Nourishment A WELLography™
First Edition

Copyright

Copyright

Copyright© 2017 International WELL Building Institute PBC. All rights reserved.

International WELL Building Institute PBC authorizes personal use of this Nourishment WELLography™, which includes the ability by the user to download and print a single copy of the Nourishment WELLography™ for the user’s own education and reference. In exchange for this authorization, the user agrees:

1. not to remove any copyright or other proprietary notices contained in the Nourishment WELLography™;

2. not to modify the Nourishment WELLography™; and

3. not to sell, reproduce, display or distribute the Nourishment WELLography™ in any way for any public or commercial purpose. If you are interested in reproducing, displaying or distributing the Nourishment WELLography™ for any public or commercial use, please contact info@wellcertified.com at International WELL Building Institute PBC.

Unauthorized use of the Nourishment WELLography™ violates copyright, trademark, and other laws and is prohibited.

Credits

The International WELL Building Institute also acknowledges the important work of Melcher Media in bringing this document to market in its current state.

Produced By:


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Assistant Editor: Karl Daum

Design & Development by Crush + Lovely

Illustrations by Kaarina Mackenzie

Animations by Vita Newstetter

Melcher Media would like to thank Callie Barlow, Jess Bass, David Brown, Dylan Butman, Tova Carlin, Maria Gagliano, Barbara Gogan, Luke Jarvis, Weronika Jurkiewicz, David Kahn, Susan Lynch, Sami Melcher, John Morgan, Lauren Nathan, Julia Sourikoff, Tori Spencer, Saif Tase, Zoe Valella, and Megan Worman.

Acknowledgements

The International WELL Building Institute (IWBI) and Delos Living LLC (Delos) acknowledge the work of the following IWBI and Delos technical staff that developed and created the WELLographies: Oriah Abera; Niklas Garrn; Trevor Granger; Soyoung Hwang; Michelle Martin; Vienna McLeod; Anja Mikic; Renu Nadkarni; Brendan O’Grady; Chris Ramos; Eric Saunders; Sara Scheineson; Nathan Stodola; Regina Vaicekonyte; Sarah Welton; Kylie Wheelock; and Emily Winer.

IWBI also is grateful for the input and insight provided by the following Subject Matter Experts:

Air: Terry Gordon, PhD; Eric Liberda, PhD; Tim McAuley, PhD; Ellen Tohn, MCP

Water: Eric Liberda, PhD; Tim McAuley, PhD; Margret Whittaker, PhD, MPH, CBiol, FSB, ERB, DABT, ToxServices LLC

Nourishment: Sharon Akabas, PhD; Alice H. Lichtenstein, DSc; Barbara Moore, PhD

Light: Chad Groshart, LEED AP BD+C; Samer Hattar, PhD; Steven Lockley, PhD, Consultant, Delos Living LLC and Member, Well Living Lab Scientific Advisory Board, Neuroscientist, Brigham and Women’s Hospital and Associate Professor of Medicine, Harvard Medical School

Fitness: Dr. Karen Lee, MD, MHSc, FRCPC, President & CEO, Dr. Karen Lee Health + Built Environment + Social Determinants Consulting; Jordan Metzl, MD

Thermal Comfort: Alan Hedge, PhD, CPE, CErgHF; David Lehrer, MArch; Caroline Karmann, PhD, MArch

Acoustics: Arline L. Bronzaft, PhD, Professor Emerita of The City University of New York; Charles Salter, PE

Materials: Clayton Cowl, MD; Matteo Kausch, PhD, Cradle to Cradle Products Innovation Institute; Megan Schwarzman, MD, MPH; Margret Whittaker, PhD, MPH, CBiol, FSB, ERB, DABT, ToxServices LLC

Mind: Anjali Bhagra, MBBS; Lisa Cohen, PhD; Keith Roach, MD; John Salamone, PhD; Nelida Quintero, PhD

Disclaimer

None of the parties involved in the funding or creation of the WELL Building Standard™ and the WELLographies™, including Delos Living LLC, its affiliates, subsidiaries, members, employees, or contractors, assume any liability or responsibility to the user or any third parties for the accuracy, completeness, or use of or reliance on any information contained in the WELL Building Standard and the WELLographies, or for any injuries, losses, or damages (including, without limitation, equitable relief) arising from such use or reliance.

Although the information contained in the WELL Building Standard and the WELLographies is believed to be reliable and accurate, all materials set forth within are provided without warranties of any kind, either express or implied, including but not limited to warranties of the accuracy or completeness of information or the suitability of the information for any particular purpose.

The WELL Building Standard and the WELLographies are intended to educate and assist building and real estate professionals in their efforts to create healthier work and living spaces, and nothing in the WELL Building Standard and the WELLographies should be considered, or used as a substitute for, medical advice, diagnosis or treatment.

As a condition of use, the user covenants not to sue and agrees to waive and release Delos Living LLC, its affiliates, subsidiaries, members, employees, or contractors from any and all claims, demands, and causes of action for any injuries, losses, or damages (including, without limitation, equitable relief) that the user may now or hereafter have a right to assert against such parties as a result of the use of, or reliance on, the WELL Building Standard and the WELLographies.

Welcome to WELL

The buildings where we live, work, learn and relax have a profound effect on our well-being: how we feel, what we eat and how we sleep at night. By examining our surroundings and our habits, and making key optimizations and changes, we have the power to cultivate spaces that promote wellness, and support efforts to live healthier, active, mindful lives – a right for every human.

The WELL Building Standard™ (WELL) envisions this reality and opens this critical dialogue. It provides a roadmap and a comprehensive set of strategies for achieving building and communities that advance human health.

WELL consists of a comprehensive set of features across seven concepts (Air, Water, Light, Nourishment, Fitness, Comfort and Mind). Together, these components address the various individual needs of the people inside buildings, while also setting forth a common foundation for measuring wellness in buildings as a whole. The standard was developed by integrating scientific research and literature on environmental health, behavioral factors, health outcomes and demographic risk factors that affect health; with leading practices in building design and management. WELL also references existing standards and best practice guidelines set by governmental and professional organizations, where available, in order to clarify and harmonize existing thresholds and requirements.

The result is the premier building standard for advancing human health and wellness – and a blueprint for creating better buildings that can enhance productivity, health and happiness for people everywhere.

How to Use this WELLography™

WELLographies™ present research relevant to health and well-being in buildings and communities. The sources included span health, wellness, and scientific and professional literature specific to the seven concepts within WELL, and other core focus areas. WELLographies are meant to complement the WELL Building Standard™ (available at standard.wellcertified.com) and provide architects, building managers, engineers, and interior designers, among others, with health- and science-focused background to support and guide their efforts to advance the healthy buildings movement.

WELLographies have three primary goals:

1. Provide background information for key topics relevant to understanding human health as it relates to the built environment.
2. Synthesize and present the science that underpins the WELL Building Standard™.
3. Outline specific, evidence-based strategies that building professionals can apply to create spaces that promote health and well-being in buildings and communities.

There are nine WELLographies:

1. Air
2. Water
3. Nourishment
4. Light
5. Fitness
6. Thermal Comfort
7. Acoustics
8. Materials
9. Mind

The Nourishment WELLography™ has the following sections:

Nourishment and the Built Environment, which broadly describes how Nourishment relates to the human experience in buildings.

Properties of Nourishment, describes important technical components, including any terms that will be discussed throughout the WELLography.

Nourishment and the Human Body, which provides an explanation of the biological mechanisms relating to Nourishment, describing how the body functions under normal, healthy conditions.

Elements of Nourishment, which describes environmental conditions or behaviors that are linked to health, focus, or occupant comfort, and that are subject to interventions in building design or policy. Each element includes coverage of associated health effects as well as solutions, interventions that can be implemented to impact the element. Some solutions may address several different elements.

Explanations of Solutions, which provides a definition and/or more detail for each solution.

Appendices include a description of the key components to a healthy diet.

Introduction

Diet is critical to human health; it plays a key role in chronic disease prevention and weight management. Poor diet can lead to overweight and obesity, increasing the risk of diabetes, heart disease, and cancer, whereas a healthy diet can do the opposite, helping to manage weight and reducing the risk of chronic illness.¹

Numerous aspects of the outdoor environment impact our food options and choices, such as proximity to grocery stores, farmers’ markets, greenmarkets, and gardening opportunities. Aspects of the spaces in which we live, learn, work, and play, and policies applied therein, also influence our choices, such as availability of healthy foods and beverages, appealing presentation of healthier food options, marketing of healthy foods, nutrition education, and other programs. If designed with human health as a top priority, spaces in which we live, learn, work, and play can act as preventive public health measures, improving and maintaining dietary patterns and in turn contributing to overall health.

Science has produced contradictory evidence regarding the relationship between specific dietary components and human health, yet nutrition scientists generally agree that a healthy dietary pattern is high in fruits and vegetables, whole grains, nuts and legumes, seafood, and low-/non-fat dairy; is moderate in alcohol (among adults) and lower in red and processed meat; and is low in sugar-sweetened foods and beverages and refined grains.² Within this broad framework for healthy eating, there is considerable room for diversity to accommodate individual food preferences. Consequently, the Nourishment WELLography™ notes the benefits of diets comprised primarily of whole plant foods that avoid processed foods high in calories, saturated fat and sugar, allowing freedom and flexibility with food choices.

The Nourishment WELLography™ addresses the aspects of diet quality that can be impacted through the environment. It provides an overview of the human body in relation to diet, lists the properties of the main nutrients, summarizes the current research on the links between nutrition and health, and proposes science-, policy- and expert recommendation–based strategies for creating spaces that encourage making the healthy choice the easy choice. It also aims to provide strategies directed towards improving the dietary patterns of individuals in order to help individuals prevent excess weight gain. From creating neighborhoods with access to fruits and vegetables to choosing dishware that helps with portion control, these solutions intend to optimize the design and management of the spaces in which people live, work, and play, and will allow designers, building managers, and professionals to promote human health and wellness in exciting new ways.

The Current State of Nutrition

The United States (U.S.) population’s dietary patterns are less than optimal, with some individuals consuming adequate nutrients but too many calories, while others consume adequate calories but too few nutrients. Data from the National Health and Nutrition Examination Survey (NHANES) shows that in the U.S. the mean intake of energy (adjusted for age, body mass index (BMI), educational status, race or ethnicity, and sex) has increased by 314 Calories from 1971–1975 to 2003–2004, from 1,955 Calories/day to 2,269 Calories/day.³

Fortunately, after rising for several decades, calorie intake is finally in decline. In 2009–2010, adjusted mean energy intake was 2,195 Calories,³ and data from 2011–2012 indicate that the mean calorie intake has declined further to 2,191 Calories/day,⁴ a significant change (78 Calories) since 2003–2004 (Figure 1).

While these trends are optimistic, Americans still follow dietary patterns that are far from optimal. Currently, the vast majority of the U.S. population does not meet the recommended nutrient intakes for key food groups, including fruits, vegetables, whole grains, and dairy, while consuming too many added sugars, solid fats, and refined grains.² In 2009, the Centers for Disease Control and Prevention (CDC) estimated that an average of only 26% of U.S. adults consumed the recommended number of vegetable servings (three or more per day) and that 33% consumed the recommended number of fruit servings (two or more per day) (Figure 2).⁵ In 2013, these trends were confirmed by the CDC’s State Indicator Report on Fruits and Vegetables, which reported that the national intake of fruits and vegetables is below the recommended level, with U.S. adults consuming fruit about 1.1x/day and vegetables 1.6x/day.⁶ Studies also show that fruit and vegetable consumption decreases with age from childhood to adolescence, with nine out of 10 children (aged two to five years) consuming fruit on a given day, compared to only six out of 10 adolescents, and more children than adolescents consuming vegetables on a given day.⁷

Along with the declining total calorie intake, the consumption of added sugars seems to be slightly decreasing as well. Evidence from NHANES data suggests that while sugar-sweetened beverage (SSB) consumption remains above recommended levels, overall SSB consumption, particularly for soda, has declined in 2009–2010 compared to what it was in 1999–2000.⁸ However, the energy intake from added sugars (such as SSBs and sugar added to foods) and alcoholic beverages has been rising for decades and is still very high. People consume large quantities of sugar both in the U.S.² and worldwide.⁹ The intake varies significantly though, from around 17 kg [37.5 lbs]/capita in Africa and Asia to nearly 44 kg [97 lbs] and 37 kg [81.5 lbs] in America and Europe, respectively.⁹

The clear majority—nearly 90%—of the U.S. population consumes calories from added sugars that are in excess of the recommended levels². In 2005–2010, males and females consumed an average of 335 and 239 Calories per day in added sugars, respectively, equal to about 21 and 15 teaspoons (tsp) of sugar, respectively.¹⁰ The Scientific Report of the 2015 Dietary Guidelines Committee shows that intake remains high, with the average consumption of added sugars and caloric sweeteners comprising about 13.4% (down from 15.7% reported in 2010) of total calories consumed per day.² These levels of intake are about 3% above the target goal of 10.8% set forth by the Healthy People 2020¹¹ and the World Health Organization (WHO).¹² Major sources of overconsumption include soda, energy and sports drinks, grain-based desserts, sugar-sweetened fruit drinks, dairy-based desserts and candy.¹³ This intake is considerably higher than the American Heart Association’s (AHA) recommendation of a five to six tsp (100 Calories) per day limit for women and a nine tsp (150 Calories) per day limit for men.^{14 15} The WHO recommends limiting added sugar to less than 10% of all calories, with a conditional recommendation to limit it to less than 5% of all calories in light of associations with dental caries.¹²

Sugar-sweetened beverages (SSBs) are the largest contributors to added sugar intake, with soda consumption leading the category.¹⁶

According to NHANES, half of the U.S. population (aged two and older) consumes SSBs on any given day, a quarter takes in less than 200 Calories (more than one 12-oz can of soda), 20% consumes between 200 and 567 Calories, and 5% consumes at least 567 Calories (more than four 12-oz cans of soda) from SSBs every day (Figure 3).¹⁷

These suboptimal dietary patterns are unfortunate because low intake of fruits and vegetables has been linked to the development of many chronic diseases as well as premature mortality,¹⁸ while the intake of added sugars has been linked to weight gain, obesity¹⁹, hypertension, heart disease²⁰, diabetes, metabolic syndrome,²¹ and dental caries.¹²

Together with physical inactivity, overconsumption of calories is a major contributor to the U.S. overweight and obesity epidemic, increasing the risk of cardiovascular disease, diabetes, and some cancers, among other health issues.²² Over two thirds (69%) of American adults (20 years and older) are overweight (BMI of 25–29.9) and more than a third (35%) are obese (BMI of 30 or higher)(Figure 4).²³ Although the rates of overweight and obese Americans have stabilized in recent years, they remain high and, as such, impose a significant health burden on the U.S. population. In addition, obesity rates have more than doubled in young children and quadrupled in adolescents in just the past 30 years,²⁴ and most the world’s population currently lives in countries where overweight and obesity kills more people than underweight.²⁵

The WHO reports that overweight and obesity are the fifth leading risk factor for global deaths.²²

The latest estimates indicate that 795 million people worldwide remain undernourished or hungry, a number that is down by an estimated 167 million over the last decade,²⁷ while 165 million children under the age of five are stunted, a symptom of chronic undernutrition.²⁸ In 2014 more than 1.9 billion people were overweight, of which over 600 million were obese, making overweight and obesity not just an epidemic but a global pandemic (FIgures 5a and 5b).²⁵

Given the high rates of obesity and its associated diseases, much research has been dedicated to examining the dietary components that may affect the risk of one or more health parameters, such as the relationship between SSBs and type 2 diabetes, or the association between red and processed meat intake and colorectal cancer. Some of this research has produced conflicting results, highlighting the challenge of assessing the totality of the data and drawing conclusions. One example of inconsistent data can be seen in the link between saturated fat and heart disease. Some of the recent research has not found an association between saturated fat intake and heart disease risk, while other studies have. Some data suggest that replacing saturated fat with carbohydrates has a neutral effect on cardiovascular disease (CVD) rates, whereas replacing saturated fat with polyunsaturated fatty acids (PUFA) reduces CVD rates.³¹ Studies that did not account for replacement found an inconsistent association with saturated fat and CVD rates,^{32 33} whereas studies that did take this into consideration found a beneficial effect of replacing saturated fat with polyunsaturated fat.^{31 34} Another example of conflicting research findings is the relationship between dietary cholesterol and CVD. Based on contemporary intakes and the lack of evidence that additional reductions in dietary cholesterol would have an appreciable effect on low-density lipoprotein cholesterol (LDL-C) concentrations, or that cholesterol consumed within the range of 300 mg per day is associated with a lower risk of heart disease, the Scientific Report of the 2015 Dietary Guidelines Advisory Committee no longer identifies cholesterol as a nutrient of concern for overconsumption, contrary to the long-standing recommendation to limit its intake to 300 mg per day.² The AHA and American College of Cardiology Lifestyle Management Guideline to Reduce Cardiovascular Risk arrived at a similar conclusion.³⁵

Fortunately, nutrition research consistently supports a singular dietary strategy for promoting health and decreasing overall risk of disease: a diet comprised primarily of whole foods (e.g., an apple vs. juice or sugar-sweetened soda; whole grain bread vs. refined bread; daily fruits, vegetables, and salad vs. microwavable pizza and other processed foods high in calories, saturated fat, and sugar). The 2015 DGAC Report recommends following a healthy dietary pattern to promote a healthy body weight and reduce the risk of chronic disease. A healthy dietary pattern is defined as one that is “…higher in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meat; and low in sugar sweetened foods and drinks and refined grains.”² Because there are many ways to achieve this pattern,² the Nourishment WELLography™ does not advocate any specific diet and instead focuses on promoting the broad principles of a healthy, wholesome, primarily plant-based diet to maintain optimal health.

Nourishment and the Built Environment

An individuals’ dietary patterns are affected by a variety of social, economic, physiological, and environmental factors; the built environment is one of them. Various design, planning, policy, and organizational strategies exist that can effectively promote and encourage people to improve their dietary patterns within the spaces in which they live, study, work, and play.

In many cases, neighborhoods, schools, workplaces, and other public places fail to promote or encourage healthy eating behaviors. For example, the CDC reports that only about 70% of all U.S. census tracts have at least one store offering a wide variety of affordable fruits and vegetables.⁶ In addition, more than two million U.S. households without cars or access to reliable transportation are located more than a mile away from a supermarket or large grocery store.³⁶ Lack of access to affordable, healthy foods has been associated with lower quality diets^{37 38} and an increased risk of obesity.³⁹ Finally, the U.S. food industry spends more than a billion dollars annually marketing foods to children and adolescents that are inconsistent with recommended dietary patterns ⁴⁰ which, according to the National Academy of Medicine, is “out of balance with healthful diets and contributes to an environment that puts their health at risk”.⁴¹

Many private, government, and health organizations are working to improve the food and beverage environment to enhance public health. Evidence suggests that our built environments can have positive and negative impacts on physical activity, body weight, and dietary patterns.^{42 43 44 45 46} Thus, it is critical that we take into account urban planning, design, and construction when building our homes, schools, workplaces, and other spaces. The places in which we live, learn, work, and play can promote wellness if we consciously construct buildings and neighborhoods that encourage healthy lifestyles and eating patterns.

Strategic design in cafeterias,⁴⁷ access to affordable grocery stores and farmers’ markets that have a variety of affordable fruits and vegetables, food marketing, accessible nutrition information, and many other properties of space can affect our overall dietary patterns. For example, places that sell food can make healthy choices (e.g., fruits and vegetables, whole grains, and low fat dairy products, etc.) more appealing via attractive displays, visual prompts, and nutritional information that can help encourage healthy food consumption. In addition, universal nutrition education in schools (including food purchasing and preparation) and farm-to-school and gardening programs can introduce healthy eating concepts while offering hands-on experiences that promote healthy behaviors from an early age. The marketing and availability of unhealthy foods can be limited or restricted to remove environmental cues and reduce access to suboptimal food choices. Furthermore, glassware, dinnerware, and meal serving sizes can be controlled; and spaces that promote mindful eating can be created to reduce calorie overconsumption. Strategies to reduce the risk of food allergies can also be implemented, such as clearly labeling all food allergens, reducing cross-contact, and providing meal alternatives for individuals with dietary restrictions.

Properties of Nourishment

The following are key terms frequently used in nutrition science. They provide an understanding of what nutrients are and how they are classified, outline their sources and composition, and explain the basis for dietary nutrient intake recommendations.

Calorie

A calorie is a unit of energy, specifically heat energy, that is used to measure a food’s energy content. In nutrition, a food calorie is the amount of energy needed to raise the temperature of one liter of water by one degree Celsius under standard conditions. A food calorie is denoted as Calorie with an upper case “C” and is equal to 1,000 calories, or one kilocalorie (kcal). The energy content of food can also be expressed in joules (J) and kilojoules (kJ); one Calorie is equal to about 4.2 kJ. The caloric content of food available to the body must be adjusted to account for the losses that occur during digestion. The remaining calories are available to the body for metabolism. Therefore, the calories reflected in food labels represent the amount of energy that is contained in a food and that is actually available to the human body for absorption and utilization (i.e., metabolism) when consumed.

One gram (g) of carbohydrate is equivalent to four Calories; one gram of protein is equivalent to about four Calories; one gram of fat is equivalent to about nine Calories; and one gram of alcohol is equivalent to about seven Calories.

