NUTRITION AND

FOOD SAFETY
IN PUBLIC HEALTH

Edited by
JANA BABJAKOVÁ
STANISLAV SEKRETÁR

First Edition

Comenius University in Bratislava

Slovakia 2015
Moderné vzdelávanie pre vedomostnú spoločnosť/Projekt je spolufinancovaný zo zdrojov EÚ

BABJAKOVÁ, J., SEKRETÁR, S. (EDs.)

NUTRITION AND FOOD SAFETY

IN PUBLIC HEALTH
First Edition

Comenius University in Bratislava, Slovakia, 2015, 136 pages.

© Jana Babjaková, MD, PhD, MPH

Assoc. prof. Stanislav Sekretár, Ing., PhD
2015

Reviewers
Prof. Ľudmila Ševčíková, MD, PhD
Prof. Ľubomír Valík, Ing., PhD

Proofreaders
Janka Bábelová, Ing., PhD
Anna Cibulková Ing.

ISBN 978-80-223-3932-2

Printed by KO& KA in Bratislava 2015

 This textbook was prepared and published within the project “MPH curriculum
development at Comenius University in Bratislava in English language“, ITMS code:
26140230009, funded by European Social Fund - Operational Programme Education
(ESF – OPE). Recipient of the ESF: Comenius University in Bratislava, Faculty of Medicine.
Head of the project: Prof. Ľudmila Ševčíková, MD, PhD

This textbook is from the series of textbooks listed below. The aim of the textbooks,
funded by ESF-OPE, is to provide students of the study program Master of Public Health
(MPH) at ComeniusUniversity in Bratislava with information and knowledge of public
health issues.

Biology and Genetics for Public Health, Pharmacology in Public Health

Basics of Clinical Microbiology and Immunology for MPH Students
Environmental Health - Hygiene
Occupational Health and Toxicology
Epidemiologyfor Study of Public Health Vol.1.
Epidemiology for Study of Public Health Vol.2.
Introductory Biostatistics
Social Medicine
Health Promotion andHealth Communication
Public Health Ethics - Selected Issues
An Introduction to Public Health Law
Healthcare Management
Information Technologies in Medicine, Medical Information Systems and eHealth
Management of Information Systems Projects in Transition to Knowledge
Management
 Authors

Jana Babjaková, MD, PhD, MPH

Institute of Hygiene
Faculty of Medicine in Bratislava, Comenius University in Bratislava

Assoc. prof. Stanislav Sekretár, Ing., PhD

Institute of Hygiene
Faculty of Medicine in Bratislava, Comenius University in Bratislava
 CONTENTS

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

NUTRITION

1 INTRODUCTION TO HUMAN NUTRITION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

2 TYPES OF STUDIES IN NUTRITION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

3 MEASURING OF FOOD INTAKE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

4 NUTRITIONAL VALUE OF FOOD AND NUTRITIONAL QUALITY

OF FOOD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.1 Proteins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4.2 Carbohydrates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.3 Fats/Lipids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4.4 Minerals and Trace Elements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
4.5 Vitamins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
5 ENERGY NEEDS, ENERGY BALANCE, PHYSICAL ACTIVITY. . . . . . . . . . . . . 37
5.1 Energy Metabolism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
5.2 Energy Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
5.3 Physical Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
6 HEALTHY DIET. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
6.1 Guidelines for Healthy Diet - the Pyramid/the Plate. . . . . . . . . . . . . . . . . . . . . . . . . 48
6.2 Recommended Dietary Allowances and Dietary Reference Intakes . . . . . . . . . . 50
6.3 General Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
6.4 Diet Quality Scores, Eating Indexes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
7 SPECIAL NUTRITIONAL NEEDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
7.1 Nutrition of Pregnant and Lactating Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
7.2 Nutrition of Infants and Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
7.3 Nutrition in Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
8 ALTERNATIVE NUTRITION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

9 DISEASES RELATED TO DIET AND THEIR PREVENTION, EATING

DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
9.1 Diseases Related to Diet and their Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
9.2 Eating Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
10 FUNCTIONAL FOODS WITH POTENTIAL HEALTH BENEFIT. . . . . . . . . . . . 76

5
11 SYSTEMS BIOLOGY APPROACHES TO NUTRITION (OMICS),
NUTRIGENOMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

12 PUBLIC HEALTH NUTRITION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

13 OVERVIEW OF IMPORTANT CURRENT DOCUMENTS . . . . . . . . . . . . . . . . . . 86

FOOD SAFETY

14 INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
15 FOOD SAFETY HAZARDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
15.1 Biological Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
15.1.1 Bacterial Food Safety Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
15.1.2 Viruses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
15.1.3 Parasites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
15.1.4 Protozoans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
15.1.5 Other Types of Parasite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
15.1.6 Prions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
15.1.7 The Most Frequent Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
15.1.8 Factors Responsible for the Prevalence of Food-borne Diseases. . . . . . 100
15.1.9 Prevention and Control of the Biological Contamination of Food . . . 100
15.2 Chemical Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
15.2.1 Naturally Occurring Toxins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
15.2.2 Fungal Toxins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
15.2.3 Seafood Toxins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
15.2.4 Biogenic Amines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
15.2.5 Environmental Contaminants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
15.2.6 Toxic Metals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
15.2.7 Processing Contaminants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
15.2.8 Food Contact Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
15.2.9 Food Additives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
15.2.10 Pesticide Residues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
15.2.11 Veterinary Drugs Residues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
15.2.12 Prevention and Control of the Chemical Contamination of Food . . . 125
15.3 Physical Hazards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
15.3.1 Physical Objects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
15.3.2 Chemicals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
15.3.3 Biological Objects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
16 FOOD SAFETY MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
16.1 HACCP and Food Safety Management Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
16.2 Food Safety Legislation in the EU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
16.3 Labeling and Information for Consumers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
16.4 Institutions Involved in Food Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
17 FOOD QUALITY ASSURANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
17.1 The Golden Rules of Food Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

6
 PREFACE

Why is this topic part of your MPH study? Everyone needs to eat. We are what we
eat and what we do. Someone who is educated in the field of public health should have
at least a basic knowledge about nutrition based on valuable supporting scientific
evidence (EBN- evidence based nutrition) and be able to advise others regarding
individual needs.
Nutrition belongs among the most important environmental factors that affect our
overall health status. Research has provided evidence that diets rich in nutrient dense
foods can help prevent diseases. To understand nutrition and to make anything out
of it can be more difficult than it seems at first sight. Nutrition topics and advice are
often controversial because the science is complicated and the final evidence can be
sometimes rather inconsistent.
Many diseases have long latent periods; they may result from cumulative exposure
during many years. Different potential determinants may act alone or in combination
and there are different interactions among them. Multiple causes of majority of diseases
potentially include not only diet, but also genetic, occupational, psychosocial factors,
together with level of physical activity, behavioural characteristics, and many other
influences.
We must also consider that it is very difficult to correctly analyse and interpret the
results of scientific studies in a definitive manner. The collective body of research on
the topic has been hampered by the lack of consistency in the methods used. Prior
knowledge of nutrition science might be reviewed under new evidence in the future
and what now belongs or does not belong to evidence-based medicine may be revised
after a couple of years.
If we try to find something in common in primary prevention by healthy diet,
different points of consensus are well-known and long-lasting in general for healthy
population (not suffering from different kinds of diseases like allergies, sensitivities,
intolerances and other serious diseases, or providing excessive vigorous physical
activity). Diverse dietary guidelines and recommendations promote diets that are
abundant in beneficial foods with more protective nutrients. They all recommend
quite simple, basic general principles of good diets as a part of healthy lifestyle –
main­ taining appropriate calories balance during each stage of life (childhood,
adolescence, adulthood, pregnancy and breastfeeding, and older age) – usually
it means lower calories intake (eating less), consuming lots of vegetables instead
of other higher energy-dense and lower nutritional-dense items (foods higher in
calories and containing fewer nutrients), in a pleasant atmosphere, avoiding “junk
food” (such as soft drinks, candies), reducing sedentary life style – be more active
and do plenty of exercise (moving more to prevent and/or reduce overweight and
obesity), managing stress and getting more sleep. What should we specifically eat to
be healthy? The keys to good nutrition are balance, variety and moderation. Increased
attention in dietary research and guidance has been focused on the whole dietary
patterns rather than particular nutrients. Our diet should be mainly plant-based
consisting of simple whole foods, it means particularly high consumption of a variety

7
of colourful vegetables, fruits (preferably freshly produced), approprate intake of
whole grains, legumes, nuts and seeds, also containing more sea items, and different
herbs. There are different recommendations regarding to amount of milk and dairy
products and meats (definitely less red meat and omit processed meat). Generally,
we should decrease amount of saturated fat, try to avoid trans-fat, limit simple sugars
and refined saccharides, reduce salt, mostly by restricting highly processed foods as
much as possible. In addition, moderation of portions can lead to better health. A big
problem in our diets includes enormous amount of calorie intake, much higher than
we need with our predominantly sedentary life style. Total calorie restriction in our
diet is recommended for the majority of our population in this part of world.
As humans we have a very similar genetic makeup, however, there are significant
interpersonal differences among us, and the specific dietary advice can vary from
person to person. Most likely, development of individual personalized medicine and
personalized nutrition in the future could give the answer to many questions, though a
great number of related ethical, economical, and other issues and consequences must
be taken into account.
It is important for individuals to try to change their behaviours and it is also
important for policymakers to help alleviate food insecurity, help create healthier food
environments, and take other steps to promote healthy eating and physical activity.
The second chapter of this textbook provides a comprehensive overview of what
we know about food safety hazards and control measures. We have to recognize that
microbiological and chemical hazards can enter the food supply at any point in the
system along the pathway from the farm through processing, transport, storage, and
retail sale. Four basic food safety principles (Clean, Separate, Cook, and Chill) work
together to reduce the risk of food-borne illnesses. All who share responsibility for food
safety should participate in continuous learning, and place first priority on protecting
the safety of food every day. That will be good for the food system – and for the
consumers it serves.

8
 NUTRITION

Jana Babjaková
Institute of Hygiene, Faculty of Medicine, Comenius University in Bratislava

1 INTRODUCTION TO HUMAN
NUTRITION

Nutrition plays an essential role in maintaining health.

Human nutrition is a complex, multifaceted scientific domain indicating how
substances in foods provide essential nourishment for the maintenance of life. Good
nutrition is the key element of human well-being; even before birth and throughout
infancy good nutrition allows brain functioning to evolve without impairment and the
immune system to develop more robustly.
Malnutrition, in all its forms, including undernutrition, micronutrient
defi­cien­cies, overweight and obesity, not only affects people’s health and well-
being by impacting negatively on human physical and cognitive development,
compromising the immune system, increasing susceptibility to communicable and
non-communicable diseases, restricting the attainment of human potential and
reducing productivity, but also poses a high burden in the form of negative social and
economic consequences to individuals, families, communities, and states.
Many of those who are under- or overweight are also micronutrient-deficient.
Whereas in the past the burden of overnutrition was highest in developed or rich
countries, the burden is now spreading to and increasing in poor or developing
countries. This trend is now referred to as the double burden of disease. There is
a complex interplay between poverty, food and nutrition insecurity, malnutrition and
infection that becomes a downward spiral, with infection adding to the metabolic
demands for nutrition, while reducing the capacity to work and earn the money
required to address the infection, which further reduces dietary intake. Thus a vicious
cycle continues. These complex interactions spiral throughout the life course, from
infants to children, to young women having babies to babies. All this is exacerbated by
basic and underlying causes, such as inequality, poverty, conflicts, and natural disasters.
Despite these enormous challenges, there have been improvements in some countries,
but these have been largely offset by setbacks elsewhere. It was estimated that, during
the last decade of the twentieth century, 826 million people were undernourished
– 792 million in developing countries and 34 million in developed countries. In

9
developing countries, more than 199 million children under the age of 5 years suffer
from acute or chronic protein and energy deficiencies. An estimated 3.5–5 billion
people are iron deficient, 2.2 billion iodine deficient, and 140–250 million vitamin
A deficient. This has led to several global initiatives and commitments, spearheaded
by a number of the United Nations organizations, to reduce global undernutrition,
food insecurity, hunger, starvation, and micronutrient deficiencies. Some progress
has been made in reducing these numbers, but the problems are far from solved.
For young children, good nutrition status averts death and equips the body to grow
and develop to its full potential. Over the course of the human lifespan, it leads to
more effective learning at school, better-nourished mothers who give birth to better-
nourished children and adults who are more likely to be productive and earn higher
wages. In their middle age, it gives people metabolisms that are better prepared to ward
off the diseases associated with changes in diet and physical activity. Without good
nutrition, people’s lives and livelihoods are built on quicksand.
We have known for many years that certain foods promote good health. However,
the latest nutritional science shows that there is not a single “healthy diet.” Instead,
there are many patterns of eating around the world that sustain good health. A healthy
eating pattern also includes enough energy (calories) to fuel the body, but not so much
as to cause weight gain.
Over the course of evolution, human beings (and their primate predecessors)
adapted progressively to a wide range of naturally occurring foods, but the types of
foods and the mix of nutrients (in terms of carbohydrates, fats and proteins) remained
relatively constant throughout the ages. Food supply was often precarious, and
starvation frequent.
Earlier populations had no choice; they only consumed foods that were produced
locally. Their availability was often extremely seasonal. This resulted in diets that
were highly variable across the globe; for example, in some Arctic climates, almost no
carbohydrates, fruits, or vegetables were consumed, and diets consisted mainly of fat
and protein from animal sources. In other regions, populations subsisted on primarily
vegetarian diets with the large majority of calories from carbohydrate sources. The
fact that humans could survive and reproduce with such varied dietary patterns
is a testimony to the adaptability of human biology. Yet, disease rates and overall
mortality varied dramatically among these various populations, and formal studies of
these relationships provided early clues about the importance of diet in human health
and disease.
In the last few decades, enormous changes have occurred in the diets of most
populations. These changes were due to a combination of increased wealth of some groups,
new processing and preservation technologies, and greatly expanded transportation
infrastructures. Collectively, these changes have allowed foods to be transported across
and among continents and to be available virtually the whole year (globalisation).
At first, these changes globally were described as the “westernization” of diets
because of increases in meat, dairy products, and processed foods. However, many of
the more recent changes are not necessarily toward the diets of western countries,
but instead emphasize refined starches, sugar and sugary beverages, and partially
hydrogenated vegetable fats. These patterns, which have been described as “industrial
diets”, are usually the cheapest source of calories, and they have permeated poor
populations of both rural and urban countries around the world.
The recent changes in diets, along with changes in physical activity and tobacco use,
have profoundly affected rates of disease, sometimes positively but often adversely. On
the one hand, we have seen declines in rates of coronary heart disease (CHD) in
many western countries thanks to positive diet changings (e.g. Finland - North Karelia

10
Project). On the other hand, e.g. in Japan, formerly a country with very low rates of
colon cancer, rates of this malignancy have increased greatly and now have surpassed
those of the United States.
Most importantly, at present an epidemic of obesity and diabetes has affected
almost all the world’s populations. The majority of deaths due to coronary heart
disease, stroke, diabetes, some kinds of cancer, and other non-communicable diseases
are largely preventable by healthy diets in combination with regular physical
activity, stress relieving, proper sleeping pattern, and avoidance of tobacco
and alternative tobacco products use.

References
Caballero B. Encyclopaedia of Food Sciences and Nutrition. London: Elsevier, Academic Press,
2003: 6406. ISBN: 978-0-12-227055-0.
Dietary Guidelines for Americans 2015. Health.gov. The U.S. Department of Health and
Human Services (HHS) and the U.S. Department of Agriculture (USDA).Home of the Office
of Disease Prevention and Health Promotion Available online: http://www.health.gov/
dietaryguidelines/2015.asp.
Erdman JW, Macdonald IA, Zeisel SH (Edited by). Present Knowledge in Nutrition, 10th edition.
International Life Sciences Institute. Published by John Wiley & Sons, Inc, 2012: 1330. ISBN
978-0-470-95917-6.
Gibney MJ, Lanham-New SA, Cassidy A, Vorster HH (edited on behalf of the Nutrition Society).
Introduction to Human Nutrition. John Wiley & Sons Ltd, A John Wiley & Sons, Ltd. Publication,
2nd edition, 2009: 386. ISBN 978-1-4051-6807-6.
Global Nutrition Report 2014: Actions and Accountability to Accelerate the World’s Progress on
Nutrition. International Food Policy Research Institute. 2014. Washington, DC Available online:
http://globalnutritionreport.org/, http://ebrary.ifpri.org/utils/getfile/collection/p15738­coll2/
id/128484/filename/128695.pdf
Ševčíková Ľ, et al. Hygiene/Environmental Medicine, Bratislava: Comenius University, 2011: 332,
ISBN 978-80-223-2900-2.
Ševčíková Ľ, et al. Hygiena. Bratislava: Comenius University, 2006: 325. ISBN 80-223-2103 6.
Willett WC. Public Health Benefits of Preventive. Nutrition. In: Preventive Nutrition, 4th edition,
Bendich A, Deckelbaum RJ. (Edt). Humana Press, a part of Springer Science+Business Media,
2010: 862, ISBN 978-1-60327-541-5 e-ISBN 978-1-60327-542-2.

11
 2 TYPES OF STUDIES IN NUTRITION

Modern nutritional research is aiming at health promotion and disease prevention

and on performance improvement. It is generally believed but very difficult to prove
that diet plays a role as a risk factor of various diseases.
Many different research designs are available for investigating nutrition-
related questions. Each one has strengths and weaknesses. The traditional methods
of nutritionists (a basic biochemistry, animal experiments, small human metabolic
studies) form the basis of dietary recommendations and contribute substantially, but
do not address directly the relation between diet and occurrence of major diseases of
our civilization. Methods using cell cultures can have high throughput and illuminate
detailed cellular and molecular relationships, but integrating such findings with the
biology of intact humans is problematic. Experiments on animals are often used for
nutrition-related research and can help as a method to study detailed pathways.
However, it is recognized that physiology and pathophysiology in animal models only
approximates that in humans.
Research studies involving human subjects require prior approval from an ethics
committee. One universal rule is “informed consent”. This safeguard is designed to
protect the rights of subjects. The purpose of the study must be explained as well as any
potential hazards. This must be done in a way that the person is able to understand it
properly. Subjects must be free to refuse to participate without feeling pressured and
must be free to withdraw from the study at any time without penalty.
The study of chronic disease in humans has required epidemiologic approaches.
According to study design it is possible to use both types of studies – observational
studies (ecological = population-based study, cross-sectional study, case-control study,
cohort study - prospective, longitudinal, panel studies) and experimental studies
(= inter­ventional studies with possibility of establishing causality).
While the formal study of diet and health is only a few decades old, the importance
of diet to maintain health was already known to the ancient Greeks. As Hippocrates
said: “If we could give every individual the right amount of nourishment and exercise,
not too little and not too much, we would have found the safest way to health.’’
The first population-based studies collecting information on nutrition were conducted
in the 20th century. Diet and physical activity are one of the most difficult exposures to
assess in observational research and are plagued by considerable measurement error.
Over the past couple of decades, a large number of observational studies have
attempted to elucidate the role of diet in health and disease.
Initially, investigations compared dietary intakes and disease rates among popu­
lations in various countries, which were termed ecological studies. These analyses
highlighted the large differences in disease rates worldwide and provided many
hypotheses; however, such studies are limited as many other factors besides diet
vary across cultures and the data are inherently aggregated. The next generation of
studies was primarily case-control investigations, which mainly examined dietary
factors retrospectively in relation to risk of cancer and other diseases. Unfortunately,

12
case-control studies of diet are generally problematic since participants are asked to
remember their diet prior to a particular time in the past, and individuals are asked
to recall their diet prior to the date of their diagnosis. Now, large prospective
studies of many thousands of persons are beginning to provide data based on both
biochemical indicators of diet and dietary questionnaires that have been rigorously
validated. Prospective studies are less subject to biases resulting from the retrospective
reporting of dietary intakes or the effects of disease on biochemical indicators. For
example, it is possible to determine that diet plays an important role in coronary
heart disease prevention with trans fats, saturated fats, and a high glycaemic index
promoting heart disease and a diet high in fibre, fish oil, and polyunsaturated fats
decreasing the risk.
Migrant studies can evaluate environmental factors as one of the major contributors
to most chronic diseases, independent of the genetic background of the population.
Cancer rates change dramatically in populations migrating from countries of sparse
nutrition to those of more affluence. Though other environmental factors probably
play an important role, the influence of dietary changes is likely.
Measuring dietary intake in large populations remains a challenge. In an attempt
to reduce the misclassification inherent in diet assessment, measurement error
correction models have been developed but are seldom used. Biomarkers of
nutrient intake represent the optimal standard for calibration of questionnaire-based
diet assessment methods, but these biomarkers are not widely available.
Recent advances in molecular biology have yet to contribute substantially to dietary
recommendations, but in the future these approaches may provide useful intermediary
endpoints, allow the study of gene-diet interactions, and enhance our understanding
of the mechanisms by which dietary factors influence disease.
Randomized dietary interventional studies have used different approaches for
ensuring that subjects comply with the intervention diet when testing their relationships
with health outcomes. For example, randomized controlled trials (RCTs), such as
Prevencion con Dieta Mediterranean (PREDIMED), coached participants to follow a
dietary pattern and provided them with key foods (e.g. olive oil or nuts) to facilitate
adherence. In contrast, feeding studies (another form of interventional study), such
as those conducted in the DASH (Dietary Approaches to Stop Hypertension) and the
Optimal Macronutrient Intake Trial for Heart Health (OmniHeart), provided all food
to be consumed to each participant. These study designs across randomized trials
and feeding studies provide strong evidence for the benefits and risks of particular
dietary patterns because a prescribed intervention allows a relatively precise definition
of dietary exposures, and randomization helps ensure that any potential confounding
variables are randomly distributed between study arms. However, some trials are
necessarily restricted to testing a dietary pattern’s effect on an intermediate outcome
or a surrogate endpoint, such as blood lipids, because of the complexities involved in
maintaining dietary compliance over long study duration. Additionally, the feeding
trials fail to represent what happens in real world situations. Observational cohort
studies provide an important evidentiary complement to RCTs because they enable the
study of hard endpoints for disease in addition to intermediate outcomes and often
provide a wider range of exposures for study.
Research methods are constantly evolving and being improved. A recent development
is the use of systematic reviews and meta-analyses. In a systematic review, the
literature is reviewed using search engines according to strict criteria. In meta-analyses,
the reviewers assume that findings from the different studies are quantitatively poolable.
As there is an enormous amount of money tied up in the results of research studies,
there is some evidence of a conflict of interest in studies that potentially affect profit of

13
the research funder, most typically in industry funding. Unfortunately some studies are
example of how the outcome of sponsored research invariably favours the sponsor’s
interests.
One of possible solutions to this problem is to create a sufficient pool of research
funds, independent of the food industry, to support needed research.
The interpretation of positive or inverse associations (or the lack of
associations) in epidemiological studies has always to receive considerable
attention.

References
Bendich A (series editor), Temple NJ, et al. (Edt.). Nutrition and Health. Strategies for disease
prevention. 3rd edition. Humana Press, Springer, 2012: 556. ISBN 978-1-61779-893-1 ISBN 978-
1-61779-894-8 (eBook).
Michels, KB. Nutritional epidemiology — past, present, future, Oxford Journals Medicine & Health.
Int. J. Epidemiol., 2003; 32:486–488, DOI: 10.1093/ije/dyg216. Available on line: http://ije.
oxfordjournals.org/content/32/4/486.full.pdf+html.
Ross AC, Cabalerro B, et al. Modern Nutrition in Health and Disease. 11th Edition. Wolters Kluwer.
Lippincott Williams and Wilkins. 2014: 1616. ISBN 978-1-60547-461-8.
Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Part D. Chapter 2: Dietary
Patterns, Foods and Nutrients, and Health Outcomes. Available at: http://www.health.gov/
dietaryguidelines/2015-scientific-report/07-chapter-2/.
Webb GP. Nutrition - A health promotion approach, 3rd Edition, Hodder Arnold, an imprint of
Hodder Education, an Hachette UK Company, 2008: 594. ISBN 978-0-340-93882-9.
Willett WC. Nutritional Epidemiology. Oxford University Press; 3rd Edition, 2013: 552. ISBN- 978-
0-19-975403-8.

14
 3 MEASURING OF FOOD INTAKE

There is no ideal tool to measure a person’s nutritional status accurately.

It is necessary to look at several different measurements in order to assess a person’s
nutritional status. This process is known as the A, B, C, D of nutritional assessment:
• Anthropometry
• Biochemical and haematological variables
• Clinical and physical assessment
• Dietary intake
Nutritional epidemiology provides data about the diet-disease relationships that
is transformed by Public Health Nutrition into the practise of prevention. The specific
contributions of nutritional epidemiology include dietary assessment, description of
nutritional exposure and statistical modelling of the diet-disease relationship. In all
these areas, substantial progress has been made over the last years.
Food consumption data may be collected at the national, household or the individual
level. There is no ideal method for assessing dietary intake.
Information on food intake can be obtained directly or indirectly.
Indirect measurements of food intake make use of information on the availability
of food at national, regional, or household levels to estimate food intakes, rather than
using information obtained directly from individuals who consume the food. Indirect
methods are most useful at the population and household levels for determining the
amount and types of foods.
Information on food intake can be obtained directly from consumers in a number
of different ways.
Direct measures are usually used to obtain food intake data from individuals.
Measuring the food intake in free-living individuals is a complex task and is very
difficult (because of existence of inter and intra-individual variation, complexity of
composition of foods, cultural relationships with foods, multiple foods, complex and
heterogeneous intake, etc.).
The procedure for measuring food and nutrient intake usually involves five steps:
1. obtaining a report of all food consumed by each individual,
2. identifying these foods in sufficient detail to choose an appropriate item in the
food tables,
3. quantifying the portion sizes,
4. measuring or estimating the frequency with which each food is eaten,
5. calculating nutrient intake from food tables.
All measurements of food intake are subject to sources of error.
The dietary assessment method used depends on the purpose of the study. The
existence of error means that it is always important to be aware of and, whenever
possible, to assess the nature and magnitude of the error.
The primary aim is to collect a true record of habitual food and nutrient intake of an
individual or group of individuals.
The dietary assessment has not only clinical but also strong public health reason (to
evaluate the adequacy and safety of the food that people eat at national or community

15
levels and to identify the need for or to evaluate nutrition-based intervention programs)
and also reason for research (to study the interrelationships between food intake and
physiological function or disease conditions under controlled conditions, or in field
conditions).

I. Methods for measuring intake on specified days:

e.g. Menu records, weighed records, recalled intake – repeated 24-hour recall, seven-
day food diary.

II. Methods for measuring intake over the longer term:

e.g. Food frequency questionnaires, diet histories.

Duplicate diet
It has the highest accuracy, so it can provide very accurate data on nutrients
consumed, but it is a very expensive method and has higher burden than other methods.
Subject prepares, weighs and keeps a duplicate portion of every item consumed, and
the nutrient content is analysed in a lab.

Weighed records
Weighed records can provide accurate data on types and amounts of foods consumed.
A subject weighs each item prior to consumption and keeps a record of all foods and
drinks consumed, as well as any leftovers.

24-hour dietary recall

It relies on a short-term memory of subjects. A trained interviewer asks the subject
to recall and describe every item of food consumed. The interview is usually conducted
face to face, but may also be conducted by telephone. In some situations, the recall is
self-administered by the subject, but this approach may not yield sufficiently reliable
data. It should be repeated at least twice during one week, and once during a weekend
to achieve more objective data.

Food frequency questionnaire (FFQ)

FFQ, sometimes referred to as a “list-based diet history”, belongs to widely used
methods, because it is cheap and quick and it is the primary dietary data collection
instrument. FFQ contains the list of foods and the subject is asked to indicate a typical
frequency of consumption often over the last 6 months to a year. FFQs are generally self-
administered but may also be interviewer-administered. The number or types of food
items may vary, as well as the number and types of frequency categories. FFQs may be
unquantified, semi-quantified or completely quantified.

Diet record method, diary method

It includes a detailed listing of all foods consumed on one or more days, and it is
supposed to be recorded by participants at the time the food is eaten.

Six main groups of innovative technologies were identified: Personal Digital Assis­
tant, Mobile-phone, Interactive computer, Web, Camera and tape-recorder and Scan and
sensor–based technologies.
Compared with the conventional food records, Personal Digital Assistant and mobile
phone devices seem to improve the recording through the possibility for “real-time”
recording at eating events, but their validity to estimate individual dietary intakes is still
low to moderate.

16
 Digital photography
Much interest is also directed towards the technique of taking and analysing
photographs of all meals ingested, which might improve the dietary assessment in
terms of precision. When using this method, of food selection and leftovers are quickly
captured. These images are later compared with images of standard portions of food
using computer software. Digital photography can remove the need for recall (and
estimation) and can be comparable to weighed records. Images can be taken at the point
of consumption either by a researcher (e.g. Digital Photo Method) or by a subject (e.g.
Remote Food Photograph Method) and then converted to portion weights by trained
analysts. A related method called the Remote Food Photography Method (RFPM) relies
on smartphones to estimate food intake in near real-time in free-living conditions.
This is a popular method mostly among younger generation and can be used as a
memory aid, but still has some shortcomings (e.g. not clear cooking methods, brand
names/fortification, leftovers).

Combined methods
Different types of dietary assessment methods may be combined to improve accuracy
and facilitate interpretation of the dietary data. Methods may also be combined for
practical reasons.

Four possible sources of error occur to some degree with all dietary methods, but
can be minimized by careful study design and execution:
• sampling bias
• response bias
• inappropriate coding of foods
• use of food composition tables in place of chemical analysis

Assessing the validity of dietary recalls and food records for estimating usual
intakes involves 3 issues:
1. reporting accuracy – agreement between items observed and items recalled
(70-80%)
2. accuracy in nutrient calculation – representativeness of food composition
database, coding procedures, calculation software; it may be assessed by comparing
calculated nutrient intake with chemical analysis of food composites
3. accuracy of assessing usual intake – to compare the results of one method designed
to measure same things, or compare the calculated intakes of individual nutrients
with biochemical indicators (urinary nitrogen – indicator of protein intake). A novel
approach of detecting and using biomarkers for estimating specific dietary intakes and
the relation to end points has been proposed in connection with the recently developed
technology of metabolomics.
The need for standardisation of food tables with the prime aim to link these food tables
with a highly standardised and comparable nutrient database is well acknowledged in
Europe.
Efforts have also been undertaken in recent years to extend existing nutrient
databases towards bioactive compounds in addition to nutrients (carotenoids,
flavonoids, phenols, phytoestrogens etc).
Statistical modelling of the dietary data and the diet-disease relationships can refer to
complex programmes that convert quantitative short-term measurements into habitual
intakes of individuals and correct for the errors in the estimates of the diet-disease
relationships by taking data from validation studies with biomarkers into account.

17
 For dietary data, substitution modelling should be preferred over simple adding
modelling. More attention should also be put on the investigation of non-linear
relationships.
Most of the new technologies in dietary assessment were seen to have
overlapping methodological features with the conventional methods predomi­
nantly used for nutritional epidemiology.
The most appropriate method to be used will depend on several factors:
nutrient or food of interest, individual or group intakes, population to be
studied, time frame, and budget. Validation should always be performed.

References
Baranowski T. 24-Hour Recall and Diet Record Methods. In: Nutritional Epidemiology. Walter C.
Willett. Oxford University Press; 3rd Edition, 2013: 552, ISBN- 978-0-19-975403-8.
Boeing H. Nutritional epidemiology: New perspectives for understanding the diet-disease
relationship? Eur J Clin Nutr. 2013; 67(5): 424-9. doi: 10.1038/ejcn.2013.47.
FAO. Preparation and use of food-based dietary guidelines. Chapter three - Methods of monitoring
food and nutrient intake. Available online: http://www.fao.org/docrep/x0243e/x0243e05.
htm.
Maclntyre UE. Measuring food intake. In: Introduction to Human Nutrition, Gibney MJ, Lanham-
New SA, Cassidy A, Vorster HH. John Wiley & Sons Ltd, A John Wiley & Sons, Ltd., Publication,
2nd edition, 2009: 386. ISBN 978-1-4051-6807-6.
Martin CK, Nicklas T, Gunturk B, et al. Measuring food intake with digital photography. J Hum
Nutr Diet. 2014; 27 (Suppl 1): 72-81. doi: 10.1111/jhn.12014. available online: http://www.ncbi.
nlm.nih.gov/pubmed/23848588.
Thompson FE, Subar AF. Dietary Assessment Methodology. In: Nutrition in the prevention and
treatment of disease, 3rd edition, Edt. Coulston AM, Boushey CJ, Ferruzzi MG. Academic Press
is an imprint of Elsevier, 2013: 46. ISBN: 978-0-12-391884-0.

18
 4 NUTRITIONAL VALUE OF FOOD AND
NUTRITIONAL QUALITY OF FOOD

The foods we consume contain thousands of specific chemicals, some known and
well quantified, some poorly distinguished and others that are presently unrecognised
and now immeasurable.
People eat food, not nutrients; however, it is the combination and amounts of
nutrients in foods that determine health. In foods, in the gut during absorption, digestion,
fermentation in the blood during transport, and in cells during metabolism, nutrients
interact with each other.
The most important categories of nutrients are proteins, carbohydrates, fats,
vitamins, minerals, and trace elements.
They belong to:
1. macronutrients (carbohydrates, proteins, fats) - daily intake of macronutrients
ranges in tens up to hundreds of grams (represent 80 – 90% of a dry part of food);
2. micronutrients (vitamins, minerals, trace elements) - their daily intake is in
milligrams or micrograms.
Nutritional value (i.e. energy and biological value) of food are quantitative and
qualitative nutritional demands of the human body.
Nutrients satisfy the basic body needs as:
• growth – formation of new body cells and tissues and their repair, development,
• chemical regulation of metabolic functions,
• energy for muscle contraction,
• conduction of nerve impulses,
• reproduction.

