Chapter 3: Food Scarcity

Chapter 3 Vocabulary
Food insecurity [
noun
]
The lack of consistent access to sufficient amounts of safe and nutritious foods.
Hidden hunger [
noun
]
Inadequate intake or absorption of vitamins and minerals. This is common with
undernourishment but also can occur when caloric intake is adequate in the presence of limited
variety in the diet.
Subclinical deficiency [
noun
]
The absence of clear physical signs of the deficiency.
Stunting [
noun
]
Inadequate height growth due to lack of adequate nutrition over an extended period of time.
Kwashiorkor [
noun
]
Undernutrition with insufficient protein intake over an extended period of time that results in loss
of muscle mass, edema, changes in skin and hair color, weakened immune system, diarrhea,
fatigue, and failure to grow age appropriately.
Marasmus [
noun
]
Severe undernutrition with insufficient protein and total calorie intake that often leads to
emaciation.
Double burden of malnutrition [
noun
]
The existence of over and undernutrition in the same person or population.

3.1 Malnutrition
The prefix “mal” means bad and when coupled with nutrition would imply bad nutrition.
Therefore, malnutrition can refer to both overnutrition or undernutrition. Overnutrition occurs
when there is an overconsumption of nutrients from food or supplementation to the point where
health is adversely affected.This could manifest as excessive caloric consumption leading to
obesity or consuming some vitamins or minerals in high amounts. Undernutrition occurs when
there is insufficient consumption of nutrients. This can manifest as impaired growth and
development or specific vitamin and mineral deficiency diseases such as scurvy, which is a
vitamin C deficiency (Collier R., 2009). It is important to understand that there may not always
be clear signs of malnutrition, initially. The potential serious effects will often develop over time.
Additionally, modern revelation teaches us that the physical well-being of an individual is
inseparably connected with their spiritual health. The biblical story of Daniel, Shadrach,
Meshach, and Abednego is an excellent example of the interconnection of dietary choices with
physical, mental, and spiritual health. (The Holy Bible, KJV, 1979). After being true to their
covenants and rejecting the king’s delicacies and wine for their traditional diet (likely rich in
beans and whole grains), these young men were blessed both physically and spiritually. It works
the same for each of us today: effort to stay true to our covenants and also care for the bodies we
have been given results in not only physical blessings, but spiritual blessings as well.

3.2 Undernutrition
Increased access to food, supplements, and medical treatment has reduced the number of those
suffering with inadequate nutrient intake. Nonetheless, it was estimated in 2018 that more than
800 million people globally are undernourished(United Nations World Food Program, Report on
Food Crisis, 2020). Many of these individuals are children. Inadequate intake of calories,
protein, and micronutrients (such as iron, vitamin A, and iodine) is still common globally. The
percentage of the population that suffers from undernourishment is diminishing, but with the
current level of population growth the actual number of those people that are undernourished
continues to increase. The term "food insecurity" is used to describe the lack of consistent
access to sufficient amounts of safe and nutritious foods. The key drivers of food insecurity
globally are armed conflict, internal violence, and civil unrest or political crises within countries
or regions that leads to the displacement of people from their homes. Other factors include
weather extremes and changing weather patterns, unexpected disease outbreaks such as COVID-
19, crop pests, and other economic challenges such as high unemployment rates or inflation. In
many places a poor infrastructure and lack of access to technology aggravates the food security
issues.
Even where sufficient calories from food may appear to be available many people may still suffer
from hidden hunger. Hidden hunger refers to inadequate intake or absorption of vitamins and
minerals. This is common with undernourishment but can also occur when caloric intake is
adequate if there is a limited variety of food available. For example, a person could eat enough
rice and beans to fulfill calorie needs, but without adding fruits and vegetables to the diet, vitamin
and mineral deficiencies will still occur. In developed countries, hidden hunger may be present
from heavy consumption of food rich in calories but low in vitamins and minerals. A moderately
low intake of vitamins and minerals may not result in any noticeable physical signs of a
deficiency but may still impact a person’s quality of life. Health professionals often refer to this
as a sub-clinical deficiency (inferring the absence of clear physical signs of the deficiency). An
example of this would be an increased rate of infection with marginally low vitamin A intake, but
the absence of more severe symptoms of low vitamin A intake such as blindness.
An infant being screened for undernutrition.

Regardless, whether noticeable nutritional deficiencies are physically present or not, inadequate
dietary intake affects the quality of life and an individual and a community’s ability to flourish.
Inadequate nutrition is detrimental at any time during the lifecycle but can be especially
concerning if it occurs in the first 2 years of a child’s life. Good nutrition during this time is
essential to support the rapid brain development that is occurring. Nutrition status of children can
be determined by following growth measures such as height, weight and mid upper arm muscle
circumference. Severe undernutrition can contribute to stunted height (low height for age) and/or
wasting (low weight compared to a person’s height). It is estimated that 144 million children
under 5 are stunted and 47 million are wasted worldwide (World Health Organization, 2020). It
is important to recognize the significance of these statistics. Good nutrition contributes to
cognitive development, resulting in better opportunities for children to realize their potential
academically, professionally and economically later in life. This impacts their quality of life as
well and the economic growth of their country. Poor nutrition, on the other hand, impairs
productivity, increases health care costs, and can perpetuate a cycle of poverty and ill health
(World Health Organization, 2020). Undernutrition is linked with suppression of the immune
system; consequently, undernourished children commonly die from bacterial or viral infections
(diarrheal diseases, respiratory infections, tuberculosis etc…). In 2020, the World Health
Organization reported about 45% of deaths among children under 5 years of age are linked to
malnutrition. The majority of these deaths occurred in low- and middle-income countries (World
Health Organization, 2021).
It is also important to consider that even when food amount and variety is plentiful that
undernutrition can still occur. This may be induced by personal choice. Sub clinical deficiencies
and hidden hunger can occur simply by making nutrient poor food choices from the options that
are available. This path to undernutrition might more commonly be seen in developed countries
where appealing, ultra processed nutrient poor foods are readily available and cleverly marketed.

3.3 Macro and Micronutrient Concerns in

Undernutrition
Many areas of the world struggle with levels of undernutrition that may lead to deficiency
diseases. Many global illnesses, symptoms and issues could be addressed by consuming adequate
amounts of nutrients. Having inadequate intake of overall calories (energy) or protein can lead to
increased death rates. Deficiencies in vitamins and minerals can also have a critical impact on
health. Vitamins and minerals are referred to as micronutrients. Some of the most common
micronutrient deficiencies include Vitamin A, iron, iodine, and folate. Calcium and Vitamin D
are also important in developing bone structure and preventing issues with weak bones in
childhood and adulthood.

Vitamin A
Vitamin A is a fat-soluble vitamin (chemically interacts well with fat). It is found in food in both
the active form of the vitamin and in a provitamin form which can be converted by the body to
the active vitamin. (National Institute of Health, Office of Dietary Supplement, 2022) The active
vitamin A is referred to as preformed vitamin A and has three forms (retinol, retinal and retinoic
acid) that are collectively referred to as the retinoids. Vitamin A provitamins come from the
carotenoid family. The three most important members of the carotenoid family that are vitamin A
provitamins are beta-carotene, alpha-carotene, and beta-cryptoxanthin. Vitamin A has several
roles in the body, which include maintaining vision, immunity, reproduction, growth and cellular
differentiation (helping stem cells become specialized cells) (BYUI, Principles of Nutrition,
2022).

Vitamin A Fast Facts

 Vitamin A deficiency affects an estimated 190 million preschool-age children
worldwide.
 Children with vitamin A deficiency are at increased risk of blindness.
 Vitamin A supports a healthy immune system. Children with a deficiency are more
likely to die from infections such as measles and diarrhea.
 Providing Vitamin A supplements to children reduces death from all causes related to
Vitamin A deficiency.
(World Health Organization, 2009)

Who is at risk for vitamin A deficiency?

Infants, children, and people who are pregnant or lactating are among those most at risk of
vitamin A deficiency. It is also important to be aware that while Vitamin A deficiency is a
concern worldwide, taking too much of the active form of Vitamin A through supplementation is
also a concern and can be harmful (National Institute of Health, 2022).
Concerns
One of the first signs of a vitamin A deficiency is night-blindness, which is the inability to see in
low light. Night-blindness is easily corrected by consuming adequate vitamin A. As the
deficiency becomes more severe, there is a decrease in the production of mucus-secreting cells
that lubricate the eye. This deficiency causes dryness of the eye (called xeropthalmia) which
progresses to deterioration of the cornea, the appearance of white patches called Bitot's spots, and
eventually leads to total blindness. This condition of the eye is called keratomalacia. Vitamin A
deficiency is one of the leading causes of preventable blindness in children.
In addition to impacting vision, a vitamin A deficiency can depress the immune system, decrease
growth, impair reproduction, and lower bone mineral density. Furthermore, a deficiency can
result in a condition called follicular hyperkeratosis, which is a buildup of the keratin (a fibrous
protein) in hair follicles creating a bumpy, goose flesh appearance to the skin.
Specific symptoms of Vitamin A deficiency include:
 Eye problems, including blindness
 Skin issues, which will result in an itchy rash or dry, scaly patches of skin
 Infertility
 Growth issues
 Infections due to vitamin A’s role in immunity. Deficiency can lead to respiratory tract
infections which are conditions of the chest and throat.

