent of American households use iodized salt, and many other countries have
followed the same public health strategy to reduce the health consequences of iodine deficiency.
It took more than one hundred years from iodine’s discovery as an effective treatment for goiter
until public health programs recognized it as such. Although a lengthy process, the scientific method
is a productive way to define essential nutrients and determine their ability to promote health and
prevent disease.

REPORTING SCIENTIFIC WORK

As we saw with the story of iodine research, scientists must share their findings in order for other
researchers to expand and build upon their discoveries. Collaboration with other scientists when
planning and conducting studies and analyzing results is important for scientific research. For this
reason, communicating with peers and disseminating study results are important aspects of a
scientist’s work. Scientists can share results by presenting them at a scientific meeting or conference,
but this approach can reach only the select few who are present. Instead, most scientists present
their results in peer-reviewed manuscripts that are published in scientific journals.
Peer-reviewed manuscripts are scientific papers that are reviewed by a scientist’s colleagues, or
peers. These colleagues are qualified individuals, often experts in the same research area, who
judge whether or not the scientist’s work is suitable for publication. The process of peer review is a
quality control step; its goal is to ensure that the research described in a scientific paper is original,
significant, logical, and thorough. It’s important to note that peer review doesn’t mean a study is
perfect or even good. Sometimes bad studies slip through peer review, but because they’re published
and other scientists read them, these are usually caught later and often retracted. Science is often
messy and imperfect, but peer-review and publication of results are essential to its progress and
ability to self-correct when people make mistakes.
 THE SCIENTIFIC METHOD 75

One or more interactive elements has been excluded from this version of the text. You can view them online here:
https://openoregon.pressbooks.pub/nutritionscience/?p=962#oembed-1

VIDEO: “Peer Review in 3 Minutes” by libncsu, YouTube (May 1, 2014), 3:14 minutes.

Self-Check:

An interactive H5P element has been excluded from this version of the text. You can view it online here:
https://openoregon.pressbooks.pub/nutritionscience/?p=962#h5p-31

Attributions:

• “The Scientific Method” section 1.13 from Lindshield, B. L. Kansas State University Human
Nutrition (FNDH 400) Flexbook. goo.gl/vOAnR, CC BY-NC-SA 4.0
• “The Broad Role of Nutritional Science,” section 1.3 from the book An Introduction to
Nutrition (v. 1.0), CC BY-NC-SA 3.0
• “Reporting Scientific Work” section 5 from Jones, T.G. The Science of Biology, CC BY-NC-SA
4.0

References:

1
• Carpenter, K. J. (2005). David Marine and the Problem of Goiter. The Journal of Nutrition,
135(4), 675–680. https://doi.org/10.1093/jn/135.4.675
2
• Zimmermann, M. B. (2008). Research on Iodine Deficiency and Goiter in the 19th and Early
20th Centuries. The Journal of Nutrition, 138(11), 2060–2063. https://doi.org/10.1093/jn/
76 TAMBERLY POWELL, MS, RDN

138.11.2060

Images:

• Figure 2.1. “The Scientific Method” by Thebiologyprimer is in the Public Domain

• Figure 2.2. “Large Goiter in Woman” by E. Theodor Kocher is in the Public Domain
Types of Research Studies and How To Interpret
Them

The field of nutrition is dynamic, and our understanding and practices are always evolving. Nutrition
scientists are continuously conducting new research and publishing their findings in peer-reviewed
journals. This adds to scientific knowledge, but it’s also of great interest to the public, so nutrition
research often shows up in the news and other media sources. You might be interested in nutrition
research to inform your own eating habits, or if you work in a health profession, so that you can give
evidence-based advice to others. Making sense of science requires that you understand the types of
research studies used and their limitations.

THE HIERARCHY OF NUTRITION EVIDENCE

Researchers use many different types of study designs depending on the question they are trying
to answer, as well as factors such as time, funding, and ethical considerations. The study design
affects how we interpret the results and the strength of the evidence as it relates to real-life nutrition
decisions. It can be helpful to think about the types of studies within a pyramid representing a
hierarchy of evidence, where the studies at the bottom of the pyramid usually give us the
weakest evidence with the least relevance to real-life nutrition decisions, and the studies at
the top offer the strongest evidence, with the most relevance to real-life nutrition decisions.

Figure 2.3. The hierarchy of evidence shows types of research studies relative to their strength of evidence
and relevance to real-life nutrition decisions, with the strongest studies at the top and the weakest at the
bottom.
The pyramid also represents a few other general ideas. There tend to be more studies published
77
78 TAMBERLY POWELL, MS, RDN

using the methods at the bottom of the pyramid, because they require less time, money, and
other resources. When researchers want to test a new hypothesis, they often start with the
study designs at the bottom of the pyramid, such as in vitro, animal, or observational studies.
Intervention studies are more expensive and resource-intensive, so there are fewer of these types of
studies conducted. But they also give us higher quality evidence, so they’re an important next step if
observational and non-human studies have shown promising results. Meta-analyses and systematic
reviews combine the results of many studies already conducted, so they help researchers summarize
scientific knowledge on a topic.

NON-HUMAN STUDIES: IN VITRO & ANIMAL STUDIES

The simplest form of nutrition research is an in vitro study

study. In vitro means “within glass,” (although
plastic is used more commonly today) and these experiments are conducted within flasks, dishes,
plates, and test tubes. These studies are performed on isolated cells or tissue samples, so they’re less
expensive and time-intensive than animal or human studies. In vitro studies are vital for zooming in
on biological mechanisms, to see how things work at the cellular or molecular level. However, these
studies shouldn’t be used to draw conclusions about how things work in humans (or even animals),
because we can’t assume that the results will apply to a whole, living organism.

Animal studies are one form of in vivo research, which translates to “within the living.” Rats and
mice are the most common animals used in nutrition research. Animals are often used in research
that would be unethical to conduct in humans. Another advantage of animal dietary studies is that
researchers can control exactly what the animals eat. In human studies, researchers can tell subjects
what to eat and even provide them with the food, but they may not stick to the planned diet. People
are also not very good at estimating, recording, or reporting what they eat and in what quantities. In
addition, animal studies typically do not cost as much as human studies.
There are some important limitations of animal research. First, an animal’s metabolism and
physiology are different from humans. Plus, animal models of disease (cancer, cardiovascular
disease, etc.), although similar, are different from human diseases. Animal research is considered
preliminary, and while it can be very important to the process of building scientific understanding
and informing the types of studies that should be conducted in humans, animal studies shouldn’t be
considered relevant to real-life decisions about how people eat.

OBSERVATIONAL STUDIES

Observational studies in human nutrition collect information on people’s dietary patterns or nutrient
intake and look for associations with health outcomes. Observational studies do not give participants
a treatment or intervention; instead, they look at what they’re already doing and see how it relates
to their health. These types of study designs can only identify correlations (relationships) between
nutrition and health; they can’t show that one factor causes another. (For that, we need intervention
studies, which we’ll discuss in a moment.) Observational studies that describe factors correlated with
1
human health are also called epidemiological studies
studies.
One example of a nutrition hypothesis that has been investigated using observational studies
is that eating a Mediterranean diet reduces the risk of developing cardiovascular disease. (A
TYPES OF RESEARCH STUDIES AND HOW TO INTERPRET THEM 79

Mediterranean diet focuses on whole grains, fruits and vegetables, beans and other legumes, nuts,
olive oil, herbs, and spices. It includes small amounts of animal protein (mostly fish), dairy, and
2
red wine. ) There are three main types of observational studies, all of which could be used to test
hypotheses about the Mediterranean diet:

• Cohort studies follow a group of people (a cohort) over time, measuring factors such as diet
and health outcomes. A cohort study of the Mediterranean diet would ask a group of
people to describe their diet, and then researchers would track them over time to see if
those eating a Mediterranean diet had a lower incidence of cardiovascular disease.
• Case-control studies compare a group of cases and controls, looking for differences between
the two groups that might explain their different health outcomes. For example,
researchers might compare a group of people with cardiovascular disease with a group of
healthy controls to see whether there were more controls or cases that followed a
Mediterranean diet.
• Cross-sectional studies collect information about a population of people at one point in time.
For example, a cross-sectional study might compare the dietary patterns of people from
different countries to see if diet correlates with the prevalence of cardiovascular disease in
the different countries.
Prospective cohort studies, which enroll a cohort and follow them into the future, are usually
considered the strongest type of observational study design. Retrospective studies look at what
happened in the past, and they’re considered weaker because they rely on people’s memory of what
they ate or how they felt in the past. There are several well-known examples of prospective cohort
studies that have described important correlations between diet and disease:

• Framingham Heart Study: Beginning in 1948, this study has followed the residents of
Framingham, Massachusetts to identify risk factors for heart disease.
• Health Professionals Follow-Up Study: This study started in 1986 and enrolled 51,529
male health professionals (dentists, pharmacists, optometrists, osteopathic physicians,
podiatrists, and veterinarians), who complete diet questionnaires every 2 years.
• Nurses Health Studies: Beginning in 1976, these studies have enrolled three large cohorts
of nurses with a total of 280,000 participants. Participants have completed detailed
questionnaires about diet, other lifestyle factors (smoking and exercise, for example), and
health outcomes.

Observational studies have the advantage of allowing researchers to study large groups of people
in the real world, looking at the frequency and pattern of health outcomes and identifying factors
that correlate with them. But even very large observational studies may not apply to the population
as a whole. For example, the Health Professionals Follow-Up Study and the Nurses Health Studies
include people with above-average knowledge of health. In many ways, this makes them ideal study
subjects, because they may be more motivated to be part of the study and to fill out detailed
questionnaires for years. However, the findings of these studies may not apply to people with less
baseline knowledge of health.
We’ve already mentioned another important limitation of observational studies—that they can
only determine correlation, not causation. A prospective cohort study that finds that people eating
a Mediterranean diet have a lower incidence of heart disease can only show that the Mediterranean
diet is correlated with lowered risk of heart disease. It can’t show that the Mediterranean diet directly
prevents heart disease. Why? There are a huge number of factors that determine health outcomes
such as heart disease, and other factors might explain a correlation found in an observational study.
For example, people who eat a Mediterranean diet might also be the same kind of people who
exercise more, sleep more, have higher income (fish and nuts can be expensive!), or be less stressed.
These are called confounding factors
factors; they’re factors that can affect the outcome in question (i.e., heart
disease) and also vary with the factor being studied (i.e., Mediterranean diet).

INTERVENTION STUDIES

Intervention studies
studies, also sometimes called experimental studies or clinical trials, include some
type of treatment or change imposed by the researcher. Examples of interventions in nutrition
research include asking participants to change their diet, take a supplement, or change the time
80 TAMBERLY POWELL, MS, RDN

of day that they eat. Unlike observational studies, intervention studies can provide evidence of
cause and effect, so they are higher in the hierarchy of evidence pyramid.
The gold standard for intervention studies is the randomized controlled trial (RCT)
(RCT). In an RCT, study
subjects are recruited to participate in the study. They are then randomly assigned into one of
at least two groups, one of which is a control group (this is what makes the study controlled).
In an RCT to study the effects of the Mediterranean diet on cardiovascular disease development,
researchers might ask the control group to follow a low-fat diet (typically recommended for heart
disease prevention) and the intervention group to eat a Mediterrean diet. The study would continue
for a defined period of time (usually years to study an outcome like heart disease), at which point the
researchers would analyze their data to see if more people in the control or Mediterranean diet had
heart attacks or strokes. Because the treatment and control groups were randomly assigned, they
should be alike in every other way except for diet, so differences in heart disease could be attributed
to the diet. This eliminates the problem of confounding factors found in observational research, and
it’s why RCTs can provide evidence of causation, not just correlation.
Imagine for a moment what would happen if the two groups weren’t randomly assigned. What
if the researchers let study participants choose which diet they’d like to adopt for the study? They
might, for whatever reason, end up with more overweight people who smoke and have high blood
pressure in the low-fat diet group, and more people who exercised regularly and had already been
eating lots of olive oil and nuts for years in the Mediterranean diet group. If they found that the
Mediterranean diet group had fewer heart attacks by the end of the study, they would have no way
of knowing if this was because of the diet or because of the underlying differences in the groups.
In other words, without randomization, their results would be compromised by confounding factors,
with many of the same limitations as observational studies.
In an RCT of a supplement, the control group would receive a placebo
placebo—a
—a “fake” treatment that
contains no active ingredients, such as a sugar pill. The use of a placebo is necessary in medical
research because of a phenomenon known as the placebo effect. The placebo effect results in a
beneficial effect because of a subject’s belief in the treatment, even though there is no treatment
actually being administered.
For example, imagine an athlete who consumes a sports drink and then runs 100 meters in 11.0
seconds. On a different day, under the exact same conditions, the athlete is given a Super Duper
Sports Drink and again runs 100 meters, this time in 10.5 seconds. But what the athlete didn’t know
was that the Super Duper Sports Drink was the same as the regular sports drink—it just had a bit of
food coloring added. There was nothing different between the drinks, but the athlete believed that
the Super Duper Sports Drink was going to help him run faster, so he did. This improvement is due
to the placebo effect. Ironically, a study similar to this example was published in 2015, demonstrating
3
the power of the placebo effect on athletic performance.

Figure 2.4. An example of the placebo effect

Blinding is a technique to prevent bias in intervention studies. In a study without blinding, the subject
and the researchers both know what treatment the subject is receiving. This can lead to bias if the
subject or researcher have expectations about the treatment working, so these types of trials are
used less frequently. It’s best if a study is double-blind
double-blind, meaning that neither the researcher nor
the subject know what treatment the subject is receiving. It’s relatively simple to double-blind
TYPES OF RESEARCH STUDIES AND HOW TO INTERPRET THEM 81

a study where subjects are receiving a placebo or treatment pill, because they could be formulated
to look and taste the same. In a single-blind study
study, either the researcher or the subject knows
what treatment they’re receiving, but not both. Studies of diets—such as the Mediterranean diet
example—often can’t be double-blinded because the study subjects know whether or not they’re
eating a lot of olive oil and nuts. However, the researchers who are checking participants’ blood
pressure or evaluating their medical records could be blinded to their treatment group, reducing the
chance of bias.
Like all studies, RCTs and other intervention studies do have some limitations. They can be
difficult to carry on for long periods of time and require that participants remain compliant with the
intervention. They’re also costly and often have smaller sample sizes. Furthermore, it is unethical to
study certain interventions. (An example of an unethical intervention would be to advise one group
of pregnant mothers to drink alcohol to determine its effects on pregnancy outcomes, because we
know that alcohol consumption during pregnancy damages the developing fetus.)

One or more interactive elements has been excluded from this version of the text. You can view them online here:

https://openoregon.pressbooks.pub/nutritionscience/?p=971#oembed-1

VIDEO: “Not all scientific studies are created equal” by David H. Schwartz, YouTube (April 28, 2014), 4:26.

META-ANALYSES AND SYSTEMATIC REVIEWS

At the top of the hierarchy of evidence pyramid are systematic reviews and meta-analyses. You
can think of these as “studies of studies.” They attempt to combine all of the relevant studies that
have been conducted on a research question and summarize their overall conclusions. Researchers
conducting a systematic review formulate a research question and then systematically and
independently identify, select, evaluate, and synthesize all high-quality evidence that relates to
the research question. Since systematic reviews combine the results of many studies, they help
researchers produce more reliable findings. A meta-analysis is a type of systematic review that goes
one step further, combining the data from multiple studies and using statistics to summarize it, as if
4
creating a mega-study from many smaller studies.
However, even systematic reviews and meta-analyses aren’t the final word on scientific questions.
For one thing, they’re only as good as the studies that they include. The Cochrane Collaboration
is an international consortium of researchers who conduct systematic reviews in order to inform
evidence-based healthcare, including nutrition, and their reviews are among the most well-regarded
and rigorous in science. For the most recent Cochrane review of the Mediterranean diet and
cardiovascular disease, two authors independently reviewed studies published on this question.
Based on their inclusion criteria, 30 RCTs with a total of 12,461 participants were included in the
final analysis. However, after evaluating and combining the data, the authors concluded that “despite
the large number of included trials, there is still uncertainty regarding the effects of a
Mediterranean‐style diet on cardiovascular disease occurrence and risk factors in people both with
and without cardiovascular disease already.” Part of the reason for this uncertainty is that different
trials found different results, and the quality of the studies was low to moderate. Some had problems
with their randomization procedures, for example, and others were judged to have unreliable data.
 82 TAMBERLY POWELL, MS, RDN

That doesn’t make them useless, but it adds to the uncertainty about this question, and uncertainty
pushes the field forward towards more and better studies. The Cochrane review authors noted that
they found seven ongoing trials of the Mediterranean diet, so we can hope that they’ll add more
5
clarity to this question in the future.
Science is an ongoing process. It’s often a slow process, and it contains a lot of uncertainty, but
it’s our best method of building knowledge of how the world and human life works. Many different
types of studies can contribute to scientific knowledge. None are perfect—all have limitations—and
a single study is never the final word on a scientific question. Part of what advances science is that
researchers are constantly checking each other’s work, asking how it can be improved and what new
questions it raises.

Self-Check:

An interactive H5P element has been excluded from this version of the text. You can view it online here:

https://openoregon.pressbooks.pub/nutritionscience/?p=971#h5p-32

Attributions:

• “Chapter 1: The Basics” from Lindshield, B. L. Kansas State University Human Nutrition
(FNDH 400) Flexbook. goo.gl/vOAnR, CC BY-NC-SA 4.0
• “The Broad Role of Nutritional Science,” section 1.3 from the book An Introduction to
Nutrition (v. 1.0), CC BY-NC-SA 3.0

References:

1
• Thiese, M. S. (2014). Observational and interventional study design types; an overview.
Biochemia Medica, 24(2), 199–210. https://doi.org/10.11613/BM.2014.022
2
• Harvard T.H. Chan School of Public Health. (2018, January 16). Diet Review: Mediterranean
Diet. The Nutrition Source. https://www.hsph.harvard.edu/nutritionsource/healthy-weight/
diet-reviews/mediterranean-diet/
3
• Ross, R., Gray, C. M., & Gill, J. M. R. (2015). Effects of an Injected Placebo on Endurance
Running Performance. Medicine and Science in Sports and Exercise, 47(8), 1672–1681.
https://doi.org/10.1249/MSS.0000000000000584
4
• Hooper, A. (n.d.). LibGuides: Systematic Review Resources: Systematic Reviews vs Other Types of
Reviews. Retrieved February 7, 2020, from //libguides.sph.uth.tmc.edu/
c.php?g=543382&p=5370369
5
• Rees, K., Takeda, A., Martin, N., Ellis, L., Wijesekara, D., Vepa, A., Das, A., Hartley, L., &
Stranges, S. (2019). Mediterranean‐style diet for the primary and secondary prevention of
cardiovascular disease. Cochrane Database of Systematic Reviews, 3. https://doi.org/10.1002/
14651858.CD009825.pub3
TYPES OF RESEARCH STUDIES AND HOW TO INTERPRET THEM 83

Images:

• Figure 2.3. The hierarchy of evidence by Alice Callahan, is licensed under CC BY 4.0
• Research lab photo by National Cancer Institute on Unsplash; mouse photo by vaun0815 on
Unsplash
• Figure 2.4. “Placebo effect example” by Lindshield, B. L. Kansas State University Human
Nutrition (FNDH 400) Flexbook. goo.gl/vOAnR
Healthy Skepticism in Nutrition Science

By this point in the unit, you should understand the types of studies used in nutrition research and
the quality of evidence each can provide. As you sift through studies, there are a few limitations of
nutrition research that are always worth keeping in mind:

• Challenges in nutrition research: There are some inherent challenges to researching

what people eat and how it affects their health. This fact limits the quality of evidence and
stirs controversy in nutrition research.
• Influence of food industry funding: Because government funding for nutrition research is
limited, much of it is funded by the food industry. Industry’s primary goal is to sell more of
their products, so they have a conflict of interest that can result in bias in the way they
design studies and interpret the results.

Being alert to these two things means always examining nutrition research with a healthy sense of
skepticism. Let’s take a closer look at these two issues in nutrition science.

84
HEALTHY SKEPTICISM IN NUTRITION SCIENCE 85

CHALLENGES IN NUTRITION RESEARCH

How does the food we eat affect our health? This question is exceedingly difficult to answer with
certainty. We all need to eat every day, but we can choose from a huge array of possible foods in
different combinations. And it’s probably not what we eat on any given day that matters, but what
we eat over months and years and decades—our long-term eating patterns—that matter to our long-
term health.
Imagine that you’re a nutrition researcher, and you’ve made the observation that over the last 50
years in the U.S., people have been consuming more and more processed foods (foods made with
refined ingredients and industrial processes, usually with the addition of sugar, fat, and/or salt). You
hypothesize that processed foods are contributing to obesity, which has also increased over the last
50 years. You might first test your hypothesis in animal studies by feeding mice and rats a buffet of
potato chips, soda, and Twinkies, and measuring changes in their body weight. You might find that
the animals do, in fact, gain weight on this diet. However, you know that what is true in rodents isn’t
always true in humans, and you’ll need to study humans in order to understand the role of processed
foods in the obesity epidemic.
Your next step might be to conduct an observational study, the most common type of study
design in human nutrition research. For example, you might do a cross-sectional study where you
compare groups of people who eat a lot of processed foods with those who eat very little. Or you
might conduct a prospective cohort study in which you ask people how much processed foods they
eat and then follow them over time, looking for correlations between processed food consumption
and their body composition.
These types of studies have been conducted, and they’ve found correlations between consumption
of processed foods and obesity. For example, a cross-sectional study published in 2018 compared
the consumption of processed foods and the prevalence of obesity in 19 European countries and
found that countries where people eat more processed foods also have a greater prevalence of
1
obesity. A prospective cohort study published in 2016 followed nearly 8,500 university graduates
in Spain and found that those who ate more processed foods were more likely to be overweight or
2
obese 9 years later.
From these results, can we conclude that eating more processed food causes weight gain? Nope.
It’s a tempting conclusion, but this brings us to the first major problem with nutrition research:
Observational studies can only show that two variables (eating processed foods and obesity,
in this case) are correlated
correlated, not that one causes the other. This distinction is especially important
in nutrition because diet is intertwined with many other lifestyle and socioeconomic factors
that also affect health outcomes. For example, people who eat more processed food might also
eat fewer fruits and vegetables, exercise or sleep less, have more stress, or have less access to
preventative healthcare. These are just a few of the confounding factors that could explain the
observed correlation between processed food consumption and weight gain. Weight gain might have
nothing to do with processed food and instead be driven by one or all of these factors, or others that
we haven’t considered.
The second major problem with observational nutrition research is that it’s difficult to
accurately quantify what and how much people eat, especially over long periods of time.
Epidemiological studies usually rely on questionnaires that ask people to remember how much food
they ate, but people are notoriously bad at remembering this type of information, and sometimes
we fudge the truth. For example, you might remember that you had a cup of coffee but forget that
you added cream, completely forget about a mid-morning muffin snack, or guess that you ate 2
cups of veggies when it was closer to 1.5 cups. And many diet questionnaires, called food frequency
questionnaires, ask people to recollect and mentally average their food and beverage intake for the
last 12 months, not just yesterday. The image below shows part of a page from a 24-page National
Health and Nutrition Examination Survey (NHANES) food questionnaire, a national survey often used
for research on country-wide dietary patterns. As you can see, these questions are detailed, and
there’s plenty of room for small errors to accumulate.
86 TAMBERLY POWELL, MS, RDN

Figure 2.5. A sample page from the NHANES Food Questionnaire.

A third challenge in nutrition research is that diet is just so complex. Stanford physician
and researcher John Ioannidis, a frequent critic of observational nutrition research, described the
complexity of diet in a 2018 editorial published in JAMA: “Individuals consume thousands of
chemicals in millions of possible daily combinations. For instance, there are more than 250,000
different foods and even more potentially edible items, with 300,000 edible plants alone.” He also
points out that how an individual responds to a particular dietary pattern can be influenced by
genetics, age, and the way they metabolize nutrients. “Disentangling the potential influence on health
outcomes of a single dietary component from these other variable is challenging, if not impossible,”
3
Ioannidis wrote.
HEALTHY SKEPTICISM IN NUTRITION SCIENCE 87

Returning to the question of processed foods, all three of these challenges impact how we
interpret observational studies that show a correlation between processed food consumption and
weight gain. It doesn’t mean that these studies are useless, but we want to be aware of their
limitations and consider other ways to test the hypothesis. One way to overcome these challenges is
to conduct a randomized controlled trial (RCT), the study design that gives us the highest quality
evidence. RCTs are time and funding-intensive experiments, so they’re usually only conducted after
consistent evidence from observational and laboratory studies has accumulated.
It turns out that there has been a randomized controlled trial of processed foods and weight gain. It
4
was funded by the National Institutes of Health and published in 2019 in the journal Cell Metabolism.
In this study, 20 participants lived in the NIH’s Clinical Center for one month, where they consumed
only processed foods for two weeks and only unprocessed foods for another two weeks, and they
could eat as much or as little as they liked during each of these periods. The diets were carefully
designed by dietitians so that they were matched in calories, sugar, fat, fiber, and macronutrients,
and the exact amounts consumed by the participants were measured every day (solving the problem
of measuring diet complexity and accurately describing what and how much people eat every day).
The study found that people ate about 500 kilocalories more and gained about a pound per
week when they were eating processed foods. This study design could show causation, not just
correlation, because the other nutritional factors like calories, sugar, fat, fiber, and macronutrients
were held constant, and the diets were tested in the same people, so other factors such as genetics,
sleep, stress, and exercise were constant between the two types of diets. (This was an example of
a crossover randomized controlled trial, in which each subject serves as their own control, and they
completed the processed and unprocessed phases of the trial in random order.)
88 TAMBERLY POWELL, MS, RDN

Figure 2.6. At left, researchers Kevin Hall and Stephanie Chung talk with one of the processed foods trial
participants at the NIH Clinical Center, an inpatient facility where participants lived for the duration of
the study. At right, an NIH worker prepares meals for participants in the center’s kitchen. All meals were
provided for study participants to carefully control their diet during the trial.
This study suggested something very important—that food processing causes people to eat more
food and gain weight. However, even the best study design has limitations. For one thing, this study
was small (just 20 participants), and it only lasted for two weeks, so we don’t know if the findings
apply to the general population over a lifetime of complex, ever-changing diets. The next steps will be
to try to repeat the study in another group of people to see if the finding holds and to design studies
to figure out why processed foods cause increased caloric intake.
As you evaluate nutrition research, especially observational studies, keep in mind the inherent
challenges of nutrition research and look for randomized controlled trials that can help solve those
challenges. Even for randomized controlled trials, consider their limitations, and know that one
study is never enough to fully answer a question in the complex field of nutrition.

INDUSTRY INFLUENCE: FOLLOW THE MONEY

Understanding how diet influences health is a pressing need. By some estimates, a suboptimal diet
is the single greatest changeable risk factor contributing to death and disability worldwide, and in
the United States, the cost of diet-related chronic diseases are estimated to be as high as $1 trillion
5
each year. Yet, for all its importance, nutrition science has long suffered from a lack of government
investment, with only about 5 percent of the National Institutes of Health (NIH) budget, or $1.8
billion, directed towards research on how the foods we eat affect our health, according to a 2019
investigation by Politico. “In 2018, NIH funding for cancer, which affects just under 9 percent of the
population, was $6.3 billion. Funding for obesity, which affects about 30 percent of the country, was
6
about $1 billion,” the article noted.
With so little government funding for nutrition science, who is funding the rest of the studies that
feed the constant news cycle? Many are funded by food companies and industry groups, either to
conduct studies in their own research divisions or in the form of grants given to university scientists.
That’s problematic, because food companies and industry groups have an inherent bias or conflict of
interest. Their primary goal is to promote their products and to sell more of them—not to advance
knowledge of food and health—and this affects how they frame research questions, design and
interpret studies, and report their results.
Marion Nestle, a retired nutrition professor at New York University, has written extensively about
this problem. For a year in 2015-2016, she informally tracked industry-funded studies and found
that 90 percent of the time, their conclusions benefitted the industry that funded them. In another
example, a 2013 meta-analysis found that among studies that looked at whether soda consumption
contributed to obesity, those funded by the soda industry were five times more likely to conclude
7
that it doesn’t contribute to obesity compared to those not funded by the industry. (Consider the
processed foods RCT we just discussed. It was funded by the National Institutes of Health, which
doesn’t have a stake in the results. Would you trust the results of a study of processed foods if it was
funded by Nabisco? Or for that matter, the Broccoli Growers of America? Probably not.)
There’s likely a long history of biased nutrition research influencing dietary advice. For example, in
the 1960s, the sugar industry paid well-respected academic scientists to publish research concluding
8
that it was fat—not sugar—that was detrimental to heart health. (Both too much fat and too much
sugar can negatively affect heart health, but it benefited the sugar industry to focus the blame on fat.)
 HEALTHY SKEPTICISM IN NUTRITION SCIENCE 89

As recently as 2015, Coca-Cola was funding research meant to promote lack of physical activity as the
9
main cause of obesity, shifting blame away from dietary factors, such as drinking soda. When food
companies drive the narrative coming out of nutrition research, this can potentially impact public
policy.
Media attention has made researchers and policy makers much more aware of the problems with
industry funding and conflicts of interest in nutrition research, and they’re working to solve them.
But regardless, if you see reports of a study that shows that blueberries can block bladder infections,
pistachios can prevent pancreatitis, or cinnamon can cure cancer… well, you should be skeptical, and
always check the funding source. Studies on a single type of food are almost always industry-funded.

HOW TO FIND CLARITY IN A COMPLEX FIELD

Let’s review some of the key issues:

• Nutrition research is really difficult to do well. We want to know how nutrition relates to
health over the long term, but it’s hard to quantify how people eat over a lifetime and track
them for long enough to see an impact.
• We often rely on observational studies, which can only show that two variables are
correlated, not that one causes the other.
• Randomized controlled trials are rare, and they’re often small, short-term studies that may
or may not tell us what happens in the real world.
• Diet is exceptionally complex, with countless combinations of different nutrients and foods.
• One study is never enough to fully answer a question in the complex field of nutrition.
• Nutrition research is often funded by the food industry, which can be biased towards
results that benefit business, not human health.

All of this can be discouraging, but you should also know that researchers are working hard to
improve the quality of nutrition research and to interpret it honestly for the rest of us. As a consumer
of nutrition information, use a skeptical eye when you read news of the latest nutrition research.
Look for areas of consensus, where committees of experts have put their heads together to come up
with the best advice they can based on the evidence we have, such as in the Dietary Guidelines for
Americans. You’ll find that while experts in this field are often debating the latest controversy, they
also agree on a lot. As we continue on in this unit, we’ll talk more about how to find accurate sources
of information and who you can trust for evidence-based advice in the field of nutrition.