The chemicals that comprise our food can be divided into groups, which are not
mutually exclusive:
1. Essential nutrients
2. Major energy sources
3. Additives
4. Agricultural chemical contaminants
5. Microbial toxin contamination
6. Inorganic contaminants
7. Chemicals formed in the cooking or processing of food
8. Natural toxins
9. Other natural compounds
Food as a basic life-support material supplies the body with certain essential
chemicals that enable to do its work and build body cells and tissues. The list of
nutrients essential or otherwise useful to human physiology is long, complex, and
probably still incomplete, nowadays it includes more than 40 distinct substances
(Table 1). They must be obtained from food sources, because the body does not
produce them or produces them in amounts too small to maintain growth and health.

19
Their dietary or metabolically-induced deficiency causes recognizable symptoms that
disappear when the nutrients are replaced.

Table 1 Essential dietary components (Source: Ševčíková et al., 2011)

1. Energy sources Carbohydrate, Fat, Protein
Isoleucine, Leucine, Lysine, Methionine, Phenylalanine, Threonine,
2. Essential amino acids
Tryptophan, Valine, Histidine
3. Essential fatty acids Linoleic, Linolenic, Arachidonic, Eicosapentaenoic Acid
4. Vitamins
Water-soluble Ascorbic Acid (C), Thiamine (B1), Riboflavin (B2), Pantothenic Acid (B3),
Pyridoxine (B6), Folacin, Niacin (PP), Biotin (H), Cobalamin (B12)
Fat-soluble Vitamin A, Vitamin D, Vitamin E, Vitamin K
5. Minerals
Major minerals [g] Calcium, Chlorine, Magnesium, Sodium, Phosphorus, Potassium, Sulphur
Trace elements [µg] Iron, Iodine, Zinc, Copper, Manganese, Chromium, Cobalt, Selenium,
Molybdenum, Fluorine
6. Fibre
7. Water

The term nutrient density for foods/beverages has been used loosely to promote the
Dietary Guidelines. The 2010 Dietary Guidelines for Americans defined ‘all vegetables,
fruits, whole grains, fat-free or low-fat milk and milk products, seafood, lean meats and
poultry, eggs, beans and peas (legumes), and nuts and seeds that are prepared without
added solid fats, added sugars, and sodium’ as nutrient dense. Guidelines further state
that nutrient-dense foods and beverages provide vitamins, minerals and other
substances that may have positive health effects with relatively few (kilo)
calories or kilojoules. The definition states nutrients and other beneficial substances
have not been ‘diluted’ by the addition of energy from added solid fats, added
sugars or by the solid fats naturally present in the food. However, the Dietary Guidelines
Advisory Committee and other scientists have failed to clearly define ‘nutrient density’ or
to provide criteria or indices that specify cut-offs for foods that are nutrient dense. Today,
‘nutrient density’ is a ubiquitous term used in the scientific literature, policy documents,
marketing strategies, and consumer messaging. However, the term remains ambiguous
without a definitive or universal definition.

4.1 Proteins
Protein is the major structural component of all cells in the body. Thus an adequate
supply of dietary protein is essential to maintain cellular integrity and function, and for
keeping the health.
The most important aspect of a protein from a nutritional point of view is its amino
acid composition, but the protein’s structure may also influence its digestibility. Some
proteins, such as keratin, are highly insoluble in water and hence are resistant to digestion,
while highly glycosylated proteins, such as the intestinal mucins, are resistant to attack
by the proteolytic enzymes of the intestine. Protein has a unique structural unit, the
amino acid, which is made up of the three elements – carbon, hydrogen, oxygen – that
make up also carbohydrates and fats. Nevertheless, amino acids and their proteins have
an additional important element – nitrogen – as the base (alkaline) (-NH ) portion of
2
their structure. Although there are hundreds of amino acids in nature, only ∼ 20 of these
commonly appear in proteins.

20
 Essential amino acids: Nine of the amino acids are vital (Table 1).
The remaining (non-essential) group can be synthesized in the human body.
Diet almost always contains a mixture of different proteins.
Complete proteins are those that contain all the essential amino acids (meat, egg,
milk, and dairy products). Incomplete proteins that are deficient in the essential
amino acids are mostly of plant origin (grains, legumes, nuts, and seeds).
Functions of proteins: the primary function is the growth, development and
maintenance of body cells, tissue and organs (basis of muscles, bones, skin, nails, mucosa,
antibodies); in detoxication processes as components of enzymes; in transportation of
nutrients; specific function in nutrition of the brain and nervous system, they help to
keep nitrogen balance in the organism.
Some amino acids perform important physiological and metabolic roles (e.g.
trypto­phan is a precursor of niacin and of neurotransmitter serotonin, prolin is an
essential component of collagen, glutamine is essential for maintenance of acid-base
balance in the kidney), contribute to the body´s overall energy metabolism; may be
used for gluconeogenesis.
Factors influencing protein requirements are: tissue growth (includes age,
body size and general physical status); diet (includes nature of protein in the diet and
its ratio or pattern of amino acid structure); presence of any disease (usually increase
protein intake).
Current Slovak recommendations 2014 are in Tables 10, 12, 14. For protein, the
recommendations are given both as population ranges expressed as was expressed as
a percentage of total energy intake (protein E %). Different dietary guidelines usually
suggest around 10-20 E%, it means it should be at least 10% of the daily calories, but not
more than 20 E% from protein, according to the Institute of Medicine (IOM) of the U.S.
National Academy of Sciences, daily caloric intake should range from 10 to 35 E%.
A recommended intake can be also in g/kg body weight (bw) per day.
Recommended daily allowances (RDAs) for dietary protein in most countries are
0.8–1 g/kg of body weight per day. According to the Institute of Medicine (Food and
Nutrition Board) RDA for both men and women is 0.80 g of good quality protein/kg
body weight/d and is based on careful analyses of available nitrogen balance studies.
That is about 60–80 g for a man and 55–80 g for a woman. For girls and boys between
15–18 years of age with increased physical activity it is recommended around 1.15 g of
proteins/kg/day, and 1.2 g of proteins/kg/day, respectively.
Increased protein intake is indicated also during pregnancy and lactation, and
vigorous physical activity. RDAs are based on the minimum protein intake needed to
prevent the loss of lean body mass, so an average adult may need generally more than
60–70 grams of protein per day.
Proteins in both the diet and body are more complex and variable than the other
energy sources, carbohydrates and fats.
Isolated protein deficiency is rare in adults but may be observed in children mostly
in developing countries. This deficiency in protein consumption may result in serious
forms of protein malnutrition such as marasmus and kwashiorkor. However, most
people eat more protein than is recommended by the RDAs.
Dietary protein quality is determined by its:
1) digestibility (the proportion of dietary protein that is absorbed),
2) amino acid composition (the higher the similarity in amino acid composition
between a dietary protein and the average body protein, the higher is the quality of the
protein),
3) any unique unavailability of specific amino acids.

21
 Plant proteins have a lower digestibility in comparison with animal proteins and
also the amino acid composition of plant proteins is less similar to human body protein.
There is a problem of limiting amino acid – grains are usually low in lysine, beans are
low in methionine. As a result, the quality of plant proteins is generally lower than that
of animal proteins, so it is recommended to combine different sources of plant proteins
to achieve a higher protein quality (protein complementation).
Protein turnover refers to the continuous synthesis (remake) and degradation of
body proteins. This overall process of protein degradation or breakdown plays many
essential roles in functioning of organisms (including cell growth, adaptation to different
physiological conditions, elimination of abnormal or damaged proteins, and normal
functioning of the immune system). Even in the steady state, body proteins constantly
undergo breakdown and resynthesis. When growth is occurring, not only is there a net
deposition of protein, but the rates of both synthesis and breakdown are increased.
Protein balance refers to the difference between how much protein goes into
the body and how much protein goes out of the body. Protein balance essentially is
nitrogen balance; it refers to the difference between nitrogen intake and excretion.
There is tendency in adults to keep nitrogen balance (balance between synthesis and
catalysis of proteins in the body). Requirements for infants and children vary according
to their age and growth pattern and nitrogen balance should be positive.
There remains uncertainty about quantitative aspects of amino acid nutrition, especially
in healthy adults, but there is now a consensus that the current international requirement
estimates for adults are far too low. This has potentially important implications for the
evaluation of dietary protein quality and for the planning, now and in the future, of food
protein supplies for population groups. There are also incohesive recommendations
for healthy adults undertaking resistance or endurance exercise about requirements of
higher dietary protein intake (some professional organizations recommend for athletes
to take from 1.2 to 1.7 grams/kg of body weight per day). On the other hand, since health
food stores are selling and promoting the ingestion of large amount of different amino
acid supplements, it is important that the safe upper limit of amino acid requirements
is determined. Nevertheless, the recommended protein intakes can generally be met
through diet alone, without the use of protein or amino acid supplements. Protein intakes
above 20% of total energy intake can be achieved usually only by a very high consumption
of animal proteins (meats, eggs and milk or dairy products).

4.2 Carbohydrates
Carbohydrates are derived primarily from plant-based foods. The name carbohydrate
comes from its chemical nature. It is composed of carbon, hydrogen, and oxygen
molecules, but this definition is not universal for all carbohydrates.
Carbohydrates are the primary energy source for most people in the world. This
makes carbohydrate quality a critical issue, since those who consume too few calories
need nutrient-dense carbohydrate sources so that every calorie counts; and those who
consume too many calories also need high-quality carbohydrates since they cannot
afford to waste calories on less nutritious sources. Carbohydrates vary tremendously
in structure and physiological function, and much of the recent carbohydrate research
has focused on these differences and their impact on chronic diseases such as diabetes
and heart disease.
The major classes of carbohydrates include:
•monosaccharides (simple sugars),
•disaccharides (simple sugars),

22
 •oligosaccharides,
•polysaccharides (complex carbohydrates).
According to the FAO/WHO the term “sugars” refers collectively to monosaccharides,
disaccharides, and sugar alcohols.
Simple carbohydrates consist of single and double sugar units that are easily
digested and provide quick energy.
Complex carbohydrates provide energy more slowly and prevent large fluctuations
in blood glucose levels.

Monosaccharides. In human metabolism, all types of sugar are converted into

glucose.
After eating food with carbohydrates, glucose enters the blood, raising blood sugar
(glucose) levels. When blood glucose levels rise, beta cells in the pancreas release
insulin. Insulin is a hormone that makes our cells absorb blood sugar for energy or
storage. As the cells absorb the blood sugar, blood sugar levels start to drop.
Fructose (found in fruits), and galactose (found in milk products) are found
naturally. Simple carbohydrates are also found in processed and refined sugars
(candies, carbonated sweet beverages - soda, and syrups). Many other simple sugars
consumed today are “hidden” in different kinds of processed foods that are not
usually seen as sweets (1 tablespoon of ketchup contains around 4 grams = around 1
teaspoon of free sugars, a single can of sugar-sweetened soda contains up to 40 grams
= around 10 teaspoons of free sugars). Refined sugars (white sugar, white flour, and
white rice) provide calories, but they lack vitamins, minerals, and fibres. Such simple
sugars are often called “empty calories” and can lead to an increase in total calories
and weight gain if they are taken in excess. Added sugars are sugars and syrups
that are added to foods during processing or preparation (white table sugar, brown
sugar, corn syrup, high fructose corn syrup – HFCS, molasses, honey, pancake syrups,
fruit-juice concentrates, and dextrose). The major sources of these sugars include soft
drinks, fruit beverages, candy, and sugar-sweetened grain-based dessert items. Most
of these food items have also lower micronutrient densities than foods and beverages
with naturally occurring sugars.
Disaccharides consist of two monosaccharides covalently linked by a glycosidic
bond. The major dietary disaccharides include sucrose (glucose + fructose) and lactose
(glucose + galactose). Sucrose occurs naturally in plants, but most often is consumed
as an extract of sugar cane or sugar beet. Sucrose is widely used as a sweetener and
preservative. The only source of lactose is milk and other dairy products. Maltose and
trehalose, both disaccharides of glucose, are also present in small amounts. Maltose is
found in wheat and barley, and is a product of starch hydrolysis. Trehalose is found in
yeast products, mushrooms, and crustacean seafood.
Sugar alcohols. Also commonly referred to as polyols, sugar alcohols are derived
from the hydrogenation of mono- and disaccharides, and include sorbitol, mannitol,
xylitol, isomalt, lactitol, maltitol, and erythritol. Polyols are not as easily digested
as other sugars, so they produce a lower glycaemic response and a reduced caloric
value. Additionally, sugar alcohols are less cariogenic than other carbohydrates.
Carbohydrates with three to nine degrees of polymerization (i.e. three to nine
monosaccharide units) are classified as oligosaccharides. Some oligosaccharides
occur naturally in plants: stachyose and raffinose in soybeans and other legumes
and fructooligosaccharides in fruits, vegetables, and grains (e.g. wheat, rye, onions,
bananas). However, because of their usefulness as food ingredients and their possible
health benefits, an increasing number of oligosaccharides are now synthesized from
sugars or obtained through extraction and/or partial hydrolysis of longer-chain

23
plant polysaccharides (inulin extracted from chicory root). Being fairly resistant to
digestion in the small intestine, oligosaccharides display physiological effects similar
to fibre, and some appear to promote the growth of beneficial colonic microflora.
Polysaccharides have a high degree of polymerization, ranging from 10 sugar
units to several thousands. Polysaccharides may act as food stores in plants in the
form of starch, or food stores in humans and other animals in the form of glycogen.
Polysaccharides also have structural roles in the plant cell wall in the form of cellulose
or pectin, and the tough outer skeleton of insects in the form of chitin. Polysaccharides
can be subdivided into starch and non-starch polysaccharides.
Starch is a source of carbohydrate made up of many chains of single sugar units and
it is the primary storage form of carbohydrate in plants, but is found primarily in grains
and grain products (e.g. cereals, corn, flour, and rice) and in some root vegetables (e.g.
potatoes and beets) and legumes. Dextrins are intermediate products in the breakdown
of starch. While most starch is digested and absorbed in the small intestine, a small portion
escapes digestive enzymes and passes into the colon, where it may be fermented by the
gut microbiota. Resistant starch (RS) is indigestible even after prolonged incubation
with amylase. In cereals, RS represents 0.4% to 2% of the dry matter; in potatoes, it is 1%
to 3.5%; and in legumes, it is 3.5% to 5.7%. There are four types of resistant starch, which
either occur naturally or are a consequence of food processing. Because RS1 and RS2
occur naturally in plants, they are considered dietary fibre by some. RS3 and RS4 are
both formed during food processing and do not occur naturally. The end products of the
fermentation of the RS in the colon are short-chain fatty acids (e.g. acetate, butyrate, and
propionate), carbon dioxide, hydrogen, and methane.
Non-starch polysaccharides also escape digestion and absorption in the small
intestine and are fermented in the colon. However, their resistance to digestion is not due
to physical or structural barriers to digestive enzymes, but rather to the lack of enzymes
capable of breaking the glycosidic bonds between the monomeric units. As a result of
their indigestibility, non-starch polysaccharides are considered dietary fibre and include
cellulose, hemicelluloses (e.g.glucans), gums, and mucilages, and pectins.
Dietary fibre can be divided into 2 groups according to water solubility:
a) the soluble (viscous fibre) includes pectin and hydrocolloids
b) the insoluble (non-viscous fibre) includes cellulose and hemicellulose.
Fibre describes a chemically diverse group of non-digestible carbohydrates so it is
not broken down by the endogenous digestive enzymes and will reach the colon mostly
intact and there it is digested by bacteria. Certain insoluble fibres such as cellulose are
not fermented at all.
Fibre is usually present in the food naturally, but sometimes there is extra fibre added
to the food (fibre obtained from food raw material by physical, enzymatic, or chemical
means and synthetic carbohydrate polymers).
This complex carbohydrate affects the digestion and absorption of foods in ways
that are beneficial to good health. By modifying the rate and site of nutrient absorption,
and by increasing faecal mass and delivering fermentation products to the circulation,
the various components of the dietary fibre complex can modify human metabolism
to a degree, which is of major significance for health. Dietary fibre contributes to the
maintenance of normal bowel function, and epidemiological evidence suggests that
high intakes are associated with reduced incidences of various dyslipidaemias, with
type 2 diabetes and coronary heart disease, and with several abnormalities of the
metabolic syndrome, which predisposes to these major pathologies. Proper fibre intake
is associated with a reduced risk of colorectal cancer. The quantity of fibre consumed
by the populations of prosperous industrialized societies was quite low. The adequate
intake (AI) for healthy individuals older than 1 year was estimated to be 14 g/1000 kcal/

24
day, which equates to about 38 g/day for a male adult and 25 g/day for a female in their
mid-life. The recommended intake for total fibre for adults over 50 years of age is set at
30 grams for men and 21 grams for women, due to decreased food consumption.
According to Scientific Advisory Committee on Nutrition the definition of dietary
fibre should be broadened, it includes resistant starch and oligosaccharides.
Glycogen is stored in relatively small amounts in the liver and muscle tissues and
helps sustain normal blood sugar levels during fasting periods.
Glycaemic carbohydrates (sugars and starches) are digested and absorbed in the
small intestine, thereby increasing blood glucose for metabolism by tissues, whereas
non-glycaemic carbohydrates (oligosaccharides, resistant starches, and non-
digestible polysaccharides – fiber) remain undigested and pass into the colon where
they can be fermented.
For total carbohydrates the population range is usually around 50–60 E%, Slovak
current recommendations from 2014 are in Tables 10, 12, 14. According to the Institute
of Medicine (IOM, 2002) adults should get 45 – 65 E% from carbohydrates. According
to the new Nordic Nutrition Recommendations (NNC, 2012) and European Food
Safety Authority (EFSA, 2010) 45–60 E%, as a consequence of the ranges for other
macronutrients and also in line with studies on dietary patterns and health outcomes.
RDA for carbohydrate is set at 130 g/d for adults and children based on the average
minimum amount of glucose utilized by the brain.
The amount of carbohydrates also relates to fat metabolism and prevents the
breaking down of fats and proteins for energy, which results in excessive production
of toxic metabolic by-products. Regarding the heart activity, the glycogen in cardiac
muscle is an important emergency source of contractile energy and a constant amount
of carbohydrate is necessary for the proper functioning of the central nervous system.
Change in blood glucose over time is called the “glycaemic response.’’
Carbohydrate-containing foods differ in their ability to raise blood glucose levels.
A number of factors can influence the glycaemic response to foods, including the
nature of the carbohydrate consumed, the rate of digestion and absorption, the rate
of clearance from the bloodstream, and the presence of other food components (e.g.
fibre, fat, and protein). In an effort to better understand how different foods impact the
glycaemic response was proposed the use of the glycaemic index (GI) as a relative
indicator of blood glucose response to the carbohydrate contained in a particular
food. The GI is determined by comparing the blood glucose response (area under
the curve) of a test food containing a specified amount of available carbohydrate to a
standard food containing the same amount of carbohydrate. Some food carbohydrates
increase the blood glucose level more than others do (Table 2). Foods that have a
high GI cause a more pronounced increase in blood glucose, spikes, whereas foods
with a lower GI cause a rather shallow increase in blood glucose. Many of these foods
can have different glycaemic responses due to differing factors, including variety of
the grain used and cooking conditions. Typically, high-GI foods would include items
with easily digested starches (e.g. refined grains and potatoes), free glucose, or large
amounts of disaccharides rapidly hydrolysed to glucose. Alternatively, low-GI foods
(e.g. unprocessed grains, non-starchy fruits, and vegetables) would contain more
slowly digested or higher fibre content. Low-GI foods may also be high in fat, which
slows carbohydrate digestion and absorption. Not only food can differ, even the same
person can vary in their glycaemic response from day to day.
The glycaemic load (GL) of a serving of food can be calculated as its carbohydrate
content measured in grams (g) multiplied by the food’s GI and divided by 100. The
glycaemic load of food is a number that estimates how much the food will raise a person’s
blood glucose level after eating it. One unit of glycaemic load approximates the effect of

25
consuming one gram of glucose. Glycaemic index and glycaemic load offer information
about how foods affect blood sugar and insulin. The lower a food’s glycaemic index or
glycaemic load, the less it affects blood sugar and insulin levels. The list of glycaemic
index and glycaemic load for some common foods is shown in Table 2.
Carbohydrates have been assigned an energy value of 4 kcal/g (17 kJ/g). The actual
caloric values of carbohydrates can vary from practically zero in the case of some fibres
(e.g. gums and cellulose) to 4.2 kcal/g for most digestible starches.

Table 2 Glycaemic index and glycaemic load (modified

http://www.health.harvard.edu/newsweek/Glycaemic_index_and_glycaemic_load_for_100_
foods.htm)
Glycaemic index Serving size Glycaemic load/
FOOD
(glucose = 100) (grams) serving

BAKERY PRODUCTS AND BREADS

Banana cake, made with sugar 47 60 14
Banana cake, made without sugar 55 60 12
Sponge cake, plain 46 63 17
Apple muffin, made with sugar 44 60 13
Apple muffin, made without sugar 48 60 9
Waffles, Aunt Jemima (Quaker Oats) 76 35 10
Bagel, white, frozen 72 70 25
Baguette, white, plain 95 30 15
Kaiser roll 73 30 12
Rye-kernel, pumpernickel bread 56 30 7
White wheat flour bread 71 30 10
Whole wheat bread, average 71 30 9
Pita bread, white 68 30 10
Corn tortilla 52 50 12
BEVERAGES
Coca Cola, average 63 250 mL 16
Apple juice, unsweetened, average 44 250 mL 30
Orange juice, unsweetened 50 250 mL 12
Tomato juice, canned 38 250 mL 4
BREAKFAST CEREALS AND RELATED PRODUCTS
Muesli, average 66 30 16
Oatmeal, average 55 250 13
Instant oatmeal, average 83 250 30
Puffed wheat, average 80 30 17
GRAINS
Pearled barley, average 28 150 12
Sweet corn on the cob, average 60 150 20
Couscous, average 65 150 9
Quinoa 53 150 13

26
 Glycaemic index Serving size Glycaemic load/
FOOD
(glucose = 100) (grams) serving

White rice, average 89 150 43

Quick cooking white basmati 67 150 28
Brown rice, average 50 150 16
Bulgur, average 48 150 12
DAIRY PRODUCTS AND ALTERNATIVES
Ice cream, regular 57 50 6
Milk, full fat 41 250mL 5
Milk, skim 32 250 mL 4
Reduced-fat yogurt with fruit, average 33 200 11
FRUITS
Apple, average 39 120 6
Banana, ripe 62 120 16
Grapefruit 25 120 3
Grapes, average 59 120 11
Orange, average 40 120 4
Peach, average 42 120 5
Peach, canned in light syrup 40 120 5
Prunes, pitted 29 60 10
Raisins 64 60 28
Watermelon 72 120 4
BEANS AND NUTS
Baked beans, average 40 150 6
Chickpeas, average 10 150 3
Navy beans, average 31 150 9
Lentils, average 29 150 5
Soy beans, average 15 150 1
Cashews, salted 27 50 3
Peanuts, average 7 50 0
PASTA and NOODLES
Macaroni, average 47 180 23
Spaghetti, white, boiled 20 min, average 58 180 26
Spaghetti, wholemeal, boiled, average 42 180 17
SNACK FOODS
Microwave popcorn, plain, average 55 20 6
Potato chips, average 51 50 12
VEGETABLES
Green peas, average 51 80 4
Carrots, average 35 80 2
Boiled white potato, average 82 150 21
Sweet potato, average 70 150 22

27
 According to the last WHO recommendations, based on analysis of the latest scientific
evidence, limiting intake of free sugars should be less than 10% of total energy
as a part of the healthy diet (equivalent to 50 g or around 12 level teaspoons). A further
reduction to below than 5% of total energy is suggested for additional health
benefits (equivalent to around 25 grams = 6 teaspoons) of sugar per day for an adult
of normal Body Mass Index (BMI). The suggested limits on intake of sugars in the draft
guideline apply to all monosaccharides (such as glucose, fructose) and disaccharides
(such as sucrose or table sugar) that are added to food by the manufacturer, the cook or
the consumer, as well as sugars that are naturally present in honey, syrups, fruit juices
and fruit concentrates. The WHO guideline does not refer to the sugars in fresh fruits
and vegetables, and sugars naturally present in milk. Adults who consume less sugar
have lower body weight and increasing the amount of sugars in the diet is associated
with weight gain. In addition, research shows that children with the highest intake of
sugar-sweetened drinks are more likely to be overweight or obese than children with a
low intake of sugar-sweetened drinks.
Strong evidence shows that higher consumption of added sugars, especially
sugar-sweetened beverages, increases also the risk for type 2 diabetes among adults
and this relationship is not fully explained by body weight. The recommendation is
further supported by evidence showing higher rates of dental caries when the intake
of free sugars is above 10% of total energy intake. There is moderate evidence from
prospective cohort studies indicating that higher intake of added sugars, especially in
the form of sugar-sweetened beverages, is consistently associated with increased risk
for hypertension, stroke, and CHD in adults. Worldwide intake of free sugars varies
by age, setting, and country. In Europe, intake in adults ranges from about 7–8% of
total energy intake in countries like Hungary and Norway, to 16–17% in countries
like Spain and the United Kingdom. Intake is much higher among children, ranging
from about 12% in countries like Denmark, Slovenia, and Sweden, to nearly 25% in
Portugal. There are also rural/urban differences. In rural communities in South Africa
intake is 7.5%, while in the urban population it is 10.3%.
Fruit, vegetables, brown rice, enriched whole-grain breads, whole grain cereals,
rolled oats, beans, legumes, and sweet potatoes are good examples of more healthy
carbohydrate foods.

4.3 Fats/Lipids
Lipid has long been recognized as an important dietary component. The term lipid
is sometimes used as a synonym for fats- fats are a subgroup of lipids.
Fat is a critical source and storage of metabolic energy, providing 9 calories per gram.
It is a substrate for the synthesis of metabolically active compounds and a regulator
of gene expression, and serves as a carrier for other nutrients such as the fat-soluble
vitamins A, D, E, and K and vitamin precursors. The roles of essential fatty acids and
their products in the achievement and maintenance of optimal health are further
elucidated through research. Depending on type, amount in the diet and other factors,
fat can have more positive or negative health effects on individuals.
Dietary lipids that are essential for our lives consist of triacylglycerols, phospho­
lipids, and sterols.
I. triacylglycerols are quantitatively the most important; they take up approximately
95% of our daily fat consumption. They are composed of glycerol and attached 3 fatty
acids. Triacylglycerols, also referred to as triacylglycerols, are an essential nutrient, which
supplies the highest density of energy, protects against low temperatures and damages of

28
the vital organs. They are helping with the transmission of nerve impulses, production of
metabolic precursors, and formation of cell membrane structure and transport of other
molecules such as protein. Because of the hydrophobic nature of lipids, dietary fat is
handled differently than protein or carbohydrate with respect to digestion and absorption.
Dietary fats are broken down throughout the gastrointestinal system. A unique group of
enzymes and cofactors allows this process to proceed in an efficient manner.
Fatty acids (FA) differ in three major characteristics:
1. the length of chain (majority of FA in our diet have 16 or 18 carbon atoms)
2. the presence and number of double bonds (saturation/degree of unsatu­
ration)
3. the point of saturation (where a double bond is located)
Saturated fatty acids have no double bonds, unsaturated fatty acids have at least
one double bond – monounsaturated fatty acids have just one double bond,
whereas polyunsaturated fatty acids have at least two double bonds.
• SFA - Saturated fats are composed mainly of saturated fatty acids from animal
sources. Foods that are rich in saturated fatty acids are: meat such as beef, pork,
lamb, and poultry skin; whole milk as well as other dairy foods such as butter, cheese,
some yogurt, and ice cream; and from plant origin there are two representatives:
coconut oil, and palm oil. Triacylglycerols containing mostly saturated fatty acids
are chemically more stable and they are less prone to oxidation, which negatively
impacts on the properties of the fat or oil.
• MUFA - Monounsaturated food fats - Oleic acid, the major monounsaturated
fatty acid in the body, is derived mainly from the diet. Fats with a high amount of
MUFA are liquids or soft products – olive, canola, and peanut oils.
• PUFA - Polyunsaturated food fats - omega-3 polyunsaturated fatty acids result
in eicosanoids that have vasodilator properties whereas omega-6 polyunsaturated
fatty acids result in eicosanoids that have vasoconstrictor properties. The main n-3
fatty acid in our diet is linolenic acid, which is used to make certain prostaglandins
and the fatty acids – eicosapentaenoic acid (EPA) and docosahexaenoic acid
(DHA) called fish oil fatty acids and it is possible to find them in fatty fish
like salmon, mackerel, herring, and trout. PUFA are also present in most nuts,
especially walnuts, pine nuts, pecans, and Brazil nuts, seeds (sesame).
The more unsaturated the fatty acids that are attached, the lower is the melting point.
Triacylglycerols composed of unsaturated fatty acids are geometric isomers of fatty
acids resulting from differences in the conformation (spatial orientation) of the double
bond(s). Studies have shown that by replacement of saturated fat with polyunsaturated
fat it is possible to get a reduction in heart disease risk (but evidently other diet factors,
genes, lifestyle habits like smoking, exercise, and stress, sleeping habits also play a role).
The presence of a cis relative to a trans double bond results in a greater bend
or kink in the acyl chain. Double bonds in dietary fats occur most commonly in the
cis configuration. Trans fatty acids, more commonly called trans fats, occur naturally
through microbial metabolism in ruminants (in beef fat and dairy fat, in small amounts),
and are made artificially by heating liquid vegetable oils in the presence of hydrogen
gas and a catalyst, a process called hydrogenation. Trans fats are a by-product of the
chemical reaction that turns liquid vegetable oil into solid margarine or shortening
and that prevents liquid vegetable oils from turning rancid. Partially hydrogenating of
vegetable oils makes them more stable and less likely to spoil. It also converts the oil
into a solid, which makes transportation easier. Partially hydrogenated oils can also
withstand repeated heating without breaking down, making them ideal for frying
fast foods. Trans fats are found in vegetable shortenings, some margarines, crackers,
cookies, snack foods, and other foods made with or fried in partially hydrogenated

29
oils. They boost LDL as much as saturated fats do and also lower protective HDL, rev up
inflammation, and increase the tendency for blood clots to form inside blood vessels.
Trans fats are contributing to the epidemic of cardiovascular disease in developing
nations around the world. It is recommended to eat them as little as possible or
eliminate them from the diet totally.
Fat has twice as many calories as proteins or carbohydrates and eating too much fat
will put on kilograms.
Daily requirements of fat depend on age, gender, health status, energy expenditure,
and other factors. Current Slovak recommendations 2014 are in Tables 10, 12, 14.
The general recommendations are 70–112 g daily for a man and 65–97 g, 30.0–
32.3 E% daily for a woman. Ratio of fatty acids SFA: MUFA: PUFA in food should be
1: 1: 1. The recommendations of daily food intake from fat increased from previously
recommended to 20–35% (IOM) in some countries. According to the NNR a population
range for total fat intake has been adjusted to 25–40 E%. Dietary recommendations for
omega-3 fatty acids are 1.6 g/day for men and 1.1 g/day for women, whereas omega-6
fatty acids recommendations are 17 g/day for men and 12 g/day for women (IOM).
According to the WHO guidelines, the traditional target is to restrict the
intake of saturated fatty acids to less than 10% of daily energy intake and less
than 7% for high-risk groups.
NNR in 2012 recommend intake for cis monounsaturated fatty acids 10–20 E%
(increased when comparing with the year 2004- 10–15 E%), cis polyunsaturated fatty
acids should be 5–10 E%, including at least 1 E% as omega-3 fatty acids, trans fatty acids
intake should be kept as low as possible.
Essential fatty acids are long-chained unsaturated fatty acids that cannot be
manufactured by the body. Humans must obtain the essential fatty acids from dietary
sources. Linoleic, linolenic, arachidonic and eicosapentaenoic are the only fatty acids
known to be essential and serve important functions of the body: they strengthen
capillary and cell membrane structure, which helps prevent and increase skin and
membrane permeability, they combine with cholesterol for its transport in the blood;
they prolong blood clotting time and increase fibrinolytic activity and they help to
form prostaglandins.
II. Phospholipids are composed of two fatty acids esterified to a glycerol molecule
and one polar head group attached via a phosphate linkage; serve as the structural
components of cellular membranes and lipoprotein particles. They are present in small
quantities in almost all plant and animal foods. However, they can be added into food
artificially during food manufacturing as emulsifiers.
III. Sterols. Cholesterol belongs to a family of substances called steroids (sterols)
and is a precursor to all steroid hormones. A derivative of cholesterol in the skin,
7-dehydrocholesterol, is irradiated by sunlight’s ultraviolet rays to produce vitamin D.
It is essential in the formation of bile acids and it is an essential component of cell
membrane, too. The highest cholesterol content is found in shrimp and egg yolk. The
relation between dietary cholesterol and blood cholesterol is very complicated and
determined also by genetics via differences in relative cholesterol absorption (varies
from 30 to 80% among humans). In people that are very efficient at taking up increased
cholesterol intake it is more likely to be translated into an increase in cholesterolaemia.
There are recommended limits in cholesterol daily intake to less than 300 milligrams
for most people according to several guidelines. The Dietary Guidelines for Americans
(DGAC) 2010 recommended that cholesterol intake be limited to no more than 300
mg/day, but new 2015 DGAC did not bring forward this recommendation because
available evidence shows no appreciable relationship between consumption of dietary

30
cholesterol and serum cholesterol, consistent with the conclusions of the American
Heart Association and American College of Cardiology (AHA/ACC).
Phytosterols. The most common dietary phytosterols are β-sitosterol, campesterol,
and stigmasterol. In contrast to cholesterol, phytosterols are poorly absorbed and levels
in plasma tend to be low. Because of their ability to displace cholesterol from intestinal
micelles, phytosterols can reduce the absorption efficiency of cholesterol, lowering
circulating LDL levels.
Prostaglandins is a group of naturally occurring long-chain fatty acids having many
tissue activities including maintaining smooth muscle tone and platelet aggregation.
Chain length of fatty acids is important in their absorption because the medium and
short chain fatty acids are more soluble in water.
Lipoproteins are packages of fat wrapped in water-soluble proteins. All the
lipoproteins are closely associated with lipid disorders related to cardiovascular
diseases.
These plasma lipoproteins contain triacylglycerols, cholesterol, fatty acids,
phospholipids (any of a class of fat-related substances that contain phosphorus, fatty
acids and a nitrogenous base), and traces of fat-soluble vitamins and steroid hormones.
The higher the protein ratio, the higher is the density: Chylomicrons have the lowest
density and are mostly triacylglycerols (90%) with a small amount of protein, delivering
diet fat to liver cells;
Very low-density lipoproteins (VLDL) are hepatically derived particles that mediate
the transport of fat from the liver to peripheral tissue;
Intermediate low-density lipoproteins (ILDL) continue the delivery of endogenous
triacylglycerols to tissue cells;
Low density lipoproteins (LDL) deliver cholesterol to the peripheral tissue cells;
Lipoprotein(a) [Lp(a)] contains an LDL-like particle and a single copy of apo(a)
covalently bound to apoB on the LDL-like particle. Blood Lp(a) concentrations are
highly heritable and affected by the apo(a) gene (LPA) located on chromosome 6q26-
27, although the precise function of Lp(a) remains to be established, high blood Lp(a)
concentrations are associated with increased coronary heart disease and stroke risk.
High-density lipoproteins (HDL) are derived from the liver and intestine, the primary
role of HDL particles is to participate in “reverse cholesterol transport” by shuttling
cholesterol from the peripheral tissues to the liver for excretion, metabolism, or storage.
HDL is a heterogeneous group of particles that differ in both the apolipoprotein
composition and size.
It may be more effective to focus on qualitative fat consumption – notably, decreased
saturated fat and increased unsaturated fat – combined with recommendations to
restrict energy intakes.
Future well-controlled clinical trials are necessary to elucidate clearly the effects of
qualitative fatty acid intake in relation to disease risk of non-communicable diseases.