Essential Nutrients

Essential nutrients are components of food that are required for the body to function properly, providing energy and materials to support growth and reproduction as well as tissue maintenance and repair. Essential nutrients are frequently grouped into categories, including macronutrients (protein, fat, and carbohydrate), micronutrients (vitamins and minerals), and water. The distinguishing characteristic of essential nutrients is that the human body cannot make them in adequate amounts to support growth, maintenance, and reproduction. Therefore, essential nutrients must be consumed in the diet and include all the vitamins and minerals required by humans as well as certain amino and fatty acids and water.

Nutrients of Concern

The 2015 DGAC has identified several nutrients that are of public health concern due to either under- or overconsumption by the U.S. population (two years old and older) relative to the Estimated Average Requirement (EAR) or Adequate Intake (AI) levels set by the National Academy of Medicine. Nutrients that are under-consumed by the U.S. population include calcium, folate, vitamin A, vitamin D, vitamin E, vitamin C, fiber, and potassium, as well as iron by adolescent and premenopausal women.² Nutrients that are over-consumed by the U.S. population include sodium and saturated fat.² This information helps shape the Nutrition Facts label which helps consumers make informed decisions about the foods they eat. As of 2018, U.S. food manufacturers are required to declare the amount of vitamin D, calcium, iron and potassium a food contains as part of the Nutrition Facts label.⁴⁸ Vitamin D and potassium were added to the label once they were identified as under-consumed nutrients in nationwide food consumption surveys.

Dietary Reference Intakes (DRIs)

The DRI is a system of nutrient intake standards developed and used by the U.S. and Canada. There are multiple categories embedded within the DRI system: Estimated Average Requirements (EAR), Recommended Dietary Allowances (RDA), Adequate Intakes (AI), and Tolerable Upper Intake Levels (UL).⁵⁰

ESTIMATED AVERAGE REQUIREMENT (EAR)

An EAR is the average daily nutrient intake level estimated to meet the requirements of half of the healthy individuals in a particular life stage and gender group.⁵⁰

RECOMMENDED DIETARY ALLOWANCE (RDA)

An RDA is the average daily dietary intake level of a nutrient that meets the requirements of nearly all (97–98%) healthy individuals in a particular life stage and gender group.⁵⁰ It is calculated by adding two standard deviations (SD) to the EAR. If there is inadequate data to calculate an SD, the SD is estimated as 10% of the EAR. RDAs are used as the basis for calculating Daily Values (DV; see explanation below) found on Nutrition Facts labels.

ADEQUATE INTAKE (AI)

Adequate intake is the recommended daily nutrient intake level assumed to be adequate and is based on observations or experimental approximations of nutrient intake by healthy individuals.⁵⁰ AI is used when scientific evidence is not sufficient to establish an RDA. A nutrient therefore has either an RDA or an AI.

TOLERABLE UPPER INTAKE LEVEL (UL)

A UL is the highest level of daily nutrient intake that is likely to pose no risk of toxicity or adverse health effects to almost all individuals in the general population.⁵⁰ It is not a nutrient’s recommended level of intake; it represents the highest intake level at which a nutrient can be consumed without the risk of causing harm. Some nutrients do not have ULs, which does not imply that they are safe to consume in any amount; it means that the data are currently insufficient to establish a UL value.⁵⁰

Acceptable Macronutrient Distribution Range (AMDR)

An AMDR is a range of healthy intakes for macronutrients that serve as energy sources (carbohydrate, fat, or protein) and is associated with reduced chronic disease risk.⁴⁹ The AMDR takes into consideration that consuming a diet within the recommended ranges allows for adequate intakes of essential nutrients. AMDRs are expressed as a percentage of total energy intake because recommended intakes are dependent on the total energy intake requirements and other energy sources of the individual. For adults, the AMDR is 10–35% of calories from protein, 20–35% from fat and 45–65% from carbohydrate.⁴⁹ They are expressed as ranges because there are no specific amounts associated with optimal health outcomes.

Two factors need to be considered when determining the optimal range of nutrient intake: the minimum amount of the nutrient needed for the body to function normally (benefit) and the maximum amount of the nutrient compatible with normal function (risk) and optimal health outcomes.⁵¹ Thus, a range of nutrient intakes has been established, which is between the lowest level of nutrient intake needed to prevent deficiency and its associated adverse health effects, and the highest level of nutrient intake before adverse health effects begin (Figure 6). The Estimated Average Requirement (EAR) is the level of nutrient intake at which inadequacy risk is 0.5 (50%); the Recommended Dietary Allowance (RDA) is the level of nutrient intake at which inadequacy risk is 0.02–0.03 (2–3%); nutrient intakes between the RDA and the Tolerable Upper Intake Level (UL) have inadequacy and excess risks close to zero; and nutrient intakes above the UL may have an increased risk of adverse effects.⁵⁰

Daily Values (DV)

Daily Values (DVs) are used to represent the nutrient content, per serving, of all packaged foods and beverages. DVs represent the highest RDAs for any age and sex group (except for pregnant and lactating women) and were established by the U.S. Food and Drug Administration (FDA) to inform consumers about how much of a given nutrient a serving of food or beverage contains in relation to the approximate requirement of that nutrient.⁵³ Nutrition Fact labels list the %DV, which are based on 2,000-calorie diet, for adults and children four years and older. These values allow consumers to more easily compare the nutritional values of different food products.

Macronutrients

Macronutrients are the three energy-containing components necessary for a balanced diet: carbohydrates, proteins, and fat.⁵⁴ They are important because, in addition to providing calories, they are food sources of essential nutrients. Healthy intake levels of macronutrients are indicated by AMDRs.

Carbohydrates

Carbohydrates are the major sources of energy in the average human diet, providing nearly half or more of the total energy intake, and are commonly classified as simple carbohydrates, which include monosaccharides and disaccharides, and complex carbohydrates, which include polysaccharides (Figure 7).

Simple Carbohydrates. Monosaccharides are the simplest form of carbohydrates consisting of one six-carbon saccharide molecule and include:⁵⁵

• Glucose. Glucose is the most abundant monosaccharide and primarily comes from the digestion of starch and disaccharides. In food, little occurs in the free form, i.e., glucose is rarely present in foods as a monosaccharide and usually occurs in disaccharide or polysaccharide form, where it is linked to other glucose, fructose, or galactose molecules. Glucose is the major source of fuel for the brain and the central nervous system.
• Fructose. Fructose, also known as fruit sugar, occurs naturally in fruits and is present in sucrose, also known as table sugar (a disaccharide, see next section).
• Galactose. Galactose, also known as milk sugar, primarily comes from milk in the form of lactose (a disaccharide, see next section).

Disaccharides are carbohydrates composed of two monosaccharides that are linked together (Figure 8). That linkage needs to be broken apart (i.e., digested) before absorption can take place. Disaccharides include:⁵⁶

• Sucrose. The most common disaccharide, which consists of one glucose molecule linked to one fructose molecule. Sucrose is otherwise known as table sugar and is the most commonly used natural sweetener. The linkage point between the glucose and sucrose molecules needs to be broken by the enzyme sucrase during the digestive process.
• Lactose. Lactose consists of one glucose molecule linked to one galactose molecule and is the disaccharide found in milk. Some individuals are lactose-intolerant, meaning that they lack the enzyme (lactase) necessary to break the linkage between the galactose and glucose molecules. Bacteria in the gastrointestinal (GI) track ferment the unabsorbed carbohydrates, often leading to bloating and diarrhea. Other dairy products, such as yogurt and hard cheese, are relatively low in lactose because the bacteria used to make the foods digest the lactose.
• Maltose. Maltose (dextrose) consists of two linked glucose molecules and is otherwise known as malt sugar. The linkage point between the two glucose molecules needs to be broken by the enzyme maltase during the digestive process.

Complex Carbohydrates. Polysaccharides are long chains (more than 10 units) of monosaccharides. Polysaccharides serve structural functions in plants (fiber) and act as a form of storage in plants (starch) and animals (glycogen). Glycogen, starch and fiber are the main polysaccharides, all consisting of glucose molecules.⁵⁷ Glycogen is a branched chain compound that consists of glucose molecules. It is the form of carbohydrate stored in the human body (liver and muscle). Starch is a straight chain compound that consists of glucose molecules. It is the form of carbohydrate found in plants. Starch is broken down into glucose molecules in the small intestine and absorbed as such. Starches can be slowly digested, rapidly digested, or resistant to digestion. Dietary fiber includes non-digestible carbohydrates and lignin. It is the form of carbohydrate found in plants. Human enzymes are unable to break down fiber but the bacteria in the colon can digest it to varying degrees via the process of fermentation, generating short-chain fatty acids (SCFA) that contribute to a small number of calories. SCFA can then be used by the body and gut microflora, acting as a prebiotic in the colon. The fiber that remains in the colon undigested is important for normal gut motility. Fiber can be classified into two types, soluble and insoluble:

• Soluble fiber. Soluble fiber dissolves in water and delays gastric emptying, decreases the rate of nutrient (e.g., glucose) absorption and increases GI transit time. It may lower blood cholesterol and help to control blood sugar.⁵⁸ Foods rich in soluble fiber include oats, barley, legumes, certain vegetables (artichokes, asparagus, broccoli, carrots, garlic, onions, tomatoes), and fruits (apples, bananas, berries, citrus fruits).⁵⁷
• Insoluble fiber. Insoluble fiber does not dissolve in water and increases the bulk content in the colon, decreasing GI transit time and easing elimination. Foods rich in insoluble fiber include the outer layers of whole grains (wheat and corn bran), whole-grain products, hulls of seeds, certain vegetables (root vegetables, cabbage family vegetables, celery, broccoli, peas), and fruits (apples and fruits with edible seeds such as strawberries).⁵⁷

Added Sugars. While sugars occur naturally in food, like fructose does in fruit and lactose in milk, they are frequently added during food preparation or processing. The major source of added sugars in U.S. diets is beverages, followed by snacks and sweets such as candies, pies, cookies, and ice creams, among others. Two common examples of added sugars include sucrose (isolated from beets and cane) and high-fructose corn syrup (HFCS, a monosaccharide mixture derived from corn, most frequently containing either 42% or 55% fructose, with the rest being glucose).⁵⁹ Added sugars lack any nutritional value and only contribute additional calories to the diet.

While most people are aware that they should limit added sugar consumption, they don’t always realize just how much sugar is added to processed foods because of sugar’s numerous pseudonyms. Many average consumers are unaware of the extensive terminology under which sugar can be “hidden,” making it hard to estimate how much sugar they consume, even if they read food labels.

FDA-approved names for added sugars on food labels:⁶⁰

• Anhydrous dextrose
• Brown sugar
• Confectioner’s sugar
• Corn syrup
• Corn syrup solids
• Dextrose
• Fructose
• High-fructose corn syrup
• Honey
• Invert sugar
• Lactose
• Malt syrup
• Maltose
• Maple syrup
• Molasses
• Nectars
• Pancake syrup
• Raw sugar
• Sucrose
• White granulated sugar

Other names used for added sugars on food labels that are not recognized by the FDA:⁶⁰

• Cane juice
• Crystal dextrose
• Evaporated corn sweetener
• Fruit nectar
• Fruit juice concentrate
• Glucose
• Liquid fructose
• Sugar cane juice

In July 2015, the FDA approved adding a percent Daily Values for added sugars to the Nutrition Facts labels of packaged foods. This addition can help consumers follow the advice of limiting their daily caloric intake from added sugars to less than 10% of their total calories (less than 200 calories, based on a 2,000-calorie diet), in line with the 2015-2020 Dietary Guidelines for Americans.⁶¹ The AHA recommends a stricter limit for added sugars: no more than nine tsp (36 g) or 150 Calories for men, and no more than six tsp (25 g) or 100 calories for women.⁶²

Protein

Proteins perform many vital functions in our bodies. They make up all muscles, such as the heart and structural tissue; provide structure for our bones; and form critical bioactive molecules such as hormones, enzymes, and antibodies. Proteins are composed of amino acids, which consist of a central carbon backbone; at least one amino group; at least one carboxyl group; and a side chain. Amino acids can be essential, meaning that the body cannot make them in adequate amounts, hence, they need to be obtained from the diet; non-essential, meaning that the body can synthesize them de novo or derive them from other amino acids; and conditionally-essential, which are usually non-essential but can become essential at times of life stage, stress, or illness.⁶³

Essential Amino Acids:⁶³

• Histidine
• Isoleucine
• Leucine
• Lysine
• Methionine
• Phenylalanine
• Threonine
• Tryptophan
• Valine

Non-essential Amino Acids:⁶³

• Alanine
• Asparagine
• Aspartic Acid
• Glutamic Acid

Conditionally-essential Amino Acids:⁶³

• Arginine
• Cysteine
• Glutamine
• Tyrosine
• Glycine
• Ornithine
• Proline
• Serine

Protein quality is determined by the amino acid composition.⁵⁷ Milk and egg protein are considered the highest quality proteins because they have an amino acid profile most similar to the one that promotes optimal growth in children and maintenance in adults. High quality proteins provide enough of all the essential amino acids in specific amounts to fulfill these needs. The body does not have amino acid storage depots; therefore, if the body does not receive enough of each essential amino acid, it must break down existing proteins to meet immediate needs. Food sources that contain all the essential amino acids in optimal proportions are referred to as complete proteins and include animal proteins—milk (and other dairy products), egg, fish, poultry, and meat—as well as some beans, grains, and seeds, such as black beans, soy beans, quinoa, buckwheat, pumpkin seeds, and hemp seeds. Although animal foods contain all the essential amino acids, they are not the only option. By combining certain categories of plant foods, such as legumes and grains, at a single meal, all the essential amino acids can be obtained. These food combinations are termed complementary proteins. Adding eggs and dairy to an otherwise vegetarian diet can also boost protein quality.⁵⁷ The 2015 DGAC recommends choosing a variety of protein foods that include both animal and plant sources.²

Lipids (Fats)

Lipids are the main form of energy storage in the human body, in the form of triglycerides. Dietary fats provide essential fatty acids, have a high satiety value and are critical for the absorption of fat-soluble vitamins.⁵⁷ One class of lipids is fatty acids, which consist of a chain of carbon molecules with a carboxyl group on one end and a methyl group on the other end. The vast majority of fatty acids are linear; however, there are a few branched-chain fatty acids. There are three major classes of lipids in foods and in the human body:⁵⁵

• Triglycerides. Three fatty acids linked to a molecule of glycerol. The majority of lipids in foods and in the human body are in the form of triglycerides.
• Phospholipids. Two fatty acids, a glycerol molecule and a phosphate group. They are the primary constituents of all cell membranes.
• Sterols. Four-cyclic-ring structure (17 carbon atoms in a four-ring structure; can also have a unique side chain). Cholesterol is the major sterol in the human body.

Fatty acids are classified as either saturated or unsaturated. Saturated fatty acids have only single bonds connecting the carbon atoms (i.e., the molecule is saturated with hydrogen atoms). Unsaturated fatty acids have at least one double bond connecting the carbon molecules (monounsaturated or polyunsaturated). Most foods contain a mixture of both saturated and unsaturated fatty acids; however, the proportions differ widely. For example, even common cooking oils can contain a variety of fats (Figure 9).⁶⁴

Saturated Fatty Acids (SFAs). Humans can make SFAs, hence, they are not essential. Saturated fats are stable at most cooking temperatures because they have no double bonds, and are thus resistant to oxidative rancidification (caused by exposure to oxygen). They are generally solid at room temperature. Foods rich in saturated fats include animal fat, meat and dairy, and tropical oils, including coconut oil, palm oil, and palm kernel oil.⁵⁷

The 2015 DGAC notes that saturated fat is one of the over-consumed nutrients in the U.S. and recommends that individuals follow a dietary pattern low in saturated fat, with a goal of less than 10% of total calories per day coming from saturated fat for the general population.² The 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines recommends that adults who would benefit from lowering their LDL (“bad”) cholesterol should aim for a total saturated fat intake of 5–6% of all daily calories, ideally replacing saturated fat with polyunsaturated fat.³⁵ In addition, the 2015 DGAC recommends reducing saturated fat intake not in isolation but “as part of a healthy dietary pattern that is balanced, as appropriate, in calories,” further noting that “rather than focusing purely on reduction, emphasis should also be placed on replacement and shifts in food intake and eating patterns. Sources of saturated fat should be replaced with unsaturated fat, particularly polyunsaturated fatty acids”.²

Monounsaturated Fatty Acids (MUFAs) MUFAs contain one carbon-carbon double bond (one point of unsaturation) in the carbon chain of the fatty acid. Foods rich in MUFAs include canola and olive oils, avocados, some nuts (almonds, peanuts, cashews, Brazil nuts, hazelnuts, macadamia nuts, pecans, and pistachios) and nut butters. Consumption of MUFAs may help lower total and LDL cholesterol.⁶⁵ Additionally, intake of MUFAs is associated with reduced cardiovascular disease risk.^{65 66} In studies that substituted MUFAs for SFAs, the high-MUFA diet increased HDL (“good”) cholesterol, although its effects on LDL cholesterol are more varied.⁶⁶ The American Heart Association recommends eating foods that contains MUFAs or PUFAs instead of foods that contain SFAs or trans fats.⁶⁷

Polyunsaturated Fatty Acids (PUFAs). PUFAs contain two or more double bonds (two or more points of unsaturation in the carbon chain). Omega-6 and omega-3 are two types of PUFAs and are essential fatty acids, that is, humans cannot synthesize them. Vegetable oils such as soybean and corn oil are rich sources of PUFAs, as is fatty fish.

Omega-3 fatty acids play an important role in brain function and development;⁶⁸ heart health, including reduced blood pressure;⁶⁹ lower triglyceride levels in hypertriglyceridemic individuals; and improved HDL cholesterol concentrations.⁷⁰ In addition, it has been suggested that omega-3 fatty acids may be associated with a lower risk of asthma, diabetes, some cancers, inflammatory bowel disease, mental decline, stroke, and ulcerative colitis, although the data are less strong for these associations.⁷¹ Foods rich in very long chain omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are most frequently associated with health benefits and include fatty fish and fish oil. Foods rich in long chain omega-3 fatty acids, such as alpha-linolenic acid (ALA), include soybean and canola oils, walnuts, and flax seed. The body has a limited capacity to convert ALA to the longer, more unsaturated and biologically active n-3 fatty acids, EPA and DHA, which is why it is important to obtain EPA and DHA from the diet. Additionally, DHA is thought to play an important role in fetal brain development and neurotransmission throughout life and may also inhibit oxidative damage in the brain, which may confer benefits for brain development and cognitive aging.⁶⁸

Omega-6 fatty acids are critical for two main functions, including acting as structural components of plasma membranes of every cell and acting as precursors to eicosanoids (locally acting hormones), and have been beneficially associated with cardiovascular disease, atherosclerosis, and endothelial function.⁷² Omega-6 fatty acids have also been associated with reduced risk of coronary heart disease, especially when substituted for SFAs in the diet.⁷³ Foods rich in omega-6 fatty acids include soybean and corn oils, walnuts, and sunflower seeds.

Trans Fatty Acids. Trans fatty acids (or trans fats) occur naturally in animal fat as a result of anaerobic bacterial fermentation in the rumen of animals and can also be created during the partial hydrogenation of vegetable oils. Vegetable oils undergo partial hydrogenation to convert them into more solid forms, decrease their susceptibility to oxidation, and increase their stability at high temperatures (increase the smoking point).⁵⁶ Trans fats have one or more carbon double bonds that are in the trans rather than cis position. This means that the three-dimensional shape, and hence the functionality of fatty acid molecules, has been altered. In the U.S., prior to the 2000s, trans fats were found in commercially fried foods, chips, crackers, baked goods, breads, margarine, and vegetable shortening. However, with the change in food labeling, legislation limiting the use of partially hydrogenated fats in restaurants, and general public pressure, the amount of trans fat in our food supply has decreased dramatically.^{74 75}

Trans fats intake has been associated with adverse health outcomes, primarily related to increased LDL cholesterol in the absence of a compensatory increase in HDL cholesterol as is seen with SFA intake.^{76 77} Trans fat intake is also associated with an increased risk of heart disease.⁷⁸ In November 2013, the FDA issued a preliminary determination that partially hydrogenated fats, traditionally the major source of dietary trans fatty acids, are no longer Generally Recognized as Safe (GRAS); and in June 2015, the FDA released its final determination that partially hydrogenated oils are not GRAS, giving the industry a three-year compliance period to either reformulate their products or petition the FDA to permit certain uses of partially hydrogenated oils.⁷⁹ It is important for individuals to read the Nutrition Facts label and choose foods with no trans fats.⁶¹

Interesterified Fats. Interesterified (IE) fats are a type of modified triglycerides whereby the positions of fatty acids are redistributed within the glycerol molecules. While the research on health effects associated with the consumption of IE fats is still limited,⁸⁰ the available evidence suggests taking a cautionary approach and emphasizing the need for more research before replacing trans fats with IE fats.⁸¹ IE fats are appearing in the food supply partially as a consequence of the phase-out of partially hydrogenated oils. Research on the health effects of IE fats is limited, but a study comparing dietary trans and IE fats with unmodified saturated fats found that both trans and IE fats negatively affect lipoprotein and glucose metabolism, warranting further investigation.⁸²

Micronutrients

Micronutrients are dietary components often referred to as vitamins and minerals. Vitamins are organic and minerals are inorganic compounds needed by the body in small amounts to support vital body functions and overall health. Vitamins and minerals are not synthesized in the human body in adequate amounts and are therefore termed essential, meaning that they must be obtained from the diet. Even though vitamins and minerals are needed only in small amounts, their deficiencies can lead to detrimental and life-threatening effects.