Self-Check:

An interactive H5P element has been excluded from this version of the text. You can view it online here:
https://openoregon.pressbooks.pub/nutritionscience/?p=980#h5p-33

References

1
• Monteiro, C. A., Moubarac, J.-C., Levy, R. B., Canella, D. S., Louzada, M. L. da C., & Cannon,
G. (2018). Household availability of ultra-processed foods and obesity in nineteen European
90 TAMBERLY POWELL, MS, RDN

countries. Public Health Nutrition, 21(1), 18–26. https://doi.org/10.1017/S1368980017001379

2
• Mendonça, R. de D., Pimenta, A. M., Gea, A., de la Fuente-Arrillaga, C., Martinez-Gonzalez,
M. A., Lopes, A. C. S., & Bes-Rastrollo, M. (2016). Ultraprocessed food consumption and risk
of overweight and obesity: The University of Navarra Follow-Up (SUN) cohort study. The
American Journal of Clinical Nutrition, 104(5), 1433–1440. https://doi.org/10.3945/
ajcn.116.135004
3
• Ioannidis, J. P. A. (2018). The Challenge of Reforming Nutritional Epidemiologic Research.
JAMA, 320(10), 969–970. https://doi.org/10.1001/jama.2018.11025
4
• Hall, K. D., Ayuketah, A., Brychta, R., Cai, H., Cassimatis, T., Chen, K. Y., Chung, S. T., Costa,
E., Courville, A., Darcey, V., Fletcher, L. A., Forde, C. G., Gharib, A. M., Guo, J., Howard, R.,
Joseph, P. V., McGehee, S., Ouwerkerk, R., Raisinger, K., … Zhou, M. (2019). Ultra-Processed
Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled
Trial of Ad Libitum Food Intake. Cell Metabolism, 30(1), 67-77.e3. https://doi.org/10.1016/
j.cmet.2019.05.008
5
• Mozaffarian, D. (2017). Conflict of Interest and the Role of the Food Industry in Nutrition
Research. JAMA, 317(17), 1755–1756. https://doi.org/10.1001/jama.2017.3456
6
• Boudreau, C., & Evich, H. B. (n.d.). How Washington keeps America sick and fat. POLITICO.
Retrieved January 27, 2020, from https://www.politico.com/news/agenda/2019/11/04/why-
we-dont-know-what-to-eat-060299
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• Bes-Rastrollo, M., Schulze, M. B., Ruiz-Canela, M., & Martinez-Gonzalez, M. A. (2013).
Financial Conflicts of Interest and Reporting Bias Regarding the Association between Sugar-
Sweetened Beverages and Weight Gain: A Systematic Review of Systematic Reviews. PLOS
Medicine, 10(12), e1001578. https://doi.org/10.1371/journal.pmed.1001578
8
• Kearns, C. E., Schmidt, L. A., & Glantz, S. A. (2016). Sugar Industry and Coronary Heart
Disease Research: A Historical Analysis of Internal Industry Documents. JAMA Internal
Medicine, 176(11), 1680–1685. https://doi.org/10.1001/jamainternmed.2016.5394
9
• O’Connor, A. (2015, August 9). Coca-Cola Funds Scientists Who Shift Blame for Obesity
Away From Bad Diets. The New York Times. https://well.blogs.nytimes.com/2015/08/09/
coca-cola-funds-scientists-who-shift-blame-for-obesity-away-from-bad-diets/

Image Credits

• “Magnifying glass” photo by Emiliano Vittoriosi on Unsplash (license information)

• Figure 2.5.”NHANES food questionnaire” by CDC is in the public domain
• “Table of food photo” by Spencer Davis on Unsplash (license information)
• Figure 2.6. “NIH study center photos” by Jennifer Rymaruk, NIDDK are in the Public Domain
Finding Accurate Sources of Nutrition
Information

As we discussed in the previous section, science is always evolving, albeit sometimes slowly. One
study is not enough to make a guideline or recommendation or to cure a disease. Science is a
stepwise process that continuously builds on past evidence and develops towards a well-accepted
consensus, although even that can be questioned as new evidence emerges. Unfortunately, the way
scientific findings are communicated to the general public can sometimes be inaccurate or confusing.
In today’s world, where instant Internet access is just a click away, it’s easy to be overwhelmed or
misled if you don’t know where to go for reliable nutrition information. Therefore, it’s important to
know how to find accurate sources of nutrition information and how to interpret nutrition-related
stories when you see them.

DECIPHERING NUTRITION INFORMATION

“New study shows that margarine contributes to arterial plaque.”

91
92 TAMBERLY POWELL, MS, RDN

“Asian study reveals that two cups of coffee per day can have detrimental effects on the nervous
system.”
How do you react when you read headlines like this? Do you boycott margarine and coffee? When
reading nutrition-related claims, articles, websites, or advertisements, always remember that one
study neither proves or disproves anything. Readers who may be looking for answers to complex
nutrition questions can quickly misconstrue such statements and be led down a path of
misinformation, especially if the information is coming from a source that isn’t credible. Listed below
are ways that you can develop a discerning eye when reading news highlighting nutrition science and
research.

• The scientific study under discussion should be published in a peer-reviewed journal.

Having gone through the peer review process, these studies have been checked by other
experts in the field to ensure that their methods and analysis were rigorous and
appropriate. Peer-reviewed articles also include a review of previous research findings on
the topic of study and examine how their current findings relate to, support, or are in
contrast to previous research. Question studies that come from less trustworthy sources
(such as non peer-reviewed journals or websites) or that are not formally published.
FINDING ACCURATE SOURCES OF NUTRITION INFORMATION 93

Figure 2.7. An example of a peer-reviewed journal, the Journal of the Academy of Nutrition and
Dietetics, which publishes research findings of nutrition scientists. Nutrition research is also
frequently published in journals like the Journal of Nutrition, American Journal of Clinical Nutrition,
and Journal of Nutrition Education and Behavior, as well as medical and behavioral journals.

• The report should disclose the methods used by the researcher(s).

94 TAMBERLY POWELL, MS, RDN

◦ Identify the type of study and where it sits on the hierarchy of evidence. Keep
in mind that a study in humans is likely more meaningful than one that’s in vitro or
in animals; an intervention study is usually more meaningful than an observational
study; and systematic reviews and meta-analyses often give you the best synthesis
of the science to date.
◦ If it’s an intervention study, check for some of the attributes of high-quality
research already discussed: randomization, placebo control, and blinding. If it’s
missing any of those, what questions does that raise for you?
◦ Did the study last for three weeks or three years? Depending on the research
question, studies that are short may not be long enough to establish a true
relationship with the issues being examined.
◦ Were there ten or two hundred participants? If the study was conducted on
only a few participants, it’s less likely that the results would be valid for a larger
population.
◦ What did the participants actually do? It’s important to know if the study
included conditions that people rarely experience or if the conditions replicated
real-life scenarios. For example, a study that claims to find a health benefit of
drinking tea but required participants to drink 15 cups per day may have little
relevance in the real world.
◦ Did the researcher(s) observe the results themselves, or did they rely on self
reports from program participants? Self-reported data and results can be easily
skewed by participants, either intentionally or by accident.
• The article should include details on the subjects (or participants) in the study. Did
the study include humans or animals? If human, are any traits/characteristics noted? You
may realize you have more in common with certain study participants and can use that as a
basis to gauge if the study applies to you.
• Statistical significance is not the same as real-world significance. A statistically
significant result is likely to have not occurred by chance, but rather to be a real difference.
However, this doesn’t automatically mean that the difference is relevant in the real world.
For example, imagine a study reporting that a new vitamin supplement causes a statistically
significant reduction in the duration of the common cold. Colds can be miserable, so that
sounds great, right? But what if you look closer and see that the supplement only
shortened study subjects’ colds by half a day? You might decide that it isn’t worth taking a
supplement just to shorten a cold by half a day. In other words, it’s not a real-world benefit
to you.
• Credible reports should disseminate new findings in the context of previous
research. A single study on its own gives you very limited information, but if a body of
literature (previously published studies) supports a finding, it adds credibility to the study. A
news story about a new scientific finding should also include comments from outside
experts (people who work in the same field of research but weren’t involved in the new
study) to provide some context for what the study adds to the field, as well as its
limitations.
• When reading such news, ask yourself, “Is this making sense?” Even if coffee does
adversely affect the nervous system, do you drink enough of it to see any negative effects?
Remember, if a headline professes a new remedy for a nutrition-related topic, it may well
be a research-supported piece of news, but it could also be a sensationalized story
designed to catch the attention of an unsuspecting consumer. Track down the original
journal article to see if it really supports the conclusions being drawn in the news report.

THE CRAAPP TEST

While there is a wealth of information about nutrition on the internet and in books and magazines,
it can be challenging to separate the accurate information from the hype and half-truths. You can
1,2
use the CRAAPP Test to help you determine the validity of the resources you encounter and
the information they provide. By applying the following principles, you can be confident that the
FINDING ACCURATE SOURCES OF NUTRITION INFORMATION 95

information is credible. We’ve added several notes to the traditional CRAAPP Test to help you expand
3
your analysis and apply it to nutrition information.
96 TAMBERLY POWELL, MS, RDN

CRAAPP
Test Questions to ask
Principle

When was it written or published? Has the website been updated recently?
Do you need current information, or will older sources meet your research need?
Where is your topic in the information cycle?
Currency Note: In general, newer articles are more likely to provide up-to-date perspectives on nutrition science, so as a
starting point, look for those published in the last 5-7 years. However, it depends on the question that you’re
researching. In some areas, nutrition science hasn’t changed much in recent years, or you may be interested in
historical background on the question. In either case, an older article would be appropriate.

Does it meet stated requirements of your assignment?

Relevance Does it meet your information needs/answer your research question?
Is the information at an appropriate level or for your intended audience?

Who is the creator/author/publisher/source/sponsor? Are they reputable?

What are the author’s credentials and their affiliations to groups, organizations, agencies or
universities?
What type of authority does the creator have? For example, do they have subject expertise (scholar),
Authority social position (public office, title), or special experience?
Note: The authority on nutrition information would be a registered dietitian nutritionist (RDN), a professional
with advanced degree(s) in nutrition (MS or PhD), or a physician with appropriate education and expertise in
nutrition. (This will be discussed in more detail on the next page). Look for sources authored or reviewed by
experts with this level of authority or written by people who seek out and include their expertise in the article.

Is the information reliable, truthful, and correct?

Does the creator cite sources for data or quotations? Who did they cite?
Are they cherry-picking facts to support their argument?
Is the source peer-reviewed, or reviewed by an editor? Do other sources support the information
Accuracy
presented?
Are there spelling, grammar, and typo errors that demonstrate inaccuracy?
Note: Oftentimes, checking the accuracy of information in a given article or website means opening a new
internet tab and doing some additional sleuthing to check the claims against other sources.

Is the intent of the website to inform, persuade, entertain, or sell something?

Does the point of view seem impartial or biased?
Is the content primarily opinion? Is it balanced with other viewpoints?
Purpose Who is the intended audience?
Note: Particularly if you’re looking at an organization’s website, do some background research on the
organization to see who funds it and what is the purpose of the group. That information can help you determine
if their point-of-view is likely to be biased.

What kind of effort was put into the creation and delivery of this information?
Is it a Tweet? A blog post? A YouTube video? A press release?
Process
Was it researched, revised, or reviewed by others before published?
How does this format fit your information needs or requirements of assignment?
FINDING ACCURATE SOURCES OF NUTRITION INFORMATION 97

Table 2.1. The CRAAPP Test is a six-letter mnemonic device for evaluating the credibility and validity of
information found through various sources, including websites and social media channels. The CRAAPP
Test can be particularly useful in evaluating nutrition related news and articles.

One or more interactive elements has been excluded from this version of the text. You can view them online here:
https://openoregon.pressbooks.pub/nutritionscience/?p=991#oembed-1

VIDEO: “How Library Stuff Works: How to Evaluate Resources (the CRAAP Test)” by McMaster Libraries,
YouTube (January 23, 2015), 2:09.

VIDEO: “Evaluating Internet Sources” by Cooperative Library Instruction Project, Lane Community College
Library, (July 21, 2015), 7:09.

RED FLAGS OF JUNK SCIENCE

When it comes to nutrition advice, the adage holds true that “if it sounds too good to be true, it
probably is.” There are several tell-tale signs of junk science
science—untested or unproven claims or ideas
usually meant to push an agenda or promote special interests. In addition to using the CRAAPP Test
to decipher nutrition information, you can also use these simple guidelines to spot red flags of junk
science. When you see one or more of these red flags in an article or resource, it’s safe to say you
should at least take the information with a grain of salt, if not avoid it altogether.
 98 TAMBERLY POWELL, MS, RDN

Figure 2.8. The Red Flags of Junk Science were written by the Food and Nutrition Science Alliance,
a partnership of professional scientific associations, to help consumers critically evaluate nutrition
information.
With the mass quantities of nutrition articles and stories circulating in media outlets each week,
it’s easy to feel overwhelmed and unsure of what to believe. But by using the tips outlined above,
you’ll be armed with the tools needed to decipher every story you read and decide for yourself how
it applies to your own nutrition and health goals.

Self-Check:
 FINDING ACCURATE SOURCES OF NUTRITION INFORMATION 99

An interactive H5P element has been excluded from this version of the text. You can view it online here:
https://openoregon.pressbooks.pub/nutritionscience/?p=991#h5p-34

Attributions:

• Lindshield, B. L. Kansas State University Human Nutrition (FNDH 400) Flexbook. goo.gl/
vOAnR, CC BY-NC-SA 4.0
• University of Hawai‘i at Mānoa Food Science and Human Nutrition Program, “Types of
Scientific Studies,” CC BY-NC 4.0
• “Principles of Nutrition Textbook, Second Edition” by University System of Georgia is
licensed under CC BY-NC-SA 4.0

References:

1
• Blakeslee, Sarah (2004). The CRAAP Test, LOEX Quarterly, 31(3)6-7.
https://commons.emich.edu/loexquarterly/vol31/iss3/4
2
• Lumen Learning. (n.d.) The CRAAPP Test. Introduction to College Research.
https://courses.lumenlearning.com/atd-fscj-introtoresearch/chapter/the-craapp-test/
3
• Fielding, J.A. (2019). Rethinking CRAAP: Getting students thinking like fact-checkers in
evaluating web sources. C&RL News, December: 620-622.

Image Credits:

• Real experts book photo by Rita Morais on Unsplash (license information)

• Figure 2.7. An example of a peer-reviewed journal photo by Heather Leonard is licensed
under CC BY 4.
• Table 2.1. The CRAAPP Test by Heather Leonard is licensed under CC BY 4.
• Figure 2.8. “The Red Flags of Junk Science” by Heather Leonard is licensed under CC BY 4.
Who Can You Trust for Nutrition Information?

TRUSTWORTHY SOURCES

Authoritative nutrition news is based on solid scientific evidence, supported by multiple studies, and
published in peer-reviewed journals. You can obtain valid nutrition information from many reputable
organizations, websites, and professionals, if you know where to look. Whatever the source of your
nutrition news, remember to apply the criteria outlined previously in this unit to ensure the validity
of the information presented. You can find many trustworthy sources that advocate good nutrition
to promote health and prevent disease using evidence-based science.

Trusted Organizations Active in Nutrition Policy and Research

US Department of Agriculture Food and Nutrition Information Center. The USDA website has
more than 2,500 links to information about diet, nutrition, disease, body weight and obesity, food
safety, food labeling, packaging, dietary supplements, and consumer questions. Using this interactive
site, you can find tips and resources on how to eat a healthy diet, nutritional information, and a food
planner.
The Academy of Nutrition and Dietetics (AND). The AND promotes scientific, evidenced-based
food and nutrition information. It is focused on informing the public about recent scientific studies,
100
WHO CAN YOU TRUST FOR NUTRITION INFORMATION? 101

weight-loss concerns, food safety topics, nutrition issues, and disease prevention. This website also
has lots of practical tips and suggestions on how to plan and prepare nutritious meals.
Department of Health and Human Services (HHS). The HHS website provides credible
information about healthful lifestyles and the latest in health news. A variety of online tools are
available to assist with food-planning, weight maintenance, physical activity, and dietary goals. You
can also find healthful tips for all age groups, tips for preventing disease, and information on general
health issues.
Centers for Disease Control and Prevention (CDC). The CDC provides up-to-date public health
information and data on many nutrition-related topics, including healthful eating, cholesterol, high
blood pressure, obesity, alcohol use, breastfeeding, infant and toddler nutrition, and food safety, as
well as other public health issues like physical activity and tobacco usage. They also publish a monthly
online newsletter called CDC Vital Signs that includes current data on the most pressing public health
matters.
Many additional websites, organizations, and professionals provide valid health and nutrition
information. Let’s take a look at some of these other resources.

Trusted Websites and Sources

Web domains can be an indicator of the reliability of a website.

• Websites of government agencies end in .gov and are usually considered to be trustworthy
sources of evidence-based health information.
• University websites typically end in .edu, indicating the source is focused primarily on
providing educational resources rather than seeking financial gain.
• Many professional organizations and non-profit organizations use websites ending in .org,
but this type of domain may also be used by special interest groups and biased groups
promoting a specific agenda. Approach these websites with a critical eye, looking for the
common signs of reliability.
• Business and company websites typically end in .com, indicating that the primary focus of
the website is to promote that particular company’s services and goods rather than to
simply educate a consumer. News organizations also have .com websites, and while their
primary mission is to inform readers, the same rules of discernment apply to make sure
they’re delivering news objectively. Major news organizations or those with a science or
health focus usually have reporters who specialize in these areas so have more background
knowledge of the field, and they’re more likely to have a process for fact-checking an article.

Any of these types of web domains could contain credible information, but you must be a savvy
consumer and use the knowledge gained in this unit to separate trusted sources from the more
questionable options. Check out this list of websites as a starter kit for generally reliable, trusted
sources for health and nutrition information.
102 TAMBERLY POWELL, MS, RDN

GOVERNMENT WEBSITES

USDA Center for Nutrition Policy and Promotion https://www.fns.usda.gov/cnpp

Food and Drug Administration http://www.fda.gov/

Healthy People https://www.healthypeople.gov/

Foodsafety.gov https://www.foodsafety.gov/

Nutrition.gov https://www.nutrition.gov/

ChooseMyPlate https://www.choosemyplate.gov/

National Center for Complementary and Integrative

https://nccih.nih.gov/
Health

National Heart, Lung, and Blood Institute https://www.nhlbi.nih.gov/health-topics

National Institutes of Health Office of Dietary

https://ods.od.nih.gov/
Supplements

INTERNATIONAL WEBSITES

World Health Organization https://www.who.int/

Food and Agricultural Organization of the United

http://www.fao.org/
Nations

NON-GOVERNMENT WEBSITES

Harvard School of Public Health https://www.hsph.harvard.edu/nutrition/

Mayo Clinic https://www.mayoclinic.org/

Linus Pauling Institute http://lpi.oregonstate.edu/

American Society for Nutrition http://www.nutrition.org/

American Cancer Society https://www.cancer.org/

American Heart Association https://www.heart.org/

WHO CAN YOU TRUST FOR NUTRITION INFORMATION? 103

American Diabetes Association http://www.diabetes.org/

Center for Science in the Public Interest https://cspinet.org/

Food Allergy Research & Education https://www.foodallergy.org/

http://nationalacademies.org/hmd/Global/Topics/Food-
Institute of Medicine: Food and Nutrition
Nutrition.aspx

Table 2.2. Reliable websites that provide nutrition information.

Trusted Professionals

When looking for credible nutrition information, one of the most important aspects to consider
is the expertise of the individual providing the information. Nutrition is a tricky field because the
term “nutritionist” is not a legally-protected or regulated term, so it’s imperative to seek experts
that are formally-educated and credentialed in nutrition. Look for professionals with the following
degrees or backgrounds:
•Registered dietitian nutritionist (RD or RDN)
•Professional with advanced degree(s) in nutrition (MS or PhD)
•Physician (MD) with appropriate education and expertise in nutrition
Registered dietitians or professionals with advanced degrees in the field of nutrition are
the most credible sources for sound nutrition advice. Be skeptical of other official-sounding
credentials, like “holistic nutrition practitioner,” or even just “nutritionist.” There are no standards for
what these titles mean, which means that anyone can call themselves a “nutritionist,” and you
could be taking advice from a well-qualified individual or someone who just took an online course or
got a mail-order certificate. Physicians can also be good sources for nutrition information, depending
on their education and background. But be mindful that most medical schools include minimal or
no education and training in nutrition so most physicians may have limited knowledge in this field
unless they have sought out specific nutrition training on their own.

Careers in Nutrition

If you are considering a career in nutrition, it is important to understand the opportunities that may
be available to you. Both dietitians and qualified nutritionists provide nutrition-related services to
people in the private and public sectors. A dietitian is a healthcare professional who has registered
credentials and can provide nutritional care in the areas of health and wellness for both individuals
and groups. While registration isn’t required to use the term “nutritionist,” a qualified nutritionist will
have an education similar to that of a dietitian, but most likely will not have completed an internship
or passed a credentialing exam like a registered dietitian. People in both professions work to apply
nutritional science, using evidence-based best practices, to help people nourish their bodies and
improve their lives.
Becoming a registered dietitian requires a bachelor’s or master’s degree in dietetics
(master’s degree will be required beginning in 2024), including courses in biology, chemistry,
biochemistry, microbiology, anatomy and physiology, nutrition, and food service management. Other
suggested courses include economics, business, statistics, computer science, psychology, and
sociology. In addition, people who pursue this path must complete a dietetic internship
(including 1200 hours of supervised practice), pass a national exam, and maintain their
registration through ongoing continuing education. Many states also have licensure that requires
104 TAMBERLY POWELL, MS, RDN

additional forms and documentation. You can learn more about the path to becoming a registered
dietitian by going to cdrnet.org/certifications.

Dietitians and nutritionists plan food and nutrition programs, promote healthy eating habits,
and recommend dietary modifications. But typically, to work in a clinical setting (like a hospital) or
outpatient setting, the RD credential is required. For example, a dietitian might teach a patient with
hypertension how to follow a lower-sodium diet. Nutrition-related careers can be extremely varied.
Some individuals work in government settings, while others work in education or the private sector.
Some jobs in nutrition focus on working with athletes, and others provide guidance to patients with
long-term, life-threatening diseases. But no matter the circumstance or the clientele, working in
the field of diet and nutrition focuses on helping people improve their dietary habits by translating
nutritional science into food choices.
In the public sector, careers in nutrition span from government work to community outreach.

• Nutritionists and dietitians who work for the government may be involved with federal food
programs (WIC, SNAP, school meals, etc), communication campaigns, or creating and
analyzing public policy.
• On the local level, clinical careers include working in hospitals and nursing-care facilities.
This requires creating meal plans and providing nutritional guidance to help patients
restore their health or manage chronic conditions. Clinical dietitians consult with doctors
and other health-care professionals to coordinate dietary recommendations with medical
needs.
• Nutrition jobs in the community often involve working in public health clinics, cooperative
extension offices, and HMOs to prevent disease and promote the health of the local
community.
• Nutrition jobs in the nonprofit world involve anti-hunger organizations, public health
organizations, and activist groups.

Nutritionists and dietitians can also find work in the private sector.
 WHO CAN YOU TRUST FOR NUTRITION INFORMATION? 105

• Increased public awareness of food, diet, and nutrition has led to employment
opportunities in advertising, marketing, and food manufacturing. Dietitians working in
these areas analyze foods, prepare marketing materials, or report on issues such as the
impact of vitamins and herbal supplements.
• Consultant careers can include working in wellness programs, supermarkets, physicians’
offices, gyms, and weight-loss clinics.
• Consultants in private practice perform nutrition screenings for clients and use their
findings to provide guidance on diet-related issues, such as weight reduction.
• Nutrition careers in the corporate world include designing wellness strategies and nutrition
components for companies, working as representatives for food or supplement companies,
designing marketing and educational campaigns, and becoming lobbyists.
• Others in the private sector work in food service management at health-care facilities or at
company and school cafeterias.
• Sustainable agricultural practices provide interesting private sector careers on farms and in
food systems.

Whether you pursue nutrition as a career or simply work to improve your own dietary choices, what
you are learning in this course can provide a solid foundation for the future. Remember, your ability
to think clearly, communicate, hope, dream, go to school, gain knowledge, and earn a living are
impacted by your health. Good health allows you to function normally and work hard to pursue your
goals. Yet, achieving optimal health is a complex process, involving multiple dimensions of wellness,
along with your physical or medical reality. It’s our hope that you use the knowledge gained in this
class, not just to earn a good grade, but that you also apply it to make a difference in your life.

Self-Check:

An interactive H5P element has been excluded from this version of the text. You can view it online here:
https://openoregon.pressbooks.pub/nutritionscience/?p=999#h5p-35

Attributions:

• University of Hawai‘i at Mānoa Food Science and Human Nutrition Program, “Careers in
Nutrition,” CC BY-NC 4.0
• Bureau of Labor Statistics, U.S. Department of Labor. (2019, September 4). Dietitians and
Nutritionists. Occupational Outlook Handbook. https://www.bls.gov/ooh/healthcare/
dietitians-and-nutritionists.htm

Image Credits:

• Laptop showing vegetable dish photo by Igor Miske on Unsplash (license information)
• Table 2.2. “Reliable websites that provide nutrition information” by Heather Leonard is
licensed under CC BY 4.0
106 TAMBERLY POWELL, MS, RDN

• Women at desk photo by Amy Hirschi on Unsplash (license information)

UNIT 3 - MOLECULES OF LIFE:
PHOTOSYNTHESIS, DIGESTION,
AND METABOLISM

107
Introduction to Molecules of Life

Life is extraordinarily complex. That’s true whether you’re considering something as seemingly
simple as a blade of grass or as obviously complicated as the human body. However, zooming in
to look at the most basic elements of living things—from atoms to molecules to cells—we can start
to see similarities and patterns that help us make sense of this complexity. And as we consider
biological processes, such as photosynthesis, digestion, and metabolism, we also see how these
processes fit together. Plants use photosynthesis to capture energy from the sun. Animals, humans
included, eat the plants (or other animals that ate the plants) and use the processes of digestion and
metabolism to utilize the energy they contain. In the process of energy metabolism, animals breathe
out carbon dioxide, which is then used by plants for photosynthesis. It’s truly a circle of life!

In this unit, we’ll also zero in on the digestive system. While all organ systems relate to nutrition
in some way, the digestive system takes center stage as the site of food processing and nutrient
extraction. And while it usually functions as an efficient and coordinated system, we’ll also consider
some common ways that it can go awry, resulting in disorders and discomforts of the digestive tract
or adverse reactions to certain foods.

109
 110 TAMBERLY POWELL, MS, RDN

Unit Learning Objectives

After completing this unit, you should be able to:

1. Define and describe the levels of structural organization of the human body—from atoms and molecules to the
whole organism—including the basic characteristics of cells and the organ systems.

2. Understand how photosynthesis is the pathway to glucose production and describe the relationship between
photosynthesis in plants and energy metabolism in the human body.

3. Identify and briefly describe the functions of the organs of the gastrointestinal tract, and discuss the five
fundamental activities of digestion, giving an example of each.

4. Describe several common disorders and discomforts of the GI tract, including their causes, symptoms, and
approaches to treatment.

5. Describe food intolerances, food allergies, and celiac disease, including the different causes, symptoms, and
treatments for each condition.

Image Credits:

“Take a bite out of fall” by Patrick Fore on Unsplash (license information)

Organization of Life

Before you begin to study the different structures and functions of the human body related to
nutrition, it is helpful to consider the basic architecture of the body; that is, how its smallest parts
are assembled into larger structures. It is convenient to consider the structures of the body in terms
of fundamental levels of organization that increase in complexity: atoms, molecules, cells, tissues,
organs, organ systems, and organisms. Higher levels of organization are built from lower levels.
Therefore, atoms combine to form molecules, molecules combine to form cells, cells combine to
form tissues, tissues combine to form organs, organs combine to form organ systems, and organ
systems combine to form organisms (Figure 3.1).

111
112 TAMBERLY POWELL, MS, RDN

Figure 3.1. Levels of structural organization of the human body. The organization of the body often is
discussed in terms of distinct levels of increasing complexity, from the smallest chemical building blocks to
a unique human organism.
ORGANIZATION OF LIFE 113

THE LEVELS OF ORGANIZATION

Consider the simplest building blocks of matter: atoms and molecules. In Unit 1, you had an
introduction to atoms and molecules. Remember, all matter in the universe is composed of one
or more unique elements, such as hydrogen, oxygen, carbon, and nitrogen. The smallest unit of
any of these elements is an atom. Atoms of individual elements combine to make molecules, and
molecules bond together to make bigger macromolecules. Four macromolecules—carbohydrates,
lipids, proteins, and nucleic acids (e.g., DNA, RNA)—make up all of the structural and functional units
of cells.