4.4 Minerals and Trace Elements

1. Minerals are inorganic elements widely distributed in nature. They have vital
and varied roles in metabolism with many of metabolic functions, building, activating,
regulating, transmitting, and controlling.
Minerals are classified as major minerals required in relatively large quantities,
which make up 60% to 80% of all the inorganic material in the body and include calcium,
magnesium, sodium, potassium, phosphorus, sulphur, and chlorine. Summary of major
minerals (required intake over 100 mg/day) is presented in Table 3.

31
 2. Trace elements are essential elements, which required intake is under 100 mg/
day. Essential trace elements include iron, iodine, zinc, copper, manganese, chromium,
cobalt, selenium, molybdenum and fluorine (Table 4).
Current Slovak Recommendations from 2014 are in Tables 10–15.

Table 3 Characteristics of minerals (Source: Ševčíková et al., 2011)

Deficiency
Physiological
Mineral RDA (adult) Diseases/Overload Food Sources
Functions
Disorders
Tetany Dairy products,
800– 1,500 Bone mineralization,
Calcium (Ca) /Calcium deposits in fortified soy and rice
mg muscle contraction
soft tissues milk, fish bones
Meat, fish, eggs,
1,000–1,500 Bone diseases legumes and dairy
Phosphorus (P) Builds bones and teeth
mg /renal insufficiency products; whole
wheat, rice
Bone mineralization, Tremor, spasm,
Whole grains, meat,
active in more than 300 /Diarrhoea,
Magnesium (Mg) 300–450 mg milk, nuts, green
chemical reactions in the decreased calcium
vegetables, legumes
body (coenzyme) absorption
Maintains body’s fluid
Salt – naturally in
balance; important for Fluid-electrolyte and
1,100– 3,000 many foods and
Sodium (Na) nerve function and acid-base balance
mg is added to many
muscle contraction; disorders
prepared foods
controls heart’s rhythm
Potatoes, dried fruits,
Helps nerves and muscles
Fluid-electrolyte and bananas, legumes,
1,800– 5,600 function; regulates heart’s
Potassium (K) acid-base balance raw vegetables,
mg rhythm; regulates bodily
disorders mushrooms; lean
fluids
meat, milk and fish
1,700– 5,000 Major anion in Hypochloremic
Chlorine (Cl) Salt (NaCl)
mg extracellular fluid alkalosis
Diet with Essential constituent of Malnutrition
Meat, egg, dairy
Sulphur (S) adequate proteins, enzyme activity, symptoms
products
proteins energy metabolism /Cystinuria

Table 4 Characteristics of trace elements (Source: Ševčíková et al., 2011)

RDA Deficiency Diseases /
Element Physiological Functions Food Sources
(adult) Overload Disorders
Meat, egg,
Haemoglobin synthesis, Anaemia hypochromic
legumes, tofu,
Iron (Fe) 10–28 mg oxygen transport, cell /haemosiderosis, heart
leafy greens,
oxidation, enzymes disease, liver cirrhosis
cereals
Endemic goiter,
cretinism, during
Thyroid hormones; Saltwater fish,
150–300 pregnancy foetal
Iodine (I2) regulation of cell shellfish, sea kelp
μg development disorders,
metabolism and iodized salt
hypothyroidism /
hyperthyroidism
Hypogonadism, test
Essential coenzyme,
and smell impairment / Oysters, meat,
growth, immunity, wound
Zinc (Zn) 10–16 mg Immune suppression, milk, poultry, fish,
healing, taste, sperm
nausea, metallic taste, grain
production, antioxidant
copper deficiency

32
 RDA Deficiency Diseases /
Element Physiological Functions Food Sources
(adult) Overload Disorders
In enzyme systems with
Meat, shellfish,
iron, maintains connective Hypocupremia –
whole-grain
Copper (Cu) 1.5–2.5 mg tissue and blood vessels; nephrosis /Wilsons
products, legumes
may play a role in cancer disease (excess storage)
and dried fruits
prevention
Enzymes component,
Tea, green
reproductive processes, With protein-energy
vegetables, whole
Manganese (Mn) 2.5–5 mg essential for normal malnutrition /Inhalation
grain, legumes,
brain function and bone toxicity
oats, rice
development
Glucose and fat Whole grains and
Chromium (Cr) 60–180 μg
metabolism molasses, legumes
Cobalt (Co) Constituent of vit. B12, As B12 deficiency Liver, meat, milk
Antioxidant, constituent Low content in soil, Whole grains
of enzyme, immunity, malnutrition from selenium-
Selenium (Se) 50–70 μg possible cancer /Brittle hair and nails, rich soils, poultry,
prevention, viral irritability, garlic breath, meat, dairy
infections fatigue, nausea products
Molybdenum 150–500 Constituent of oxidase Whole grain, milk,
(Mo) μg enzymes legumes
Seafood, tea,
Promotes bone and tooth Dental caries,
coffee, soybeans,
Fluorine (F) 1.5–4 mg formation; prevents tooth osteoporosis
sodium fluoride is
decay /fluorosis
added to water

4.5 Vitamins
Vitamins are a chemically disparate group of compounds with a variety of functions
in the body. What they have in common is that they are organic compounds that are
required for the maintenance of normal health and metabolic integrity. Three key
characteristics of these non-calorigenic food substances are evident: they are not
“burned” to yield energy, they are vital to life, often not a single substance but a group
of related substances turned out to have the particular metabolic activity.
Vitamins are grouped according to their solubility in either fat or water.
The fat-soluble vitamins – A, D, E, and K – are closely associated with lipids, they
are absorbed from the intestinal tract by bile acids, may be stored in the liver or adipose
tissue, excessive intake can cause hypervitaminosis, it may become toxic. There is no
need to consume them as often as water-soluble vitamins, although adequate amounts
are needed. These vitamins are not excreted as easily as water-soluble vitamins. Their
functions are more related to structural activities (Table 5).
The water-soluble vitamins – B complex and C (Table 6) – have fewer problems
in absorption and transport, cannot be stored except in the “tissue saturation” sense,
are excreted mainly by urine, their blood level depends on the actual intake. The body
needs water-soluble vitamins in frequent, small doses. These vitamins are not as likely
as fat-soluble vitamins to reach toxic levels. But niacin, vitamin B6, folate, choline,
and vitamin C have upper consumption limits. Vitamin B6 at high levels over a long
period of time has been shown to cause irreversible nerve damage. A balanced diet
usually provides enough of these vitamins. They function more as coenzyme factors
in cell metabolism.

33
Table 5 Characteristics of fat-soluble vitamins – adults (including pregnancy and lactation)
(Source: Ševčíková et al., 2011, http://www.webmd.com/vitamins-and-supplements/tc/vitamins-
their-functions-and-sources-topic-overview), Intakes (DRIs): Recommended Dietary Allowances
and Adequate Intakes, Vitamins, Food and Nutrition Board, Institute of Medicine, National
Academies, 2011)
Deficiency
Physiological
Vitamin RDA (adult) Diseases/ Overload Food Sources
Functions
Disorders
Vitamin A from
Production of night blindness,
animal sources
rhodopsin, healthy xerophthalmia,
(retinol): fortified
A immune barriers keratomalacia;
milk, cheese, cream,
and epithelial tissue, /Hypervitaminosis
700–1300 μg/d butter, eggs, liver
Beta-carotene growth, reproduction, liver toxicity,
Beta-carotene (from
(carotenoids) bone and red blood cell dry rough skin
plant sources): leafy,
retinol formation, vision and cracked lips,
dark green vegs;
antioxidant, possible irritability, headache,
orange vegs (carrots,
cancer prevention birth defects
sweet potatoes)
Rickets,
Osteomalacia,
osteoporosis,
D Calcium metabolism, osteogenesis
Fortified milk, fatty
Ergocalciferol, 10-15 μg/d bone mineralization, imperfecta, fractures
fish, sunlight on skin
cholecalciferol cancer prevention /Hypervitaminosis:
heart, liver,
kidney toxicity,
hypercalcaemia*
Deficiency is very Polyunsaturated
Antioxidant, rare; mild haemolytic plant oils (soybean,
haemopoesis, anaemia in newborn corn, cottonseed,
E
anticoagulant, infants, impaired fat safflower); leafy green
Tocopherols, 15–19 mg/d
protection from heart absorption vegetables; wheat
tocotrienols
disease, possible cancer /Possible increase in germ; whole-grain
prevention heart disease, excess products; liver; egg
bleeding yolks; nuts and seeds
12–20 μg/d
Green leafy
K Bleeding diathesis
Bone mineralization, vegetables,
Phylloquinone, /Interaction with
blood clotting synthesized by
menaquinones 90-120 μg/d blood thinners
intestinal bacteria
(+)
RDA: recommended dietary allowance * is used for conditions of CVD, diabetes, obesity, muscle
weakness, multiple sclerosis, rheumatoid arthritis, chronic obstructive pulmonary disease (COPD),
asthma, bronchitis, premenstrual syndrome, vitiligo, scleroderma, psoriasis, lupus vulgaris, tooth
and gum disease, boosting the immune system, preventing autoimmune diseases; asterisk (+)

34
Table 6 Characteristics of water-soluble vitamins – adults (Source: Ševčíková et al., 2011, http://
www.webmd.com/vitamins-and-supplements/tc/vitamins-their-functions-and-sources-topic-
overview, Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Vitamins,
Food and Nutrition Board, Institute of Medicine, National Academies, 2011)
Deficiency
Vitamin RDA (adult) Physiological Functions Diseases/ Overload Food Sources
Disorders
Antioxidant, immunity, Scurvy Fruits and
C antiviral in test-tubes, /Pro-oxidant, excess vegetables,
75–120 mg/d
Ascorbic Acid cancer prevention, iron absorption, especially peppers
increases iron absorption diarrhoea and citrus fruits
Beriberi, Wernicke-
Carbohydrate metabolism, Pork, whole-grain or
Korsakoff syndrome /
B1 Energy metabolism, mood, enriched breads and
1.1–1.4 mg/d Drowsiness or muscle
Thiamine nervous system, muscles cereals, legumes,
relaxation with large
and heart nuts and seeds
doses
Milk and dairy
Part of an enzyme needed products, leafy
Ariboflavinosis,
B2 for energy metabolism; green vegetables;
1.1–1.6 mg/d cheilosis, glossitis,
Riboflavin important for normal vision whole-grain,
skin disorders
and skin health enriched breads and
cereals liver, oysters
Poultry, red meat,
Important for nervous
fish, legumes,
system, digestive system,
PP, B3 Pellagra, anorexia / peanut butter,
and healthy skin, energy
Niacin Itching, skin flushing, nuts, vegetables
14–23 mg/d metabolism, lowers
Nicotinic acid liver toxicity, insulin (especially
LDL cholesterol and
resistance mushrooms,
triacylglycerols, raises HDL
asparagus, and leafy
cholesterol
green vegetables)
Paraesthesia /
B5 Widespread in
Coenzyme A, general Diarrhoea; possibly
Pantothenic 8–10 mg/d foods, e.g. liver, egg,
metabolism nausea and heart
acid milk
burn
Meat, liver, fish,
Protein metabolism,
Anaemia, peripheral poultry, eggs,
immunity, neurotransmitter
B6 neurological potatoes, fortified
1.3–2.0 mg/d synthesis (e.g. serotonin
Pyridoxine disorders / cereals, peanuts,
and dopamine), treats
neuropathy soybeans, leafy
peripheral neuropathy
vegetables
in foods; also
B7 30–35 μg/d produced in
General metabolism Dermatitis, enteritis
Biotin (+) intestinal tract by
bacteria
General metabolism,
Deficiency during
prevents neural tube
pregnancy is
defects and other birth
B9 associated with birth Leafy greens,
defects, part of an enzyme
Folic Acid defects - neural tube legumes, oranges,
400-600 μg/d needed for making DNA
Folate defects /May mask broccoli, cauliflower,
and new cells, especially
symptoms of vitamin peanuts
red blood cells, lowers
B12 deficiency; other
homocysteine, possible
effects, nerve damage
cancer prevention
Megaloblastic
Cell division, amino acid anaemia (pernicious
B12 Fish, shellfish, meat,
2–2.6 μg/d metabolism, nervous anaemia),
Cobalamin liver, milk
system, mental function neurological
disturbance

35
 The content of vitamins in fresh dietary sources is reduced during processing that
should be considered (Table 7.).

Table 7 Losses of vitamins by food processing (Source: Ševčíková et al., 2011)

Losses by Vitamins destruction by
Vitamin
processing [%] Light Temperature Oxygen Leach out
A 10–30 + + + –
D – – – – –
E 50 + – + –
K – – – – –
C 50–55 + + + +
B1 25–45 + + + +
B2 20–50 + + – +
B3 25–50 – + – +
B6 30–60 + – – +
B12 > 10 – 300°C – +
Folic acid 50–90 – 250°C – +
Niacin 10–20 – – – +
Biotin 0–70 – 230°C – +

References
Dangour AD, Dodhia SK, Hayter A, Allen E, Lock K, Uauy R. Nutritional quality of organic foods: a
systematic review. Am J Clin Nutr, 2009; 90:680-5.
Harvard Health Publications. Trusted advices for a healthier life. Harvard Medical School. Available
online: http://www.health.harvard.edu/newsweek/Glycaemic_index_and_glycaemic _load_
for_100_foods.htm.
IOM. Institute of Medicine. National Academy of Sciences, Food and Nutrition Board. Dietary
Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and
Amino Acids (Macronutrients), 2005:1357. ISBN 0-309-08525-X (pbk.) — ISBN 0-309-08537-
3 (hardcover). Available online: http://www.iom.edu/reports/2002/dietary-reference-
intakes-for-energy-carbohydrate-fiber-fat-fatty-acids-cholesterol-protein-and-amino-acids.
aspx and http://iom.nationalacademies.org/~/media/Files/Activity%20Files/Nutrition/
DRIs/New%20Material/2_%20RDA%20and%20AI%20Values_Vitamin%20and%20Elements.
pdf.
Nordic Nutrition Recommendations 2012, Integrating Nutrition and Physical Activity, Nordic
Council of Ministers 2014, Narayana Press, Available online: http://www.norden.org/en/
theme/themes-2014/nordic-nutrition-recommendation. ISBN 978–92–893–2670–4.
Ševčíková Ľ, et al. Hygiena.Bratislava:Comenius University, 2006: 325. ISBN 80-223-21036.
Ševčíková Ľ, et al. Hygiene/Environmental Medicine, Bratislava: Comenius University, 2011:332,
ISBN 978-80-223-2900-2.
USDA National Nutrient Database for Standard Reference, Available online: http://www.ars.usda.
gov/main/site_main.htm?modecode=12-35-45-00.
USDA Dietary Reference Intakes (DRIs) - New Dietary Guidelines Really Are New! Available at:
http://www.ars.usda.gov/News/docs.htm?docid=10870.
USDA United States Department of Agriculture. USDA National Nutrient Database for
Standard Reference, Available online: http://www.ars.usda.gov/main/site_main.htm?mode­
code=80-40-05-25.
WebMD Medical Reference from Healthwise. Vitamins: Their Functions and Sources - Topic
Overview. National Cancer Institute (NCI). Available online: http://www.webmd.com/
vitamins-and-supplements/tc/vitamins-their-functions-and-sources-topic-overview?page=2

36
 5 ENERGY NEEDS, ENERGY BALANCE,
PHYSICAL ACTIVITY

Humans and other mammals constantly need to expend energy to perform physical
work; to maintain body temperature and concentration gradients; and to transport,
synthesize, degrade, and replace small and large molecules that make up body tissue.
This energy is generated by the oxidation of various organic substances.

5.1 Energy Metabolism

Energy is available in four basic forms for life processes: chemical, electrical,
mechanical, and thermal.
Metabolism is changing of chemical energy in food into electrical energy of brain
and nerve activity, mechanical energy of muscle contraction, thermal energy of body
temperature control, and other forms of chemical energy in the body.
There are two types of metabolic reactions, which constantly occur:
• anabolism (substances are synthesized and energy is stored),
• catabolism (substances are broken down and energy is released).
The chemical free energy of food is the only form of energy humans can use to maintain
the structural and biochemical integrity of the body. Energy is that force (power) which
enables the body to carry out its life-sustaining or metabolic activities. It is expended
by the body to maintain electrochemical gradients, transport molecules, support
biosynthetic processes, produce the mechanical work required for respiration and blood
circulation, and generate muscle contraction. Most of these biological processes cannot
directly harness energy from the oxidation of energy-containing substrates (primarily
carbohydrate and fat from food and body energy stores). Instead, the resulting energy
from the oxidation of metabolic fuels is captured by adenosine triphosphate (ATP) in
the form of high-energy bonds. ATP is the major energy carrier to body sites and releases
the energy required for chemical and mechanical work. Use of that energy results in the
production of heat, carbon dioxide, and water, which are all eliminated from the body.
The energy provided by foods is measured in kilocalories (kcal) or joules (J).
This is the amount of heat required to raise the temperature of l kg of water by l° C.
1 kcal equals 4.184 kilojoules (kJ); 1 megajoule (MJ) equals 239 kcal.

The total amount of energy in a food is referred to as gross energy and it can be
calculated by burning the food in a special device (bomb calorimeter) and measuring
how much heat is liberated. However, not all the energy that is consumed in the form
of macronutrients actually enters the body, a small portion leaves the body undigested
(excrements). The absorbed proportion (digestibility) is a constant value for each of
these macronutrients (98% –carbohydrates, 95% – fats, 92% – proteins). The amount
of energy that is absorbed is digestible energy. Metabolisable energy is the energy
that is available for the body to use after taking into account the loss of dietary energy
(by stools and urine).

37
 5.2 Energy Balance
There are several components of energy balance:
1. Energy intake
Energy intake is defined as the caloric or energy content of food as provided by the
major sources of dietary energy:
• carbohydrate (16.8 kJ/g)
• protein (16.8 kJ/g)
• fat (37.8 kJ/g)
• alcohol (29.4 kJ/g)
These numbers are referred to as the so-called Atwater factors (i.e. metabolisable
energy for carbohydrate is 4 calories/gram, 9 calories/gram of fat and 4 calories/gram
of protein).

There are several factors that can influence food intake:

– factors in the digestive system
– factors in the central nervous system, mostly the hypothalamus
– circulating factors (provide a link between the digestive system and the central
nervous system)
– signals from the periphery (e.g. insulin, leptin, adiponectin, etc.)
– non-physiological, external factors (psychological factors, environmental factors,
physical characteristics of food as taste, texture, colour, temperature, and
presentation, cultural influences in the environment, such as time of day, social
factors, peer influence, and cultural preferences)
2. Energy storage
The energy that is consumed in the form of food or drinks can either be stored in the
body in the form of fat (adipose tissue, the major energy store), glycogen (short-term
energy/carbohydrate reserves, in the liver, and the muscles), or protein (body tissue
rarely used by the body for energy except in severe cases of starvation and other wasting
conditions) or be used by the body to fuel energy-requiring events.
3. Energy expenditure
The food consumed is oxidized or combusted in the presence of oxygen to release
carbon dioxide, water, and heat.
The energy that is consumed in the form of food is required by the body for metabolic,
cellular, and mechanical work such as breathing, heartbeat, and muscular work, all of
which require energy and result in heat production. Total energy needs are based on
basal and non-basal requirements.
The basal metabolic rate (BMR) is the energy expended by the body to maintain
basic physiological functions (e.g., heartbeat, muscle contraction and function, and
respiration). BMR is the minimum level of energy expended by the body to sustain life
in the awake state. It can be measured after a 12-hour fasting while the subject is resting
physically and mentally, and maintained in a thermoneutral, quiet environment. BMR
is slightly elevated above the metabolic rate during sleep, because energy expenditure
increases above basal levels owing to the energy cost of arousal. The energy cost
associated with meal ingestion is primarily influenced by the composition of the food
that is consumed, and is also relatively stable within individuals over time. BMR is
influenced by many factors. The best indicator of BMR is body composition especially
lean body mass. Growth is also important (during growing periods BMR is increasing
from 15% to 20%). Fever can increase the BMR by about 7% for each 0.83°C. Cold climate
causes BMR rise in response to lower temperatures.

38
 Non-basal requirement for energy includes food intake and physical exercise. The
thermic effect of a meal usually constitutes approximately 10% of the caloric content
of the meal that is consumed. The third source of energy expenditure in the body is
the increase in metabolic rate that occurs during physical activity, which includes
exercise as well as all forms of physical activity. Physical activity energy expenditure
(or the thermic effect of exercise) is the term frequently used to describe the increase
in metabolic rate that is caused by use of skeletal muscles for any type of physical
movement. Physical activity energy expenditure is the most variable component of
daily energy expenditure and can vary greatly within and between individuals owing to
the volitional and variable nature of physical activity patterns.
Total energy requirements: The energy demands of basal metabolism and the
effect of food and of physical activity make up a total energy requirement (Table 10, 12
and 14).
Energy regulation is the process by which energy intake and energy expenditure are
balanced.
Energy balance is the accounting for the energy consumed in foods, losses in
excreta, heat produced, and retention or secretion of organic compounds.
E intake – E faeces – E urine – E combustible gas – E expenditure = E retention or E
secretion
Energy balance is regulated by a complex set of neuroendocrine feedback mechanisms.
Changes in energy intake or in EE trigger metabolic and behavioural responses aimed at
restoring energy balance.
The average adult human consumes close to 1,000,000 calories (4,000 MJ) per year.
Despite this huge energy intake, most healthy individuals are able to strike a remarkable
balance between how much energy is consumed and how much energy is expended,
thus resulting in a state of energy balance in the body. This accurate balance between
energy intake and energy expenditure is an example of homeostatic control and results
in maintenance of body weight and body energy stores. This regulation of energy
balance is achieved over the long term despite large fluctuations in both energy intake
and energy expenditure within and between days.
Energy balance is a state where energy intake is equivalent to energy expenditure.
Energy balance is attained when energy intake equals total energy expenditure (TEE)
and body stores are stable.
An individual is said to be in positive energy balance when energy intake exceeds
TEE (and consequently body energy stores increase).
Negative energy balance occurs when energy intake is less than TEE and body
energy stores decrease. Perturbations to this homeostatic model affect body weight
regulation. Net energy deficit results in weight loss and underweight. Imbalance in the
energy equation, when daily intake of calories is greater than energy expended (a net
energy surplus), leads to weight gain and obesity.

Overnutrition: Occurs when energy intake exceeds energy expenditure and

results in excess body fat accumulation. Several levels of overnutrition are defined in
adults using the body mass index (BMI, weight in kilograms divided by height in meters
squared, kg/m2).
• Overweight BMI = 25–29.9 kg/m2
• Class I Obesity BMI = 30–34.9 kg/m2
• Class II Obesity BMI = 35–39.9 kg/m2
• Class III Obesity BMI ≥ 40.0 kg/m2

39
 In children, BMI changes with development; BMI definitions of overweight and
obesity at different ages are now available.
Undernutrition: Occurs when energy intake is less than TEE over a considerable
period of time resulting in clinically significant weight loss. In adults, undernutrition is
classified using BMI.
• BMI of 18.5–24.9 is considered normal
• BMI of 17–18.49 is mild undernutrition
• BMI of 16–16.99 is moderate undernutrition
• BMI < 16 is severe undernutrition.
In children, undernutrition is classified using the weight-for-height (or length)
index and height-for-age index with reference values derived from the World Health
Organization data.
Wasting is defined as a low weight for height, with < −1SD (i.e. −1 Z-score) being
mild, < −2 SDs being moderate, and < −3 SDs being severely wasted relative to the
National Center for Health Statistics and the World Health Organization International
Growth Reference.
Similarly, stunting is associated with a low height for age with < −1 SD being mild,
< −2 SDs being moderate, and < −3 SDs of the reference values being severely stunted.

Methods for measuring energy expenditure (EE) include direct calorimetry,

indirect calorimetry, and non-calorimetric methods.
Direct calorimetry is the measurement of the heat emitted from the body over a
given period.
Indirect calorimetry estimates heat production indirectly by measuring oxygen
consumption (VO2), CO2 production (VCO2), and the respiratory quotient (RQ), which
is equal to the ratio of the VCO2 to VO2.
Other methods to assess EE applicable to field conditions include heart rate (HR)
monitoring and doubly labeled water method (DLW).

5.3 Physical Activity

The energy expended for physical activity (PA) varies greatly among individuals
as well as from day to day. In sedentary individuals, about two thirds of total energy
expenditure goes to sustain basal metabolism over 24 hours (the BEE), while one-third
is used for physical activity. In very active individuals, 24-hour total energy expenditure
can rise to twice as much as basal energy expenditure.
Some physical activity is better than none. However, more physical activity has more
benefits for health.
Physical activity affects many health conditions, and the specific amounts and
types of activity that benefit each condition vary. Both endurance and resistance are
beneficial.
I. Aerobic Activity (an endurance activity or cardio activity)
In this kind of physical activity the body’s large muscles move in a rhythmic manner
for a sustained period of time (brisk walking, running, cycling, jumping rope, and
swimming).
Aerobic physical activity has three components:
1. Intensity, or how hard a person works to do the activity. The intensities most
often examined are moderate intensity (equivalent in effort to brisk walking)
and vigorous intensity (equivalent in effort to running or jogging);
2. Frequency, or how often a person does aerobic activity;

40
 3. Duration, or how long a person does an activity in any one session.
Although these components make up a physical activity profile, research has shown
that the total amount of physical activity is more important for achieving health benefits
than is any one component (frequency, intensity, or duration).
II. Muscle-Strengthening Activity (resistance training and lifting weights)
This kind of activity, causes the body’s muscles to work or hold against an applied
force or weight. These activities often involve relatively heavy objects, such as weights,
which are lifted multiple times to train various muscle groups. Muscle-strengthening
activity can also be done by using elastic bands or body weight for resistance (climbing
a tree or doing push-ups).
Muscle-strengthening activity also has three components:
1. Intensity, or how much weight or force is used relative to how much a person is
able to lift;
2. Frequency, or how often a person does muscle-strengthening activity;
3. Repetitions, or how many times a person lifts a weight (analogous to duration
for aerobic activity).
III. Bone-Strengthening Activity
This kind of activity (weight-bearing or weight-loading activity) produces a force on
the bones that promotes bone growth and strength. This force is commonly produced
by impact with the ground. Examples of bone-strengthening activity include jumping
jacks, running, brisk walking, and weight-lifting exercises. Bone-strengthening activities
can also be aerobic and muscle strengthening.

Cardiorespiratory fitness is defined as ability of the cardiovascular and respiratory

systems to supply oxygen to the working muscles during sustained hard dynamic
exercise.
Cardiorespiratory fitness is normally evaluated by measuring maximal oxygen
uptake (VO2max) during a progressive graded exercise test on a treadmill or bicycle
ergometer. Muscular strength is defined as the maximum force or tension that
can be generated by a muscle and is measured by determining how much weight
an individual can lift in a certain movement or by how much force or torque an
individual can exert during an isometric (no movement) or isokinetic (constant
velocity) contraction.
Overload is the physical stress placed on the body when physical activity is greater
in amount or intensity than usual. The body’s structures and functions respond and
adapt to these stresses. For example, aerobic physical activity places a stress on the
cardiorespiratory system and muscles, requiring the lungs to move more air and the
heart to pump more blood and deliver it to the working muscles. This increase in
demand increases the efficiency and capacity of the lungs, heart, circulatory system,
and exercising muscles. In the same way, muscle-strengthening and bone-strengthening
activities overload muscles and bones, making them stronger.
Progression is closely tied to overload. Once a person reaches a certain fitness
level, he or she progresses to higher levels of physical activity by continued overload
and adaptation. Small, progressive changes in overload help the body adapt to the
additional stresses while minimizing the risk of injury.
Specificity means that the benefits of physical activity are specific to the body
systems that are doing the work. For example, aerobic physical activity largely benefits
the body’s cardiovascular system.

41
 According to the research, there are plenty of general benefits connected with
providing of physical activity:
• Regular physical activity reduces the risk of many adverse health outcomes.
• For most health outcomes, additional benefits occur as the amount of physical
activity increases through higher intensity, greater frequency, and/or longer
duration.
• Most health benefits occur with at least 150 minutes a week of moderate intensity
physical activity, such as brisk walking. Additional benefits occur with more
physical activity.
• Both aerobic and muscle-strengthening physical activities are beneficial.
• Health benefits occur for children and adolescents, young and middle-aged adults,
older adults, and those in every studied racial and ethnic group.
• The health benefits of physical activity occur for people with disabilities.
• The benefits of physical activity far outweigh the possibility of adverse outcomes.

Physical exercise (PE) is a form of physical activity that is planned, structured,

repetitive, and performed with the goal of improving health or fitness.
Physical exercise can improve overall health and fitness and help to prevent many
adverse health outcomes.
The benefits of physical activity occur in generally healthy people, in people at
risk of developing chronic diseases, and in people with current chronic conditions or
disabilities and include decreasing the risk of different non-communicable diseases
(reduce risk of cardiovascular disease, type 2 diabetes and metabolic syndrome,
some cancers) and increase the chances of living longer.
Many large observational studies have demonstrated a reduced risk of incident
dementia and reduced progression of cognitive decline among older adults who
regularly exercise.
Regular physical activity can produce long-term health benefits. Most health benefits
occur with at least 150 minutes (2 hours and 30 minutes) a week of moderate intensity
physical activity, such as brisk walking. For most health outcomes, additional benefits
occur as the amount of physical activity increases through higher intensity, greater
frequency, and/or longer duration.

Children and adolescents strongly benefit from the following:

• Improved cardiorespiratory and muscular fitness
• Improved bone health
• Improved cardiovascular and metabolic health biomarkers
• Favourable body composition
Moderate evidence:
• Reduced symptoms of depression
The beneficial effects of increasing physical activity are mostly about overload,
progression, and specificity.
Children and adolescents should be provided with facilities and opportunities to
take part in daily programmes of enjoyable exercise so that physical activity may develop
into a lifetime habit. Regular physical activity in children and adolescents promotes
health and fitness.
Compared to those who are inactive physically active youth have higher levels of
cardiorespiratory fitness and stronger muscles. In addition, they typically have lower
body fatness. Their bones are stronger, and they may have reduced symptoms of anxiety
and depression.

42
 Youth can achieve substantial health benefits by doing moderate- and vigorous-
intensity physical activity for periods of time that add up to 60 minutes (1 hour) or
more each day. This activity should include aerobic activity as well as age-appropriate
muscle- and bone-strengthening activities.

Key Guidelines for Children and Adolescents

Children and adolescents should do 60 minutes (1 hour) or more of physical activity
daily.
• Aerobic: Most of the 60 or more minutes a day should be either moderate- or
vigorous-intensity aerobic physical activity, and should include vigorous-intensity
physical activity at least 3 days a week.
• Muscle-strengthening: As part of their 60 or more minutes of daily physical
activity, children and adolescents should include muscle-strengthening physical
activity on at least 3 days of the week.
• Bone-strengthening: As part of their 60 or more minutes of daily physical activity,
children and adolescents should include bone-strengthening physical activity at
least 3 days of the week.

Adults and older adults have strong evidence of the following benefits:
• Lower risk of early death
• Lower risk of coronary heart disease
• Lower risk of stroke
• Lower risk of high blood pressure
• Lower risk of adverse blood lipid profile
• Lower risk of type 2 diabetes
• Lower risk of metabolic syndrome
• Lower risk of colon cancer
• Lower risk of breast cancer
• Prevention of weight gain
• Weight loss, particularly when combined with reduced calorie intake
• Improved cardiorespiratory and muscular fitness
• Prevention of falls
• Reduced depression
• Better cognitive function (for older adults)
Moderate to strong evidence:
• Better functional health (for older adults)
• Reduced abdominal obesity
Moderate evidence
• Lower risk of hip fracture
• Lower risk of lung cancer
• Lower risk of endometrial cancer
• Weight maintenance after weight loss
• Increased bone density
• Improved sleep quality

Adults should be encouraged to increase habitual activity gradually, aiming to carry

out every day at work and during recreational time at least 30 minutes of physical
activity of moderate intensity, e.g. brisk walking and stair climbing. More strenuous
activities (e.g. slow jogging, cycling, field and court games and swimming) could
provide additional benefits. The health benefits of physical activity far outweigh the
risks of getting hurt. The US Federal Physical Guidelines and many studies show that

43
150 minutes per week of moderate intensity physical activity is required to achieve
these health benefits. Adults gain additional and more extensive health and fitness
benefits with even more physical activity. Muscle-strengthening activities also provide
health benefits and are an important part of an adult’s overall physical activity plan.
According to the last available studies, adults with better muscle strength have a 20%
lower risk of mortality (33% lower risk of cancer specific mortality) than adults with
low muscle strength.