A mango tree. Mangos are a good source of beta carotene.

Individuals that take too much of the retinoids through supplementation are also at risk of
toxicity. Consequences of taking too much can cause a variety of symptoms that may eventually
lead to death. If excess consumption occurs in pregnancy issues can occur at much lower levels,
problems can include spontaneous abortion (miscarriage of a pregnancy) and fetal malformations
(of a developing baby if the individual is pregnant) (World Health Organization, 2009)

Vitamin A Recommendations
There are several food sources of vitamin A. Some sources provide the provitamin (beta-carotene
or other carotenoids) and some foods provide the active form (the retinoids).

Vitamin A Food Sources

Retinoids (active form) Carotenoids (Beta-Carotene)

Beef and chicken liver Sweet potatoes

Eggs Pumpkin

Fish liver oils Dark-leafy greens

Dairy products such as whole milk, whole Mangoes

milk yogurt

Butter Peaches

Cheese Carrots

Table 1: Vitamin A Food Sources (Harvard School of Public Health, 2023)

In many areas throughout the world, vitamin A supplementation has been used to treat deficiency
with great results. Global efforts to increase vitamin A intake has led to extensive
supplementation programs, fortification of foods, promoting food sources rich in vitamin A such
as orange fleshed sweet potatoes, and genetic modification to increase vitamin A levels in foods.

Iron
Iron is a mineral that is needed by the body for oxygen transport and production of usable energy
in the body. Hemoglobin is part of the red blood cell that carries oxygen. It is made up of heme
and globin. Heme is a ring-like structure containing carbon, hydrogen, and oxygen. Globin is the
protein that holds the heme. Iron is found in the center of each heme. When all these components
are present, hemoglobin is an efficient carrier of oxygen. In the muscle, a similar structure used to
transport oxygen is called myoglobin. The majority of the body’s iron (approximately 70%) is
found in the red blood cells of hemoglobin and myoglobin. Iron is also necessary to convert the
food we eat into usable energy. It is also a cofactor for hundreds of enzymes and is needed to
make DNA. (Principles of Nutrition, 2022)

Iron Fast Facts

 Iron plays an important role in cognitive and motor development.
 Iron deficiency is a major cause of anemia which affects 40% of children under the
age of 5 years old and 30% of pregnant women worldwide.
  Children and pregnant women are at increased risk for deficiency.
 Iron deficiency increases death rates of pregnant women and puts infants at risk of
low-birthweight.
(Center for Disease Control, 2022)

Who is at risk?
Iron deficiency affects over 2 billion people worldwide. It is the most common nutritional
disorder in the world. Those at highest risk of iron deficiency include children, pregnant women,
infants, women with heavy menstrual cycles, and individuals that have cancer or gastrointestinal
disorders (especially those that cause bleeding) (Short, 2013).

Concerns
Individuals with low iron stores may not show specific signs at first. However, over time and
after development of iron deficiency anemia, individuals may experience a variety of symptoms.
Symptoms include inability to concentrate, being tired or weak, difficulty with physical activity,
inability to regulate body temperature, and they may have a hard time fighting off infection.
Learning difficulties like short attention span may develop in children with iron deficiency
anemia (NIH- Iron, 2022).

Iron Recommendations
In food, iron comes in two different forms: heme iron and non-heme iron. Heme iron is found in
foods that also contain the meat or blood of the animal. This form of iron is absorbed at a higher
rate than the other form of iron, which is referred to as non-heme iron. This type of iron is found
in plants, fortified foods and supplements. Some food sources of heme and non-heme sources of
iron are listed below:

Iron Food Sources

Heme iron Non-heme iron

Beef Legumes (beans, lentils, chickpeas)

Lamb Sweet Potatoes

Ham Kale

Shrimp Fortified grains and breakfast cereals

Turkey Dried fruit

Chicken Nuts

Tuna Collard greens

Sardines Figs
Table 2: Iron Rich Food Sources (American Red Cross, 2023)
The absorption of non-heme iron can be increased by eating it with a food source of vitamin C,
which is commonly found in many citrus fruits like oranges.
An interesting way that is being explored to increase iron intake around the world I the use of a
product called the Lucky Iron Fish. The World Health Organization reports that 40% of pregnant
women are iron deficient (WHO-Anaemia,n.d.). Despite global efforts to provide iron
supplements and fortify foods with iron, the incidence of iron deficiency anemia continues to be
significant. The Lucky Iron Fish is a novel approach to improve iron status. The lucky iron
fish is a reusable cooking utensil made of ferrous iron that adds extra iron to meals. When added
during the preparation of liquid meals, a small but significant amount of iron will release into the
liquid as it is boiled. It has proven to be an effective way to reduce iron deficiency. It is
estimated that regular use of the lucky iron fish in cooking can provide up to 75% of the iron
needs a woman in her reproductive years has. The principle is the same as cooking with cast
iron cookware, but the Lucky Iron Fish is convenient to use and more accessible to the
populations in underdeveloped countries that are at high risk for deficiency (Principles of
Nutrition, BYUI).
 What type of foods would increase the release of the iron into the food?
 Is this heme or non-heme iron?
 How could you increase the absorption of this type of iron?
Lucky fish being used to increase iron in cooked foods.
'LDSC/ CARE Benin - Protein for People ' (Latter-Day Saints Charities/ CARE Benin -- Protein
for People project) (Special permission was granted by "Care" for use of these pictures, Jay
Keller has the copyright documents from Care)

Iodine
Iodine is a mineral and is used to make thyroid hormones which regulate basal metabolism,
growth, and development. The thyroid gland is located on the front of the neck just below the
Adam’s apple and in front of the trachea (windpipe). When dietary iodine is consumed, the
majority is in the thyroid gland. Seventy to eighty percent of the iodine in a human body is
concentrated within the thyroid gland. Iodine is also used to help build strong bones and to help
the developing brain of a baby while a woman is pregnant (Farhana, A. and Ganie, S.A, 2010).

Iodine Fast Facts

 Iodine is necessary for the healthy development of the baby’s brain and healthy
growth during pregnancy.
 About 1.8 billion people have inadequate intake of iodine worldwide.
 There are not a lot of foods that naturally have a significant amount of iodine.
 One of the cheapest, effective ways to prevent a deficiency of iodine is to add it to
salt.
(NIH-Iodine, 2022)

Who is at risk?
Individuals that may be at highest risk of a deficiency include:
 Pregnant women.
 People who do not use iodized salt.
  People who follow a vegan intake or eat a minimal amount of dairy, seafoods and eggs.
 People who eat mostly local foods in areas where the soil is very low in Iodine. Most of
these regions are in the mountains, such as near the Andes, Himalayas and the Alps.
(NIH-Iodine, 2022)

Concerns
A diet that does not provide enough iodine in a pregnant woman may harm the fetus by impairing
its growth, intellectual development, and sexual maturation. A deficiency of iodine can also cause
issues with metabolism related to the thyroid, referred to hypothyroidism, as well as the
development of an enlarged thyroid which is called a goiter (Farhana, A. and Ganie, S.A, 2010)
(NIH-Iodine, 2022).

Iodine Recommendations
There are only a few foods that have a naturally significant amount of iodine. It is recommended
that you include a variety of those foods in your diet. Recommended foods include:

Iodine Food Sources

Cod Milk

Tuna Yogurt

Seaweed Cheese

Shrimp Eggs

Iodized salt – Processed foods, such as canned foods, although high in salt, is usually not
prepared with iodized salt. Other types of salt such as sea salt, kosher salt and Himalayan salt
are also usually NOT iodized.

Table 3: Iodine Food Sources (NIH-Iodine, 2022)

Calcium
Calcium is a mineral that is needed in the diet whose main function is to support bone health. The
majority of calcium in the human body is in the bones. Strong, healthy bones provide structure to
the body and allow individuals to move safely. A small amount of calcium is in the body fluids.
Calcium in the body fluids has several key bodily functions such as blood clotting and muscle
contraction. It needs to be maintained for proper body function (Principles of Nutrition, 2022).

Calcium Fast Facts

 Calcium is the most abundant mineral in the body.
 Vitamin D helps the body absorb more calcium.
 Calcium also helps the body maintain a healthy blood pressure and improves heart
health.
  Approximately 200 million women around the world have osteoporosis, a condition
often associated with low intakes of calcium.
(NIH- Calcium, 2022)

Who is at risk?
Because calcium is such an important mineral in creating healthy bone, those that are at risk of
not having adequate intake include the following:
 Children and teens
 Black or Asian individuals tend to have lower intake
 Adults aged 50 and older, especially if they have a low economic income (NIH-Calcium,
2022)

Concerns
A low intake, or deficiency, of calcium can have a serious impact on bone health. The constant
need for the body to supply calcium to the fluids results in low bone calcium because the body
will remove calcium from the bones to maintain the calcium in the fluids. When this occurs over
time, the body develops weak bones. This condition is referred to as osteoporosis. This condition
is usually not a concern until later in life. If children or adolescents do not consume an adequate
amount of calcium they may end up with weaker bones and be at higher risk of osteoporosis as
they get older (Principles of Nutrition, 2022). Generally, women are at higher risk for
osteoporosis than men. Women typically have a lower calcium intake, smaller bones on average,
and their bone mass can be significantly impacted during menopause.