While an overview of the nutritional requirements, functions and sources of all vitamins and minerals is beyond the scope of the Nourishment WELLography^™, their classification, as well as some major features, are outlined below.

Water-soluble Vitamins

Water-soluble vitamins are essential organic compounds that function within the aqueous environment of the body. They include thiamin (vitamin B1), riboflavin (vitamin B2), niacin (vitamin B3), pantothenic acid (vitamin B5), pyridoxine (vitamin B6), biotin (vitamin B7), folate (vitamin B9, also referred to as folic acid), cobalamin (vitamin B12), and ascorbic acid (vitamin C). The body absorbs water-soluble vitamins into the portal vein and, with the exception of vitamin B12, does not store them.⁵⁷ Because any excess of water-soluble vitamins is excreted in urine, these vitamins must be consumed frequently in the diet.

Lipid-soluble Vitamins

Lipid or fat-soluble vitamins are essential compounds that are found in fats and oils and require the presence of fat and bile for absorption. They include vitamins A (including carotene, a pro-vitamin), D, E, and K, and are stored in the liver and adipose (fat) tissue of the body. In addition to dietary sources, vitamins D and K can also be synthesized endogenously—vitamin D upon exposure of skin to the sun and vitamin K by gut bacteria.

Minerals

Minerals are inorganic compounds that support numerous biological processes. There are seven essential macrominerals, defined as required in amounts greater than 100 milligrams (mg) per day: calcium, chloride, magnesium, phosphorus, potassium, sodium, and sulfur.⁵⁷ There are nine essential trace minerals, or microminerals, defined as required in amounts less than 100 mg per day: cobalt, copper, fluoride, iodine, iron, manganese, selenium, and zinc.⁸³

Electrolytes. Electrolytes are electrically charged minerals that are distributed via blood and other fluids throughout the body, regulating blood pH, water balance, muscle function, and other key physiological processes.⁸⁴ Some of the key electrolytes in the human body are sodium, potassium, calcium, magnesium, chloride, and phosphorus.⁸⁴

Water

Water is an indispensable nutrient. It is the most abundant constituent in the human body, comprising up to 55–60% of the total body weight in an average female and male adult, respectively, which in a 60 kg [132.2 lbs] person is equal to about 33–36 liters of water.⁸⁵ Water is needed for thermoregulation, provides a medium for amino acid, glucose, mineral, and vitamin transport and metabolism, and cushions and lubricates internal organs. The daily recommended total water intake is about 2.7 liters for adult women and 3.7 liters for adult men which can be obtained from all beverages (including water), as well as high-moisture foods (foods that contain water), such as fruits, vegetables, and soups.⁸⁶

Nourishment and the Human Body

The body needs six classes of nutrients for optimal nourishment: carbohydrates, lipids, protein, minerals, vitamins and water.⁵⁷

The body also needs soluble and insoluble fiber. When the body needs energy or hydration, our brain and hormones alert us to the sensation of hunger or thirst, prompting us to seek out and consume foods or beverages. In order to obtain nutrients from the foods we eat, the food must be digested, or broken down and absorbed. This involves mechanical and chemical processes that occur in the digestive tract. When sufficient energy has been consumed, the sensation of hunger diminishes and a sense of satiety or fullness normally develops.⁵⁷ The development of hunger and satiety, digestive processes, as well as metabolism are regulated by the actions of multiple factors, including hormones and peptides, some of which are summarized below.

The Digestive System

The digestive or gastrointestinal (GI) tract is comprised of about a nine meter (m) [30 ft] long tube that begins at the mouth and ends at the anus and the accessory organs that accompany it.⁵⁵ The key parts of the GI tract are the oral cavity, esophagus, stomach, and small and large intestines. The gallbladder, liver, and pancreas are the accessory organs that assist in digestion by producing, storing, and secreting regulatory compounds. Each organ comprising and associated with the GI tract has a different function, the main features of which are summarized below (Figure 10).

The Oral Cavity

Ingestion and digestion begin in the oral cavity, which includes the mouth and throat (pharynx).⁵⁶ Once the food enters the mouth, it gets manipulated by the tongue and teeth. The food is cut and ground, and mixed with the saliva. Saliva is produced by three pairs of salivary glands (parotid, submandibular, and sublingual) and delivered through ducts in the oral cavity. The salivary glands together produce about one liter of saliva per day, which functions to lubricate and partially dissolve the food in preparation for swallowing. Salivary glands also produce the enzyme lingual lipase, which starts the digestion of the lipids and fats, and the enzyme amylase, which breaks down complex carbohydrates into smaller chains. When the food is chewed and mixed with saliva, it is ready to be swallowed and is called a bolus.⁵⁶

The Esophagus

Once the bolus is swallowed via passing through the pharynx, it enters the esophagus, which connects the oral cavity and the stomach.⁵⁷ The food goes down the esophagus with the help of peristalsis, a wavelike contraction and relaxation of the smooth muscles in the lining of the organs of the digestive system (esophagus, stomach, and small intestine). At the base of the esophagus is the lower esophageal sphincter, which allows the food to pass from the esophagus into the stomach.⁸⁷ During swallowing, the esophageal sphincter pressure drops, relaxing the sphincter and allowing the food to enter the stomach. The sphincter remains closed at all other times except during swallowing because the tonic pressure of the esophageal sphincter is higher than that in the stomach; this prevents the food in the stomach from coming back up into the esophagus, a process called gastroesophageal reflux, commonly known as heartburn.⁵⁷

The Stomach

When the food passes down the esophagus and through the esophageal sphincter, it enters the stomach, a muscular, hollow organ positioned just below the diaphragm in the upper left part of the abdominal cavity.⁵⁷ The stomach walls are highly elastic and in an adult can store up to about two liters of food or more when full. The stomach is composed of four major areas: cardia, fundus (upper portions of the stomach), the body, and antrum (the lower portions of the stomach). The upper regions of the stomach, cardia and fundus, is where food from the esophagus enters and where extra food and liquid are stored, whereas the lower portions of the stomach, the body and the antrum, are where highly acidic gastric juice is produced and mixed with food, and where food is held prior to being released into the small intestine at a constant rate. Once food in the stomach is mixed with gastric juices, it is called chyme. Chyme empties into the duodenum (first part of the small intestine) through the pyloric sphincter.⁵⁷.

The Small Intestine

The majority of food digestion and absorption occurs in the small intestine, which is about six meters [20 ft] long.⁸⁸ Similar to the peristaltic movements in the esophagus and the stomach, the chyme in the small intestine is mixed and churned with the digestive secretions of the small intestine and moved forward by the peristaltic contractions of the smooth muscles of the intestinal wall. The small intestine is composed of three major sections:

The duodenum, which is about 25 cm [10 in] long, is the first part of the small intestine.⁸⁸ It receives chyme from the stomach and digestive juices (containing enzymes and bile) from the gall bladder and pancreas. The digestive enzymes break down proteins into amino acids and dipeptides, and carbohydrates into monosaccharides. Bile emulsifies fats to form micelles, which are essential for the digestion of fat. In addition, the glands in the duodenum produce bicarbonate, which, together with the bicarbonate from the pancreas, neutralizes the hydrochloric acid carried in from the stomach with the chyme, facilitating the activity of the digestive enzymes. Absorption of vitamins and minerals, as well as macronutrients, starts in the duodenum and continues throughout the digestive system.⁸⁸

The jejunum, which is about 2.5 m [eight ft] long, is the second section of the small intestine and the area where much of nutrient absorption occurs.⁸⁸ The jejunum contains large circular folds of mucosa—villi—microscopic fingerlike projections of enterocytes (intestinal cells). On the villi are microvilli, which are hair-like extensions of the plasma membrane of the enterocytes. This unique structure maximizes the total surface area of the small intestine, facilitating nutrient absorption.⁸⁸

The ileum, which is about 3.5 m [12 ft] long, is the third and final part of the small intestine.⁸⁸ It is similar in structure to the jejunum and absorbs the remaining nutrients that were not absorbed in the jejunum. The ileum ends at the beginning of the large intestine, joining the cecum, the first section of the large intestine. The ileum empties unabsorbed materials into the cecum via the ileocecal sphincter.⁸⁸

All three major classes of macronutrients (carbohydrates, lipids, and proteins) are digested and absorbed in the small intestine.⁸⁸

Proteins are broken down into amino acids and dipeptides, triglycerides are broken down into glycerol and free fatty acids, and carbohydrates are broken down into monosaccharides. However, some carbohydrates, primarily fiber, pass the small intestine undigested and are broken down in the large intestine by bacteria; and some, such as cellulose, are not digested at all. Vitamins and minerals are also absorbed in the small intestine. The absorption of lipid-soluble nutrients is dependent on the presence of dietary fat and bile. In contrast to amino acids and saccharides, which are absorbed directly into the portal vein, the enterocytes package lipid-soluble compounds into lipoprotein particles that are absorbed into the lymphatic system before entering the blood stream. Any remaining undigested matter that is not absorbed in the small intestine is passed on to the large intestine.⁸⁸

The Large Intestine (The Colon)

The large intestine, or the colon, is about 1.5 m [five ft] long and is the last part of the digestive system.⁵⁷ Any food that is not absorbed in the small intestine is passed on to the cecum (first section of the large intestine) via the ileocecal sphincter.

The large intestine has five major sections: the cecum, followed by the ascending colon, transverse colon, descending colon and sigmoid colon.⁵⁷ Vitamins produced by the bacteria in the colon are absorbed, most notable of which is vitamin K. As the material passes through the colon, water and sodium are reabsorbed. For every one liter of chyme that comes into the large intestine, less than 200 g of fecal matter remain, consisting of water, gut bacteria, unabsorbed nutrients, inorganic matter (e.g., dietary fiber), and sloughed gastrointestinal cells. It usually takes 12 to 24 hours for the material in the colon to pass from the cecum to the rectum. The final part of the large intestine, the rectum, stores that fecal matter before it is excreted.⁵⁷

The Gallbladder

The gallbladder is a small sack that stores and concentrates bile synthesized by the liver, releasing it into the duodenum when needed to aid in lipid digestion and absorption.⁵⁵

The Liver

The liver is the largest internal organ in the body and, among other things, is one of the accessory organs of the digestive system.⁵⁵ It contains two lobes (left and right) that are composed of hepatocytes (liver cells). The liver has a broad range of functions that include filtering blood that comes in from the digestive tract, detoxification, glycogen storage, production of hormones and compounds needed for digestion, and protein synthesis.⁵⁵

When nutrients, apart from fat, are absorbed from the small intestine, they enter the portal vein, which goes directly to the liver.⁵⁵ The liver then uses these nutrients to synthesize compounds for secretion or releases nutrients for use by other parts of the body.⁵⁵

The Pancreas

The pancreas functions as both an endocrine gland and digestive organ and is located in the upper left part of the abdomen, behind the stomach.⁵⁵ The pancreas secretes pancreatic juice into the duodenum that contains enzymes essential for the digestion of food in the small intestine. In addition, the pancreas secretes several key hormones, two of which are insulin and glucagon. Insulin is secreted by beta cells in response to high blood sugar. It is the body’s central hormone for regulating carbohydrate and fat metabolism, prompting the body cells to take up glucose from the blood stream to skeletal muscles and fat tissue. The release of insulin inhibits the production of glucose by the liver and the breakdown of fat in adipose tissue, promoting fat storage. Glucagon is the hormone secreted in response to low blood sugar, prompting the liver to break down gylcogen and release glucose into the blood stream.⁵⁵

Intestinal Microflora

Gut Microbiota

Microbes in and on the human body outnumber the body’s cells ten to one. As the Institute of Medicine (IOM) has stated, “our gastrointestinal (GI) tracts harbor a vast and still largely unexplored microbial world”.⁸⁹ Microflora found in the large intestine microflora are comprised of complex microbial communities and are now thought to play a vital role in health and disease.⁹⁰ About 5,000 different species of bacteria are estimated to live in the human gut and about one trillion are found per gram of intestinal matter.⁹¹ These microbes produce vitamins, alter the immune system, play essential roles in digestion, inflammation, and metabolic function, including energy balance, and have many other functions that we are just beginning to understand. There are numerous conditions that have now been linked to dysbiosis, or disturbance of the resident microflora, such as inflammatory bowl disease (IBD), irritable bowl syndrome (IBS), celiac disease, allergies, asthma, cancer, cardiovascular disease, metabolic syndrome, non-alcoholic fatty liver disease (NAFLD), neurological diseases, obesity, and type 2 diabetes.⁹² This is a fast-emerging field of study, and diet plays an important role in determining our gut microbiome.⁸⁹

One of the key processes that occurs via the help of the intestinal flora is the fermentation of carbohydrates into short-chain fatty acids (SCFAs), called saccharolytic fermentation, which improve the absorption of several dietary minerals, including calcium, magnesium, and iron.⁹³ SCFAs produced by gut bacteria contribute about 10% of total energy, although amounts can vary depending on the amount of fiber in the diet.⁹⁴ SCFAs produced during saccharolytic fermentation include important compounds such as acetate, which is used by muscles; propionate, which is used to generate ATP in the liver; and butyrate, which provides energy to intestinal cells.⁹⁵ In addition to SCFAs, the colon bacteria also generate vitamin K and biotin, and degrade amino acids, producing compounds that maintain the gut flora.

Prebiotics

Prebiotics are compounds that:⁸⁹

• Are resistant to the stomach’s acidity, as well as to enzymatic hydrolysis and intestinal absorption.
  
• Are fermented by gut bacteria.
• Stimulate the activity and/or growth of beneficial gut bacteria that contribute to colonic and host health, or are nonviable food components that contribute to the host’s health via interactions with gut microbiota.

Prebiotics can be naturally occurring or added to food. Human milk oligosaccharides, fructins (chicory root extract, inulin, oligofructose, and short-chain fructooligosaccharides), galactooligosaccharides and lactulose are some of the well-established prebiotics, with numerous other potential prebiotic candidates currently under investigation.⁸⁹

Probiotics

Probiotics are live cultures of “good” gut bacteria that either occur naturally or are added to foods and are thought to be beneficial to human health.⁸⁹ Common foods in which probiotics (such as Lactobacillus and Bifidobacterium) can be found include fermented milk and milk products, such as yogurt, kefir, and yakult; fermented soy and soy beverages, such as miso, tempeh, and soy milks; and other fermented vegetables, such as sauerkraut, pickles, and kimchi.⁹⁶

Metabolic Regulation of Digestion

Digestion and absorption of food are regulated via the action of multiple neuropeptides and GI hormones. They regulate hunger and satiety, and control many digestive functions, including GI motility and the secretion of digestive enzymes. Two major complementary pathways—homeostatic and hedonic—regulate energy intake. The homeostatic pathway regulates energy balance by stimulating appetite after a period of no food intake and signaling satiety after a meal. In contrast, the hedonic pathway is reward-based and increases the propensity to consume highly palatable foods (foods that are energy-dense and rich in fats and/or sugars) during times of relative energy abundance and may override the homeostatic pathway.⁹⁷ The hedonic pathway is mediated by the brain’s limbic system, which is the same system that contributes to substance abuse. Overall, however, the homeostatic and hedonic pathways interact in regulating food intake;⁹⁷ and many hormones and steroids secreted by the GI tract, pancreas, and adipose tissue regulate appetite and food intake via their actions on the hypothalamus, the brain stem, and the autonomic nervous system.⁹⁸ Cholecystokinin (CCK), insulin, ghrelin, and leptin are some of the key agents of energy regulation that respond to both short-term and long-term cues, including the macronutrient composition of a meal, timing since the last meal, the body’s energy status, and the amount of adipose (fat) tissue in the body.⁹⁹ Some of the functions of these and other hormones involved in metabolic regulation of energy are summarized below.

Overall, in order to maintain weight and not gain excess fat, individuals need to maintain caloric, or energy balance, which means expending the same amount of calories that are consumed each day. When energy is consumed in excess, weight gain occurs, leading to overweight, obesity, and their associated disorders.

Key Hormones for Energy Regulation

CHOLECYSTOKININ (CCK). CCK is released from the small intestine in response to energy intake and signals fullness/satiety to the brain, suppressing appetite/food intake.⁵⁷

GHRELIN. Ghrelin is secreted in the stomach and the small intestine and is the only known hunger- and food intake–stimulating hormone identified to date.¹⁰⁰ Ghrelin levels typically increase between meals and decrease after eating.⁵⁷

INSULIN. Insulin is a peptide hormone produced by beta cells in the pancreas and is the body’s central hormone for regulating carbohydrate and fat metabolism.⁵⁵ It promotes the uptake of glucose from the blood to skeletal muscles and fat tissue and promotes fat storage. Insulin also inhibits the production of glucose by the liver and breakdown of fat in adipose tissue. Insulin suppresses hunger and stimulates leptin release, and is the key hormone that switches many of the body’s tissues from a catabolic state (breaking down tissue into nutrients and using them for fuel) to an anabolic one (building tissue from nutrients).⁵⁵

LEPTIN. Leptin plays a key role in regulating energy expenditure, appetite, and metabolism. It signals to the brain when there is an energy deficiency and suppresses food intake by signaling to the brain that the body has had enough to eat, producing feelings of satiety.^{101 102}

Leptin is produced primarily by the white adipose (fat) tissue in the body and the level of circulating leptin is proportional to the fat stores in the body. Thus, leptin levels increase with increased food consumption and greater stores of body fat, and decrease with starvation and lower stores of body fat. However, individuals who are obese exhibit resistance to leptin, whereby increased levels of leptin fail to suppress food intake. Individuals who are leptin-deficient (an extremely rare genetic condition that has been reported only in consanguineous families) exhibit hyperphagia (unrestricted, excessive eating) as well as severe obesity. Normophagia (normal, non-excessive eating) is restored with the administration of leptin, and body weight normalizes as well.

Hedonic Regulation

Hedonic regulation of food intake is the reward-based regulation of energy consumption that can occur in the absence of a biological need, motivating individuals to consume foods that are highly palatable and producing a hedonic response in the brain.¹⁰³ Consumption of highly palatable foods results in potent dopamine release in the area of the brain that is associated with reward (nucleus accumbens). Studies have shown that the concentration of dopamine receptors in the brain are lower in individuals who are obese, suggesting that this deficiency may lead to continuous energy overconsumption as a way of compensating for the lower activation of reward mechanisms.¹⁰⁴

The term “food addiction,” which remains controversial, has been used widely in studies on reward-based eating and has been broadly defined as “a loss of control over food intake”.⁹⁷ There is currently no formal definition of food addiction in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), but some studies have modeled addiction defined by DSM-V among self-reported food addicts and found that their overeating behaviors conform to the substance use disorder criteria defined by the DSM-V.¹⁰⁵ There is even a way of evaluating food addiction: the Yale Food Addiction Scale, developed by Yale scientists to assess the symptoms of food addiction in clinical populations.¹⁰⁶ A comprehensive discussion of all factors implicated in hedonic regulation of food intake is beyond the scope of this WELLography™, but it is important to note that there is emerging evidence that hedonic eating—eating in the absence of hunger—can occur in the modern food environment, which is abundant in highly palatable foods, and may thus play a role in the obesity epidemic.¹⁰⁷

Nutrient Storage

The body stores energy-containing nutrients to ensure that energy is available to the body during periods when food is not consumed. The excess energy that is not immediately used by the body is stored for later use in two different forms:⁵⁷

• Glycogen. Excess glucose is stored as glycogen in the liver and muscles, and can provide enough energy for a few hours.
• Triglycerides. Glucose, in excess of what is needed and in excess of the capacity of the liver and muscle glycogen storage, can be converted by the liver into fatty acids. These de novo synthesized fatty acids and preformed fatty acids from food can be stored as triglycerides in the adipose (fat) tissue. Whereas the capacity to store glucose as glycogen is limited, the capacity to store fatty acids as triglycerides is much larger.

If glucose continues to be introduced into the body when the muscle and liver glycogen stores are full, the body will use that glucose to synthesize fatty acids and preferentially use glucose as an energy source.¹⁰⁸ That will result in elevated plasma triglyceride concentrations, otherwise termed carbohydrate-induced hypertriglyceridemia.¹⁰⁸

Lipid Transport

Four main lipoprotein particles transport fats in the body:⁵⁵

• Chylomicrons. Chylomicrons carry fatty acids, as triglycerides, and fat-soluble compounds from the small intestine to the peripheral tissue for uptake. This transport initially involves the lymphatic system.
• Very low-density lipoproteins (VLDL). VLDLs carry triglycerides, cholesterol, and other lipid soluble compounds from the liver for use by the body cells. They have a high proportion of lipid to protein, hence are termed very low-density lipoprotein particles.
• Low-density lipoproteins (LDL). LDLs carry primarily cholesterol that is left after triglycerides are removed, but also other lipid-soluble compounds, e.g., fat-soluble vitamins, in plasma. High levels of LDL cholesterol are associated with increased risk of coronary heart disease.
• High-density lipoproteins (HDL). HDLs carry cholesterol from the body cells to the liver for disposal. HDL is associated with a lower risk of heart disease. These particles have the lowest proportion of fat to protein, hence are termed high-density lipoprotein particles.

Elements of Nourishment

The elements of Nourishment described below include a balanced diet, energy excess, food allergies and intolerance, and foodborne illness.

Healthy Eating Pattern

In addition to regular physical activity, a balanced diet is essential for promoting and maintaining good health and optimal body weight, as well as reducing the risk of chronic disease and preventable premature mortality. The elements of and solutions for a balanced diet provided in this section rely on the general principles of a healthy diet as outlined in Appendix A: Key Principles of a Healthy Diet

A healthy eating pattern provides the body with all the nutrients, both energy containing and essential, in the proportions needed for optimal health.

