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Nutrition is essential for growth and development, health, and well-being. Behaviors to promote health should start early in life with breastfeeding[1] and continue through life with the development of healthful eating habits. Nutritional, or dietary, factors contribute substantially to the burden of preventable illnesses and premature deaths in the United States.[2] Indeed, dietary factors are associated with 4 of the 10 leading causes of death: coronary heart disease (CHD), some types of cancer, stroke, and type 2 diabetes.[3] These health conditions are estimated to cost society over $200 billion each year in medical expenses and lost productivity.[4] Dietary factors also are associated with osteoporosis, which affects more than 25 million persons in the United States and is the major underlying cause of bone fractures in postmenopausal women and elderly persons.[5]
Many dietary components are involved in the relationship between nutrition and health. A primary concern is consuming too much saturated fat and too few vegetables, fruits, and grain products that are high in vitamins and minerals, carbohydrates (starch and dietary fiber), and other substances that are important to good health. The 2000 Dietary Guidelines for Americans recommend that, to stay healthy, persons aged 2 years and older should follow these ABCs for good health: Aim for fitness, Build a healthy base, and Choose sensibly. To aim for fitness, aim for a healthy weight and be physically active each day. To build a healthy base, let the Pyramid guide food choices; choose a variety of grains daily, especially whole grains; choose a variety of fruits and vegetables daily; and keep food safe to eat. To choose sensibly, choose a diet that is low in saturated fat and cholesterol and moderate in total fat; choose beverages and foods to moderate intake of sugars; choose and prepare foods with less salt; and if consuming alcoholic beverages, do so in moderation.[6] The Food Guide Pyramid, introduced in 1992, is an educational tool that conveys recommendations about the number of servings from different food groups each day and other principles of the Dietary Guidelines for Americans.[7] [Note: In text that follows in this chapter, Dietary Guidelines for Americans will refer to the 2000 Dietary Guidelines for Americans unless otherwise noted.]
The Dietary Guidelines for Americans also emphasize the need for adequate consumption of iron-rich and calcium-rich foods.6 Although some progress has been made since the 1970s in reducing the prevalence of iron deficiency among low-income children,[8] much more is needed to improve the health of children of all ages and of women who are pregnant or are of childbearing age. Since the start of this decade, consumption of calcium-rich foods, such as milk products, has generally decreased and is especially low among teenaged girls and young women.[9] Because important sources of calcium also can include other foods with calcium—occurring naturally or through fortification—as well as dietary supplements, the current emphasis is on tracking total calcium intake from all sources, as demonstrated by an objective in this focus area. In addition, in recent years there has been a concerted effort to increase the folic acid intake of females of childbearing age through fortification and other means to reduce the risk of neural tube defects.[10], [11] (See Focus Area 16. Maternal, Infant, and Child Health.)
In general, however, excesses and imbalances of some food components in the diet have replaced once commonplace nutrient deficiencies. Unfortunately, there has been an alarming increase in the number of overweight and obese persons.[12], [13] Overweight results when a person eats more calories from food (energy) than he or she expends, for example, through physical activity. This balance between energy intake and output is influenced by metabolic and genetic factors as well as behaviors affecting dietary intake and physical activity; environmental, cultural, and socioeconomic components also play a role.
When a body mass index (BMI) cut-point of 25 is used, nearly 55 percent of the U.S. adult population was defined as overweight or obese in 1988–94, compared to 46 percent in 1976–80.12, [14], [15] In particular, the proportion of adults defined as obese by a BMI of 30 or greater has increased from 14.5 percent to 22.5 percent.12 A similar increase in overweight and obesity also has been observed in children above age 6 years in both genders and in all population groups.[16]
Many diseases are associated with overweight and obesity. Persons who are overweight or obese are at increased risk for high blood pressure, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and some types of cancer. The health outcomes related to these diseases, however, often can be improved through weight loss or, at a minimum, no further weight gain. Total costs (medical costs and lost productivity) attributable to obesity alone amounted to an estimated $99 billion in 1995.[17]
Disparities in health status indicators and risk factors for diet-related disease are evident in many segments of the population based on gender, age, race and ethnicity, and income. For example, overweight and obesity are observed in all population groups, but obesity is particularly common among Hispanic, African American, Native American, and Pacific Islander women. Furthermore, despite concerns about the increase in overweight and certain excesses in U.S. diets, segments of the population also suffer from undernutrition, including persons who are socially isolated and poor. Over the years, the recognition of the consequences of food insecurity (limited access to safe, nutritious food) has led to the development of national measures and surveys to evaluate food insecurity and hunger and to the ability to assess disparities among different population groups. With food security and other measures of undernutrition, such as growth retardation and iron deficiency, disparities are evident based not only on income but also on race and ethnicity.