Calcium Recommendations
Calcium is found in many foods, and you can get an adequate amount of calcium by eating a
variety of foods from different food groups.

Calcium Food Sources

Dairy Non-dairy

Milk Canned fish

Yogurt Non-dairy beverages (soy, almond

beverages)

Cheese Kale

Bok choi

Fortified juices

Fortified cereals

Most grains such as bread and pasta

Table 4: Calcium Food Sources (National institute of Health, 2022; Harvard school of public
health, 2023; Yuyan et al, 2022)

Vitamin D

Vitamin D is a fat-soluble vitamin. It is not found in a lot of foods, which can make meeting the
recommendation for vitamin D difficult. The human body can also make Vitamin D when the
skin is exposed to the sun’s ultraviolet B (UVB) rays. Although the body can produce some
vitamin D, it is not enough, so it is important to consume this nutrient in food or supplement
form. Vitamin D helps our body absorb the calcium we consume which makes it important for the
development and maintenance of strong bones. Other reasons Vitamin D is important is because
it helps our nerves carry messages in our body, regulates inflammation, and helps our bodies fight
infections (NIH - Vitamin D Health Professionals - 2022).

Vitamin D Fast Facts

 An estimated 1 billion people have inadequate levels of vitamin D in their blood.
 Low vitamin D is a problem even in countries with sun exposure year-round.
 Deficiencies occur in all ethnicities and age groups.
 A poor intake can lead to soft bones resulting in rickets in children and osteomalacia
in adults.
(Cleveland Clinic, 2022)

Who is at risk?
Several groups of people are at higher risk of getting a vitamin D deficiency. Those groups of
people include the following:
 Individuals who stay home or are homebound. If you remain home or indoors, the time
spent in the sun when your skin can synthesize vitamin D is limited.
  Individuals with darker skin don’t synthesize as much vitamin D as individuals with fair
skin.
 People over age 65 don’t make as much vitamin D because the skin’s ability to make
vitamin D decreases as you age.
 Individuals who spend time outside but cover their skin with clothing are at a higher risk
because their sun exposure is limited.
 Breastfed infants are also at high risk of vitamin D deficiency. The amount of vitamin D
passed through in breastmilk is not sufficient to meet the needs of an infant. Vitamin D
supplements are recommended.
 Obese individuals.
 Living in Northern latitudes during the winter.
(NIH - Vitamin D- Consumer, 2022)

Concerns
Vitamin D deficiency can lead to the development of other diseases such as rickets in children
and osteomalacia in adults. Rickets is a rare disease that causes the bones to be very soft and to
bend which causes “bowing” of the legs. Osteomalacia in adults is also a condition of soft bones
which causes weak bones, bone pain and weakness.
There also is a possible connection between inadequate levels of vitamin D and other disease
such as high blood pressure, diabetes, cancer and depression. (NIH - Vitamin D - Consumer,
2022)

Vitamin D Recommendations
Since our body can synthesize vitamin D, one recommendation is to spend time outside in the
sunshine. Your body cannot produce too much vitamin D from sun exposure, however extended
time in the sun can put you at risk of skin cancer. Dietary intake is important and vitamin D
supplementation may be required, if available, to help meet the needs of the body. High levels of
vitamin D consumption can be harmful from food or supplements (Cleveland Clinic - Vitamin D,
2022)

Vitamin D Food Sources

Salmon Fortified milk

Tuna Fortified orange juice

Trout Fortified cereal

Cod liver oil Egg yolk

Canned sardines

Table 5: Vitamin D Food Sources: (National institute of Health, 2022; Harvard school of public
health, 2023; Yuyan et al, 2022)
Energy (Calories) and Protein
Food that we eat provides calories and we use those calories to produce energy for our bodies.
Individuals who have a low intake of calories are at high nutritional risk, meaning they could
experience several conditions related to a poor dietary intake. If adequate calories are not
available, that most likely means there is an inadequate amount of protein available as well. There
are two specific protein malnutrition diseases: marasmus, and kwashiorkor.

Marasmus comes from a Greek word meaning “withering” or “to waste away.” Marasmus is a
severe deficiency of both protein and calories over an extended period of time. Extended
marasmus leads to starvation. Signs of marasmus include being severely underweight and wasting
appearance, loss of muscle and fat. Marasmus does not cause edema, or swelling tissues
(Cleveland Clinic, Marasmus, 2022).
Kwashiorkor comes from the language of Ghana. It means “disease of deposed child.” Deposed
child refers to a child who is no longer being breastfed because of the birth of a new baby. In
place of breast milk, the child is fed a watery, low protein, but adequate calorie porridge made
from grain. Kwashiorkor is caused by a deficiency in dietary protein. It is characterized by
swelling (edema) of the feet and abdomen, poor skin health, growth retardation, low muscle
mass, and liver malfunction. One of the classic signs of kwashiorkor is a swollen belly that can be
attributed to either a build-up of fluid in the abdomen, or an enlarged, or fatty, liver. In
kwashiorkor, the child does not appear dramatically thin because enough calories are consumed
to prevent muscle wasting (Cleveland Clinic, Kwashiorkor, 2022).

Calories and Protein Fast Facts

 462 million adults are underweight worldwide.
 In 2020, it was estimated that globally:
 45 million children under age 5 were wasted (too thin for height).
  149 million children under age 5 were stunted (too short for age).
 Undernutrition was linked to 45% of deaths in children under the age of 5.
 In 2020, it is estimated that between 720 and 811 million people in the world faced
hunger (WHO, Malnutrition, 2020).

Who is at risk?
Individuals at highest risk of energy and protein malnutrition include women, infants, children
and adolescents. Low income or poverty increases the risk of malnutrition and magnifies the risks
from malnutrition (WHO, Malnutrition, 2020). Infants, whose calorie needs are high to support
their proper growth are at increased risk and those in developing countries are at an even higher
risk. In these areas, problems such as poverty, parasites, and infectious diseases increase calorie
needs and contribute to food scarcity and make this condition more common. Those at risk of
kwashiorkor are breastfed toddlers who are quickly weaned when a new baby is born and begins
breastfeeding. They transition to a high carbohydrate diet that lacks adequate amounts of protein
(Cleveland Clinic, Kwashiorkor, 2022). Specific conditions put people at risk such as wasting
diseases like AIDS and some cancers.
Areas of the world at high risk for protein and energy malnutrition include poorer areas of Africa,
Central America and Southeast Asia. Dietary intake in these areas is typically high in
carbohydrates which increases the risk of poor protein intake. Environmental factors, such as
famine, war and natural disasters which impact the food supply for a population, also increase the
risk of these deficiencies (Cleveland Clinic, Kwashiorkor, 2022).

Concerns
Malnutrition, in one form or another, affects all countries around the globe. Battling malnutrition
is one of the biggest health challenges in the world. Undernutrition, especially from calories and
protein, can cause several disruptions in the body. The body may experience low blood sugars,
suppressed immunity resulting in increased risk of infection and illness, low body temperature,
growth and developmental delays in children and eventually starvation can occur. In situations
where starvation exists, the body's fat and muscle are used to provide energy instead of other key
functions. The heartbeat slows, and blood pressure and temperature both drop. Parts of the
digestive tract can stop working. Inadequate intake of calories can result in death (Cleveland
Clinic - malnutrition, 2022).

Calorie/Protein recommendations
Beginning to feed someone that has experienced severe energy malnutrition needs to be
approached carefully and may require medical attention depending on the severity of the
condition. If they have been suffering from starvation for a significant amount of time, there are
several things that need to be addressed before they can begin eating. They need to be rehydrated
with fluids and micronutrients to help stabilize their body before they can begin eating food. They
must also be kept warm and treated for any infections. After they are stable, the individual can
start to be refed, which starts slowly and usually with liquid supplements. Calories will start low
and then be increased above their recommended intake to make up for delayed growth in
children. This may last several weeks. These individuals should be monitored and receive follow-
up care. If a person has been facing hunger from a temporary lack of food resources, then
providing the needed energy and protein can be addressed quickly (Cleveland Clinic,
Kwashiorkor, 2022; Cleveland Clinic, Marasmus, 2022).
In situations where war, economic issues, weather extremes or other factors cause a scarcity of
food leading to severe acute weight loss and malnourishment, a variety of ready to use
therapeutic foods (RUTF’s) are available. Aid agencies such as the World Food Program and
UNICEF utilize these products when providing emergency aid. One of the most widely used
RUTF products is called Plumpy’nut. It is a shelf stable paste made of peanut butter fortified
with protein and other added nutrients. It is most often used to help malnourished children.
Feeding someone in this type of situation has to be done with care. In cases of extreme
malnourishment, feeding too aggressively can be deadly. The rush of food into the system can
cause shifts in already strained blood electrolyte levels leading to cardiac arrest. This is termed
“Refeeding Syndrome” (Principles of Nutrition, 2022).