1. Fruits and Vegetables

Sufficient consumption of fruits and vegetables is an essential component of a healthy diet. It can help to get an adequate intake of micronutrients, dietary fiber, and other essential non-nutrient substances,¹⁸ and may also help to prevent major chronic diseases and reduce the risk of premature mortality.¹⁰⁹ Various phytochemicals (carotenoids, flavonoids, anthocyanins, sulfides), vitamins, minerals, dietary fiber, and other compounds present in fruits and vegetables may be involved in their protective effects.¹¹⁰

The World Health Organization (WHO) reports that low intake of fruits and vegetables is one of the top 10 risk factors contributing to global mortality,¹⁸ leading to about 5.2 million annual deaths worldwide in 2013.¹¹¹ In addition to preventing premature death, fruit and vegetable intake contributes to quality of life. In 2013, it was estimated that over 114 million disability-adjusted life years (DALYs, “a measure of the potential life lost due to premature mortality and the years of productive life lost due to disability”¹⁸ worldwide were attributable to low fruit and vegetable intake.¹¹²

Increasing the consumption of fruits and vegetables is a national public health priority in the U.S. as well as a global priority.¹¹³ The WHO and the Food and Agriculture Organization (FAO) expert consultation report, Diet, Nutrition, and the Prevention of Chronic Diseases, recommends a minimum daily intake of 400 g (five servings) of fruits and vegetables to prevent diet-related chronic diseases such as cancer, diabetes, cardiovascular disease, and obesity.¹¹⁴ Diets higher in fruits and vegetables may help with weight loss (if the fruits and vegetables replace foods that are higher in fat or energy) and aid in weight stability.¹¹⁵ The 2015-2020 Dietary Guidelines for Americans recommend and encourage adults to consume at least two cup-equivalents of fruits (especially whole fruits) and at least 2½ cup-equivalents of vegetables per day (for a 2,000 Calorie per day diet).⁶¹ Similarly, the 2015 DGAC Report encourages individuals to adopt dietary patterns that are high in fruits and vegetables in order to achieve and maintain optimal health.²

An overall healthy dietary pattern—not just adding fruits and vegetables in isolation—is key to achieving optimal health.²

Health Effects

Cardiovascular System

Blood pressure. Increasing the intake of fruits and vegetables (along with low-fat dairy products) may help to lower blood pressure. Adhering to the DASH (Dietary Approaches to Stop Hypertension) diet—a diet rich in fruits, vegetables, whole grains, and low-fat dairy products—has been shown to be effective in lowering blood pressure in hypertensive adult patients in both intervention and cohort studies.¹¹⁵ The effects of a similar diet, characterized by high fruit and vegetable intake (and low-fat dairy products), also had beneficial effects on blood pressure in children throughout childhood.¹¹⁶

Cardiovascular mortality. A systematic review found that higher consumption of fruits and vegetables is associated with a lower risk of cardiovascular mortality, with each additional daily serving of fruits and vegetables (combined) associated with a 4% lower risk when controlling for total calorie intake.¹⁰⁹

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Coronary heart disease (CHD). Higher intake of fruits and vegetables is associated with a lower risk of coronary heart disease, with each additional daily portion of fruits and vegetables associated with a 4% lower risk of CHD.¹¹⁷

Ischemic heart disease. Higher consumption of fruits and vegetables reduces the risk of ischemic heart disease. The highest (90th percentile) compared to the lowest (10th percentile) consumption of fruits and vegetables is associated with a 15% lower risk of ischemic heart disease.¹¹⁸ The WHO estimates that low fruit and vegetable consumption is responsible for about 31% of ischemic heart disease deaths globally.¹¹⁶

Stroke. Higher consumption of fruits and vegetables is associated with a lower risk of stroke (both ischemic and hemorrhagic). Individuals consuming three to five servings of fruits and vegetables have an 11% lower risk, and those consuming more than five servings have a 26% lower risk of stroke compared to people who consume less than three servings of fruits and vegetables per day.¹¹⁹ The WHO estimates that low fruit and vegetable consumption is responsible for about 11% of strokes globally.¹¹⁶.

Digestive System

Gastrointestinal cancers. The WHO estimates that low fruit and vegetable consumption causes about 19% of gastrointestinal cancers globally.¹¹⁶ A meta-analysis of prospective cohort studies found that higher intakes of fruits, vegetables, and fruits and vegetables combined are associated with a lower risk of colon cancer.¹²⁰

A meta-analysis of 19 prospective cohort studies found that the highest compared to lowest intake of fruits, vegetables, and fruits and vegetables combined, was associated with a 10%, 9%, and 8% lower relative risk, respectively, for colon cancer.¹²⁰

Endocrine System

Type 2 diabetes. Higher intake of fruits and vegetables has been associated with a lower risk of type 2 diabetes in some studies, especially for root vegetables, green leafy vegetables, and fruit.^{121 122} However, not all studies have found an association between fruit and vegetable intake and the risk of type 2 diabetes, particularly when not linked to weight status. A review of studies and meta-analyses concluded that independent of overweight, type 2 diabetes risk is likely not influenced by fruit and vegetable intake, although there may be an indirect effect on diabetes prevention as higher intake of fruits and vegetables may reduce the risk of weight gain.¹¹⁵

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Reproductive System

Breast cancer. Some research has correlated vegetable consumption with a reduced risk of breast cancer. Specifically, women in the highest quintile of vegetable consumption had a 35% lower risk of breast cancer compared to those in the lowest quintile.¹²³ These findings have been borne-out by reviews on the topic, which have also linked greater fruit and vegetable consumption to lower risk of breast cancer.^{124 125} Specifically, a 2012 review found that individuals who ate the most fruits and vegetables had an 11% lower risk of breast cancer compared to those who ate the least amount of fruits and vegetables, and that fruits were associated with an 8% reduction in breast cancer risk.¹²⁴

Respiratory System

Lung cancer. More recent research has examined the effects of fruit and vegetable consumption on lung cancer risk. A systematic review and meta-analysis of 27 prospective cohort studies found that the risk of lung cancer decreased by 27% with increasing fruit and vegetable intake up to 400 g per day, with no additional benefit observed above this quantity.¹²⁶

Chronic obstructive pulmonary disease (COPD). A prospective cohort study of more than 40,000 Swedish men examined the association between high consumption of fruits and vegetables and incidence of COPD, a chronic inflammatory lung disease.¹²⁷ The highest quintile of total fruit and vegetable consumption (≥5.3 servings per day) as compared with the lowest quintile (<2 servings per day) was associated with a 40% decreased risk of COPD in current smokers and a 34% decreased risk of COPD in ex-smokers.¹²⁷

Solutions

1. Supermarkets and Full-Service Grocery Stores Within Walking Distance

Availability and access to fruits and vegetables is an important factor in individual fruit and vegetable intake.

Research suggests that increased availability and density of supermarkets is associated with a lower BMI,¹²⁸ smaller waist circumference,¹²⁸ and increased ability to meet USDA dietary guidelines, specifically the recommended amount of fruits and vegetables.¹²⁹ A study published in 2002 found a 32% increase in fruit and vegetable intake among Black Americans with the presence of each additional supermarket within a census tract and an 11% increase in meeting the recommended daily fruit and vegetable intake among White Americans with the presence of at least one supermarket within a census tract.³⁸ Similarly, another study found that in adult women, having access to supermarkets within an 0.8 km [0.5 mi] walking distance of work is associated with greater odds of consuming two or more portions of fruits and vegetables per day, and the presence of a supermarket within 2 km [1.2 mi] of the workplace is associated with greater odds of consuming two or more portions of fruits but not vegetables per day.¹³⁰ In addition, a greater number of supermarkets within 2 km [1.2 mi] of the place of residence was associated with higher odds of consuming two portions of vegetables (but not fruit) per day.¹³⁰ Based on the associations between the food environment and fruit and vegetable consumption noted in these studies, ensuring that at least one supermarket is present within a census block and having supermarkets and full-service grocery stores near places of residence or work is an important strategy for increasing the access, availability, and consumption of fruits and vegetables by individuals.

The CDC recommends improving supermarket availability in areas that are underserved,¹³¹ noting that “having access to stores that sell fruits and vegetables and other healthier foods may increase fruit and vegetable consumption among adults.” ⁶ Based on the existing research,^{129 132} the CDC notes that strategies to increase the access to fruits and vegetables can also include increasing fruit and vegetable availability in small stores.⁶ Similar to the CDC, the Active Design Guidelines recommend developing supermarkets and full-service grocery stores near workplaces and residences and having “full-service grocery stores within walking distance in all residential neighborhoods” that would stock a variety of fresh fruits and vegetables in order to increase access to fresh foods.¹³³

2. Farmers’ Markets and Greenmarkets Near Workplaces and Residences

Based on available research,^{129 132 134} the CDC notes that strategies to increase access to fruits and vegetables include having farmers’ markets that sell a variety of fruits and vegetables.⁶ The CDC Guide to Strategies to Increase the Consumption of Fruits and Vegetables recommends to “start or expand farmers’ markets in all settings,” reporting that better access to farmers’ markets may be associated with a greater consumption of fruits and vegetables.¹³⁵ Indeed, a survey conducted by the New York City Department of Health and Mental Hygiene in the South Bronx neighborhood of New York City found that residents who shopped at farmers’ markets consumed ¾ to a serving more of fruits and vegetables per day compared to residents who only shopped at supermarkets.¹³⁶

Similar to the recommendations by the CDC, the Active Design Guidelines recommends introducing farmers’ markets or greenmarkets near work or home locations as a complement to grocery stores,¹³³ as they have been associated with increased fruit and vegetable consumption in areas that are densely populated but have limited access to supermarkets, or to other sources of fruits and vegetables.¹³⁶

3. Strategic Dining Design

In a series of design intervention and behavioral economics studies, researchers from the Cornell University Food and Brand Lab applied several healthy food placement, packaging, and promotion interventions to examine how making small changes to cafeterias affects individuals’ choices and consumption of healthy foods (see Explanations of Solutions for a list of strategies).^{137 138 139} Implementing the design interventions in the Smarter Lunchroom Makeover pilot study resulted in an 18% increase in fruit and a 25% increase in vegetable consumption. Students were 13.4% more likely to take a fruit, 23% more likely to take a vegetable, 16% more likely to eat the entire serving of fruit and 10% more likely to eat an entire serving of vegetables.¹³⁷ The researchers concluded that the intervention was effective and resulted in a significant impact on students’ choices toward healthier behaviors.¹³⁷

Similarly, when the salad bar in a school cafeteria was moved away from the wall to the middle of the lunchroom, allowing 360-degree access (no changes were made to the salad selection), it resulted in a 300–400% increase in salad sales (depending on the specific item) compared to the year-to-date sales numbers.¹³⁸ The USDA is in support of the Smarter Lunchroom movement and encourages schools to implement the Smarter Lunchroom strategies by providing grant funding.¹⁴⁰ Additionally, the CDC developed the Healthy Eating Design Guidelines for School Architecture to encourage the selection of healthy foods and beverages, which recommends “positioning salad bars away from walls for 360-degree circulation”.¹⁴¹

The USDA’s Meal Appeal food marketing guide intended for school food-service professionals suggests similar strategies to promote the consumption of nutritious foods, including fruits and vegetables¹⁴² (see Explanations of Solutions for a list of the strategies).

Based on the findings of the Smarter Lunchroom study, as well as the recommendations by the USDA, implementing strategic dining design changes may be an effective and low-cost strategy to encourage healthier food choices, including an increased consumption of fruits and vegetables

4. Cut-up Fruits and Vegetables

In a 2012 study by Cornell University’s Food and Brand Lab, interviews with children indicated that eating whole fresh fruit can be difficult for reasons such as a fruit’s large size, the presence of braces, missing teeth, or concerns that the fruit is messy and unattractive to eat in the presence of other students.¹⁴³ In the study, elementary school children were more likely to eat fruit if the fruits were cut because they were easier and less messy to eat. The study provided three out of six selected public elementary schools with a food slicer that cut apples in six pieces. In schools that cut the fruit, daily average apple sales increased by 71% compared to the three control schools. In addition, there was a 73% increase in the proportion of students who selected apples and consumed more than half of the serving, and a 48% decrease in the proportion of students who wasted half or more of the apple serving.¹⁴³

5. Visual Prompts that Increase Nutrition Knowledge

The USDA notes that awareness of the relationship between nutrition and health may prompt interest in learning about healthy eating habits, thereby acting as a first step in acquiring the knowledge necessary for dietary improvement.¹⁴⁴ Research shows that adults are more likely to have a higher intake of fruits and vegetables if they have better nutrition knowledge. In a study with 1,040 adults, those in the highest quintile of nutrition knowledge (assessed using a well-validated measure of nutrition knowledge) were nearly 25 times more likely to eat a healthy diet and meet the dietary recommendations for fruit and vegetable intake, compared to the participants in the lowest quintile of nutrition knowledge.¹⁴⁵ Another study showed that adults who knew that the recommended intake of fruits and vegetables was five or more servings per day were 1.55 times more likely to consume the recommended servings or more compared to the adults who did not know the recommendations.¹⁴⁶

The USDA’s Meal Appeal food marketing guide, intended for school food-service professionals, recommends decorating the cafeteria with fruit and vegetable posters to remind students that these are healthy food options. Schools are encouraged to use the materials that fruit and vegetable associations provide free of charge; use Team Nutrition’s “Feed Me” poster; purchase the Five-A-Day The Color Way materials; add posters that depict the fruits and vegetables featured in the cafeteria line; and decorate the cafeteria walls and school hallways with student-drawn posters of fruits and vegetables.¹⁴² Research also suggests that gain-framed messages (e.g., listing the benefits associated with consuming fruits and vegetables) are more effective than loss-framed messages (e.g., describing the detrimental health effects linked with insufficient fruit and vegetable intake) for promoting low-risk behaviors intended to improve health.^{147 148}

Based on the findings of these studies, increasing people’s knowledge and awareness of the recommended fruit and vegetable intake via signs, posters, and other media within buildings and other spaces may help to increase the intake of fruits and vegetables. In addition, utilizing gain-framed messages to promote fruit and vegetable consumption may be more effective than using loss-framed messages.

6. Gardening

The USDA supports and encourages community and school gardens that employ sustainable gardening practices, are collaborative, and benefit the community by either providing a recreational space or by providing produce to food banks or shelters.¹⁴⁹ In addition, the Let’s Move! initiative encourages school, kitchen, and community gardens in order to incorporate more healthy foods into individuals’ diets.¹⁵⁰ The CDC recommends growing vegetables in school gardens as one of the ways to increase the intake of fruits and vegetables of students.¹⁵¹ Finally, gardening is also beneficial on a personal level, as adults with a household member who participated in community gardening consume more fruits and vegetables compared to households who do not participate.¹⁵² Participants in community gardening projects also have higher fruit and vegetable intake, are more socially engaged, and have a decreased likelihood of consuming less nutritious options, such as sugar-sweetened beverages or processed sweets.^{152 153}

Several schools have already successfully implemented small-scale gardening, which has been associated with increased fruit and vegetable consumption.^{154 155} A study conducted with 115 second-grade students looked at the effectiveness of nutrition education and gardening experience on fruit and vegetable knowledge, preference, and consumption. Researchers found that children in the nutrition education and gardening group were more likely to eat vegetables during lunch at the end of the intervention period compared to the children in the control groups.¹⁵⁴ While the first randomized controlled trial (conducted in 2014) investigating whether school gardening programs can influence children’s fruit and vegetable intake found little evidence to support the idea that gardening alone will increase children’s fruit and vegetable consumption, it did find that when implemented at a high level (with additional components that include parent involvement and other strategies), school gardening programs may increase fruit and vegetable intake by, on average, 81 g (one portion) daily.¹⁵⁵ The authors suggest that schools develop high-level, engaging gardening programs that also include farm visits, education, and cooking classes in order to increase children’s fruit and vegetable intake.¹⁵⁵ Long-term data is still needed to evaluate the effect of gardening programs in increasing long-term fruit and vegetable intake.

7. Farm to School Programs

The USDA supports Farm to School programs by providing funding, training, research, and technical support.¹⁵⁶ Based on a review of the research evaluating the effects of Farm to School programs, the National Farm to School Network reports that such programs help to increase the consumption of fruits and vegetables in children by 0.99–1.3 servings per day.¹⁵⁷ In addition, Farm to School programs strengthen students’ knowledge and attitude toward food, diet quality, agriculture, and the environment.¹⁵⁸

The CDC notes that Farm to School programs can encourage and support higher fruit and vegetable consumption in children and adolescents. In addition, the CDC states that “the existence of state-level farm to school/preschool policies shows support for creation, expansion, or maintenance of these programs”.⁶

8. Promotion in Grocery Stores

A review of strategies, examples, and available research on ways to increase fruit and vegetable intake suggests promoting and advertising fruits and vegetables in grocery stores, stating that there is “strong support for the feasibility of these approaches and modest evidence of their efficacy in influencing eating behavior”.¹⁵⁹ The review notes that fruit and vegetable promotion and advertisement can be either independent strategies for increasing fruit and vegetable consumption in the community or can be combined with other strategies implemented in grocery stores.¹⁵⁹ Another review reports that grocery store marketing strategies for promoting healthful eating include increased “availability, affordability, prominence, and promotion of healthful foods and/or restricting or de-marketing unhealthy foods”,¹⁶⁰ whereas a study on strategies to increase the sales of healthier foods in supermarkets concluded that “straightforward placement strategies can significantly enhance the sales of healthier items in several food and beverage categories”.¹⁶¹

9. Availability and Promotion in Foodservice Venues

The 2015 DGAC Report notes that, based on reviews of existing scientific evidence, worksite approaches that employ multi-component strategies (dietary modification interventions and nutrition education) can increase fruit and vegetable intakes among employees.² In addition, the CDC recommends that cafeterias and other foodservice venues in workplaces, universities, medical centers, and other institutions should implement policies and strategies that promote fruit and vegetable intake.¹³⁵

10. Nutition Lunch & Learn Lectures

A practical way to increase fruit and vegetable intake in institutional and commercial settings may be to provide occasional lunchtime lectures (“lunch & learn”) on nutritional topics, with a particular focus on fruits and vegetables. Nutrition experts recommend providing samples of fruits and vegetables and/or fruit and vegetable dishes for a “hands-on” experience and to help increase knowledge and consumption.

11. Nutrition Education in Schools

Educating children and adolescents about food and nutrition helps them learn and be aware of the components of a healthy diet and how to achieve healthy eating patterns. Therefore, mandating nutrition education in schools (K–12) may be a practical strategy to increase individuals’ nutrition knowledge both as children and as adults.¹⁶²

2. Sugar-sweetened Beverages

The 2015-2020 Dietary Guidelines for Americans define sugar-sweetened beverages (SSBs) as “liquids that are sweetened with various forms of added sugars; these beverages include, but are not limited to, soda (regular, not sugar-free), fruitades, sports drinks, energy drinks, sweetened waters, and coffee and tea beverages with added sugars”.⁶¹ Similarly, the CDC’s definition of SSBs includes soft drinks, sports drinks, energy drinks, fruit drinks, sweetened milk and milk alternatives, tea and coffee drinks, and “any other beverages to which sugar, typically high fructose corn syrup or sucrose (table sugar), has been added”.¹⁶³

With the exception of sweetened milks, SSBs have few to zero nutrients and are the primary source of added sugar in children and account for a third of added sugar consumption in adults.^{164 165} In 1965, the average adult consumed about 50 Calories per day from SSBs (excluding sweetened milks).¹⁶⁶ In 1999–2000, this number rose to about 223 Calories for youth (aged two to 19) and 196 Calories per day for adults (aged 20 and older).⁸ Fortunately, however, while SSB consumption rose dramatically between the 1960s and 1999–2000, the intake levels have finally started to decline in both youth and adults. In 2009–2010, it was estimated that youth consumed 155 Calories per day and adults consumed 151 Calories per day from SSBs.⁸

It is estimated that 184,000 deaths worldwide are attributable to SSB consumption each year.¹⁶⁷

Liquid calories are less satiating and are thus easier to over-consume, and some researchers assert there is now sufficient evidence that decreasing SSB intake will decrease the risk of obesity and type 2 diabetes.¹⁶⁸ In addition, the CDC has identified SSB consumption as a target behavior for obesity control and prevention, suggesting and supporting strategies aimed at reducing SSB consumption in order to combat obesity in the U.S.¹⁶⁹

An expert report by the World Cancer Research Fund and the American Institute for Cancer Research, Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective, recommends avoiding drinks with added sugars, noting that there is impressive evidence that the consumption of sugary drinks “’fools’ the human satiety mechanism, thereby promoting weight gain.”¹⁷⁰ Consumption of SSBs is associated with excess caloric intake, weight gain and obesity in both children and adults.^{19 114 168 169 171} For example, children with the highest intakes of SSBs are 55% more likely to be overweight or obese compared to those with the lowest intakes.¹⁹ Furthermore, substituting non-caloric beverages for SSBs is associated with decreased weight gain in children¹⁷² and adults.¹⁷³

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Higher intake of SSBs is also associated with increased risk for the metabolic syndrome, with a 20% higher risk among individuals consuming the highest amounts (usually one to two servings per day) of SSBs compared to those with the lowest intakes (none to less than one serving per month).²¹

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Numerous other major organizations and associations support reducing or avoiding the intake of SSBs, including the AHA ¹⁷⁴, the American Academy of Pediatrics (AAP),¹⁷⁵ the American Diabetes Association (ADA),²¹ the American Medical Association (AMA),¹⁷⁶ the Institute of Medicine of the National Academies (IOM),¹⁷⁷ the USDA,¹⁷⁸ the 2015 Dietary Guidelines Advisory Committee² and the WHO.¹⁷⁹

Health Effects

Digestive System

Dental caries. Frequent consumption of SSBs may increase the risk of dental caries. A study of children found a significant association between dental caries and greater consumption of SSBs. Young children who drank three or more SSBs per day had 47% more decayed, missing, or filled deciduous teeth compared to children who did not consume SSBs.¹⁸⁰ In addition, adults who drank only one to two SSBs per day had a 31% greater increase in decayed, missing, and filled teeth over the course of four years compared to those who did not consume any SSBs.¹⁸¹

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Dental erosion. The WHO report Diet, Nutrition and the Prevention of Chronic Diseases notes that studies have shown the consumption of SSBs is associated with dental erosion. The report recommends limiting the amount and frequency of soft drink consumption to reduce the risk of dental erosion.¹⁴¹

Endocrine System

Type 2 diabetes. About 133,000 annual deaths worldwide due to diabetes are estimated to be attributable to SSB consumption.¹⁶⁷ Research suggests that consuming one to two servings of SSBs per day is associated with a 26% higher risk of type 2 diabetes compared to consuming none or less than one serving of SSBs per month.²¹

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Solutions

1. Drinking Water Promotion

The CDC Guide to Strategies for Reducing the Consumption of Sugar-Sweetened Beverages recommends ensuring ready access to potable drinking water as a strategy to reduce the consumption of SSBs.¹⁶³ Specifically, the CDC recommends that in order to promote water consumption, “potable drinking water should be easily accessible to children and adults in homes and public facilities, including parks, playgrounds, schools, public buildings, worksites, and clinics.”¹⁶³

2. Availability of Beverages

The CDC Guide to Strategies for Reducing the Consumption of Sugar-Sweetened Beverages recommends providing access to alternatives to sugar-sweetened beverages in order to reduce SSB consumption.¹⁶³ The CDC notes that decreasing the availability of SSBs while increasing the availability of healthier alternatives (e.g., skim or low-fat milk) can lead to decreased SSB intake and an increased intake of the healthier alternatives.^{163 183}

The NYC Food Standards for Meals/Snacks Purchased and Served requires that all beverages (other than 100% fruit juice or milk) served in City agencies contain 25 Calories or less per 8-oz serving,¹⁸⁴ meaning that there can be a maximum of 6.25 g of sugar per 8-oz serving, assuming that all calories in the beverage come from added sugar. In addition, beverages other than 100% juice or milk served in schools in the U.S. must have five Calories or less per 8-oz serving,¹⁸⁵ meaning that they can have up to 1.25 g of sugar per 8-oz serving.