Key Guidelines for Adults

• All adults should avoid inactivity. Some physical activity is better than none,
and adults who participate in any amount of physical activity gain some health
benefits.
• For substantial health benefits, adults should do at least 150 minutes (2 hours
and 30 minutes) a week of moderate-intensity, or 75 minutes (1 hour and 15
minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent
combination of moderate- and vigorous-intensity aerobic activity. Aerobic activity
should be performed in episodes of at least 10 minutes, and preferably, it should
be spread throughout the week.
• For additional and more extensive health benefits, adults should increase their
aerobic physical activity to 300 minutes (5 hours) a week of moderate intensity,
or 150 minutes a week of vigorous-intensity aerobic physical activity, or an
equivalent combination of moderate- and vigorous-intensity activity. Additional
health benefits are gained by engaging in physical activity beyond this amount.
• Adults should also do muscle-strengthening activities that are moderate or high
intensity and involve all major muscle groups on two or more days a week, as
these activities provide additional health benefits.
Pedometers and similar equipment can be a motivation tool for people wanting to
increase their physical activity to achieve daily limit approximately 10,000 steps/8km.
The use of a pedometer is associated with significant increases in physical activity and
significant decreases in body mass index and blood pressure.

Key Guidelines for Older Adults

• When older adults cannot do 150 minutes of moderate-intensity aerobic activity a
week because of chronic conditions, they should be as physically active as their
abilities and conditions allow.
• Older adults should do exercises that maintain or improve balance if they are at
risk of falling.
• Older adults should determine their level of effort for physical activity relative to
their level of fitness.
• Older adults with chronic conditions should understand whether and how their
conditions affect their ability to do regular physical activity safely.

Physical Activity Level (PAL), the Physical Activity Index.

The level of physical activity is commonly described as the ratio of total to basal
daily energy expenditure (TEE/BEE) - PAL. Describing physical activity habits in terms
of PAL is not entirely satisfactory because the increments above basal needs in energy
expenditure, brought
about by most physical activities where body weight is supported against gravity
(e.g., walking, but not cycling on a stationary cycle ergometer), are directly proportional
to body weight, whereas BEE is more nearly proportional to body weight.

44
 It is important to encourage people to participate in physical activities that are
appropriate for their age, that are enjoyable, and that offer variety.
Researchers from the EPIC study (European Prospective Investigation into Cancer
and Nutrition) found that an increase in physical activity reduced the risk of mortality,
particularly when comparing inactive people with those that were moderately inactive.
They concluded that these findings provide evidence that even a small increase in the
amount of PA by the most inactive members of society should be encouraged. It has the
potential to improve greatly public health-related outcomes.
According to other studies, rigorous physical activity may be a key to boosting
longevity.

Physical inactivity is a fast-growing public health problem and contributes to a

variety of chronic diseases and health complications, including obesity, diabetes, and
cancer. In addition to improving a patient’s overall health, increasing physical activity
has proven effective in the treatment and prevention of chronic diseases. Even with all
the benefits of physical activity levels of inactivity are alarming.
Physical inactivity is the fourth leading cause of death worldwide. Although
evidence for the benefits of physical activity for health has been available since the
1950s, promotion to improve the health of populations has lagged in relation to the
available evidence and has only recently developed an identifiable infrastructure,
including efforts in planning, policy, leadership and advocacy, workforce training
and development, and monitoring and surveillance. The reasons for this late start are
myriad, multifactorial, and complex. This infrastructure should continue to be formed,
intersectoral approaches are essential to advance, and advocacy remains a key pillar.
Although there is a need to build global capacity based on the present foundations, a
systems approach that focuses on populations and the complex interactions among
the correlates of physical inactivity, rather than solely a behavioural science approach
focusing on individuals, is the way forward to increase physical activity worldwide.
Physically inactive doctors and health care professionals are less likely to
provide exercise counselling to patients and provide less credible role
models for the adoption of healthy behaviours.

References:
EUFIC. The European Food Information Council. An increase in physical activity
may reduce mortality risk in inactive people. 2015. Available online: http://www.
eufic.org/page/sk/show/latest-science-news/fftid/An_increase_in_physical_
activity_may_reduce_mortality_risk_in_inactive_people
FAO. Food and Agriculture Organization of the United Nations. Food and nutrition
technical report series. Human energy requirements. Report of a Joint FAO/WHO/
UNU Expert Consultation Rome, 17–24 October 2001:103, Available online: http://
www.fao.org/docrep/007/y5686e/y5686e04.htm.
IOM. Institute of Medicine. National Academy of Sciences, Food and Nutrition
Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids,
Cholesterol, Protein, and Amino Acids (Macronutrients), 2005:1357. ISBN 0-309-
08525-X (pbk.) — ISBN 0-309-08537-3 (hardcover). Available online: http://www.
nal.usda.gov/fnic/DRI//DRI_Energy/107-264.pdf.

45
 Kohl HW, Craig Cl, Lambert EV. The pandemic of physical inactivity: global action
for public health. The Lancet, 2012; 380 (9838): 294–305.
Nordic Nutrition Recommendations 2012, Integrating Nutrition and Physical Activity,
Nordic Council of Ministers 2014, Layout and ebook production: Narayana Press
Available online: http://www.norden.org/en/theme/themes-2014/nordic-nutrition-
recommendation. ISBN 978–92–893–2670–4.
Physical Activity Guidelines for Americans 2008, Be Active, Healthy, and Happy!
Available online: http://www.health.gov/paguidelines/pdf/paguide.pdf.
Physical Activity Guidelines (PAG). 2008. Health.gov. The Office of Disease
Prevention and Health Promotion (ODPHP). Available online: http://www.
health.gov/paguidelines/.
WHO Global Strategy on Diet, Physical Activity and Health. Geneva: World Health
Organization, 2004. Available online: http://www.who.int/dietphysicalactivity/
strategy/eb11344/strategy_english_web.pdf.

46
 6 HEALTHY DIET

Diet should satisfies the nutritional needs, i.e. covers the physiological requi­
rements for normal metabolic functions and growth, and supports overall
good health and contributes to a reduced risk of diet-associated diseases.
The ideal diet should provide energy and essential nutrients within optimal
ranges from foods that are available, affordable, and palatable.
Nowadays in developed societies, there is characteristic excessive intake of energy,
presence of enormous quantities of processed and refined food loaded with sugars, fat,
salt, and artificial additives in diet.
General recommendations suggest consumption of nutrient-dense, energy balan­
ced diet. Whole-foods approach to healthy eating (basic foods that are naturally lower in
calories and packed with nutrients) seems to be better than consuming mostly processed
foods.
The recommendations derive from an assessment of the evidence on chronic
diseases, but should be used in combination with the recommended dietary allowances
of the country to achieve an optimal and highly desirable pattern for the maintenance
of good health.
The guidelines for individuals differ somewhat from the population goals,
which need to be more stringent in order to achieve the goals for the individuals. Given
our present understanding of food-health relationships, it seems likely that a large
variety of foods can be combined in varying amounts to provide a healthy diet.
Increased attention in dietary research and guidance has been focused on dietary
patterns rather than worrying about single nutrients or food groups, because dietary
components are consumed in combination and correlated with one another. Different
dietary patterns can bring health benefits. There is currently a large body of evidence
directly supporting the importance of specific food patterns or dietary patterns in
maintaining good health. This evidence might facilitate the formulation of food-based
dietary guidelines and recommendations for nutrient intakes. Common characteristics
of dietary patterns associated with positive health outcomes include higher intake of
vegetables, fruits, whole grains, fish/seafood, non-fat dairy, legumes and nuts, lower
consumption of red, processed meat, low intake of refined grains, sugar-sweetened
foods and beverages, alcohol, and reducing salt.
The Mediterranean diet or whole food plant-based diet (the regimen empha­
sizing vegetables, fruits, whole grains, legumes, nuts, fish and olive oil, containing
variety of unprocessed plant foods, rich in fibre and micronutrients with anti-oxidatory
and anti-inflammatory potential, low in meat, sugar and salt) has been consistently
linked with health benefits, including reduced mortality and reduced risk of chronic
diseases.
According to the results from current studies, it seems that there are benefits of
adherence to these types of diets for promoting health and longevity. Greater adherence
to the Mediterranean diet was associated with longer telomeres. Telomere length
variability may be partially explained by lifestyle practices; as accelerated telomere

47
attrition may underlie many chronic diseases, identifying modifiable factors that affect
telomere dynamics is important.
But there are differences among Mediterranean countries and therefore it is
important to evaluate the adherence of a population to the Mediterranean diet pattern.
Diet indexes attempt to make a global evaluation of the quality of the diet based on
a traditional Mediterranean reference pattern, described as a priori, general and
qualitative. The Mediterranean diet indexes summarise the diet by means of a single
score that results from a function of different components, such as food, food groups
or a combination of foods and nutrients.
The old diet advice from previous decades (“fat is always bad”) was probably
incorrect. But the new oversimplification — “fat isn’t bad, carbs are bad” — seems
also incorrect. Some fats (polyunsaturated) are essential and some are more harmful
(trans and saturated), and some carbs are rather harmful (sugar) and some look more
helpful (fibre).
The high-carb diet rich in sugar and refined grains increases the risk of obesity,
diabetes and heart disease, but on the other hand, according to the last available
epidemiological studies it is suggested that encouraging population to eat more meat
and full-fat dairy is not such good advice and it has no basis in science.
Higher diet quality is associated with decreased risk of all-cause, cardiovascular
disease, and cancer mortality among older adults, whereas opposite food patterns, rich
in animal foods and poor in plant-based foods, typically called western or westernized
diets are associated with higher risks.
It is interesting to search what the places called “Blue Zones’’ have in common
(i.e. Okinawa, Sardinia, Loma Linda, Icaria, Nicoya). Their diets are quite diverse (vary
from Italy and Greece to California, Costa Rica, and Japan) but their inhabitants live
longer and healthier lives (fewer cases of heart disease, cancers, diabetes, dementia...).
Among the lifestyle habits that are common to those populations are: a wise diet-high
consumption of fruit, wild plants, vegetables, legumes and low consumption of meat
(mostly pork − but only 5 times per month), never overeating (usually stop eating when
their stomach is 80% full), high levels of daily physical activity (gardening, walking),
social engagement, no alcohol consumption or moderate drinking, no smoking, positive
attitude and enriching their days with periods of calm, enjoying the sun, nature and
family surroundings.

6.1 Guidelines for Healthy Diet - the Pyramid/the Plate

Dietary guidelines are published in different countries. The goals of these are
to prevent nutrient deficiencies and to reduce the risk of chronic diseases.
Various nutrition guides are published by medical and governmental institutions to
educate the public on what they should eat to promote health. Several sets of
dietary guidelines include quantitative recommendations that focus on nutrients. They
are usually intended for health professionals who in turn translate them into practical
advice for the public. Other sets of dietary guidelines are based entirely on foods rather
than nutrients; these are known as food-based dietary guidelines.
Nutrition facts labels are also mandatory in some countries to allow consumers
to choose between foods based on the components relevant to health. It is difficult to
determine a precise indispensable intake of individual foods that can, when combined
with other foods, provide a nutritionally adequate diet under all conditions. Guidelines
most likely can be harmonized following a unified approach to defining them, but
there must be room to accommodate nutritional individuality; a one-size-fits-all
approach should not be too strictly and rigidly applied.

48
 History of one of the most important Food Guides from USDA started in 1916 with
“Food for Young Children” and “How to Select Food” guidance, that was based on
“protective foods”, followed in the 1940s with A Guide to Good Eating (Basic Seven).

Figure 1 Food Guide Pyramid 1992. Figure 2 MyPyramid Food Guidance

(Source: USDA, 2014) System 2005. (Source: USDA, 2014)

In 1992, recommendations were expressed in a well-known The Food Guide

Pyramid (Figure 1), which emphasizes foods from the five food groups shown in the
sections of the pyramid. Each of these groups provides required nutrients for good
health. For everyday living, the simplest and most practical plan is to follow those
same guidelines, selecting from the various food groups the type and amount of food
recommended.
All around the world there is a similar kind of Pyramids adjusted for local
conditions and habits.
Levels for nutrients are established according to age, sex, developmental stage, body
size, levels of physical activity, safe and adequate range.
In 2005, the MyPyramid (Figure 2) Food Guidance System was introduced along
with updating of Food Guide Pyramid food patterns for the 2005 Dietary Guidelines for
Americans, including daily amounts of food at 12 calorie levels. It continued “pyramid”
concept, based on consumer research, but simplified illustration. The system added a
band for oils and the concept of physical activity, illustration could be used to describe
concepts of variety, moderation, and proportion.
In 2011, a so-called MyPlate (Figure 3) was introduced along with updating of
USDA food patterns for the 2010 Dietary Guidelines for Americans. It has a different
shape to help grab consumers’ attention with a new visual cue. Its icon serves as
a reminder for healthy eating, and is not intended to provide specific messages. Its
visual is linked to food and is a familiar mealtime symbol in consumers’ minds, as
identified through testing. The term “My” continues the personalization approach
from MyPyramid.

49
Figure 3 MyPlate (Source: USDA, 2014) Figure 4 Healthy eating plate.
(Source: http://www.hsph.harvard.edu/nutri-
tionsource/healthy-eating-plate-vs-usda-my-
plate/2014)

The U.S. Department of Health and Human Services (HHS) and the U.S. Department
of Agriculture (USDA) have jointly published the Dietary Guidelines every 5 years
since 1980. The Dietary Guidelines encourage individuals to eat a healthful diet — one
that focuses on foods and beverages that help achieve and maintain a healthy weight,
promote health, and prevent disease.
The Healthy Eating Plate (Figure 4), created by nutrition experts at the Harvard
School of Public Health and Harvard Medical School, points consumers to the healthiest
choices in the major food groups. The Healthy Eating Plate is based exclusively on
the best available science and was not subjected to political or commercial pressures
from food industry lobbyists. The red figure running across the Healthy Eating Plate’s
placemat is a reminder that staying active is also important in weight control. The main
message of the Healthy Eating Plate is to focus on diet quality.
• The type of carbohydrate in the diet is more important than the amount of
carbohydrate in the diet, because some sources of carbohydrate — like vegetables
(other than potatoes), fruits, whole grains, and beans — are healthier than others.
• The Healthy Eating Plate also advises consumers to avoid sugary beverages, a major
source of calories — usually with little nutritional value — in the diet.
• The Healthy Eating Plate encourages consumers to use healthy oils, and it does
not set a maximum on the percentage of calories people should get each day
from healthy sources of fat. In this way, the Healthy Eating Plate recommends the
opposite of the low-fat message promoted for decades by the USDA.

6.2 Recommended Dietary Allowances and Dietary

Reference Intakes
Recommended dietary allowances (RDAs) were established by the Food and
Nutrition Board of the National Academy of Sciences. These numerical values provide
nutrition guidance to health professionals and to the general public. RDAs are defined
as the levels of intake of essential nutrients that are judged to be adequate to
meet the known needs of practically all healthy persons.
In addition to providing information for labels on food, RDAs are used for many
other purposes. Institutions use the RDAs to plan healthful diets for schools, prisons,

50
hospitals, and nursing homes. Industry uses them to develop new food products. Policy
makers use them to evaluate and improve food supplies to meet national needs, and
health workers use them to provide nutrition education.
Since 1941, when the first RDAs were published, they have been updated 10 times in
USA. The most recent revision was in 1989 when RDAs were determined for protein, 11
vitamins, and 7 minerals. RDAs were set for different age groups, for men and women,
and for pregnant and nursing mothers. The board also established Estimated Safe and
Adequate Daily Dietary Intakes (ESADDIs) for 7 nutrients where available data were
insufficient to set an RDA. New research was showing the importance of higher intakes
of some nutrients for promoting health (preventing chronic disease) and performance;
there was tremendous growth in food fortification and the use of dietary supplements;
and the existing RDAs did not adequately distinguish guidelines for groups and
populations from those for individuals.
The United Kingdom adopted the term dietary reference value (DRV), the EU
introduced the term population reference intake (PRI), mostly in the USA and Canada
the term dietary reference intake (DRI) was introduced, and Australia and New Zealand
now use the term nutrient intake value (NIV). All are precisely equivalent to the original
concept of the RDA, a term that many countries prefer to continue to use.
The Board replaced and expanded the RDAs with Dietary Reference Intakes
(DRIs) to provide recommended nutrient intakes for use in a variety of settings. The
dietary reference intake was introduced in 1997 in order to broaden the existing
guidelines (RDAs).
It is a system of nutrition recommendations from the Institute of Medicine (IOM)
of the U.S. National Academy of Sciences and it provides several different types of
reference value.
The DRIs are a set of four reference values as follows:
• Estimated Average Requirement (EAR) is the amount of a nutrient that
is estimated to meet the requirement of half of all healthy individuals in the
population.
• Recommended Dietary Allowance (RDA) is the average daily dietary intake
of a nutrient that is sufficient to meet the requirement of nearly all (97−98%)
healthy persons. RDAs represent the mean requirement plus 2 SDs (Standard
Deviation).
• Adequate Intake (AI) for a nutrient is similar to the ESADDI and is only
established when an RDA cannot be determined. Therefore, a nutrient either has
an RDA or an AI. The AI is based on observed intakes of the nutrient by a group of
healthy persons.
• Tolerable Upper Intake Level (UL) is the highest daily intake of a nutrient that
is likely to pose no risks of toxicity for almost all individuals. As intake increases
above the UL, the potential risk of adverse effects may increase.

RDAs are published for professionals as well as for public. The RDAs (Figure 5) are
modified according to expanding knowledge of nutrition and have become a guideline
for proper nutrition for the health-conscious individuals. Each of these reference values
distinguishes between gender and different life stages. RDAs, AIs and ULs are dietary
guidelines for individuals, whereas EARs provide guidelines for groups and populations.
In addition, factors that might modify these guidelines, such as bioavailability of
nutrients from different sources, nutrient-nutrient and nutrient-drug interactions, and
intakes from food fortificants and supplements, are incorporated into the guidelines in
much greater detail than previously.

51
Figure 5 Dietary reference intakes (Source: Ševčíková et al., 2011, Nestle, 2008)

The World Health Organization (WHO) has taken a rather different approach,
defining population safe ranges of intake. “Normative requirement” is now used
to describe the population mean normative requirement (which would allow the
maintenance of, or a desirable, body store or reserve); “maximum” to refer to the
upper limit of safe ranges of population mean intakes; and “basal” for the lower such
limit, below which clinically detectable signs of inadequacy would be expected to
appear. These WHO requirements are revised in groups of nutrients at different times.

Recommended nutrient intakes (RNIs) are customarily defined as the intake of

energy and specific nutrients necessary to satisfy the requirements of a group of healthy
individuals. This nutrient-based approach has served well to advance science, but has
not always fostered the establishment of nutritional and dietary priorities consistent
with broad public health interests at national and international levels.
Food-based dietary guidelines (FBDGs) address health concerns related to
dietary insufficiency, excess, or imbalance with a broader perspective, considering the
totality of the effects of a given dietary pattern. They are more closely linked to the
diet-health relationships of relevance to the particular country or region of interest. In
addition, they take into account the customary dietary pattern, the foods available, and
the factors that determine the consumption of foods. They consider the ecologic setting,
the socioeconomic and cultural factors, and the biologic and physical environment that
affects the health and nutrition of a given population or community. Finally, they are
easy to understand and accessible for all members of a population.
The Joint Food and Agriculture Organization (FAO)/World Health Organization
(WHO) consultation on preparation and use of Food-Based Dietary Guidelines has
indicated the need to consider the following nine key factors in developing
national FBDGs:
• Scientific evidence concerning diet-health relationships
• The prevalence of diet-related public health problems
• Food consumption patterns of the population
• Nutritional requirements
• The potential food supply
• The composition of foods, including consideration of food preparation practices
• The bioavailability of nutrients supplied by the mixed local diet
• Sociocultural factors that relate to food choices and accessibility
• Food costs
RDAs valid in Slovakia are in Tables 10−15.

52
 6.3 General Recommendations
Common recommendations for healthy diet are as follows and they offer important
messages about diet quality, not just quantity:
• Fill half of your plate with vegetables and fruits. The more colour, and the more
variety, the better.
• Save a quarter of your plate for whole grains. The less processed the whole grains,
the better. But grains are not essential for good health.
• Pick a healthy source of protein to fill one quarter of your plate: some protein
sources (fish, chicken, beans, nuts) are healthier than others (red meat and pro­
cessed meat).
• Enjoy healthy fats like olive, avocado, nuts for making the salads, and at the table.
Limit butter, and avoid unhealthy trans fats.
• Drink water, coffee, or tea (which are also low-calorie and have health benefits).
Limit milk and dairy products to one to two servings per day and limit juice. Skip
sugary drinks.
• Staying active is half of the secret to weight control. The other half is eating a
healthy diet with modest portions that meet your calorie needs.

To be more specific:
• Carbohydrates intake: to consume fibre-rich fruits, vegetables, increase intake
of starches and other complex carbohydrates by eating more daily servings of a
combination of whole grains and legumes. Consume foods and beverages with
very little added sugars or caloric sweeteners.
• Fat intake: limiting intake of fats and oils high in saturated (consumption less
than 7−10 % of calories from saturated fatty acids), and avoiding trans-fatty acid
consumption (meat should be lean, preferably poultry; milk and dairy products
preferably low-fat), majority of fats should come from sources of polyunsaturated
and monounsaturated fatty acids (such as fish, nuts, seeds and vegetable oils).
• Maintain protein intake at moderate level (e.g. about 1 g/kg body weight for
adults).
• Try to eat every day five or more servings/portions of vegetables and
fruits (One adult portion of fruit or vegetables is 80g, is equal to a half cup or
cup for most fresh or cooked vegetables = three heaped tablespoons of cooked
vegetables; one medium piece of fresh fruit (one apple, banana), or 2-3 smaller
(two kiwi fruit, three apricots), dry fruits = 30g (one tablespoon of mixed fruit,
two figs, three prunes); or a combination of vegetables and fruits, especially
green and yellow vegetables and citrus fruits; one 150ml glass of unsweetened
100% fruit or vegetable juice can count as a portion.
• Do not drink alcoholic beverages, alcohol is a carcinogen. If it is not possible to
avoid alcohol consumption totally, limit the doses. Moderate alcohol consumption
is defined as having up to 2 drinks per day for men, but only up to 1 drink per day
for women (the equivalent of less than 30 g of pure alcohol daily for men, half
for women). This definition is referring to the amount consumed on any single
day and is not intended as an average over several days. The Dietary Guidelines
also state that it is not recommended that anyone begins drinking or drinks more
frequently on the basis of potential health benefits because moderate alcohol
intake is also associated with increased risk of breast cancer, violence, drowning,
and injuries from falls and motor vehicle crashes. Pregnant women should totally
avoid alcoholic beverages.
• Limit total daily intake of salt to 6 g or less (approximately 1 tsp of salt,
total maximum recommended limit of sodium for adults should be less than

53
 2300 mg/ day). Limit the use of salt in cooking and avoid adding it to food at the
table. Salty, highly processed food, salt-preserved, and salt-pickled foods should
be consumed sparingly. At the same time, consume potassium-rich foods, such
as fruits and vegetables.
• Maintain adequate calcium intake.
• Avoid taking dietary supplements in excess of the recommended dietary
allowance. A single daily dose of multiple vitamin-mineral supplements containing
100% of the recommended dietary allowance is not known to be harmful or
beneficial. However, vitamin-mineral supplements that exceed the recommended
dietary allowance and other supplements (such as protein powders, single amino
acids, fibre, and lecithin) do not only have health benefits for the population, but
their use may be detrimental to health. The desirable way for the general public
is to obtain recommended levels of nutrients by eating a variety of foods.
• Maintain an optimal intake of fluoride, particularly during the years of primary
and secondary tooth formation and growth.
• Maintain body weight: in a healthy range, balance calories from foods and
beverages with calories expended.
• Also according to the recommendations of the American Heart Association, World
Cancer Research Fund, and American Institute for Cancer Research a diet that
consists mostly of unprocessed plant foods, with emphasis on a wide range of
whole grains, legumes, and non-starchy vegetables and fruits should be preferable.
Healthy diet is low in energy density, which may protect against weight gain and
associated metabolic diseases.
• Limiting or better avoiding consumption of sugary drinks, energy rich
foods, including “fast foods”, red and processed meats − it can improve
health and reduce the risk of chronic disease.

6.4 Diet Quality Scores, Eating Indexes

Predefined diet quality scores are valuable tools to assess nutritional habits of
individuals and populations. They reflect a more comprehensive picture of diet than
individual food or nutrient intakes and provide a more holistic approach to study the
relationship between diet and health. Healthy diet indicator (HDI) was originally
developed in 1997, reflecting the 1990 dietary recommendations of the WHO for the
prevention of chronic diseases. Being based on international guidelines, it is often used
in cross-cultural settings.

Table 8 Healthy diet indicator (HDI), (Source: Stefler, 2014)

Components of the HDI scores 0 Point 0–10 Points 10 Points
SFAs, energy % >15 10–15 0–10
n3-PUFAs, energy % >3 0–1 or 2–3 1–2
n6-PUFAs, energy % >13 0–5 or 8–13 5–8
Trans fatty acids, energy % >2 1–2 <1
Mono and disaccharides, energy % >30 10–30 0–10
Protein, energy % >25 0–10 or 15–25 10–15
Cholesterol, mg/day >400 300–400 0–300
Fruits/vegetables, g/day 0 0–400 >400
NSP, g/day 0 0–20 >20
Abbreviations: energy %, percentage of daily alcohol-free energy intake; HDI, healthy diet indicator;
NSP, non-starch polysaccharides; PUFA, polyunsaturated fatty acid; SFA, saturated fatty acid.

54
 Examples of dietary quality scores include: the Healthy Eating Index (HEI)-2005
and 2010, the Alternate HEI (AHEI) and updated AHEI-2010, the Recommended
Food Score (RFS), the Dietary Approaches to Stop Hypertension (DASH) Score,
the Mediterranean Diet Score (MDS), and the Alternate Mediterranean Diet
Score (aMed).
The Healthy Eating Index (HEI) (Table 9) is a measure of diet quality that assesses
conformance to federal dietary guidance. USDA’s primary use of the HEI is to monitor the
diet quality of the U.S. population and the low-income subpopulation. For this purpose,
the Centre for Nutrition Policy and Promotion (CNPP) uses the data collected via 24-hour
recalls of dietary intake in national surveys. The HEI is also used to examine relationships
between diet and health-related outcomes and between diet cost and diet quality, to
determine the effectiveness of nutrition intervention programmes, and to assess the
quality of food assistance packages, menus, and the US food supply. The HEI is a scoring
metric that can be applied to any defined set of foods, such as previously collected dietary
data, a defined menu, or a market basket. The original HEI was created by CNPP in 1995.
It was revised in 2006 by a federal working group, led by CNPP with members from
the National Cancer Institute and the USDA Food and Nutrition Service, to reflect the
2005 Dietary Guidelines for Americans, and updated in 2012 to reflect the 2010 Dietary
Guidelines for Americans. A score of 100 meant following the federal recommendations
to the last dot and comma, while a score of 0 meant totally ignoring them.
Harvard School of Public Health researchers created an Alternate Healthy Eating
Index and they did appear to correlate more closely with better health in both sexes.
Men with high scores (those whose diets most closely followed the Healthy Eating
Pyramid guidelines) were 20 per cent less likely to have developed a major chronic
disease than those with low scores. Women with high scores lowered their overall risk
by 11 per cent. Men whose diets most closely followed the Healthy Eating Pyramid
lowered their risk of cardiovascular disease by almost 40 per cent; women with high
scores lowered their risk by almost 30 per cent.
These findings suggest that closer adherence to the 2005 Dietary Guidelines may
lower risk of major chronic disease. However, the AHEI-2010, which included additional
dietary information, was more strongly associated with chronic disease risk, particularly
CHD and diabetes.

The Eating Choices Index (ECI) score includes four components as follows:
1. consumption of breakfast
2. consumption of two portions of fruit per day
3. type of milk consumed
4. type of bread consumed
Each component provides a score from 1 to 5.
ECI scores correlate with nutrient profiles consistent with a healthy diet.
ECI provides a simple method to rank diet healthiness in large observational studies.

55
Table 9 The Healthy Eating Index (HEI), (Source: http://epi.grants.cancer.gov/hei/developing.
html, 2014)

M a x . Standard for max. score/ Standard for min. score of

Component
points per 1,000 kcal zero

Adequacy:

Total Fruit 2 5 ≥0.8 cup equiv. No Fruit

Whole Fruit 3 5 ≥0.4 cup equiv. No Whole Fruit

Total Vegetables 4 5 ≥1.1 cup equiv. No Vegetables

Greens and Beans 4 5 ≥0.2 cup equiv. No Green Vegs, Beans, Peas

Whole Grains 10 ≥1.5 oz equiv No Whole Grains

Dairy 5 10 ≥1.3 cup equiv. No Dairy

Total Protein Foods 6 5 ≥2.5 oz equiv No Protein Foods

Seafood and Plant Proteins 6,7 5 ≥0.8 oz equiv. No Seafood or Plant Proteins

Fatty Acids 8 10 (PUFAs+MUFAs)/SFAs >2.5 (PUFAs + MUFAs)/SFAs <1.2

Moderation:
≤1.8 oz equiv. per 1,000
Refined Grains 10 ≥4.3 oz equiv. per 1,000 kcal
kcal
Sodium 10 ≤1.1 gram per 1,000 kcal ≥2.0 grams per 1,000 kcal

Empty Calories 9 20 ≤19% of energy ≥50% of energy

1. Intakes between the minimum and maximum standards are scored proportionately
2. Includes fruit juice.
3. Includes all forms except juice.
4. Includes any beans and peas not counted as Total Protein Foods.
5. Includes all milk products, such as fluid milk, yogurt, and cheese, and fortified soy
beverages.
6. Beans and peas are included here (and not with vegetables) when the Total
Protein Foods standard is otherwise not met.
7. Includes seafood, nuts, seeds, soy products (other than beverages) as well as
beans and peas counted as Total Protein Foods.
8. Ratio of poly- and monounsaturated fatty acids to saturated fatty acids.
9. Calories from solid fats, alcohol, and added sugars; threshold for counting alcohol
is >13 grams/1000 kcal.

56
 References
Francis JJ, Klitzke CJ. Dietary Reference Intakes: Cutting Through the Confusion. In: Nutrition
guide for physicians. Edt. Wilson T et. Al. Humana Press, a part of Springer Science+Business
Media, LLC 2010: 437. ISBN 978-1-60327-430-2 e-ISBN 978-1-60327-431-9.
Healthy eating plate. The Nutrition Source. Harvard T.H. Chan. School of Public Health.
Available online: http://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate-vs-usda-
myplate/2014.
Institute of Medicine. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements.
Edt. Otten JJ et al. Aviable online: http://www.nap.edu/catalog/11537.html, http://www.nal.
usda.gov/fnic/DRI/Essential_Guide/DRIEssentialGuideNutReq.pdf.
Kajaba I, Štencl J, Ginter E, Šašinka MA, Trusková I, Gazdíková K, Hamade J, Bzdúch V. Recommended
Dietary Allowances for Adults, Children and Youth (9th Revision) – Basic, Additional tables, .
Vestník MZ SR 2015, čiastka 4-5, roč. 63, 19.jún 2015, str. 19, Odporúčané výživové dávky pre
obyvateľstvo v Slovenskej republike (9. revízia).
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Eating Index 2010. Components & Scoring Standards. Available online: http://appliedresearch.
cancer.gov/hei/developing.print.html.
Nestle M. Nutrition in Public Health and Preventive Medicine. In: Maxcy-Rosenau-Last. Public
Health and Preventive Medicine. 15th edition, Ed. Wallace RB, New York, 2008: 1195-1203.
ISBN 0-07-144198-0.
Pot GK, Richards M, Prynne CJ, Stephen AM. Development of the Eating Choices Index (ECI):
a four-item index to measure healthiness of diet. Public Health Nutr., 2014; 17(12): 2660-
6. doi: 10.1017/S1368980013003352. Available online: http://www.ncbi.nlm.nih.gov/
pubmed/24477178.
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populations: prospective evidence from the HAPIEE cohort. Eur J Clin Nutr. 2014 Dec;
68(12):1346-52.
Ševčíková Ľ, et al. Hygiene/Environmental Medicine, Bratislava: Comenius University, 2011: 332,
ISBN 978-80-223-2900-2.
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National Nutrient Database for Standard Reference, Available online: http://www.ars.usda.
gov/main/site_main.htm?modecode=12-35-45-00.
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Nutrition Policy and Promotion. Dietary Guidelines for Americans 2015, The Advisory Report.
Available online: http://www.cnpp.usda.gov/DietaryGuidelines.

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 7 SPECIAL NUTRITIONAL NEEDS

The RDAs also accept special nutritional needs in some population groups such as
pregnant and lactating women, children and adolescents, elderly people, physically
active persons, or sportsmen.