International Agencies that Provide Food Assistance

World Food Program

Actions Against Hunger

CARE

United Nations Children’s Emergency Fund (UNICEF)

USAID

Catholic Relief services

LDS Charities

Bountiful Children’s Foundation

The best thing to do is work towards solutions that can prevent these types of conditions from
occurring.

3.4 What Threatens our Food Supply and How Can

it be Fixed?
For food to reach the individuals who need it, adequate food must be produced and then
efficiently moved from the farm to the markets and then reach individuals’ homes. This requires
wise farming practices, use of appropriate technology, effective harvesting, and efficient
transportation. Other less obvious factors can impact the production and the movement of the
food to the consumer, including government regulations, market influences, and taxes that can
affect availability of agricultural materials and crop prices. Even changes in national and
international policies can impact people’s access to food. People’s health and well-being are
negatively impacted when the agricultural and food systems and networks break down.
Ensuring an adequate food supply for everyone will require the ingenuity of more than one
generation. Some specific factors contributing to an insufficient availability of food include the
following:
Population growth – it is estimated that the global population is growing exponentially. The
United Nations estimates that the earth could have 9.7 billion people by 2050 (United Nations,
ND). Lower child mortality and increased longevity are contributing to this growth. Not only
does this result in more mouths to feed, but potentially less land on which to produce food. This
will strain our food and water supply if we are not resourceful.
Everyone is a child of God. Our Heavenly Father knows each of us and has a plan for us. In
Doctrine and Covenants section 104 the Lord promises us, “For the earth is full, and there is
enough and to spare; yea, I prepared all things, and have given unto the children of men to be
agents unto themselves.” (D@C 104:17) As we exercise faith and work, God will help us find
solutions to the challenges we face.
D&C 104:17 For the earth is full, and there is enough and to spare; yea, I prepared all things, and
have given unto the children of men to be agents unto themselves.

(God wants us to move forward every day in faith)

The continued use of unsustainable agricultural practices in some places: A wide variety of
unwise agricultural practices can lead to a long-term impact on food availability. Some examples
include the following:
Loss of topsoil: Maintaining adequate, well-nourished topsoil is critical. Developing a productive
depth of topsoil can take decades, and without proper care, that topsoil can be lost in mere days
through wind and water erosion. Deforestation continues in many places in the world and can be a
significant contributor to soil erosion. Compaction of topsoil by heavy machinery and even foot
traffic can damage topsoil. Contamination of soils with toxic chemicals continues to be a problem
in many places. Poor crop rotation and unwise use of fertilizers can also impact soil
quality. Topsoil needs to be managed well or conserved to preserve a people’s or nation’s ability
to produce their own food.
Reduction of crop diversity: Small farms produce the majority of the food in the world, they are
especially important in developing countries. As more and more of our food production moves to
larger scale production farms, there is a risk that crop variety will decrease. Reliance on only a
few crops may lead to food shortages if a failure of any one of the crops occurs. The Irish potato
famine offers an example of when this happened. In the 1800s, potatoes were a staple food for
most people in Ireland. The farmers primarily produced one type of potato. A disease called late
blight swept through the soil in Ireland destroying potato crops. Many people died of hunger or
were displaced. New disease-resistant varieties became available that helped people plant potato
crops again in Ireland. This demonstrates the danger of relying too heavily on a single crop as a
source of food.
Uneven distribution of agricultural knowledge and technology: In the last 100 years, advances in
agricultural knowledge and technology have increased exponentially. The result is increasing
food production in many places through improved agricultural management, fertilization, and
pest control. Due to a variety of reasons, access, and utilization of these advances in technology
and improved agricultural techniques have not been utilized in many areas of the world that most
desperately need it.
More people are needed around the world that are well educated in sustainable agricultural
techniques.
Global climate change – Weather patterns continue to change globally, impacting food
production. Alternately, drought and flooding regularly devastate food production capacity
around the world.
Food choices– A lack of understanding about the long-term implications of food choices can be
detrimental to our food security. This can be from a lack of education or from competing
priorities and poor planning. For example, as countries grow economically, they typically move
from a plant-based to an increasingly animal-based diet. Meat consumption can require more
resources to produce the same calories, protein, vitamins and minerals than grains, legumes,
fruits, or vegetable crops.
Government policies – Government policies can dramatically affect the commodity markets and
influence what crops are grown, what are subsidized, what is imported and exported, how crop
damages are handled, and many more aspects of large-scale food production. This can impact the
ability of food to get into the hands of those who need it most. For example, the Irish Potato
Famine of the 1840s was impacted by British policies. When a fungus destroyed the Irish potato
crops many people died from starvation as it was their only food source. Policies put in place by
the British government directed food sources, like wheat crops, be moved out of Ireland. These
sources could have been used to relieve hunger.
Political instability and conflict – Warfare is the number one cause of food insecurity and
hunger. Wars continue to rage worldwide. In section 89 verse 4 of the Doctrine and Covenants,
the Lord tells us that the Word of Wisdom is given to warn us "in consequence of evils and
designs which do and will exist in the hearts of conspiring men in the last days. " We see this in
the instance of wars that displace people from their homes and homelands, inhibit food
production, and result in loss of crops and the ability of food supply chains to distribute food.
Food deserts – In developed countries, urban growth and/or inadequate community planning can
result in food deserts. A food desert is anywhere people have limited access to affordable and
healthy food. They commonly occur in low income urban or rural areas and are often due to a
combination of inadequate access to transportation and long distances to the closest grocery store
(or other facility that provides access to affordable healthy foods such as fruits, vegetables and
dairy products). Individuals living in these areas often turn to fast food, convenience store foods,
or other less optimal food sources that are high in calories and nutrient poor. This often
contributes to hidden hunger and the double burden of malnutrition.
Food waste – The United Nations reports that 14% of the world’s food is lost annually while
moving from the field to the market, another 17% is wasted at home or in the markets. (FOA,
2023). Together this accounts for roughly 1/3 of the food produced.

What are Some Solutions to Undernutrition?

The solutions to world hunger are understandably a complex discussion. According to the
leading global organizations that address world hunger, we currently are not making progress
towards reducing global malnutrition. In fact, the number of people unable to afford a healthy diet
has been increasing. The key factors currently contributing to this rise are the lingering economic
effects of the COVID 19 pandemic and wars (FAO, The State of Food Security and Nutrition in
the World, 2022). Some possible strategies to reduce world hunger include the following:
1. Effective adjustment of financial support for food production and food
policies:
Governments and other organizations are actively engaged in economic support of food
production to lower malnutrition rates around the world. Often the production of staple foods
such as rice, corn, wheat, sugar, and some meats are economically supported by governmental
agencies. This allows for increased production of these foods and makes them available at a lower
price. Inadvertently, it reduces the production of fruits, vegetables, and pulses and increases the
cost to produce them. This system allows for adequate food calorie production but inadequate
vitamin and mineral intake. Adjusting economic support so it equally supports the production of
foods from all the food groups, in a sustainable way, that can sell at a reasonable price will
improve rates of malnutrition. Carefully crafted legislation regulating the healthiness of processed
foods, food labeling, food marketing, and food safety could also contribute to improved nutrition.

2. Science
Increased crop production: Advances in agricultural technology have been increasing the
amount of food produced on a given amount of land. In the last 150 years, the amount of corn that
could be produced on an acre of land has risen from around 20 bushels/acre in the mid 1800s to
around 200 bushels per acre by 2020. This increase production was largely accomplished by
advances in planting and harvesting machinery, plant breeding, better pest control, improved
irrigation, and fertilization. For example, 150 years ago, crops in the United States were primarily
planted and harvested by hand and rainwater was relied upon for crop production. In most
developed nations today, seeds are planted by large machinery that can sow and fertilize large
fields in a fraction of the time. Sophisticated irrigation systems can sense the water needs of
plants and adjust the rate of water delivery based on need. Selective breeding of plants has
resulted in the development of large and faster producing crop varieties that can flourish in a wide
variety of conditions.
As these technologies continue to advance and to become more economically feasible and
accessible in developing nations, food production can continue to increase. Over 70% of the food
produced in the world is produced on small farms, mostly in developing countries. Helping small
farms increase food production, in a sustainable way, is an important piece to the solution for
hunger. Developing new land for crop production is an unlikely strategy to help feed the world.
Farmers will need to be able to produce more crops on the land they have or less land.
Look in the community where you live. What are advances that could be made in your
community that could increase food production? Small changes initiated now could be the means
of blessing future generations.
Increased animal production: Advances in animal production are similar to those described
with plant production. Around 70 years ago, the average broiler chicken weighed about 2 pounds
at maturity. In the early 2000’s the same chicken weighed roughly 9 pounds. Over a similar
period of time, the average weight of a beef cow went from 650 pounds to 900 pounds. Advances
in breeding (selective breeding), nutritional care, management, and health care of the animals
have been primarily responsible for these advances.
Genetically modified organism (GMO): Selective breeding of plants and animals has been a
very effective strategy to increase the production of plant and animal foods but is imprecise and
can take many generations before improvement is noted. Genetic modification of plants and
animals can target changes in specific genes in a precise way. It can be used to increase plant and
animal production, increase nutritional quality of food products, or make them more resistant to
extreme environments. GMO’s have been viewed suspiciously in many places. The safety and
usefulness of GMO’s should not be judged globally but needs to be assessed on a case-by-case
basis. Of course, there are certain specific types of GMO’s that, if handled unwisely, could be
potentially harmful. However, in most cases the genetic modifications made through genetic
engineering can certainly be a safe tool used in the global battle against hunger (WHO: Food-
Genetically Modified, 2014).