In addition, there are concerns about the nutritional status of persons in hospitals, nursing homes, convalescent centers, and institutions; persons with disabilities, including physically, mentally, and developmentally disabled persons in community settings; children in child care facilities; persons living on reservations; persons in correctional facilities; and persons who are homeless. National data about these population groups are currently unavailable or limited. Data also are insufficient to target the fastest growing segment of the population, old and very old persons who live independently.
Establishing healthful dietary and physical activity behaviors needs to begin in childhood. Educating school-aged children about nutrition is important to help establish healthful eating habits early in life.[18], [19] Research suggests that parents who understand proper nutrition can help children in preschool choose healthful foods, but they have less influence on the choices of school-aged children.[20] Thus, the impact of nutrition education on health may be more effective if targeted directly at school-aged children. Unfortunately, a survey done in 1994 showed that only 69 percent of States and 80 percent of school districts required nutrition education for students in at least some grades from kindergarten through 12th grade.[21]
A well-designed curriculum that effectively addresses essential nutrition education topics can increase students’ knowledge about nutrition, help shape appropriate attitudes, and help develop the behavioral skills students need to plan, prepare, and select healthful meals and snacks.18, [22], [23] Curricula that encourage specific, healthful eating behaviors and provide students with the skills needed to adopt and maintain those behaviors have led to favorable changes in student dietary behaviors and cardiovascular disease risk factors.18, 22, 23 In order to enhance the effectiveness of these lessons, however, nutrition course work should be part of the core curriculum for the professional preparation of teachers of all grades and should be emphasized in continuing education activities for teachers.
Topics considered to be essential at the elementary, middle, junior high, and senior high school levels include using the Food Guide Pyramid; learning the benefits of healthful eating; making healthful food choices for meals and snacks; preparing healthy meals and snacks; using food labels; eating a variety of foods; eating more fruits, vegetables, and grains; eating foods low in saturated fat and total fat more often; eating more calcium-rich foods; balancing food intake and physical activity; accepting body size differences; and following food safety practices.18, [24] In addition, the following topics are considered to be essential at the middle, junior high, and senior high school levels: the Dietary Guidelines for Americans; eating disorders; healthy weight maintenance; influences on food choices such as families, culture, and media; and goals for dietary improvement.18
Nutrition education should be taught as part of a comprehensive school health education program, and essential nutrition education topics should be integrated into science and other curricula to reinforce principles and messages learned in the health units. Nutrition education is addressed within a school health education objective. (See Focus Area 7. Educational and Community-Based Programs.) In addition, students must have access to healthful food choices to enhance further the likelihood of adopting healthful dietary practices. For these reasons, monitoring students’ eating practices at school is important.
Although health promotion efforts should begin in childhood, they need to continue throughout adulthood. In particular, public education about the long-term health consequences and risks associated with overweight and how to achieve and maintain a healthy weight is necessary. While many persons attempt to lose weight, studies show that within 5 years a majority regain the weight.[25] To maintain weight loss, healthful dietary habits must be coupled with decreased sedentary behavior and increased physical activity and become permanent lifestyle changes. (See Focus Area 22. Physical Activity and Fitness.) Additionally, changes in the physical and social environment may help persons maintain the necessary long-term lifestyle changes for both diet and physical activity.
Policymakers and program planners at the national, State, and community levels can and should provide important leadership in fostering healthful diets and physical activity patterns among people in the United States. The family and others, such as health care practitioners, schools, worksites, institutional food services, and the media, can play a key role in this process. For example, registered dietitians and other qualified health care practitioners can improve health outcomes through efforts focused on nutrition screening, assessment, and primary and secondary prevention.