3. Limited Marketing and Advertising

The CDC Guide to Strategies for Reducing the Consumption of Sugar-Sweetened Beverages recommends limiting the marketing of SSBs to minimize the impact of marketing on children.¹⁶³

3. Limited Availibility

The CDC Guide to Strategies for Reducing the Consumption of Sugar-Sweetened Beverages recommends limiting access to SSBs, noting that it “can decrease SSB consumption and increase the consumption of more healthful beverages”.¹⁶³ The Guide reports that students participating in the National School Lunch Program, which restricts selling carbonated soft drinks where lunch is served, have lower intakes of added sugar (17% of daily calories from added sugars) compared to students who do not participate in the program (20% of daily calories from added sugars).^{163 186}

The National Academies of Medicine recommends that “carbonated water, fortified water, flavored water, and similar products are excluded because such products are associated with displacement of more healthful beverages; they are unnecessary for hydration purposes; and the increasing variety of products increases the difficulty of making clear distinctions among them”.¹⁸⁷ Based on recommendations from the IOM and other organizations and institutions, as well as existing research evidence, as of the 2014–2015 school year, all beverages sold in high schools in the U.S. as competitive foods have to meet USDA nutrition standards that limit the energy value of a beverage (that is not 100% fruit or vegetable juice or milk) to 40 Calories or less for an 8-oz serving and 60 Calories or less for a 12-oz serving,¹⁸⁵ thus excluding all regular sodas that usually have 35 to 45 g of sugar per 12-oz serving (beverages sold in elementary and middle schools have more strict rules).

5. Provision of Nutritional Information

The FDA has finalized two rules requiring all chain restaurants (with 20 or more locations) and similar eating establishments and vending machines (when an owner owns 20 or more vending machines) to post caloric information on menus and menu boards, including information for beverages sold at these establishments or vending machines.^{188 189} Given that Americans consume about one-third of their calories away from home, making calorie information available is important in helping consumers make informed nutritional choices.¹⁹⁰

6. Physical Activity Calorie Equivalent Labeling

In a national survey of more than 800 parents, parents were randomly given one of four food menu types: no labels, calories-only labels, calories plus minutes needed to walk off the calories, and calories plus miles needed to walk to burn off the calories. The parents were asked to assume they are in a fast food restaurant and ordering food for their children. Parents whose menus showed no label ordered food containing more calories than parents whose menus showed calories only, calories plus minutes, or calories plus miles. The authors of the study concluded that physical activity calorie equivalent labeling may influence parents’ decisions when ordering fast food for their children.¹⁹¹ A similar study using a web-based survey randomly assigned over 800 participants to one of the four menu options. Participants ordered less calories from the menus with labels compared to the menu with no nutritional information, with 82% of participants reporting a preference for physical activity based menu labels over labels with calorie information alone and no nutritional information.¹⁹²

7. Visualisation of Sugar Content

A study found that individuals “view SSBs more negatively and show less preference for SSBs when they are able to concretely visualize the quantity of sugar in SSBs”.¹⁹³ In a series of small, similar experiments on college students, researchers found that when the sugar content of an SSB is visually presented in the form of a pyramid of sugar cubes (in addition to providing written information with the total sugar content), individuals are less likely to choose to consume it. Based on the results of the study, the authors suggest displaying a visual reference for the amount of sugar in an SSB since individuals are less likely to select a beverage when they can see a representation of its sugar content as opposed to merely reading a number.¹⁹³

3. 100% Fruit Juice

Fruit juice is made from squeezing or cold-pressing the pulp of fresh fruits and eliminating the fiber. Fruit juice that is 100% natural does not contain additives (e.g., added sugar) other than water but it can be fortified (e.g., with vitamin C). While some fruit juices are high in certain vitamins and minerals (e.g., vitamin C, folate, thiamin, potassium), fruit juice does not contain the fiber found in whole fruit. Fruit juice also does not provide the nutrients identified as under-consumed by the 2015 DGAC Report.² In addition, fruit juice can be very high in sugar: a 12-oz glass of apple juice has about 36 g of sugar,¹⁹⁴ similar to the sugar content in a 12-oz glass of Coca Cola (39 g)¹⁹⁵. Without the fiber to slow down sugar absorption and limit the insulin response, juice consumption can lead to similar spikes in blood glucose as those seen with SSBs.¹⁹⁶ The absence of fiber also inhibits the satiety response,¹⁹⁷ which likely contributes to over-consumption and additional caloric intake rather than replacing caloric foods in the diet. Therefore, drinking fruit juice is not equivalent to eating fruit and is not a good substitute for SSBs.

A 2014 Lancet Diabetes & Endocrinology commentary advocates for re-examining the evidence regarding whether fruit juice consumption should be permissible within the recommended fruit and vegetable intake guidelines. The authors also advocate for better fruit juice labeling that indicates the maximum recommended daily intake of fruit juice on juice containers. The authors conclude that fruit juices are sugary drinks, just like SSBs, “with a probable net adverse effect on health”.¹⁹⁸ The American Academy of Pediatrics,¹⁹⁹ the World Cancer Research Fund and the American Institute for Cancer Research,¹⁷⁰ as well as the WHO and the USDA all recommend limiting fruit juice consumption.^{13 114}

The WHO notes that high intake of fruit juice may promote weight gain and obesity.¹¹⁴ The 2015-2020 Dietary Guidelines for Americans report that about one-third of the intake of fruits in the U.S. population comes from fruit juice and the remaining two-thirds from whole fruits.⁶¹ Moreover, the American Academy of Pediatrics states that for infants under six months, fruit juice offers no nutritional benefits, and for infants older than six months as well as for children, fruit juice offers no nutritional benefits over whole fruit.¹⁹⁹ A study on long-term weight gain and changes in diet and lifestyle also notes that consumption of 100% fruit juice was associated with weight gain, but of smaller magnitude than that associated with SSBs, potentially due to consumption in smaller servings.²⁰⁰

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Health Effects

Digestive System

Dental erosion. The WHO notes that fruit juice consumption is associated with dental erosion.¹¹⁴ In addition, a review of studies found an increased occurrence of teeth erosion with greater consumption of acidic fruit juices in children and adolescents.²⁰²

Endocrine System

Type 2 diabetes. High fruit juice intake has been linked to a higher risk of diabetes. A study of three cohorts (Nurses’ Health Study, Nurses’ Health Study II, and the Health Professionals Follow-up Study) found an 8% increased risk of diabetes with each three-serving increase in fruit juice per week, whereas each three-serving increase in whole fruit intake per week was associated with a 2% lower risk.²⁰³ In a study looking at just one of the three cohorts (Nurses’ Health Study), consuming more than three cups of apple juice per month was associated with a 15% higher risk of type 2 diabetes compared to consuming less than one cup per month, and drinking one or more cups of orange juice per day was associated with a 24% higher risk of diabetes compared to drinking less than one cup per month.²⁰⁴

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Solutions

1. Limits on Serve Sizes

An expert report by the World Cancer Research Fund and the American Institute for Cancer Research recommends limiting fruit juice consumption.¹⁷⁰ The WHO also recommends limiting the amount and frequency of fruit juice consumption.¹¹⁴ The NYC Food Standards: Meals/Snacks Purchased and Served requires that if juice is offered in places served by City agencies, it must be 100% fruit juice, in portions no larger than six oz per serving.¹⁸⁴

The 2015-2020 Dietary Guidelines for Americans recommend that at least half of the recommended amount of fruits come from whole fruits instead of 100% fruit juice.⁶¹ According to the guidelines, one cup of 100% fruit juice is equivalent to 1 cup of fruit.⁶¹ In addition, the American Academy of Pediatrics recommends limiting fruit juice intake to four to six oz per day in children one to six years old.¹⁹⁹

2. Limited Marketing and Advertising

Based on the recommendations to limit access to SSB,¹⁶³ limiting the availability of fruit juice in places where beverages are sold or served can be a potential strategy to reduce overall fruit juice intake.

2. Limited Availability

Based on the recommendations to limit access to SSB,¹⁶³ limiting the availability of fruit juice in places where beverages are sold or served can be a potential strategy to reduce overall fruit juice intake.

4. Red and Processed Meat

Red meat includes beef, lamb, and pork. Processed meat is any meat that has been smoked, cured, salted, or otherwise preserved, including bacon, cold cuts, hot dogs, pastrami, salami, sausages, and others.²⁰⁵ Processed and unprocessed meats differ nutritionally, with about four times more salt in processed compared to lean, unprocessed meat.

There is a large discrepancy between red meat consumption among different countries, as well as types of meat. For example, the three countries consuming the least beef and veal (India, Mozambique and Bangladesh) had an average intake of just 0.8 kilogram (kg) (1.8 lbs) per person per year in 2015, whereas the three countries that consuming the most (Argentina, Uruguay, and Brazil) averaged 35.4 kgs (78 lb) per person per year, with Argentina consuming the most—41.8 kgs (92.2 lbs) per person per year. For lamb, the lowest-consuming three countries (Thailand, Vietnam, and Korea) had an average intake of less than 0.1 kg (0.22 lbs) per person per year, whereas the three countries with the highest consumption (Australia, Sudan, and Kazakhstan) averaged 8.6 kgs (19 lbs) per person per year, with Australia having the highest intake at 9.5 kgs [21.0 lbs] per person per year. Some countries do not consume pork at all (Pakistan, Iran, Bangladesh, Sudan, Algeria, Ethiopia, and Turkey), whereas the top three countries (China, Vietnam, and Korea) consumed 29.2 kgs (64.4 lbs) per person per year, with China consuming the most at 31.8 kgs (70.1 lbs) per person per year in 2015.²⁰⁶ Overall, red meat consumption rates in the U.S. are high, and the USDA estimated 45 kgs [99.2 lbs] per capita red meat consumption in the U.S. in 2015,²⁰⁷ making the U.S. one of the largest meat consumers worldwide.

High intake of red meat, and especially processed meat, has been associated with several negative health outcomes as well as increased all-cause mortality.^{208 209} A review of studies suggests that a higher intake of red and processed meat (adjusted for energy intake) is associated with a greater BMI, waist circumference and a higher risk of obesity.²¹⁰

Numerous institutions, including the AHA,²¹¹ the WHO, the FAO,¹¹⁴ the American Cancer Society,¹¹⁰ the American Institute for Cancer Research (AICR) and the World Cancer Research Fund International (WCRF)¹⁷⁰ recommend limiting the consumption of red meat and avoiding processed meat. Specifically, the AICR recommends eating no more than 18 oz (cooked weight) of red meat per week, avoiding processed meat, and replacing red meat with fish, low-fat poultry, and plant protein sources when possible.²⁰⁵

Health Effects

Cardiovascular System

Coronary heart disease. A review of studies with over 1.2 million individuals on the consumption of unprocessed and processed red meat found an association between processed red meat consumption and coronary heart disease. Each 50-g (one serving) daily increase in processed meat was associated with a 42% increase in coronary heart disease.²¹² An association was not found between unprocessed red meat and coronary heart disease.

CVD mortality. A review of studies with nearly 1.7 million individuals found that those consuming the most processed meat had an 18% higher risk, and those consuming the most red meat had a 16% higher risk for cardiovascular disease mortality compared to the participants in the lowest category of consumption. The review did not find any association between total meat (red meat, processed meat, and white meat combined) intake and CVD mortality.²⁰⁹

Heart failure. One study suggests that processed meat consumption is associated with heart failure, with a 28% higher risk of heart failure and more than double the risk of dying from heart failure seen in men who consume 75 g of processed meat or more per day compared to those who consume less than 25 g per day.²¹³ A prospective cohort study also examined the association of red meat consumption and risk of heart failure in U.S. male physicians from the Physician’s Healthy Study and found that increased consumption of red meat is associated with a higher risk of heart failure.²¹⁴

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Hypertension Research shows that women who report consuming five or more servings of processed red meat per week have a 17% higher rate of hypertension compared to women who consume less than one serving (50 g) of processed meat per week, an association which the researchers speculated may be due to increased salt intake.²¹⁵ The models used to calculate risk were adjusted for BMI, fruit and vegetable intake, and other parameters. No association was found between the consumption of unprocessed red meat and hypertension.²¹⁵

Digestive System

Colorectal cancer In a review of studies, individuals with the highest intakes of red and processed meat had a 22% higher risk of colorectal cancer compared to those with the lowest intakes. Each 100 g per day increase in red and processed meat intake was associated with a 14% increase in risk of colon cancer.²¹⁶ The U.S. FDA ²¹⁷ and the American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention¹¹⁰ both note that current scientific evidence shows increased risk of colorectal cancer with greater intakes of red and processed meat, and recommend reducing red and processed meat intake in order to reduce the risk of colorectal cancer.

Endocrine System

Type 2 diabetes. Dietary patterns lower in red and processed meat (as well as lower in high-fat dairy products, refined grains, sweets/SSBs, and higher in fruits and vegetables and whole grains) are associated with a lower risk of type 2 diabetes,² whereas eating more red meat over time is associated with a higher risk of developing type 2 diabetes. In a review of studies, greater than a half-serving increase in daily red meat intake (processed and unprocessed) over a four-year period was associated with a 48% increase in diabetes risk, whereas a greater than a half-serving decrease in daily meat intake was associated with a 14% lower risk over the same period of time.²¹⁸ However, these associations were partially mediated by body weight, and after adjusting for initial BMI and concurrent weight gain, the association between increased red meat intake of more than a half-serving over four years and type 2 diabetes was 30%, and that for decreased intake was 10%.²¹⁸ Another review of studies found that only processed meat intake was associated with diabetes, with a 19% greater risk associated with each 50-g daily serving of processed meat, whereas the intake of red meat was not associated with type 2 diabetes; the associations for total meat consumption were intermediate (12% greater risk with each daily serving of total meat).²¹²

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Reproductive System

Breast cancer. Greater intake of red meat has been associated with an increased risk of breast cancer. A review of studies found a 24% greater risk of breast cancer among women consuming the most red meat compared to those with the lowest intakes, adjusting for weight, energy intake, fruit and vegetable intake, total fat intake, and other parameters.²¹⁹ In addition, highest total meat intake was associated with more than double the risk of breast cancer compared to lowest intake in a study of nearly 7,000 Chinese women, and highest intakes of red meat were associated with 1.45 times the risk of breast cancer compared to the lowest levels of intake, adjusting for BMI, total energy intake, fruit and vegetable intake, and other parameters.²²⁰

Solutions

1. Limited Availability

Based on the dietary recommendations to limit the intake of red and processed meat by the World Cancer Research Fund and the American Institute for Cancer Research,¹⁷⁰ the 2015 Dietary Guidelines Advisory Committee,² and the American Cancer Society,¹¹⁰ limiting the availability of red and processed meat options in food establishments, schools, and workplaces may be a practical strategy to reduce individual intake of red and processed meat.

One way to limit availability is by adopting “Meatless Mondays,” a public health initiative aimed at encouraging the consumption of healthy, plant-based foods and reducing red and processed meat intake to decrease the risk of preventable diseases linked to excessive meat consumption. The public health campaign started in 2003 in association with Johns Hopkins Bloomberg School of Public Health. As of 2015, the campaign has gained traction in 36 countries, where people are encouraged to skip eating meat one day per week because lower meat intake is good for individuals’, nations’ and the planet’s health. FoodNYC: A Blueprint for a Sustainable Food System, published by the president of the Borough of Manhattan, recommends “Meatless Mondays” to be implemented in New York City public schools.²²¹ It has also been approved for implementation in San Francisco in 2010, whereby grocery stores, restaurants, and schools have been encouraged to offer a wider variety of plant-based foods on Mondays.²²²

In addition, Sodexo has implemented “Meatless Mondays” in nearly 3,000 hospitals, corporate, and government client locations in order to promote health, wellness, and sustainability in places where the company operates.²²³ While meatless options should always be available in places where food is sold or served, “Meatless Mondays” promotes healthy alternatives to meat dishes on one day per week that is specifically dedicated to eating healthy meatless meals.