The Basic Structural and Functional Unit of Life: The Cell

Cells are the most basic building blocks of life. All living things are composed of cells. New cells
are made from preexisting cells, which divide in two. Who you are has been determined because
of two cells that came together inside your mother’s womb. The two cells containing all of your
genetic information (DNA) fused to begin the development of a new organism. Cells divided and
differentiated into other cells with specific roles that led to the formation of the body’s numerous
organs, systems, blood, blood vessels, bones, tissues, and skin. While all cells in an individual contain
the same DNA, each cell only expresses the genetic codes that relate to that cell’s specific structure
and function.
As an adult, you are made up of trillions of cells. Each of your individual cells is a compact and
efficient form of life—self-sufficient, yet interdependent upon the other cells within your body to
supply its needs. There are hundreds of types of cells (e.g., red blood cells, nerve cells, skin cells).
Each individual cell conducts all the basic processes of life. It must take in nutrients, excrete wastes,
detect and respond to its environment, move, breathe, grow, and reproduce. Many cells have a short
life span and have to be replaced continually. For example, enterocytes (cells that line the intestines)
are replaced every 2-4 days, and skin cells are replaced every few weeks.
Although a cell is defined as the “most basic” unit of life, it is structurally and functionally complex
(Figure 3.2). A human cell typically consists of a flexible outer cell membrane (also called a plasma
membrane) that encloses cytoplasm
cytoplasm, a water-based cellular fluid, together with a variety of
functioning units called organelles
organelles. The organelles are like tiny organs constructed from several
macromolecules bonded together. A typical animal cell contains the following organelles:

• Nucleus
Nucleus: houses genetic material (DNA)
• Mitochondria
Mitochondria: often called the powerhouse of the cell, generates usable energy for the cell
from energy-yielding nutrients
• Ribosomes
Ribosomes: assemble proteins based on genetic code
• Endoplasmic reticulum
reticulum: processes and packages proteins and lipids
• Golgi apparatus (golgi body): distributes macromolecules like proteins and lipids around the
cell
• Lysosomes
Lysosomes: digestive pouches which break down macromolecules and destroy foreign
invaders
114 TAMBERLY POWELL, MS, RDN

Figure 3.2. The cell structure

Tissues, Organs, Organ Systems, and Organisms

A tissue is a group of many similar cells that share a common structure and work together to perform
a specific function. There are four basic types of human tissues: connective tissue
tissue, which connects
tissues; epithelial tissue
tissue, which lines and protects organs; muscle
muscle, which contracts for movement and
support; and nerve
nerve, which responds and reacts to signals in the environment.
An organ is a group of similar tissues arranged in a specific manner to perform a specific
physiological function. Examples include the brain, liver, and heart. An organ system is a group of two
or more organs that work together to perform a specific physiological function. Examples include the
digestive system and central nervous system.
There are eleven distinct organ systems in the human body (Figure 3.3). Assigning organs to organ
systems can be imprecise since organs that “belong” to one system can also have functions integral
to another system. In fact, many organs contribute to more than one system. And most of these
organ systems are involved in nutrition-related functions within the body (Table 3.1). For example,
the cardiovascular system plays a role in nutrition by transporting nutrients in the blood to the cells
of the body. The endocrine system produces hormones, many of which are involved in regulating
appetite, digestive processes, and nutrient levels in the blood. Even the reproductive system plays a
role in providing nutrition to a developing fetus or growing baby.
ORGANIZATION OF LIFE 115

Figure 3.3. Organ systems of the human body

 116 TAMBERLY POWELL, MS, RDN

Organ
Major Organ Components Major Functions
System

Transport oxygen, nutrients, and waste

Cardiovascular Heart, blood/lymph vessels, blood, lymph
products

Mouth, esophagus, stomach, intestines, salivary glands,

Digestive Digestion and absorption
pancreas, liver and gallbladder

Produce and release hormones, regulate

Endocrine Endocrine glands (e.g., thyroid, ovaries, pancreas)
nutrient levels

Immune White blood cells, lymphatic tissue, marrow Defend against foreign invaders

Integumentary Skin, nails, hair, sweat glands Protection, body temperature regulation

Muscular Skeletal, smooth, and cardiac muscle Body movement

Interpret and respond to stimuli,

Nervous Brain, spinal cord, nerves
appetite control

Reproductive Gonads, genitals Reproduction and sexual characteristics

Gas exchange (oxygen and carbon

Respiratory Lungs, nose, mouth, throat, trachea
dioxide)

Skeletal Bones, tendons, ligaments, joints Structure and support, calcium storage

Urinary/
Kidneys, bladder, ureters Waste excretion, water balance
Excretory

Table 3.1. The eleven organ systems in the human body and their major functions
An organism is the highest level of organization—a complete living system capable of conducting all
of life’s biological processes. In multicellular organisms, including humans, all cells, tissues, organs,
and organ systems of the body work together to maintain the life and health of the organism.

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Attributions:

• Rice University, “Anatomy and Physiology” CC BY 4.0

• University of Hawai‘i at Mānoa Food Science and Human Nutrition Program, “Basic Biology,
Anatomy, and Physiology” CC BY-NC 4.0
ORGANIZATION OF LIFE 117

Images:

• Figure 3.1. “Levels of Structural Organization of the Human Body” by OpenStax, Rice
University is licensed under CC BY 4.0
• Figure 3.2. “The Cell Structure” by University of Hawai‘i at Mānoa Food Science and Human
Nutrition Program is licensed under CC BY-NC-SA 4.0
• Figure 3.3. “The eleven organ systems in the human body and their major functions” by
University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed
under CC BY-NC-SA 4.0
• Table 3.1. “The eleven organ systems in the human body and their major functions” by
University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed
under CC BY-NC-SA 4.0
Photosynthesis and Metabolism

As we just learned in the previous section, cells are the most basic building blocks of life. Cells make
up your tissues, organs, and ultimately, you as a human being. And every one of those cells needs
energy to perform their specific functions. Where does that energy come from? It comes from the
macronutrients that we eat—carbohydrates, protein, and fat. In order to understand how the cells
of the body put that energy to use, you must have a basic understanding of photosynthesis, cellular
respiration, and the relationship between these two processes.

PHOTOSYNTHESIS

Photosynthesis is essential to all life on earth; both plants and animals depend on it. It is the only
biological process that can capture energy that originates from sunlight and convert it into a chemical
compound (glucose) that every organism uses to power its daily functions. Photosynthesis is also a
source of oxygen necessary for many living organisms.

The importance of photosynthesis is not just that it can capture sunlight’s energy. Photosynthesis
is vital because it provides a way to capture the energy from solar radiation (the “photo-” part) and
store that energy in the carbon-carbon bonds of glucose (the “-synthesis” part). Glucose is the main
118
PHOTOSYNTHESIS AND METABOLISM 119

energy source that animals and humans use to power the synthesis of adenosine triphosphate (ATP) (ATP).
ATP is the energy-containing molecule found in the cells of all animals and humans. Energy from the
1
foods we eat is captured in ATP and used to fuel the workload of cells.
The energy stored in carbohydrate molecules from photosynthesis passes through the food chain.
Consider a predator, such as a wolf, preying on a deer. The wolf is at the end of an energy path that
went from atoms colliding on the surface of the sun, to visible light, to photosynthesis, to vegetation,
to the deer, and finally to the wolf. The wolf, by feeding on the deer, receives a portion of the energy
that originated in the photosynthetic vegetation that the deer consumed.
Our food supply is also directly linked to photosynthesis. Major grocery stores in the United States
are organized into departments, such as dairy, meats, produce, bread, cereals, and so forth. Each
aisle contains hundreds, if not thousands, of different products for customers to buy and consume.
Although there is a large variety, each item ultimately can be linked back to photosynthesis. Meat
and dairy link because the animals were fed plant-based foods. The breads, cereals, and pastas come
largely from starchy grains, which are the seeds of photosynthesis-dependent plants. What about
desserts and drinks? All of these products contain sugar—sucrose is a plant product, a carbohydrate
molecule, which is also derived from photosynthesis. Many items are less obviously derived from
plants: virtually every spice and flavoring in the spice aisle was produced by a plant as a leaf, root,
bark, flower, fruit, or stem. (Salt is a notable exception.) Ultimately, photosynthesis connects to every
meal and every food a person consumes.

Main Structures and Summary of Photosynthesis

Photosynthesis generally takes place in the leaves of plants. It is a multi-step process that requires
sunlight, carbon dioxide (CO2, found in the air), and water (H2O, from the soil). After the process
is complete, the plant releases oxygen into the air (O2, essential for many living organisms) and
produces the simple carbohydrate molecule of glucose, which can be used as an energy source
by the plant, converted to starch and stored for a later energy source, or converted into other
organic molecules such as fats, proteins and vitamins. This glucose contains the energy that all living
organisms need to survive.
120 TAMBERLY POWELL, MS, RDN

Figure 3.5. Depiction of photosynthesis in plants. The carbohydrates produced are stored in or used by
the plant.
The basic formula for photosynthesis is as follows:
6CO2 + 6H2O + sun’s energy = C6H12O6 + 6O2
Another way of saying this:

6 molecules of carbon dioxide (6CO2)

Photosynthesis uses: 6 molecules of water (6H2O)
the sun’s energy

1 molecule of glucose (C6H12O6)

Photosynthesis produces:
6 molecules of oxygen (6O2)

Starch is the storage form of glucose in plants, stored in seeds, roots, and tubers for later use as
an energy source for the plant to reproduce. When a seed is buried deep in the soil, this starch can
be broken down into glucose to be used for energy for the seed to sprout. As the seed sprouts,
and shoots go above the ground and leaves start to form, the new plant can then photosynthesize
glucose for an energy source. When we eat foods that contain starch, we must digest that starch
down into single sugars (glucose) in order for the glucose to be absorbed into the intestinal cells,
where it will enter the bloodstream to be carried to all cells of the body to use as an energy source.
The basic process of digestion of these foods will be covered in the next section.

CELLULAR RESPIRATION

All living things require energy to survive. For humans, and many other organisms, that energy is
generated by the complex interaction of photosynthesis and cellular respiration
respiration. Cellular respiration
is a key pathway in energy metabolism (the process of converting food into energy) of all aerobic
organisms. Respiration refers to breathing: taking in oxygen and removing carbon dioxide. But
ultimately, the reason we need to breathe is to provide the oxygen needed to carry out cellular
respiration in our cells and to remove the carbon dioxide that is produced as a byproduct.
In the process of cellular respiration, energy that is stored in the food we eat is converted to the
body’s energy currency, ATP, while a small amount is lost as heat. During cellular respiration, glucose
is broken down to carbon dioxide and water; in the process, ATP is released. Cellular respiration
occurs in part in the mitochondria of cells and is an aerobic process, which means that oxygen
is required. It is a series of reactions that can be summarized as follows:
glucose + 6O2 → 6CO2 + 6H2O + energy (ATP and heat)
Another way of saying this:

1 molecule of glucose (C6H12O6)

Cellular respiration uses:
6 molecules of oxygen (6O2)

6 molecules of carbon dioxide (6CO2)

Cellular respiration produces: 6 molecules of water (6H2O)
Energy

Even though glucose is the starting substance used in cellular respiration, we do not consume only
glucose as an energy source. Instead, many different kinds of food molecules are broken down
into smaller molecules, metabolized, and then enter the cellular respiration pathway. For example,
complex carbohydrates like starch are readily converted to glucose. Fats and proteins can also be
used in cellular respiration, but they must be modified before they can feed into the process.
PHOTOSYNTHESIS AND METABOLISM 121

Figure 3.6. Nutrients fuel cellular respiration. Other carbohydrates, like starch and sugars, are converted
to glucose before entering cellular respiration.

PHOTOSYNTHESIS-CELLULAR RESPIRATION CYCLE

If you compare the summary reactions of photosynthesis and cellular respiration, you can see that
cellular respiration is the opposite of photosynthesis. Because each process starts where the other
ends, they form a cycle. What one reaction uses, the other reaction produces, and what one produces
the other uses.
122 TAMBERLY POWELL, MS, RDN

Figure 3.7. The relationship between the reactions of photosynthesis and cellular respiration.
The cycling that occurs between photosynthesis and cellular respiration is vital to the health of
planet Earth. If there was no way for the carbon dioxide produced through cellular respiration
to be utilized, breathing organisms (like humans and animals) would soon suffocate. Additionally,
photosynthetic organisms are at the base of almost every food chain on the planet, so without
these organisms, mass starvation would result. Luckily, this planet is full of organisms capable of
photosynthesis (e.g., trees and grass on land and algae and bacteria in the ocean). Without this vital
connection between photosynthesis and cellular respiration, life as we know it would cease to exist.
 PHOTOSYNTHESIS AND METABOLISM 123

Figure 3.8. The photosynthesis-cellular respiration cycle. The two processes are intimately linked.

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Attributions:

• Rice University, “Overview of Photosynthesis” by Mary Ann Clark, Matthew Douglas, Jung
Choi, Biology 2e, OpenStax is licensed under CC BY 4.0
• “Metabolism”, Introduction to Biology is licensed under CC BY-NC-SA 3.0
124 TAMBERLY POWELL, MS, RDN

References:

1
• Adenosine Triphosphate. (n.d.) Encyclopaedia Britannica. https://www.britannica.com/
science/adenosine-triphosphate

Images:

• Green leafed plant in sunlight by Vlad Kutepov on Unsplash (license information)

• Figure 3.5. “Depiction of photosynthesis in plants” by Nefronus is licensed under CC BY-SA
4.0
• Figure 3.6. “Fuels feed into cellular respiration” by Introduction to Biology is licensed under
CC BY-NC-SA 3.0
• Figure 3.7. “The relationship between the reactions of photosynthesis and cellular
respiration” by Heather Leonard is licensed under CC BY-NC-SA 3.0 / A derivative from the
original work
• Figure 3.8. “The photosynthesis-cellular respiration cycle” by Introduction to Biology is
licensed under CC BY-NC-SA 3.0
The Digestive System

We just learned that our body is composed of billions of cells. To function, these cells need essential
nutrients—carbohydrates, proteins, fats, vitamins, and minerals—which we obtain from foods.
However, before our cells can access these nutrients, foods need to be broken down or digested into
their simplest units, so that the nutrients can be absorbed and enter the bloodstream. Digestion is a
complex process that involves many organs and chemicals, as we’ll explore on this page.

AN OVERVIEW OF THE ORGANS INVOLVED IN DIGESTION

The function of the digestive system is to break down the foods you eat, release their
nutrients, and absorb those nutrients into the body. Although the small intestine is the
workhorse of the system where the majority of digestion and absorption occurs, each of the digestive
system organs makes a vital contribution to this process.
The easiest way to understand the digestive system is to divide its organs into two main categories:
the gastrointestinal tract (GI tract) and the accessory organs.

• The GI tract is a one-way tube about 25 feet in length, beginning at the mouth and ending at
the anus. Between these two points, the GI tract also contains the pharynx, esophagus,
stomach, small and large intestines, and the rectum. The small intestine is comprised of
three parts: the duodenum, the jejunum, and the ileum. The large intestine, also called the
colon, is similarly divided into three sections: the ascending colon, transverse colon, and
descending colon. Both the mouth and anus are open to the external environment; thus,
food and wastes within the GI tract are technically considered to be outside the body. Only
through the process of absorption do the nutrients in food enter into and nourish the
body’s “inner space.”

• Accessory organs, despite their name, are critical to the function of the digestive system.
They are considered accessory organs since they are not actually part of the intestinal tract
itself, but have ducts that deliver digestive juices into the tract to help aid in digestion.
There are four accessory organs: the salivary glands, liver, gallbladder, and pancreas. All of
these organs secrete fluids containing a variety of chemicals such as enzymes and acids
that aid in digestion.

125
126 TAMBERLY POWELL, MS, RDN

Figure 3.9. An overview of the organs involved in digestion. The parts of the GI tract are highlighted in
blue, and the accessory organs are highlighted in yellow.

AN OVERVIEW OF THE DIGESTIVE PROCESS

The process of digestion includes five main activities: ingestion, mechanical digestion, chemical
digestion, absorption, and excretion.
The first of these processes, ingestion
ingestion, refers to the entry of food into the GI tract through the
mouth. There, the food is chewed and mixed with saliva, which contains enzymes that begin breaking
down the carbohydrates and lipids in food. Mastication (chewing) increases the surface area of the
food and allows for food to be broken into small enough pieces to be swallowed safely.
Food (now called a bolus since it has been chewed and moistened) leaves the mouth when the
tongue and pharyngeal muscles propel the bolus into the esophagus. The bolus will travel down
the esophagus through an involuntary process called peristalsis. Peristalsis consists of sequential,
alternating waves of contraction and relaxation of the smooth muscles in the GI tract, which act to
propel food along (Figure 3.10). These waves also play a role in mixing food with digestive juices.
Peristalsis is so powerful that foods and liquids you swallow enter your stomach even if you are
standing on your head.
THE DIGESTIVE SYSTEM 127

Figure 3.10. Peristalsis moves food through the digestive tract with alternating waves of muscle
contraction and relaxation.
Digestion includes both mechanical and chemical processes. Mechanical digestion is a purely
physical process of making food particles smaller to increase both surface area and mobility.
Mechanical digestion does not change the chemical nature of the food. It includes mastication,
tongue movements that help break food into smaller bits and mix it with saliva, mixing and churning
of the stomach to further break food apart and expose more of its surface area to digestive juices,
and peristalsis to help move food along the intestinal tract. Segmentation is also an example of
mechanical digestion. Segmentation
Segmentation, which occurs mainly in the small intestine, consists of localized
contractions of circular muscle of the GI tract. These contractions isolate small sections of the
intestine, moving their contents back and forth while continuously subdividing, breaking up, and
mixing the contents. By moving food back and forth in the intestinal tract, segmentation mixes food
with digestive juices and facilitates absorption.

Figure 3.11. Segmentation separates chyme and then pushes it back together, mixing it and providing
time for digestion and absorption.
In chemical digestion
digestion, digestive secretions that contain enzymes start to break down the
macronutrients into their chemical building blocks (for example, starch into glucose). Enzymes are
chemicals that help speed up or facilitate chemical reactions in the body. They bring together two
compounds to react, without undergoing any changes themselves. For example, the main chemical
reaction in digestion is hydrolysis.Hydrolysis
Hydrolysis is the splitting of one molecule into two with the addition
of water. For example, the sugar sucrose (a double sugar) needs to be broken down to its building
blocks, glucose and fructose (both single sugars), before it can be absorbed. This breakdown happens
through hydrolysis, and the enzyme, sucrase, brings together the sucrose molecule and the water
molecule to react. This process is illustrated in the following animation.
128 TAMBERLY POWELL, MS, RDN

Video: Enzyme Action and the Hydrolysis of Sucrose by McGraw-Hill Animations, YouTube (June 3, 2017). 1:46
minutes.

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Nutrients are of little to no value to the body unless they enter the bloodstream. This occurs
through the process of absorption
absorption, which takes place primarily within the small intestine. There, most
nutrients are absorbed from the lumen (or inside space) of the GI tract into the bloodstream. Larger
lipids are absorbed into lymph but eventually enter the bloodstream as well.
In excretion
excretion, the final step of digestion, undigested materials are removed from the body as feces feces.
The feces is stored in the rectum until it leaves the body through the anus.

FUNCTIONS OF THE DIGESTIVE ORGANS

Now that you have an overview of the digestive organs and the digestive process, let’s discuss in
more detail what types of mechanical and chemical digestion take place in each of the organs of
the GI tract. Let’s imagine eating a peanut butter and jelly sandwich that contains carbohydrates,
proteins, fats, vitamins, and minerals. How does each organ participate in breaking this sandwich
down into units that can be absorbed and utilized by cells throughout the body?

Mouth

Ingestion of the peanut butter and jelly sandwich happens in the mouth or oral cavity. This is where
mechanical and chemical digestion also begin. Teeth physically crush and grind the sandwich into
smaller particles and mix the food particles with saliva. Salivary amylase (a digestive enzyme) is
secreted by salivary glands (salivary glands produce saliva which is a mixture of water, enzymes, and
other chemicals) and begins the chemical breakdown of carbohydrates in the bread, while lingual
lipase (another digestive enzyme) starts the chemical breakdown of triglycerides (the main form of
fat in food) in the peanut butter.

Esophagus

The esophagus is a muscular tube that transports food from the mouth to the stomach. No chemical
digestion occurs while the bolus is mechanically propelled through this tube by peristalsis.
THE DIGESTIVE SYSTEM 129

Stomach

The stomach is an expansion of the GI tract that links the esophagus to the first part of the small
intestine (the duodenum). The empty stomach is only about the size of your fist but can stretch to
hold as much as 4 liters of food and fluid—more than 75 times its empty volume—and then return to
its resting size when empty. An important function of the stomach is to serve as a temporary holding
chamber. You can ingest a meal far more quickly than it can be digested and absorbed by the small
intestine. Thus, the stomach holds food and secretes only small amounts into the small intestine at
a time. (The length of time food spends in the stomach varies by the macronutrient composition of
the meal. A high-fat or high-protein meal takes longer to break down than one rich in carbohydrates.
It usually takes a few hours after a meal to empty the stomach contents completely into the small
intestine.)
When the peanut butter and jelly sandwich enters the stomach, a highly muscular organ, powerful
peristaltic contractions help mash, pulverize, and churn it into chyme. Chyme is a semiliquid mass of
partially digested food along with gastric juices secreted by cells in the stomach. These gastric juices
contain hydrochloric acid
acid, which lowers the pH of the chyme in the stomach. This acidic environment
kills many bacteria or other germs that may have been present in the food, and it causes the three-
dimensional structure of dietary proteins to unfold. Gastric juices also contain the enzyme pepsin
pepsin,
which begins the chemical breakdown of proteins in the peanut butter and bread. Gastric lipase
continues the breakdown of fat from the peanut butter.

Small Intestine

Chyme released from the stomach enters the small intestineintestine, where most digestion and absorption
occurs. The small intestine is divided into three parts, all part of one continuous tube: the duodenum,
the jejunum, and the ileum.
Once the chyme enters the duodenum (the first segment of the small intestine), the pancreas and
gallbladder are stimulated to release juices that aid in digestion. The pancreas (located behind the
stomach) produces and secretes pancreatic juices which consist mostly of water, but also contain
bicarbonate that neutralizes the acidity of the stomach-derived chyme and enzymes that further
break down proteins, carbohydrates, and lipids. The small intestine’s absorptive cells also synthesize
digestive enzymes that aid in the breakdown of sugars and proteins.
The gallbladder (a small sac located behind the liver) stores, concentrates, and secretes a fluid
called bile that helps to digest fats. Bile is made in the liver and stored in the gallbladder. Bile is an
emulsifier; it acts similar to a detergent (that would remove grease from a frying pan) by breaking
large fat droplets into smaller fat droplets so they can mix with the watery digestive juices.
Peristalsis and segmentation control the movement and mixing of chyme through the small
intestine. As in the esophagus and stomach, peristalsis consists of circular waves of smooth muscle
contractions that propel food forward. Segmentation helps to mix food with digestive juices and
facilitates absorption.
Nutrient absorption takes place mainly in the latter part of the small intestine, the ileum
ileum.
The small intestine is perfectly structured for maximizing nutrient absorption. Its surface area is
greater than 200 square meters—about the size of a tennis court! The large surface area is due to the
multiple levels of folding, villi, and microvilli that cover the internal tissue of the small intestine. Villi
are tiny finger-like projections that are covered with enterocytes or absorptive cells. The absorptive
cell membrane is made of even smaller projections, called microvilli (Figure 3.12). These microvilli are
referred to collectively as the brush border since their appearance resembles the bristles on a brush.
130 TAMBERLY POWELL, MS, RDN

Figure 3.12. Histology of the small intestine. (a) The absorptive surface of the small intestine is vastly
enlarged by the presence of circular folds, villi, and microvilli. (b) Micrograph of the circular folds. (c)
Micrograph of the villi. (d) Electron micrograph of the microvilli.
Digested nutrients are absorbed into either capillaries or lymphatic vessels contained within
each villus. Amino acids (from protein digestion), small fatty acids (from triglyceride digestion),
sugars (from carbohydrate digestion), water-soluble vitamins, and minerals are transported from the
intestinal cells into the bloodstream through capillaries. The larger fatty acids, fat-soluble vitamins,
and other lipids (that are packaged in lipid transport particles) are transported first through
lymphatic vessels and then eventually meet up with the blood. Water-soluble nutrients that enter the
bloodstream are transported directly to the liver where the liver processes, stores, or releases these
nutrients to other body cells.
THE DIGESTIVE SYSTEM 131

Figure 3.13. The digestion and absorption of nutrients in the small intestine.

Large Intestine

Most of the nutrients from the peanut butter and jelly sandwich have now been digested and
absorbed. Any components that still remain (usually less than ten percent of food consumed) and
the indigestible fiber move from the small intestine to the large intestine (colon). A main task of the
large intestine is to absorb much of the remaining water. Water is present not only from the solid
foods and beverages consumed, but also the digestive juices released by the stomach and pancreas.
As water is reabsorbed, liquid chyme becomes a semisolid, referred to as feces. Feces is composed
of undigested food residues, unabsorbed digested substances, millions of bacteria, old cells from the
lining of the GI tract, inorganic salts, and enough water to let it pass smoothly out of the body.
Feces is stored in the rectum (a temporary holding area) until it is expelled through the anus via
defecation. No further chemical breakdown of food takes place in the large intestine except that
accomplished by the bacteria that inhabit this portion of the GI tract. There are trillions of bacteria
residing in the large intestine (referred to as the bacterial flora), exceeding the total number of cells
in the human body. This may seem rather unpleasant, but the great majority of bacteria in the large
intestine are harmless and many are even beneficial—facilitating chemical digestion and absorption,
132 TAMBERLY POWELL, MS, RDN

improving immune function, and synthesizing vitamins such as biotin, pantothenic acid, and vitamin
K.
The figure below summarizes the functions of the digestive organs.

Figure 3.14. Summary of digestion and absorption. Digestion begins in the mouth and continues as food
travels through the small intestine. Most absorption occurs in the small intestine.

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 THE DIGESTIVE SYSTEM 133

Video: “The Digestive System” by National Geographic, YouTube (November 26, 2012), 5:07 minutes.

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Attributions:

• “The Digestive System,” unit 23 from J. Gordon Betts, Kelly A. Young, James A. Wise, Eddie
Johnson, Brandon Poe, Dean H. Kruse, Oksana Korol, Jody E. Johnson, Mark Womble, Peter
DeSaix, Anatomy and Physiology, CC BY 4.0
• University of Hawai‘i at Mānoa Food Science and Human Nutrition Program, “The Digestive
System,” CC BY-NC 4.0

Images:

• Figure 3.9. “GI tract and accessory organs” by Alice Callahan is licensed under CC BY 4.0;
edited from “Digestive system diagram edit” by Mariana Ruiz, edited by Joaquim Alves
Gaspar, Jmarchn is in the Public Domain
• Figure 3.10. “Peristalsis” by J. Gordon Betts, Kelly A. Young, James A. Wise, Eddie Johnson,
Brandon Poe, Dean H. Kruse, Oksana Korol, Jody E. Johnson, Mark Womble, Peter DeSaix,
Anatomy and Physiology, OpenStax, licensed under CC BY 4.0
• Figure 3.11. “Segmentation” by OpenStax College is licensed under CC BY 3.0
• Figure 3.12. “Histology Small Intestines” by OpenStax College is licensed under CC BY 3.0
• Figure 3.13. “Absorption of Nutrients” by Tamberly Powell is licensed under CC BY 4.0;
edited from University of Hawai‘i at Mānoa Food Science and Human Nutrition Program,
“The Digestive System,” CC BY-NC 4.0
• Figure 3.14. “Functions of the Digestive Organs” by Tamberly Powell is licensed under CC BY
4.0; edited from “Figure 23.28 Digestion and Absorption” by J. Gordon Betts, Kelly A. Young,
James A. Wise, Eddie Johnson, Brandon Poe, Dean H. Kruse, Oksana Korol, Jody E. Johnson,
Mark Womble, Peter DeSaix , Anatomy and Physiology, OpenStax, licensed under CC BY 4.0
Disorders of the GI Tract

Now that we’ve covered the structures and functions of the digestive system, it should be clear
that the digestion of food requires the coordinated action of multiple organs. If any of these aren’t
working well, it can wreak havoc on the function of the entire system and interfere with health and
quality of life. Let’s look at some common discomforts and disorders of the GI tract.

HEARTBURN AND GASTROESOPHAGEAL REFLUX

Heartburn is a burning, often painful, sensation in the chest (behind the breastbone) or throat.
Heartburn is caused by gastroesophageal reflux (GER)
(GER), when the acidic chyme in the stomach escapes
back into the esophagus and even into the mouth. Normally, this reflux is prevented by the lower
esophageal sphincter (a tight ring of muscle) that sits between the esophagus and stomach. The
muscles of the sphincter contract to keep it closed, only relaxing to allow food boluses and liquid to
pass from the esophagus into the stomach and then quickly contracting again to keep the contents
of the stomach separate from the esophagus. The lower esophageal sphincter can be weakened
because of increased pressure on the abdomen from obesity or pregnancy, exposure to tobacco
smoke, and some medications, so the risk of GER is increased in these scenarios.

134
DISORDERS OF THE GI TRACT 135

Figure 3.15. In gastroesophageal reflux, the acidic contents of the stomach escape backwards into the
esophagus, causing pain and burning sensations in the chest and/or throat.
Occasional heartburn is a common complaint, especially after eating large greasy or spicy meals.
However, if it occurs more than twice per week, it may be diagnosed as gastroesophageal reflux
disease (GERD)
(GERD), which should be treated not only to relieve the discomfort that it causes but also to
prevent damage to the tissues of the esophagus, which can increase the risk of cancer. In addition
to heartburn, GER and GERD can cause difficult and painful swallowing, a persistent sore throat or
cough, a sense that there’s a lump in your throat, and nausea and vomiting.
The symptoms of GER and GERD can often be addressed through diet and lifestyle changes,
including the following:

• Avoid foods that seem to trigger symptoms. Common culprits are greasy or spicy foods,
chocolate, coffee, peppermint, alcohol, and acidic foods such as tomatoes or citrus.
• Eat smaller, more frequent meals instead of large meals.
• Avoid eating 3 hours before bedtime, and stay upright for 3 hours after eating.
• Wear clothing that is loose around the abdomen.
• Raise the head of your bed by 6 to 8 inches by placing blocks under the bedposts. (Extra
pillows will not help.)
• Quit smoking and avoid secondhand smoke, if needed.
• Lose weight, if needed.

Over-the-counter medications like antacids (Maalox, Mylanta, Rolaids) can also help with occasional
heartburn. If symptoms are persistent and frequent, it’s wise to see a doctor to be checked out for
1,2
GERD and to discuss other treatment and medication options.
136 TAMBERLY POWELL, MS, RDN

PEPTIC ULCERS

Peptic ulcers are sores on the tissues lining the esophagus, stomach, or duodenum (the first section
of the small intestine). They occur when the mucous coating the GI tissues is damaged, exposing
the tissue to pepsin and hydrochloric acid. This further erodes away the tissues, causing pain if it
damages a nerve and bleeding if it damages a blood vessel. Ulcers are most serious if they perforate
the wall of the GI tract, which can cause a serious infection. Peptic ulcers cause stomach pain, often
when the stomach is empty, and may go away when you eat or take antacids. In the most serious
cases, blood may be seen in vomit and/or the stool, and the patient may have very sharp and
persistent stomach pain.