7.1 Nutrition of Pregnant and Lactating Women

The foetal origin of adult disease (Barker hypothesis) suggests that adverse
environments in foetal life and early childhood can increase risk of disease in adult life,
e.g. malnutrition during gestation induces programming in the pancreatic beta cells,
muscle, liver, adipose tissues, and neuroendocrine axis. Poor prenatal environment and
a too rich postnatal environment lead to a poor ability to adapt, which increases the
risk of obesity, glucose intolerance and coronary heart disease later in life. According
to epidemiological studies, it seems that the perinatal environment can predispose
human offspring to develop obesity and type 2 diabetes. Maternal malnutrition, obesity,
diabetes, different stressors (psychological and pharmacological) could promote
obesity and diabetes, while early-onset exercise can ameliorate these issues, especially
in genetically predisposed offspring.
The need for most nutrients is increased during pregnancy to meet the high demands
of both the growing foetus and the mother who herself goes through a period of growth
to carry the child and prepare for lactation. Pregnant and lactating women have a higher
need for energy and some vitamins and minerals. Foetal growth during pregnancy and
milk secretion during lactation are nutrient-requiring processes. In well-nourished
women, normal physiologic and metabolic adjustments in nutrient utilization probably
provide the additional nutrients needed for foetal growth and milk secretion. In poorly
nourished women, the additional demand for nutrients during these processes may
lead to maternal and or foetal nutrient deficiencies.
The daily nutrient requirements of the lactating woman are higher than require­
ments during pregnancy. The higher recommended intakes are based primarily on
the amounts secreted in milk. RDAs assume that the mother secretes about 500 kcal/
day in milk, including about 5% as protein, more than 50% as fat, and 38% as lactose
(IOM). This falls to 400 kcal/day in the second 6 months. The recommended intake of
most micronutrients is also increased to cover the amounts secreted in milk. The only
nutrient that is needed in lower amounts during lactation is iron, except for women
who need to synthesize large amounts of blood to replace major blood losses during
delivery.

7.2 Nutrition of Infants and Youth

The normal infant experiences a three -fold increase in weight and a two-fold
increase in length during the first year of life, and also experiences dramatic develop­
men­tal changes in organ function and body composition. These rapid rates of growth

58
and development are superimposed on relatively high maintenance needs incident
to the higher metabolic and nutrient turnover rates of infants vs. adults. The first
2 years of a child’s life are vital as optimal nutrition during this period reduces the
risk of dying and of developing NCDs. It also fosters better development and healthy
growth and development overall. Advice on a healthy diet for infants and children is
similar to that for adults but these elements are also important according to the WHO
recommendations.
• Infants should be breastfed exclusively for the first 6 months of life. Breastfeeding
for the first 6 months of age best supports healthy growth and development.
• Breastfeeding is recommended for 12 months and thereafter at the discretion of
the mother. Mother´s milk as the only one absolutely ideal “food” provides the
correct balance of nutrients, enzymes, immunoglobulin, hormones, anti-infective
and anti-inflammatory substances, and growth factors for the infant. Breastfeeding
is especially effective in developing countries where access to sanitized water is
limited.
• From 6 months of age, breast milk should be complemented with a variety of
adequate, safe and nutrient-dense complementary foods.
• Children over the age of two should follow a balanced diet as defined by
the Dietetic Associations or individual countries’ health ministries. Children
who do not follow a balanced diet are at risk for lifetime healthcare problems
such as obesity, high blood pressure, cardiovascular diseases, and diabetes or
undernourishment deficiency diseases.
• Salt and sugars should not be added to complementary foods.
Optimal nutrition is necessary for growth, development, metabolism, health, and
well-being of children and adolescents. Early nutrition has a powerful effect on cognitive
development and growth, particularly in the first 2–3 years.
It is important to develop healthy eating habits in childhood and adolescence, help
with healthy food choices, and raise a healthy eater by setting a good example and
practising positive habits and following food safety rules.
Recommended dietary allowances for children and adolescents are presented in
Tables 14 and 15.

In developed countries children and adolescents are more likely to eat pre-
packaged foods, high in sugar and fat, rather than more nutritious alternatives, which
lead to obesity. With many countries now seeing a rapid rise in obesity among infants
and children, the WHO in May 2014 set up the Commission on Childhood Obesity. The
Commission will draw up a report for 2015 specifying which approaches and actions
are likely to be most effective in different contexts around the world.
In developing countries, malnutrition still remains a big problem; effects of
undernourishment can last a lifetime including blindness, stunted growth, disability, and
death. Diarrhoeal diseases are consequences of sanitation deficiencies, and contaminated
food. Globally, 161 million under-five-year-olds were estimated to be stunted in 2013. The
global trend in stunting prevalence and numbers affected is decreasing. Between 2000
and 2013, stunting prevalence declined from 33% to 25% (numbers declined from 199
million to 161 million). In 2013, about half of all stunted children lived in Asia and over
one third in Africa. Globally, 51 million under-five-year-olds were wasted and 17 million
were severely wasted in 2013, wasting prevalence in 2013 was estimated at almost 8%
and nearly a third of that was for severe wasting, totalling 3%. Alongside undernutrition,
a ‘double burden’ of malnutrition is emerging with rates of obesity and related chronic
diseases associated with urbanisation, aging populations, technological development and
globalisation of food supplies and industry. Children are increasingly exposed to high-fat,

59
high-sugar, high-salt, energy-dense, micronutrient-poor foods which tend to be cheaper
than healthy foods. There is a general imbalance in energy intake compared to physical
activity levels, which is driving the obesity epidemic.
The number of overweight children increased all around the world. Globally, more
than 42 million under-five-year-olds were overweight in 2013, up from 32 million in
2000. It is estimated that at least 35 million overweight children are living in developing
countries and approximately 8 million in developed countries.
Adolescence is an important period during which major biological, social,
physiological, and cognitive changes take place. Adolescents have special nutritional
needs as a result of rapid growth (lean body mass, fat mass, bone mineralization) and
maturational changes associated with the onset of puberty. Dietary surveys show that
most adolescents do not meet age and gender nutrient recommendations and have
inadequate dietary intake of calcium, iron, and zinc, thiamine, riboflavin, and vitamins
A, C, D. Despite their poor dietary intakes, the only clinical nutrient deficiency
commonly seen among adolescents is iron-deficiency anaemia. To accommodate rapid
gains, calcium requirements are higher for adolescents than for children or adults.

7.3 Nutrition in Older Adults

Older adults are a diverse and extremely heterogeneous population group. Aging
is a uniquely individual process that is influenced by an accumulation of life events.
Differentiation between chronologic age and senescence must be taken into account.
Some 70-year-old persons are fit and less “aged” from a cellular and functional standpoint
than are some 40-year olds as a result of a variety of genetic, health status, and lifestyle
characteristics. However, functional declines naturally occur with advancing age.
Elderly people are often categorized by chronological age, with stratification so that
the cohort of 65- to 74-year-olds is referred to as the “young old,” 75- to 84-year-olds as
“old,” and those 85 years and older as the “oldest old.”
The average age and the proportion of the population, which is older increase every
year: according to the last available data from the WHO around the world the number
of people aged 60 years and over was estimated at 600 million in 2000, a figure that is
expected to rise to 1.2 billion by 2025 and 2 billion by 2050. Many of the physiological
changes associated with aging can be slowed down to some extent by eating a healthy
diet and taking physical exercise, and many of the chronic diseases prevalent in older
adults are either preventable or modifiable with healthy lifestyle habits. Thus, older
adults can experience successful aging that allows them to achieve physical, social, and
mental well-being over the life course and to participate in society.
Aging is associated with a physiological anorexia; as shown by NHANES III data,
energy intakes between ages 25 and 70 years can decline by as much as 1000 to 1200
kcal/day for men and 600 to 800 kcal/day for women. By age 80, 1 in 10 men consumed
less than 890 kcal/day whereas 1 in 10 women consumed less than 750 kcal/day (This
decrease in appetite is influenced by multiple physiological changes. Much of the intake
decrease in early old age is an appropriate response to decreased energy needs due to
reduced physical activity and loss of lean body mass.
Other physiological changes associated with aging promote anorexia as follows:
• Early satiety develops with age, related to gastrointestinal changes (delayed
gastric emptying and altered gastric distension) and gastric hormone changes;
and increased cytokine activity.

60
 • Senses of taste and smell tend to decline in later years. These changes in taste
and smell may decrease one’s appetite for foods to such an extent that the diet
becomes unbalanced.
• Vision generally becomes poorer with age. As a result, shopping, cooking, and
eating may become more difficult. These problems may result in decreased meal
preparation.
• Less saliva may be produced with aging and foods are more difficult to swallow.
• The loss of teeth makes it difficult to eat and chew foods properly. This often
leads to eating softer foods, which restricts food intake and can lead to an
unbalanced diet.
• Muscular tone and coordination often decreases with aging. This may make
swallowing difficult and causes food to move slower through the intestine. Older
adults are primary targets for laxative advertisements. A well-balanced diet with a
variety of foods, adequate fibre, fluids, and physical activity often help to combat
constipation.
• A decrease in the amount of acid in the stomach gastric juice may occur with
aging. This causes decreased digestion and a feeling of indigestion. Older adults
may be tempted to take baking soda, which can further decrease the stomach
acid content. A decrease in the amount of digestive enzymes may decrease
tolerance of milk or high fat foods.
• A decrease in strength and energy may occur with increasing age. As a result,
food purchasing, carrying heavy groceries, choosing from a wide variety of foods
and preparing meals may become difficult.
• Body composition changes with age and the decline in lean body mass leads
to decreased strength and mobility, poor balance and an increased frequency of
falls. Conserving muscle mass in old age is therefore a strategy for preserving
strength, and is of great significance in maintaining physical activity, retarding
insulin resistance, and ensuring normal immune function, too. Preventing age-
related decline in cognitive functions and maintaining good eye health into older
age are both major challenges.
The importance of good nutrition among older people for the maintenance of
health has long been advocated, and evidence-based dietary recommendations for
older people have been published by the WHO. However, for a variety of functional,
physiological, psychological, and social reasons older people are nutritionally
vulnerable and frequently consume diets that are poor in both quality and quantity.
This vulnerability often results in macronutrient and micronutrient undernutrition.
Improving the diet of older people may be able to delay the initiation, or slow the
progression, of cognitive decline.
The single most important clinical aspect leading to diagnosis of malnutrition is
weight change and especially unintentional weight loss. More recently developed,
the Mini Nutritional Assessment represents the most widely accepted and validated
nutritional assessment tool for older people, regardless of setting, with clearly
defined thresholds. Its aims are to evaluate the risk of malnutrition without the need
for specialized personnel. Malnutrition is a dynamic phenomenon that starts when
nutritional intakes are insufficient to match requirements. Most commonly, malnutrition
is used to refer to inadequate intakes of energy and protein, but the same reasoning can
be applied to other nutrients (e.g. specific lipids such as longchain polyunsaturated
fatty acids, vitamins, and micronutrients).
The prevalence of obesity decreases in extreme old age, but remains a common
problem in the elderly. Aging is accompanied by an increase in fat mass and a decrease

61
in lean mass. There are several explanations of increased fat mass: reduced physical
activity and energy expenditure, reduced growth hormone secretion, diminished sex
hormones, and decreased resting metabolic rate due to reduction of lean mass. Moreover,
fat mass distribution changes with aging: there is an increased central distribution of
fat (intra-hepatic and intra-abdominal), which is associated with insulin resistance and
non-insulin-dependent diabetes mellitus. For the population as a whole, overweight and
obesity are associated with increase in all-cause mortality, as well as morbidity related
to diseases for which overweight and obesity are risk factors (such as hypertension,
dyslipidaemia, diabetes, coronary heart disease, stroke, osteoarthritis, sleep apnoea, and
some cancers).
Sarcopenia has been defined as the loss of muscle mass and strength that occurs
with advancing age. It is a complex, multifactorial process facilitated by a combination
of voluntary and involuntary factors. These include the aging process over the life
course, less than optimal diet in older age, sedentary lifestyle, chronic diseases, and
some drug treatments.
Hydration Disorders. With aging, there is a decline in total body water. Elderly
people are more susceptible to dehydration than younger people for many reasons.
Simple interventions such as regularly offering fluids to elderly people have been
shown to significantly decrease the frequency with which dehydration develops.
To prevent above-mentioned complications in the elderly is a challenge facing
developed and developing countries alike. Promoting healthy aging must become a
major policy initiative globally.
Recommended dietary allowances for older people are presented in Tables 10–13.

References
Drewnowski A, Evans WJ. Nutrition, physical activity, and quality of life in older adults: summary.
J Gerontol A Biol Sci Med Sci, 2001; 56: 89–94.
Edelstein S. Life Cycle Nutrition. An Evidence-Based Aproach. 2nd edition. Jones & Bartlett
Learning, Burlington, MA, 2015: 559. ISBN 978-1-4496-9430-2.
Kajaba I, Štencl J, Ginter E, Šašinka MA, Trusková I, Gazdíková K, Hamade J, Bzdúch V. Recommended
Dietary Allowances for Adults, Children and Youth (9th Revision) – Basic, Additional Tables,
Vestník MZ SR 2015, čiastka 4-5, roč. 63, 19.jún 2015, str. 19, Odporúčané výživové dávky pre
obyvateľstvo v Slovenskej republike (9. revízia).
Musacchio NS, Forcier M. Adolescent Health. In: International Encyclopaedia of Public Health.
Heggenhougen HK, Quah S. Bergen: Elsevier, 2008. ISBN: 978-0-12-373960-5.
Ševčíková Ľ, et al. Hygiene/Environmental Medicine, Bratislava: Comenius University, 2011: 332,
ISBN 978-80-223-2900-2.
Scientific Advisory Committee on Nutrition Carbohydrates and Health. London: TSO, part of
Williams lea. Published for Public Health England under licence from the Controller of Her
Majesty’s Stationery Office. 2015: 369. ISBN 978 0 11 708284 7. Available online: https://
www.gov.uk/government/uploads/system/uploads/attachment_data/file/445503/SACN_
Carbohydrates_and_Health.pdf.

62
 8 ALTERNATIVE NUTRITION

Alternative ways of nutrition recommend other types of nutrition than recommended

in guidelines. They can have scientific background and health benefits, but some do not
respect principles of evidence-based medicine.
The most widely used diet worldwide is a vegetarian diet, which we take as an
example.

Vegetarian diet
If it is balanced, it has positive effects in disease prevention, but it assumes deep
knowledge to prevent nutrient deficiency. Vegetarians usually have healthier attitudes
overall; many vegetarians avoid tobacco, use alcohol in moderation, if at all, and are
more physically active than other adults. When researchers take into account all the
effects of a total health-conscious lifestyle on disease development, the evidence still
often weighs in favour of vegetarian eating patterns.
Vegetarianism is the practice of abstaining from the consumption of meat (red meat,
poultry, seafood and the flesh of any other animal), and may also include abstention
from animal by-products. Many millions of people have become vegetarians, replacing
meats as a main item of protein with legumes, grains, and vegetables. It is therefore
needed to achieve the necessary balance of essential amino acids. According to the
American Dietetic Association, vegetarian diets that are appropriately planned and
monitored are healthful and nutritionally adequate, and may provide health benefits in
disease prevention and treatment.
Vegetarians tend to have higher fibre intakes than omnivores. The high fibre and low
fat content of vegetarian foods are beneficial, and can result in decreased energy intake.
Dietary protein may be used for energy, thus negatively affecting protein status. High
intakes of grains containing anti-nutrients can decrease intestinal absorption of iron,
calcium, and zinc. The most common deficiencies include vitamins B12 and D, calcium,
iron, zinc, iodine, riboflavin, and essential fatty acids. Strict vegetarians acquire also
very little carnitine in their diets.
Both lacto-ovo-vegetarians and meat eaters can generally rely on their diets during
critical times of life (particularly pregnant women, infants, children, adolescents,
and the elderly). Vegetarians have to be careful also to get enough kcal generally, but
especially pregnant women and children. During pregnancy, nutrient needs for
vegetarians are the same as for non-vegetarians except for a higher recommendation
for iron intake. Analysis of available studies suggests that pregnant vegetarians consume
lower levels of protein, vitamin B12, calcium, and zinc, but no evidence indicates
detrimental outcomes for mother or foetus. Vegetarian diets can be planned in order
to meet the needs for all nutrients, with special attention to vitamin B12, vitamin D,
calcium, iron, and zinc. Women - lacto-ovo-vegetarians who consume also some animal
products usually get enough proteins and other essential nutrients for a successful
pregnancy, but occasionally uses of supplements are recommended to take in order to
cover their extra nutritional needs.

63
 Children and adolescents have a variety of motivations for following a vegetarian
diet. Some are members of vegetarian families. Others cite an assortment of reasons,
including health, animal welfare, and environmental concerns. There are numerous
health benefits for adults following a vegetarian diet, including a lower body mass
index (BMI), reduced risk of cardiovascular disease, lower blood pressure and lower
rates of hypertension, reduced risk of type 2 diabetes, and a lower risk for prostate
and colorectal cancers. Less is known about benefits for vegetarian children. Vegetarian
children do tend to be leaner than nonvegetarian children are. Positive food patterns
of vegetarian adolescents include greater consumption of fruits, vegetables, nuts, and
legumes and lower consumption of sweets, fast food, and salty snack foods. In addition,
diets of vegetarian children and adolescents tend to be lower in cholesterol, saturated
fat, and total fat and higher in fibre than diets of nonvegetarians are. Key nutrients for
vegetarian children and adolescents include protein, iron, zinc, calcium, vitamin D,
vitamin B12, and omega-3 fatty acids. In the nonvegetarian diet, these nutrients are
frequently largely obtained from animal products, so questions have been raised about
their adequacy in vegetarian or vegan diets.
The meals of vegetarians follow a variety of patterns. This concerns the following
types of vegetarians:
Vegans who rely only on plant foods.
Fruitarians who eat only fresh and dried fruits, nuts, some vegetables, seeds, honey,
and sometimes olive oil.
Lacto-vegetarians, as the only allowed animal protein comes from milk, cheese
and other dairy products.
Ovo-vegetarians who use eggs as their only source of animal protein.
Lacto-ovo-vegetarians, a food plan consisting of plant food plus diary products
and eggs.
Pescetarians (Quasi-vegetarians) whose diet excludes beef, pork, poultry,
includes mosty plant foods, fish, dairy products and eggs.
Semi-vegetarian (Flexitarians) whose diets consist largely of vegetarian foods,
but may include fish or poultry, or sometimes other meats, on an infrequent basis.
“Far“ vegetarians who eat mostly vegetarian diet, occasionally eat meat, but
exclude red meat.
To find much more different advice is possible in the USDA National Agriculture
Library’s Vegetarian Nutrition Resource List.

References
Mangels R, Stallmann I, et al. Special Topics in School-Aged Nutrition: Pediatric Vegetarianism,
Childhood Obesity, and Food Allergies, Chapter 7. In: Life Cycle Nutrition. An Evidence-Based
Aproach. Second edition. Sari Edelstein- editor. Jones & Bartlett Learning, Burlington, MA.
2015: 559. ISBN 978-1-4496-9430-2.
McEvoy C, Woodside JW. Vegetarian and VeganDiets: WeighingtheClaims. In: Nutrition guide for
physicians. Edt. Wilson T, et. al. Humana Press, a part of Springer Science+Business Media, LLC
2010: 437. ISBN 978-1-60327-430-2 e-ISBN 978-1-60327-431-9.
Ševčíková Ľ, et al. Hygiene/Environmental Medicine, Bratislava: Comenius University, 2011: 332,
ISBN 978-80-223-2900-2.
USDA National Agriculture Library’s Vegetarian Nutrition Resource List. 2015. Available online:
http://fnic.nal.usda.gov/lifecycle-nutrition/vegetarian-nutrition.

64
Table 10 Recommended Dietary Allowances for Adults/Females (9th Revision) – Basic Table
(Source: Kajaba et al., 2015)
Working females Females Working females Not working
19–34y 19–51y 35–62y females
Nutritional factor Pregnant
Light Medium Hard Breast Light Medium Hard 65 (63 ) 80y
until 2nd
work work work feeding work work work – 79y + more
trimester
Energy kJ 9200 10300 11300 10900 12100 8800 9600 10900 8200 7700
kcal 2200 2450 2700 2600 2900 2100 2300 2600 1950 1850
Proteins g 58 63 70 80 80 57 60 68 56 55
Fats g 75 85 92 87 97 72 80 90 68 65
PUFA n-6 (linoleic ac.) g 6.3 7.0 7.7 7.6 8.2 6.0 6.5 7.3 5.5 5.3
PUFA n-3: ALA (alfa-
linolenic ac.) g 1.0 1.1 1.3 1.4 1.5 0.9 1.0 1.2 0.8 0.7
DHA + EPA mg 350 350 350 400 350 350 350 350 350 350
PUFA n-3 together g 1.4 1.5 1.7 1.8 1.9 1.3 1.4 1.6 1.2 1.1
Cholesterol mg 300 350 350 450 400 300 300 350 300 300
Carbohydrates g 324 358 398 375 427 306 335 380 279 262
Calcium mg 1000 1100 1200 1400 1600 1000 1100 1200 1200 1200
Iron mg 15 17 18 30 22 15 16 17 14 10
Vitamin A μg 800 900 950 1100 1300 800 850 900 800 800
Vitamin B1 mg 1.1 1.3 1.4 1.4 1.5 1.1 1.2 1.3 1.,0 1.0
Vitamin B2 mg 1.3 1.5 1.7 1.6 1.7 1.3 1.4 1.5 1.2 1.2
Vitamin C mg 100 110 120 120 150 95 100 110 100 100
Vitamin E mg 15 16 17 16 19 14 15 16 14 14
Proteins E% 10.5 10.3 10.4 12.3 11.0 10.8 10.4 10.5 11.5 11.8
Fats E% 30.7 31.2 30.7 30.1 30.1 30.9 31.3 31.2 31.4 31.6
Carbohydrates E% 58.8 58.5 58.9 57.6 58.9 58.3 58.3 58.3 57.1 56.6

Table 11 Recommended Dietary Allowances for Adults/Females (9th Revision) – Additional Table
(Source: Kajaba et al., 2015)
Working females Females Working females Not working
19–34y 19–51y 35–62y females
Nutritional factor Pregnant Pregnant
Light Medium Hard Light Medium Hard Light Medium
until 2nd until 2nd
work work work work work work work work
trimester trimester

Fibre g 24 26 27 26 28 24 25 26 22 20
Magnesium mg 300 320 350 350 330 300 300 320 300 300
Phosphorus mg 700 800 800 900 1000 700 800 800 700 700
Zinc mg 8 10 11 11 12 8 9 10 7 7
Copper μg 1000 1200 1400 1100 1300 900 1000 1200 900 900
Chromium μg 100 130 150 150 180 80 100 130 75 70
Selenium μg 50 50 55 65 70 50 50 55 50 50
Iodine μg 150 150 150 250 250 150 150 150 150 150
Vitamin B6 mg 1.3 1.5 1.6 1.9 1.9 1.2 1.4 1.5 1.2 1.2
Vitamin PP mg 13 15 16 18 17 13 15 15 13 13
(niacin)
Pantothenic Ac. mg 5 7 7 6 7 5 6 6 5 5
Folacin μg 400 400 400 600 500 400 400 400 400 400
Vitamin B12 μg 2.4 2.4 2.5 2.6 2.8 2.4 2.4 2.4 2.4 2.4
Vitamin D3 μg 15 15 17.5 20 20 15 15 17.5 20 20
β-carotene mg 90 90 95 100 100 90 90 90 90 90
Vitamin K μg 5 6 7 8 10 4 5 6 5 5

65
Table 12 Recommended Dietary Allowances for Adults/Males (9th Revision) – Basic Table (Source:
Kajaba et al., 2015)
Working males Working males Not working males
19–34y 35–62y
Nutritional factor
Light Medium Hard Light Medium Hard
65(63)–79y 80y+more
work work work work work work
Energy kJ 11000 11700 13400 10000 11300 12500 9200 8200
kcal 2550 2800 3200 2400 2700 2950 2150 1950
Proteins g 70 75 80 67 72 78 62 60
Fats g 85 95 112 80 92 100 75 70
PUFA n-6 (linoleic ac.) g 7.3 8.0 9.2 6.9 7.7 8.5 6.2 5.6
PUFA n-3: ALA (alfa-
linolenic ac.) g 1.2 1.4 1.7 1.1 1.3 1.5 1.0 0.8
DHA + EPA mg 350 350 350 350 350 350 350 350
PUFA n-3 together g 1.6 1.8 2.1 1.5 1.7 1.9 1.4 1.2
Cholesterol mg 300 350 400 300 300 350 300 300
Carbohydrates g 377 415 468 353 397 435 307 270
Calcium mg 1000 1200 1300 1000 1100 1200 1200 1200
Iron mg 10 11 12 9 10 11 10 10
Vitamin A μg 1000 1000 1000 1000 1000 1000 1000 1000
Vitamin B1 mg 1.2 1.3 1.4 1.2 1.3 1.3 1.1 1.1
Vitamin B2 mg 1.4 1.5 1.6 1.4 1.5 1.5 1.2 1.2
Vitamin C mg 100 120 130 100 110 120 100 100
Vitamin E mg 15 16 18 14 15 17 15 15
Proteins E% 10.9 10.3 10.0 11.2 10.6 10.6 11.5 12.3
Fats E% 30.0 30.5 31.5 30.0 30.6 30.5 31.4 32.3
Carbohydrates E% 59.1 59.2 58.5 58.8 58.8 58.9 57.1 55.4

Table 13 Recommended Dietary Allowances for Adults/Males (9th Revision) – Additional Table
(Source: Kajaba et al., 2015)
Nutritional factor Working males Working males Not working males
19–34y 35–62y
Light Medium Hard Light Medium Hard Light Medium
work work work work work work work work
Fibre g 26 30 32 25 28 30 24 22
Magnesium mg 400 400 420 410 410 420 420 420
Phosphorus mg 700 700 700 700 700 700 700 700
Zinc mg 10 14 16 10 12 14 10 10
Copper μg 1400 1600 1800 1200 1400 1600 1200 1200
Chromium μg 40 40 40 35 130 150 100 100
Selenium μg 70 70 85 65 65 75 65 65
Iodine μg 160 160 180 150 150 160 150 150
Vitamin B6 mg 1.5 1.7 1.9 1.3 1.5 1.8 1.5 1.4
Vitamin PP mg 17 19 22 16 17 19 15 14
(niacin)
Pantothenic Ac. mg 7 8 8 6 7 7 6 6
Folacin μg 400 400 400 400 400 400 400 400
Vitamin B12 μg 2.6 2.6 2.7 2.5 2.5 2.6 2.5 2.5
Vitamin D3 μg 15 15 17,5 15 15 17.5 20 20
β-carotene mg 120 120 130 120 120 125 110 110
Vitamin K μg 6 7 8 5 6 7 6 6

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Table 14 Recommended Dietary Allowances for Children and Youth (9th Revision) – Basic Table
(Source: Kajaba et al., 2015)
Children Adolescents boys
Schoolchildren years Adolescents girls years
Infants toddler/ years
Nutritional factor
months preschool
years 11–14 15–18 15–18
7–10

physically
physically
0–6 7–12 1–3 4–6 boys girls studying more studying
more active
active

Energy kcal/kg 95 90 90 80 72 60 55 50 58 42 53
kJ/day 2300 3100 5000 6900 8800 10700 10300 12600 15500 10000 12100
kcal/day 550 750 1200 1650 2100 2550 2450 3000 3700 2400 2900
Proteins g 12 16 25 35 53 64 62 75 90 60 70
Physical Activity (PAL) 1.4 1.4 1.4 1,5 1.6 1.7 1.8 1.7 2.1 1.65 2.0
Fats g 29 36 48 63 78 87 82 100 125 82 97
PUFA n-6 (linoleic ac.)* g 2.5 3.0 3.4 4,6 5.9 7.2 6.9 8.7 10.4 6,8 8.2
PUFA n-3**: ALA (alfa- 0,3 0,4 0.4 0.7 1.0 1.3 1.3 1.7 1.9 1.2 1.6
lino lenic ac.) g
DHA mg 100 100 250 250 250 250 250 250 250 250 250
PUFA n-3 together g 0.4 0.5 0.7 1.0 1.3 1.6 1.6 2.0 2.2 1.5 1.9
Cholesterol mg 270 250 250 250 300 350 400 400 450 350 400
Carbohydrates g 60 91 167 236 297 378 367 450 554 354 437
Calcium mg 300 400 600 700 900 1200 1300 1300 1500 1200 1400
Iron mg 7 10 8 9 10 12 16 12 15 15 18
Vitamin A μg 500 600 600 700 800 1000 1000 1100 1300 900 1100
Vitamin B1 mg 0.3 0.4 0.6 0.8 1.0 1.3 1.2 1.3 1.5 1.1 1.3
Vitamin B2 mg 0.4 0.5 0.7 0.9 1.1 1.5 1.3 1.5 1.7 1.2 1.5
Vitamin C mg 50 55 60 70 80 90 100 100 130 90 120
Vitamin E mg 4 5 6 8 10 13 14 15 18 14 17

Proteins E% 8.7 8.5 8.3 8.5 10.1 10.0 10.1 10.0 9.7 10.0 9.7
Fats E% 47.5 43.2 36.0 34.4 33.4 30.7 30.1 30.0 30.4 30.7 30.1
Carbohydrates E% 43.8 48.3 55.7 57.1 56.5 59.3 59.8 60.0 59.9 59.3 60.2

In 0–6-month-old children average weight is 6.4 kg (+ 1SD 6.9 kg) in 7–12-month-old children
average weight is 5 kg (+ 1SD 10.3 kg)
+
average weight x + 1SD kg* % E from n-6: for 0–6-month-old 4%, for 7–12-month-old 3.5%, for
1–3-year-old 3% for the others 2.5 %
** % E from n-3: for all physiological groups 0.5 %

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Table 15 Recommended Dietary Allowances for Children and Youth (9th Revision) – Additional
Table (Source: Kajaba et al., 2015)

Children
Infants Schoolchildren Adolescents boys
toddler/ Adolescents girls years
Nutritional factor years years
preschool
months
years
11–14 15–18 15–18
physically
physically
0–6 7–12 1–3 4–6 7–10 boys girls studying more studying
more active
active
Fibre g 18 22
1* 3 10 14 17 20 18 22 25
Magnesium mg 350 380
30 60 80 120 200 300 330 400 430
Phosphorus mg 1100 1300
200 300 400 500 800 1000 1100 1200 1400
Zinc mg 9 12
2 3 4 5 7 10 10 12 15
Copper μg 850 900
200 500 600 800 1000 1200 1300 900 950
Chromium μg 30 40
5 10 20 20 25 30 35 35 45
Selenium μg 55 65
10 15 20 25 35 40 45 60 70
Iodine μg 150 150
60 70 90 100 120 130 140 150 150
Vitamin B6 mg 1.7 1.9
0.2 0.4 0.6 0.8 1.2 1.4 1.6 1.8 2.0
Vitamin PP mg 18 14 16
3 5 8 10 12 14 15 16
(niacin)
Pantothenic Ac. mg 5 6
2 3 4 4 5 6 6 6 7
Folacin μg 400 450
70 80 150 200 250 300 350 400 470
Vitamin B12 μg 2.5 3.0
0.4 0.8 1.0 1.5 1.8 2.5 3,0 3.0 3.5
Vitamin D3 μg 25 17.5 20
10 10 15 15 15 15 20 20
β-carotene mg 5.0 3,0 4.0
0.4 0.7 1.0 1.5 2.0 2.5 3.0 3.5
Vitamin K μg 80 60 70
4 10 15 20 30 40 50 70

* 4–6-month-old children

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 9 DISEASES RELATED TO DIET AND
THEIR PREVENTION, EATING
DISORDERS

The nutritional quality and quantity of foods eaten, and therefore nutritional
status, are major modifiable factors in promoting health and well-being, in preventing
diseases, and in treating some diseases.
It is now widely accepted that our nutritional status influences our health and
risk for both infectious and non-communicable diseases.

9.1 Diseases Related to Diet and their Prevention

In developed countries excessive intakes of macronutrients (overnutrition) and
suboptimal intakes of micronutrients (hidden hunger), mainly because of low fruit
and vegetable consumption, lead to obesity and related non-communicable diseases
(NCDs).
Developing countries are suffering from a double burden of disease because of the
persistence of undernutrition and related deficiency and infectious diseases (including
human immunodeficiency virus/acquired immunodeficiency syndrome HIV/AIDS),
and the emergence of NCDs as a result of the nutrition transition. It explains the vicious
cycle of poverty and undernutrition and how this is related to underdevelopment and
increased risk for NCDs in the developing world.
Chronic diseases may well originate in childhood and nutrition during these early
periods may have long-lasting consequences. Tissues may be particularly susceptible to
the influence of nutrients during periods of growth, the effect of diet may be cumulative,
and the long-term impact may only translate into disease decades later. There is a need
to examine diets at various times in life and with long follow-up, especially for studies
of cancer.

Malnutrition
Malnutrition in developing countries affects individuals throughout the life course:
from birth to infancy and childhood, through adolescence into adulthood, and into old
age. Malnutrition affects, therefore, critical periods of growth and mental development,
maturation, active reproductive as well as economical productive phases.
• 161 million children under 5 are stunted (low height-for-age). Stunting is irreversible,
and has severe consequences for health and development.
• 2 billion people – around 1/3 of the developing world population – suffer from
vitamin or mineral (micronutrient) deficiencies.
• 42 million children under 5 are overweight. More than 500 million adults are
obese.
• Malnutrition (hunger, micronutrient deficiencies and obesity) costs an estimated
$2.8-3.5 trillion, or 4-5% of global GDP. That is $400-500 per person.

69
 • 99 million children under 5 are underweight (low weight-for-age) with severe
consequences for health and the development of individuals and society.
• Micronutrient deficiencies lead to poor growth and ill health, including blindness,
brain damage, and early death.
• Unhealthy diet and lack of exercise account for almost 10% of global disease and
disability burden.
• 200 million fewer people are undernourished today than 20 years ago, but 805
million people still go to bed hungry every day – that is 1 in 9 people.