3. Reducing food waste

The benefit of an increased food production is minimized if food waste cannot be controlled.
Where most food waste happens in developed and developing countries is different. Where food
production is high and advanced technology is available, food waste is highest after meals or
from non-purchased foods in the stores. In developing countries, food waste most often occurs
between the farm and the market. It is estimated that 1/3 of the food produced globally is wasted.
Food wasted at home can be minimized with forethought when shopping, fixing, and serving
food. Creating a meal plan before shopping can guide the types and amounts of food purchased.
This can reduce the amount of food that spoils at home before it is used. Being wise in the
amount of food prepared and selected can reduce food waste after a meal. If possible, proper
storage and then creative use of leftovers is an excellent way to minimize food waste.

Food waste that occurs from the farm to the market can be a more difficult problem to manage.
Long distances between farms and markets on rough roads make it difficult to get food to where
they can be sold before they are damaged or spoiled. This involves larger scale operations to
improve roads and infrastructure and the ability to bring people and the markets together more
easily.
Advanced technology that improves refrigeration and opens the door to some food processing and
preservation can have a huge impact on food waste. Food processing can improve the stability of
the food for transport and storage. It can also be used to improve the nutrient value of foods
through enrichment and fortification (adding in vitamins and minerals). If done correctly, food
preservation techniques like drying, bottling, and pickling can be a safe way to decrease waste
and increase the availability of perishable foods.

4. Education
Certainly, if healthy food choices are not easily accessible, education on how to select healthy
foods may just be frustrating. But in most cases, healthy food choices are available, but a lack of
knowledge impedes good choices. An educated set of consumers can also drive food production:
if healthy food is demanded, food producers will find a way to provide them. Having a healthy
sustainable food supply depends on consumers making wise choices and what the farmers select
to grow.

5. Willingness to change
Food events and traditions knit families, communities, and populations together. Having this
cultural and family identity is important in having a sense of belonging. However, some food
traditions may carry with them consequences that put us at risk for undernutrition. When our
food traditions put us at risk nutritionally, we must be willing to mold and adapt them.
Highly processed, nutrient-poor foods that are easily accessed, inexpensive, and cleverly marked
are becoming more and more available. If they become the center of a person’s diet, they can
contribute to forms of undernutrition (such as sub-clinical deficiencies) even though caloric
intake may be sufficient. A wiliness to manage these types of highly palatable foods is important
for long term health.

6. Living gospel principles

Throughout our lives there are times we may be a giver and other times we may be the
receiver. In one way or another, we all need help from time to time and can give help other
times. As followers of Christ, we have a covenant responsibility to care for those in need. Many
in the world are struggling to have adequate food and clothing. If you are currently in a position,
you can help others with the necessities, you might reflect on the things you may already be
doing and see if there are additional ways to help. Brother Carmack, in his article “Bless the Poor
and Needy,” has four suggestions for us to consider (Carmack, 2004):
1. Not set our hearts upon riches, where your treasure is, there will your heart be also." This
will help us prepare our hearts for readiness when opportunity arises.
2. Keep your eyes open for opportunities around you.
3. If we have an abundance, be willing to share it with credible institutions and programs
that have the means to get the help to those in need.
4. Take care of your own family the best you can

In 2011 a severe drought led to a food crisis that turned into a severe famine largely due to
political unrest leading to war. War reduces crop production and hampers food supply chains and
the ability of aid to be provided. Corruption in high positions additionally decreased the ability of
food to get to those most in need, turning a bad situation into a disaster. As the gospel continues
to move forth and becomes more deeply etched in our hearts, peaceful solutions can be more
readily sought, and the welfare of others will be given priority over personal gain (Maxwell and
Fitzpatrick, 2012).
“If any man shall take of the abundance which I have made, and impart not his portion, according
to the law of my gospel, unto the poor and the needy, he shall, with the wicked, lift up his eyes in
hell, being in torment” (D&C 104:18).
3.5 Overnutrition and Chronic Disease
Overnutrition may manifest itself in several different forms. Excessive nutrient intake from
supplementation or fortified foods may lead to toxicities of some vitamins and minerals. Despite
how devastating this type of overconsumption can be when it occurs, the magnitude of the public
health concern from excess intake of vitamins and minerals is small in comparison to the concern
of the over consumption of calorie rich, nutrient poor food that is becoming common throughout
the world. This type of “malnutrition” is a contributor to chronic diseases such as
overweight/obesity, heart disease and stroke, type 2 diabetes, hypertension, and some cancers.
Many of the health problems of modern society could be minimized by simply addressing poor
diet choices. Cancer and heart disease account for over 40% of the total deaths in the US. Both
diseases have a strong relationship to dietary habits.

Figure 1: Percentage of total Deaths. (Kochane, K.D. et) al. (2019).

Globally, other high-income countries display a similar disease pattern as the United States
(WHO, Top Ten causes of death, 2020). The rate of chronic diseases, like heart disease and
stroke, are increasing in low-income countries as well, but the highest percentage of deaths are
still related to infectious disease such as respiratory and diarrheal disease and neonatal deaths.
This can be attributed to factors such as higher rates of undernutrition, lack of access to
healthcare, and limited sanitation services.

High income countries, 2019 Low income countries, 2019

Heart Disease Neonatal conditions (infections, low birth

weight, malaria, birth defects, and so on)

Cancers Lower Respiratory Disease

Alzheimer’s disease and other dementias Heart Disease

Stroke Stroke (cerebrovascular disease)

Chronic obstructive pulmonary disease Diarrheal Diseases

Lower Respiratory Disease Malaria

Kidney Disease Road Injury

Hypertensive disease Tuberculosis

Diabetes mellitus HIV/AIDS

Table 1: Leading causes of death globally in high income and low-income countries (listed from
highest to lowest (WHO, 2020).

3.6 Diet and Chronic Disease Prevention

The National Cancer Institute defines a chronic disease as “a disease or condition that lasts for 3
months or longer and may get worse over time” (National Cancer Institute, ND). They also
typically require ongoing medical care and limit daily activities.
Most often chronic conditions occur in adulthood, but with the increase in obesity in children,
these conditions do occur at younger ages as well.
Achieving a healthy eating pattern can have an immediate effect on our health as well as
minimize our risk for chronic disease and may even reduce health risks of future generations.
Several eating styles have been highlighted as examples of healthy eating patterns to prevent
chronic disease, such as the Mediterranean diet and the DASH diet. In reality, healthy meals
patterns can be constructed from local foods anywhere in the world. A healthy eating pattern is
flexible and takes into account individual calorie needs, personal preferences, age, gender, racial
and ethnic background, food and time availability, and budget. However, the basics of a healthy
diet will be similar. It is best to include healthy nutrient dense choices in each of the food groups
within a healthy eating pattern – vegetables, fruits, lean protein, low-fat dairy and grains –
especially whole grains, and oils (unsaturated fats). Healthy eating patterns limit calories from
added sugar and saturated fats and reduce sodium intake.

Nutrient Dense Foods (Choose Nutrient Dense Foods)

Incorporating all food groups, including different foods from each food group, will help ensure
variety and maximize your diet’s nutrient quality. Selecting foods that are high in nutrient
density (foods high in nutrients as compared to calories), helps you reach your nutrient
recommendations within a day without going over your calorie level. The amount you consume is
important as well. In many places, serving sizes have increased in the last few decades and it has
become easier to overeat. All foods can be enjoyed if the amounts are appropriate. Vegetables,
whole grains, legumes, lean meats and low-fat dairy products are all considered nutrient dense
foods (for example: whole grain bread, chicken, plain low-fat yogurt and dried beans).

Nutrient Dense Meal

Small changes to meals can make a big difference in a person’s overall nutrient and caloric
intake. The nutrient-density of most food items or meals can be influenced by how it is prepared
at home or by the manufacturer. For instance, sugar and fats added to foods at home or during
the manufacturing process will lower the nutrient-density. If yogurt has a significant amount of
sugar added to sweeten it, the nutrient density is decreased.
Highly processed foods typically have either nutrients removed or empty calories added, most
often as added sugars or fats. The processing of foods most often provides a nutritional benefit.
But when processing is taken to the point it has a significant impact on the nutrient quality of the
food it is referred to as ultra processing. For example, applesauce is produced from apples
through processing. When the applesauce is canned properly, it can be stored safely for a long
period of time and makes a nutritious food possibly during a season when apples may not grow.
But if excess sugar is included during the process and the apple is possibly turned into a
sweetened apple pie type product, it is referred to as ultra processed and the nutrient density of
the original apple has been significantly affected. Being able to identify ultra processed foods
and manage the amount of them in our diets is an important skill to have.