The World Cancer Research Fund and the American Institute for Cancer Research recommend choosing beans, fish, and poultry instead of red meat, and recommend that people who eat red meat choose lean cuts and consume smaller portions, and limit their intake to 500 g [18oz] per week, of which very little, if any, is processed meat.¹⁷⁰ The 2015-2020 Dietary Guidelines for Americans recommend a limit of 26 ounce-equivalents per week for the meats, poultry, and eggs subgroup.⁶¹

5. Energy-Dense, Nutrient- And/Or Fiber-Poor Foods

Dietary energy density (DED) is the amount of energy that can be metabolized per unit weight or volume of food.²²⁴ Energy-dense foods can be nutrient- and/or fiber-rich foods, such as nuts and seeds, avocados, and nut and seed oils; or they can be nutrient- and/or fiber-poor foods, such as candies, refined grains, jams and jellies, and processed meats. Energy-dense, nutrient- and/or fiber-poor foods usually have fat and/or sugar added in the manufacturing or preparation process to improve their taste, leading to more calories per ounce. For example, a 100-g [3.5 oz] apple pie (265 Calories)²²⁵ contains 4.5 times more calories than 100 g [3.5 oz] of raw apple (52 Calories, the equivalent of a very small apple).²²⁶ Foods that are rich in fats and sugars (commonly referred to as highly palatable foods) are consequently high in calories. It is suggested that highly palatable foods activate the brain’s mesocorticolimbic reward circuits by releasing dopamine and other hormones and neurotransmitters (chemicals that transmit nerve impulses from one neuron to another across a synapse).¹⁰³ While most foods will activate reward pathways to some extent, especially after food deprivation, highly palatable foods stimulate the reward pathways much more potently and reliably relative to foods that are not as delicious.¹⁰³

The WHO notes that a high intake of energy-dense, micronutrient-poor foods results in overconsumption of energy, and hence promotes excess weight gain.¹¹⁴

In addition, research suggests that dietary patterns of greater energy density are associated with greater adiposity in children and adolescents, whereas dietary patterns of lower energy density in adults are associated with weight maintenance and weight loss.²²⁷ The 2015 DGAC Report notes that based on limited evidence, dietary patterns higher in energy-dense, fiber-poor foods (e.g., sweets, refined grains, processed meats, SSBs, whole milk, fried potatoes, certain fats and oils, fast foods) in children and adolescents increase obesity risk later in life.²

A relatively large proportion of Americans’ diets come from energy-dense, nutrient- and/or fiber-poor foods. Approximately 28% of calories in the American diet are from a combination of snacks, sweets, and beverages (not including milk and 100% fruit juice).²

Health Effects

Cardiovascular System

Cardiovascular disease. The 2015 DGAC Report notes that dietary patterns lower in refined grains, sugar-sweetened foods and beverages, and red and processed meats are associated with a lower risk of cardiovascular disease.²

Endocrine System

Type 2 diabetes. The 2015 DGAC Report notes that dietary patterns lower in refined grains, sweets and SSBs, red and processed meats, and high-fat dairy products are associated with a lower risk of type 2 diabetes.²

Digestive System

Colorectal cancer. The 2015 DGAC Report notes that dietary patterns higher in red and processed meats, French fries/potatoes, and sugars (sweets, desserts, sodas) are associated with a greater risk of colon/rectal cancer.²

Solutions

1. Provision of Nutritional Information

The FDA has finalized two rules requiring all chain restaurants (with 20 or more locations) and similar eating establishments and vending machines (when an owner owns 20 or more vending machines) to post caloric information on menus and menu boards, including information for beverages sold at these establishments or vending machines.^{188 189}

Furthermore, the 2015 DGAC Report states that “food and menu labels can provide information that improves an individual’s food selection and potentially improves body weight outcomes”.² However, the Committee notes that current research still needs to identify the best combination of menu labeling information (e.g., information on daily caloric needs or physical activity equivalents) that minimizes excessive energy intake. It recommends future research to develop “novel labeling approaches to provide informative strategies to convey caloric intake values on food items consumed at home and in restaurant settings”.²

A study with nearly 1,300 Australian adults used an online menu simulation to examine whether providing energy information alone or accompanied by other nutritional information affected decision making when selecting fast food meals typically served at chain restaurants. The varied menus included energy information alone (kJ); energy information and percent daily intake; energy information and a traffic light picture (indicating food energy level); and energy information, a traffic light picture, and percent of daily intake. Participants who were provided with calorie information along with the traffic light picture selected meals that had a significantly lower mean energy content (120 Calorie or 500 kJ reduction) compared to those who were not provided any energy content or nutritional information. In addition, the participants most commonly reported that they used the traffic light labels in making their selections. However, because online menu simulation and not actual energy intake was assessed, it was impossible to determine whether menu labeling would have an effect on energy intake. Nevertheless, the authors concluded that the findings of the study “provide support for the policy of disclosure of energy content on menus at restaurant chains”.²²⁸

2. Limited Marketing and Advertising

The WHO states that heavy marketing of energy-dense foods is associated with an increased risk of weight gain and obesity. The organization recommends limiting heavy marketing of energy-dense, micronutrient-poor foods to children; instead, children should be provided with the information and skills needed to make healthy food choices.¹¹⁴ The International Association of Consumer Food Organizations’ (IACFO) report to the WHO states that “frequent exposure to marketing messages, along with changes in social circumstances, such as children’s increasingly independent spending power, contribute to a nutritionally ‘toxic’ or ‘obesogenic’ environment—that is, environments that predispose children to desire and be able to obtain and consume certain foods, especially those that are energy-dense and low in nutrients.”²²⁹

In addition, research on the effects of food marketing, and especially food marketing to children, strongly advocates changing the current marketing environment,²³⁰ which “almost exclusively promotes calorie-dense, nutrient-poor foods and takes advantage of children’s vulnerability to persuasive messages,” and has a detrimental effect on children’s health.²³¹ The 2015 DGAC Report recommends implementing strategies that limit the access to nutrient-dense, nutrient-poor foods.²

The Federal Trade Commission (FTC) reports that in 2006, the food industry spent nearly $10 billion in marketing food and beverages to children and adolescents in the U.S., including $1.6 billion to specifically target children and adolescents with cereal, fast-food, and soft drink promotions.²³² The Institute of Medicine states that “food and beverage marketing influences the preferences and purchase requests of children, influences short-term consumption, may contribute to less healthful diets, and contributes to an environment that puts their health at risk.”²³³

3. Physical Activity Colorie Equivalent Labeling

In a national survey of more than 800 parents, parents were randomly given one of four food menu types: no labels, calories-only labels, calories plus minutes needed to walk off the calories, and calories plus miles needed to walk to burn off the calories.¹⁹¹ The parents were asked to assume they are in a fast food restaurant and ordering food for their children. Parents whose menus showed no label ordered food containing more calories than parents whose menus showed calories only, calories plus minutes, or calories plus miles. The authors of the study concluded that physical activity calorie equivalent labeling may influence parents’ decisions when ordering fast food for their children.¹⁹¹ A similar study using a web-based survey randomly assigned over 800 participants to one of the four menu options. Participants ordered less calories from the menus with labels compared to the menu with no nutritional information, with 82% of participants reporting a preference for physical activity based menu labels over labels with calorie information alone and no nutritional information.¹⁹²

Based on the findings of the study, providing a relatable reference point alongside caloric information, such as physical activity calorie equivalents, may be a practical strategy to help individuals make smarter beverage choices and potentially help them lower the intake of energy from energy-dense, nutrient- and/or fiber-poor foods.

6. Partially Hydrogenated Oils

Trans fats, or trans fatty acids are unsaturated fatty acids that contain one or more unsaturated (double) bonds in the trans, rather than the more common cis configuration. While trans fats do occur naturally in some foods (ruminant fat such as meat and milk), traditionally the greatest source of trans fats is from partially hydrogenated vegetable oils. During the hydrogenation process, oils are partially hydrogenated to increase their melting point, which makes them more solid at room temperature and increases their shelf life and heat stability (smoking point). Trans fats that occur naturally in ruminant fat (e.g., meat and milk) are produced by microbial activity in the rumen and are subsequently absorbed. However, many trans fats consumed in the diet come from partially hydrogenated oils, not from naturally occurring foods that contain small amounts of trans fats.

The National Academy of Medicine states that trans fats are “not essential and provide no known benefit to human health.”⁴⁹ In November 2013, the FDA issued a preliminary determination that trans fats are no longer Generally Recognized as Safe (GRAS) in human food. Some cities and states (i.e., New York City and California) already have laws in effect that ban the storage, usage, or serving of any food products that contain more than 0.5 g of trans fat per serving.²³⁴ In June 2015, the FDA released its final determination that partially hydrogenated oils are not GRAS, giving the industry a three-year compliance period to either reformulate their products or petition the FDA to permit certain uses of partially hydrogenated oils.⁷⁹

Currently, the FDA allows food companies to label their food products as “trans fat free” if they contain less than 0.5 g of trans fatty acids per serving. While this might seem like a small amount, it can represent several grams of trans fat per day for people who regularly consume foods with up to 0.5 g of trans fats per serving. The AHA, the CDC, the FDA, and other organizations recommend not only looking for foods that are labeled “trans fat free” but also looking at the ingredients list to make sure the food does not contain any partially hydrogenated fats or oils, aiming for as little trans fatty acid consumption as possible.^{235 236 237} Foods that may currently contain trans fats include cakes, cookies, crackers, frozen pies and other baked goods, coffee creamer, fast food, frozen pizza, snack foods (e.g., microwave popcorn), ready-to-use frostings, refrigerated dough products (e.g., biscuits, cinnamon rolls), stick margarine, vegetable shortening, and other foods.²³⁸ If the FDA’s decision to remove partially hydrogenated fat from the GRAS list is upheld, these foods will need to be reformulated to comply with the new guidance.

Health Effects

Cardiovascular System

Coronary heart disease. Trans fatty acid intake has been associated with a higher risk of coronary heart disease.⁷⁹ A systematic review and meta-analysis of 32 studies and over 500,000 individuals found that the highest third compared to lowest third of trans fat intake is associated with 16% higher risk for coronary heart disease.³² In addition, the CDC reports that reducing trans fatty acid intake may prevent as many as 10,000 to 20,000 heart attacks and 3,000 to 7,000 coronary heart disease deaths per year in the United States.²³⁹

Plasma cholesterol. The CDC reports that trans fat consumption increases LDL cholesterol and decreases HDL cholesterol levels, both of which are risk factors for coronary heart disease.²³⁹ The association between trans fat intake and coronary heart disease is thought to be related primarily to plasma lipoprotein patterns. The data are consistent that all fatty acids with one or more trans double bonds raise the ratio of LDL to HDL cholesterol, irrespective of their origin (ruminant or partially hydrogenated fat sources) or structure, consistent with increasing the risk of coronary heart disease.²⁴⁰ When each percent in energy intake from mono-unsaturated fatty acids was replaced by trans fatty acids from partially hydrogenated sources, LDL (“bad”) to HDL (“good”) cholesterol ratio increased by 0.055, and by 0.038 when replaced by ruminant trans fatty acids.²⁴⁰

Solutions

1. Partially Hydrogenated Oil Ban

Trans fatty acid intake should be minimized. Removing partially hydrogenated fat from the FDA GRAS list,⁷⁹ coupled with reducing the intake of fat from meat and dairy products, are the most reliable approaches to achieve this goal. Until partially hydrogenated fats are eliminated from the food supply in the U.S. (and due to the labeling “loophole” allowing foods to be labeled “trans fat-free” if they contain less than 0.5 g of trans fat per serving) and in countries where partially hydrogenated fats are not yet eliminated from the food supply, food items that contain “partially hydrogenated oil” as an ingredient should not be sold or distributed in schools, workplaces, food establishments, and other places.

Energy Excess

Energy excess is the consumption of more calories per day than the body expends. The 2015-2020 Dietary Guidelines for Americans recommend managing calorie intake for maintaining calorie balance, which is defined as “the balance between the calories taken in from foods and the calories expended from metabolic processes and physical activity.”⁶¹ However, Americans are consuming more calories than ever before. In 2010, the average American consumed an estimated 2,544 Calories, a 505-Calorie increase from 1970, with the majority of additional calories coming from refined grains and added fats and sugars.²⁴¹

1. Excess Calorie Intake

Excess calorie intake, or overeating, occurs when more food and beverages are consumed than are required to maintain calorie balance. It can lead to excess weight gain, and if the excess intake continues over time, it can result in overweight and obesity. Eating food away from home, eating while emotional or distracted, and eating large food and beverage portions (common in many food establishments) can contribute to excess calorie consumption. These factors have contributed to the current high rates of overweight and obesity in the U.S. and worldwide. In the U.S., more than two thirds of all American adults (20 years and older) are categorized as overweight or obese.²³ Overweight and obesity are difficult to treat due to a number of factors, including disruptions in insulin sensitivity and hormonal control of appetite regulation, both of which promote weight gain. An added factor is that obesity and overweight also impact individuals’ biochemistry. Fat cells excrete hormonal signals, called adipokines, which can increase inflammation throughout the body. As individuals gain weight, their fat cells grow larger and excrete more adipokines, thereby increasing inflammation levels.²⁴² Inflammation can be involved in several different ailments including various chronic diseases.

Excess calorie intake can also increase the risk for metabolic syndrome—a group of risk factors that heighten the risk for heart disease, diabetes, and other health issues.¹ Children and adolescents who are obese have an increased risk of overweight and obesity as adults, along with obesity-associated health issues.¹ The effect of portion size on food intake has been the subject of many studies, which have consistently shown that larger portions result in increased calorie intake that is sustained, without compensating for the excess calorie intake (e.g., reducing calorie intake) later on.²⁴³ The WHO notes that “large portion sizes are a possible causative factor for unhealthy weight gain.”¹¹⁴ Similarly, the National Heart, Lung and Blood Institute notes that eating large portions leads to ingesting too many calories, which over time causes weight gain if the increased intake is not balanced with physical activity.²⁴⁴ Finally, liquid calories are usually not balanced through reduced food calorie consumption and can also lead to excess energy intake and subsequent weight gain.

Some of the manifestations of excess calorie intake may be diagnosed as eating disorders,²⁴⁵ such as binge eating disorder, bulimia nervosa, night eating syndrome, and others. However, this section of the WELLography™ will discuss the health effects associated with general (i.e., nonpathological) calorie overconsumption and suggest ways to minimize the risk of excess calorie intake. Prevention and treatment of eating disorders is beyond the scope of this document.

Because excess calorie intake and positive energy balance lead to overweight and obesity, the following sections discuss the health risks associated with being overweight and obese.

Health Effects

Cardiovascular System

Cardiovascular disease risk factors. Both children and adults who are overweight or obese are more likely to have high blood pressure, high levels of triglycerides and LDL cholesterol, and low levels of HDL cholesterol, all of which are risk factors for cardiovascular disease.^{1 24} In a study looking at the cardiovascular parameters in overweight and obese children, 70% of those who were overweight (in the 95th or higher BMI percentile for age) had one cardiovascular risk factor, and 39% had two or more cardiovascular risk factors.²⁴⁶

Coronary heart disease, angina, heart attack, stroke. Individuals who are overweight or obese have a higher risk of having coronary heart disease (whereby plaque builds up inside arteries, limiting the supply of oxygen-rich blood to the heart); angina or chest discomfort and heart attack (due to narrowing or blockage of the coronary arteries from plaques); heart failure (whereby the heart is unable to pump enough blood throughout the body); and stroke (whereby a plaque formed in the arteries close to the brain ruptures, causing a blood clot and blocking the blood flow to the brain).¹ A 26-year-long study of over 5,200 individuals found that weight status at the beginning of the study was related to coronary disease (both angina and others), coronary death, and congestive heart failure, independent of various factors including age, cholesterol, and systolic blood pressure, among others.²⁴⁷ A review of 97 prospective cohorts involving 1.8 million participants found that every five kg per m² increase in BMI was associated with a 27% increase in the hazard of coronary heart disease and an 18% increase in the risk for stroke; after adjusting for cholesterol, blood pressure, and glucose, the risks decreased to 15% and 4%, respectively.²⁴⁸

Digestive System

Gallstones and gall bladder cancer. Individuals who are overweight or obese have a higher risk for gallstones.¹ In addition, body fatness (percentage of one’s body weight that is comprised of fat) is associated with an increased risk for gall bladder cancer.² A meta-analysis of 11 studies found that overweight and obesity increased gallbladder cancer risk by 15% and 66%, respectively.²⁴⁹

Colorectal and esophageal cancer. Body fatness is associated with an increased risk of colorectal and esophageal cancers.² In a review of prospective studies, obesity was related to a 33.4% increase in the risk of colorectal cancer.²⁵⁰ A review of studies found that an obese BMI (defined as a BMI of 30 or greater) was associated with anywhere from a nearly twofold to a fourfold increase in the risk of esophageal adenocarcinoma.²⁵¹

Endocrine System

Impaired glucose tolerance, insulin resistance, type 2 diabetes. Individuals who are overweight or obese have a higher chance of impaired glucose tolerance, insulin resistance, and type 2 diabetes, whereby the body is not able to properly control blood sugar levels.¹ A meta-analysis of nine studies found that obese men and women had up to 6.7 and 12.4 times the rate of type 2 diabetes, respectively, compared to their non-obese counterparts.²⁵²

Nervous System

Depression. Research has found a bi-directional relationship between depression and obesity, in that people who are obese are more likely to be depressed, and people who are depressed are more likely to be obese. Specifically, the CDC has found that between 2005 and 2010, obesity rates were higher among adults with depression compared to adults without depression and this was especially true among women and older men; specifically, women in all age groups, and men over 60 years old, were significantly more likely to be depressed if they were obese when compared with their non-obese counterparts.²⁵³ Furthermore, a meta-analysis found that individuals with abdominal obesity had 38% higher odds of depression when compared to non-obese individuals.²⁵⁴

Sleep. A review article found that sleep and obesity have a reciprocal relationship.²⁵⁵ People who sleep less or for shorter durations tend to be heavier, and reduced sleep has been linked with overeating. Furthermore, obesity can cause obstructive sleep apnea, which can reduce the quantity and quality of individuals’ sleep. In this way, obesity can be both a cause and symptom of poor sleep.²⁵⁵

Reproductive System

Breast, endometrial, and prostate cancer. Overweight and obesity are associated with a higher risk of breast and endometrial cancers.¹ In addition, body fatness is associated with a greater risk of ovarian and prostate cancers.² A meta-analysis found that obesity was associated with a 3.22 times greater risk for endometrial cancer, 1.13 times greater risk for breast cancer, and 1.05 times greater risk of prostate cancer.²⁵²

Respiratory System

Obesity hyperventilation syndrome. Some individuals who are obese can be affected by obesity hyperventilation syndrome, which causes poor breathing and in turn, higher carbon monoxide and lower oxygen levels in the blood, and can cause serious health problems, including death.²⁵⁶ Approximately 10–20% of obese individuals will suffer from obesity hyperventilation syndrome.²⁵⁷

Skeletal System

Osteoarthritis. Because excess body weight adds more pressure on the joints, individuals who are overweight or obese are at greater risk for osteoarthritis, affecting hip, knee, and lower back.¹ One systematic review found that obese individuals were at approximately twice the risk of being diagnosed with osteoarthritis of the hip,²⁵⁸ while another found that obese individuals were at more than 2.5 times the risk of osteoarthritis of the knee when compared with non-obese individuals.²⁵⁹

Urinary System

Kidney cancer. Body fatness is associated with an increased risk of kidney cancer.² A meta-analysis of 141 studies found that obesity was related to a 34% increase in risk for kidney cancer among women and a 24% increase in men.²⁶⁰

Solutions

1. Dinnerware Size

Research on portion and plate size effects on food consumption recommends replacing larger dinnerware with smaller dinnerware.²⁶¹ This reduces the likelihood of over-serving (relative to the personal consumption norm) but does not lead to decreased satisfaction, noting that “it could simply lead consumers to satisfy their hunger while unknowingly eating less food.”²⁶² The color of the dinnerware also influences how much food is self-served on a plate, with lower amounts of food served on a plate that contrasts most with the food being served.²⁶² However, the evidence of dinnerware size and food intake is still mixed as some studies have found only a marginal²⁶³ or no effect.²⁶⁴

Based on these findings, smaller dinnerware could be provided in places where food is sold or distributed, such as workplaces, schools, restaurants, cafeterias, and other food establishments, to help minimize overeating. Due to the “visually deceiving” effects of larger plates and bowls on serving size, consumption, and perceived consumption of food, different types of food could be served on different kinds of plates to promote higher intake of foods that are healthy and lower consumption of foods that should be eaten in moderation.²⁶⁵ For example, large plates could be used to serve fresh fruits and vegetables,²⁶⁴ whereas smaller plates could be used to serve energy-dense meals or desserts. In addition, plates of several contrasting colors could be made available, when possible and/or practical, and be used based on the color of the food being served in order to provide a contrast between a plate and the food served.²⁶²

2. Portion Size

The 2015-2020 Dietary Guidelines for Americans defines portion size as “the amount of food served or consumed in one eating occasion” and notes that “a portion is not a standardized amount, and the amount considered to be a portion is subjective and varies.”⁶¹ Research shows that larger portions may promote and contribute to overconsumption of calories, whereas smaller portions and lower energy density may promote lower caloric intake. ^{13 266 267} In addition, the CDC notes that individuals will often eat more when presented with larger portion sizes and recommends portion control.²⁶⁸ Similarly, the 2015-2020 Dietary Guidelines for Americans recommend “reducing the portion size of foods and beverages that are not in nutrient-dense forms,” e.g., processed foods.⁶¹

To address the issue of portion size and total energy intake, the New York City Standard for Cafeteria/Café Implementation Guide intended for increasing the availability of healthier foods and beverages recommends that all sandwiches, salads, and entrées offered contain no more than 700 Calories, 50% contain no more than 500 Calories, and that at least one value meal (consisting of at least two menu items that would otherwise be sold separately) is offered daily that consists of no more than 650 Calories.²⁶⁹

3. Mindful Eating Places

Research shows that distracted eating (such as eating while watching TV) may lead to overeating.²⁷⁰ In a systematic review and meta-analysis of 24 studies, eating when distracted led to a small increase in immediate intake and a greater increase in later food intake.²⁷¹ Some of the studies included in the meta-analysis controlled for what the study participants were doing while eating, such as watching television, reading, or listening to the radio. The study noted that “distraction influences later memory of food consumed and calorie intake,” concluding that eating attentively likely has an impact on food intake.²⁷¹

Research also shows that eating slowly and carefully chewing the food can lead to a significantly lower meal energy intake in people of normal weight.²⁷² Conversely, faster eating is associated with a greater BMI. In a study of 2,500 middle-aged women, BMI was 2.8% greater with each category increase in self-reported eating speed.²⁷³

Furthermore, experts on the social influences of eating note that “social context (‘the immediate physical surroundings, social relationships, and cultural milieus within which defined groups of people function and interact’)²⁷⁴ influences eating via multiple mechanisms, including identity signaling [a way of communicating preferences about a particular behavior modeled by an individual; others perceive these communications and then converge or diverge on those behaviors as a way to signal their own identity and perception of that behavior] and self-presentation [behaviors that are meant to present the desired image of self to others] concerns.”²⁷⁵. A study on high school students that used a modeling approach to investigate how social interactions may influence eating behavior found that “students will change their eating behavior from unhealthy to healthy as a result of positive social and environmental influences.”²⁷⁶

4. Physical Activity Calorie Equivalent Labeling

In a national survey of more than 800 parents, parents were randomly given one of four food menu types: no labels, calories-only labels, calories plus minutes needed to walk off the calories, and calories plus miles needed to walk to burn off the calories.¹⁹¹ The parents were asked to assume they are in a fast food restaurant and ordering food for their children. Parents whose menus showed no label ordered food containing more calories than parents whose menus showed calories only, calories plus minutes, or calories plus miles. The authors of the study concluded that physical activity calorie equivalent labeling may influence parents’ decisions when ordering fast food for their children.¹⁹¹ A similar study using a web-based survey randomly assigned over 800 participants to one of the four menu options.¹⁹² Participants ordered less calories from the menus with labels compared to the menu with no nutritional information, with 82% of participants reporting a preference for physical activity based menu labels over labels with calorie information alone and no nutritional information.¹⁹²

Food Allergies and Intolerances

A food allergy is an exaggerated immune system response occurring after consuming a specific food. Allergic reactions tend to be rapid and highly sensitive—minute amounts of an allergen can trigger a response, anywhere from several minutes to two hours after eating the food containing the allergen. About 4–8% of children and 2% of adults in the U.S. have food allergies.^{277 278} According to the Food Safety and Inspection Service (FSIS), about 30,000 people require emergency room treatment, 2,000 are hospitalized and 150 die each year because of allergic reactions to food.²⁷⁸

Adverse reactions to foods can be divided into two categories based on the mechanism of action: 1) Immune-mediated, which include food allergies and celiac disease; and 2) Non-immune-mediated reactions, which primarily include food intolerances (Figure 11).