Food-related businesses also can help consumers achieve healthful diets by providing nutrition information for foods purchased in supermarkets, fast-food outlets, restaurants, and carryout operations. For example, the introduction of a new food label in 1993 has resulted in nutrition information on most processed packaged foods, along with credible health and nutrient content claims and standardized serving sizes.[26] While efforts were made in the 1990s to increase the availability of nutrition information, reduced-fat foods, and other healthful food choices in supermarkets, significant challenges remain on these fronts for away-from-home foods purchased at food service outlets. The importance of addressing these challenges is suggested by recent data indicating that nearly 40 percent of a family’s food budget is spent on away-from-home food, including food from restaurants and fast-food outlets.[27] One analysis found that away-from-home foods are generally higher in saturated fat, total fat, cholesterol, and sodium and lower in dietary fiber, iron, and calcium than at-home foods.27 Away-from-home sites include restaurants, fast-food outlets, school cafeterias, vending machines, and other food service outlets. This study also suggested that persons either eat larger amounts when they eat out, eat higher calorie foods, or both.
Many of the Healthy People 2010 objectives that address nutrition and overweight in the United States measure in some way the Nation’s progress toward implementing the recommendations of the Dietary Guidelines for Americans. The recommendations for food and nutrient intake are not intended to be met every day but rather on average over a span of time. Although the Healthy People 2010 dietary intake objectives address the proportion of the population that consumes a specified level of certain foods or nutrients, it is also important to track and report the average amount eaten by different population groups to help interpret progress on these objectives. Other objectives target aspects of undernutrition, including iron deficiency, growth retardation, and food security.
In summary, several actions are recognized as fundamental in achieving this focus area’s objectives:
| n | Improving accessibility of nutrition information, nutrition education, nutrition counseling and related services, and healthful foods in a variety of settings and for all population groups. |
| n | Focusing on preventing chronic disease associated with diet and weight, beginning in youth. |
| n | Strengthening the link between nutrition and physical activity in health promotion. |
| n | Maintaining a strong national program for basic and applied nutrition research to provide a sound science base for dietary recommendations and effective interventions. |
| n | Maintaining a strong national nutrition monitoring program to provide accurate, reliable, timely, and comparable data to assess status and progress and to be responsive to unmet data needs and emerging issues. |
| n | Strengthening State and community data systems to be responsive to the data users at these levels. |
| n | Building and sustaining broad-based initiatives and commitment to these objectives by public and private sector partners at the national, State, and local levels. |
(A listing of abbreviations and acronyms used in this publication appears in Appendix H.)
Anemia: A condition in which the hemoglobin in red blood cells falls below normal. Anemia most often results from iron deficiency but also may result from deficiencies of folic acid, vitamin B12, or copper, or from chronic disease, certain conditions, or chronic blood loss.
Body mass index (BMI): Weight (in kilograms) divided by the square of height (in meters), or weight (in pounds) divided by the square of height (in inches) times 704.5. Because it is readily calculated, BMI is the measurement of choice as an indicator of healthy weight, overweight, and obesity.
Calorie: Unit used for measuring the energy produced by food when metabolized in the body.
Cholesterol: A waxy substance that circulates in the bloodstream. When the level of cholesterol in the blood is too high, some of the cholesterol is deposited in the walls of the blood vessels. Over time, these deposits can build up until they narrow the blood vessels, causing atherosclerosis, which reduces the blood flow. The higher the blood cholesterol level, the greater is the risk of getting heart disease. Blood cholesterol levels of less than 200 mg/dL are considered desirable. Levels of 240 mg/dL or above are considered high and require further testing and possible intervention. Levels of 200-239 mg/dL are considered borderline. Lowering blood cholesterol reduces the risk of heart disease.
HDL (high-density lipoprotein) cholesterol: The so-called good cholesterol. Cholesterol travels in the blood combined with protein in packages called lipoproteins. HDL is thought to carry cholesterol away from other parts of the body back to the liver for removal from the body. A low level of HDL increases the risk for CHD, whereas a high HDL level is protective.
LDL (low-density lipoprotein) cholesterol: The so-called bad cholesterol. LDL contains most of the cholesterol in the blood and carries it to the tissues and organs of the body, including the arteries. Cholesterol from LDL is the main source of damaging buildup and blockage in the arteries. The higher the level of LDL in the blood, the greater is the risk for CHD.