Saturated Fats (Limit)

Fats are an essential nutrient in the body. However, there are different types of fats. Saturated fats
generally come from animal products and are solid at room temperature. When calories are
adequate, it is recommended to decrease intake of saturated fats to less than 10% of our total
calories by replacing saturated fats with unsaturated fats (Dietary Guidelines for Americans,
2020). Unsaturated fats include both mono and poly unsaturated fats. Modifying dietary fats in
this manner improves bad LDL cholesterol (LDL= ow density lipoprotein) levels and increases
the good HDL cholesterol (HDL = High density Lipoprotein) levels, which decreases risk of heart
disease.

Types of Fats

Saturated Fats Monounsaturated Fats Polyunsaturated Fats

Butter, lard Olive, peanut, and canola Sunflower, corn, soybean,

oils and flaxseed oils

High—fat dairy Avocado Walnuts

Meat products such as Peanuts and peanut oil Flax seeds

sausage and bacon

Almonds, hazelnuts, and Fish

pecans

Pumpkin and sesame seeds

Table 2: Example of different types of fat.

Some tips for reducing saturated fat when dietary intake is high (WHO-
Healthy Diet, 2022):
 Steaming or boiling instead of frying in saturated fat
 Read food labels and learn to identify foods high in saturated fats
 Replace butter, lard, and ghee with oils such as olive oil, canola oil, corn oil or sunflower
oil
 Consuming low-fat, instead of full fat, dairy products
  Choose lean proteins and trimming visible fat from meat
 Replace some animal proteins with plant proteins such as beans, legumes and lentils

The recommendation to keep saturated fats to <10% of total Calories can be calculated for an
individual’s daily intake using a person’s calorie recommendation. See below for examples:

Example 1:
Sam’s estimated caloric recommendation is 2300 Calories/day. What is the limit of saturated fats
in his diet in Calories and grams?
 2300 Calories x 10% (.10) = 230 Calories/day
 230 Calories / 9 kcal/gram = 25.5 (rounds up to 26) so 26 grams/day

Example 2:
Ingrid’s estimated caloric recommendations is 1870 Calories/day. What is the limit of saturated
fats in her diet in Calories and grams?
 1870 Calories x 10% (.10) = 187 Calories/day
 187/ 9 kcal/gram = 20.7 (rounds up to 21) so 21 grams/day
If food labels are available, they can often be used to determine if foods are high in total fat or
saturated fats.

Using food labels to make choices about fat content

(British Heart Foundation, n.d.)

Low fat 3 grams or less per 100 grams of food

High fat 17.5 grams or more per 100 grams of food

Low saturated fat 1.5 grams or less per 100 grams of food

High saturated fat 5 grams or more per 100 grams of food

Table 3: Food label definitions

Added Sugars (Limit)
Sugars are considered added sugars when they are added to foods or drinks by the manufacturer
or consumer, as well as sugars naturally present in honey, syrups, and fruit drinks (WHO-Healthy
Diet, 2022). The recommendation for added sugars is less than 10% of total calories (Dietary
Guidelines for Americans, 2020). And intake of excess calories that could come from added
sugars can lead to undesired weight gain and obesity. It can also increase the risk of high blood
pressure, heart disease and dental carries.

Recommendations to decrease intake of added sugars include (WHO-

Healthy Diet, 2022):
 Limit the consumption of foods and drinks containing high amounts of sugar such as
soda, sugary snack foods, sweetened juices drinks, cakes, pies, candy, and doughnuts.
 Eat fresh fruits and vegetables as a snack instead of snacks that contain a high amount of
sugar.
The recommendation to keep added sugars to <10% of total Calories can be calculated from an
individual’s daily calorie recommendation. See below for examples:

Example 1:
Kai’s estimated caloric recommendation is 2820 Calories/day. What is the limit of added sugars
in his diet in Calories and grams?
 2820 Calories x 10% (.10) = 282 Calories/day
 282 Calories / 4 kcal/gram = 70.5 (rounds up to 71) so 71 grams/day
Examples 2:
Natalia’s estimated caloric recommendation is 2110 Calories/day. What is the limit of added
sugars in her diet in Calories and grams?
 2110 Calories x 10% (.10) = 211 Calories/day
 211 Calories / 4 kcal/gram = 52.75 (rounds up to 53) so 53 grams/day

Sodium/Processed foods (limit)

Sodium is an essential nutrient and required in the body to perform specific functions. However,
in many developed countries, sodium intake is high. When too much sodium is consumed, it
increases the risk of high blood pressure and heart disease. Sodium is a component of salt, which
is one of the biggest contributors to sodium in our diets. The recommendation is to consume less
than 5 grams of salt, which is about 2000 mg of sodium. Most of the sodium we eat comes from
consumed processed foods such as bacon, canned vegetables, ham (and other packaged meats),
cheese, salty snacks, soy sauce and broth.

Recommendations to decrease the amount of sodium include (WHO -

Healthy Diet, 2022):
 Limit the amount of ultra-processed foods consumed
 Limit the amount of salt and high sodium condiments such as soy sauce and fish sauce
  Remove the saltshakers from the table
 Limit consumption of salty snacks
 Choose low-sodium or reduced sodium options when available

Unsaturated Fats (increase)

Increasing intake of unsaturated fats is beneficial and can reduce health risks. Unsaturated fats are
typically from plants and are liquid at room temperature. Some of these types of fats are
protective against chronic diseases such as heart disease. Examples of plant sources of
unsaturated fats includes a variety of nuts and seeds, olives, and avocados.
An important animal source of unsaturated fats is fish. EPA and DHA are specific fats found in
fish that are recognized to have unique health promoting properties. They are part of a special
class of fats called “omega-3 fats”. They have been reported to promote cardiovascular health by
reducing inflammation, blood pressure and triglyceride levels (Innes and Calder, 2020). EPA and
DHA are also involved in fetal development and may be protective against the developmental
process of other disease such as Alzheimer’s.
Evidence supports the health benefits associated with these oils through the consumption of fatty
fish, but the benefits of fish oil supplementation remain unclear. Small amounts of the plant
omega-3 fatty acid alpha linolenic acid (ALA) can be converted to EPA and DHA when eaten by
humans. Sources of ALA include canola oil, walnuts, flaxseed and chia seeds.

Recommendations to help increase polyunsaturated oils are:

 Replace saturated fat intake with plant oils
 Have regular consumption of fatty fish
 Increase intake of nuts, seeds, and nut butters

Whole grains (increase)

There are many types of grains. Some of these grains (like wheat) are often milled and refined
into flour. In a whole grain, three major parts are present. The bran (outer shell that contains most
of the fiber), the germ (which contains most of the micronutrients or vitamins and minerals) and
the endosperm (which contains the starchy carbohydrates and the protein). In a refined grain, the
bran and germ are removed, leaving only the endosperm. This means that the outer bran shell is
broken, and parts of the grain are removed. When this occurs, the nutrients in the grain are
altered. It has been shown that whole grains are more supportive of good health than refined
grains. Whole grains have more vitamins, minerals, and fiber, all of which support the prevention
of chronic diseases such as heart disease, cancer, and diabetes.
Figure 2: Whole Grain

You can often identify whole grain products by the food labels. Labels may say 100% whole
grain, or list “whole” grain flour as the first ingredient in an ingredient’s list such as “whole
wheat flour." Grains provide energy and nutrients for our body. Most countries that have
published recommendations on grain intake encourage intake of whole grains to be at least one-
third of their intake up to more than half of their intake.

Ways to increase whole grains include:

 Read food labels and identify “whole” grains.
 Include one whole grain with each meal.
 Replace refined grains, such as white bread or pasta, with whole grain options.
 Use whole grains in soups, stews, salads or casseroles.
 Replace white rice with brown rice, barley or quinoa.
 Look for ways to include whole grains that are new to you into your diet.

Examples of whole grains

 Barley Brown Rice

Bulgur, or cracked wheat Red rice

Farro Popcorn/corn meal

Millet Whole-wheat flour

Quinoa Oatmeal

Teff Amaranth

Table 4: Whole grains

If you are selecting refined grains, look for ones marked “enriched” or “fortified” because that
will make sure they included some of the nutrients that were taken out when the grain was
refined. (References include the following: Whole Grains Council- Whole grain guidelines
worldwide (n.d.). Whole Grains: Heart Healthy Options’ British Heart Foundation (n.d.).)

Fruits/Vegetables (Increase)
Most people struggle to consume adequate amounts of fruit and vegetables. Fruits and vegetables
are low in calories and high in vitamins and minerals, which makes them nutrient dense. These
foods increase our intake of fiber and nutrients that are protective against chronic disease. In
general, a diet high in fruits, vegetables, nuts, seeds, and whole grains is associated with a
reduced risk of cardiovascular disease and many other diseases.

Tips to include more fruits and vegetables include (WHO -Healthy Diet,
2022):
 Eat a vegetable with meals.
 Eat fresh fruits and vegetables as snacks.
 Choose fruits and vegetables that are in season.
 Plant a garden if able and use fruits and vegetables that you grow.
 Eat a variety of fruits and vegetables.