Figure 3.16. Peptic ulcers. (A) The location of a peptic ulcer in the stomach. (B) A photo from an endoscopy
of a patient with an ulcer in the duodenum.
Doctors used to believe that stress and excessive stomach acid caused peptic ulcers, so they would
recommend a bland diet, stress reduction, and acid-suppressing medications as treatment. However,
these treatments often didn’t work, because they weren’t actually treating the root cause of the
ulcers. We now know that there are two main causes of peptic ulcers. The first and most common
cause is infection with a bacteria called Helicobacter pylori (H. pylori). H. pylori infection is very
common, with about 50% of the population worldwide harboring the bacteria, most of them living
without any symptoms. It’s not certain how people are infected with H. pylori or why they cause ulcers
in some people and not in others. However, understanding the link between H. pylori and ulcers
was an important discovery, because it led to effective treatments. The H. pylori bacteria are able to
survive the acidic environment of the stomach, and they damage the mucous coating of the GI tract,
leaving it vulnerable to further damage from acid and pepsin. Ulcers caused by H. pylori infection are
treated with antibiotics to kill the bacteria, with the addition of an acid-suppressing medication to
allow the tissue to heal.
The second major cause of peptic ulcers is long-term use of nonsteroidal anti-inflammatory drugs
(NSAIDs)
(NSAIDs), such as aspirin or ibuprofen. One of the side effects of NSAIDS is that they block the
production of an enzyme that protects the stomach lining, so using these medications frequently
and chronically can increase the risk of developing a stomach ulcer. To treat an ulcer caused by
NSAIDs, doctors recommend stopping or reducing the use of NSAIDs. They may also prescribe an
3
acid-reducing medication to allow the tissue to heal.

DIARRHEA AND CONSTIPATION

Both diarrhea and constipation can occur if the normal function and rhythm of the GI tract is
disrupted. If waste matter moves too quickly through the large intestine, not enough water is
absorbed, resulting in the loose, watery stools characteristic of diarrhea. This is most commonly
caused by ingesting food or water contaminated with bacteria (e.g., E. coli, Salmonella), viruses (e.g.,
norovirus, rotavirus), or parasites (e.g., Cryptosporidium enteritis, Giardia lamblia). Dietary allergies
and intolerances can also cause diarrhea, as we’ll discuss on the next page. Complications of diarrhea
4
include dehydration and malabsorption of nutrients.
On the other end of the spectrum is constipation, characterized by infrequent bowel movements
(less than 3 times per week) with stools that are hard, dry, or lumpy, and often painful to pass.
DISORDERS OF THE GI TRACT 137

Sometimes, constipation is caused by holding stool and delaying defecation. That gives the colon and
rectum additional time to absorb water, making the feces too hard and dry. Delaying defecation is
common in children or others who may fear that it will hurt to pass a stool, but of course, holding
it only worsens the problem. Constipation can also occur due to other disruptions in daily rhythms,
such as changing what or how much you eat, travel, or medication changes. Constipation is common
in pregnancy due to hormonal changes. It also becomes more common with age, which may be due
to decreased physical activity, medication use, or weakness in the smooth muscle of the intestine.
Constipation can be a sign of another medical problem, so chronic constipation should be checked
out by a doctor.
Constipation can often be addressed by dietary changes, including eating more high-fiber foods
(whole grains, legumes, fruits, vegetables, nuts, etc.) and drinking more water. It can also be helpful
to attempt a bowel movement after meals, when the intestine is more active, and to make that a
habit to try to establish more regularity in bowel movements. A caffeinated beverage with breakfast
can help, as can increasing physical activity.
Fiber supplements such as Metamucil, Citrucel, or Benefiber can be helpful for increasing fiber
intake and addressing constipation, at least in the short term. However, it’s preferable to transition
to dietary sources of fiber, as they come packaged with many other valuable nutrients.
Laxatives may also be helpful to address constipation in the short-term but are usually not a
good long-term solution. It’s possible to become dependent on some types of laxatives for bowel
movements, meaning that the colon doesn’t contract normally on its own. In these cases, a doctor
can help make a plan to gradually reduce laxative use and find other ways to improve bowel
4
regularity.

IRRITABLE BOWEL SYNDROME (IBS)

Irritable bowel syndrome (IBS) is a type of functional GI disorder, meaning that it’s caused by a
disruption in the signals between the brain and gut. People suffering from IBS often experience
abdominal pain, bloating, the feeling that they can’t finish a bowel movement, as well as diarrhea or
constipation or both, often in cycles. IBS is common; about 12% of people in the U.S. are thought to
 138 TAMBERLY POWELL, MS, RDN

have it. It’s more common in women, seems to run in families, and is often associated with stress,
history of trauma, or severe GI infections. IBS isn’t well understood. It’s not clear what causes it, and
5
it may have different causes in different people.
Of course, since the cause of IBS isn’t understood, that lack of understanding makes it difficult to
treat. Some people find that eating more fiber-rich foods and increasing physical activity improve
their symptoms, so these are good first steps (and good for health regardless of their effect on IBS).
Others find that following a diet that is low in carbohydrates called FODMAPs helps their symptoms.
FODMAPs are fermentable carbohydrates found in many foods and can usually be eaten without
issue by most people. Foods that are high in FODMAPs include fruits, vegetables, legumes, dairy
products, wheat, and honey, so this is a very restrictive diet and should only be attempted with
the guidance of a dietitian. Without careful planning, a low-FODMAP diet can be deficient in fiber,
vitamins, and minerals. It is usually followed for just a few weeks, and if it helps with symptoms, foods
6,7
are gradually added back to see what can be tolerated.
In addition to dietary strategies, physicians sometimes prescribe medications to treat the
8
symptoms of diarrhea or constipation associated with IBS.

INFLAMMATORY BOWEL DISEASE (IBD)

Inflammatory bowel disease (IBD) includes two types of disorders: ulcerative colitis and Crohn’s
disease. Ulcerative colitis is specific to the large intestine (colon) and rectum, whereas Crohn’s disease
can affect any part of the GI tract. Both are chronic inflammatory conditions in which symptoms may
periodically flare and become more severe. IBD is often confused with IBS, because of the similarities
in their names and some symptoms. However, they are different disorders with different causes. IBD
is generally more severe and long-lasting, and it causes damage to the GI tract that can be seen on
endoscopy (when a camera is inserted into the GI tract to visualize the interior). It’s important to get
9
an accurate diagnosis of IBD in order to treat the disorder appropriately.
Common symptoms of IBD are diarrhea, cramping and abdominal pain, feeling tired, and weight
loss. IBD may be caused by autoimmune reactions (in which the immune system attacks the body’s
own cells, in this case the cells of the GI tract) or certain genes, and other causes are being
investigated. IBD often develops in people during adolescence or in their 20s. It may be treated with
10,11
medications to reduce inflammation or modulate the immune system, or sometimes surgery.

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References

1
• Kahrilas, P. J. (2019, October 24). Patient education: Gastroesophageal reflux disease in adults
(Beyond the Basics)—UpToDate. UpToDate. https://www.uptodate.com/contents/
gastroesophageal-reflux-disease-in-adults-beyond-the-
basics?search=GER&topicRef=2265&source=see_link
2
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Acid Reflux (GER
& GERD) in Adults. National Institute of Diabetes and Digestive and Kidney Diseases.
DISORDERS OF THE GI TRACT 139

Retrieved February 23, 2020, from https://www.niddk.nih.gov/health-information/digestive-

diseases/acid-reflux-ger-gerd-adults
3
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Peptic Ulcers
(Stomach Ulcers). National Institute of Diabetes and Digestive and Kidney Diseases.
Retrieved February 23, 2020, from https://www.niddk.nih.gov/health-information/digestive-
diseases/peptic-ulcers-stomach-ulcers
4
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Constipation.
National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved February 23,
2020, from https://www.niddk.nih.gov/health-information/digestive-diseases/constipation
5
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Irritable Bowel
Syndrome (IBS). National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved
February 23, 2020, from https://www.niddk.nih.gov/health-information/digestive-diseases/
irritable-bowel-syndrome
6
• Harvard Health Publishing. Try a FODMAPs diet to manage irritable bowel syndrome. Harvard
Health. Retrieved February 23, 2020, from https://www.health.harvard.edu/diet-and-
weight-loss/a-new-diet-to-manage-irritable-bowel-syndrome
7
• Slomski, A. (2020). The Low-FODMAP Diet Helps IBS Symptoms, but Questions Remain.
JAMA. https://doi.org/10.1001/jama.2020.0691
8
• Wald, A. (2019, October 23). Treatment of irritable bowel syndrome in adults—UpToDate.
UpToDate. https://www.uptodate.com/contents/treatment-of-irritable-bowel-syndrome-in-
adults?search=IBS&source=search_result&selectedTitle=1~150&usage_type=default&displa
y_rank=1#H2957204
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• Crohn’s and Colitis Foundation. IBS vs IBD. Crohn’s & Colitis Foundation. Retrieved
February 23, 2020, from https://www.crohnscolitisfoundation.org/what-is-ibd/ibs-vs-ibd
10
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (n.d.-a). Crohn’s
Disease. National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved
February 23, 2020, from https://www.niddk.nih.gov/health-information/digestive-diseases/
crohns-disease
11
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Ulcerative
Colitis. National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved February
23, 2020, from https://www.niddk.nih.gov/health-information/digestive-diseases/ulcerative-
colitis

Images:

• Figure 3.15. “GastroEsophageal Reflux Disease” by BruceBlaus is licensed under CC BY-SA

4.0
• Figure 3.16. (a) “Gastric ulcer” by BruceBlaus is licensed under CC BY-SA 4.0 ; (b) “Duodenal
ulcer A2 stage, acute duodenal mucosal lesion(ADML)” by melvil is licensed under CC BY-SA
4.0
• “Abdominal pain” by derneuemann is in the Public Domain, CC0
Food Intolerances, Allergies, and Celiac Disease

Food is a source of nutrients for our bodies, and as we’ve learned, the GI tract functions to extract
those nutrients from food and absorb them into the body. But sometimes, specific foods can cause
problems for the GI tract and the body, including food intolerances, food allergies, and celiac disease.
These conditions are often confused for one another, but they have different causes, symptoms, and
approaches to treatment.

FOOD INTOLERANCES

A food intolerance occurs when a person has difficulty digesting a specific food or nutrient, causing
unpleasant GI symptoms such as gas, bloating, flatulence, cramping, and diarrhea. Food intolerances
are commonly caused by the body not producing enough of a particular digestive enzyme, so the
symptoms generally involve the digestive system, and the severity of symptoms usually correlates
with how much of the food was eaten. Unlike food allergies, the immune system does not play a role
in food intolerance, and while the symptoms are unpleasant, they are generally not dangerous and
will subside once the food passes out of the GI tract. People with food intolerances can also often
1
consume small amounts of the offending food without symptoms.
Lactose intolerance is a common food intolerance. People with lactose intolerance do not produce
enough of the enzyme lactase, which is responsible for digesting the milk sugar lactose into single
sugar molecules that can be absorbed in the small intestine. Undigested lactose can’t be absorbed,
so it continues on to the large intestine. There, it draws more water into the large intestine, and
bacteria metabolize the lactose, resulting in gas and acid production. These conditions cause the
uncomfortable symptoms of gas, bloating, and diarrhea within about 30 minutes to two hours of
consuming dairy foods.
As with most food intolerances, people with lactose intolerance can often consume some amount
of lactose without discomfort, although this varies from person to person. Aged hard cheese,
buttermilk, and yogurt (as long as it doesn’t include added milk solids) are often well-tolerated
because they are low in lactose, which is consumed by bacteria during fermentation and aging. In
addition, lactose-free milk and lactase enzyme supplements are available. Dairy products are some
of the main dietary sources of calcium and vitamin D, so people who avoid dairy need to take special
2
care to include other sources of these nutrients in their diets.

140
FOOD INTOLERANCES, ALLERGIES, AND CELIAC DISEASE 141

Figure 3.17. Taking a lactase enzyme supplement allows many people with lactose intolerance to eat
dairy products without suffering symptoms.
The vast majority of humans are born with the ability to digest lactose. All mammalian milk,
including human milk, contains lactose, so historically, infants with lactose intolerance wouldn’t have
survived. (Today, infants with lactose intolerance can consume soy-based infant formula.) Beyond
infancy, lactose intolerance depends on your genes. In much of the world, it’s common for the
activity of the lactase gene to decline with age, resulting in less lactase production and more lactose
intolerance. Worldwide, 65% of the human population has some degree of lactose intolerance in
adulthood. On the other hand, lactose tolerance is common in cultures where early domestication
of dairy animals provided an important source of nutrition. In the U.S., adults of European descent
can often tolerate lactose, whereas lactose intolerance is common among Asian Americans, African
3
Americans, Mexican Americans, and Native Americans.
142 TAMBERLY POWELL, MS, RDN

Figure 3.18. The prevalence of lactose intolerance worldwide.

FOOD ALLERGIES

In addition to its role in digestion, the GI tract serves an important immune function. Intestinal cells
form the barrier between the interior of the body and the lumen, or tube, of the GI tract, which is
technically outside of the body and teeming with potential pathogens. Immune tissue in the GI tract
and other parts of the body produce immune cells that target foreign invaders, in part through the
production of antibodies
antibodies, protective proteins that bind to foreign substances. However, this function
requires the immune system to accurately distinguish between normal food proteins and invading
pathogens. A food allergy is what happens if the immune system mistakenly identifies a food protein
as an invasive threat.
The most common type of food allergy involves immunoglobulin E (IgE)(IgE), a type of antibody produced
by the immune system in response to a specific substance, orallergen allergen. Symptoms of an allergic
reaction usually occur immediately after consuming the food (i.e., within seconds to minutes),
although reactions can sometimes be delayed by two hours or more. Because an allergic reaction
is caused by the immune system, it can lead to symptoms all over the body, including skin rashes;
swollen lips, face, or throat; wheezing and difficulty breathing; nausea and vomiting; cramping;
diarrhea; and rarely, a dangerous drop in blood pressure. A severe allergic reaction involving more
than one organ system—a rash coupled with difficulty breathing, for example—is called anaphylaxis
anaphylaxis.
Anaphylaxis can be life-threatening and should be treated immediately with epinephrine, commonly
administered by injection with a device such as an EpiPen, and then person should seek immediate
1
medical attention.
FOOD INTOLERANCES, ALLERGIES, AND CELIAC DISEASE 143

Figure 3.19. Common food allergens: peanuts, dairy, wheat, eggs, and shrimp. At right, an EpiPen,
containing injectable epinephrine, is pictured.
The most common food allergies in the U.S. are caused by proteins in peanuts, tree nuts, milk,
4,5
shellfish, eggs, fish, wheat, soy and sesame. A 2019 study reported that 19% of adults in the
U.S. believe they’re allergic to at least one food. After asking people about their symptoms, the
researchers estimated that the true incidence of food allergies is closer to 11%, while the remaining
4
8% of people likely have a food intolerance.
Food allergies are common in children, affecting about 8% of U.S. children, although allergies
5
can also develop later in life. It’s common for young children to outgrow allergies to egg, dairy,
wheat, or soy, but peanut, tree nut, and shellfish allergies are often lifelong. Recent research has
found that letting babies eat common food allergens, particularly peanut products, can prevent the
development of allergies, perhaps by allowing the immune system an early opportunity to learn to
6
differentiate between food proteins and invading pathogens.
If you think you may have a food allergy, it’s important to see an allergist to ensure you have
an accurate diagnosis. Food allergies are diagnosed based on symptoms after consuming a food,
specific IgE blood tests, and/or skin prick tests, where a tiny amount of food protein is scratched
onto the skin to test for a reaction. Blood and skin tests determine whether a person is sensitized
to an allergen, meaning that they’re producing IgE antibodies to the food. However, the presence of
IgE antibodies doesn’t definitively mean a person has a food allergy; it’s common to have a positive
IgE test but still be able to eat the food without symptoms. The gold standard test for diagnosing
is an oral food challenge—consuming a small amount of the food and watching for signs of a
reaction—although due to time, cost, and risk, these are not always conducted. If you are diagnosed
with a food allergy, you will be counseled to strictly avoid the food and carry injectable epinephrine
in case of accidental consumption. Unlike with food intolerances, consuming even a small amount of
1
food can cause a serious reaction in those with food allergies.
There are some promising new therapies for treating food allergies that involve exposing a person
to small amounts of the allergen to try to teach the body to tolerate it. These don’t cure the allergy
completely but may reduce the risk of a severe allergic reaction. The first of these therapies was
7
approved by the U.S. Food and Drug Administration in January 2020.
There are blood tests available that claim to screen for as many as 90 to 100 food allergies from
one blood sample. These measure a different type of antibody called IgG, but the presence of IgG
does not indicate a food allergy. Therefore, these tests are not recommended by allergy experts,
because they may cause a person to unnecessarily fear and avoid a long list of foods to which they
8
are not allergic.

CELIAC DISEASE

Celiac disease is an autoimmune disorder affecting between 0.5 and 1.0% of people in the U.S., or one
9
in every 100 to 200 people. Inautoimmune
autoimmune diseases
diseases, the immune system produces antibodies that
attack and damage the body’s own tissues. In the case of celiac disease, the body has an abnormal
immune reaction to gluten (a group of proteins found in wheat, rye, and barley), causing antibodies
to attack the cells lining the small intestine. This results in damage to the villi, decreasing the surface
144 TAMBERLY POWELL, MS, RDN

area for nutrient absorption. There is no cure for celiac disease, but it’s very effectively treated by
10
eliminating gluten from the diet.
Symptoms of celiac disease can range from mild to severe and can include pale, fatty, loose stools,
gastrointestinal upset, constipation, abdominal pain, and skin conditions. Nutrient malabsorption
can lead to weight loss and in children, a failure to grow and thrive. Symptoms can appear in infancy
or much later in life, as late as age seventy. Celiac disease is not always diagnosed, because the
symptoms may be mild. Even without symptoms, the disease can still damage the small intestine and
impair nutrient absorption. Nutrient deficiencies can cause health problems over time, particularly
in children and the elderly. For example, poor absorption of iron and folic acid can cause anemia,
which impairs oxygen transport to cells in the body. Calcium and vitamin D deficiencies can lead to
osteoporosis, a disease in which bones become brittle.
Diagnosis of celiac disease begins with a blood test for specific antibodies that are elevated in those
with the disease. If the blood test is positive, the diagnosis is confirmed with a biopsy of the small
intestine, a procedure in which a small amount of tissue is removed for examination. These tests may
not accurately detect celiac disease in people already consuming a gluten-free diet, because without
gluten, antibody levels may be low and damage to the small intestine may not be visible. This is why
it’s best to be tested for celiac before eliminating gluten from the diet.
It isn’t clear what causes celiac disease; genetics play a role, but other factors also seem to
influence its development. Celiac disease is most common in people of European descent and is rare
in people of African American, Japanese, and Chinese descent. It is more prevalent in women and in
people with type 1 diabetes, autoimmune thyroid disease, and Down and Turner syndromes.
Celiac disease is treated by completely avoiding gluten, as consuming even small amounts can
cause intestinal damage. People with celiac can consume grains that don’t contain gluten, including
rice, corn, millet, buckwheat, and quinoa. Oats can be consumed, although they are often
contaminated with gluten from neighboring fields or shared processing equipment, so it’s best to
buy oats labeled gluten-free. There are also an increasing number of gluten-free products available
in stores. After eliminating gluten from the diet, the tissues of the small intestine usually heal within
six months.

Figure 3.20. Celiac disease is caused by an autoimmune response to gluten, found in wheat, rye, and
barley. At right is a section of the small intestine from a biopsy, visualized under a microscope, from a celiac
patient. The villi, which would normally be finger-like projections, are blunted and flattened by damage
caused by the disease.
Celiac disease is different from a wheat allergy in both cause and symptoms. Because celiac
disease is an autoimmune condition, the cells of the small intestine come under attack, and damage
causes chronic symptoms. A wheat allergy, on the other hand, is caused by antibodies attacking an
allergen in the wheat itself, and the symptoms are usually immediate and acute.
Sometimes, people test negative for celiac disease but still believe that consuming gluten is causing
symptoms, usually gastrointestinal in nature. They may eliminate gluten from their diet and find that
they feel better. This is often called non-celiac gluten sensitivity (NCGS)
(NCGS). It’s not clear what causes NCGS
or why a gluten-free diet is helpful. In some cases, it may be a placebo effect. In others, it seems that
it’s not gluten causing the problem but other dietary components, such as FODMAPs, that happen to
also be low in a gluten-free diet. And in some cases, gluten does seem to cause symptoms in people
11,12
without celiac disease, although researchers don’t understand why.
Except in the case of celiac disease, wheat allergy, or confirmed NCGS, gluten-free foods or a
 FOOD INTOLERANCES, ALLERGIES, AND CELIAC DISEASE 145

gluten-free diet are not inherently more healthful. In fact, packaged gluten-free foods are often
more highly processed, with more added sugar, salt, and fat, compared to foods containing wheat.
A gluten-free diet can also be lower in fiber, so those following the diet should be sure to include
13
naturally gluten-free whole grains, legumes, nuts, fruits, and vegetables to provide adequate fiber.

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Attributions:

• University of Hawai‘i at Mānoa Food Science and Human Nutrition Program, “Nutrition and
Health,” CC BY-NC 4.0

References:

1
• Commins, S. P. (2020). Food intolerance and food allergy in adults: An overview. UpToDate.
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and-food-allergy-in-adults-an-
overview?search=food%20intolerance&source=search_result&selectedTitle=1~150&usage_t
ype=default&display_rank=1
2
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (n.d.). Lactose
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4
• Gupta, R. S., Warren, C. M., Smith, B. M., Jiang, J., Blumenstock, J. A., Davis, M. M.,
Schleimer, R. P., & Nadeau, K. C. (2019). Prevalence and Severity of Food Allergies Among
US Adults. JAMA Network Open, 2(1), e185630–e185630. https://doi.org/10.1001/
jamanetworkopen.2018.5630
5
• Gupta, R. S., Warren, C. M., Smith, B. M., Blumenstock, J. A., Jiang, J., Davis, M. M., &
Nadeau, K. C. (2018). The Public Health Impact of Parent-Reported Childhood Food Allergies
in the United States. Pediatrics, 142(6). https://doi.org/10.1542/peds.2018-1235
6
• Greer, F. R., Sicherer, S. H., Burks, A. W., Nutrition, C. O., & Immunology, S. on A. A. (2019).
The Effects of Early Nutritional Interventions on the Development of Atopic Disease in
Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Hydrolyzed
Formulas, and Timing of Introduction of Allergenic Complementary Foods. Pediatrics, 143(4).
https://doi.org/10.1542/peds.2019-0281
7
• U.S. Food and Drug Administration. (2020, February 20). FDA approves first drug for
treatment of peanut allergy for children. FDA; FDA. http://www.fda.gov/news-events/press-
146 TAMBERLY POWELL, MS, RDN

announcements/fda-approves-first-drug-treatment-peanut-allergy-children
8
• American Academy of Allergy Asthma & Immunology. (n.d.). The myth of IgG food panel
testing. AAAAI. Retrieved March 2, 2020, from https://www.aaaai.org/conditions-and-
treatments/library/allergy-library/IgG-food-test
9
• Choung, R. S., Unalp-Arida, A., Ruhl, C. E., Brantner, T. L., Everhart, J. E., & Murray, J. A.
(2017). Less Hidden Celiac Disease But Increased Gluten Avoidance Without a Diagnosis in
the United States: Findings From the National Health and Nutrition Examination Surveys
From 2009 to 2014. Mayo Clinic Proceedings, 92(1), 30–38. https://doi.org/10.1016/
j.mayocp.2016.10.012
10
• Kelly, C. P., & Dennis, M. (2019, July 1). Patient education: Celiac disease in adults (Beyond the
Basics). UpToDate. https://www.uptodate.com/contents/celiac-disease-in-adults-beyond-
the-basics
11
• Hill, I. D. (2020, January 8). Epidemiology, pathogenesis, and clinical manifestations of celiac
disease in children. UpToDate. https://www.uptodate.com/contents/epidemiology-
pathogenesis-and-clinical-manifestations-of-celiac-disease-in-children
12
• Francavilla, R., Cristofori, F., Verzillo, L., Gentile, A., Castellaneta, S., Polloni, C., Giorgio, V.,
Verduci, E., DʼAngelo, E., Dellatte, S., & Indrio, F. (2018). Randomized Double-Blind Placebo-
Controlled Crossover Trial for the Diagnosis of Non-Celiac Gluten Sensitivity in Children. The
American Journal of Gastroenterology, 113(3), 421–430. https://doi.org/10.1038/ajg.2017.483
13
• Egan, S. (2018, January 12). Is There a Downside to Going Gluten-Free if You’re Healthy?
The New York Times. https://www.nytimes.com/2018/01/12/well/eat/gluten-free-grain-free-
diet.html

Images:

• Figure 3.17. “Home-breakfast (lactaid photo)” by Ernesto Andrade is licensed under CC BY-
ND 2.0
• Figure 3.18. “Worldwide prevalence of lactose intolerance in recent populations” by
NmiPortal is licensed under CC BY-SA 3.0
• Figure 3.19. “peanuts” by Tom Hermans; “cheese and bread on tray” by Alla Hetman; “fried
eggs” by Gabriel Gurrola; “fried shrimp” by Jonathon Borba, all on Unsplash (license
information); “Epi Pen” by Vu Nguyen is licensed under CC BY 2.0
• Figure 3.20. “bread” by Wesual Click on Unsplash (license information); “coeliac path” by
Samir is licensed under CC BY-SA 3.0
UNIT 4- CARBOHYDRATES

147
Introduction to Carbohydrates

If someone says to you, “I love carbohydrates, and I eat them all day long!” what would you assume
they’re eating?
Do you picture this?

Figure 4.1. Examples of carbohydrate-rich snack foods.

And this?

Figure 4.2. Examples of grain-based foods.

When we ask this question in class, most students describe foods like the ones above. However,
carbohydrates are found not just in grains, or in sweets and processed foods, but in every food
group.
In fact, carbohydrates are the most abundant nutrient (except water) in the diets of most humans
around the world. Since the dawn of agriculture, human cultures have relied on staple grains, such as
corn, rice, and wheat, as the foundation of their diets, and these foods are rich in carbohydrates. But
fruits and vegetables, dairy products, legumes, and nuts also have naturally-occurring carbohydrates.
And of course, carbohydrates are a key ingredient in desserts, sugar-sweetened beverages like sodas,
and many of the packaged snack foods that are readily available and—let’s face it—can be hard to
stop eating.
In other words, if someone says they eat a high carbohydrate diet, that could mean many different
things. They very well could be talking about a balanced diet focused on whole foods, like this:

149
 150 TAMBERLY POWELL, MS, RDN

Figure 4.3. Examples of whole foods containing carbohydrates, including fresh fruit, legumes and grains,
and cheese.
The diet industry likes to sell us simple messages about “good” and “bad” foods, and these days,
we tend to hear that carbohydrates are in the “bad” group. But given that carbohydrates are in so
many different types of foods, that’s obviously an oversimplified message—and it’s not fair to all of
the awesome sources of carbohydrates in the world of food. Not all carbohydrate-rich foods are the
same. In this unit, you’ll learn to appreciate the nutrient-dense carbohydrate foods, identify which
don’t offer as valuable a nutritional package, and understand how a balanced diet can include all of
them.

Unit Learning Objectives

After completing this unit, you should be able to:

1. Classify the different types of carbohydrates, identify their food sources, and discuss how these carbohydrates
are digested and absorbed in the body.

2. Define the guidelines for total carbohydrate, fiber, and added sugar intake.

3. Explain how glucose is regulated and utilized in the body and describe how the body adapts to a low carbohydrate
intake.

4. List the causes, complications, and treatment for different types of diabetes.

5. Be able to describe the health benefits, types of, and food sources of dietary fiber.

6. Differentiate between whole and refined grains in foods by examining food labels.

7. Distinguish between added and natural-occurring sugars in foods, and discuss health implications of too much
added sugar.

8. Identify sugar substitutes in foods, and describe potential benefits and drawbacks of sugar substitutes.

Image Credits:

• Figure 4.1.”Potato chips” by Kate Ter Haar is licensed under CC BY 2.0; “M&Ms” by Wade
Brooks is licensed under CC BY-NC 2.0; “Pecan pastry” by Artizone is licensed under CC BY-
NC-ND 2.0
• Figure 4.2. “Bread” by David Stewart is licensed under CC BY 2.0; “Pasta” by Yasumari
INTRODUCTION TO CARBOHYDRATES 151

SASAKI is licensed under CC BY 2.0; “Rice” by Francesca Nocella is licensed under CC BY-SA
2.0, .
• Figure 4.3. “Assorted Fruit Bowl” by Allen Gottfried is licensed under CC BY-SA 2.0; “Schalen
mit verschiedenen Getreidesorten wie Reis, Hirse, Linsen, Erbsen und Buchweizen” by
Marco Verch is licensed under CC BY 2.0; “Cheese” by Finite Focus is licensed under CC BY-
NC 2.0.
Types of Carbohydrates

On this page, we’ll get acquainted with the chemical structure of different types of carbohydrates and
learn where we find them in foods.
First, all carbohydrates are made up of the same chemical elements:

• carbon (that’s the “carbo-” part)

• hydrogen and oxygen, in about a two-to-one proportion, just like in H2O (that’s the “-
hydrate” part)

For this reason, you may see carbohydrates abbreviated as “CHO” in our class.
Carbohydrates can be divided into two main types: simple and complex. Simple
carbohydrates are made up of just one or two sugar units, whereas complex carbohydrates are made
up of many sugar units. We’ll look at each of these in turn. This figure gives you an overview of the
types of carbohydrates that we’ll cover.

Figure 4.4. Carbohydrates can be divided into two main types: simple (including monosaccharides and
disaccharides) and complex.
152
TYPES OF CARBOHYDRATES 153

SIMPLE CARBOHYDRATES

Simple carbohydrates are sometimes called “sugars” or “simple sugars.” There are 2 types of simple
carbohydrates: monosaccharides and disaccharides.
Monosaccharides contain just one sugar unit, so they’re the smallest of the carbohydrates. (The
prefix “mono-” means “one.”) The small size of monosaccharides gives them a special role in digestion
and metabolism. Food carbohydrates have to be broken down to monosaccharides before they can
be absorbed in the gastrointestinal tract, and they also circulate in blood in monosaccharide form.
There are 3 monosaccharides:

1. Glucose
2. Fructose
3. Galactose

Note that all three have the same chemical formula (C6H12O6); the atoms are just arranged a bit
differently.