The prevalence of food allergies has been on the rise. In 2008, the CDC reported an 18% increase in food allergies in children between 1997 and 2007.²⁸⁰ Some childhood food allergies, such as allergies to egg, milk, soy, and wheat generally resolve in childhood by the time a child is five years old; however, they have been resolving slower now than in the past several decades—many children still have allergies at the age of five and older. Fish, peanut, tree nut, and shellfish allergies are usually lifelong allergies.²⁸¹ Some of the most common food allergies in children are shown in Figure 12.²⁸²

Food intolerances, or non-immune mediated food reactions, are more common compared to food allergies and occur due to difficulty in digesting or metabolizing certain foods. An example is lactose intolerance, caused by lactase deficiency (an enzyme that breaks down the sugar lactose in milk). Some of the symptoms caused by food allergies can also result from food intolerances, but they are generally less severe than food allergies, not life-threatening, and usually limited to the digestive system.

Celiac disease is not an allergic reaction. It is a non-IgE-mediated hereditary autoimmune disorder that occurs in genetically predisposed individuals from ingesting gluten and leads to damage in the small intestine. Damage to the central nervous system and other organs may also occur over time. The estimated combined prevalence of both diagnosed and undiagnosed celiac disease is about 0.7–2% in most populations (Europe and the U.S.), and it is estimated that there may be three to seven undiagnosed cases for each diagnosed case of celiac disease, and that 1–3% of the general U.S. and Europe population is affected by celiac disease at some point in their lifetime.²⁸³

Finally, some people are neither allergic nor intolerant to certain foods but choose to eliminate them from their diets due to health, personal belief, moral, ethical, or religious reasons. Certain foods that are often eliminated from a diet include meat, poultry, fish and/or seafood (shellfish), milk and dairy products, eggs, honey, and other foods.

1. Food Allergies

The National Institute of Allergy and Infectious Diseases (NIAID) defines food allergy as “an abnormal response to a food triggered by the body’s immune system.”²⁸⁴ There are about 160 foods that have been identified to cause allergic reactions in sensitive people.²⁸⁵ The eight most common food allergens that account for over 90% of allergic reactions in the U.S., and the food allergens that are considered “major” by the Food Allergen Labeling and Consumer Protection Act (FALCPA) of 2004 are:²⁸⁵

• Crustacean shellfish
• Eggs
• Fish
• Milk
• Peanuts
• Tree nuts (e.g., almonds, walnuts, pecans)
• Soybeans
• Wheat

The U.S. Food and Allergy Labeling and Protection Act (FALPCA) requires that all eight major allergens are listed on food packaging in simple terms (common names), either in the ingredient list (including the name of the food source in parentheses following the common name of the major food allergen) or in a separate allergen statement, such as “Contains: Milk, Wheat, Soy.”²⁸⁶

FALCPA also requires food labels to state the type of nut, fish, or shellfish that a product contains or if a food contains flavoring, coloring or incidental additives that have any of the major food allergens.²⁸⁶ These labeling requirements serve to inform all individuals in terms that are easy to understand, allowing people to consciously avoid the foods to which they may be allergic. In addition, in 2013, the FDA defined the term “gluten-free” for voluntary food labeling, whereby food manufacturers can label their products as gluten-free if they contain less than 20 parts per million of gluten.²⁸⁷

In addition to the mandatory labeling of the major food allergens, food manufacturers can also voluntarily use allergen advisory statements such as “may contain [allergen]” or “produced in a facility that also uses [allergen]” to indicate the potential or unintentional presence of major food allergens in their food products due to cross-contact, such as shared equipment used during the manufacturing process. However, the FDA guidance states that such advisory statements should not be used as a substitute for following good manufacturing practices.²⁸⁵

Health Effects

Digestive and Immune System

Gastrointestinal symptoms. Some food allergies can cause gastrointestinal distress symptoms, including an itching sensation in the mouth, swollen tongue or lips, and digestive issues such as abdominal cramps and pain, diarrhea and vomiting.²⁸⁴

Gastrointestinal disorders. A variety of specific gastrointestinal disorders can result from immune responses to food allergens, including eosinophilic esophagitis, eosinophilic gastroenteritis, food protein-induced allergic proctocolitis, food protein-induced enterocolitis syndrome, immediate gastrointestinal hypersensitivity, and oral allergy syndrome.²⁷⁹

Intugementry and Immune System

Cutaneous disorders. Several disorders affecting the skin can result due to the immunological reactions to food allergens, including acute urticaria, angioedema, atopic dermatitis, allergic contact dermatitis, and contact urticaria.²⁷⁹

Swelling, hives, eczema, and comorbid skin conditions. Food allergy symptoms can affect the integumentary system and may include hives, face swelling, and worsening of eczema.^{284 285} Children who have food allergies are more likely to have skin or other allergic conditions. In 2007, 27% of children with a food allergy also had eczema or skin allergy, whereas only 8% of children without a food allergy had these conditions.²⁸⁰

Nervous and Immune Systems

Dizziness, loss of consciousness. Food allergy symptoms can include feeling dizzy, lightheaded, and losing consciousness.²⁸⁵

Respiratory and Immune Systems

Anaphylaxis. Anaphylaxis is the most serious form of an allergic reaction, caused by a sudden and widespread mast cell degranulation in response to an antigen. It is a life-threatening reaction characterized by a severe drop in blood pressure (due to an abrupt dilation of peripheral blood vessels), swollen throat and difficulty breathing, rapid pulse, and lightheadedness. Teenagers and young adults who have food allergies are at the highest risk of food-induced anaphylaxis.²⁸¹

Comorbid respiratory conditions: asthma and respiratory allergies. According to the CDC, children who have food allergies have a higher likelihood of having respiratory or other allergic conditions. In 2007, more than 30% of children with a food allergy also had a respiratory allergy (defined as having any kind of respiratory allergy within the past 12 months), compared to only 9% of children who did not have a food allergy. In addition, 29% of children with a food allergy also had asthma, whereas only 12% of children without a food allergy had it.²⁸⁰

Difficulty breathing, itching and swelling of the throat. Food allergy symptoms can affect the respiratory system and include itching, tightening, and swelling of the throat and vocal cords, as well as trouble breathing.²⁸⁵

Solutions

1. Food Allergy Labelling

The NIAID Expert Panel recommends strict allergen avoidance for people who have both IgE- and non-IgE-mediated food allergies.²⁷⁹ The FDA (FALPCA) requires clear labeling of the eight major food allergens on all packaged foods, but currently does not require food allergens to be labeled in restaurants and other eating establishments, such as cafeterias. However, there is some advocacy for labeling food allergens in foods served in restaurants, noting that proper labeling would allow individuals to easily avoid the foods to which they are allergic.²⁹⁰

Based on recommendations by the NIAID and others, the eight major food allergens and gluten should be labeled in all places where food is regularly sold or served to allow allergic consumers to protect themselves against the allergens to which they are sensitive—not only when consuming packaged foods from the grocery store, but with all foods, anywhere they eat.

2. Food Additive Labelling

The Asthma and Allergy Foundation of America notes several food additives that may trigger allergic reactions or intolerances in susceptible individuals. Some of these additives include artificial sweeteners (e.g., aspartame), preservatives (e.g., nitrates), sulfites, and BHT, among others.²⁹¹ Because these substances may lead to allergic reactions or intolerance symptoms in susceptible individuals, and because non-packaged foods are not currently required by law to indicate whether they include these substances, all foods sold or served in workplaces, schools, foodservice establishments, and other places should clearly indicate if they contain food additives so that consumers can be better informed and protected.

3. Food Alternatives

To enable individuals with food allergies to eat a regular, balanced diet without worrying that the foods they eat may contain allergens to which they are sensitive, food items and meals that are egg-, fish-, shellfish-, gluten-, lactose-, peanut-, soy-, tree nut–, and wheat-free should be available in places where foods are sold or distributed, including workplaces, schools, cafeterias, restaurants, and other establishments.

4. Cross Contact Avoidance

The Food Allergy Research and Education (FARE) organization recommends for people with food allergies to avoid cross-contact by cleaning all equipment and utensils with soap and water before using them to prepare allergen-free food because even a trace amount of the offending food on a utensil (which may not be visible to the naked eye) can cause an allergic response.²⁹² Based on recommendations by FARE, placing signs with tips on avoiding cross-contact in places where food is stored, handled, or prepared may be a practical strategy for reducing cross-contact and thus reducing the risk of an allergic reaction in individuals with food allergies.

2. Food Intolerants

Food intolerances can share some of the same symptoms as food allergies, but apart from celiac disease, they do not involve the immune system and therefore cannot trigger anaphylaxis.²⁷⁹ While food intolerance symptoms often involve the digestive system, differently from food allergies, the symptoms usually come on gradually and usually happen when a larger quantity of a food is eaten (compared to amounts that trigger food allergies), or if a food is eaten often.

Food intolerances can be caused by:²⁹³

• A lack of specific enzymes, such as lactase, leading to lactose (dairy) intolerance, or a lack of the alcohol dehydrogenase and/or aldehyde dehydrogenase, leading to alcohol intolerance, or a lack of fructose 1,6-bisphosphate aldolase, leading to fructose intolerance;
• Pharmaceutical agents, such as aspirin;
• Non-IgE-immune response to food, such as celiac disease;
• Food additives, such as sulfites;
• Toxic compounds produced naturally in plants, such as lectins, goitrogens, cyanogens, solanidine, saponins, glucosinolates, and many others.

Some of the most common foods that can lead to symptoms of Food intolerances include: ^{294 295}

• Dairy and dairy products;
• Fermented or ripe foods, alcohol, stock, and other items that contain yeast;
• Eggs, especially egg whites;
• Foods high in histamine, such as fermented foods and drinks, tofu and soy sauce, cheese, mushrooms, chocolate, dried foods;
• Legumes;
• Processed foods that contain flavor enhancers and food additives, such as monosodium glutamate (MSG) and sodium nitrate;
• Strawberries, citrus fruits, tomatoes;
• Wheat and other foods and food products that contain glutens, gliadin and glutenin;
• Wine, especially red wine.

Health Effects

Cardiovascular System

Chest discomfort, palpitations. Food intolerance can cause breathing problems and heart palpitations,²⁹⁴ flushing, and chest discomfort in individuals sensitive to food additives, such as MSG.²⁹⁶

Digestive System

Gastrointestinal disturbance. Many of the foods that commonly cause food intolerance lead to gastrointestinal disturbance. For example, the symptoms of lactose intolerance include abdominal pain, bloating, cramps, gas, and nausea.²⁹⁷ Some of the symptoms of celiac disease include abdominal pain, bloating, canker sores inside the mouth, constipation, diarrhea, vomiting, and weight loss.²⁹⁸

Integumentary System

Rashes. Food intolerance can lead to adverse skin conditions. For example, one of the symptoms of celiac disease is dermatitis herpetiformis, an itchy skin rash.²⁹⁸ The elbows and upper forearms are affected by the rash in more than 90% of the patients who develop dermatitis herpetiformis.²⁹⁹

Nervous System

Headaches. Various nervous system problems, including headache and sensations of warmth, have been linked to food additives, including MSG.²⁹⁶ Other food additives can trigger migraine headaches, such as aspartame, citrate, nitrates/nitrites, and tyramine.³⁰⁰

Neurological symptoms. Food intolerance can lead to neurological symptoms. For example, gluten sensitivity symptoms include brain fog; depression; fatigue; headache; and numbness in legs, arms or fingers,²⁹⁹ while symptoms of celiac disease can also include anxiety and seizures.²⁹⁸

Reproductive System

Reproductive issues. Food intolerance can lead to reproductive issues. For example, some of the symptoms of celiac disease include missed menstrual periods, infertility, and recurrent miscarriage.²⁹⁸

Respiratory System

Breathing problems. Food intolerance can cause symptoms such as breathing problems in people with asthma, typically caused by food additives, including sulfites.²⁹⁶

Skeletal System

Arthritis and bone and joint pain. Gluten sensitivity can cause various skeletal system problems including arthritis and bone and joint pain.²⁹⁸

Bone loss. Some of the symptoms of celiac disease include bone loss and osteoporosis.²⁹⁸

Solutions

1. Provision of Nutritional Information

While Food intolerances do not pose a risk of anaphylaxis and are therefore not immediately life-threatening, they can lead to many severe and unpleasant symptoms. In order to protect individuals with food intolerances from exposure to the intolerants to which they are sensitive, all ingredients should be listed for food products—including packaged and non-packaged foods and beverages—in all places where food is regularly sold or served.

2. Food Additive Labeling

The Asthma and Allergy Foundation of America notes several food additives that may trigger adverse reactions in susceptible individuals. Some of these additives include artificial sweeteners (e.g., aspartame), preservatives (e.g., nitrates), sulfites, and BHT, among others.²⁹¹ Because these substances may lead to allergic reactions or intolerance symptoms in susceptible individuals, and because non-packaged foods are not currently required by law to indicate whether they include these substances, all foods sold or served in workplaces, schools, foodservice establishments, and other places should clearly indicate if they contain food additives so that consumers can be better informed and protected.

2. Food Alternatives

To enable individuals with dietary restrictions to eat a regular, balanced diet without worrying that the foods they eat may contain ingredients that they want to avoid due to religious, moral, or other reasons, special diet options, such as vegetarian, vegan, lacto-ovo-vegetarian, Halal or Kosher should be available in places where foods are sold or distributed, including workplaces, schools, cafeterias, restaurants, and other establishments.

Foodborne Illness

Foodborne illness (or foodborne disease, infection, or poisoning) can be caused by microbes or pathogens that contaminate food, or by toxins that are inadvertently added to food. Every year, one in six people (or about 48 million) in the U.S. get sick, 128,000 are hospitalized and 3,000 die from eating contaminated foods and beverages, making foodborne illness a major cause of preventable illness and death, personal distress, and avoidable economic burden.^{301 302} The CDC reports that reducing foodborne illness by just 10% could spare five million Americans from getting sick each year ³⁰¹

The most common foodborne pathogens contributing to domestically acquired foodborne illnesses are Norovirus, Salmonella (nontyphoidal), Clostridium perfringens, Campylobacter spp., and Staphylococcus aureus.³⁰² In addition, five major risk factors have been identified via epidemiological outbreak data as contributing to foodborne illness:³⁰³

• Improper holding temperatures;
• Inadequate cooking;
• Contaminated equipment;
• Food from unsafe sources;
• Poor personal hygiene.

1. FOOD CONTAMINATION

Certain pathogens are often transmitted via food that has been contaminated by infected individuals. When food-handlers do not properly wash their hands after handling raw meat, using the toilet, cleaning spills, or carrying garbage, or if they do not wear clean gloves or use clean utensils, it can lead to the transmission of various foodborne pathogens.³⁰³

The CDC has designated six organisms “as having high infectivity via contamination of food by infected food employees,”³⁰³ summarized below:

• Noroviruses. Noroviruses are the leading cause of foodborne illness in the U.S. They are highly infective and easily spread via contaminated food, water, or surface, or an individual who is infected.³⁰⁴
• Nontyphoidal Salmonella (NTS). Investigations of numerous NTS outbreaks have shown that food workers are often the source of the outbreak, and often serve as reservoirs of NTS and transmit NTS to individuals who eat at foodservice establishments.³⁰³
• Salmonella typhi. S. typhi causes a systemic bacterial disease (typhoid fever) and is easily transmitted via infected food or water or by infected individuals who handle food. The bacteria is estimated to cause 21.5 million typhoid fever cases annually in the developing world, with about 5,700 cases occurring in the U.S. every year.³⁰⁵
• Shiga toxin-producing Escherichia coli (STEC). STEC can lead to foodborne disease both via contaminated raw or undercooked ingredients as well as by person to person transmission.³⁰⁶
• Shigella spp. Shigella spp. is estimated to cause 80–165 million cases of shigellosis and 600,000 deaths annually worldwide, and transmission is likely to occur in places where hygiene and sanitation are poor. Consumption of contaminated foods and water, as well as infected food handlers, are common ways of Shigella spp. transmission.³⁰⁷
• Hepatitis A virus. Hepatitis A is highly contagious and is usually spread via the fecal-oral route, both through ingesting water or food that has been contaminated with feces or through person-to-person contact.³⁰⁸

The FDA Food Code notes that an analysis of 816 reported worker-associated foodborne illness outbreaks (during 1927–2006) has shown that more than 61% of the outbreaks resulted from foodservice facilities and catered events, while another 11% came from day-care centers, healthcare institutions, and schools, with the two most commonly reported risk factors being linked to food handlers having “bare hand contact with food” and a “failure to properly wash hands.”³⁰³ This highlights the need for effective hygiene and sanitation practices to minimize foodborne disease transmission and its associated symptoms and consequences.

Health Effects

Digestive System

Abdominal pain, diarrhea, vomiting. All six pathogens that have high infectivity via food contamination by infected food handlers can lead to digestive problems.³⁰³ Norovirus results in vomiting, diarrhea, abdominal cramps, and nausea. Salmonellosis symptoms include abdominal cramps, diarrhea, and fever. Typhoid fever symptoms include abdominal pain, diarrhea, constipation, and loss of appetite. Symptoms of STEC infection include hemorrhagic colitis, which includes diarrhea, severe abdominal pain, nausea, and/or vomiting. Shigella spp. infection symptoms include abdominal pain, cramps, diarrhea, fever, nausea, and vomiting; in young children, infections are also linked to severe dehydration and rectal bleeding. Hepatitis A infection results in diarrhea, fever, abdominal pain, nausea, vomiting, and jaundice.³⁰³

Skeletal System

Arthritis. Two of the six pathogens that have high infectivity via food contamination by infected food handlers can lead to negative musculoskeletal effects.³⁰³ A small number of individuals who become infected with NTS have long-term consequences, such as arthritis, which can last for months or even years, whereas typhoid fever may lead to septic arthritis.³⁰³

Integumentary System

Rash. One of the six pathogens that have high infectivity via food contamination by infected food handlers can lead to negative dermatological effects. Typhoid fever may sometimes produce a rash that consists of flat, rose-colored spots.³⁰³

Nervous System

Headache. Two of the six pathogens that have high infectivity via food contamination by infected food handlers lead to negative nervous system effects.³⁰³ Some of the symptoms of typhoid fever include lethargy, headache, and achiness, whereas some of the symptoms of hepatitis A infection include fever and headache.³⁰³

Solutions

1. Hand Washing Sinks

The FDA Food Code requires food employees to wash their hands only in hand-washing sinks or approved automatic hand washing facilities. Food employees may not wash their hands in sinks that are used for food preparation, dish washing or disposal of mop water. An automatic hand washing facility may also be used for hand washing, if it is approved and able to remove “the types of soils encountered in the food operations involved.” ³⁰³ The FDA Food Code reports that hand washing is more likely to occur in restaurants with more than one sink for hand washing and at sinks that are in workers’ sight.^{309 303}

Based on these requirements and study findings, buildings that include food handling or preparation facilities should have dedicated hand-washing sinks that are easily accessible.

2. Hand Washing Signage

The FDA Food Code requires signs or posters to be present and clearly visible at all hand-washing sinks used by food employees to notify them to wash their hands.³⁰³

3. Hand Washing Supplies

It is essential to have hand-washing supplies at hand-washing stations to remove any germs that may be present on individuals’ hands. The FDA has not found antibacterial soap to be more effective than plain soap in preventing illness, noting that “new data suggest that the risks associated with long-term, daily use of antibacterial soaps may outweigh the benefits,” and that some of the antibacterial soap ingredients may contribute to antibiotic resistance as well as have unforeseen hormonal effects that the FDA is concerned about.³¹⁰ In addition, the CDC recommends against refilling partially empty soap dispensers, noting that such a practice may result in soap contamination.³¹¹

Based on the recommendations about soap by the FDA and the CDC, non-antibacterial liquid soap should be used in disposable and sealable cartridges for safe hand washing and reduction of foodborne pathogen transmission.

4. Disposable Paper Towels

The FDA Food Code requires that each hand-washing sink (or a group of sinks adjacent to each other) be provided with 1) disposable towels; or 2) a continuous towel system that provides an individual with a clean towel; or 3) a hot-air hand dryer; or 4) an air-knife system hand dryer. In addition, it notes that in order to avoid hand recontamination after hand washing, “food employees may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a hand-washing sink or the handle of a restroom door.”³⁰³

A review of articles on the effectiveness of different hand-drying methods found that paper towels can “dry hands efficiently, remove bacteria effectively, and cause less contamination of the washroom environment,” concluding that “from a hygiene viewpoint, paper towels are superior to electric air dryers,” and recommending that paper towels be used in places where hygiene is of great importance.³¹² In addition, a study comparing jet air, warm air, and paper towel drying found that both jet and warm air drying methods resulted in much greater bacterial aerosolization close to the area of hand drying compared to drying hands with a paper towel.³¹³

Based on the requirements set forth in the FDA Food Code and the findings of the studies, disposable paper towels should be provided in places where hygiene is of paramount importance (e.g., hospitals and foodservice establishments), while other hand-drying methods (e.g., cloth towels and automatic hand dryers) should not be prohibited in other places such as offices, schools, and residences.