Complex carbohydrate: Starch and dietary fiber.
Coronary heart disease (CHD): The type of heart disease due to narrowing of the coronary arteries.
Dietary fiber: Plant food components, including plant cell walls, pectins, gums, and brans that cannot be digested.
Dietary Guidelines for Americans: A report published by the U.S. Department of Agriculture and U.S. Department of Health and Human Services that explains how to eat to maintain health. The guidelines form the basis of national nutrition policy and are revised every 5 years. This chapter refers mostly to the 2000 guidelines.
Fats/fatty acids: Fats and fatty acids are hydrocarbon chains ending in a carboxyl group at one end that bond to glycerol to form fat. Fatty acids are characterized as saturated, monounsaturated, or polyunsaturated depending on how many double bonds are between the carbon atoms. Fatty acids supply energy and promote absorption of fat-soluble vitamins. Some fatty acids are “essential,” because they cannot be made by the body.
Saturated fatty acids: Fatty acids with no double bonds between carbon atoms. Levels of saturated fatty acids are especially high in meat and dairy products that contain fat. Saturated fatty acids are linked to increased blood cholesterol levels and a greater risk for heart disease.
Trans-fatty acids: Alternate forms of naturally occurring unsaturated fatty acids produced in fats as a result of hydrogenation, such as when vegetable oil becomes margarine or shortening. Trans-fatty acids also occur in milk fat, beef fat, and lamb fat. These fatty acids have been associated with increased blood cholesterol levels.
Unsaturated fatty acids: Fatty acids with one or more double bonds between carbon atoms. These fatty acids do not raise blood cholesterol levels.
Polyunsaturated: Fatty acids with more than one double bond between carbon atoms.
Monounsaturated: Fatty acids with one double bond between carbon atoms.
Food Guide Pyramid: A graphic depiction of U.S. Department of Agriculture’s current food guide that includes five major food groups in its “base” (grains, vegetables, fruits, milk products, and meats, and meat substitutes) and a “tip” depicting the relatively small contribution that discretionary fat and added sugars should make in U.S. diets. The Food Guide Pyramid provides information on the choices within each group and the recommended number of servings.
Food security: Access by all people at all times to enough food for an active, healthy life. It includes at a minimum (1) the ready availability of nutritionally adequate and safe foods, and (2) an assured ability to acquire acceptable foods in socially acceptable ways.
Food insecurity: Limited or uncertain availability of nutritionally adequate and safe foods or limited and uncertain ability to acquire acceptable foods in socially acceptable ways.
HDL-cholesterol: See cholesterol.
Hunger: The uneasy or painful sensation caused by a lack of food.
Hypertension: High blood pressure.
Hypertriglyceridemia: Elevated levels of triglycerides in the blood.
Iron deficiency: Lack of adequate iron in the body to support and maintain functioning. It can lead to iron deficiency anemia, a reduction in the concentration of hemoglobin in the red blood cells due to a lack of iron supply to the bone marrow.
LDL-cholesterol: See cholesterol.
Linear growth: Increase in length or height.
Medical nutrition therapy: Use of specific nutrition counseling and interventions, based on an assessment of nutritional status, to manage a condition or treat an illness or injury.
Metabolism: The sum total of all the chemical reactions that go on in living cells.
Nutrition: The set of processes by which nutrients and other food components are taken in by the body and used.
Obesity: A condition characterized by excessive body fat.
Osteoporosis: A bone disease characterized by a reduction in bone mass and a deterioration of the bone structure leading to bone fragility.
Overweight: Excess body weight.
Physical activity: Bodily movement that substantially increases energy expenditure.
Registered dietitian: A food and nutrition expert who has met the minimum academic and professional requirements to receive the credential “RD.” Many States and Commonwealths also have licensing laws for dietitians and nutrition practitioners.
Sedentary behavior: A pattern of behavior that is relatively inactive, such as a lifestyle characterized by a lot of sitting.
Type 2 diabetes: The most common form of diabetes, which results from insulin resistance and abnormal insulin action. Type 2 diabetes was previously referred to as noninsulin-dependent diabetes mellitus (NIDDM) and adult-onset diabetes.
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