Non-communicable diseases (NCDs)

The type of diet prevailing in the developed countries is characterized by an excess of
energy-dense foods, rich in fat and free sugars, but a deficiency of complex carbohydrate
foods (the main source of dietary fibre). Research and practice have demonstrated close
and consistent relationships between the establishment of this type of diet and the
emergence of a range of different diseases.
The complex chain of events where behavioural and lifestyle factors influence
the development of the biological risk factors for NCDs, emphasizes the need for a
multisectorial approach in which all factors in the chain are targeted throughout the
life course.
CVD (Cardiovascular disease), Coronary heart disease (CHD). Lipids
and lipoproteins play a key role in the development of coronary heart disease.
Epidemiological studies carried out in middle-aged men provide clear evidence that the
risk of coronary heart disease is increased by major factors: high serum total cholesterol,
high blood pressure, obesity, and cigarette smoking. The presence of several risk factors,
simultaneously, increases the risk for the disease. A variety of different dietary patterns
to manage lipids and lipoproteins provide options to target specific CHD risk factors.
A recommendation to maintain normal BMI, a diet high in complex carbohydrates, low
intake of industrially synthesized TFAs (trans fats) and SFA (saturated fatty acids), law
salt intake, minimizing of the alcohol intake is important for preventing the disease.
There is strong and consistent evidence in support of the association between intake of
polyunsaturated fatty acids (PUFAs) and an improvement in blood lipids, particularly
when PUFAs replace SFAs and TFAs in the diet.
The acceptable macronutrient distribution range (AMDR) for carbohydrate (45 –
65 % of energy) promotes achieving nutrient adequacy and attaining a healthy lipid
and lipoprotein profile. Minimally processed plant sources of carbohydrate, such
as whole grains, legumes, fruits, and vegetables, are an integral part of the dietary
recommendations to reduce CVD risk. Some bioactive compounds, found in small
quantities in plant-based foods, may exhibit antioxidant, antithrombotic, and/or anti-
inflammatory properties. Higher-protein diets (22– 34% of energy), both isocaloric and
calorie - restricted, have demonstrated favourable effects on body composition and CVD
risk factors. Further intervention studies are needed to investigate the safety, efficacy,
and feasibility of long-term adherence to high-protein/low - carbohydrate diets.
Obesity. Prevalence rates of obesity have escalated worldwide over the past
3 decades, both in developed and developing countries. As it has a multifactorial
origin, from a public health point of view, the challenge is to modify, first of all, the
populations’ environment with increasing of the physical activity and providing
an adequate diet. Dietary composition is a key factor in total energy intake with
energy-dense foods providing less satiety than foods with a low energy density; this
can encourage passive overconsumption.
Non-insulin-dependent diabetes mellitus. Approximately 80% of patients are
obese and therefore the most rational approach to preventing this disease is to prevent

70
obesity. Physical activity not only improves glucose tolerance by reducing overweight,
but also acts independently by having a beneficial effect on insulin metabolism.
Many individuals with type 2 diabetes have also dyslipidaemia and hypertension, so
decreasing intakes of saturated fat, cholesterol, and sodium should also be a priority.
Several meta-analyses and reviews have concluded that Mediterranean-style diets,
low-glycemic-index (GI) or low-glycemic-load (GL) diets, and low-carbohydrate, high-
protein diets may be more effective (or just as effective) for improving components of
the insulin resistance syndrome as traditional low- fat, high-carbohydrate diets. On the
other hand the GI or GL values of a food do not meaningfully improve carbohydrate
selection, and it is suggested that consumers ultimately focus on caloric intake, caloric
density, and fiber content.
High blood pressure and cerebrovascular diseases. The risk of both coronary
heart disease and stroke increases as blood pressure rises. There is a fivefold difference
in CHD and a tenfold difference in risk of stroke over a range of diastolic blood pressure
of 40 mmHg (5.33 kPa). A high body mass index (Body Mass Index = weight in kg/height
in m2) and high alcohol intake have strong, independent effects on blood pressure. Salt
intake has a significant negative effect on the rise of blood pressure. Several studies
suggest lower blood pressures among vegetarians than non-vegetarians.
Cancer. Cancer is a general term that represents more than 100 diseases, each with
their own aetiology. The probability of suffering from cancer is extremely high. Cancer
risk is influenced by both genetic and environmental factors, including dietary habits.
Evidence continues to mount that dietary habits can significantly influence one’s
cancer risk and/or tumor behaviour. Some epidemiologists estimate that 30–40% of
cancers in men and up to 60% of cancers in women are attributable to diet. Overweight
(BMI > 25 kg/m2) and obesity (BMI > 30 kg/m2) are associated with increased risk
for many, but not all, common cancers. So one of the most important ways to reduce
overall cancer risk is to maintain a healthy weight throughout life. Studies indicate
that increased consumption of fruits, vegetables, and whole grains is associated with
reduced cancer risk. Therefore, it is recommended eating mostly foods of plant origin
(at least five portions/servings = 400–600 g) of a variety of vegetables and fruits every
day; eating whole grains and/or pulses (legumes); and limiting refined starchy foods.
Alcohol consumption has been associated with an increased risk for some cancers. The
responses to food and/or food components, which may be inhibitory or stimulatory,
depending on the specific bioactive food component, are mediated through one
and likely multiple, biological mechanisms. The identification and elucidation of the
specific molecular sites of action for food components are critical for identifying those
who will benefit maximally or be placed at risk from a particular dietary change. Until
this information is available, it remains prudent to eat a variety of foods and to maintain
a healthy weight through appropriate caloric intake and regular exercise.
Cancers of the oral cavity, pharynx, larynx, and oesophagus. In developed
countries, the results of studies indicate that drinking alcoholic beverages is causally
related to cancers of mouth, pharynx, oesophagus, and upper part of the larynx. There
are also positive associations between oesophageal cancer and several dietary factors,
including low intakes of green vegetables, fresh fruits, animal proteins, vitamins A and
C, riboflavin, nicotinic acid, magnesium, calcium, zinc and molybdenum, high intakes
of pickles, and mouldy foods containing N-nitroso compounds.
Stomach cancer. A high incidence of stomach cancer is found in Japan and other
parts of Asia and in South America, but not in North America and Western Europe
where the rates are low and still decreasing. These diseases are associated also with
diets comprising large amounts of smoked and salt-preserved foods (which may contain
precursors of nitrosamines). Total, red and processed meat intakes are associated with

71
an increased risk of gastric noncardia cancer, especially in H. pylori antibody-positive
subjects. Although there is no clear association between fruit/vegetables and risk of
gastric cancer, there is an evidence of a lower risk of GC with higher plasma levels of
micronutrient such as vitamin C and carotenoids.
Colorectal cancer. Diets low in fibre-containing foods and high in fat increase the
risk of colon cancer. Several studies also demonstrate positive associations between
the risk for colorectal (primarily colon) cancer and dietary fat (saturated rather than
unsaturated fatty acids), protective effect of fibre and dairy products.
Female breast cancer. Correlation studies provide evidence of a direct association
between breast cancer mortality and the intake of high kJ diet and specific sources of
dietary fats (e.g. milk and beef).
Endometrial cancer. Specific dietary factors, other than obesity, have not been
identified for this disease.
Prostate cancer. Analyses show positive correlations between mortality from
prostate cancer and total intake of food, excessive amount of milk and dairy products
in diet.
Evidence indicates that a diet low in saturated fats, trans-fats, high in plant foods
(especially green and yellow vegetables and citrus fruits), and low in alcohol, salt-
pickled, smoked, and salt-preserved foods is consistent with a low risk of many of the
current major cancers (cancer of the colon, prostate, breast, stomach, and oesophagus).
Osteoporosis. Advances in understanding of the roles of nutrient requirements
for bone health in older populations have been achieved over the last decade. Calcium
needs have been established as more critical than other single nutrients as determined
by several meta-analyses of randomized controlled trials. Several other nutrients,
including phosphorus, vitamin D, vitamin K, and protein, remain important for bone
health and the prevention or delay of osteoporosis and fragility fractures. Healthy diets
providing balanced intakes of all nutrients continue to be the preferred way to promote
bone health of older adults along with other healthy lifestyles, such as participating
in routine physical activities, not smoking, and consuming only moderate amounts
of alcohol per day, if any. Physical activity helps maintain muscle mass, equilibrium/
balance, and the general overall health of organ systems.
Dental caries. Dental caries is a very common health problem affecting a large
proportion of people. There is a direct relationship between the quantity and a sucrose
consumption and development of caries (very little incidence of caries, when the sugar
consumption is below 10 kg/person yearly and steep increase may occur from 15 kg
upwards).
Gastrointestinal disorders. Specific disease states for which nutrition has a
profound role in medical and/or surgical management include diseases that affect the
esophagus (eosinophilic esophagitis and gastroesophageal reflux disease), the small
intestine (celiac disease, inflammatory bowel disease, and intestinal failure), and the
pancreas (acute and chronic pancreatitis). In some cases, nutrition may have a role in
the pathogenesis and treatment of disease (eosinophilic esophagitis, gastroesophageal
reflux disease, celiac disease, and Crohn’s disease), and in others nutritional issues
arise as a result of the disease (Crohn ’ s disease, celiac disease, intestinal failure, and
pancreatitis).
Chronic kidney disease (CKD). The kidneys play a key role in maintaining fluid
and electrolyte homeostasis, in excretion of metabolic waste products, and in the
regulation of various hormonal and metabolic pathways. Even a slight reduction in
renal function may therefore have metabolic and nutritional consequences.
Eye diseases. There is biological plausibility for a relationship between certain
nutrients and certain eye diseases. Nutrition can have a strong impact on eye diseases

72
such as cataract, age -related macular degeneration (AMD), and retinitis
pigmentosa (RP), which together account for ∼60% of blindness worldwide. High
dietary intake of vitamins C and E, starting early in life, may prevent the incidence of
age -related nuclear cataracts as well as AMD.
Lutein and zeaxanthin intake may protect against nuclear and posterior subcapsular
cataract (PSC), while vitamins B 1, B 2, B 3, and folate may protect against nuclear and
cortical cataract.
The immune system provides the body with a major defence against environmental
assaults, particularly invasion by microorganisms and spontaneously arising neoplasms.
A variety of chemicals commonly found in the workplace and widely distributed in the
environment has induced changes in the immune system. Immunosuppression may
be associated with severe infection and cancer whereas immunopotentiation may be
associated with allergic or autoimmune diseases. Nutrition, through its modulation of
specific and non-specific immune responses, is a critical determinant of optimum immune
function. Both severe and moderate nutritional deprivations are associated with impaired
immune responses and malnutrition is the most frequent cause of immunodeficiency
throughout the world. It is very important that correction of nutritional deficiencies
improves the immune function and so enhances the body’s defence against environmental
loads.
A food allergy (FA) is an allergic reaction to a particular food. Many different
foods can cause allergic reactions. Most commonly they are triggered by certain nuts,
peanuts, shellfish, fish, milk, eggs, wheat, and soybeans. Additives such as monosodium
glutamate, metabisulphite, and tartrazine can cause allergy. Allergic reactions to foods
may be severe and sometimes include an anaphylactic reaction. FA are most common
among children whose parents have food allergies, allergic rhinitis, or allergic asthma.
Food allergens are sometimes also blamed for such disorders as hyperactivity in
children, chronic fatigue, arthritis.
Food intolerance differs from a food allergy in that it does not involve the immune
system. Instead, it involves a reaction in the digestive tract that results in digestive upset.
The most important general recommendations about healthy lifestyle/diet are
as follows:
• Staying lean and physically active throughout adult life has major health benefits.
• Diets low in the percentage of energy from fat have not been associated with
lower risks of heart disease, cancer, or better long-term weight control. Fat intake
(%E): SFA <7%; TFA <1%; 6–10% of PUFAs (n -6: 5 –8%, n -3: 1–2%); MUFAs ≈15–
30% is recommended.
• Avoiding industrially produced transfat, keeping saturated fat low, and
emphasizing unsaturated fats will minimize risks for heart disease and type 2
diabetes.
• High intake of fruits and vegetables help to prevent risks for cardiovascular
disease- 400 –500g/day is recommended to reduce the risk of CHD, stroke and
high blood pressure.
• Consuming grains in their original high fibre/whole grain form is likely to reduce
risk for type 2 diabetes and heart disease.
• Consumption of sugary beverages increases risk for type 2 diabetes and probably
heart disease.
• Various components found in red and processed meat products increase risk for
developing type 2 diabetes.
• Restrict daily salt (sodium chloride) intake to less than 5 g/day; minimize other
forms of sodium consumption through food additives and preservatives, such as

73
 monosodium glutamate (MSG); 1.7 g of sodium per day is beneficial in reducing
blood pressure and is not associated with adverse effects.
• Regular fish consumption, as consumed on a weekly basis - consumption of fish
and other marine foods should provide over 200mg/day of DHA and EPA.
• High consumption of alcohol have many adverse health and social consequences,
and intakes as low as one drink per day or less are associated with greater risks for
breast cancer.

9.2 Eating Disorders

Eating disorders are characterised by an abnormal attitude towards food that causes
someone to change their eating habits and behaviour. A person with an eating disorder
may focus excessively on their weight and shape, leading them to make unhealthy
choices about food with damaging results to their health.
Eating disorders can affect persons of all shapes and sizes. Eating disorders range
from severe caloric restriction to severe overeating - from extremes in underweight,
across the spectrum of normal weight up to the extremes of obesity, underlying
nutritional, psychological, and medical effects of eating disorders can be found.
Eating disorders include:
• pica syndrome,
• rumination disorder,
• avoidant/restrictive food intake disorder (ARFID),
• anorexia nervosa (AN),
• bulimia nervosa (BN),
• binge eating disorder (BED),
• feeding and eating conditions not elsewhere classified (FEC-NEC;
atypical anorexia, subthreshold BN, purging disorder, and night eating
syndrome).

Pica syndrome involves:

1. persistent eating of non-nutritive, non-food substances over a period of at least 1
month
2. eating is inappropriate to the developmental level of the individual
3. eating is not part of a culturally sanctioned practice
4. if the eating behaviour occurs in the context of another mental disorder, it is
sufficiently severe to warrant independent clinical attention.

Rumination disorder is described as repeated regurgitation of food over a period

of at least 1 month. The regurgitated food may be re-chewed, re-swallowed, or spit out.

ARFID consists of an eating or feeding disturbance in which there is a persistent

failure to meet expected nutritional and/or energy needs associated with at least one of
the following features:
1. significant weight loss or disturbance in growth curves in growing children
2. significant nutritional deficiency
3. dependence on enteral feeding
4. marked interference with psychosocial functioning.
The hallmark of BED is eating large amounts of food, accompanied by a loss of
control. Additionally, at least three of the following five signs must be present during
binge-eating episodes:

74
 1. eating more rapidly than normal
2. eating until uncomfortably full
3. eating when not physically hungry
4. eating alone due to embarrassment
5. feeling disgusted, depressed, or markedly guilty after an episode.

Anorexia Nervosa
The first core feature is a refusal to maintain a minimally normal body weight for age
and height. For adolescents and children, lack of weight gain, rather than active weight
loss, would also be an appropriate measure. The second criterion describes an intense
fear of gaining weight or persistent behavior that prevents weight gain. The third requires
a distortion in the way that body weight and shape are viewed or a “persistent lack of
recognition of the seriousness of the low body weight”. Amenorrhea lasting >3 months
has been a diagnostic criterion in the past. However, women on hormonal birth control,
girls who have not reached menarche, and men are not able to apply this criterion.
The restricting type is classified by the strict use of caloric restriction and excessive
exercise as a means of controlling their weight.
The binge eating/purging subtype describes those who engage in binge eating or
inappropriate compensatory measures, such as vomiting or misuse of laxatives,
diuretics, or enemas.
Almost every physical system is negatively impacted by AN and it is considered the
deadliest psychiatric disorder.

Bulimia Nervosa
The core features of BN are binge eating and the subsequent use of inappropriate
compensatory behaviors (occur at least once/week for at least 3 months). These
behaviors are used in an attempt to attain a low body weight or prevent weight gain.
Inappropriate compensatory behaviors consist of various forms of purging, restricting,
and excessive exercise. Purging behaviors most often consist of vomiting and laxative
abuse. Most persons with BN have a BMI in the healthy weight range, with some in the
overweight and obese ranges.

There are many forms of disordered eating that are serious and cause
psychological and physical distress but that do not fit the diagnostic criteria.

References
Allison KC. Eating Disorders. In: Nutritional Health Strategies for Disease Prevention, Third
Edition, Edt. Temple NJ, Wilson T, Jacobs DR. Humana Press Springer New York Heidelberg
Dordrecht London. 2012: 559. ISBN 978-1-61779-893-1 ISBN 978-1-61779-894-8 (eBook) DOI
10.1007/978-1-61779-894-8.
Erdman JW, Macdonald IA, Zeisel SH (Edt.). Present Present Knowledge in Nutrition, 10th Edition.
International Life Sciences Institute. Published by John Wiley & Sons; 2012: 1330. Inc. ISBN
978-0-470-95917-6.
Kim Y, Keogh J, Clifton P. A review of potential metabolic etiologies of the observed association
between red meat consumption and development of type 2 diabetes mellitus. Metabolism.
2015; 64:768-779.
Ševčíková Ľ, et al. Hygiene/Environmental Medicine, Bratislava: Comenius University, 2011: 332,
ISBN 978-80-223-2900-2.

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World Cancer Research Fund / American Institute for Cancer Research. Policy and Action for
Cancer Prevention. Food, Nutrition, and Physical Activity: a Global Perspective Washington DC:
AICR, 2009: 188. ISBN: 978-0-9722522-4-9. Available online: http://www.dietandcancerreport.
org/cancer_resource_center/downloads/Policy_Report.pdf .
World Health Organization. Who Library Cataloguing-In-Publication Data. Global action plan for
the prevention and control of noncommunicable diseases 2013-2020. ISBN 978-92-4-150623-
6. Available online: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.
pdf?ua=1.2013.

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 10 FUNCTIONAL FOODS WITH
POTENTIAL HEALTH BENEFIT

“Functional foods” (FF) are foods and food components that provide health
benefits beyond basic nutrition.
“Functional foods” lack any standard definition despite their worldwide promotion
and growth as a category of food.
FF are whole or modified foods that contain bioactive food components. Usually we
recognise two groups of functional foods:
1. Conventional fresh whole foods, unprocessed, and unrefined. These are the
simplest and most cost-effective forms of healthful functional foods that may be found
in various grains, vegetables, fruits, seeds, nuts, milks, eggs, and fish.
2. Artificially produced foods - In characterizing this broad range of functional foods,
the American Dietetic Association (ADA) describes these as including “conventional
foods” (e.g. probiotic yogurts), “modified foods” that have been fortified or enriched
(e.g. calcium fortified orange juice), “medical foods” that aid in the dietary management
of a disease (e.g. diabetic beverage formulations), and “foods for special dietary use”
sold at the retail level (e.g. gluten-free cookies).
It is the position of the Academy of Nutrition and Dietetics to recognize that although
all foods provide some level of physiological function, the term functional foods
is defined as whole foods along with fortified, enriched, or enhanced foods
that have a potentially beneficial effect on health when consumed as part of a
varied diet on a regular basis at effective levels based on significant standards
of evidence.
Selected “functional foods” with potential bioactive ingredient they contain are
shown in Table 16. However, a lot of different nutritious foods can support health in
some ways.

Table 16 Examples of some “functional foods” and potential bioactive ingredients they contain
(Source: Modern Nutrition in Health and Disease, 2014)
Suspected health– Potential bioactive Suspected health– Potential bioactive
promoting functional ingredient promoting functional ingredient
food food
Bluberries Polyphenols Nuts Flavonoids
Tomatoes Lycopene Fish n-3 fatty acids
Mushrooms Beta-glucans Soy Genistein, dadzein, equol
Broccoli Sulphoraphane Oats and other grains Fiber, glucan, flavonois
Garlic Allyl sulphur Green tea Catechins

The links between several “functional foods” and health continue to mount. However, a
clear understanding of the impacts of dietary exposure on the health of individuals is still

77
evolving. “Functional foods” must be considered in the context of the other constituents
of the diet as well as the consumer’s genetics and environmental exposures.
“Functional foods” do more than simply provide nutrients because they assist in
maintaining health and thereby reducing the risk of disease. These foods represent a
continuum of items that contain ingredients or natural constituents in conventional,
fortified, enriched, and enhanced foods. The FDA (the Food and Drug Administration)
does not officially recognize the term “functional food”. Nevertheless, the FDA does
regulate these foods according to whether it is considered a conventional food, a food
additive, a dietary supplement, a medical food, or a food for special dietary use.
Both effect biomarkers, which predict a change in the true molecular targets
(effect biomarker), and susceptibility biomarkers, which identify nutrient-nutrient
and nutrient-gene interactions, will be needed to evaluate functional foods and
nutraceuticals (nutrient with a drug-like action) adequately.
Oxidative stress can cause oxidative damage to large biomolecules such as
proteins, DNA, and lipids, resulting in an increased risk for cancer and CVD. To prevent
or slow down the oxidative stress induced by free radicals, sufficient amounts of
antioxidants need to be consumed.
Although there are many thousands of compounds in the plant kingdom,
only a handful are present in significant amounts in the diet of most humans.
Over the last 20 years, there has been an enormous and growing interest in this class of
compounds, which have also been referred to as polyphenols, phytonutrients, non-
nutrients, protective factors, dietary bioactives, and phytochemicals.
A large body of evidence has reported that numerous bioactive compounds
reduce CHD risk through a variety of mechanisms, many of which are non-lipid related.
Bioactive compounds, found in small quantities in plant-based foods, may exhibit
antioxidant, antithrombotic, and/or anti-inflammatory properties. Some compounds
may also protect against several forms of cancer.
Phytochemicals are defined as bioactive non-nutrient plant compounds in fruit,
vegetables, grains, and other plant foods, which have been linked to reducing the risk
of major chronic diseases. Phytochemicals are classified into phenolics, carotenoids,
alkaloids, nitrogen-containing compounds, and organosulphur compounds.
The additive and synergistic effects of phytochemicals in fruit, vegetables, and whole
grains are responsible for their potent antioxidant and anticancer activities. The benefit
of a diet rich in fruit, vegetables, and whole grains is attributed to the complex mixture
of phytochemicals present in these and other whole foods.
Phenolic compounds in our diet may provide health benefits associated with
reduced risk for chronic diseases. Among fruits rich in these compounds there belongs
apple, red grape, strawberry, pineapple, banana, peach, lemon, orange, pear, and
grapefruit. Among the most common vegetables, the highest total phenolic content is
found in broccoli, spinach, yellow onion, red pepper, carrot, cabbage, potato, lettuce,
celery, and cucumber.
Data from experimental and clinical studies suggest that polyphenols, particularly
flavonoid rich foods, can reduce CHD risk by improving endothelial function and
decreasing blood pressure. Nonextractable polyphenols, a major part of dietary
polyphenols, probably have a significant physiological impact within the large intestine,
affecting microflora development and intestinal antioxidant status by producing
metabolites that can be absorbed through the mucosa.
Flavonoids are found in a wide variety of plant-based foods and beverages. More
than 4 000 distinct flavonoids have been identified. In plants, they protect against
stress and excess ultraviolet light exposure. They also are responsible for the colour
of most fruits and flowers, and also contribute to the taste sensation of foods such as
red wine, tea, coffee, and chocolate, as well as fruits. Intake varies widely between

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individuals but is typically several hundred milligrams per day. The pathways of
absorption are quite well understood and the amount absorbed and excreted
for many flavonoids has been documented. For many flavonoids, a substantial
percentage of the dose is absorbed, but is also rapidly metabolized and excreted
within 24 hours. Some flavonoids such as proanthocyanidins and anthocyanins
are poorly absorbed intact, but their catabolites are very efficiently absorbed after
microbial biotransformation. Flavonoids are chemical antioxidants, but work in
vivo primarily by indirect antioxidant mechanisms, such as inhibition of oxidative
enzymes and induction of antioxidant defences. Certain flavonoids modulate sugar
metabolism, blood pressure, LDL cholesterol, and platelet function. Together,
these mechanisms possibly reduce the risk type 2 diabetes and inflammatory
diseases, as supported by human interventional and epidemiological studies.
There is now a substantial body of evidence, both in vivo and mechanistic in vitro,
to show that flavonoids affect risk factors for cardiovascular disease. One of the
important indicators of cardiovascular risk is endothelial function and this biomarker
is disrupted by factors such as a high-fat diet. Improvement of endothelial function
is seen in vivo in volunteers from red wine, tea and cocoa, and by pure epicatechin.
Epicatechin, and especially its metabolite – methylepicatechin, inhibits NADPH
oxidase (nicotinamide adenine dinucleotide phosphate-oxidase), inhibits arginase,
and modulates nitric oxide concentration in endothelial cells. There is also evidence
from interventional studies that certain flavonoids, such as grape seed extract, can
affect markers of diabetes risk in type 2 diabetic patients and pycnogenol (aflavonoid-
rich pine bark extract) can improve metabolic markers in diabetic patients, although
not all epidemiological studies show an effect of flavonoids at reducing diabetes risk.
There are some epidemiological studies but the evidence for reduction in the risk of
cancer is ambiguous. Effect of flavonoids on neurodegenerative diseases is an area of
much interest, but there is only limited data at the current time. Chronic inflammation
is associated with obesity, arthritis, Crohn’s disease, and ulcerative colitis, and may be
influenced by diet, including flavonoids with anti-inflammatory effects.
Carotenoids are nature’s most widespread pigments with yellow, orange, and red
colours, and have also received substantial attention because of both their provitamin
and antioxidant roles. Lycopene and β-carotene are examples of acyclized and cyclized
carotenoids, respectively. Carotenoids are especially powerful against singlet oxygen
generated from lipid peroxidation or radiation. Astaxanthin, zeaxanthin, and
lutien are excellent lipid-soluble antioxidants that scavenge free radicals, especially in
a lipid-soluble environment. Carotenoids at sufficient concentrations can prevent lipid
oxidation and related oxidative stress.
Dietary modification by increasing the consumption of a wide variety of fruit,
vegetables and whole grains daily is a practical strategy for consumers to optimize
their health and reduce the risk for chronic diseases. Phytochemical extracts from fruit
and vegetables have strong antioxidant and antiproliferative activities, and the major
part of total antioxidant activity is from the combination of phytochemicals. The
additive and synergistic effects of phytochemicals in fruit and vegetables are
responsible for their potent antioxidant and anticancer activities.
The development and testing of functional foods is a new exciting area. These foods
may help to improve or restore nutritional status in many people. However, much more
should be known about suitable biomarkers to test their efficacy, variability in human
response to specific food products, safety, consumer understanding, and how their
health messages must be formulated, labelled, and communicated.
It is necessary to emphasize that additional research is needed to concentrate
on the precise role of foods and their components on health.

79
 References
Gibney MJ, Lanham-New SA, Cassidy A, Vorster HH (edited on behalf of the Nutrition Society).
Introduction to Human Nutrition, 2nd edition, John Wiley & Sons Ltd, A John Wiley & Sons,
2009: 386. ISBN 978-1-4051-6807-6.
Ross AC, Cabalerro B. et al. Modern nutrition in health and disease. 11th edition. Wolters Kluwer.
Lippincott Williams and Wilkins, 2014: 1646. ISBN: 978-1-60547-461-8.
Shashank K, Abhay KP. Chemistry and Biological Activities of Flavonoids: An Overview. The
Scientific World Journal, Article ID 162750, 2013; doi:10.1155/2013/162750
Temple NJ, Wilson T, Jacobs DR, Jr.(editors). Nutritional Health: Strategies for Disease Prevention,
3rd edition. Humana Press. Springer Science+Business Media, LLC 2012: 557. ISBN 978-1-61779-
893-1.
Waterland RA. Nutritional Epigenetics. In: Present Present Knowledge in Nutrition, 10th edition.
Edt. Erdman JW, Macdonald IA, Zeisel SH. International Life Sciences Institute. Published by
John Wiley & Sons; 2012: 1330. Inc. ISBN 978-0-470-95917-6.

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 11 SYSTEMS BIOLOGY APPROACHES
TO NUTRITION (OMICS),
NUTRIGENOMICS

Not all individuals should be expected to respond identically to bioactive

food components because of genetic and environmental factors.
The “omics” of nutrition can be used to identify responders and non-
responders.
Nutrition requires an understanding of disciplines such as physiology, cell biology,
chemistry, biochemistry, and molecular biology among others.
The tools of systems biology can be applied to settings relevant to nutrition with
the goal of better understanding the breadth and depth of the impact that changing
nutrient status has on physiology and chronic disease risk.
The ultimate goal of systems biology is to generate a predictive model of
the system. Most researchers work with only one type of data, but the ideal is to use all
types of data simultaneously.
While traditional nutrition research has dealt with providing nutrients to nourish
populations, it nowadays focuses on improving health of individuals through
diet.
On the one hand, nutrients can alter the expression or function of a gene (including
epigenetic modifications). On the other hand, genetic polymorphisms can alter the
response to a nutrient.
As a consequence, the disciplines “nutrigenetics” and “nutrigenomics” have evolved.
Nutrigenetics asks the question how individual genetic disposition, manifesting
as single nucleotide polymorphisms, copy-number polymorphisms and epigenetic
phenomena, affects susceptibility to diet.
Nutrigenomics addresses the inverse relationship that is how diet influences gene
transcription, protein expression and metabolism. This latter approach also includes
the study of how genetic variations influence food intake and eating behaviours.
A major methodological challenge and first pre-requisite of nutrigenomics is
integrating genomics (gene analysis), transcriptomics (gene expression analysis),
proteomics (protein expression analysis) and metabonomics (metabolite profiling)
to define a “healthy” phenotype.

Genome Transcriptome Proteome Metabolome

Phenotype

Although genetics can play a major role in the variable responses to nutrient
intakes, it is also important to consider other factors such as age, sex, physical
activity, smoking, and nutritional status.

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 The science of nutrigenomics seeks to improve human health by understanding
how dietary constituents interact with the genome, and how individual genetic
heterogeneity affects these interactions. Nutrigenomics is a branch of nutritional
genomics and is the study of the effects of foods and food constituents on gene
expression. This complex field is further complicated by the growing recognition that
nutrition, in addition to acutely affecting gene regulation, can influence epigenetic
processes and thereby induce persistent changes in transcriptional regulation and
associated phenotype.
The long-term deliverable of nutrigenomics is personalised nutrition for maintenance
of individual health and prevention of disease.
Epigenetic dysregulation, long recognized as playing a role in cancer and various
developmental syndromes, is increasingly being investigated as a potential factor in the
aetiology of a wide range of human diseases. Given that epigenetic mechanisms are most
susceptible to environmental perturbation when they are undergoing developmental
changes, nutritional influences on epigenetic processes must be considered in a
developmental perspective. Accordingly, a major goal of nutritional epigenetics is to
understand the extent to which human nutrition affects developmental epigenetics to
cause persistent changes in disease susceptibility. The field of nutritional epigenetics
faces extraordinary challenges: diverse nutritional exposures have the potential to
influence epigenetic regulation in myriad genomic regions, potentially in a tissue-
specific and cell-type-specific fashion. But this field also promises extraordinary
opportunities to improve human health. Short-term nutrition interventions targeted
to critical ontogenic periods could potentially optimize developmental epigenetics,
conferring lifelong health benefits and the promise of nutritional therapies designed
to correct pathogenic epigenetic dysregulation. Such ambitious goals will become
reality only if we can improve dramatically our understanding of how diet affects
the establishment and maintenance of epigenetic mechanisms, and how epigenetic
dysregulation contributes to human disease.
Nutrigenomics (or nutritional genomics) refers to the application of high-
throughput “omics” technologies, together with systems biology and bioinformatics
tools, to understand how nutrients interact with the flow of genetic information
to affect various health outcomes.
Genomics is the study of the genomes of organisms including influences of DNA
sequence variation on biology and the impact of modifying DNA and histones on
influencing gene transcription and DNA function – epigenomics, e.g. production of
the universal methyl donor S-adenosylmethionine, so it has been proposed that dietary
inadequacy may have a global influence on DNA methylation. However, the evidence for
this diet-induced regulatory paradigm is not yet secure and despite the fact that recent
advances in human genomics have uncovered extensive variations in genes affecting
nutrient metabolism, their full impact on nutrient requirements remains to be elucidated.
Transcriptomics is the study of transcripts from the genome including
messenger RNA and non-coding RNA such as micro RNA. For some nutrients that
are known to have a direct
impact on gene transcription through the activation of a nuclear receptor (e.g.
vitamin D and VDR, vitamin A and the retinoic acid receptor bioactive lipids and the
peroxisome proliferator-activated receptor, [PPAR]), transcriptomics is a primary
endpoint for understanding the impact of the nutrient on biology.
Proteomics is the study of proteins in a biological system including
their level, location, physical properties, post -translational modifications,
structures, and functions. The proteome refers to all of the proteins expressed
and functional in a system. Unfortunately, the methods to assess the proteome cannot

82
measure the entire proteasome simultaneously. Experiments usually measure one or
more subproteomes, proteins within subcellular or specific tissues, or proteins with
specific physical properties.
Metabolomics is the study of the unique chemicals (metabolites) that
are produced as a result of cellular processes, e.g. lipids, metabolites of
intermediary metabolites. Evaluating the metabolome gives a snapshot of the
physiology of a cell or organism by simultaneously measuring the levels of metabolites
within a biological space. As the goal of genomics is to study all of our genes, the
goal of metabolomics is to profile the entire complement of the small molecules that
are involved in processes from signalling to transcription, from building proteins, to
creating and shuttling energy.
Ionomics is the study of the mineral nutrient and trace element composition
of an organism. Mineral elements are involved at all levels of biological regulation,
e.g. in transcription factors (zinc), in enzymes (zinc, iron, copper, calcium), and in
establishing electrochemical gradients in cells (calcium, sodium, potassium). It is also
well established that direct and indirect interactions exist between mineral elements
that can affect biology. Alterations in the ionome reflect changes in critical biological
functions.
The Omics disciplines applied in the context of nutrition and health have the
potential to deliver biomarkers for health and comfort, reveal early indicators for
disease disposition, assist in differentiating dietary responders from non-responders,
and, last but not least, discover bioactive, beneficial food components.
With an increasing understanding of gene-nutrient interactions, personalised
nutrition may become a potential resource of diet optimisation, at least in at-risk
populations. Research in this area is paving the way for personalized nutrition where
dietary advice can ultimately be tailored to an individual’s unique genetic profile in order
to improve on the current one-size-fits-all approach to dietary guidance. However
a high variety of foods in a balanced diet seems to be the best way to optimal nutrient
supply without risking excessive intakes of single components. Nevertheless, further
extensive research in the form of genotype-specific nutritional interventional
studies are needed to elucidate individual response to diet.