5. Refrigerated Storage

The FDA Food Code requires raw animal foods to be separated during storage, preparation, holding, and display from raw ready-to-eat foods including other raw animal foods (e.g., fish for sushi) or other raw ready-to-eat foods (e.g., fruits and vegetables), and from cooked ready-to-eat foods.³⁰³ In addition, the NYC Department of Health and Mental Hygiene Food Protection Training Manual requires raw meat, fish, and poultry be stored below the foods that are ready-to-eat. Specifically, raw meats should be stored in the following order (top to bottom): poultry, ground meats, pork, and all other meats. Food that does not need to be washed or cooked should be kept separately from the food that does.³¹⁴

Explanations of Solutions

SUPERMARKETS AND FULL-SERVICE GROCERY STORES WITHIN WALKING DISTANCE

Compared to convenience stores and smaller food stores, full-service grocery stores and supermarkets offer a wider variety of more affordable healthy foods, including fresh and frozen fruits and vegetables.³¹⁵ When available within walking distance from home or work, supermarkets and full-service grocery stores can provide better access to fruits, vegetables, and other healthy food options.

FARMERS’ MARKETS AND GREENMARKETS NEAR WORKPLACES AND RESIDENCES

A farmers’ market is a regular gathering of farmers who sell the foods and food products from their farms directly to consumers. Depending on climate, farmers’ markets may occur weekly/bi-weekly, outdoors when the weather permits, and indoors during the cold season or in inclement weather. Many farmers’ markets and greenmarkets that located in places that have colder temperatures for part of the year are seasonal and operate only during warmer months. Foods sold can include fruits, vegetables, honey, eggs, dairy and dairy products, poultry, meat, baked goods, jams and jellies, and other raw or prepared food products. The markets can be set up either as temporary structures used during the harvest season, or take place in permanent venues (e.g., local community or senior centers). Farmers’ markets can increase access to the foods they sell in areas that lack grocery stores, and, in general, increase a community’s access to local foods and food products. The number of farmers’ markets per 100,000 state residents is a broad estimate of the availability of fruits and vegetables from farmers’ markets in a state population (adjusted for variation).⁶ Farmers’ markets that accept nutrition assistance program benefits (e.g., Supplemental Nutrition Assistance Program) can also help increase access to fruits and vegetables among lower income populations.⁶

STRATEGIC DINING DESIGN

Strategic dining design is a series of small design changes intended to encourage healthy eating. Based on the behavioral science principal known as “libertarian paternalism” (defined as influencing but not restricting choice), a series of school cafeteria interventions called Smarter Lunchroom were first implemented in one study in two schools¹³⁷ and in a salad bar study.¹³⁸ The studies were carried out to establish whether these changes could influence healthy food consumption. The changes were inexpensive and took little time to implement (less than $50 and a total of three hours) and included:

• A “healthy convenience checkout line” (in addition to an existing regular checkout line), only allowing purchases of healthier food options, such as salads, submarine sandwiches, fruits, and vegetables;
• Fresh fruit placed by the cash register along with a sign which reads, “Last chance for fruit”;
• Salad packaged in see-through to-go containers;
• Descriptive names for vegetable dishes;
• Displaying fresh fruits in bowls and tiered stands to make them more appealing;
• A menu with appealing, color photos of the fruits and vegetables served;
• Placing the salad bar away from the wall, providing a 360-degree access.

Similar to the strategies outlined above, the USDA’s Meal Appeal guide recommends:¹⁴²

• Using creative (“jazzed-up”) names for cafeteria menu items (e.g., “Popeye spinach,” “Crazy carrots,” “Super salad”) when labeling healthy vegetable food options;
• Placing fruits and vegetables at the front of the foodservice line;
• Providing nutrition information by specifying which of the served foods are good sources of vitamins A and C, calcium, iron, and other nutrients.

CUT-UP FRUITS AND VEGETABLES

Cut-up fruits and vegetables are fresh, ready-to-eat fruits and vegetables that are cut into several pieces, making them easier and cleaner to eat. Cutting up fruits and vegetables is a strategy that may be especially beneficial for younger children (due to missing teeth) as well as middle-school children (due to missing teeth, the presence of braces, or perceiving whole fruit as messy or unattractive to eat).¹⁴³

VISUAL PROMPTS THAT INCREASE NUTRITION KNOWLEDGE

Visual prompts that encourage greater daily fruit and vegetable intake include pictures, posters, photos, or drawings of fruits and vegetables that can be displayed in visible spaces and high-traffic areas both indoors and outdoors.

Based on the Nutrition Knowledge Questionnaire,³¹⁶ nutrition knowledge entails having knowledge regarding the recommended intake level of different food groups (e.g., knowing how many servings of fruits and vegetables individuals should consume per day), knowledge of the nutritional content of various foods (e.g., being able to tell if a given food is high or low in added sugar), knowledge of everyday food choices (e.g., what food choices should be selected if one wants to reduce the fat intake in his/her diet), and knowledge of the relationship between diet and disease (e.g., knowing what health conditions are linked to a low-fiber intake).¹⁴⁵

GARDENING

Gardening can be a means of increasing fruit and vegetable intake. It entails dedicating a space at home, school or the workplace for small-scale gardening and the hands-on experience of planting, maintaining, harvesting and consuming the produce grown. Gardening programs at schools can have additional components, such as education about healthy eating habits, health and nutrition, cooking classes, farm visits, and others.

FARM TO SCHOOL PROGRAMS

Farm to School is an initiative that links students with local farms, farmers, and foods. Farm to School programs entail one or more of the following:¹⁵⁷

• Educational activities for students about food, health, nutrition or agriculture;
• Purchase, promotion and provision of local foods in school cafeterias or classrooms;
• Gardening at school.

Farm to school programs benefit students, parents, schools, communities, and food producers in a variety of ways. The National Farm to School Network estimated that in 2015, 40 states in the U.S. had policies that support Farm to School initiatives, with 44% of U.S. schools already participating in the program, which included a total of 23.5 million students.¹⁵⁸

Farm to School programs do face unique challenges. For example, growers lack knowledge about how to sell to schools and other institutions, crops may not be ready for harvest during the school year, and schools pay low prices for the fruits and vegetables.³¹⁷

PROMOTION IN GROCERY STORES

Food promotion is a strategy intended to influence consumers’ food choices and eating behavior by encouraging them to purchase, prepare, and consume certain foods. Promotion in grocery stores involves making healthy food and beverage options available at affordable prices; displaying healthy foods prominently and attractively; using advertisements, posters depicting multiple forms (e.g., frozen, fresh, dried), messages, games, tastings, and supermarket tours that focus on healthy shopping; cooking demonstrations that use fruits and vegetables; and other strategies that encourage purchasing healthy foods.

ACCESS AND PROMOTION IN FOODSERVICE VENUES

Many individuals spend a large portion of their time at work, consuming at least one meal while there, and usually several snacks. In workplaces that sell food, employee food choices depend on what foods are available at the workplace cafeteria or on workplace coffee carts. Strategies to improve the quality of available food include encouraging or requiring cafeterias to offer a variety of high-quality, affordable fruits and vegetables; and signage to point out healthy fruit and vegetable options can be used to nudge employees toward these healthier options, among other strategies.¹³⁵ These policies are not limited to workplaces but can also be implemented in foodservice venues within K–12 schools, and higher education and medical care facilities. Beyond these strategies, the 2015 DGAC Report notes that menu labeling, provision of point-of-purchase information, and catering policies are effective strategies to increase fruit and vegetable consumption and it recommends that they be implemented via foodservice policies and corporate wellness and health benefits programs in workplaces.²

NUTRITION LUNCH AND LEARN LECTURES

Nutrition lunch and learn lectures entail offering continued learning opportunities about nutrition and health at schools and workplaces. Such lectures may involve nutrition experts, dieticians, and/or other food professionals teaching about the relationship between diet and health, optimal dietary choices, food shopping, and other nutrition-related issues, usually during lunch but also during other dedicated times.

NUTRITION EDUCATION IN SCHOOLS

Nutrition education in schools entails providing nutrition education to K–12 students. It involves educating students about healthy dietary patterns and providing age-appropriate nutrition education. These educational programs are intended to improve the students’ dietary habits and overall health.

DRINKING WATER PROMOTION

Access to potable water includes providing easy access to drinking water fountains, water bottle refilling stations, and vending machines selling plain water in buildings and public spaces. These spaces include but are not limited to schools, workplaces, hospitals, public buildings, homes, parks, and playgrounds. In addition, water stations should be conveniently placed and located in close proximity to high traffic/regularly occupied spaces.

AVAILABILITY OF HEALTHIER BEVERAGES

New York City Food Standards: Meals/Snacks Purchased and Served requires that beverages served by City agencies in NYC include only the following: water; 100% fruit juice in 6-oz servings or less; 1% or non-fat unsweetened milk; and unflavored fluid milk substitutes (e.g., soy milk). Beverages other than milk or 100% juice must have 25 Calories or less per 8-oz serving (e.g., unsweetened tea or coffee). For children four to 18 years old, flavored milk and flavored fluid milk substitutes are permitted if they have 130 Calories or less per serving. However, it is recommended that they are phased out over time. In addition, where the majority of the population served is under 18 years of age, beverages with artificial sweeteners must not be served.¹⁸⁴ These standards help to not only increase the availability of healthier beverage alternatives but also reduce the availability of unhealthy beverages.

LIMITED MARKETING AND ADVERTISING

Food marketing and advertising are strategies intended to influence consumers’ food choices and eating behavior, encouraging them to purchase advertised foods. Limited marketing and advertising means banning the promotion of a given product within the building site, while promoting healthier alternatives. These limitations can include banning posters, images, or digital displays advertising the product; displays of the product’s company logo; and the distribution of promotional materials. Banning marketing and advertising is meant to reduce the exposure to environmental cues to consume the given product. Together with limited availability, this strategy may help reduce a person’s desire for unhealthy foods and beverages and limit their ability to obtain such products.

LIMITED AVAILABILITY

Limited availability entails eliminating or reducing the number of unhealthy food or beverage options and increasing the number of healthier alternatives within the building site. Limited availability of a given product is intended to make it more difficult to obtain that product, thereby reducing the potential for consumption.

PROVISION OF NUTRITIONAL INFORMATION

The FDA requires all chain restaurants (with 20 or more locations) and similar eating establishments and vending machines (operators who own or operate 20 or more vending machines) to 1) post caloric information on menus and menu boards, including information for beverages sold at these establishments or vending machines:^{188 189}

“Covered establishments will list calorie information for standard menu items on menus and menu boards and a succinct statement about suggested daily caloric intake. Other nutrient information—total calories, calories from fat, total fat, saturated fat, trans fat, cholesterol, sodium, total carbohydrates, fiber, sugars, and protein—will have to be made available in writing on request.”³¹⁸

In addition to the provision of caloric information, information about foods and beverages could also be provided wherever food is sold or distributed in the form of a poster, sign, or label, listing the number of calories and the nutritional content of the foods and beverages.

Provision of nutritional information includes the number of calories and the amount of sugar, protein, fat, saturated fat, and salt per serving of a food or beverage. The caloric information can be accompanied by additional nutritional information, such as a graphic indicating/suggesting how the nutritional composition of that food compares to dietary recommendations, and what percentage of the daily recommendation/allowance is met for each of the specified nutrients. There are many ways to present this information (Figure 13).³¹⁹

PHYSICAL ACTIVITY CALORIE EQUIVALENT LABELING

Physical activity calorie equivalent labeling displays caloric content of foods and beverages in the form of duration and type of physical activity and/or distance and pace of walking needed to burn off the calories in selected foods or beverages. The information can be provided in the form of a separate poster, or as part of a menu, and is a potential strategy for encouraging individuals to choose foods and beverages that contain less calories.^{191 192}

VISUALIZATION OF SUGAR CONTENT

Visualizing the amount of sugar entails providing a visual depiction of a food or beverage’s sugar content. There are several different visualization strategies, including placing an amount of sugar equal to that contained in the food or beverage into a clear re-sealable storage bag, providing a photo of said amount of sugar, or displaying a photo of the number of teaspoons or cubes of sugar that are present in the food or beverage (Figure 14). Such depictions can be provided in places where foods and/or beverages are sold or distributed.

LIMITS ON SERVING SIZES

Limits on serving sizes entails serving 100% juice in portions no larger than six oz per serving, if it is served on the building premises.¹⁸⁴

PARTIALLY HYDROGENATED OIL BAN

Banning partially hydrogenated oil restricts the sale or provision of any foods or meals that list “partially hydrogenated oil” as an ingredient, or that have more than one gram of trans fat per serving of food. While “Nutrition Facts” labels, required by law on all packaged foods, should be an easy way to identify foods that contain partially hydrogenated oils, not all foods have such labels. Banning partially hydrogenated oils means banning not only foods with such oils listed on their Nutrition Facts labels but also foods that contain these oils that are not labeled.

DINNERWARE SIZE

Dinnerware includes plates, bowls, cups, glasses, and utensils. While various factors impact how much people eat, one factor most individuals are not aware of is the size of the plates, bowls, cups, glasses, and utensils they use to eat. Research has shown that people tend to underestimate the amount of food they serve in larger plates and bowls. Due to a difference between the size of the plate or bowl and the quantity of food served (termed “the size-contrast illusion”), individuals perceive the serving as small (relative to the plate or bowl) and inconsequential when, in fact, it is large; or they perceive the serving as large when in fact it is small but is served on a small plate or bowl. The size-contrast illusion leads to serving and consuming more food when provided with a larger plate compared to a smaller plate.²⁶⁵

In other words, large plates may make the same amount of food appear smaller, whereas smaller plates may make the food portion appear larger. Research shows that when larger bowls or spoons are used for self-serving food, more food is consumed compared to when smaller bowls or spoons are used.³²¹ It also results in a false perception that less food is consumed compared to the actual intake.²⁶⁵

PORTION SIZE

Portion size is the amount of food that a person chooses to eat when consuming a meal at home, at a restaurant or from a package. Portion sizes in foodservice establishments have gotten larger over the past few decades, leading to eating more.

MINDFUL EATING SPACES

Mindful eating spaces are spaces where individuals can eat while either socializing with others or without being distracted, if they so choose. An example of a mindful eating space is a dedicated room in a workplace where individuals can focus on eating (as opposed to eating at a desk or in front of a computer/television), either alone or with others.

FOOD ALLERGY LABELING

Food allergy labeling means listing any of the eight major food allergens (crustacean shellfish, eggs, fish, milk, peanuts, soybeans, tree nuts, and wheat) and gluten that are present in the food. Allergen labeling includes foods that are not packaged and that do not have Nutrition Facts labels, such as foods served in restaurants, cafeterias, catered food, or food provided in workplaces. Food allergen information could be provided in the form of an icon, followed by “Contains: Allergen” next to each menu item on a menu or menu board, or on cards that are placed on the protective glass shields or next to the hot holding trays in cafeterias and buffets (Figure 15).

FOOD ADDITIVE LABELING

Food additive labeling includes listing the food additives present in a food or food product, including foods that are not packaged and/or that do not have a Nutrition Facts label, such as foods served in restaurants, cafeterias, catered foods or foods provided in workplaces. The food additive information could be provided next to each menu item on a menu or menu board, or on cards that are placed on protective glass shields or next to the hot holding trays in cafeterias and buffets, indicating “Contains: [Food Additive]”.

FOOD ALTERNATIVES

Providing food alternatives means providing a reasonable variety of foods for individuals who have food allergies or intolerances. Alternatives should include foods that are egg-, fish-, shellfish-, gluten-, lactose-, peanut-, soy-, tree nut– and wheat-free, as well as foods that are vegan, vegetarian, lacto-ovo-vegetarian, Halal, and Kosher. Such foods should be packaged to avoid potential contamination (if necessary, prepared off-site) and labeled to indicate that they do not contain a particular allergen or that they belong to a specific category of foods (e.g., Kosher or vegan).

CROSS-CONTACT AVOIDANCE

Cross-contact occurs when a food containing the allergen comes into contact with another food that does not contain the allergen. Small, often invisible amounts of the allergen from one food can get mixed into the food that did not previously contain allergens.²⁹² For example, using a knife to cut a boiled egg, and then using the same knife to spread butter on a piece of toast can transfer small amounts of egg protein onto the bread and butter, even after wiping the knife clean. Even in these small amounts, food proteins can cause allergic reactions in people who are allergic to that food. Cooking does not reduce or eliminate the risk of exposure in the case of cross-contact.²⁹² Reducing cross-contact entails cleaning all equipment and utensils with soapy water before using them to make allergen-free foods.²⁹² Using separate workstations when preparing allergen-containing and allergen-free foods can also help to reduce cross-contact.

Cross-contact should not be confused with cross-contamination, which is the unintentional transfer of bacteria or other potentially harmful microorganisms from one object or surface to another, potentially leading to foodborne illness. Cross-contamination can be reduced or eliminated by proper food storage and preparation practices as well as appropriate cleaning protocols.

NUTRITIONAL INFORMATION

Nutritional information entails providing a complete list of ingredients in a food or beverage either on the package of the product, or as a separate sign that lists the ingredients of a given product.

HAND-WASHING SINKS

Hand-washing sinks are sinks used solely for washing hands. The FDA Food Code requires that hand-washing sinks be conveniently located, always accessible for hand washing, properly maintained, and provide water at a temperature of at least 38°C (40°C±2°C).³⁰³

HAND-WASHING SIGNAGE

Hand-washing signage includes clearly visible signs or posters that remind individuals to wash their hands.

HAND-WASHING SUPPLIES

Hand-washing supplies for safe hand washing include non-antibacterial liquid soap in disposable and sealable soap cartridges.

DISPOSABLE PAPER TOWELS

Disposable paper towels are used to dry hands to effectively remove bacteria after washing.

REFRIGERATED STORAGE

Refrigerated storage entails storing raw animal products separately from other raw and cooked ready-to-eat foods in the refrigerator.

APPENDIX: KEY PRINCIPLES OF A HEALTHY DIET

The key principles of a healthy diet on which the Solutions of the Nourishment WELLography™ are broadly based are summarized below. These principles reflect the dietary recommendations provided in the 2015-2020 Dietary Guidelines for Americans and the Scientific Report of the 2015 Dietary Guidelines Advisory Committee, and are based on current scientific evidence.²

1. Achieve and Maintain a Healthy Weight

A healthy body weight (BMI of 18.5–24.9) can be maintained and excessive weight gain prevented by balancing the number of calories consumed with the number of calories expended each day. When more calories are consumed than expended, weight gain occurs, which in adults leads to overweight and obesity; conversely, when fewer calories are consumed than expended, weight loss occurs. The level of physical activity can impact total calorie balance.

2. Consume Nutrient-Dense Foods

To avoid excessive weight gain and ensure an adequate intake of essential nutrients, a healthy eating pattern should emphasize nutrient-dense foods and beverages such as fruits, vegetables, whole grains, seafood, beans and peas, nuts and seeds, eggs, lean meats and poultry, and low-fat or fat-free dairy and dairy products.

3. Increase Fruit and Vegetable Intake

Most people do not consume the recommended amount of fruits and vegetables. Consciously increasing the intake of fruits and vegetables by ensuring they are available at home (fresh and frozen) and identifying sources of fruits and vegetables when consuming food prepared outside the home can help to increase the overall intake of fruits and vegetables.

4. Eat a Variety of Fruits and Vegetables

Consuming a variety of fruits and vegetables, especially those that are dark green, red, and orange, will ensure adequate intake of essential vitamins and minerals present in fruits and vegetables.

5. Consume Whole Grains and Limit Refined Grains

Replace refined grain products with whole grain products, such as breads, pasta and foods made with unrefined cereal grains, as they provide fiber and essential minerals.

6. Minimize the Intake of Foods and Beverages with Added Sugars

To minimize the risk of over-consuming calories, limit the intake of foods with added sugars, as they often provide few to none essential nutrients. Examples include candy, ice cream, pies, cookies, jams, and jellies. In addition, to minimize the intake of added sugars, limit the intake of sugar-sweetened beverages (SSBs), such as sodas, fruit drinks, sweetened ice teas, and presweetened coffee drinks. SSBs can contain a substantial amount of calories, typically as sugars, yet have a minimal impact on satiety compared with solid foods.

7. Eliminate Trans Fatty Acids From the Diet

Trans fatty acid consumption should be kept to a minimum by limiting the consumption of foods that contain partially hydrogenated oils, and by preparing foods with oils (with the exception of tropical oils) that have not been modified.

8. Reduce the Consumption of Red and Processed Meat

Red meat (beef, lamb, pork) and processed meat (meat that has been smoked, cured, salted, or otherwise preserved, including bacon, cold cuts, hot dogs, pastrami, salami, sausages) intake can be reduced by choosing alternate protein sources, such as fish and seafood, poultry, tofu, beans, and legumes.²⁰⁵

9. Limit or Eliminate Energy-Dense, Nutrient- and/or Fiber-Poor Foods

The consumption of energy-dense, nutrient- and/or fiber-poor foods should be limited or eliminated from the diet by choosing foods that are low in added fats (saturated and trans fatty acids) and added sugars and rich in fiber.

10. Ensure Adequate Hydration

For optimal body hydration, consume adequate amounts of water, from both beverages and foods. The general recommendation for daily water intake from all sources is about 2.7 liters for women and 3.7 liters for men.³²⁴

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