1 – Glucose

Here’s the chemical structure of glucose

glucose:

In this class, we’ll sometimes use a simpler green hexagon to represent glucose:
You’re already familiar with glucose, because it’s the main product of photosynthesis. Plants make
glucose as a way of storing the sun’s energy in a form that it can use for growth and reproduction.
In humans, glucose is one of the most important nutrients for fueling the body. It’s especially
important for the brain and nervous system, which aren’t very good at using other fuel
sources. Muscles, on the other hand, can use fat as an energy source. (In practice, your muscles are
usually using some combination of fat and glucose for energy, which we’ll learn more about later.)
Food sources of glucose: Glucose is found in fruits and vegetables, as well as honey, corn syrup,
and high fructose corn syrup. (All plants make glucose, but much of the glucose is used to make
starch, fiber, and other nutrients. The foods listed here have glucose in its monosaccharide form.)

2 – Fructose

Here’s the chemical structure of fructose

fructose:
154 TAMBERLY POWELL, MS, RDN

In this class, we’ll sometimes use a simpler purple pentagon to represent fructose:
Fructose is special because it is the sweetest carbohydrate. Plants make a lot of fructose as
a way of attracting insects and animals, which help plants to reproduce. For example, plants
make nectar, which is high in fructose and very sweet, to attract insects that will pollinate it. Plants
also put fructose into fruit to make it tastier. Animals eat the fruit, wander away, and later poop out
the seeds from the fruit, thereby sowing the seeds of the next generation. Animal gets a meal, and
the plant gets to reproduce: win-win!

Figure 4.5. Fructose in nature: A bee collects sweet nectar from a flower, in the process spreading pollen
from flower to flower and helping plants to reproduce. Bees use nectar to make honey, which humans
harvest for use as a sweetener. (Honey contains a mix of sucrose, fructose, and glucose). A kiwi is sweetened
in part by fructose. Animals enjoy the sweet fruit and then later poop out the seeds, sowing them for a new
generation of kiwi trees.
Food sources of fructose: Fruits, vegetables, honey, high fructose corn syrup

3 – Galactose

Here is the chemical structure of galactose

galactose:

In this class, we’ll sometimes use a blue hexagon to represent galactose:

Food sources of galactose: Galactose is found in milk (and dairy products made from milk), but
it’s almost always linked to glucose to form a disaccharide (more on that in a minute). We rarely find
it in our food supply in monosaccharide form.
The second type of simple carbohydrates is disaccharides. They contain two sugar units bonded
together.
TYPES OF CARBOHYDRATES 155

There are 3 disaccharides:

1. Maltose (glucose + glucose)

2. Sucrose (glucose + fructose)
3. Lactose (glucose + galactose)

1 – Maltose

Here is the chemical structure of maltose

maltose:

Maltose is made of two glucose molecules bonded together. It doesn’t occur naturally in any
appreciable amount in foods, with one exception: sprouted grains. Grains contain a lot of starch,
which is made of long chains of glucose (more on this in a minute), and when the seed of a grain
starts to sprout, it begins to break down that starch, creating maltose. If bread is made from those
sprouted grains, that bread will have some maltose. Sprouted grain bread is usually a little heavier
and sweeter than bread made from regular flour.
Maltose also plays a role in the production of beer and liquor, because this process involves the
fermentation of grains or other carbohydrate sources. Maltose is formed during the breakdown of
those carbohydrates, but there is very little remaining once the fermentation process is complete.
You can taste the sweetness of maltose if you hold a starchy food in your mouth for a minute
or so. Try this with a simple food like a soda cracker. Starch is not sweet, but as the starch in the
cracker begins to break down with the action of salivary amylase, maltose will form, and you’ll taste
the sweetness!

2 – Sucrose

Here is the chemical structure of sucrose

sucrose:

Sucrose is made of a glucose molecule bonded to a fructose molecule. It’s made by plants for
the same reason as fructose — to attract animals to eat it and thereby spread the seeds.
Sucrose is naturally-occurring in fruits and vegetables. (Most fruits and vegetables contain a
mixture of glucose, fructose, and sucrose.) But humans have also figured out how to concentrate
the sucrose in plants (usually sugar cane or sugar beets) to make refined table sugar. We also find
sucrose in maple syrup and honey.
The sucrose found in a sweet potato is chemically identical to the sucrose found in table
sugar. Likewise, the fructose found in a fig is chemically identical to the fructose found in high
fructose corn syrup. As we’ll discuss more later, what’s different is the package the sugars come in.
When you eat a sweet potato or a fig, you also get lots of fiber, vitamins, and minerals in that package,
whereas sugar and high fructose corn syrup only provide sugar, nothing else. It’s not a bad thing
to eat sugar. After all, it’s a vital fuel for our brain and nervous system. But paying attention to the
package it comes in can help us make good overall choices for health.
156 TAMBERLY POWELL, MS, RDN

3 – Lactose

Here is the chemical structure of lactose

lactose:

Lactose is made of a glucose molecule bonded to a galactose molecule. It is sometimes called

“milk sugar” as it is found in dairy products like milk, yogurt, and cheese. These are the only
animal foods that have significant amounts of carbohydrate. Most of our carbohydrates come from
plant foods.

COMPLEX CARBOHYDRATES

Complex carbohydrates are also called polysaccharides, because they contain many sugars. (The
prefix “poly-” means “many.”) There are 3 main polysaccharides:

1. Starch
2. Glycogen
3. Fiber

All three of these polysaccharides are made up of many glucose molecules bonded together, but
they differ in their structure and the type of bonds.

1 – Starch

Starch is made up of long chains of glucose. If these chains are straight, they’re called amylose; if
they’re branched, they’re called amylopectin.
Here is an amylose segment containing 3 glucose units.

The next figure shows an amylopectin segment containing 4 glucose units. The chemical structure
is represented differently, but can you spot the place where it branches?
TYPES OF CARBOHYDRATES 157

Using our green hexagon to represent glucose, you can picture starch as something like this:

Humans have digestive enzymes to break down both types of starch, which we’ll discuss on the
next page.
Starch is the storage form of carbohydrate in plants. Plants make starch in order to store
glucose. For example, starch is in seeds to give the seedling energy to sprout, and we eat those seeds
in the form of grains, legumes (soybeans, lentils, pinto and kidney beans, for example), nuts, and
seeds. Starch is also stored in roots and tubers to provide stored energy for the plant to grow and
reproduce, and we eat these in the form of potatoes, sweet potatoes, carrots, beets, and turnips.
When we eat plant foods with starch, we can break it down into glucose to provide fuel for
our body’s cells. In addition, starch from whole plant foods comes packaged with other valuable
nutrients. We also find refined starch—such as corn starch—as an ingredient in many processed
foods, because it serves as a good thickener.

2 – Glycogen

Glycogen is structurally similar to amylopectin, but it’s the storage form of carbohydrate in
animals, humans included. It’s made up of highly branched chains of glucose, and it’s stored in the
liver and skeletal muscle. The branched structure of glycogen makes it easier to break down quickly
to release glucose to serve as fuel when needed on short notice.
Liver glycogen is broken down to glucose, which is released into the bloodstream and can be used
by cells around the body. Muscle glycogen provides energy only for muscle, to fuel activity. That can
come in handy if you’re being chased by a lion, or sprinting to make your bus! Both liver and muscle
glycogen serve as relatively short-term forms of energy storage; together, they can only provide
enough glucose to last for about 24 hours in a person fasting or eating a very low carbohydrate diet.
Even though glycogen is stored in the liver and muscles of animals, we don’t find it in meat, because
it’s broken down soon after slaughter. Thus, glycogen is not found in our food. Instead, we have to
make it in our liver and muscle from glucose.
Here’s a beautiful depiction of glycogen.
158 TAMBERLY POWELL, MS, RDN

Figure 4.6. Glycogen is made from long, branching chains of glucose, radiating around a central protein.

3 – Fiber

Fiber includes carbohydrates and other structural substances in plants that are indigestible to human
enzymes. Fiber is made by plants to provide protection and structural support. Think about thick
stems that help a plant stand upright, tough seed husks, and fruit skin that protect what’s growing
inside. These are full of fiber.

Figure 4.7. Examples of food plants high in fiber, including wheat, broccoli, and apples.
In our food, we find fiber in whole plant foods like whole grains, seeds, nuts, fruits, vegetables,
and legumes.
One of the most common types of fiber is cellulose
cellulose, the main component in plant cell walls. The
chemical structure of cellulose is shown in the figure below, with our simplified depiction next to it.
You can see that cellulose has long chains of glucose, similar to starch, but they’re stacked up, and
there are hydrogen bonds linking the stacks.
 TYPES OF CARBOHYDRATES 159

When we eat fiber, it passes through the small intestine intact, because we don’t have
digestive enzymes to break it down. Then, in the large intestine, our friendly microbiota—the
bacteria that live in our colons—go to work on the fiber. Some fiber can be fermented by those
bacteria. We’ll discuss fiber more later in the unit.

Self Check:

An interactive H5P element has been excluded from this version of the text. You can view it online here:

https://openoregon.pressbooks.pub/nutritionscience/?p=66#h5p-1

References:

• Levin, R. J. (1999). Carbohydrates. In Modern Nutrition in Health and Disease (9th ed.).
Baltimore: Lippincott Williams and Wilkins.
• U.S. Department of Agriculture. (n.d.). FoodData Central. Retrieved November 15, 2019,
from https://fdc.nal.usda.gov/

Image Credits:

• Figure 4.4. “Types of carbohydrates diagram” by Alice Callahan made with Microsoft
SmartArt is licensed under CC BY-SA 4.0
• “Structure of alpha-D-glucopyranose (Haworth projection)” , “Structure of beta-D-
fructofuranose (Haworth projection)” , and “Structure of beta-D-galactopyranose (Haworth
projection)” by NEUROtiker is in the Public Domain
160 TAMBERLY POWELL, MS, RDN

• “Simple carbohydrate diagrams” (with hexagons, pentagon) by Alice Callahan is licensed

under CC BY-SA 4.0
• Maltose structure is cropped from “Amylase reaction consisting of hydrolyzing amylose,
producing maltose” by BQmUB2012134 is in the Public Domain, CC0
• “Skeletal formula of sucrose” by NEUROtiker is in the Public Domain, CC0
• ” Lactose (simplified structure)” by NEUROtiker is in the Public Domain, CC0
• Figure 4.5. “Flower with bee” by pontla; “Honey” by sunny mama; “Kiwi” by ereta ekarafi; all
licensed under CC BY-NC-ND 2.0
• Figure 4.6. “Glycogen” by Häggström, Mikael (2014). “Medical gallery of Mikael Häggström
2014“. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.008. ISSN 2002-4436. Public
Domain.
• Figure 4.7. “Wheat” by Bernat Caser; “Broccoli” by albedo20; “Apple” by Fiona Shields; all
licensed under CC BY-NC-ND 2.0
• “Chemical structure of cellulose” by laghi.l is licensed under CC BY-SA 3.0
Carbohydrate Food Sources and Guidelines for
Intake

WHERE DO WE FIND CARBOHYDRATES IN FOODS?

Looking at the food groups represented in MyPlate below, which food groups do you think contain
carbohydrates? If you answered, all of them, you’re correct! This section will review which food
groups contain the different types of carbohydrates. One of the goals of this course is to learn more
about the different nutrients in foods and to understand the importance of eating a wide variety of
foods from the different food groups.

161
162 TAMBERLY POWELL, MS, RDN

Figure 4.8. Choose MyPlate graphic illustrating the USDA food groups: fruits, vegetables, grains, protein
and dairy.
Fruits– Fruits are sweet, so we know they must contain sugar. Fruits contain sucrose, glucose,
and fructose. This sugar is naturally-occurring and comes packaged with other great nutrients, like
Vitamin C and potassium. Whole fruit also contains fiber, since fiber is found in all whole plant foods.
Juice has little to no fiber, even high pulp orange juice.
Vegetables– Some vegetables are sweet and also contain sugar, although much less than fruit.
Similar to fruits, some vegetables (like carrots and green beans) contain small amounts of sucrose,
glucose, and fructose. Starchy vegetables (corn, peas, and potatoes, for example) primarily contain
starch but some are also sweet and contain sucrose, glucose, and fructose (sweet potatoes and sweet
corn, for example). Just like whole fruit, any whole vegetable also contains fiber.
Grains– Grains naturally contain starch and fiber. Sprouted grains also contain maltose. If grains
are sweetened (sugar is added), they might contain sucrose (white cane sugar) or fructose and
glucose (honey and/or HFCS).
Dairy- This is the one animal food that contains carbohydrate. Milk, cheese, and yogurt contain
naturally-occurring lactose. If dairy (like yogurt) is sweetened, then it will also contain added sugar
like sucrose (white cane sugar) or fructose and glucose (honey and/or HFCS).
Protein– Meats do not contain carbohydrate, but many plant foods that fall into the protein group,
like beans and nuts, contain starch and fiber.
Fats– Concentrated fats like butter and oil do not contain carbohydrate.
CARBOHYDRATE FOOD SOURCES AND GUIDELINES FOR INTAKE 163

This information is summarized in the table below:

Food
Example of Food Type of Carbohydrate Present
Group

Apple, orange, banana Sucrose, glucose, fructose, and fiber

Fruits
Orange juice Sucrose, glucose, fructose

Non-starchy veggies Sucrose, glucose, fructose, and fiber

Vegetables Starchy veggies (corn, potatoes, sweet Starch and fiber, with varying amount of sucrose, glucose, and
potatoes, peas) fructose

Dairy Milk, plain yogurt, cheese Lactose

Wheat, rice, oatmeal, barley Starch and fiber

Grains
Sprouted grains Starch, fiber, and maltose

Meat None
Protein
Beans and nuts Starch and fiber

Fats Oils, Butter None

Table 4.1. USDA food groups with examples of foods and type of carbohydrate present within each food
group.
Looking at all the foods that contain carbohydrates, you might be able to guess why eliminating
carbohydrates from the diet can lead to weight loss. It drastically reduces the variety of choices one
has, leaving you primarily with low carbohydrate veggies and meats. Not surprisingly, people usually
consume less calories with this way of eating. However, for most people, this is not a sustainable
or enjoyable way of eating, and it can also be hard to consume a nutritionally balanced diet with so
many foods off-limits.

CARBOHYDRATE GUIDELINES FOR INTAKE

Total Carbohydrate Intake

The recommended dietary allowance (RDA) for total carbohydrate intake is 130 grams. This is
the minimum amount of glucose utilized by the brain, so if you consume less than this, you will
probably go into ketosis. In order to meet the body’s high energy demand for glucose, the acceptable
macronutrient distribution range (AMDR) for an adult is 45%-65% of total calories. This is about 225
grams to 325 grams of carbohydrate per day if eating a 2,000 Calorie diet. (REMEMBER: 1 gram of
carbohydrate contains 4 calories.)
Fiber Intake
The Adequate Intake (AI) for fiber is 14 grams of fiber for every 1,000 calories consumed. This is
about 28 grams for an adult female (19-30 years old) and 38 grams for an adult male (19-30 years
old). Most people in the United States only get half the amount of fiber they need in a day—about 12
to 18 grams.
Added Sugar Intake
The 2020 Dietary Guidelines recommend that less than 10% of total calories come from added
sugars because of its link to obesity and chronic disease. This means that someone eating a 2,000
calorie diet would want to limit their added sugar intake to about 12 teaspoons per day. To put that
in perspective, a 12 oz can of soda has about 10 teaspoons of sugar. We will discuss added sugar in
more detail later in the unit.
Below is a chart summarizing the above recommendations.
 164 TAMBERLY POWELL, MS, RDN

Recommendations

RDA for Total Carbohydrate 130 grams

AMDR for Total Carbohydrate 45% – 65% of total calories

AI for Fiber 14 grams for every 1,000 calories consumed

Dietary guidelines for added sugar Less than 10% of total calories

Table 4.2 Dietary Recommendations for Carbohydrates

Self-Check:

An interactive H5P element has been excluded from this version of the text. You can view it online here:

https://openoregon.pressbooks.pub/nutritionscience/?p=71#h5p-2

Resources:

• U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020).
Dietary Guidelines for Americans, 2020-2025, 9th Edition. Retrieved from
https://www.dietaryguidelines.gov/
• Institute of Medicine, Food and Nutrition Board. (2005). Dietary Reference Intakes for
Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids
(Macronutrients). Retrieved from https://www.nap.edu/read/10490/chapter/1

Image Credits:

• Figure 4.8. “ChooseMyPlate Graphic” by The USDA is in the Public Domain

• Table 4.1. “USDA food groups with examples of foods and type of carbohydrate present
within each food group” by Tamberly Powell is licensed under CC BY-NC-SA 4.0
• Table 4.2. “Dietary Recommendations for Carbohydrates” by Tamberly Powell is licensed
under CC BY-NC-SA 4.0; data from Institute of Medicine, Food and Nutrition Board, 2005.
Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol,
Protein, and Amino Acids (Macronutrients). Washington, DC; The National Academy of
Sciences.
Digestion and Absorption of Carbohydrates

Imagine taking a bite of pizza. It tastes amazing, but it’s

also full of fuel for your body, much of it in the form of
carbohydrates.
What types of carbohydrates would you find in that
bite?

• Lactose from the cheese

• Sucrose, glucose, and fructose from the
naturally-occurring sugars in the tomatoes, as
well as sugar that may have been added to the
sauce
• Starch in the flour used to make the crust
• Fiber in the flour, tomatoes, and basil

In order to use these food carbohydrates in your body,

you first need to digest them. Last unit, we explored the
gastrointestinal system and the basic process of
digestion. Now that you know about the different types
of carbohydrates, we’ll take a closer look at how these
molecules are digested as they travel through the GI
system.

CARBOHYDRATE DIGESTION

In the image below, follow the numbers to see what

happens to carbohydrates at each site of digestion.

165
166 TAMBERLY POWELL, MS, RDN

Figure 4.9. The digestive system

1 – Mouth or Oral Cavity

As you chew your bite of pizza, you’re using mechanical digestion to begin to break it into smaller
pieces and mix it with saliva, produced by several salivary glands in the oral cavity.
Some enzymatic digestion of starch occurs in the mouth, due to the action of the enzyme salivary
amylase
amylase. This enzyme starts to break the long glucose chains of starch into shorter chains, some as
small as maltose. (The other carbohydrates in the bread don’t undergo any enzymatic digestion in
the mouth.)
DIGESTION AND ABSORPTION OF CARBOHYDRATES 167

Fig. 4.10. The enzyme salivary amylase breaks starch into smaller polysaccharides and maltose.

2 – Stomach

The low pH in the stomach inactivates salivary amylase, so it no longer works once it arrives at the
stomach. Although there’s more mechanical digestion in the stomach, there’s little chemical digestion
of carbohydrates here.

3 – Small intestine

Most carbohydrate digestion occurs in the small intestine, thanks to a suite of enzymes. Pancreatic
amylase is secreted from the pancreas into the small intestine, and like salivary amylase, it breaks
starch down to small oligosaccharides (containing 3 to 10 glucose molecules) and maltose.

Figure 4.11. The enzyme pancreatic amylase breaks starch into smaller polysaccharides and maltose.
The rest of the work of carbohydrate digestion is done by enzymes produced by the enterocytes,
the cells lining the small intestine. When it comes to digesting your slice of pizza, these enzymes will
break down the maltose formed in the process of starch digestion, the lactose from the cheese, and
the sucrose present in the sauce.
Maltose is digested by maltase
maltase, forming 2 glucose molecules.

Lactose is digested by lactase

lactase, forming
glucose and galactose.
168 TAMBERLY POWELL, MS, RDN

Sucrose is digested by sucrase

sucrase, forming
glucose and fructose.

Figure 4.12. Action of the enzymes maltase,

lactase, and sucrase.
(Recall that if a person is lactose intolerant,
they don’t make enough lactase enzyme to
digest lactose adequately. Therefore, lactose
passes to the large intestine. There it draws water in by osmosis and is fermented by bacteria,
causing symptoms such as flatulence, bloating, and diarrhea.)
By the end of this process of enzymatic digestion, we’re left with three monosaccharides: glucose,
fructose, and galactose. These can now be absorbed across the enterocytes of the small intestine
and into the bloodstream to be transported to the liver.
Digestion and absorption of carbohydrates in the small intestine are depicted in a very simplified
schematic below. (Remember that the inner wall of the small intestine is actually composed of large
circular folds, lined with many villi, the surface of which are made up of microvilli. All of this gives the small
intestine a huge surface area for absorption.)

Figure 4.13. Digestion and absorption of carbohydrates in the small intestine.

Fructose and galactose are converted to glucose in the liver. Once absorbed carbohydrates
pass through the liver, glucose is the main form of carbohydrate circulating in the bloodstream.

4 – Large Intestine or Colon

Any carbohydrates that weren’t digested in the small intestine—mainly fiber—pass into the large
intestine, but there’s no enzymatic digestion of these carbohydrates here. Instead, bacteria living
in the large intestine, sometimes called our gut microbiota, ferment these carbohydrates to feed
themselves. Fermentation causes gas production, and that’s why we may experience bloating and
flatulence after a particularly fibrous meal. Fermentation also produces short-chain fatty acids, which
our large intestine cells can use as an energy source. Over the last decade or so, more and more
research has shown that our gut microbiota are incredibly important to our health, playing important
roles in the function of our immune response, nutrition, and risk of disease. A diet high in whole food
sources of fiber helps to maintain a population of healthy gut microbes.
DIGESTION AND ABSORPTION OF CARBOHYDRATES 169

SUMMARY OF CARBOHYDRATE DIGESTION:

The primary goal of carbohydrate digestion is to break polysaccharides and disaccharides into
monosaccharides, which can be absorbed into the bloodstream.
1. After eating, nothing needs to happen in the digestive tract to the monosaccharides in a
food like grapes, because they are already small enough to be absorbed as is.
2. Disaccharides in that grape or in a food like milk are broken down (enzymatically digested)
in the digestive tract to monosaccharides (glucose, galactose, and fructose).
3. Starch in food is broken down (enzymatically digested) in the digestive tract to glucose
molecules.
4. Fiber in food is not enzymatically digested in the digestive tract, because humans don’t have
enzymes to do this. However, some dietary fiber is fermented in the large intestine by gut
microbes.

Carbohydrates in What is absorbed into the villi after

Is this carbohydrate enzymatically digested? (enzyme name)
food digestion?

Monosaccharides

Glucose No Glucose

Fructose. It is then transported to the liver

Fructose No
where it is converted to glucose.

Galactose. It is then transported to the

Galactose No
liver where it is converted to glucose.

Disaccharides

Maltose Yes (maltase) Glucose

Sucrose Yes (sucrase) Glucose, Fructose

Lactose Yes (lactase) Glucose, Galactose

Polysaccharides

Yes
Starch Glucose
(amylase, maltase)

No (Humans don’t have the digestive enzymes to break down fiber,

Fiber N/A
but some is fermented by gut microbes in the large intestine.)

Table 4.3. Summary of enzymatic digestion of carbohydrates

 170 TAMBERLY POWELL, MS, RDN

VIDEO: “Digestion and Absorption of Carbohydrates” by How It Works.

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VIDEO: “Carbohydrates in Foods, Digestion and Absorption” by Tamberly Powell, YouTube (September 26,
2018), 7:31 minutes. This video will help you identify carbohydrates in foods, what carbohydrates need to be
enzymatically digested, and what is absorbed.

Self-Check:

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References:

• Klein, S., Cohn, S. M., & Alpers, D. H. (1999). The Alimentary Tract in Nutrition. In Modern
DIGESTION AND ABSORPTION OF CARBOHYDRATES 171

Nutrition in Health and Disease (9th ed.). Baltimore: Lippincott Williams and Wilkins.
• Harvard T.H. Chan School of Public Health. (n.d.). The Microbiome. Retrieved November 15,
2019, from The Nutrition Source website: https://www.hsph.harvard.edu/nutritionsource/
microbiome/

Image Credits:

• “Pizza” photo by Kate Voytsutskaya on Unsplash

• Figure 4.9. “The digestive system” by Alice Callahan is licensed under CC BY 4.0 / A
derivative from the original work
• Figure 4.10. “Carbohydrate digestion schematics” by Alice Callahan is licensed under CC BY-
NC-SA 4.0
• Figure 4.11. “Starch digestion” by Alice Callahan is licensed under CC BY-NC-SA 4.0
• Figure 4.12. “Disaccharide digestion” by Alice Callahan is licensed under CC BY-NC-SA 4.0
• Figure 4.13. “Carbohydrate absorption” by Alice Callahan is licensed under CC BY-NC-SA 4.0
• Table 4.3. “Carbohydrate and digestion summary chart” by Tamberly Powell is licensed
under CC BY-NC-SA 4.0
Glucose Regulation and Utilization in the Body

On the last page, we traced the process of digesting the carbohydrates in a slice of pizza through the
gastrointestinal tract, ending up with the absorption of monosaccharides across the cells of the small
intestine and into the bloodstream. From there, they travel to the liver, where fructose and galactose
are converted to glucose.
After any meal containing carbohydrates, you experience a rise in blood glucose that can serve as
fuel for cells around the body. But during the periods between meals, including while you’re sleeping
and exercising, your body needs fuel, too. To ensure that you have enough glucose in your blood at
any given time, your body has a finely-tuned system to regulate your blood glucose concentration.
This system allows you to store glucose when you have excess available (when your blood glucose is
high) and to pull glucose out from your stores when needed (when your blood supply gets low).
Your body’s ability to maintain equilibrium or a steady state in your blood glucose concentration is
called homeostasis
homeostasis. It’s a critical part of normal physiology, because if your blood glucose gets too low
(called hypoglycemia), cellular function starts to fail, especially in the brain. If blood glucose gets too
high (called hyperglycemia), it can cause damage to cells.

HORMONES INVOLVED IN BLOOD GLUCOSE REGULATION

Central to maintaining blood glucose homeostasis are two hormones, insulin and glucagon
glucagon, both
produced by the pancreas and released into the bloodstream in response to changes in blood
glucose.

• Insulin is made by the beta-cells of the pancreas and released when blood glucose is
high. It causes cells around the body to take up glucose from the blood, resulting in
lowering blood glucose concentrations.
• Glucagon is made by the alpha-cells of the pancreas and released when blood glucose is
low. It causes glycogen in the liver to break down, releasing glucose into the blood,
resulting in raising blood glucose concentrations. (Remember that glycogen is the storage
form of glucose in animals.)

The image below depicts a mouse islet of Langerhans, a cluster of endocrine cells in the pancreas.
The beta-cells of the islet produce insulin, and the alpha-cells produce glucagon.

172
GLUCOSE REGULATION AND UTILIZATION IN THE BODY 173

Figure 4.14. A mouse islet of Langerhans, visualized with immunofluorescent microscopy. In this image,
cell nuclei are stained blue, insulin is stained red, and blood vessels are stained green. You can see that this
islet is packed with insulin and sits right next to a blood vessel, so that it can secrete the two hormones,
insulin and glucagon, into the blood. Glucagon is not stained in this image, but it’s there!
In the figure below, you can see blood glucose and insulin throughout a 24-hour period, including
three meals. You can see that when glucose rises, it is followed immediately by a rise in insulin,
and glucose soon drops again. The figure also shows the difference between consuming a sucrose-
rich food and a starch-rich food. The sucrose-rich food results in a greater spike in both glucose
and insulin. Because more insulin is required to handle that spike, it also causes a more precipitous
decline in blood glucose. This is why eating a lot of sugar all at once may increase energy in the short-
term, but soon after may make you feel like taking a nap!
174 TAMBERLY POWELL, MS, RDN

Figure 4.15. Typical pattern of blood glucose and insulin during a 24-hour period, showing peaks for each
of 3 meals and highlighting the effects of consumption of sugar-rich foods.
Let’s look a little closer at how insulin works, illustrated in the figure below. Insulin is released by
the pancreas into the bloodstream. Cells around the body have receptors for insulin on their cell
membranes. Insulin fits into its receptors (labeled as step 1 in Figure 4.16), kind of like a key in a lock,
and through a series of reactions (step 2), triggers glucose transporters to open on the surface of the
cell (step 3). Now glucose can enter the cell, making it available for the cell to use and at the same
time lowering the concentration of glucose in the blood.

Figure 4.16. Insulin binds to its receptors on the cell membrane, triggering GLUT-4 glucose transporters
to open on the membrane. This allows glucose to enter the cell, where it can be used in several ways.
The figure also shows several different ways glucose can be used once it enters the cell.

• If the cell needs energy right away, it can metabolize glucose through cellular respiration,
producing ATP (step 5).
• If the cell doesn’t need energy right away, glucose can be converted to other forms for
storage. If it’s a liver or muscle cell, it can be converted to glycogen (step 4). Alternatively, it
can be converted to fat and stored in that form (step 6).

In addition to its role in glucose uptake into cells, insulin also stimulates glycogen and fat synthesis
as described above. It also stimulates protein synthesis. You can think of its role as signaling to the
body that there’s lots of energy around, and it’s time to use it and store it in other forms.
On the other hand, when blood glucose falls, several things happen to restore homeostasis.

1. You receive messages from your brain and nervous system that you should eat.
2. Glucagon is released from the pancreas into the bloodstream. In liver cells, it stimulates the
breakdown of glycogen, releasing glucose into the blood.
3. In addition, glucagon stimulates a process called gluconeogenesis
gluconeogenesis, in which new glucose is
made from amino acids (building blocks of protein) in the liver and kidneys, also
contributing to raising blood glucose.
GLUCOSE REGULATION AND UTILIZATION IN THE BODY 175

HOW GLUCOSE PROVIDES ENERGY

Now let’s zoom in on how exactly glucose provides energy to the cell. We can trace this process in the
figure below.

Figure 4.17. Overview of glucose metabolism in the fed state, when there is adequate glucose available.
Glucose can be used to generate ATP for energy, or it can be stored in the form of glycogen or converted to
fat for storage in adipose tissue.

1. Glucose, a 6-carbon molecule, is broken down to two 3-carbon molecules called pyruvate
through a process called glycolysis
glycolysis.
2. Pyruvate enters a mitochondrion of the cell, where it is converted to a molecule called
acetyl CoA
CoA.
3. Acetyl CoA goes through a series of reactions called the Krebs cycle
cycle. This cycle requires
oxygen and produces carbon dioxide. It also produces several important high energy
electron carriers called NADH2 and FADH2.
4. These high energy electron carriers go through the electron transport chain to produce
ATP—energy for the cell!
5. Note that the figure also shows that glucose can be used to synthesize glycogen or fat, if
the cell already has enough energy.
176 TAMBERLY POWELL, MS, RDN

WHAT HAPPENS WHEN THERE ISN’T ENOUGH GLUCOSE?