3.7 Specific Dietary Strategies to Prevent Disease

Poor food choices can lead to the development of chronic diseases such as overweight obesity,
type 2 diabetes, heart disease and stroke, and cancer. We will briefly discuss these conditions,
how diet is related to these chronic diseases, and recommendations to prevent these conditions.
Keeping a healthy weight
Overweight and obesity are conditions that are defined by excess fat accumulation that may harm
health. Generally, Body Mass Index (BMI) is used to determine overweight and obesity. BMI
measures an individual’s weight for height. It is calculated as a person’s weight in kilograms
divided by their height in meters squared (kg/m2). For non-metric, you can take their weight in
pounds divided by height in inches squared and multiplied by 703. Both adults and children can
have BMI determined; however, children must have their BMI plotted on a growth chart to be
able to assess their BMI appropriately. Please see table below for assessment of weight status.
BMI and assessment will be discussed in this course later, but this table helps identify the
classification of BMI and BMI percentiles. Caution must be used when applying BMI to
individuals. It simply looks at the ratio of a person’s weight and height. A muscular person may
have a high BMI that can result in an inappropriate assessment of their health risks based on
BMI.

BMI Category Children & Adolescents Adults

(ages 2-19 years)
(BMI)
(BMI-for-Age Percentile)

Underweight Less than the 5th percentile Less than 18.5 kg/m2

Healthy Weight 5th to < 85th percentile 18.5-24.9 kg/m2

Overweight 85th to < 95th percentile 25.0-29.9 kg/m2

Obese Greater than or equal to the 30.0 kg/m2

95th percentile

Extreme Obesity - 40.0 kg/m2 or greater

Table 5: BMI Classification (CDC-Assessing Your Weight, 2022)

Overweight/Obesity Fast Facts

 Worldwide obesity has nearly tripled since 1975.
 Most of the world’s population live in countries where overweight and obesity kills more
people than underweight.
 39 million children under the age of 5 were overweight or obese in 2020.
 In most cases, obesity is preventable.
Overweight/Obesity Causes
The most common cause of obesity is an imbalance between calories consumed and calories
expended. When there are too many calories consumed or not enough calories used by the body,
weight gain occurs and can lead to overweight and obesity. Increased intake of in energy-dense
foods with a high amount of fat and sugar and an increase in inactivity and sedentary lifestyles
have been key factors in the global increase in obesity.

Obesogenic Diet (leads to obesity)

● Caloric intake exceeding needs ● High fat intake

● Unstructured eating ● Sugar-sweetened beverage

consumption

● Frequent fast-food consumption ● Energy-dense, nutrient poor food

choices

Table 6: Practices that can contribute to obesity

Overweight/Obesity Concerns
An elevated BMI puts individuals at higher risk of other chronic (noncommunicable) diseases
such as heart disease, diabetes, osteoarthritis and certain cancers. Children have additional risks
such as breathing issues, premature death and disability in adulthood, as well as development of
chronic disease at earlier ages.

Overweight/Obesity Recommendations
In most instances, overweight and obesity are preventable. Small changes in diet and physical
activity can impact the health of an individual and can increase health.

Recommendations to prevent overweight/obesity

Limit energy intake from total fats and sugar

Increase intake of fruit and vegetables

Increase intake of legumes, whole grains and nuts

Participate in regular physical activity

60 minutes/day for children
150 minutes/week for adults
Table 7: Obesity prevention recommendations

References for Obesity

 World Health Organization (2021) - Obesity and overweight.
 Brown J.E et al (2020).

Heart Disease/Stroke
Heart disease is a group of disorders of the heart and blood vessels. There are several diseases
that fall under the term heart disease. A detailed description of the different types of heart disease
will not be included in this text, but generally they are associated with the vessels that are
affected. For example, stroke and heart attacks are the result of a blockage of a vessel leading to
the brain or heart respectively. The blockage of a vessel is typically referred to as plaque. Plaque
is the collection of fatty substances and other cellular debris under the lining of the blood vessels
that if left unchecked can grow to the point it will restrict blood flow and increase the workload
of the heart.

Heart Disease/Stroke Fast Facts

● Heart diseases are the number one cause of death worldwide.
● Most cardiovascular diseases can be prevented by making behavior changes such as
stopping tobacco use, modifying unhealthy diet patterns and obesity, physical activity patterns
and harmful alcohol use.
● Early detection is important so that treatment with diet and medication can begin.

Heart Disease/Stroke Causes

Several of the risk factors for heart disease and stroke are modifiable behaviors. These include
unhealthy dietary intake, low physical activity, and tobacco and harmful alcohol intake.
Modifying diet and lifestyle will have a positive impact on reducing risk of heart disease. Dietary
choices that may increase risk of heart disease include in the table below.
Other, non-modifiable factors include poverty, stress, genetics as well as urbanization of
developing countries and older age.

Heart Disease/Stroke Recommendations

Often there are no outward symptoms of heart disease. Unfortunately, that means that a heart
attack or a stroke may be the first sign of disease. For this reason, it is important to monitor both
blood pressure and blood cholesterol levels.

Atherogenic Diet (Associated with heart disease)

High saturated fat (>10% of total calories) Excess alcohol intake

Trans-fatty acid intake High sodium intake

Low fruit and vegetable intake Low potassium intake

 Low antioxidants Low intake of milk and dairy foods

Low intake of whole grains High waist circumference (men > 40 inches,
women > 35 inches)

Table 8: Practices associated with heart disease

Blood pressure
High blood pressure can promote plaque development as well as be an indication of the existence
of plaques in the blood vessels.
For those that can have their blood pressure taken, it measures the pressure of the blood vessels at
work and at rest. The top number is referred to as systolic pressure and the bottom number is
referred to diastolic pressure. An example of a blood pressure would be 118/78, which is read
“118 over 78”. This would be considered a healthy blood pressure. See table below to assess
blood pressure.

Blood Pressure Systolic Diastolic

Category
(mm Hg) (mm Hg)

Normal Less than 120 AND Less than 80

Elevated 120-129 AND Less than 80

High Blood 130-139 OR 80-89

Pressure
(hypertension)
Stage 1

High Blood 140 or Higher OR 90 or higher

Pressure
(hypertension)
Stage 2

Table 9: Blood pressure categories (American Heart Association, 2023)

Blood Cholesterol
An in-depth discussion of blood cholesterol is beyond the scope of this text. In brief, fat and
cholesterol are transported around the body in the blood. Fat and cholesterol are needed by the
cells for a variety of essential functions. They are often transported inside carriers to help move
efficiently in the blood. Two important carriers are low density lipoproteins (LDL) and high-
density lipoproteins (HDL). Both carry out very important functions, but when levels become
imbalanced, they can contribute to the development of heart disease. The table below lists the
basic role of these two carriers as well as normal blood levels. Normal levels for total cholesterol
and triglyceride are also listed.

Blood Lipid Category Importance Normal Level

Low Density Lipoprotein Delivers cholesterol and fat Optimal if below 100 mg/dl
(LDL) to cells. It serves a good
function but if to high it can
lead heart disease.

High Density Lipoprotein Picks up cholesterol from Above 40 mg/dl

(HDL) body cells. High levels are
associated with good
cardiovascular health.

Total Cholesterol High levels are associated Less than 200 mg/dl
with cardiovascular disease.

Triglycerides High levels are associated Less than 150 mg/dl

with cardiovascular disease.

Table 10: Recommended blood cholesterol ranges

Recommendations to help reduce the risk of heart disease, strokes and heart attacks are aimed at
preventing and managing high blood pressure and cholesterol levels.

Recommendations to prevent heart disease

Reduce salt intake (less than 5 g/day)

Increase intake of fruit and vegetables

Avoid use of tobacco

Replace saturated fat intake with unsaturated fats, especially polyunsaturated fats

Participate in regular physical activity

60 minutes/day for children
150 minutes/week for adults

Table 11: Practices to reduce risk of heart disease

Heart Disease/Stroke Concerns
Individuals that live in low- and middle-income countries that may not have access to primary
care, or regular visits with a doctor or health care worker are of particular concern. Early
detection and behavior modification is important to prevent major events such as a stroke or heart
attack.
Symptoms to be aware of for heart attack include pain or discomfort in the chest and/pain or
discomfort in the arms, the left shoulder, elbows, jaw or back.
Symptoms of stroke include sudden weakness of the face, arm, or leg, usually just on one side of
the body. Other symptoms could include severe headache with an unknown cause, difficulty
walking or dizziness, blurred vision in one or both eyes, difficulty speaking or understanding
speech. Immediate medical care should be sought for people experiencing these symptoms listed
above.

References For Heart Disease/Stroke

 World Health Organization- HTN (n.d.)
 World Health Organization - Cardiovascular Disease (n.d.)
 British Heart Foundation (n.d.)- 10 Tips for understanding food labels.
 Brown J.E. et al. (2020)
 John Hopkins Medicine-Lipid Panel (n.d.)
 American Heart Association – Understanding Blood Pressure Readings (2023)

Type 2 Diabetes
Type 2 diabetes is a chronic disease that results from the body’s inability to use insulin
effectively. Insulin is a hormone that helps the body manage blood sugar. When the body is
unable to use blood sugar correctly, the blood sugar becomes elevated. Type 2 diabetes is related
to excess body weight and being physically inactive.