References:
Fenech M, El-Sohemy A, Cahill L, et al. Nutrigenetics and Nutrigenomics: Viewpoints on the
Current Status and Applications in Nutrition Research and Practice. Journal of Nutrigenetics
and Nutrigenomics. 2011; 4(2):69-89. doi:10.1159/000327772.
Chango A, Pogribny IP. Considering Maternal Dietary Modulators for Epigenetic Regulation and
Programming of the Fetal Epigenome. Nutrients. 2015; 7: 2748-2770; doi:10.3390/nu7042748.
Kanherkar RR, Bhatia-Dey N, Csoka AB. Epigenetics across the human lifespan. Frontiers in Cell
and Developmental Biology. 2014; 2: 49. doi:10.3389/fcell.2014.00049.
Kussmann M, Raymond F, Affolter M. OMICS-driven Biomarker Discovery in Nutrition and
Health. Journal of Biotechnology, Highlights from ECB12-Bringing genomes to life, 12th
European Congress on Biotechnology (ECB12) 2006; 124 (4), pp. 758-787doi:10.1016/j.
jbiotec.2006.02.014.
Waterland RA. Nutritional Epigenetics. In: Present Present Knowledge in Nutrition, 10th edition.
Edt. Erdman JW, Macdonald IA, Zeisel SH. International Life Sciences Institute. Published by
John Wiley & Sons; 2012: 1330. Inc. ISBN 978-0-470-95917-6.

83
 12 PUBLIC HEALTH NUTRITION

Public health nutrition (PHN) as a discipline and as a field of practice is of

immense importance to human health and the societies in which we live. As
a discipline draws heavily on related fields, such as health promotion and public
health. PHN practice is often similar to and draws on the principles and practice of
health promotion – the process of enabling people to increase control over and to
improve their health. PHN is also the art and science of promoting population health
status via sustainable improvements in the food and nutrition system. Based on public
health principles, it is a set of comprehensive and collaborative activities, ecological
in perspective and inter-sectoral in scope, including environmental, educational,
economic, technical and legislative measures.
Main aims are:
•Improving health and wellbeing in the population
•Preventing nutrition related disease and minimising its consequences
•Prolonging valued life through good nutrition
•Reducing inequalities in health
The defining features of a health promotion approach include actions that are:
• implemented across the whole population, not just those at risk of specific
diseases;
• directed towards improving people’s ability to control the factors that
determine their health;
• part of a process involving a mix of strategies from a number of stakeholders
which aim to improve health;
• focus on the prevention of disease and enhancement of health for all
through tackling the social determinants of health.

Public health nutrition programs can be supply driven or demand driven.

In the supply-driven option, the government takes the decision centrally to
alter some properties of foods the most common approach being mandatory food
fortification.
In demand-driven approaches, efforts are made to create a demand for a new
food-purchasing pattern through a nutrition communication process.

The term ‘public nutrition’ was defined in 1997 by Rogers and Schlossman as “a new
field encompassing the range of factors known to influence nutrition in populations,
including diet and health, social, cultural and behavioural factors; and the economic and
political context.’’ Like public health, public nutrition would focus on problem-solving
in a real-world setting, making its definition an applied field of study whose success
is measured in terms of effectiveness in improving nutrition situations. According
to Hughes and Somerset, “Public health nutrition is the art and science of promoting
population health status via sustainable improvements in the food and nutrition
system. Based on public health principles, it is a set of comprehensive and collaborative
activities, ecological in perspective and inter-sectoral in scope, including environmental,

84
educational, economic, technical, and legislative measures”. Later in 1998, the Nutrition
Society (UK) added that “PHN focuses on the promotion of good health through nutrition
and the primary prevention of diet-related illness in the population and the emphasis is
on the maintenance of wellness in the whole population.’’
A working group for the European Master’s Programme for PHN offered a shorter
definition: “PHN focuses on the promotion of good health through nutrition and
physical activity and the prevention of related illness in the population.’’
Johnson (2001) wrote that “PHN practice includes an array of services and activities
to assure conditions in which people can achieve and maintain nutritional health,
including surveillance and monitoring nutrition-related health status and risk factors,
community or population based assessment, programme planning and evaluation,
leadership in community/population interventions that collaborate across disciplines,
programmes and agencies, and leadership in addressing the access and quality issues.’’
A popular definition from Beaudry and Delisle (2005, Canada) states that “Public
Nutrition applies the population health strategy to the resolution of nutrition problems.
Its fundamental goal is to fulfil the human right to adequate food and nutrition. It is in
the interest of the public, involves participation of the public, and calls for partnership
with relevant sectors beyond health.”
The most recent is a definition from the World Public Health Nutrition Association
(2007) as ‘‘the promotion and maintenance of nutrition-related health and
well-being of populations through the organised efforts and informed choices
of society.’’
PHN practice can best be defined by the nature of the work or core functions and
by an understanding of the competencies required to perform this work. PHN practice
is primarily about problem - solving – developing interventions in the population that
address the socio - cultural, economic, environmental and individual determinants of
suboptimal nutrition.
The nutrition challenges for the twenty-first century emphasize that the
focus should be on prevention of nutrition-related diseases to minimize their
serious economic and social consequences.

References
Beaudry M, Delisle H. Public(‘s) nutrition. Public Health Nutr, 2005; 8(6A):743-8.
Gibney MJ, McKevitt A. Food and Nutrition: Policy and Regulatory Issues. In: Introduction to
Human Nutrition. Edt. Gibney MJ, Lanham-New SA, Cassidy A, Vorster HH. John Wiley & Sons
Ltd, A John Wiley & Sons, Ltd., Publication, 2ndedition, 2009: 386. ISBN 978-1-4051-6807-6.
Hughes R, Somerset S. Definitions and conceptual frameworks for public health and community
nutrition: a discussion paper. Aust J Nutr Diet, 1997; 54 (1): 40 – 45.
Hughes R, Margetts BM. Practical Public Health Nutrition. Wiley-Blackwell, A John Wiley & Sons,
Ltd., Publication, 2011: 284. ISBN 978-1-4051-8360-4.
Johnson D, et al. Public health nutrition practice in the United States. J Am Diet Assoc, 2001;
101(5): 529 – 534.
Landman J, Buttriss J, Margetts B. Curriculum design for professional development in public
health nutrition in Britain. Public Health Nutrition, 1998;1 (1): 69 –74.
Rogers B, Schlossman N. Public nutrition: the need for cross – disciplinary breadth in the
education of applied nutrition professionals. Food and Nutrition Bulletin, 1997; 18(2): 120
– 133.
Yngve A, et al. Effective promotion of healthy nutrition and physical activity in Europe requires
skilled and competent people; European Master’s Programme in Public Health Nutrition.
Public Health Nutrition, 1999; 2 (3a): 449 – 452.

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 13 OVERVIEW OF IMPORTANT CURRENT
DOCUMENTS

1. WHO/FAO. UNDERSTANDING THE CODEX ALIMENTARIUS

CODEX ALIMENTARIUS - international food standards - is about safe, good
food for everyone - everywhere. Codex standards are based on the best available science
assisted by independent international risk assessment bodies or ad-hoc consultations
organized by the FAO and WHO. Biotechnology, pesticides, food additives, and
contaminants are some of the issues discussed in Codex meetings. While Third edition,
2006, Rome being recommendations for voluntary application by members, Codex
standards serve in many cases as a basis for national legislation. Codex members cover
99% of the world’s population. More and more developing countries are taking an active
part in the Codex process. The first session of the Codex Alimentarius Commission was
held in Rome from 25 June to 3 July 1963.
The booklet “Understanding Codex” was first published in 1999 to foster a wider
understanding of the evolving food code and of the activities carried out by the Codex
Alimentarius Commission – the body responsible for compiling the standards, codes
of practice, guidelines, and recommendations that constitute the Codex Alimentarius.
The Codex Alimentarius, or the food code, has become the global reference point for
consumers, food producers and processors, national food control agencies, and the
international food trade. The code has had an enormous impact on the thinking of food
producers and processors as well as on the awareness of the end users – the consumers.
Its influence extends to every continent, and its contribution to the protection of public
health and fair practices in the food trade is immeasurable.

2. Key points from GLOBAL NUTRITION REPORT. Action and accounta­

bility
1. People with good nutrition are a key to sustainable development.
• Malnutrition affects nearly every country in the world.
• More nutrition indicators need to be embedded within the Sustainable
Development Goal accountability framework.
2. We need to commit to improving nutrition faster and build this goal into the
Sustainable Development Goal targets for 2030.
• The 2030 Sustainable Development Goal targets should be more ambitious than
simple extensions of the 2025 World Health Assembly targets. A new consensus
about what is possible needs to be established.
3. The world is currently not on course to meet the global nutrition targets set by
the World Health Assembly, but many countries are making good progress
in the target indicators.
• More high-quality case studies are needed to understand why progress has or has
not been made.

86
 4. Dealing with different, overlapping forms of malnutrition is the “new
normal.”
• Nutrition resources and expertise need to be better aligned toward the evolving
nature of malnutrition.
5. We need to extend coverage of nutrition-specific programmes to more
people who need them.
• More attention needs to be given to coverage data - an important way of assessing
presence on the ground where it counts.
6. A greater share of investments to improve the underlying determinants
of nutrition should be designed to have a larger impact on nutritional outcomes.
• We need to keep tracking the proportion of nutrition resources to these
approaches.
• We must also provide more guidance on how to design and implement these
approaches to improve their effectiveness and reach.
7. More must be done to hold donors, countries, and agencies accountable
for meeting their commitments to improve nutrition.
• Stakeholders should work to develop, pilot, and evaluate new accountability
mechanisms.
• Civil society efforts to increase accountability need support.
• We need to develop targets or norms for spending on nutrition.
8. Tracking spending on nutrition is currently challenging, making it difficult
to hold responsible parties accountable.
• Efforts to track financial resources need to be intensified — for all nutrition
stakeholders.
9. Nutrition needs a data revolution.
• Of the many information gaps, the ones that most need to be filled are those that
constrain priority action and impede accountability.
10. National nutrition champions need to be recognized, supported, and expanded
in number.
• We must fill frontline vacancies, support nutrition leadership programmes, and
design country-led research programmes.
The challenge of improving nutritional status is a quintessentially 21st-century
endeavour. It is a challenge that resonates the world over: nearly every country in the
world experiences a level of malnutrition that constitutes a serious public health risk.
Between 2 and 3 billion people are malnourished — they experience some form of
undernutrition, are overweight or obese, or have some sort of micronutrient deficiency.
The faces of poor nutrition are many: from children living under famine conditions that
appear to be made of skin and bone, to adults who have trouble breathing owing to
obesity, to infants who do not live to see their first birthday as a result of a combination
of poor diets, poor infant feeding practices, and exposure to infectious disease. It is
a challenge that requires effective action across a number of sectors and areas (food,
health, social welfare, education, water, sanitation, and women) and across a number
of actors (government, civil society, business, research, and international development
partners). Strong alliances for action are much more effective than silver bullets, and
the multiple causes of malnutrition often represent multiple opportunities to improve
nutrition in a sustainable way.
Lastly, poor nutrition is a challenge that casts a long shadow: its consequences
flow throughout the life cycle and cascade down the generations affecting everyone —
especially children, adolescent girls, and women — and include mortality, infection,
cognitive impairment, lower work productivity, early onset and higher risk of
non-communicable diseases (NCDs), stigma, and depression.

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 3. ROME DECLARATION ON NUTRITION, 2014
One of the latest conference outcome documents that came from the Second
International Conference on Nutrition, Rome, 19–21 November 2014, organised by
the Food and Agriculture Organisation of the United Nations (FAO) and World
Health Organisation (WHO):
“Welcoming the participation of Heads of State and Government and other high-
level guests,
1. We, Ministers and Representatives of the Members of the Food and Agriculture
Organization of the United Nations (FAO) and the World Health Organization
(WHO), assembled at the Second International Conference on Nutrition in Rome
from 19 to 21 November 2014, jointly organized by FAO and WHO, to address the
multiple challenges of malnutrition in all its forms and identify opportunities for
tackling them in the next decades.
2. Reaffirming the commitments made at the first International Conference on
Nutrition in 1992, and the World Food Summits in 1996 and 2002 and the World
Summit on Food Security in 2009, as well as in relevant international targets and
action plans, including the WHO 2025 Global Nutrition Targets and the WHO
Global Action Plan for the Prevention and Control of Non-communicable Diseases
2013–2020.
3. Reaffirming the right of everyone to have access to safe, sufficient, and
nutritious food, consistent with the right to adequate food and the
fundamental right of everyone to be free from hunger consistent with the
International Covenant on Economic, Social and Cultural Rights and other relevant
United Nations instruments.
Multiple challenges of malnutrition to inclusive and sustainable development
and to health
4. Acknowledge that malnutrition, in all its forms, including undernutrition,
micronutrient deficiencies, overweight and obesity, not only affects people’s
health and well-being by impacting negatively on human physical and cognitive
development, compromising the immune system, increasing susceptibility to
communicable and non-communicable diseases, restricting the attainment of
human potential and reducing productivity, but also poses a high burden in the
form of negative social and economic consequences to individuals, families,
communities and States.
5. Recognize that the root causes of and factors leading to malnutrition are
complex and multidimensional:
a. poverty, underdevelopment and low socio-economic status are major
contributors to malnutrition in both rural and urban areas;
b. the lack of access at all times to sufficient food, which is adequate both in
quantity and quality which conforms with the beliefs, culture, traditions,
dietary habits and preferences of individuals in accordance with national and
international laws and obligations;
c. malnutrition is often aggravated by poor infant and young child feeding and
care practices, poor sanitation and hygiene, lack of access to education, quality
health systems and safe drinking water, food-borne infections and parasitic
infestations, ingestion of harmful levels of contaminants due to unsafe food
from production to consumption;
d. epidemics, such as of the Ebola virus disease, pose tremendous challenges to
food security and nutrition.

88
6. Acknowledge that different forms of malnutrition co-exist within most
countries; while dietary risk affects all socio-economic groups, large inequalities
exist in nutritional status, exposure to risk and adequacy of dietary energy and
nutrient intake, between and within countries.
7. Recognize that some socioeconomic and environmental changes can have
an impact on dietary and physical activity patterns, leading to higher susceptibility
to obesity and non-communicable diseases through increasing sedentary
lifestyles and consumption of food that is high in fat, especially saturated and
trans-fats, sugars, and salt/sodium.
8. Recognize the need to address the impacts of climate change and other
environmental factors on food security and nutrition, in particular on the
quantity, quality and diversity of food produced, taking appropriate action to
tackle negative effects.
9. Recognize that conflict and post conflict situations, humanitarian emer­
gen­ cies and protracted crises, including, inter alia, droughts, floods and
desertification as well as pandemics, hinder food security and nutrition.
10. Acknowledge that current food systems are being increasingly challenged
to provide adequate, safe, diversified and nutrient rich food for all that contribute
to healthy diets due to, inter alia, constraints posed by resource scarcity
and environmental degradation, as well as by unsustainable production and
consumption patterns, food losses and waste, and unbalanced distribution.
11. Acknowledge that trade is a key element in achieving food security and
nutrition and that trade policies are to be conducive to fostering food security
and nutrition for all, through a fair and market-oriented world trade system,
and reaffirm the need to refrain from unilateral measures not in accordance
with international law, including the Charter of the United Nations, and which
endanger food security and nutrition, as stated in the 1996 Rome Declaration.
12. Note with profound concern that, notwithstanding significant achievements
in many countries, recent decades have seen modest and uneven progress in
reducing malnutrition and estimated figures show that:
a) the prevalence of undernourishment has moderately declined, but absolute
numbers remain unacceptably high with an estimated 805 million people
suffering chronically from hunger in 2012–2014;
b) chronic malnutrition as measured by stunting has declined, but in 2013 still
affected 161 million children under five years of age, while acute malnutrition
(wasting) affected 51 million children under five years of age;
c) undernutrition was the main underlying cause of death in children under five,
causing 45% of all child deaths in the world in 2013;
d) over two billion people suffer from micronutrient deficiencies, in particular
vitamin A, iodine, iron and zinc, among others;
e) overweight and obesity among both children and adults have been increasing
rapidly in all regions, with 42 million children under five years of age affected
by overweight in 2013 and over 500 million adults affected by obesity in 2010;
f) dietary risk factors, together with inadequate physical activity, account for
almost 10% of the global burden of disease and disability.

A common vision for global action to end all forms of malnutrition

13. We reaffirm that:
a) the elimination of malnutrition in all its forms is an imperative for health,
ethical, political, social and economic reasons, paying particular attention to

89
 the special needs of children, women, the elderly, persons with disabilities,
other vulnerable groups as well as people in humanitarian emergencies;
b) nutrition policies should promote a diversified, balanced and healthy diet at all
stages of life. In particular, special attention should be given to the first 1,000
days, from the start of pregnancy to two years of age, pregnant and lactating
women, women of reproductive age, and adolescent girls, by promoting and
supporting adequate care and feeding practices, including exclusive breast
feeding during the first six months, and continued breastfeeding until two
years of age and beyond with appropriate complementary feeding. Healthy
diets should be fostered in preschools, schools, public institutions, at the
workplace and at home, as well as healthy eating by families;
c) coordinated action among different actors, across all relevant sectors at
international, regional, national and community levels, needs to be supported
through cross-cutting and coherent policies, programmes and initiatives,
including social protection, to address the multiple burdens of malnutrition
and to promote sustainable food systems;
d) food should not be used as an instrument for political or economic pressure;
e) excessive volatility of prices of food and agricultural commodities can
negatively impact food security and nutrition, and needs to be better moni­
tored and addressed for the challenges it poses;
f) improvements in diet and nutrition require relevant legislative frameworks
for food safety and quality, including for the proper use of agrochemicals,
by promoting participation in the activities of the Codex Alimentarius
Commission for the development of international standards for food safety
and quality, as well as for improving information for consumers, while avoiding
inappropriate marketing and publicity of foods and non-alcoholic beverages
to children, as recommended by resolution WHA63.14;
g) nutrition data and indicators, as well as the capacity of, and support to all
countries, especially developing countries, for data collection and analysis,
need to be improved in order to contribute to more effective nutrition
surveillance, policy making and accountability;
h) empowerment of consumers is necessary through improved and evidence-
based health and nutrition information and education to make informed
choices regarding consumption of food products for healthy dietary practices;
i) national health systems should integrate nutrition while providing access for all
to integrated health services through a continuum of care approach, including
health promotion and disease prevention, treatment and rehabilitation, and
contribute to reducing inequalities through addressing specific nutrition-
related needs and vulnerabilities of different population groups;
j) nutrition and other related policies should pay special attention to women
and empower women and girls, thereby contributing to women’s full and
equal access to social protection and resources, including, inter alia, income,
land, water, finance, education, training, science and technology, and health
services, thus promoting food security and health.
14. We recognize that:
a) international cooperation and Official Development Assistance for nutrition
should support and complement national nutrition strategies, policies and
programmes, and surveillance initiatives, as appropriate;

90
b) the progressive realization of the right to adequate food in the context of
national food security is fostered through sustainable, equitable, accessible in
all cases, and resilient and diverse food systems;
c) collective action is instrumental to improve nutrition, requiring collaboration
between governments, the private sector, civil society and communities;
d) non-discriminatory and secure access and utilization of resources in accordance
with international law are important for food security and nutrition;
e) food and agriculture systems, including crops, livestock, forestry, fisheries
and aquaculture, need to be addressed comprehensively through coordinated
public policies, taking into account the resources, investment, environment,
people, institutions and processes with which food is produced, processed,
stored, distributed, prepared and consumed;
f) family farmers and small holders, notably women farmers, play an important
role in reducing malnutrition and should be supported by integrated and
multisectoral public policies, as appropriate, that raise their productive
capacity and incomes and strengthen their resilience;
g) wars, occupations, terrorism, civil disturbances and natural disasters, disease
outbreaks and epidemics, as well as human rights violations and inappropriate
socio-economic policies, have resulted in tens of millions of refugees,
displaced persons, war affected non-combatant civilian populations and
migrants, who are among the most nutritionally vulnerable groups. Resources
for rehabilitating and caring for these groups are often extremely inadequate
and nutritional deficiencies are common. All responsible parties should
cooperate to ensure the safe and timely passage and distribution of food and
medical supplies to those in need, which conforms with the beliefs, culture,
traditions, dietary habits and preferences of individuals, in accordance with
national legislation and international law and obligations and the Charter of
the United Nations;
h) responsible investment in agriculture, including small holders and family
farming and in food systems, is essential for overcoming malnutrition;
i) governments should protect consumers, especially children, from inappropriate
marketing and publicity of food;
j) nutrition improvement requires healthy, balanced, diversified diets, including
traditional diets where appropriate, meeting nutrient requirements of all
age groups, and all groups with special nutrition needs, while avoiding
the excessive intake of saturated fat, sugars and salt/sodium, and virtually
eliminating trans-fat, among others;
k) food systems should provide year-round access to foods that cover people’s
nutrient needs and promote healthy dietary practices;
l) food systems need to contribute to preventing and addressing infectious
diseases, including zoonotic diseases, and tackling antimicrobial resistance;
m) food systems, including all components of production, processing and distri­
bution should be sustainable, resilient and efficient in providing more diverse
foods in an equitable manner, with due attention to assessing environmental
and health impacts;
n) food losses and waste throughout the food chain should be reduced in order
to contribute to food security, nutrition, and sustainable development;
o) the United Nations system, including the Committee on World Food
Security, and international and regional financial institutions should work

91
 more effectively together in order to support national and regional efforts,
as appropriate, and enhance international cooperation and development
assistance to accelerate progress in addressing malnutrition;
p) EXPO MILANO 2015, dedicated to “feeding the planet, energy for life”,
among other relevant events and fora, will provide an opportunity to stress
the importance of food security and nutrition, raise public awareness, foster
debate, and give visibility to the ICN2 outcomes.
Commitment to action
15. We commit to:
a) eradicate hunger and prevent all forms of malnutrition worldwide, particularly
undernourishment, stunting, wasting, underweight and overweight in children
under five years of age; and anaemia in women and children among other
micronutrient deficiencies; as well as reverse the rising trends in overweight and
obesity and reduce the burden of diet-related non-communicable diseases in all
age groups;
b) increase investments for effective interventions and actions to improve people’s
diets and nutrition, including in emergency situations;
c) enhance sustainable food systems by developing coherent public policies
from production to consumption and across relevant sectors to provide year-
round access to food that meets people’s nutrition needs and promote safe and
diversified healthy diets;
d) raise the profile of nutrition within relevant national strategies, policies, actions
plans and programmes, and align national resources accordingly;
e) improve nutrition by strengthening human and institutional capacities to address
all forms of malnutrition through, inter alia, relevant scientific and socio-economic
research and development, innovation and transfer of appropriate technologies
on mutually agreed terms and conditions;
f) strengthen and facilitate contributions and action by all stakeholders to improve
nutrition and promote collaboration within and across countries, including
North-South cooperation, as well as South-South and triangular cooperation;
g) develop policies, programmes and initiatives for ensuring healthy diets throughout
the life course, starting from the early stages of life to adulthood, including of
people with special nutritional needs, before and during pregnancy, in particular
during the first 1,000 days, promoting, protecting and supporting exclusive
breastfeeding during the first six months and continued breastfeeding until two
years of age and beyond with appropriate complementary feeding, healthy eating
by families, and at school during childhood, as well as other specialized feeding;
h) empower people and create an enabling environment for making informed
choices about food products for healthy dietary practices and appropriate
infant and young child feeding practices through improved health and nutrition
information and education;
ch) implement the commitments of this Declaration through the Framework for
Action which will also contribute to ensuring accountability and monitoring
progress in global nutrition targets;
i) give due consideration to integrating the vision and commitments of this
Declaration into the post-2015 development agenda process including a possible
related global goal.
16. We call on FAO and WHO, in collaboration with other United Nations agencies, funds
and programmes, as well as other international organizations, to support national
governments, upon request, in developing, strengthening, and implementing their
policies, programmes, and plans to address the multiple challenges of malnutrition.

92
 17. We recommend to the United Nations General Assembly to endorse the Rome
Declaration on Nutrition, as well as the Framework for Action, which provides a
set of voluntary policy options and strategies for use by governments, as appro­
priate, and to consider declaring a Decade of Action on Nutrition from 2016 to
2025 within existing structures and available resources.

References
FAO. Food and Agriculture Organization of the United Nations. Rome Declaration. October
2014, Second International Conference on Nutrition. ISBN: 978-0-89629-564-3. Available
online: http://www.fao.org/3/a-ml542e.pdf, http://www.fao.org/assets/infographics/FAO-
infographic-ICN2-RomeDeclaration-en.pdf.
Global Nutrition Report 2014: Actions and Accountability to Accelerate the World’s Progress on
Nutrition. International Food Policy Research Institute. 2014. Washington, DC DOI: http://
dx.doi.org/10.2499/9780896295643. Available online: http://ebrary.ifpri.org/utils/getfile/
collection/p15738coll2/id/128484/filename/128695.pdf.
Understanding the Codex Alimentarius. Food and Agriculture Organization of the United Nations/
World Health Organization. FAO/WHO 1999; Editorial Group FAO Information Division, M-83
ISBN 92-5-104248-9. Available online: http://www.fao.org/docrep/w9114e/w9114e00.htm.

93
 FOOD SAFETY

Stanislav Sekretár
Institute of Hygiene, Faculty of Medicine, Comenius University in Bratislava

14 INTRODUCTION

The term food safety has no universally accepted definition. In fact, it is sometimes
used, wrongly, in relation to defects in food commodities that are much more to do
with food quality than with safety. For example, microbial spoilage of food may make
it unattractive, or even inedible, but if neither the microorganisms concerned, nor the
by-products of their growth and metabolism have any adverse effect on health, then it
is not strictly a food safety issue, but one of acceptability.
Food safety is a scientific discipline describing handling, preparation, and storage
of food in ways that prevent food-borne illness. Food safety can be defined as the
assurance that food will not cause harm to the consumer, when it is prepared and/or
eaten according to its intended use. This definition covers a broad range of topics, from
basic domestic and personal hygiene, to highly complex technical procedures designed
to remove contaminants from sophisticated processed foods and ingredients.
Contaminated food is one of the most widespread public health problems of the
contemporary world and causes considerable morbidity and mortality. Food poisoning
can be very serious in vulnerable groups such as the elderly, infants, young children,
pregnant women, and immunocompromised individuals. There are more than 250
food-borne diseases registered today. Food safety programmes are focusing on the farm-
to-table approach as an effective means of reducing food-borne hazards. These hazards
may emerge from microbiological, chemical, or physical contamination of food. Health
significance of these hazards is estimated through risk assessment method, and thus
hazards are regulated, controlled, and kept under surveillance. The practice of food
safety can be distilled down to three basic operations:
• Protection of the food supply from harmful contamination.
• Prevention of the development and spread of harmful contamination.
• Effective removal of contamination and contaminants.
Most food safety procedures fall into one, or more than one, of these categories.
For example, good hygiene practice is concerned with the protection of food against
contamination, effective temperature control is designed to prevent the development
(growth) and spread of contamination, and pasteurisation or disinfection are the
measure to remove biological contaminants.

94
 References
Lawley, R., Curtis, L., Davis, J.: The Food Safety Hazard Guidebook, 2nd Ed., The Royal Society of
Chemistry, Cambridge UK 2012, 546 p. ISBN: 978-1-84973-381-6.
Motarjemi, Y. ed.: Encyclopaedia of Food Safety. Academic Press, Elsevier, London 2014, 2356 p.
ISBN 978-0-12-378612-8.
Redman, N. E.: Food Safety. A Reference Handbook, 2nd Ed. ABC-CLIO, Inc., Santa Barbara 2007,
344 p. ISBN 978-1-59884-048-3.
Satin, M.: Food Alert! The Ultimate Sourcebook for Food Safety, 2nd Ed., Facts on File, Inc. New
York 2008, 371 p. ISBN 978-0-8160-6968-2.
Schmidt, R. H., Rodrick, G. E. eds: Food Safety Handbook, John Wiley & Sons, Inc., New Jersey,
2003, 928 p. ISBN 0-471-21064.

95
 15 FOOD SAFETY HAZARDS

A food safety hazard can be defined as any biological, physical or chemical agent
present in food that has the potential to cause harm to the consumer, either by causing
illness or injury. The term contaminant covers harmful substances or microorganisms
that are not intentionally added to food. Contaminants may enter the food accidentally
during growth, cultivation, or preparation, accumulate in food during storage, form in
the food through the interaction of chemical components, or may be concentrated from
the natural components of the food. There are three main types of hazard: biological,
such as pathogenic bacteria, chemical, such as a toxin produced during processing, or a
physical object, like a stone or piece of metal. In other words, hazards are the factors that
food safety practice seeks to protect against, contain, and eliminate from foods.

15.1 Biological Hazards

Biological agents of concern to public health include pathogenic strains of
bacteria, viruses, helminths, protozoa and algae, and certain toxic products they may
produce. Technically, biological hazards may include also larger organisms, such
as insects and rodents. However, these rarely present a direct threat to health. It is
microorganisms and certain food-borne parasites that are of most concern as food
safety hazards. Food-borne infections are caused when microorganisms are ingested,
and these can multiply in the human body. Intoxications result when microbial or
naturally occurring toxins are consumed in contaminated foods. Microorganisms
or toxins may be introduced directly from infected food animals or from workers,
other foods, or the environment during the preparation or processing of food.
Poisonous substances may also be produced by the growth of bacteria and moulds in
food. Pathogenic organisms of public health importance, which may be transmitted
through contaminated food, are as follows:
• Bacteria (spore-forming): Clostridium botulinum, Clostridium perfringens,
Bacillus cereus
• Bacteria (nonspore-forming): Brucella abortis, Brucella suis, Campylobacter
spp., Pathogenic Escherichia coli, Listeria monocytogenes, Salmonella spp.,
Shigella (S. dysenteriae), Staphylococcus aureus, Streptococcus pyogenes, Vibrio
cholera, Vibrio parahaemolyticus, Vibrio vulnificus, Yersinia enterocolytica
• Viruses: hepatitis A and E, Norwalk virus group, rotavirus
• Protozoa and parasites: Cryptosporidium parvum, Diphyllabothrium, Entamoeba
histolytica, Giardia lamblia, Ascaris lumbricoides, Taenia solium, Taenia saginata,
Trichinella spiralis
A significant number of bacterial species can be classified as food safety hazards.
Some of these, such as Salmonella and Listeria monocytogenes, are very well known and
familiar to consumers, whereas others are much less common and less well understood.
With the improvement of standards of personal hygiene, basic sanitation, vaccination,
food control and increasing application of technologies (e.g. pasteurization), many food-

96
borne diseases either have been eliminated or considerably reduced (e.g. poliomyelitis,
cholera, brucellosis, typhoid and paratyphoid fevers, bovine TB). Nevertheless, most
countries are experiencing a great increase in several other foodborne diseases.

15.1.1 Bacterial Food Safety Hazards

Bacteria fall into one of two categories according to the mechanism by which they
cause illness:
• Infection. Most food-borne bacterial pathogens cause illness by multiplying in the
gut after ingestion of contaminated food. They may then provoke symptoms by
invading the cells lining the intestine, or in some cases, invading other parts of the
body and causing more serious illnesses. Salmonella, Campylobacter and E. coli
O157 are all examples of bacteria that cause infective food poisoning. This type of
food poisoning is usually characterised by a delay, or incubation time, of at least
8–12 hours (sometimes much longer) before symptoms develop. This category
also includes some bacteria that produce symptoms by multiplying in the gut and
producing toxins, rather than by actively invading the tissues. An example of this
type is Clostridium perfringens, a food-poisoning bacterium usually associated
with cooked meat products.
• Intoxication. There are a few food-borne pathogenic bacteria that produce
illness not by infection, but by intoxication. These organisms are able to grow in
certain foods under favourable conditions and produce toxins as a by-product
of growth. The toxin is thus pre-formed in the food before ingestion and in
some cases toxin may still be present even after all the bacterial cells have
been destroyed by cooking. Bacillus cereus and Staphylococcus aureus are the
examples of bacteria able to cause intoxication, but the most important and
potentially serious cause of intoxication is Clostridium botulinum. Intoxications
usually have much shorter incubations times than infections, because the toxins
are pre-formed in the food.

15.1.2 Viruses
Viral gastroenteritis is very common worldwide. There are a number of viruses that
are capable of causing food-borne infections, although in most cases, other forms of
transmission are more common. Perhaps the best known are noroviruses and hepatitis
A, which have been responsible for a number of serious food-borne disease outbreaks,
often as a result of poor personal hygiene by infected food handlers. ‘New’ viruses
may also pose a threat to food safety. For example, highly pathogenic avian influenza
viruses primarily affect birds, but in some cases may be transmitted to humans and
cause serious disease. So far, there is no direct evidence that this transmission can be
food-borne, but these viruses are a source of great concern to the poultry industry and
there is still much to learn about them.