We’ve already talked about what happens when blood glucose falls: glucagon is released, and
that stimulates the breakdown of glycogen as well as the process of gluconeogenesis from amino
acids. These are important mechanisms for maintaining blood glucose levels to fuel the brain when
carbohydrate is limited. Hypoglycemia (low blood glucose) can cause you to feel confused, shaky,
and irritable, because your brain doesn’t have enough glucose. If it persists, it can cause seizures
and eventually coma, so it’s good we have these normal mechanisms to maintain blood glucose
homeostasis!
What happens if your carbohydrate supply is limited for a long time? This might happen if a person
is fasting, starving, or consuming a very low carbohydrate diet. In this case, your glycogen supplies
will become depleted within about 24 hours. How will you get enough glucose (especially for the
brain) and energy? You’ll have to use the other two macronutrients in the following ways:

1. Protein: You’ll continue to use some amino acids to make glucose through
gluconeogenesis and others as a source of energy through acetyl CoA. However, if a person
is starving, they also won’t have extra dietary protein. Therefore, they start breaking down
body proteins, which will cause muscle wasting.
2. Fat: You can break down fat as a source of energy, but you can’t use it to make glucose.
Fatty acids can be broken down to acetyl CoA in the liver, but acetyl CoA can’t be converted
to pyruvate and go through gluconeogenesis. It can go through the Krebs cycle to produce
ATP, but if carbohydrate is limited, the Krebs cycle gets overwhelmed. In this case, acetyl
CoA is converted to compounds called ketones or ketone bodies. These can then be
exported to other cells in the body, especially brain and muscle cells.

These pathways are shown in the figure below:

Figure 4.18. During starvation or when consuming a low-carbohydrate diet, protein (amino acids) can be
used to make glucose by gluconeogenesis, and fats can be used to make ketones in the liver. The brain can
adapt to using ketones as an energy source in order to conserve protein and prevent muscle wasting.
Ketone production is important, because ketones can be used by tissues of the body as a source
GLUCOSE REGULATION AND UTILIZATION IN THE BODY 177

of energy during starvation or a low carbohydrate diet. Even the brain can adapt to using ketones as
a source of fuel after about three days of starvation or very low-carbohydrate diet. This also helps to
preserve the protein in the muscle.
Ketones can be excreted in urine, but if ketone production is very high, they begin to accumulate in
the blood, a condition called ketosis
ketosis. Symptoms of ketosis include sweet-smelling breath, dry mouth,
and reduced appetite. People consuming a very low carbohydrate diet may be in ketosis, and in
fact, this is a goal of the currently popular ketogenic diet. (Ketones are acidic, so severe ketosis
can cause the blood to become too acidic, a condition called ketoacidosis
ketoacidosis. This mainly happens with
uncontrolled diabetes.)
Is following a ketogenic diet an effective way to lose weight? It can be, but the same can
be said of any diet that severely restricts the types of foods that you’re allowed to eat. Following
a ketogenic diet means eating a high fat diet with very little carbohydrate and moderate protein.
This means eating lots of meat, fish, eggs, cheese, butter, oils, and low carbohydrate vegetables, and
eliminating grain products, beans, and even fruit. With so many fewer choices, you’re likely to spend
more time planning meals and less time mindlessly snacking. Being in ketosis also seems to reduce
appetite, and it causes you to lose a lot of water weight initially. However, studies show that being
in ketosis doesn’t seem to increase fat-burning or metabolic rate. There are also concerns that the
high levels of saturated fat in most ketogenic diets could increase risk of heart disease in the long
term. Finally, it’s a very difficult diet to maintain for most people, and reverting back to your previous
dietary patterns usually means the weight will come back. The ketogenic diet is also very similar to
the Atkins diet that was all the rage in the 1990’s, and we tend to be skeptical of such fad diets,
preferring to focus instead on balance, moderation, and enjoyment of a wide variety of foods.

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Video: “Glucose Regulation and Utilization in the Body,” by Alice Callahan, YouTube (October 1, 2018), 13:11
minutes.

DIABETES

Diabetes is a chronic disease in which your normal system of regulating blood glucose doesn’t work.
There are three main types of diabetes: type 1, type 2, and gestational diabetes.

Type 1 Diabetes:

This is an autoimmune disease in which the beta-cells of the pancreas are destroyed by your own
immune system. Without the beta-cells, you can’t make enough insulin, so in type 1 diabetes
diabetes, you
simply don’t have enough insulin to regulate your blood glucose levels. Remember how we said
178 TAMBERLY POWELL, MS, RDN

insulin is like the key that lets glucose into the body’s cells? In type 1 diabetes, you’re missing the key,
so glucose stays in the blood and can’t get into cells.

Figure 4.19. In type 1 diabetes, the pancreas does not make enough insulin, so glucose transporters
(GLUT-4) do not open on the cell membrane, and glucose is stuck outside the cell.
Common symptoms include weight loss and fatigue, because the body’s cells are starved of
glucose. Excess glucose from the blood is also excreted in the urine, increasing urination and thirst.
Once diagnosed, type 1 diabetics have to take insulin in order to regulate their blood glucose.
Traditionally, this has required insulin injections timed with meals. New devices like continuous
glucose monitors and automatic insulin pumps can track glucose levels and provide the right amount
of insulin, making managing type 1 diabetes a little easier. Figuring out the right amount of insulin
is important, because chronically elevated blood glucose levels can cause damage to tissues around
the body. However, too much insulin will cause hypoglycemia, which can be very dangerous.
Type 1 diabetes is most commonly diagnosed in childhood, but it has been known to develop at
any age. It’s much less common than type 2 diabetes, accounting for 5-10% of cases of diabetes.

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Video: “What is Type 1 Diabetes?” by Diabetes UK, YouTube (April 10, 2018), 2:27 minutes.
GLUCOSE REGULATION AND UTILIZATION IN THE BODY 179

Type 2 Diabetes:

Development of type 2 diabetes begins with a condition called insulin resistance

resistance. At least initially, the
pancreas is producing enough insulin, but the body’s cells don’t respond appropriately. It’s as if you
still have the insulin key but can’t find the keyhole to unlock the doors and let the glucose in.

Figure 4.20. In type 2 diabetes, the cell does not respond appropriately to insulin, so glucose is stuck
outside the cell.
The result is the same: high blood glucose. At this point, you may be diagnosed with a condition
called prediabetes
prediabetes. The pancreas tries to compensate by making more insulin, but over time, it
becomes exhausted and eventually produces less insulin, leading to full-blown type 2 diabetes.
According to the CDC, 100 million Americans are living with diabetes (30.3 million) or prediabetes
(84.1 million).
Although people of all shapes and sizes can get Type 2 diabetes, it is strongly associated with
abdominal obesity. In the past, it was mainly diagnosed in older adults, but it is becoming more and
more common in children and adolescents as well, as obesity has increased in all age groups. In the
maps below, you can see that as obesity has increased in states around the country, so has diabetes.
180 TAMBERLY POWELL, MS, RDN

Figure 4.21. Data from the CDC show the increasingly prevalence of both obesity and type 2 diabetes
between 1994 and 2015.
The complications of type 2 diabetes result from long-term exposure to high blood glucose, or
hyperglycemia. This causes damage to the heart, blood vessels, kidneys, eyes, and nerves, increasing
the risk of heart disease and stroke, kidney failure, blindness, and nerve dysfunction. People with
uncontrolled Type 2 diabetes can also end up with foot infections and ulcers because of impaired
nerve function and wound healing. If left untreated, this results in amputation.

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Video: “What is Type 2 Diabetes?” by Diabetes UK, YouTube (April 10, 2018), 2:36 minutes. This video reviews
the causes, complications, and treatments for type 2 diabetes.
GLUCOSE REGULATION AND UTILIZATION IN THE BODY 181

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Video: “Obesity and Type 2 Diabetes (HBO: The Weight of the Nation)”, by HBO Docs, YouTube (May 14, 2012),
15:20 minutes.

Gestational diabetes:

Gestational diabetes is diabetes that develops during pregnancy in women that did not previously
have diabetes. It affects approximately 6 percent of pregnancies in the U.S. It can cause pregnancy
complications, mostly associated with excess fetal growth because of high blood glucose. Although
it usually goes away once the baby is born, women who have gestational diabetes are more likely to
6
develop type 2 diabetes later in life, so it is a warning sign for them.

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Video: “Types of Diabetes” by KhanAcadamyMedicine, YouTube (May 14, 2015), 5:57 minutes. This video does
a nice job of explaining the causes of the different types of diabetes.
 182 TAMBERLY POWELL, MS, RDN

Diabetes Management:

All of the following have been shown to help manage diabetes and reduce complications. Diabetes
management, as well as prevention (particularly if you’ve been diagnosed with prediabetes), starts
with lifestyle choices.

• Exercise helps to improve your body’s insulin response and can also help maintain a
healthy weight.
• Eating well with diabetes doesn’t require a special diet but instead regular, balanced meals
following the Dietary Guidelines. It isn’t necessary to eliminate carbohydrates or eat a low-
carbohydrate diet, but emphasizing whole food sources of carbohydrate helps with blood
glucose regulation.
• Managing stress levels and getting enough sleep can also help with blood glucose
regulation.
• Medications may be needed. Insulin is needed for type 1 diabetes and may be needed for
more advanced or severe cases of type 2 or gestational diabetes. Other medications can
also help. If lifestyle choices aren’t enough to manage diabetes, it is important to use
medications appropriately to help reduce the complications of chronic high blood glucose.

Self-Check:

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References:

• Salway, J. G. (2004). Metabolism at a Glance (3rd ed.). Malden, Mass.: Blackwell Publishing.
• Smolin, L., & Grosvenor, M. (2016). Nutrition Science and Applications. Danvers, Mass.: John
Wiley & Sons, Ltd.
1
• Gibson, A. A., Seimon, R. V., Lee, C. M. Y., Ayre, J., Franklin, J., Markovic, T. P., … Sainsbury, A.
(2015). Do ketogenic diets really suppress appetite? A systematic review and meta-analysis.
Obesity Reviews: An Official Journal of the International Association for the Study of
Obesity, 16(1), 64–76. https://doi.org/10.1111/obr.12230
2
• Hall, K. D., Chen, K. Y., Guo, J., Lam, Y. Y., Leibel, R. L., Mayer, L. E., … Ravussin, E. (2016).
Energy expenditure and body composition changes after an isocaloric ketogenic diet in
overweight and obese men. The American Journal of Clinical Nutrition, 104(2), 324–333.
https://doi.org/10.3945/ajcn.116.133561
3
• Abbasi, J. (2018). Interest in the Ketogenic Diet Grows for Weight Loss and Type 2 Diabetes.
JAMA, 319(3), 215–217. https://doi.org/10.1001/jama.2017.20639
GLUCOSE REGULATION AND UTILIZATION IN THE BODY 183

4
• Belluz, J. (2018, February 21). The keto diet, explained. Retrieved November 15, 2019, from
Vox website: https://www.vox.com/science-and-health/2018/2/21/16965122/keto-diet-reset
5
• Centers for Disease Control and Prevention. (2019, June 11). Diabetes Basics. Retrieved
November 15, 2019, from https://www.cdc.gov/diabetes/basics/index.html
6
• Deputy, N. P., Kim, S. Y., Conrey, E. J. & Bullard, K. M. Prevalence and Changes in
Preexisting Diabetes and Gestational Diabetes Among Women Who Had a Live Birth —
United States, 2012–2016. MMWR Morb Mortal Wkly Rep 67, (2018). https://www.cdc.gov/
mmwr/volumes/67/wr/mm6743a2.htm

Image Credits:

• Figure 4.14. “Mouse pancreatic Islet” by Jakob Suckale is licensed under CC BY-SA 3.0
• Figure 4.15. “Glucose/insulin patterns in 24-hours” by Jakob Suckale and Michele Solimena,
is licensed under CC BY 3.0
• Figure 4.16. “Insulin glucose metabolism” by Alice Callahan is licensed under CC BY-NC-SA
4.0 / A derivative from the original work
• Figure 4.17. “Glucose metabolism” by Alice Callahan is licensed under CC BY-NC-SA 4.0, with
“ATP star” by Anastasia Latysheva is in the Public Domain
• Figure 4.18. “Gluconeogenesis and ketogenesis” by Alice Callahan is licensed under CC BY-
NC-SA 4.0, with “brain” by monstara and “liver” by maritacovarrubias, both in the public
domain
• Figure 4.19 and 4.20. “Type 1 diabetes” and “Type 2 diabetes” by Brian Lindshield, “Kansas
State University Human Nutrition (FNDH 400) Flexbook” is licensed under CC BY-NC-SA 4.0
• Figure 4.21. “Prevalence of Obesity” by the CDC is in the Public Domain
Fiber - Types, Food Sources, Health Benefits, and
Whole Versus Refined Grains

Dietary fiber is defined by the Institute of Medicine’s Food and Nutrition Board as “nondigestible
carbohydrates and lignin that are intrinsic and intact in plants.” Fiber plays an important role in giving
plants structure and protection, and it also plays an important role in the human diet.
Cellulose is one type of fiber. The chemical structure of cellulose is shown in the figure below,
with our simplified depiction next to it. You can see that cellulose has long chains of glucose, similar
to starch, but they’re stacked up, and there are hydrogen bonds linking the stacks. The special
bonds between these glucose units in fiber are not enzymatically digested in the digestive tract, and
therefore, fiber passes undigested to the colon or large intestine.

Figure 4.22. The chemical structure of cellulose, and a simplified illustration of cellulose.
You might be wondering how fiber has any benefit to us if we can’t digest it. However, it doesn’t just
pass through the digestive tract as a waste product. Instead, it serves many functions on its journey,
and these contribute to our health. Let’s explore the different types of fiber, where we find them in
foods, and what benefits they provide!

TYPES OF FIBER

Whole plant foods contain many different types of molecules that fit within the definition of fiber.
One of the ways that types of fiber are classified is by their solubility in water. Whole plant foods
contain a mix of both soluble and insoluble fiber, but some are better sources of one than the other.

1. Soluble Fiber – These fibers dissolve in water, forming a viscous gel in the GI tract, which
helps to slow digestion and the absorption of glucose. This means that including soluble
fiber in a meal helps to prevent sharp blood sugar spikes, instead making for a more
gradual rise in blood glucose. Consuming a diet high in soluble fiber can also help to lower
blood cholesterol levels, because soluble fiber binds cholesterol and bile acids (which
contain cholesterol) in the GI tract. Soluble fiber is also highly fermentable, so it is easily
digested by bacteria in the large intestine. Pectins and gums are common types of soluble
fibers, and good food sources include oat bran, barley, nuts, seeds, beans, lentils, peas, and
184
FIBER - TYPES, FOOD SOURCES, HEALTH BENEFITS, AND WHOLE VERSUS REFINED GRAINS 185

some fruits and vegetables. (Psyllium fiber supplements like Metamucil are composed
mainly of soluble fiber, so if you’ve ever stirred a spoonful of this into a glass of water,
you’ve seen the viscous consistency characteristic of soluble fiber.)
2. Insoluble Fiber – These fibers typically do not dissolve in water and are nonviscous. Some
are fermentable by bacteria in the large intestine but to a lesser degree than soluble fibers.
Insoluble fibers help prevent constipation, as they create a softer, bulkier stool that is
easier to eliminate. Lignin, cellulose, and hemicellulose are common types of insoluble
fibers, and food sources include wheat bran, vegetables, fruits, and whole grains.

FOOD SOURCES OF DIETARY FIBER

Since fiber provides structure to plants, fiber can be found in all whole plant foods, including
whole grains (like oatmeal, barley, rice and wheat), beans, nuts, seeds, and whole fruits and
vegetables.

Figure 4.23. A bowl of oatmeal topped with blueberries and sunflower seeds.
This meal is packed with fiber from the oatmeal, blueberries, and sunflower seeds.
When foods are refined, parts of the plant are removed, and during this process, fiber and
other nutrients are lost. For example, fiber is lost when going from a whole fresh orange to orange
juice. A whole orange contains about 3 grams of fiber, whereas a glass of orange juice has little to no
fiber. Fiber is also lost when grains are refined. We will discuss this more a little later.
Take a look at the list of foods below to see the variety of foods which provide dietary fiber.
186 TAMBERLY POWELL, MS, RDN

Standard Calories in Standard Dietary Fiber in Standard

Food Portion Size Portion Portion (g)

Shredded wheat ready-to-eat cereal

1-1 ¼cup 155-220 5.0-9.0
(various)

Wheat bran flakes ready-to-eat cereal

¾ cup 90-98 4.9-5.5
(various)

Lentils, cooked ½ cup 115 7.8

Black beans, cooked ½ cup 114 7.5

Refried beans, canned ½ cup 107 4.4

Avocado ½ cup 120 5.0

Pear, raw 1 medium 101 5.5

Pear, dried ¼ cup 118 3.4

Apple, with skin 1 medium 95 4.4

Raspberries ½ cup 32 4.0

Mixed vegetables, cooked from

½ cup 59 4.0
frozen

Potato, baked, with skin 1 medium 163 3.6

Pumpkin seeds, whole, roasted 1 ounce 126 5.2

Chia seeds, dried 1 Tbsp 58 4.1

Sunflower seed kernels, dry roasted 1 ounce 165 3.1

FIBER - TYPES, FOOD SOURCES, HEALTH BENEFITS, AND WHOLE VERSUS REFINED GRAINS 187

Almonds 1 ounce 164 3.5

Plain rye wafer crackers 2 wafers 73 5.0

Bulgur, cooked ½ cup 76 4.1

Popcorn, air-popped 3 cups 93 3.5

Whole wheat spaghetti, cooked ½ cup 87 3.2

Quinoa, cooked ½ cup 111 2.6

Table 4.4. Common foods listed with standard portion size, and calories and fiber in a standard portion.
Although you can get fiber from supplements, whole foods are are a better source, because the
fiber comes packaged with other essential nutrients and phytonutrients.

HEALTH BENEFITS OF DIETARY FIBER

A high-fiber diet has many benefits, which include:

• Helps prevent constipation. Many fibers (but mostly insoluble fibers) help provide a
softer, bulkier stool which is then easier to eliminate.
• Helps maintain digestive and bowel health. Dietary fiber promotes digestive health
through its role in supporting elimination and fermentation, and it’s positive impact on gut
microbiota. Since fiber provides a bulkier stool, this helps keeps the digestive tract muscles
toned and strong which can help prevent hemorrhoids and diverticula.
• Lowers risk of cardiovascular disease. Higher fiber intake has been shown to improve
blood lipids by reducing total cholesterol, triglycerides, and low density cholesterol (“bad
cholesterol,” associated with a higher risk of cardiovascular disease), and increasing high
density cholesterol (“good cholesterol,” associated with lower risk of cardiovascular
disease). Higher fiber intake has also been associated with lower blood pressure and
reduced inflammation.
• Lowers risk of type 2 Diabetes. Higher fiber intake (especially viscous, or soluble fibers)
has been shown to slow down glucose digestion and absorption, benefiting glucose
metabolism. A higher fiber diet may also decrease diabetes risk by reducing inflammation.
• Lowers risk of colorectal cancer. More evidence is supporting the idea that higher fiber
intake lowers the risk of colorectal cancer, although researchers aren’t sure why. One
hypothesis is that dietary fiber decreases transit time (the time it takes for food to move
through the digestive tract), thereby exposing the cells of the gastrointestinal tract to
carcinogens from food for a shorter time.
• Helps maintain a healthy body weight. Research has shown a relationship between
higher dietary fiber intake and lower body weight. The mechanisms for this are unclear, but
perhaps high-fiber foods are more filling and therefore keep people satisfied longer with
fewer calories. High-fiber foods also tend to be more nutrient-dense compared to many
processed foods, which are more energy-dense.
188 TAMBERLY POWELL, MS, RDN

WHOLE VS. REFINED GRAINS

Before they are harvested, all grains are

whole grains. They contain the entire seed (or
kernel) of the plant. This seed is made up of
three edible parts: the bran, the germ, and the
endosperm. The seed is also covered by an
inedible husk that protects the seed.

Figure 4.24. Wheat growing in a field.

1. The bran is the

outer skin of
the seed. It
contains
antioxidants,
B vitamins and fiber.
2. The endosperm is by far the largest part of the seed and
provides energy in the form of starch to support
reproduction. It also contains protein and small amounts
of vitamins and minerals.
3. The germ is the embryo of the seed—the part that can
sprout into a new plant. It contains B vitamins, protein,
minerals like zinc and magnesium, and healthy fats.

Figure 4.25. The anatomy of a wheat kernel which

includes the bran, endosperm, and germ.

The Dietary Guidelines for Americans define whole grains and

refined grains in the following way:
“Whole
Whole Grains
Grains—Grains and grain products made from the entire
grain seed, usually called the kernel, which consists of the bran,
germ, and endosperm. If the kernel has been cracked, crushed, or
flaked, it must retain the same relative proportions of bran, germ,
and endosperm as the original grain in order to be called whole
grain. Many, but not all, whole grains are also sources of dietary
fiber.”
Whole grains include foods like barley, corn (whole cornmeal and popcorn), oats (including
oatmeal), rye, and wheat. (For a more complete list of whole grains, check out the Whole Grain
Council.)
“Refined
Refined Grains
Grains—Grains and grain products with the bran and germ removed; any grain product
that is not a whole-grain product. Many refined grains are low in fiber but enriched with thiamin,
riboflavin, niacin, and iron, and fortified with folic acid.”
Refined grains include foods like white rice and white flour. According to the Whole Grain Council,
“Refining a grain removes about a quarter of the protein in a grain, and half to two thirds or more of
a score of nutrients, leaving the grain a mere shadow of its original self.”
Refined grains are often enriched with vitamins and minerals, meaning that some of the nutrients
lost during the refining process are added back in after processing. However, many vitamins and
minerals are not added back, and neither are the fiber, protein, and healthy fats found in whole
grains. In the chart below you can see the differences in essential nutrients between whole wheat
flour, refined wheat flour, and enriched wheat flour.
FIBER - TYPES, FOOD SOURCES, HEALTH BENEFITS, AND WHOLE VERSUS REFINED GRAINS 189

Figure 4.26. The nutrient content of refined wheat and enriched wheat as compared to whole wheat flour.
Because whole grains offer greater nutrient density, MyPlate and the Dietary Guidelines
recommend that at least half of our grains are whole grains. Yet current data show that while most
Americans are eating enough grains overall, they’re eating too many refined grains and not enough
whole grains, as shown in this graphic from the Dietary Guidelines:
190 TAMBERLY POWELL, MS, RDN

Figure 4.27. Average Whole & Refined Grain Intakes in Ounce-Equivalents per Day by Age-Sex Groups,
Compared to Ranges of Recommended Daily Intake for Whole Grains & Limits for Refined Grains.
Looking for whole grain products at the grocery store can be tricky, since the front-of-package
labeling is about marketing and selling products. Words like “made with whole grain” and “multigrain”
on the front of the package make it appear like a product is whole grain, when in fact there may be
very few whole grains present.
The color of a bread can be deceiving too. Refined grain products can have added caramel color to
make them appear more like whole grains.
To determine if a product is a good source of whole grain, the best place to look is the
ingredient list on the Nutrition Facts panel. The ingredients should list a whole grain as the first
ingredient (e.g., 100% whole wheat), and it should not be followed by a bunch of refined grains such
as enriched wheat flour.
Getting familiar with the name of whole grains will help you identify them. Common varieties
include wheat, barley, brown rice, buckwheat, corn, rye, oats, and wild rice. Less known varieties
include teff, amaranth, millet, quinoa, black rice, black barley, and spelt.
Most, but not all, whole grains are a good source of fiber, and that is one of the benefits of choosing
whole grains. Keep in mind that some products add extra fiber as a separate ingredient, like wheat
bran, inulin, or cellulose. These boost the grams of fiber on the Nutrition Facts label and may make
the product a good source of fiber, but it doesn’t mean it’s a good source of whole grains. In fact, it
may be a product made mostly of refined grains, so it would still be missing the other nutrients that
come packaged in whole grains and may not have the same health benefits. Therefore, just looking
at fiber on the Nutrition Facts label is not a good indicator of whether or not the product is made
with whole grains.
Also, some products that are 100% whole wheat but do not appear to be a good source of fiber,
because the serving size is small. The bread label below is an example of this. The first ingredient is
“stone ground whole wheat flour” with no refined flours listed, but it still has only 2g of fiber and 9%
DV. But of course, that still contributes to your fiber intake for the day, and if you made yourself a
sandwich with two slices of bread, that would provide 18% of the DV.
FIBER - TYPES, FOOD SOURCES, HEALTH BENEFITS, AND WHOLE VERSUS REFINED GRAINS 191

Figure 4.28. Example of 100% whole wheat bread with Nutrition Facts and ingredient list.
 192 TAMBERLY POWELL, MS, RDN

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VIDEO: “Label Reading and Whole Grains” by Tamberly Powell, YouTube (September 24, 2018), 7:46 minutes.

Self-Check:

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References:

• Institute of Medicine, Food and Nutrition Board. (2005). Dietary Reference Intakes for
Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids
(Macronutrients). Retrieved from https://www.nap.edu/read/10490/chapter/1
• U.S Department of Agriculture, Agricultural Research Service, Nutrient Data Laboratory.
(2014). USDA National Nutrient Database for Standard Reference, Release 27. Available at:
http://www.ars.usda.gov/nutrientdata.
• Academy of Nutrition and Dietetics. (2015). Position of the Academy of Nutrition and
Dietetics: Health Implications of Dietary Fiber. Journal of the Academy of Nutrition and
Dietetics, 115(11), 1861–1870. doi: 10.1016/j.jand.2015.09.003
• Whole Grain Council. Definition of a Whole Grain. Retrieved from
https://wholegrainscouncil.org/definition-whole-grain
FIBER - TYPES, FOOD SOURCES, HEALTH BENEFITS, AND WHOLE VERSUS REFINED GRAINS 193

• Mayo Clinic Staff. (2018). Dietary Fiber: Essential for a healthy diet. Retrieved from
https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/fiber/
art-20043983

Image Credits:

• Figure 4.22. “Chemical structure of cellulose” by laghi.l is licensed under CC BY-SA 3.0
• Figure 4.23. “Bowl of oatmeal” by Rusvaplauke is licensed under CC BY-NC-ND 2.0
• Table 4.4. “Common foods listed with standard portion size, and calories and fiber in a
standard portion” by Tamberly Powell is licensed under CC BY-NC-SA 4.0 ; values in table
from USDA National Nutrient Database are in the Public Domain
• Figure 4.24. “Grain” by rethought is licensed under CC BY-NC 2.0
• Figure 4.25. “Wheat kernel” by Phuthinh Co is licensed under CC BY-SA 2.0
• Figure 4.26. “Chart comparing nutrient content of whole wheat flour, refined flour and
enriched wheat flour” permission for use was given by “Oldways Whole Grains Council”
• Figure 4.27. “Whole grain intake graphic” by Dietary Guidelines for Americans, Figure 2-5 is
in the Public Domain
• Figure 4.28. “100% whole wheat bread and label photos” by Tamberly Powell is licensed
under CC BY-NC-SA 4.0
Sugar: Food Sources, Health Implications, and
Label-Reading

Most of us enjoy the taste of sweetness, but you’ve also probably heard that you shouldn’t eat too
much sugar. Maybe you’ve even heard that sugar is toxic. The truth about sugar is more complex. It’s
true that most Americans eat more added sugar than recommended and would benefit from cutting
back. It’s also true that added sugars are hidden in many foods, and it can take savvy label-reading
to find them. But let’s also remember the big picture when we think about sugar. Some sugar is
naturally-occurring in whole foods, packaged with other valuable nutrients. There’s also room in the
diet for some added sugar, and it can be valuable for making nutrient-dense foods more palatable or
just for the pleasure of enjoying a treat. Let’s look closer at the role of sugar in the diet.

FOOD SOURCES OF NATURALLY-OCCURRING AND ADDED SUGARS

As we’ve already discussed, sugars are naturally found in fruits, veggies, and dairy. These are nutrient
dense foods that come packaged with other essential nutrients too.

Figure 4.29. Examples of food that contain naturally occuring sugars: fruit, vegetables, and dairy.
Fresh fruits and veggies contain naturally-occurring sugars like glucose, fructose, and sucrose, but
also come packaged with fiber, potassium, and Vitamin C. Dairy foods like unsweetened yogurt, milk,
and cheese contain naturally-occurring lactose but also come packaged with calcium, potassium,
phosphorus, and riboflavin.
Another food that contains natural sugar in the form of maltose is sprouted grain bread. In the
example below, the only ingredients are sprouted organic rye kernels and water, yet there are 7
grams of sugar per slice. This sugar must be naturally-occuring maltose, and as you can imagine, it
comes packaged with nutrients like fiber, protein, and iron.

194
SUGAR: FOOD SOURCES, HEALTH IMPLICATIONS, AND LABEL-READING 195

Figure 4.30. An example of a sprouted wheat bread that contains naturally occuring maltose from
sprouted rye kernels.
In contrast, added sugars are concentrated sweeteners that are added as ingredients to foods to
make them sweeter. They add calories to a food but contribute little to no essential nutrients, so they
decrease the nutrient density of foods. Among the most common sources of added sugar are table
sugar (sucrose) and high fructose corn syrup, but they come in many different forms with different
names. For example, honey, maple syrup, agave nectar, and brown rice syrup may all sound more
wholesome and natural, but they’re still added sugars, because they are concentrated sweeteners
that contribute little to no other nutrients. Other names for added sugar you might not recognize as
sweeteners at all, like barley malt or treacle. Here’s a list of 61 different names for added sugars:
196 TAMBERLY POWELL, MS, RDN

Figure 4.31. Names of sugar commonly added to food.

We find added sugars in some expected places, like cookies, ice cream, and soda, but there can
also be a surprising amount of added sugar in yogurt, breakfast cereals, energy bars, and plant-based
milk alternatives, like soy milk. We also find added sugars hiding in unexpected places, like ketchup,
salad dressings, bread, and pasta sauce. In fact, nearly 75% of packaged products in the U.S. food
supply are now sweetened.
In general, most people don’t need to worry much about how much naturally-occurring sugar
they consume. This goes back to the fact that naturally-occurring sugars are packaged with other
nutrients. For example, a large apple contains about 23 grams of sugar, more than half of it in the
1
form of fructose. However, it also has more than 5 grams of fiber, plus a significant amount of
vitamin C and potassium. The fiber slows down the digestion and absorption of the sugar into your
bloodstream, giving your body more time to metabolize it and giving you a greater feeling of fullness.
1
A single can of soda, on the other hand, contains about 33 grams of sugar. It’s in a similar chemical
form as the sugar in the apple—a mix of fructose and glucose—but it’s not accompanied by any fiber
to slow down digestion. Therefore, it’s rapidly absorbed into your bloodstream, and your body has
to quickly metabolize the fructose to glucose and increase insulin secretion to process the spike in
sugar. Plus, although the soda contains 150 calories and the apple has just 116, the apple is probably
going to leave you feeling more satisfied and less hungry compared with the soda.
For all of these reasons, it’s the added sugars that we worry about, not the naturally-occurring
ones. That said, there is room for some added sugar in a balanced diet, and you can use it to make
nutrient-dense food tastier. For example, you can drizzle honey into plain yogurt or sprinkle some
brown sugar on roasted winter squash. You get far more nutritional “bang for your buck” using added
sugars in this way than consuming them in something like a soda. (And of course, there’s also room
in a balanced diet for occasional treats!)
SUGAR: FOOD SOURCES, HEALTH IMPLICATIONS, AND LABEL-READING 197

HOW MUCH ADDED SUGAR ARE WE EATING?