Type 2 Diabetes Fast Facts

 Diabetes is a major cause of heart attacks and stroke, blindness, kidney failure and lower
limb amputation.
 Uncontrolled diabetes over a period of time can lead to damage of the nerves and blood
vessels leading to neuropathy.
 In 2019 alone, approximately 2 million deaths were attributed to diabetes and diabetes
related kidney disease.

Type 2 Diabetes Causes

The direct cause of type 2 diabetes is unknown, but the most common links are that of poor
dietary intake, physical inactivity and excess body weight, especially extra weight in the
abdomen. Genetics also plays a role in the development of this chronic disease. Specific ethnic
and racial groups are at higher generic risk. Dietary and lifestyle choices that increase risk of
type 2 diabetes include those listed for both obesity and heart disease.
 Racial/ethnic Groups at Higher Risk for Type 2 diabetes

African Americans Asian Americans

Alaska Natives Hispanics/Latinos

American Indians Native Hawaiians

Pacific Islanders

Table 12: Groups at increased risk for type 2 diabetes

Type 2 Diabetes Concerns

This chronic disease, if uncontrolled, can damage several of the body’s organs and systems
including the heart, kidneys, eyes, blood vessels and nerves. Individuals with type 2 diabetes are
at increased risk of developing other chronic diseases such as heart attacks and strokes. Nerve
damage resulting in lower limb amputations could result as well as blindness due to damaged
blood vessels in the retina. Type 2 diabetes is one of the main causes of kidney damage and
individuals with type 2 diabetes also have poorer outcomes with other illnesses such as COVID-
19.

Type 2 Diabetes Recommendations

Like other chronic diseases that result from poor lifestyle factors, type 2 diabetes prevention
includes the same general recommendations for prevention.

Recommendations to prevent type 2 diabetes

Achieve and maintain a healthy weight

Eat a healthy diet

Monitor intake of added sugars and saturated fats

Avoid use of tobacco

Participate in regular physical activity

At least 30 minutes most days to help blood glucose management
60 minutes/day for children

Table 13: Practices that can reduce risk of type 2 diabetes

Common blood tests used to test for type 2 diabetes include fasting blood glucose and
hemoglobin A1C. In the table below, a brief description of the test and normal values are listed.
Levels above normal is an indication of prediabetes or diabetes.

Test Importance Normal Level

Fasting Glucose Measures blood sugar levels 99 mg/dl or lower

after an overnight fast

A1C Measures the average blood Below 5.7%

sugar level over the past 2-3
months

Table 14: Test for Diabetes (Center for Disease Control – Diabetes Tests, 2023)

Sources for Diabetes

 World Health Organization- Diabetes (2023)
 National Institute of Health (2016) Symptoms and Causes of Diabetes
 National Institute of Diabetes and Digestive and Kidney Disease
 Brown J.E. et al. (2020)
 Center for Disease Control- Diabetes Tests (2023)

Cancer
Cancer is caused by uncontrolled division of some body cells that can then spread to other parts
of the body (NCI, 2021). Cancer can start almost anywhere in the body. While some cancers have
a clear genetic connection, there are other cancers that are linked strongly to diet. Types of cancer
that have known relationships to diet include breast, colorectal, endometrial, stomach and mouth
cancers.

Cancer Fast Facts

 Cancer is a leading cause of death worldwide. Approximately 10 million deaths were
attributed to be caused by cancer in 2020.
 The most common types of cancer are breast, lung, colon, rectum, and prostate.
 Approximately 1/3 of deaths from cancer are related to modifiable lifestyle behaviors
such as tobacco use, excess weight, alcohol intake, low fruit and vegetables consumption,
and physical inactivity.
Cancer Causes
There are several causes of cancer. Interactions between a person’s genetic factors (which are not
modifiable) and three groups of environmental factors result in cancer. The three different
environmental groups include:
 Biological carcinogens such as infections from viruses and bacteria
 Chemical carcinogens such as tobacco smoke and alcohol
 Physical carcinogens such as ultraviolet light
A dietary pattern that may be linked to the development of cancer have the characteristics listed
in table 15.

Carcinogenic Diet (leads to cancer)

Low fruit and vegetable intake Nitrosamines, burnt and charred foods

Low intake of antioxidants High intakes of pickled and fermented food

Low intake of whole grains and fiber Alcohol consumption

High dietary fat intake High-animal-food, low plant-food intake

Table 15: Diet characteristics that may increase risk of cancer

The incidence of cancer increases with age.

Cancer Concerns
It is estimated that the percentage of cancers that could be prevented by modifying dietary intake
and other unhealthy lifestyle choices is about 30-50%. Cancer accounts for a large loss of life and
can be prevented if detected early and treated.

Cancer Recommendations
Among the recommendations such as avoiding ultraviolet radiation exposure, getting vaccinated
against viruses, and reducing exposure to chemical carcinogens, there are several
recommendations that include modifying nutrition and activity choices.

Recommendations to prevent cancer

Avoid use of tobacco

 Maintain a healthy weight

Increase intake of fruits and vegetables

Consume a plant-based diet including lean proteins from plants such as beans and
legumes

Reduce intake of processed foods and red meat

Avoid or reduce intake of alcohol

Participate in regular physical activity

60 minutes/day for children
150 minutes/week for adults

Table 16: Practices that may reduce cancer risk

References for Cancer

 World Health Organization- Cancer (2022)
 American Cancer Society (2020)
 Effects of Diet and Physical Activity on Certain Types of Cancer
 National Cancer Institute (2021)
 Risk Factors for Cancer; Brown J.E. et al. (2020)
3.8 Double burden of malnutrition

Although undernutrition continues to be an issue worldwide, a noticeable number of

underdeveloped countries are progressing economically, socially, and culturally. As a country
becomes more urban or developed, access to education increases which allows for improved
employment opportunities. As a result, income increases, but the time available to prepare
traditional foods decreases (UNICEF, 2016). Urbanization within developing countries yields a
greater availability of food in the country. Access to a variety of foods results in a more
westernized diet which includes higher fat, added sugars, meat, milk and overall calories than
typically consumed in the traditional diet (Drake et al., 2010). The loss of the traditional lifestyle
results in an increased consumption of ultra-processed foods. Ultra-processed foods are foods
that contain many added ingredients (such as fat and sugar) and have gone through multiple
refinement processes. Examples include foods such as soda, some fast foods, candy and
packaged foods like chips and cookies.
The shift to a westernized diet composition in developing countries is leading to the development
of overnutrition in previously undernourished countries. Thus, countries that were mainly
concerned about undernutrition and infectious disease are now also faced with the burden of
chronic diseases caused by this transition to an industrial lifestyle, adoption of a Western diet
high in ultra-processed foods and decreased physical activity (Popkin, 2002).
This coexistence of overnutrition and undernutrition in the same populations has led to the
coining of the phrase the double burden of malnutrition (Uusitalo, 2003). The term also
includes other situations where the presence of over and undernutrition is combined. For
example, in a single household a child may be vitamin A deficient, but the parents are obese.
Even a single individual can display the double burden of malnutrition. For example, a person
may be iron deficient but also be overweight.
The urbanization of developing countries has some positive results, such as a decrease in
infectious diseases and nutrient deficiencies, and an increase in overall lifespan. However, when a
country does not recognize the risks of overnutrition, or correcting undernutrition with increased
consumption of ultra-processed foods, the battle with chronic disease begins. This rapidly
increasing double burden among developing countries emphasizes the importance of educating
about risks of both undernutrition and overnutrition (Jaacks, 2011).
The increased availability of cheap, ultra-processed foods in developing countries is a central
factor to the global growing presence of the double burden of malnutrition. A focus on eating a
variety of locally available healthy foods is critical to curb the declining global health trend and
to minimize the presence of the double burden of malnutrition.
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Brown, J. E., Lechtenberg, E., Murtaugh, M. A., Splett, P. L., Strant, J., Wong, R., Browser, E.
K., Leonberg, B. L., & Sahyoun, N. R. (2020). Nutrition through the lifecycle (7th ed.). Cengage.
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Centers for Disease Control and Prevention. (2022). Micronutrient facts.
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Cleveland Clinic. (2022). Vitamin D deficiency.
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Images
 Infant being screened for undernutrition (2 pictures): Taken by BYUI faculty- Jay Keller
 Mango Tree: Taken by BYUI faculty- Jay Keller
 Lucky Fish: ‘LDSC/ CARE Benin - Protein for People’ (Latter-Day Saints
Charities/ CARE Benin – Protein for People project) (Special permission was granted
by “Care” for use of these pictures, Jay Keller has the copyright documents from Care)
 Picture of a Salmon: Taken by BYUI faculty- Jay Keller
 Starving man: Wikimedia Commons-File: Starved Vietnamese man, 1966.JPEG|thumb|
Starved Vietnamese man, 1966
 Fish in market: Taken by BYUI faculty- Jay Keller

Figures
 Figure 1: Created at BYUI
 Figure 2: Created at BYUI
 Figure 3: Created at BYUI

Images
 Nutrient dense meal: Taken by BYUI faculty – Dixie Jamison
 KFC restaurant: Taken by BYUI faculty – Jay Keller
Read this online at https://books.byui.edu/nutr_110_readings/chapter_3_food_scarcity