On average, Americans consume 22 to 30 teaspoons of added sugar daily, up to 17% of calories, well
in excess of the recommendation to limit added sugar intake to 10% of calories or less. This is
shown in the image below from the Dietary Guidelines.

Figure 4.32. Average intakes of added sugars as a percent of calories per day by age-sex group, in
comparison to the Dietary Guidelines’ maximum limit of less than 10 percent of calories.
Where are all of these added sugars coming from? Nearly half of them come from soda, juices, and
other sugary drinks, as illustrated below. Therefore, the Dietary Guidelines recommend that people
drink more water and less sugary drinks.
198 TAMBERLY POWELL, MS, RDN

Figure 4.33. Food category sources of added sugars in the U.S. population ages 2 years and older.
On the Nutrition Facts panel, sugar is expressed in grams, but most of us don’t think in grams.
Therefore, it can be helpful to convert gram amounts to teaspoons, which are easier to visualize. Use
the conversions shown in the graphic below to make these calculations.

Figure 4.34. One teaspoon is equal to 4 grams of sugar or a sugar cube.

The sugar in soda adds up fast, especially with our super sized portions. For example, a 64-ounce
soda has 186 grams of sugar, or about 46 teaspoons. (186 grams divided by 4g/tsp = 46 teaspoons.)
SUGAR: FOOD SOURCES, HEALTH IMPLICATIONS, AND LABEL-READING 199

Figure 4.35. Forty six sugar cubes stacked next to a big gulp to illustrate the 46 teaspoons of sugar that
the soda contains.
It can be eye-opening to track your added sugar intake for a few days, and this may give you an
idea of sources of added sugar that you can live without and replace with something else. However,
tracking added sugar intake can be tedious. In the big picture, it’s most important to focus on
eating whole foods that are minimally processed and to consume added sugars in moderation.

BENEFITS OF EATING LESS ADDED SUGAR

Research shows that adopting an eating pattern that is relatively low in added sugars has many
benefits, including a lower risk of:

• Cardiovascular disease
• Obesity
• Type 2 diabetes
• Some cancers
• Dental cavities

Why does too much added sugar cause health problems? The reasons are complex, and this is
an ongoing area of research and controversy. One possible explanation is that a diet high in added
sugar means the pancreas has to work hard to make enough insulin, and over time, it can begin to fail
and the body’s cells start to become insulin resistant. The liver also has to work hard to metabolize
fructose, and too much fructose increases fat synthesis, which can raise blood lipid and cholesterol
levels, increasing risk of heart disease.
Both dietary sucrose and starch are associated with tooth decay. Bacteria living in the mouth
can utilize the carbohydrates passing through the oral cavity for their own benefit. Those bacteria
200 TAMBERLY POWELL, MS, RDN

happily metabolize carbohydrates, especially sucrose, but also starchy foods, which stick to teeth
and linger there. Acid is formed in the process, and this can dissolve your tooth enamel, eventually
causing cavities, also known as dental caries. Reducing sugar intake, limiting between-meal snacks,
and brushing after meals to remove lingering carbohydrates can help reduce the risk of dental caries.
The use of fluoride and regular dental care also help.

Fig. 4.36. Dental caries are formed because of a combination of factors: the presence of oral bacteria; a
supply of sugar and/or starch for them to eat; tooth surface where they can form colonies, or plaque; and
time.

ARE SOME ADDED SUGARS BETTER THAN OTHERS?

Students often ask which sugar is healthiest: high fructose corn syrup, honey, agave syrup, or sugar?
In general, as far as the body is concerned, sugar is sugar. These are all concentrated sweeteners that
contain calories with very few/no other nutrients, so all should be used only in moderation.
High fructose corn syrup (HFCS) has gotten a lot of attention in the last several decades and has
been blamed for the obesity epidemic and many other poor health outcomes. This is in part because
it’s widely used to sweeten soda and so has become a large part of the American diet. It’s true that
fructose is more work for the body to process, because it has to be converted to glucose. Here’s what
the website Sugar Science, written by researchers and scientists from the University of California, San
Francisco, has to say about the difference between table sugar and high fructose corn syrup:
“Table sugar (sucrose), derived from sugar cane and beets, is made up of equal portions of
two types of sugars. It’s half (50%) glucose and half (50%) fructose. High-fructose corn syrup
(HFCS) is derived from corn syrups that have undergone enzymatic processing to convert some of
their glucose into fructose to produce a desired sweetness. HFCS comes in different formulations,
depending on the manufacturer. More common formulations contain 42% fructose or 55% percent,
but some contain as much as 90%. Why should we care? First, because there is significant evidence
that fructose is processed differently in the body than other sugars and can be toxic to the liver,
just like alcohol. Second, because as a nation, we have been consuming more of our sugars in HFCS
over time.”
But focusing too much attention on fructose as the problem may risk missing the forest for the
trees. Here’s what Dr. Luc Tappy, a fructose researcher at University of Lausanne, had to say about
the issue in an article on Vox.com:
“Given the substantial consumption of fructose in our diet, mainly from sweetened beverages, sweet
snacks, and cereal products with added sugar, and the fact that fructose is an entirely dispensable
nutrient, it appears sound to limit consumption of sugar as part of any weight loss program and
in individuals at high risk of developing metabolic diseases. There is no evidence, however, that
fructose is the sole, or even the main factor in the development of these diseases, nor that it
is deleterious to everybody, and public health initiatives should therefore broadly focus on the
promotion of healthy lifestyles generally, with restriction of both sugar and saturated fat intakes,
and consumption of whole grains, fresh fruits and vegetables rather than focusing exclusively on
reduction of sugar intake.”
SUGAR: FOOD SOURCES, HEALTH IMPLICATIONS, AND LABEL-READING 201

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Video: “What’s The Difference Between Sugar and High Fructose Corn Syrup?” by Reactions, YouTube (March
23, 2015), 2:41 minutes.

Are sweeteners such as honey, maple syrup, and molasses any better than more refined and
processed sweeteners? Maybe. These sweeteners do contain minerals and antioxidants, so they may
offer a slight edge in terms of nutrition. However, keep in mind that minerals and antioxidants are
abundant in whole foods such as whole grains, vegetables, and fruits, and these obviously offer many
other benefits. These sweeteners are still considered sources of added sugar and should be used
in moderation. That said, each of them offers different delicious flavors, and honey has the added
benefit that it can be purchased locally, so there are good reasons to turn towards these products
when you want to add some sweetness to your food.

LABEL-READING TO IDENTIFY SUGAR

If you’re trying to figure out if a food is high in added sugar and what ingredients are contributing
the added sugar, there are two places you should look on the label. First, check the Nutrition Facts
panel to see how many grams of added sugar are in one serving. Be aware that the “total sugars”
on the label includes both added and naturally-occurring sugars. The ingredients list will identify the
sources of added sugar, which may be listed as any of the 61 different names in the graphic high on
this page.
Let’s take a look at some labels to practice identifying naturally occurring and added sugars in
foods.
Below are labels from a 6-ounce serving of plain yogurt. There are 6 grams of total sugar and 0
grams of added sugar listed on the label. What ingredients contain naturally-occurring sugar?
202 TAMBERLY POWELL, MS, RDN

Figure 4.37. Plain yogurt with Nutrition Facts and ingredient list.
The ingredients include nonfat milk, maltodextrin (a food additive that is a polysaccharide), milk
protein concentrate, vitamins, and bacteria. There are no sources of added sugar in the ingredient
list and zero grams of added sugar shown in the Nutrition Facts, so the 6 grams of total sugars are
from naturally–occurring lactose in the milk.
Next, look at the label below for a 6-ounce serving of sweetened strawberry yogurt. There are
28 grams of total sugar and 21 grams of added sugar listed on the label. What ingredients are
contributing naturally-occurring and added sugar in this product?

Figure 4.38. Strawberry yogurt with Nutrition Facts and ingredient list.
To answer this question, we again have to look at the ingredients list. Like the plain yogurt, the
first ingredient is milk, but this strawberry yogurt also contains cane sugar and strawberries. Based
 SUGAR: FOOD SOURCES, HEALTH IMPLICATIONS, AND LABEL-READING 203

on these ingredients, the added sugar comes from sucrose in cane sugar,and the naturally-occurring
sugar is from the lactose from the milk and the glucose, fructose, and sucrose in the strawberries.
Not all yogurts are created equal, and many of them have less ingredients and less sugar than the
example given above with the Greek yogurt. One example is siggi’s Icelandic style skyr. As you can see
in the images below, the ingredients are simple, and there is a lot less sugar than traditional yogurts.

Figure 4.39. Siggi’s strawberry yogurt and Nutrition Facts.

In the siggi’s strawberry yogurt, a 5.3 oz (150g) serving has 11 grams of total sugar and 7 grams of
added sugar. This is a combination of naturally-occurring sugar from the milk and strawberries and
added sugar from the cane sugar. However, this product only has 7 grams of added sugar (just under
2 teaspoons), which is a lot less than the strawberry Greek yogurt with 21 grams of added sugar (just
over 5 teaspoons) shown above. It is important to pay attention to labels when shopping for nutrient-
dense foods.

Self-Check:

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References:

• US Department of Health and Human Services and U.S. Department of Agriculture. (2015).
Dietary Guidelines for Americans. Retrieved from https://health.gov/dietaryguidelines/
2015/
• Institute of Medicine, Food and Nutrition Board. (2005). Dietary Reference Intakes for
Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids
(Macronutrients). Retrieved from https://www.nap.edu/read/10490/chapter/1
204 TAMBERLY POWELL, MS, RDN

• Ng, S.W., Slining, M.M., & Popkin, B.M. (2012). Use of caloric and noncaloric sweeteners in
US consumer packaged foods, 2005-2009. Journal of the Academy of Nutrition and Dietetics.
112(11), 1828-1834. e1-6. doi: 10.1016/j.jand.2012.07.009
1
• U.S Department of Agriculture, Agricultural Research Service, Nutrient Data Laboratory.
(2014). USDA National Nutrient Database for Standard Reference, Release 27. Available at:
http://www.ars.usda.gov/nutrientdata.
• Belluz and Zarracina. (2017). Sugar, explained. Vox. Retrieved from https://www.vox.com/
science-and-health/2017/1/13/14219606/sugar-intake-dietary-nutrition-science
• Sugar Science, “Too Much Can Make Us Sick,” University of California, San Franciso,
http://sugarscience.ucsf.edu/too-much-can-make-us-sick/#.W5lUKy-ZP-Y, accessed
September 12, 2018.
• Whitaker, E.M., “The Sweet Science of Honey,” Sugar Science, UCSF,
http://sugarscience.ucsf.edu/the-sweet-science-behind-honey.html#.W5qtp1InYdU,
accessed September 13, 2018.
• Phillips, K.M., et al. (2009). Total antioxidant content of alternatives to refined sugar. J Am
Diet Assoc. 109(1), 64-71. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/19103324

Image Credits:

• Figure 4.29. “Fruit” by Allen Gottfried is licensed under CC BY-SA 2.0; “vegetables” by
johnbillu is licensed under CC BY-NC-ND 2.0; “Cheese” by Finite Focus is licensed under CC
BY-NC 2.0
• Figure 4.30. “Sprouted bread and label” by Tamberly Powell is licensed under CC BY-NC-SA
4.0
• Figure 4.31. “61 Names for Added Sugar” by Alice Callahan is licensed under CC BY-NC-SA
4.0. Source for list of sugars: SugarScience, “Hidden in Plain Sight,” University of California,
San Franscisco, http://sugarscience.ucsf.edu/hidden-in-plain-sight/#.W5li71Inbq0, accessed
September 12, 2018.
• Figure 4.32 and Fig 4.33. “Added sugar intake graphics” from Dietary Guidelines for
Americans, Figures 2-9 and 2-10 is in the public domain
• Figure 4.34. “Sugar conversion” by Alice Callahan is licensed under CC BY-NC-SA 4.0, “Sugar
cube” by jhnri4 and “measuring spoon” by mazeo, both in the Public Domain
• Figure 4.35. “Big Gulp with sugar cubes” by Tamberly Powell is licensed under CC BY-NC-SA
4.0
• Figure 4.36. “Dental caries” by Alice Callahan is licensed under CC BY-NC-SA 4.0, “cavity” by
Suyash.dwivedi is licensed under CC BY-SA 4.0,
• Figure 4.37- Fig 4.39. “Yogurt and label images” by Tamberly Powell is licensed under CC BY-
NC-SA 4.0
Sugar Substitutes

You should now understand the problems with consuming too much added sugar, but what if you’ve
sworn off regular soda and switched to diet versions? What if you’re choosing “sugar-free” products,
sweetened not with sugar but with sugar substitutes like aspartame, saccharin, or stevia? Are these
a better choice?

Figure 4.40. Examples of products containing high-intensity sweeteners: diet soda, sugar-free chocolate,
and bulk containers of Splenda and stevia extract.
Diet sodas are the biggest source of sugar substitutes in the American diet, but these ingredients
are found in a range of foods, including ice cream, yogurt, cereals, iced tea, energy drinks, candy,
1
cookies, granola bars, salad dressings, frozen dinners, and energy bars. Products containing sugar
substitutes are often labeled as sugar-free or “lite,” but some don’t have any front-of-package
labeling with this information, and you may not even realize that you’re consuming them. With more
consumers watching their sugar intake, the use of sugar substitutes is growing, and the food industry
is working hard to market them as a healthier choice. We can expect to see them in more and more
products, so it’s important to understand what these substances are and what they may mean for
our health.

WHAT ARE SUGAR SUBSTITUTES?

You may find sugar substitutes called lots of different things, including artificial, non-nutritive, high-
intensity, or low-calorie sweeteners. Regardless of the name, these are substances that have a sweet
2
taste but few or no calories. In fact, they are much sweeter than sucrose, so a tiny amount can add
a lot of sweetness to food. (Sweetener packets like Splenda and Equal contain a small amount of
sweetener and a lot of filler ingredients.)

205
206 TAMBERLY POWELL, MS, RDN

Sweetness
Sweetener Brand Names
(relative to sucrose)

Sweet One®
Acesulfame Potassium (Ace-K) 200x
Sunett®

Advantame 20,000x

Nutrasweet®
Aspartame Equal® 200x
Sugar Twin®

Neotame Newtame® 7,000-13,000

Sweet’N Low®
Sweet and Low®
Saccharin 200-700x
Sweet Twin®
Necta Sweet®

Sucralose Splenda® 600x

Nectresse®
Luo Han Guo or
Monk Fruit in the Raw® 100-250 x
monk fruit extracts
PureLo®

Truvia®
Stevia PureVia® 200-400 x
Enliten®

Table 4.5. Sugar substitutes approved by the FDA for use in the United States with their brand names and
3
sweetness relative to sucrose.
Unlike regular sugar, the sweeteners listed in the table above are not associated with dental caries,
1
and they generally don’t raise blood glucose.
Sugar alcohols are another type of sugar substitute. They include sorbitol, mannitol, lactitol,
erythritol, and xylitol. They are chemically similar to monosaccharides but different enough that they
aren’t processed in the body to the same extent. However, they are at least partially metabolized and
contain about 2 kcal/gram (compared with 4 kcal/gram for sucrose). (An exception is erythritol, which
contains just 0.2 kcal/g.) Unlike the sweeteners listed in the table above, they are not “high-intensity”
but instead are generally less sweet than sucrose. Because they are not fully digested, consuming
1
large amounts of them can cause bloating, gas, and diarrhea.
Sugar alcohols are often used in sugar-free chewing gums and breath mints and can carry a health
claim that they don’t promote tooth decay, because mouth bacteria can’t easily metabolize them.
Xylitol in particular has been studied for its ability to decrease the incidence of tooth decay. However,
these studies generally use large doses. For example, a person might have to chew xylitol gum five
times per day to see a benefit. The American Academy of Pediatric Dentistry supports the use of
xylitol but says the evidence for benefit is not clear and that amounts required may not be practical
4
in real life.

CAN SUGAR SUBSTITUTES HELP WITH WEIGHT LOSS?

When people choose diet soda or a sugar-free dessert, they’re probably assuming that it’s a healthier
choice and perhaps that it could help them lose weight. However, studies show this isn’t necessarily
the case.
In the short-term, if someone who drinks a lot of sugar-sweetened beverages switches to diet
versions, studies show that this can result in weight loss. That makes sense, because you’re removing
5
a lot of empty calories from the diet.
However, in the long-term, studies show there isn’t a clear benefit to consuming sugar substitutes.
A recent systematic review and meta-analysis combined the results of studies that lasted at least
6
6 months. Among the randomized controlled trials, they found no difference in body mass index
(BMI—a measure of the ratio of body weight to height) between people who consumed sugar and
those who consumed sugar substitutes. Observational studies that tracked large groups over years
found that people who consumed sugar substitutes tended to have a higher BMI, greater weight
and waist circumference, and a higher incidence of obesity, hypertension, metabolic syndrome, type
SUGAR SUBSTITUTES 207

7
2 diabetes, and cardiovascular events. Because these are observational studies, we can’t conclude
that the sugar substitutes cause these health outcomes, but we can conclude that their use is not
associated with better health.
When it comes to weight management, the goal is to adopt eating habits that support a
sustainable healthy body weight. Sugar substitutes might help in the short-term with decreasing
calorie intake and perhaps gradually moving away from sweetened beverages, but better long-term
goals for health would be to shift to water and other unsweetened beverages. If you’re looking for
a way to sweeten your oatmeal or yogurt, you might try adding fresh fruit rather than sugar or an
artificial sweetener packet. (Or go ahead and add a bit of brown sugar or a drizzle of honey, keeping
in mind the overall goal of moderation.)

ARE HIGH-INTENSITY SWEETENERS SAFE?

Over the years, there have been a number of concerns about non-nutritive sweeteners. For example,
in the 1970s, studies showed that saccharin was linked to bladder cancer in lab rats, so it was labeled
as a potential carcinogen, although its use as a sweetener continued. In 2000, after many studies
showed no link between cancer and saccharin, the warning labels were no longer required. Some
studies have also raised concerns about a link between aspartame and sucralose and cancer, but
the FDA has reviewed this evidence and concluded: “Based on the available scientific evidence, the
agency has concluded that the high-intensity sweeteners approved by FDA are safe for the general
population under certain conditions of use.” The National Cancer Institute also says there is no clear
8
evidence that high intensity sweeteners cause cancer.
208 TAMBERLY POWELL, MS, RDN

Figure 4.41. A “Saccharin Notice” sign warns consumers that a grocery store shelf contains products with
saccharin, which has been shown to cause cancer in laboratory animals. Between 1977 and 2000, products
containing saccharin had to include a cancer warning label. This requirement was removed after the U.S.
Department of Health and Human Services determined it was not a concern in humans at doses typically
consumed.
There are other emerging safety concerns about sugar substitutes, though. Small studies on
both mice and humans show that consuming artificial sweeteners can change our gut bacteria and
9-11
cause glucose intolerance. Glucose intolerance means that blood glucose is abnormally elevated,
showing that glucose metabolism is not working properly, and it is a precursor to the development
of diabetes. Other researchers worry that having the taste of sweetness signaled to the brain without
accompanying calories could derail our normal pathways for sensing hunger and satiety and for
12
regulating glucose metabolism. This research is alarming but still preliminary. However, it is an
active area of study, and we can expect more information to emerge in the years to come.

ARE NATURAL SWEETENERS BETTER THAN ARTIFICIAL ONES?

Sweeteners made from the stevia plant and from monk fruit extracts are both derived from plants
and so are considered more natural than the other choices. However, it’s important to not confuse
natural with safe. Remember that many things in nature are dangerous, even deadly. (Consider
 SUGAR SUBSTITUTES 209

cyanide, poisonous mushrooms, and botulinum toxin, for example.) Stevia sweeteners, which are
growing in popularity and are often marketed as a more natural alternative, are made through a
highly industrial extraction process, and some are produced by genetically-modified yeast. None of
that makes them inherently less safe, but it does highlight that they aren’t exactly natural.

Figure 4.42. A box of Sweetleaf sweetener, marketed as “Natural Stevia Sweetener.”

What’s important is how well these products are tested and studied for their safety. The Center
for Science in the Public Interest, a consumer advocacy nonprofit organization, has criticized the FDA
for not requiring more testing of stevia and monk fruit extracts, although they recommend stevia as
one of the safer options for sugar substitutes based on existing data. However, recent research has
shown that, like artificial sweeteners, stevia also affects the growth of gut bacteria.

WHAT’S THE BOTTOM LINE?

Sugar substitutes can add sweetness to a food without the calories, and they aren’t associated with
tooth decay. Despite concerns over the years, they probably don’t cause cancer. However, they may
not help with weight loss or maintenance in the long-term, and recent research shows that they may
alter the gut microbiota and metabolic health.

Self-Check:

An interactive H5P element has been excluded from this version of the text. You can view it online here:

https://openoregon.pressbooks.pub/nutritionscience/?p=141#h5p-7
210 TAMBERLY POWELL, MS, RDN

References:

1
• Center for Science in the Public Interest. (2015). Sweet Nothings: Safe… Or scary? The
inside scoop on sugar substitutes.
2
• Food and Drug Administration. (2019b). High-Intensity Sweeteners. FDA. Retrieved from
http://www.fda.gov/food/food-additives-petitions/high-intensity-sweeteners
3
• Food and Drug Administration. (2019a). Additional Information about High-Intensity
Sweeteners Permitted for Use in Food in the United States. FDA. Retrieved from
http://www.fda.gov/food/food-additives-petitions/additional-information-about-high-
intensity-sweeteners-permitted-use-food-united-states
4
• American Academy of Pediatric Dentistry. (2015). Policy on the Use of Xylitol. Retrieved
from https://www.aapd.org/research/oral-health-policies–recommendations/use-of-
xylitol/#section-policy-statement
5
• de Ruyter, J. C., Olthof, M. R., Seidell, J. C., & Katan, M. B. (2012). A Trial of Sugar-free or
Sugar-Sweetened Beverages and Body Weight in Children. New England Journal of
Medicine, 367(15), 1397–1406. https://doi.org/10.1056/NEJMoa1203034
6
• Azad, M. B., Abou-Setta, A. M., Chauhan, B. F., Rabbani, R., Lys, J., Copstein, L., …
Zarychanski, R. (2017). Nonnutritive sweeteners and cardiometabolic health: A systematic
review and meta-analysis of randomized controlled trials and prospective cohort studies.
CMAJ, 189(28), E929–E939. https://doi.org/10.1503/cmaj.161390
7
• Pearlman, M., Obert, J., & Casey, L. (2017). The Association Between Artificial Sweeteners
and Obesity. Current Gastroenterology Reports, 19(12), 64. https://doi.org/10.1007/
s11894-017-0602-9
8
• National Cancer Institute. (2005, August 18). Artificial Sweeteners and Cancer. Retrieved
September 20, 2018, from https://www.cancer.gov/about-cancer/causes-prevention/risk/
diet/artificial-sweeteners-fact-sheet
9
• Shell, E. R. (n.d.). Artificial Sweeteners May Change Our Gut Bacteria in Dangerous Ways.
https://doi.org/10.1038/scientificamerican0415-32
10
• Suez, J., Korem, T., Zeevi, D., Zilberman-Schapira, G., Thaiss, C. A., Maza, O., … Elinav, E.
(2014). Artificial sweeteners induce glucose intolerance by altering the gut microbiota.
Nature, 514(7521), 181–186. https://doi.org/10.1038/nature13793
11
• Wang, Q.-P., Browman, D., Herzog, H., & Neely, G. G. (2018). Non-nutritive sweeteners
possess a bacteriostatic effect and alter gut microbiota in mice. PLoS ONE, 13(7).
https://doi.org/10.1371/journal.pone.0199080
12
• Pepino, M. Y. (2015). Metabolic Effects of Non-nutritive Sweeteners. Physiology &
Behavior, 152(0 0), 450–455. https://doi.org/10.1016/j.physbeh.2015.06.024

Image Credits:

• Fig 4.40. “Diet Hansen’s can” by 7 Bits of Truth is licensed under CC BY 2.0; “Sugar-free
chocolate” by m01229 is licensed under CC BY 2.0; “Sweeteners” by sriram bala is licensed
under CC BY-NC 2.0
• Table 4.5. “Sugar substitutes” by Alice Callahan is licensed under CC BY-NC-SA 4.0
• Fig 4.41. “Saccharin notice” by Linda Bartlett, National Cancer Institute is in the Public
Domain
• Fig 4.42. “Stevia” by Mike Mozart is licensed under CC BY 2.0
UNIT 5- LIPIDS

211
Introduction to Lipids

When you think of foods important to the Pacific Northwest, salmon may first come to mind. But to
many indigenous people who have long made their home along the Pacific coast, a smaller, humbler
fish is considered even more vital: the eulachon smelt.
Traditionally, one of the first signs of spring in the region was the migration of the eulachon smelt
into the region’s rivers. These thin, blue and silver fish spend most of their lives in the cold Pacific
Ocean, but when it’s time for them to lay their eggs in early spring, they swim up into the rivers of
Oregon, Washington, Canada, and Alaska to sow the seeds of their next generation.
For indigenous people living in this region, who historically subsisted through long winters on
stored and preserved foods, the arrival of the eulachon smelt would have been a welcome infusion
of calories and flavor. Legends describe the small oily fish saving entire villages from starvation; it’s
also known as “halimotkw,” translated as “savior fish” or “salvation fish.”

Figure 5.1. Fresh-caught eulachon smelt from the Kuskokwim River, Alaska, 2008.
Beyond the timing of its late winter arrival, what makes the eulachon so valuable is its high lipid
content. It’s so oily that dried eulachon will ignite and burn like a candle, and nutritionally, it’s a
dense source of calories. (Remember: Fat contains 9 kilocalories per gram compared to just 4 for
carbohydrate and protein.) It’s also a good source of fat-soluble vitamins, especially vitamin A, and
high in omega-3 fatty acids. William Clark (of the Lewis and Clark expedition), after tasting eulachon
from the Columbia River in 1805, wrote: “They are so fat they require no additional sauce, and I think
them superior to any fish I ever taste[d], even more delicate and luscious than the white fish of the
lakes which have heretofore formed my standard of excellence among the fishes.”
Clark may have been the first person of European descent to document the eulachon, but it had
long been valued by indigenous people, including members of the Tsimshian, Tlingit, Haida, Nisga’s,
and Bella Coola tribes. The eulachon run was an annual community event, and people camped for
several weeks at the mouths of rivers to net and process the fish. They smoked eulachon to preserve
213
214 TAMBERLY POWELL, MS, RDN

it, but even more importantly, they fermented it in large batches and then cooked it to extract its oils.
Once cooled, the fat was solid at room temperature—similar to lard or butter—and could be used for
fat and flavor in cooking for the year ahead. It was so valuable that it was traded hundreds of miles
inland, forming the great “grease trials” of the Northwest.

VIDEO: “Watch a Fish Transform From Animal to Candle,” by National Geographic (July 10, 2015), 2 minutes.

One or more interactive elements has been excluded from this version of the text. You can view them online here:

https://openoregon.pressbooks.pub/nutritionscience/?p=247#oembed-1
 INTRODUCTION TO LIPIDS 215

Figure 5.2 (left): A page from William Clark’s journal of 1805, describing his observations of the euchalon
smelt, including its “delicate and luscious” taste. Figure 5.3 (right): Mural panel by Will S. Taylor, entitled “A
Tsimshian Family Making Eulachon Butter,” circa 1825, with this description: “The glow of the ember fire is
on the girls face as she waits for stones to heat. In the box at the right, fish are being boiled by means of
the heated stones: the oil thus removed from the fish forms “butter.” The residue is being strained by the
woman at the left.”
These traditional uses of the eulachon continue on a smaller scale, but since the 1990s, the
eulachon population has collapsed. Researchers say its biggest threat is climate change, and
eulachon have been classified as a threatened species under the Endangered Species Act since 2010.
In today’s world—when we can obtain a day’s worth of calories and more than enough fat with
just a quick trip through a fast food drive-through—it’s easy to forget the biological and cultural
importance of lipids. But the historical significance of the eulachon remind us of how vital these
molecules are to our survival.

Unit Learning Objectives

After completing this unit, you should be able to:

1. Describe and appreciate the important functions of fats in our bodies and our diets.

2. Identify the three major types of lipids, and describe their structure, food sources, and functions.

3. Describe the structure, food sources, and health impacts of saturated, polyunsaturated, monounsaturated, and
trans fatty acids.

4. Identify and define the essential fatty acids and their major functions.

5. Describe the processes of digestion and absorption of fats in the body.

6. Describe how lipids are transported around the body and utilized by cells, and what blood cholesterol values
indicate about a person’s health.

7. Explain the dietary recommendations for fats and the evidence for how dietary fats impact heart health.

References:

• Wolf, E. C., Woody, E., & Zuckerman, S. (2011). Salmon Nation: People, Fish, and Our Common
Home (2nd ed.). Corvallis, Oregon: Oregon State University Press.
• MacKinnon, J. B. (2015, July 7). ‘Salvation Fish’ That Sustained Native People Now Needs
Saving. Retrieved September 30, 2019, from National Geographic News website:
https://www.nationalgeographic.com/news/2015/07/150707-salvation-fish-canada-first-
nations-animals-conservation-world/
• National Marine Fisheries Service. September 2017. Recovery Plan for the Southern Distinct
Population Segment of Eulachon (Thaleichthys pacificus). National Marine Fisheries Service,
West Coast Region, Protected Resources Division, Portland, OR, 97232.

Image Credits:

• Fig 5.1 “Kuskokwim Smelt” by Andrea Pokrzywinski is licensed under CC BY 2.0

• Fig 5.2 and Fig 5.3. “Page of William Clark’s handwriting with sketch of the Eulachon
216 TAMBERLY POWELL, MS, RDN

(Thaleichthys pacificus), the first notice of the species.” by David Starr Jordan, Freshwater
and Marine Image Bank, University of Washington is in the Public Domain
• “A TSIMSHIAN FAMILY MAKING EULACHON BUTTER” by Will S. Taylor, American Museum of
Natural History Library is in the Public Domain
The Functions of Fats

Fats serve useful functions in both the body and the diet. In the body, fat functions as an important
depot for energy storage, offers insulation and protection, and plays important roles in regulating
and signaling. Large amounts of dietary fat are not required to meet these functions, because most
fat molecules can be synthesized by the body from other organic molecules like carbohydrate and
protein (with the exception of two essential fatty acids). However, fat also plays unique roles in the
diet, including increasing the absorption of fat-soluble vitamins and contributing to the flavor and
satisfaction of food. Let’s take a closer look at each of these functions of fats in the body and in the
diet.

THE FUNCTIONS OF FATS IN THE BODY

Storing Energy

The excess energy from the food we eat is incorporated into adipose tissue, or fatty tissue. Most
of the energy required by the human body is provided by carbohydrates and lipids. As discussed in
the Carbohydrates unit, glucose is stored in the body as glycogen. While glycogen provides a ready
source of energy, it is quite bulky with heavy water content, so the body cannot store much of it for
long. Fats, on the other hand, can serve as a larger and more long-term energy reserve. Fats pack
together tightly without water and store far greater amounts of energy in a reduced space. A fat gram
is densely concentrated with energy, containing more than double the amount of energy as a gram
of carbohydrate.
We draw on the energy stored in fat to help meet our basic energy needs when we’re at rest and
to fuel our muscles for movement throughout the day, from walking to class, playing with our kids,
dancing through dinner prep, or powering through a shift at work. Historically, when humans relied
on hunting and gathering wild foods or on the success of agricultural crops, having the ability to store
energy as fat was vital to survival through lean times. Hunger remains a problem for people around
the world, and being able to store energy when times are good can help them endure a period of
food insecurity. In other cases, the energy stored in adipose tissue might allow a person to weather
a long illness.
Unlike other body cells that can store fat in limited supplies, fat cells are specialized for fat storage
and are able to expand almost indefinitely in size. An overabundance of adipose tissue can be
detrimental to your health not only from mechanical stress on the body due to excess weight,
but also from hormonal and metabolic changes. Obesity can increase the risk for many diseases,
including type 2 diabetes, heart disease, stroke, kidney disease, and certain types of cancer. It can
also interfere with reproduction, cognitive function, and mood. Thus, while some body fat is critical
to our survival and good health, in large quantities it can be a deterrent to maintaining good health.

217
218 TAMBERLY POWELL, MS, RDN

Figure 5.3. Scanning electron micrograph of adipose tissue, showing adipocytes. Computer-
coloured orange.

Insulating and Protecting

1
The average body fat for a man is 18 to 24 percent and for a woman is 25 to 31 percent , but adipose
tissue can comprise a much larger percentage of body weight depending on the degree of obesity
of the individual. Some of this fat is stored within the abdominal cavity, called visceral fatfat,, and some
is stored just underneath the skin, called subcutaneous fat
fat. Visceral fat protects vital organs—such as
the heart, kidneys, and liver. The blanket layer of subcutaneous fat insulates the body from extreme
temperatures and helps keep the internal climate under control. It pads our hands and buttocks and
prevents friction, as these areas frequently come in contact with hard surfaces. It also gives the body
the extra padding required when engaging in physically demanding activities such as ice skating,
horseback riding, or snowboarding.
THE FUNCTIONS OF FATS 219

Figure 5.4. There are two types of fat stored as adipose tissue: subcutaneous fat and visceral fat.

Regulating and Signaling

Fats help the body to produce and regulate hormones. For example, adipose tissue secretes the
hormone leptin, which signals the body’s energy status and helps to regulate appetite. Fat is also
required for reproductive health; a woman who lacks adequate amounts may stop menstruating and
be unable to conceive until her body can store more energy as fat. Omega-3 and omega-6 essential
fatty acids help regulate cholesterol and blood clotting and control inflammation in the joints, tissues,
and bloodstream. Fats also play important functional roles in sustaining nerve impulse transmission,
memory storage, and tissue structure. Lipids are especially focal to brain activity in structure and
in function, helping to form nerve cell membranes, insulate neurons, and facilitate the signaling of
electrical impulses throughout the brain.

THE FUNCTION OF FATS IN THE DIET

Aiding Absorption and Increasing Bioavailability

The dietary fats in the foods we eat aid in the transport of fat-soluble vitamins, carrying them through
the digestive process and improving their intestinal absorption. This improved absorption is known
as increased bioavailability
bioavailability. Dietary fats can also increase the bioavailability of compounds known
as phytochemicals—non-essential plant compounds considered beneficial to human health. Many
phytochemicals are fat-soluble, such as lycopene found in tomatoes and beta-carotene found in
carrots, so dietary fat improves the absorption of these molecules in the digestive tract.
In addition to improving bioavailability of fat-soluble vitamins, some of the best dietary sources of
these vitamins are also foods that are high in fat. For example, good sources of vitamin E are nuts
(including peanut butter and other nut butters), seeds, and plant oils such as those found in salad
dressings, and it’s difficult to consume enough vitamin E if you’re eating a very low-fat diet. (Although
fried foods are usually cooked in vegetable oils, vitamin E is destroyed by high heat, so you won’t find
a lot of vitamin E in french fries or onion rings. Your best bets are minimally-processed, whole foods.)
Vegetable oils also provide some vitamin K, and fatty fish and eggs are good sources of vitamins A
and D.

Contributing to the Smell, Taste, and Satiety of Foods

Fats satisfy appetite (the desire to eat) because they add flavor to foods. Fat contains dissolved
compounds that contribute to mouth-watering aromas and flavors. Fat also adds texture, making
baked foods moist and flakey, fried foods crispy, and adding creaminess to foods like ice cream
and cream cheese. Consider fat-free cream cheese; when fat is removed from the cream, much
of the flavor is also lost. As a result, it is grainy and flavorless—nothing like its full-fat
counterpart—and many additives are used in an attempt to replace the lost
flavor.
 220 TAMBERLY POWELL, MS, RDN

Fats satisfy hunger (the need to eat) because they’re slower to be digested and absorbed than other
macronutrients. Dietary fat thus contributes to satiety
satiety—the feeling of being satisfied or full. When
fatty foods are swallowed, the body responds by enabling the processes controlling digestion to slow
the movement of food along the digestive tract, giving fats more time to be digested and absorbed
and promoting an overall sense of fullness. Sometimes, before the feeling of fullness arrives, people
overindulge in fat-rich foods, finding the delectable taste irresistible. Slowing down to appreciate the
taste and texture of foods can give your body time to send signals of satiety to your brain, so you can
eat enough to be satisfied without feeling overly full.

Providing Essential Fatty Acids

Most lipid molecules can be synthesized in the body from other organic molecules, so they don’t
specifically need to be provided in the diet. However, there are two that are considered essential and
must be included in the diet: linoleic acid and alpha-linolenic acid. We’ll discuss these two fatty acids
in detail later in the unit.

Self-Check:
 THE FUNCTIONS OF FATS 221

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Attributions:

• University of Hawai‘i at Mānoa Food Science and Human Nutrition Program, “The Function
of Lipids in the Body,” CC BY-NC 4.0

References:

• ACE (2009) What are the guidelines for percentage of body fat loss? American Council on
Exercise (ACE). Ask the Expert Blog. December 2, 2009.
• Obesity Prevention Source. Harvard T.H. Chan School of Public Health. Health Risks: Weight
Problems Take a Hefty Toll on Body and Mind. Retrieved from:
https://www.hsph.harvard.edu/obesity-prevention-source/obesity-consequences/health-
effects/

Images:

• Figure 5.3. “Adipose tissue, close-up showing adipocytes, SEM” by David Gregory & Debbie
Marshall is licensed under CC BY 4.0
• Figure 5.4. “Pandemic of Lifestyle Disease” by Sandra Cohen-Rose and Colin Rose is licensed
under CC-BY-2.0
• “French Fries in Paris” by Jim Larrison is licensed under CC BY 2.0
• “Eating a Burger Jonny B’z Dog and More Lourdie Dinner March 24, 20116” by Steven
Depolo is licensed under CC-BY-2.0
Lipid Types and Structures

Lipids are a family of organic compounds that are mostly insoluble in water, meaning they do not mix
well with water. There are three main types of lipids: triglycerides, phospholipids, and sterols.
On this page, we’ll learn about the structures of these three types of lipids, as well as their functions
in the body and where you can find them in foods.

TRIGLYCERIDES

Triglycerides are the main form of lipids in the body and in foods. More than 95 percent of lipids in
the diet are in the form of triglycerides, some having a visible presence and some hidden in foods.
Concentrated fats (butter and vegetable oil, for example) and marbling of fat in meat are obviously
visible. But fat can also be hidden in foods, as in baked goods, dairy products like milk and cheese,
and fried foods. Naturally occurring triglycerides are found in many foods, including avocados, olives,
corn, and nuts. We commonly call the triglycerides in our food “fats” and “oils.” Fats are lipids that are
solid at room temperature, whereas oils are liquid. The terms fats, oils, and triglycerides are often
used interchangeably. In this unit, when we use the word fat, we are referring to triglycerides.

222
LIPID TYPES AND STRUCTURES 223

Figure 5.5. 95% of fats in the diet are in the form of triglycerides. Sterols (like cholesterol) make up about
3% of dietary fat intake and phospholipids make up roughly 2% of dietary fat intake.
The structure of a triglyceride is made up of glycerol and three fatty acids. Glycerol is the three-
carbon backbone of triglycerides, while fatty acids are longer chains of carbon molecules attached
to the glycerol backbone. The “glyceride” in the word “triglyceride” refers to this glycerol backbone,
while the “tri” refers to the fact that there are three fatty acids attached. Fatty acids are called acids
because they have an acid group (−COOH) on one end of a carbon chain. A monoglyceride contains
glycerol with one fatty acid attached, and a diglyceride contains glycerol with two fatty acids attached.
224 TAMBERLY POWELL, MS, RDN

Figure 5.6. The chemical structure of a triglyceride, showing the glycerol backbone and three attached
fatty acids.

Figure 5.7. The structure of a triglyceride is often depicted as a simplified drawing of the glycerol
backbone and three fatty acids.
There are different types of fatty acids, and triglycerides can contain a mixture of them. Fatty
acids are classified by their carbon chain length and degree of saturation. Foods contain different
proportions of fatty acid types, and this influences disease risks associated with dietary patterns. We
will take a closer look at these differences, along with food sources, in the next section.

PHOSPHOLIPIDS

Phospholipids are found in both plants and animals but make up only about 2 percent of dietary
lipids. However, they play many important roles in the body and in foods. Phospholipids can also be
synthesized by the body, so they don’t have to be consumed in the diet.
Phospholipids are similar in structure to triglycerides (Figure 5.8). Like triglycerides, phospholipids
have a glycerol backbone. But unlike triglycerides, phospholipids only have two fatty acid molecules
attached to the glycerol backbone, while the third carbon of the glycerol backbone is bonded to a
phosphate group—a chemical group that contains the mineral phosphorus.
LIPID TYPES AND STRUCTURES 225

Figure. 5.8. The structural difference between a triglyceride (on the left) and a phospholipid (on the right)
is in the third carbon position, where the phospholipid contains a phosphate group instead of a fatty acid.
The unique structure of phospholipids makes them both fat- and water-soluble, or amphiphilic amphiphilic.
The fatty-acids are hydrophobic (dislike water), and the phosphate group and glycerol are hydrophilic
(attracted to water).
226 TAMBERLY POWELL, MS, RDN

Figure 5.9. A phospholipid molecule consists of a polar phosphate “head,” which is hydrophilic, and a
non-polar lipid “tail,” which is hydrophobic.
The amphiphilic nature of phospholipids makes them very useful for several functions in the
body. Every cell in the body is encased in a membrane composed primarily of a double layer of
phospholipids (also known as the phospholipid bilayer), which protects the inside of the cell from
the outside environment while at the same time allowing for transport of fat and water through the
membrane. Phospholipids also play a role in transporting fats in the blood, as we’ll learn later in this
unit.

Figure 5.10. The phospholipid bilayer consists of two adjacent sheets of phospholipids, arranged tail to
tail. The hydrophobic tails associate with one another, forming the interior of the membrane. The polar
heads contact the fluid inside and outside of the cell.
Another important role of phospholipids is to act as emulsifiers
emulsifiers. Emulsions are mixtures of two
liquids that do not normally mix (oil and water, for example). Without an emulsifier, the oil and water
separate out into two layers. Because of their ability to mix with both water and fat, phospholipids
are ideal emulsifiers that can keep oil and water mixed, dispersing tiny oil droplets throughout the
water. Lecithin—a phospholipid found in egg yolk, soybean, and wheat germ—is often used as a food
emulsifier. Emulsifiers also play an important role in making food appetizing; their inclusion in foods
like sauces and creams makes for a smoother texture and prevents the oil and water ingredients
from separating out. They also can extend shelf life.

https://youtu.be/QIRUMRc90BA
VIDEO: “How to Emulsify Sauces,” by International Culinary Center, YouTube (June 14, 2013), 2 minutes. In this
video, chef Sixto Alonso demonstrates how using an emulsifier—mustard, in this case—can allow oil and vinegar
to mix and stay in solution to make a salad dressing

STEROLS

Sterols have a very different structure from triglycerides and phospholipids. Most sterols do not
contain any fatty acids but rather are multi-ring structures, similar to chicken wire. They are complex
 LIPID TYPES AND STRUCTURES 227

molecules that contain interlinking rings of carbon atoms, with side chains of carbon, hydrogen, and
oxygen attached.
Cholesterol is the best-known sterol because of its role in heart disease. It forms a large part of the
fatty plaques that narrow arteries and obstruct blood flow in atherosclerosis
atherosclerosis. However, cholesterol
also has many essential functions in the body. Like phospholipids, cholesterol is present in all body
cells as it is an important substance in cell membrane structure. Cholesterol is also used in the body
as a precursor in the synthesis of a number of important substances, including vitamin D, bile, and
sex hormones such as progesterone, testosterone, and estrogens.

Figure 5.11. Cholesterol is made up of multiple carbon rings bonded together.

Cholesterol is not an essential nutrient; it does not need to be consumed in the diet, because it
is manufactured in the liver. Only foods that come from animal sources contain cholesterol.
Cholesterol is found in foods like meat, poultry, fish, egg yolks, butter, and dairy products made from
whole milk.
Plant foods do not contain cholesterol, but sterols found in plants resemble cholesterol in
structure. Plant sterols inhibit cholesterol absorption in the human body, which can contribute
to lower cholesterol levels, particularly lower LDL (“bad”) cholesterol levels. Plant sterols occur
naturally in vegetable oils, nuts, seeds, and whole grains. In addition, some foods like margarines and
dressings are fortified with plant sterols.

Self-Check:

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228 TAMBERLY POWELL, MS, RDN

Attributions:

• Lindshield, B. L. Kansas State University Human Nutrition (FNDH 400) Flexbook. goo.gl/
vOAnR, CC BY-NC-SA 4.0
• University of Hawai‘i at Mānoa Food Science and Human Nutrition Program, “Digestion and
Absorption of Lipids,” CC BY-NC 4.0

Image Credits:

• Figure 5.5. “Types of Fat” by Allison Calabrese is licensed under CC BY 4.0

• Figure 5.6. “The Structure of a Triglyceride” by Allison Calabrese is licensed under CC BY 4.0
• Figure 5.7. “Simple Triglyceride Diagram” by Alice Calahan is licensed under CC BY-SA 4.0
• Figure 5.8. “The Difference Between Triglycerides and Phospholipids” by Allison Calabrese is
licensed under CC BY 4.0
• Figure 5.9. “Phospholipid Structure” by J. Gordon Betts, Kelly A. Young, James A. Wise, Eddie
Johnson, Brandon Poe, Dean H. Kruse, Oksana Korol, Jody E. Johnson, Mark Womble, Peter
DeSaix is licensed under CC BY 4.0
• Figure 5.10. “Phospolipid Bilayer” by J. Gordon Betts, Kelly A. Young, James A. Wise, Eddie
Johnson, Brandon Poe, Dean H. Kruse, Oksana Korol, Jody E. Johnson, Mark Womble, Peter
DeSaix is licensed under CC BY 4.0
• Figure 5.11. “Cholesterol Chemical Structure” by Wesalius is in the Public Domain
Fatty Acid Types and Food Sources

On the previous page, we learned that triglycerides—the main form of fat in the body and in
food—are made up of a glycerol backbone with three fatty acids attached. As mentioned, fatty
acids can differ from one another in both carbon chain length and degree of saturation. These
characteristics influence the resulting fat in many ways.

CHAIN LENGTH OF FATTY ACIDS

Fatty acids have different chain lengths, typically between four and 24 carbons, and most contain an
even number of carbon atoms. When the carbon chain length is shorter, the melting point of the fatty
acid becomes lower (such as fats found in dairy products) and the fatty acid becomes more liquid.
Longer chain lengths tend to result in more solid fats, although melting point is also influenced by
the degree of saturation.

DEGREES OF SATURATION OF FATTY ACIDS

Fatty acid chains are composed primarily of carbon and hydrogen atoms that are bonded to each
other. The term “saturation” refers to whether the carbon atom in a fatty acid chain is filled (or
“saturated”) to capacity with hydrogen atoms. In a saturated fatty acid
acid,, each carbon is bonded to two
hydrogen atoms, with single bonds between the carbons.
Alternatively, fatty acids can have points where hydrogen atoms are missing, because there is a
double bond between carbons (C=C). This is referred to as a point of unsaturation, because the
carbon is only bonded to one hydrogen atom instead of two. Unsaturated fatty acids have one or
more points of unsaturation, or double bonds between the carbons. A monounsaturated fatty acid
is a fatty acid with one double bond, and a polyunsaturated fatty acid is a fatty acid with two or more
double bonds.

229
230 TAMBERLY POWELL, MS, RDN

Figure 5.12. The structures of a saturated, monounsaturated, and polyunsaturated fat. Note the
differences in points of unsaturation (C=C double bonds) on some of the fatty acids.
Triglycerides in food contain a mixture of saturated, monounsaturated, and
polyunsaturated fatty acids, but some foods are better sources of these types of fatty acids than
others (Figure 5.13). For example, coconut oil is very high in saturated fat, but it still contains some
monounsaturated and polyunsaturated fatty acids. Peanut oil is often thought of as a good source
of monounsaturated fat, because that is the predominant fatty acid in the oil, but peanut oil also
contains a fair amount of polyunsaturated fatty acids and even some saturated fatty acids.
FATTY ACID TYPES AND FOOD SOURCES 231

Figure 5.13. Dietary fats contain a mixture of saturated, monounsaturated, and polyunsaturated fatty
acids. Foods are often categorized by the predominant type of fatty acids they contain, even though foods
contain all three types.

Saturated Fatty Acids

Fat sources with a high percentage of saturated fatty acids tend to be solid at room temperature.
This is because the lack of double bonds in the carbon chains of saturated fatty acids makes them
very straight, so they pack together well (like a box of toothpicks). Fats that have mostly saturated
fatty acids, like butter and coconut oil, are solid at room temperature, as are the visible fat layers
in a strip of bacon or a cut of beef. Consuming a diet high in saturated fats is associated with an
increased risk of heart disease, because such a diet increases blood cholesterol, specifically the LDL
(“bad”) cholesterol level. (More on this later.) Food sources of predominately saturated fatty acids
include most animal fats (with the exception of poultry and eggs, which contain more unsaturated
fatty acids), dairy products, tropical oils (like coconut and palm oil), cocoa butter, and partially or fully
hydrogenated oils.
232 TAMBERLY POWELL, MS, RDN

Figure 5.14. Examples of foods high in saturated fat, such as meat and dairy products

Unsaturated Fatty Acids

Fat sources rich in unsaturated fatty acids tend to be liquid at room temperature, because the
C=C double bonds create bends in the carbon chain, making it harder for fatty acids to pack together
tightly. Consuming a diet rich in mono- and polyunsaturated fats is associated with a lower LDL
cholesterol level and a lower risk of heart disease.
Food sources of predominately monounsaturated fats include nuts and seeds like almonds,
pecans, cashews, and peanuts; plant oils like canola, olive, and peanut oils; and avocados. The
fat in poultry and eggs is predominantly unsaturated and contains more monounsaturated than
polyunsaturated fatty acids.

Figure 5.15. Examples of foods high in monounsaturated fat, such as olive oil, avocado, nut butters, and
seeds
Food sources of predominately polyunsaturated fats include plant oils (soybean, corn); fish;
flaxseed; and some nuts like walnuts and pecans.
FATTY ACID TYPES AND FOOD SOURCES 233

Figure 5.16. Examples of foods high in polyunsaturated fats, like fish and nuts

OMEGA-3, OMEGA-6, AND ESSENTIAL FATTY ACIDS

In addition to the length of the carbon chain and the number of double bonds, unsaturated fatty
acids are also classified by the position of the first double bond relative to the methyl (-CH3)
or “omega” end of the carbon chain (the end furthest from the glycerol backbone in a triglyceride).
Fatty acids with the first double bond at the third carbon from the omega end are called omega-3 fatty
acids
acids. Those with the first double bond at the sixth carbon from the omega end are called omega-6
fatty acids
acids. (There are also omega-9 fatty acids.)

Figure 5.17. The position of the first C=C double bond determines whether an unsaturated fatty acid
is classified as omega-3 or omega-6. The two essential fatty acids, linoleic acid (an omega-6) and alpha-
linolenic acid (an omega-3) are shown here.
Fatty acids are vital for the normal operation of all body systems, but the body is capable of
synthesizing most of the fatty acids it needs. However, there are two fatty acids that the body
cannot synthesize: linoleic acid (an omega-6) and alpha-linolenic acid (ALA, an omega-3). These are
called essential fatty acids because they must be consumed in the diet. Other fatty acids are called
nonessential fatty acids, but that doesn’t mean they’re unimportant; the classification is based solely
on the ability of the body to synthesize the fatty acid. Excellent food sources of linoleic fatty acid
include plant oils such as corn oil and soybean oil, often found in salad dressings and margarine.
Rich food sources of alpha-linolenic acid (ALA) include nuts, flaxseed, whole grains, legumes, and
dark green leafy vegetables.
234 TAMBERLY POWELL, MS, RDN

Figure 5.18. The chemical structure of the essential fatty acids shown in shorthand, without individual
carbon and hydrogen atoms marked.
Most Americans easily consume enough linoleic acid and other omega-6 fatty acids, because
corn and soybean oil are common ingredients in our food supply. However, sources of ALA and
other omega-3 fatty acids are less common in the American diet, and many people could benefit
from incorporating more sources of these into their diet. As an added benefit, whole foods rich
in ALA come packaged with other healthful nutrients, like fiber, protein, vitamins, minerals, and
phytochemicals.
A true essential fatty acid deficiency is rare in the developed world, but it can occur, usually in
people who eat very low-fat diets or have impaired fat absorption. Symptoms include dry and scaly
skin, poor wound healing, increased vulnerability to infections, and impaired growth in infants and
1
children.
Omega-3 and omega-6 fatty acids are precursors to a large family of important signaling molecules
called eicosanoids (prostaglandins are one type of eicosanoid). Among the many functions of
eicosanoids in the body, one of the most important is to regulate inflammation. Without these
hormone-like molecules, the body would not be able to heal wounds or fight off infections each time
a foreign germ presented itself. In addition to their role in the body’s immune and inflammatory
processes, eicosanoids also help to regulate circulation, respiration, and muscle movement.
Eicosanoids derived from omega-6 fatty acids tend to increase blood pressure, blood clotting,
immune response, and inflammation. These are necessary functions, but they can be associated
with disease when chronically elevated. In contrast, eicosanoids derived from omega-3 fatty acids
tend to lower blood pressure, inflammation, and blood clotting, functions that can benefit heart
health. Omega-3 and omega-6 fatty acids compete for the same enzymatic pathways in the formation
of different eicosanoids, so increasing omega-3 fatty acids in the diet may have anti-inflammatory
effects.
Two additional omega-3 fatty acids with important health benefits are eicosapentaenoic acid (EPA)
and docosahexaenoic acid (DHA)
(DHA). These long-chain polyunsaturated fatty acids have been shown
to help lower blood triglycerides and blood pressure, reduce inflammation, and prevent blood
clot formation. They also promote normal growth and development in infants, especially in the
development of the brain and eyes. Both of these important omega-3 fatty acids can be synthesized
in the body from ALA, so they are not considered essential fatty acids. However, the rate of
conversion of ALA to these omega-3s is limited, so it is beneficial to consume them regularly in the
diet. Fish, shellfish, fish oils, seaweed, and algae are all good sources of EPA and DHA. DHA is
also found in human breast milk in quantities dependent on the mother’s own intake of DHA sources.
FATTY ACID TYPES AND FOOD SOURCES 235

Figure 5.19. EPA and DHA are important but non-essential omega-3 fatty acids that can be made in the
body from ALA.
Fish oil and omega-3 supplements are among the most commonly used dietary supplements in
the United States. Researchers have hypothesized that these supplements might decrease risk of
cardiovascular disease, be helpful for those with rheumatoid arthritis, and improve infant brain
development when taken in pregnancy or in infancy. Some studies have found such benefits of
the supplements, but others haven’t. One reason for these inconsistent results may be that studies
often don’t measure participants’ baseline omega-3 levels and intake from foods, and those already
consuming adequate omega-3s are less likely to benefit from a supplement. The Dietary Guidelines
for Americans recommends consuming 8 ounces of a variety of seafood each week, and in general,
people who meet this recommendation likely consume enough omega-3 fatty acids already (along
with the other healthful nutrients found in fish) and are unlikely to see an added benefit of taking a
fish oil supplement. Some doctors may recommend that people at risk of cardiovascular disease take
2
a fish oil or omega-3 supplement, especially if they don’t eat fish regularly.

A WORD ABOUT TRANS FATS

The carbon-carbon double bond in an unsaturated fatty acid chain can result in different shapes
depending on whether the fatty acid is in a cis or trans configuration. When the hydrogen atoms are
bonded to the same side of the carbon chain, it is called a cis fatty acid. Because the hydrogen atoms
are on the same side (and repelling one another), the carbon chain has a bent structure. Naturally-
occurring fatty acids usually have a cis configuration.
In a trans fatty acid, the hydrogen atoms are bonded on opposite sides of the carbon chain,
resulting in a more linear structure. Unlike cis fatty acids, most trans fatty acids are not found
naturally in foods, but instead are a result of an industrial process called hydrogenation.
Hydrogenation is the process of adding hydrogen to the carbon-carbon double bonds, thus making
the fatty acid saturated (or less unsaturated, in the case of partial hydrogenation).
Hydrogenation creates both saturated and trans fatty acids. Trans fatty acids are actually
unsaturated fatty acids, but they have the linear shape of saturated fatty acids. (The carbon chains
are not bent like naturally-occurring unsaturated fats.) The trans fatty acids formed through
partial hydrogenation have an unusual shape, which makes their properties and actions in
the body similar to saturated fatty acids.
236 TAMBERLY POWELL, MS, RDN

Figure 5.20. Comparison of a saturated fatty acid to both the cis and trans forms of an unsaturated fatty
acid.
Hydrogenation was developed in order to make oils semi-solid at room temperature, enabling
production of spreadable margarine and shortening from inexpensive ingredients like corn oil.
Hydrogenation also makes oils more stable and less likely to go rancid, so partially hydrogenated
oils were favored by fast food restaurants for frying, and manufacturers of processed baked goods
like cookies and chips found they gave their products a longer shelf life. And because trans fats
are unsaturated, nutrition scientists and the medical community believed that they were a healthier
alternative to saturated fats.
But around the 1990s, evidence that trans fats were not healthy—far worse than saturated fats,
in fact—began to accumulate. Like saturated fat, trans fats increase LDL (“bad”) cholesterol, but
they also have the effect of decreasing HDL (“good”) cholesterol and of increasing inflammatory
processes in the body. Researchers found that consuming trans fats, even at low levels (1 to 3
percent of total energy intake), was associated with an increased risk of coronary heart disease. They
estimated that eliminating industrial trans fats from the food supply might prevent as many as 19
3
percent of heart attacks in the U.S. at the time, coming to 228,000 heart attacks averted.
In 2006, the U.S. Food and Drug Administration (FDA) began requiring food companies to list trans
fat information on the Nutrition Facts panel of food labels to keep consumers informed of their
 FATTY ACID TYPES AND FOOD SOURCES 237

intake of these fats. That prompted the food industry to mostly eliminate partially hydrogenated oils
from their products, often substituting palm oil and coconut oil in their place (both of which are
high in saturated fat and may promote heart disease). In 2013, the FDA determined that trans fats
were no longer considered safe in the food supply, and in 2015, the agency issued a ruling requiring
that manufactured trans fats no longer be included in the U.S. food supply. A one-year extension
was granted in 2018, and foods produced prior to that date were given time to work through the
food supply. The final ruling requires all manufactured trans fats to be eliminated from the U.S. food
4
supply by 2021.

Self-Check:

An interactive H5P element has been excluded from this version of the text. You can view it online here:

https://openoregon.pressbooks.pub/nutritionscience/?p=271#h5p-10

Attributions:

• Lindshield, B. L. Kansas State University Human Nutrition (FNDH 400) Flexbook. goo.gl/
vOAnR, CC BY-NC-SA 4.0
• University of Hawai‘i at Mānoa Food Science and Human Nutrition Program, “Digestion and
Absorption of Lipids,” CC BY-NC 4.0

References:

1
• Oregon State University. (2014, April 28). Essential Fatty Acids. Retrieved October 17, 2019,
from Linus Pauling Institute website: https://lpi.oregonstate.edu/mic/other-nutrients/
essential-fatty-acids
2
• National Institutes of Health. Office of Dietary Supplements—Omega-3 Fatty Acids.
Retrieved October 17, 2019, from https://ods.od.nih.gov/factsheets/Omega3FattyAcids-
HealthProfessional/
3
• Mozaffarian, D., Katan, M. B., Ascherio, A., Stampfer, M. J., & Willett, W. C. (2006). Trans
fatty acids and cardiovascular disease. The New England Journal of Medicine, 354(15),
1601–1613. https://doi.org/10.1056/NEJMra054035
4
• Center for Food Safety and Applied Nutrition. (2018, May 18). Final Determination
Regarding Partially Hydrogenated Oils. Retrieved from https://www.fda.gov/food/food-
additives-petition