15.1.3 Parasites
A wide range of intestinal parasites can be transmitted to humans via contaminated
foods, although for most, faecal–oral, or water-borne transmission is more common.
These organisms are much more prevalent in developing countries with poor sanitation,
but the increasingly global nature of the food supply chain may increase their importance
in the developed world. Currently, protozoan parasites are the most important, but other
types also need to be considered as food safety hazards.

97
 15.1.4 Protozoans
The protozoan parasites that can cause food-borne illness in humans include several
well-known species, such as Entamoeba histolytica, the cause of amoebic dysentery,
and Cryptosporidium parvum. However, in recent years, some unfamiliar species have
emerged as threats to food safety, especially as contaminants in imported produce. An
example is Cyclospora cayetanensis, the cause of several outbreaks of gastroenteritis in
the USA associated with imported fruit.

15.1.5 Other Types of Parasite

Other types of food-borne parasite include nematode worms, such as Trichinella
spiralis and the anisakid worms found in fish, and cestodes (tapeworms), such as Taenia
solium. Although many of these are far less prevalent in developed countries than was
once the case, thanks to improved sanitation, they are still significant causes of illness
worldwide.

15.1.6 Prions
Prions are a relatively recent threat to food safety and are still not fully understood,
but their probable involvement in potentially food-borne new variant Creutzfeldt–
Jakob disease, an invariably fatal brain disease, has led to a considerable concern.

15.1.7 The Most Frequent Infections

The most frequent infections are caused by Escherichia coli, Salmonella, Campylo­
bacter jejuni, Listeria monocytogenes, and parasites like cryptosporidium, cryptospora,
trematodes, and viruses:
• Botulism is a disease caused by Bacillus botulinum, an agent emerging from soil.
The most common sources are canned meat and vegetables and the production
of toxin can be regulated by controlling the acid pH of food.
• Campylobacteriosis is a bacterial gastrointestinal infectious disease caused
by Campylobacter jejuni, C. fetus, and C. coli. The germs are found in the
intestines of animals. Infection can be caused by handling raw poultry, eating
undercooked poultry, drinking non-chlorinated water or raw milk, or handling
infected animal or human faeces. Most frequently, poultry and cattle waste are
the sources of the bacteria, but faeces from puppies, kittens, and birds may be
contaminated too.
• Escherichia coli infectionis caused by different strains of E. coli bacteria. Harmless
strains of E. coli can be found widely in nature, including the intestinal tracts
of humans and warm-blooded animals. Disease-causing strains, however, are a
frequent cause of both intestinal and urinary-genital tract infections. Several
different strains of harmful E. coli can cause diarrhoeal disease. A particularly
dangerous type is called Enterohaemorrhagic E. coli, or EHEC. EHEC often
causes bloody diarrhoea and can lead to kidney failure in children or people
with weakened immune systems. In 1982, scientists identified the first dangerous
strain in the United States. The type of harmful E. coli most commonly found
in this country is named O157:H7, which refers to chemical compounds found
on the bacterium’s surface. This type produces one or more related, powerful
toxins, which can severely damage the lining of the intestines. This strain is now
found worldwide and presents one of the most serious bacterial sources to be
found in food and water.

98
 • Salmonellosis is usually provoked by Salmonella sp. Salmonella sp. can be found
in food products such as raw poultry, eggs, and beef, and sometimes on unwashed
fruit. Food prepared on surfaces that previously were in contact with raw meat or
meat products can, in turn, become contaminated with the bacteria. This is called
cross-contamination. With the spread of organic farming, new cases are recorded
from eating raw alfalfa sprouts grown in contaminated soil. Salmonellosis may
frequently occur after handling pets.
• Shigellosis, also called bacillary dysentery, is an infectious disease caused by
Shigella (Shigella dysenteriae, S. flexneri, S. boydii, and S. sonnei). It is commonly
transmitted by food service workers who are sick or infected, but have no
symptoms, and adequate personal hygiene.
• Listeriosis is caused by Listeria monocyotogenes. This food-borne illness in
pregnant women can result in miscarriage, foetal death, and severe illness or
death of a newbornn infant. Others at risk for severe illness or death are older
adults and those with weakened immune systems. Listeriosis is now attributed to
ready-to-eat foods and deli products.
• Food-borne viruses (caliciviruses, rotavirus, astrovirus, and hepatitis A virus)
present in food and water are frequent cause of diarrhoea. Hepatitis A is also
common throughout the world (e.g. shellfish-borne hepatitis A, food infected by
food handlers, and not subsequently sufficiently heated may also transmit the
disease and many cases of hepatitis A are known to be restaurant associated).
• Norwalk virus (a particular calicivirus) caused a number of outbreaks of food
poisoning at buffets and caterings.
• Prions. Mad Cow Disease is the commonly used name for Bovine Spongiform
Encephalopathy (BSE), a slowly progressive, degenerative, fatal disease affecting
the central nervous system of adult cattle. In cattle with BSE, these abnormal
types of protein, prions, initially occur in the small intestines and tonsils, and
are found in central nervous tissues, such as the brain and spinal cord, and other
tissues of infected animals experiencing later stages of the disease. There is a
disease similar to BSE called Creutzfeldt-Jakob Disease (CJD) that is found in
people. A variant form of CJD is believed to be caused by eating contaminated
beef products from BSE-affected cattle.
• Parasitic infections (e.g. Cryptosporidium infection) – infection is believed to
be more common than Salmonella infection in young children. Helminths (e.g.
Trichinella spiralis, Taenia saginata and Taenia solium), which are acquired
through consumption of undercooked or uncooked meat. Ascaris lumbricoides
affects humans and causes the disease ascariasis. Biological contaminants are
responsible for a wide range of food-borne diseases and infant diarrhoea is the
dominant problem. According to WHO data almost 1.8 million children die each
year in developing countries from diarrhoeal disease caused by microbes, which
are present in food and water.
Despite progress in science and technology, contaminated food and water remain
in this day a major public health problem. However, only a small portion of cases
comes to the notice of the health services (in developed countries only about 10% are
reported while in developing countries about 1% of the total). Food-borne diseases
may also cause other serious health problems (e.g. chronic diarrhoea can lead to
undernutrition, some diseases – listeriosis and toxoplasmosis are dangerous during
pregnancy, and some food-borne infections may lead to chronic diseases (e.g. joint
disease, immune system disorders, heart and vascular diseases, diseases of the renal
system).

99
 15.1.8 Factors Responsible for the Prevalence of Food-borne Diseases
Factors responsible for the prevalence of foodborne diseases are as follows:
• improved standards of living have led to an increase in consumption of food of
animal origin;
• mass production of animals with the risk that many of these animals are
subclinically infected by various pathogens (e.g. Salmonella and Campylobacter);
• many of the foodborne diseases are to errors in food preparation or lack of
personal hygiene on the part of the foodhandlers;
• traditions and beliefs contribute to the occurrence of food-borne diseases (e.g.
consumption of raw meat products, raw fish or raw milk);
• with increasing number of international travellers, some of the diseases are
imported from endemic areas;
• many outbreaks occur as a result of failures during the food processing (e.g.insuffi­
cient cooking or reheating the food);
• international trade in food and animal food plays an important role in the spread
of pathogens (e.g. animals given the contaminated feeds contaminated the
environment);
• soil, rivers, surface water and, in turn, insects, rodents and birds with their faeces.
In such a manner, the microorganisms have established themselves widely in the
environment, including animals.

15.1.9 Prevention and Control of the Biological Contamination

of Food
For the prevention and control of the biological contamination of food, three lines
of defence are available:
• The first line of defence is to improve the hygienic quality of raw foodstuffs at
the agricultural level, by applying the principles of good agricultural practice and
animal husbandry.
• The second line of defence is the application of food processing technologies
(e.g. pasteurization, sterilization, fermentation, or irradiation).
• The third line of defence is the most critical and will protect the health of
consumers when the other two fail. This concerns education of food handlers
(professional cooks, persons handling with food in food service establishment,
as well as those in charge of the preparation of food at home). The education of
food handlers is of special importance, because the cases of food-borne diseases
frequently occur due to mishandling of food in the home, as a result of negligence,
ignorance or ingrained traditions and habits.

15.2 Chemical Hazards

The presence of chemical hazards in food is usually less immediately apparent
than that of bacteria and other biological hazards. Acute toxicity caused by food-borne
chemical contaminants is now very rare in developed countries. Of much more
concern is the potentially insidious effect of exposure to low levels of toxic chemicals
in the diet over long periods. In some cases, this can lead to chronic illness and there is
also the risk that some contaminants may be carcinogenic.
There is potential for an enormous range of chemical contaminants to enter the food
chain at any stage in production. For example, agricultural chemicals, such as herbicides
and insecticides, may contaminate fresh produce during primary production, some

100
 FOOD SAFETY (pripomienky Sekretár)

Poznámka
commodities may contain ‘natural’ biological toxins, and chemicals such as detergents
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• Contaminants from food contact materials (e.g. plasticisers)
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medzeru za čiarku Listeria monocytogenes,and
The total number of potentially
parasites opraviťna Listeria monocytogenes, harmful chemicals that may contaminate food is
and parasites.
very large. For example, UK legislation contains maximum residue levels (MRLs) for
Str.28,000
over 97 nižšie od stredu strany: odstrániť
pesticide/commodity čiarku z výrazu
combinations. Thecontaminated, too. opraviťna
list of potential adulterants is also
contaminated too.
an extensive one.
Str. 97 nižšie od stredu strany: výraz strains of E. coli can upraviť na strains of E. coli can
(kurzíva
15.2.1vo výraze E. coli).
Naturally Occurring Toxins
Str. 98 prvý riadok: výraz by Salmonella and S. . Salmonellasp. can be opraviť na by
Alkaloids
Salmonella sp. Salmonella
Plant alkaloids sp. can be.
are secondary metabolites having one or more nitrogen atoms. Many
ofStr.
them have a pharmacological activity in
98, 6. a 7. riadok: výraz Salmonellosismay the na
opraviť animals and humans
Salmonellosis that consume
may (medzera).
them, affecting the nervous system and other essential processes. The major alkaloids
Str. 100, Fig. 6: vzorce sú vo vrchnej časti orezané a substituenty nenadväzujú na väzby.
possessing these properties are solanine, caffeine, morphine, lupanine, nicotine,
Prosím, opraviť podľa nasledujúceho vzoru:
senecionine, ergocristine, hyoscyamine, coniine and many others (Fig. 6).

CH3 O CH3 HO
H3C
N CH3
N
N
CH3 CH3 N
O
O N N CH3
N
R O
CH3
HO

α-solanine caffeine morphine nicotine

H3C CH3
N
HO
O O
O H 3C
CH3 N
OH O
O
O O
N N CH3
H

hyoscyamine senecionine lupanine coniine

Figure 6 Chemical structures of some common alkaloids.

In some cases, they are found as natural components (solanum glycosides) of some
important food plants such as potatoes. Potatoes, which were exposed to light, can contain
up to 350 mg.kg-1 of glycoalkaloids. Ingestion of potatoes with high glycoalkaloid content
can cause stomach pains, weakness, nausea, vomiting, and breathing difficulties between
2 and 24 h after ingestion, which may persist for several days. Solanine is not removed by

101
boiling, but it can be destroyed by frying. In other cases, alkaloids can contaminate food
that does not itself contain them. The most important example of this is the fungus ergot,
which infects mainly rye, wheat, and barley, and has achieved notoriety through major
poisoning outbreaks. Alkaloid transfer into the milk of cows, sheep, and goats can also
lead to human poisoning. The transfer of alkaloids from food into the milk of humans is
of considerable concern, because newborn babies are very sensitive to toxins, and may
derive all of their food from breast milk. Medicinal morphine and caffeine are rapidly
absorbed into the blood and pass into breast milk. Nicotine and cotinine from smoking
mothers also contaminates milk and can be detected in infants’ urine.

Other plant toxins

Plant toxins are generally secondary metabolites having usually the defence function
against animal and insect predators. Some toxin-containing plants are occasionally eaten
on account of mistaken identity, but some of them may be consumed purposely as an
act of suicide. The fruits of toxic plants such as the very poisonous deadly nightshade
appear similar to edible fruits such as blueberries, and the very toxic poison hemlock
and hemlock water dropwort resemble wild versions of carrot, parsnip, and chervil.
Very young children are at the highest risk from plant toxins as they regularly put almost
anything of suitable size within reach into their mouths, and might find berries and
leaves attractive. Poisons can be transferred from plants to human foods also in animal
products such as milk, bird’s eggs, and honey produced by bees foraging on toxic plants.
The most important plant toxins are: ricin, linamarin, goitrin, glucosinolate, β-ODAP,
hypoglycin A and B, myristicin, and oxalic acid (Fig. 7).
One of the most dangerous toxins is ricin. This toxin can be found in the seeds of the
castor oil plant (Ricinus communis). Intact seeds may pass through the digestive tract
without releasing the toxin. Ricin poisoning -1
can occur when-1 broken seeds contaminate
Str.notably
cereals, 100, 3. riadok
soya zdola:
beans. výraz
The350mg.kg
lethal doseorpaviť na 350 is
in adults mg.kg (medzerato
considered za be
číslom).
4–8 seeds. If
Str. 101,
ingested, vyššie odmay
symptoms stredu
bestránky:
delayedopraviť
by upvýraz
to glucosinolate, -ODAP, hypoglycin
36 h but commonly na výraz
begin within 2–4 h.
Unlessglucosinolate,
treated, death β-ODAP,
can behypoglycin
expected (zviditeľniť
to occurpísmeno
withinbeta).
3–5 days. On the other hand, the
castorStr.
oil101,
has Fig.
qualities that
7: vzorce sú give it numerous
vo vrchnej industrial
časti orezané uses,nenadväzujú
a substituenty but it contains no toxin.
na väzby.
Prosím, opraviť podľa nasledujúceho vzoru:
-
O
S
CH3 CH2 R N O
H3C N
O
OH
O S CH2
O O HO O

N S HO OH O
HO OH
H OH O
OH CH3

linamarin goitrin glucosinolate β-ODAP

O O O O CH 2

HO H 2C
OH H2C
OH OH NH2
O
NH2 HN OH
O O
CH3
O O

oxalic acid hypoglycin A hypoglycin B myristicin

Str. 102, 2. odstavec: výraz (e.g. -ODAP) opraviť na (e.g. β-ODAP) (zviditeľniť písmeno
Figurebeta).
7 Chemical structures of some plant toxins.

Str. 102, Tab. 17: v hlavičke tabuľky (aj v jej pokračovaní na str. 103) výraz mg kg–1 upraviť
102 na výraz mg.kg–1(pridať bodku ako znamienko násobenia).
Str. 103, odstavec pod tabuľkou: výraz A total of 500 mg kg–1 of amatoxins (LD50 0.2–0.5 mg
kg–1) can opraviť na A total of 500 mg.kg–1 of amatoxins (LD50 = 0.2–0.5 mg.kg–1) can (pridať
bodky ako znamienka násobenia a znamienko =).
Str. 104, Fig. 8: vzorce sú vo vrchnej časti orezané a substituenty nenadväzujú na väzby.
Prosím, opraviť podľa nasledujúceho vzoru:
 Cyanogenic glycosides are compounds that can release hydrogen cyanide (HCN)
under certain conditions, notably in an acid environment or through enzyme action.
The major food plants that do contain cyanogenic glycosides are cassava (Manihot
esculenta), sorghum (Sorghum spp.), and corn (Zea mays).
Glucosinolates are sulphur-containing oximes and glycosides associated with
brassicas (cabbage, broccoli, cauliflower, rapeseed, mustard, horseradish, and wasabi).
During the cooking, the glycosides hydrolyze and release volatile isothiocyanates or
nitriles and thiocyanates. The major toxicity is associated with oxazolidine-2-thiones,
such as goitrin, which are formed from these compounds, and which impair thyroid
function by inhibiting the formation of thyroxine by binding iodine and suppressing
thyroxine secretion from the thyroid. Nitriles released from glucosinolates depress
growth and cause damage to the liver and kidneys in severe cases.
Legumes of the species Lathyrus sativus (Indian pea), which grow in Europe, Asia,
and Africa, contain several neurotoxic amino acids (e.g. β-ODAP) that cause largescale
disease epidemics. The toxins cause paralysis of the lower body and wasting disease
(neurolathyrism) if eaten over a long time. Consumption of the peas has caused major
poisoning incidents; most recently in India in 1958, when over 25,000 people were
poisoned in one district. The neurotoxic amino acids can be removed from the seeds by
soaking in water before cooking.

15.2.2 Fungal Toxins

Mushrooms and toadstools toxins
Mushrooms are the edible fruiting bodies of fungi, which are large enough to be
picked by hand. Toadstools are the inedible, or poisonous, equivalents that are often
mistaken for mushrooms. There are approximately 14,000 of fungi species in the world
that are large enough to be considered as mushrooms or toadstools. The occurrence,
toxicity, and clinical manifestations for some of the major mushroom toxin classes are
summarized in Table 17.

Table 17 Summary of mushroom toxins, their source, toxicity, and effects

LD50
Toxin class Toxin Fungi species Poisoning
mg.kg–1
Acroduria–
Acromelic acid Acromelic acid Clitocybe acromelalga
neuroexcitation
Cyanides Hydrogen cyanide Lepista nuda 3 Cyanosis
Cyclopeptides Amatoxins Amanita phalloides 0.2–0.5 Hepatic and renal failure
Virotoxins Amanita verna 2.5 Hepatic and renal failure
Coprinus
Cyclopropanes Coprinine – Antabuse syndrome
atramentarius
Prop-2-ene carboxylic
Russula subnigricans 2.5 Rhabdomyolysis
acid
Hallucinogens Psilocybin Psilocybes emilanceata – Hallucinations
Bufotenine Amanita citrina 200 Hallucinations
Convulsions and GI
Hydrazine Gyromitrin Gyromitra esculenta 10–30
disorders
Mycoatropinic and
Isoxazoles Muscimol Amanita muscaria 7.5–10
delirium
Mycoatropinic and
Ibotenic acid Amanita pantherina 45
delirium
Muscarine Clitocybe dealbata 150
Tricholomic acid Tricholoma muscarium

103
 LD50
Toxin class Toxin Fungi species Poisoning
mg.kg–1
Necatorin Necatorin Lactarius necator
Aminohydroxyhexynoic Sudden unexplained
Norleucines Trogia venenata 71
acid death
Hallucination, spasms,
Stizolobic acid A. pantherina
and sleep
Pain and red coloration
Nucleosides Clitidine C. acromelalga 50
of toes
Orellanines Orellanine Cortinarius orellanus 15–20 Renal failure
Kills Diarrhoea, tremors, and
Terphenyls Ustalic acid Tricholoma ustale
mice death
Podostroma cornu-
Trichothecenes Roridin 1
damae
Verrucarin P. cornu-damae 0.7
Satratoxin P. cornu-damae 0.5
Hebeloma
Triterpenes Hebevinosides 66 Paralysis
vinosphyllum
Hebeloma GI disorders and renal
Crustulinols 100
crustuliniforme failure
Naematoloma
Fasciculols 50–168
fasciculare
Lampteromyces
Sesquiterpenes Illudin S 5 GI disorders
japonicus
Lectins Bolesatine Boletus satanas 3.3 Haemolytic poisoning
Rubescenslysine Amanita rubescens 0.15–0.3 Haemolytic poisoning
Phallolysin A. phalloides 0.2–0.7 Haemolytic poisoning

Abbreviation: GI, gastrointestinal

Only a few percent of them are truly poisonous (2%) and a similarly low percentage
are considered as choice edible species (4–5%). The greatest cause of poisoning is
mistaken identity, where a forager assumes they can identify an edible species and
collects a common look-alike poisonous species. The correct identification of fungi is
then at the heart of mushroom safety. A total of 500 mg.kg–1 of amatoxins (LD50 = 0.2–0.5
mg.kg–1) can be found in the death cap (Amanita phalloides) and this then requires
only a 50 g portion of the fresh toadstool to be considered lethally dangerous (Table
17). In reality, some 95% of deaths from ‘mushroom’ poisoning are due to a single cause
– the amatoxins, which are present in species found around the world.

Mycotoxins
Mycotoxins are fungal metabolites, which when ingested, inhaled, or absorbed through
the skin, can cause sickness or death in humans or domestic animals, including birds.
Mycotoxins have been responsible for major epidemics in humans and animals throughout
history. The most important epidemics have been ergotism, due to growth of the fungus
Claviceps purpurea in rye grains, which killed and maimed hundreds of thousands of
people in Europe in the past millennium; alimentary toxic aleukia, caused by T-2 toxin
produced by Fusarium sporotrichioides in grain, which was responsible for the death
of at least 100,000 Russian people between 1942 and 1948; and stachybotryotoxicosis
caused by growth of Stachybotrys chartarum in hay, which killed tens of thousands of
horses in the USSR in the 1930s. The term mycotoxicosis was first used in 1952 for the
diseases resulting from the growth of fungi in foods and feeds. The event that ushered
in the modern era of mycotoxin investigation was the discovery of aflatoxins due to the

104
 O O O O CH 2

HO H 2C
OH H2C
OH OH NH2
O
NH2 HN OH
O O
CH3
O O
growth of Aspergillus parasiticus in a peanut meal, which killed 100,000 young turkeys in
the
oxalic UK in 1960. Mycotoxins
acid hypoglycinexhibit
A four basic kindsBof toxicity: acute, chronic,
hypoglycin myristicinmutagenic,
and teratogenic. The most commonly described effect of acute mycotoxin poisoning is
deterioration
Str. 102, of liver
2. odstavec: výrazor(e.g.
kidney function,
-ODAP) which
opraviť nain(e.g.
extreme
β-ODAP)cases(zviditeľniť
may lead to písmeno
death. Five
mycotoxins
beta). are considered to be of major importance in human or animal health today:
aflatoxins, ochratoxin A, fumonisins, deoxynivalenol (and the related trichothecene
–1
Str. 102, Tab. 17:and
nivalenol), v hlavičke (Fig.(aj8).v jej pokračovaní na str. 103) výraz mg kg upraviť
tabuľky
zearalenone
–1
mg.kg (pridať
na výrazAflatoxins bodku akoby
are produced znamienko
Aspergillus násobenia).
species primarily in cereals and nuts.
Ochratoxin A is produced by both Aspergillus and Penicillium –1
species in a range of
Str. 103,
foodsodstavec
– grapes podand
tabuľkou:
productsvýraz A total of
including 500 and
wines mg kg driedof vine
amatoxins
fruits,(LD 50 0.2–0.5
cereals mg
in cool
–1 –1 –1
kg )temperate
can opraviťclimates,
na A total
andofcoffee, cocoa,ofand
500 mg.kg amatoxins
chocolate.(LDThe
50 =remaining
0.2–0.5 mg.kg
major) toxins
can (pridať
are
bodky ako znamienka
primarily produced násobenia a znamienko
by Fusarium species =).in cereals. Good agricultural practice, i.e.
drying food commodities as soon as possible and keeping them dry, is the only sure
Str. 104, Fig. against
defence 8: vzorce sú vo vrchnej
mycotoxin časti orezané
formation in storeda substituenty
commodities. nenadväzujú na väzby.
Prosím, opraviť podľa nasledujúceho vzoru:
O O O O O O

O O O
OH

O O O
CH3 CH3
O O O CH3
O O O

aflatoxin B1 aflatoxin G1 aflatoxin M1

O OH O
O

OH
O OH OH
H 3C CH3
O OH O CH3
H3C

NH O CH3 O CH3 OH NH2

OH
CH3 O
O
Cl O OH

ochratoxin A (OTA) fumonisin B1

H H OH O CH3
H3C O H H
H3C O
OH OH O
O
O O
O HO
OH
OH CH3 OH
OH CH3 OH
O

deoxynivalenol nivalenol zearalenone

Figure 8 Chemical structures of some mycotoxins.

Str. 106, Fig. 9: vzorec je vo vrchnej časti orezaný a substituenty nenadväzujú na väzby.
Prosím, opraviť podľa nasledujúceho vzoru:
15.2.3 Seafood Toxins
Seafood constitutes a significant proportion of/ Rthe world
TTX analogue R1 food
R2 supply,
R3 andR4more thanR5
70 million tons are harvested
HO each year.
TTXAlthough it is an H important
OH OH and popular
11-CH2OHfood
OH
HO
source, seafood Hingestion is not free from associated public-health
4-epiTTx OH H risks.
OH In fact,
11-CHseafood
2OH OH
1
ranked third
+ on the list
R of
R
2 products
O most frequently
6-epiTTX associated
H with
OH food-borne
11-CH2OH OH disease. OH
H2N O
N 11-deoxyTTX H OH OH 11-CH3 OH
H H
N 11-oxoTTX H OH OH 11-CHO OH
H
R
5
TTX-11-carboxylic acid H OH OH 11-COO- OH
H H
H
4
R
11-norTTX-6,6-diol H OH OH OH 105
OH
3 11-norTTX-6(S)-ol H OH OH H OH
R
11-norTTX-6(R)-ol H OH H OH OH

Str. 107, 2. odstavec odspodu: výraz mg.kg-1in USA upraviť na mg.kg-1 in USA (vložiť
One type of seafood-related disease, ciguatera fish poisoning, is the most commonly
reported food poisoning caused by a chemical toxin.
Algae and microalgae toxins
Seafood-related diseases are caused by ingestion of seafood (bivalve shellfish,
primarily scallops, mussels, clams, oysters, and cockles, some fish species and crabs)
contaminated with potent neurotoxins that are naturally produced by marine algae and
microalgae. Many types of microalgae, such as dinoflagellates and diatoms, produce
some of the most powerful known natural toxins called phycotoxins. Phycotoxins
accumulated in seafood can cause a number of human diseases upon ingestion of the
contaminated seafood, including:
• neurotoxic shellfish poisoning (NSP),
• paralytic shellfish poisoning (PSP),
• amnesic shellfish poisoning (ASP),
• diarrhoeic shellfish poisoning (DSP),
• azaspiracid shellfish poisoning (AZP),
• ciguatera fish poisoning (CFP)
The main acute symptoms are:
• Gastrointestinal: diarrhoea, nausea, vomiting,
• Respiratory: shortness of breath, progressing to paralysis,
• Cardiovascular: arrhythmias, hypertension or hypotension,
• Neurologic: paraesthesias of mouth and lips, weakness, dysphasia, dysphonia, etc.
The major phycotoxins are saxitoxin (20 derivatives), brevetoxin (10 derivatives),
okadaic acid, dinophysistoxins (6 derivatives), domoic acid (3 derivatives), azaspiracid
(5 derivatives), ciguatoxin (10 derivatives), maitotoxin, and scaritoxin.
These potent natural toxins are tasteless and odourless, and contaminated seafood
appears to be completely normal. They are not destroyed by cooking or by food
preservation (e.g. freezing, drying, or salting). In addition, these toxins are refractory
to the action of human digestive enzymes, and there are no antidotes against their
biological activity. Phycotoxin contamination of seafood is therefore a challenge for
those people responsible for ensuring seafood quality and has important implications
for public health (including nutrition and medical care).

Fish toxins – Tetrodotoxin and others

Tetrodotoxin (TTX, CAS number 4368-28-9) (Fig. 9) is a marine neurotoxin associated
with certain fish species, notably pufferfish (22 species). Consumption of these fish can
cause very severe food-borne intoxication, often referred to as pufferfish poisoning,
or fugu poisoning. Unlike other marine biotoxins, it is not produced by the growth
of toxic algae. It is now generally accepted that TTX is produced by certain marine
bacteria – notably members of the Vibrionaceae, some Pseudomonas, Shewanella,
Photobacterium phosphoreum and Alteromonas species. It is thought that the toxin
passes up the food chain through plankton, small gastropods, and flatworms and
is eventually accumulated in the tissues of pufferfish species, possibly as a defence
against predators. Pufferfish appear to be immune to the toxic effects of TTX. Pufferfish
poisoning has been known for many years, especially in Japan, where the fish are
a delicacy and where it is required that specially trained fish cutters or chefs have a
license to process and prepare puffer fish.

106
Str. 106, Fig. 9: vzorec je vo vrchnej časti orezaný a substituenty nenadväzujú na väzby.
Prosím, opraviť podľa nasledujúceho vzoru:

TTX analogue / R R1 R2 R3 R4 R5
HO TTX H OH OH 11-CH2OH OH
HO
H 4-epiTTx OH H OH 11-CH2OH OH
1
+ R 2
O 6-epiTTX H OH 11-CH2OH OH OH
H2N R O
N 11-deoxyTTX H OH OH 11-CH3 OH
H H
N 11-oxoTTX H OH OH 11-CHO OH
H
R
5
TTX-11-carboxylic acid H OH OH 11-COO- OH
H 11-norTTX-6,6-diol H OH OH OH OH
H H 4
R
3 11-norTTX-6(S)-ol H OH OH H OH
R
11-norTTX-6(R)-ol H OH H OH OH

Figure 9 Chemical structures of tetrodotoxin and analogues.

Str. 107, 2. odstavec odspodu: výraz mg.kg-1in USA upraviť na mg.kg-1 in USA (vložiť
medzeru
TTX pred
is ain).
very potent neurotoxin. Commonly, reports of a human mortal dose of
tetrodotoxin are 1–2 mg with the victim eventually dying from respiratory paralysis.
Str. 108, Fig. 10: vzorce sú vo vrchnej časti orezané a substituenty nenadväzujú na väzby.
Initial symptoms appear between 20–180 min of ingestion. A slight numbness of
Prosím, opraviť podľa nasledujúceho vzoru:
the lips and tongue is then followed by increasing paraesthesia (tingling, ‘pins and
Clx
needles’)
Cl x
inO the face, hands, and feet. VictimsO may be completely paralysed and Cl xunable
Cl x
to move orO speak, yet remaining xconscious. Death usually occurs
Cl
Cl x within 4–6 hours
but may be as rapid as 20 min in some cases. TTX is relatively heat stable and is not
affected by normal cooking procedures. TTX is absorbed with activated charcoal,
which may PCDDreduce its toxic effect. PCDF PCB
TTX is 10–100 times as lethal as black widow spider venom and more than 10,000
Str. 108, 7. riadok odspodu: upraviť vetu The WHO/FAO Joint Expert Committee on Food
times deadlier than cyanide. It has a similar toxicity as saxitoxin, which causes
Additives (JECFA) established a provisional tolerable monthly intake (PTMI) of 70 pg World
paralytic shellfish poisoning and also blocks the–1sodium channel – both are found in
Health Organization
the tissues toxicfish.
of puffer equivalents (WHO-TEQ).kg
A recently of bodyweight
discovered naturally occurringper month in June
congener of TTX
2001. na vetu The WHO/FAO Joint Expert Committee on Food Additives (JECFA)
has proven to be four to five times as potent as TTX. Except for a few bacterial protein
established
toxins, onlya provisional
palytoxin, tolerable monthly
a bizarre intakeisolated
molecule (PTMI) from
of dioxins to 70
certain pg of World (small,
zoanthideans
–1
Health Organization toxic equivalents (WHO-TEQ).kg
colonial, marine organisms resembling sea anemones) of the genus 2001.
of bodyweight in June Palythoa, and
maitotoxin, found in certain fishes associated with ciguatera poisoning, are known
to be significantly more toxic than tetrodotoxin. Palytoxin and maitotoxin have
potencies nearly 100 times that of TTX and saxitoxin, and all four toxins are unusual
in being non-proteins.

15.2.4 Biogenic Amines

Biogenic amines are low-molecular-weight organic bases produced in a variety of
foods by the decarboxylation of specific free amino acids (Table 18). The presence of
significant amounts of biogenic amines, especially in meat and fish products, is often
an indicator of bacterial spoilage, can have adverse effects on health and is generally
undesirable.

Table 18 Biogenic amines and their chemical precursors

Biogenic amine Precursor
Histaminea Histidine
Putrescineb Ornithine
Cadaverineb Lysine
Tyraminec Tyrosine
Tryptaminea Tryptophan
β-phenylethylaminec Phenylalanine
a
Heterocyclic amine, bAlipathic amine, cAromatic amine.

107
 Biogenic amines are known to occur in a wide variety of food products: fish products,
cheese, meat products (especially fermented meats), wine, beer, and fermented vegetable
products, such as sauerkraut. Certain biogenic amines are also found naturally in a range
of fruit juices and fresh fruit and vegetables, including cocoa beans, mushrooms, and
lettuce. Histamine, tyramine, and to a lesser extent phenylethylamine are the main dietary
biogenic amines associated with several acute adverse reactions in consumers.
Histamine is extremely stable once formed and is not affected by cooking. It can
survive canning and retorting processes and is not reduced during freezing or frozen
storage. Scombrotoxic (histamine) poisoning is a chemical intoxication, in which
symptoms typically develop rapidly (from 10 minutes to 2 hours) after ingestion of
food containing toxic histamine levels (scombroid fish – especially tuna, skipjack,
bonito, and mackerel). The range of symptoms experienced is quite wide, but may
include an oral burning or tingling sensation, skin rash and localised inflammation,
hypotension, headaches and flushing. In some cases, vomiting and diarrhoea may
develop and elderly or sick individuals may require hospital treatment. The symptoms
usually resolve themselves within 24 hours. Antihistamines may be used effectively to
treat the symptoms.
The threshold toxic level for histamine remains unclear. Individuals also vary in
the severity of their response to histamine in fish. Analysis of outbreaks suggests that
levels of histamine above 200 ppm are potentially toxic. Histamine occurs naturally
in the human body; exposure to large doses can rapidly produce the symptoms of
toxicity. The deleterious effects in relation to the amount of histamine ingested at one
meal are as follows:
• 8 to 40 mg histamine – mild poisoning
• 70 to 1,000 mg – histamine disorders of moderate intensity
• 1,500 to 4,000 mg – histamine severe incident
Although the role of histamine in scombrotoxic poisoning is well established, the
food safety significance of other biogenic amines is much more uncertain. Tyramine,
cadaverine, and putrescine all have acute oral toxicities of at least 2,000 mg per kg of
body weight. Spermine and spermidine were reported to be slightly more toxic, with
acute oral toxicities of 600 mg per kg of body weight. When administered intravenously,
all these amines, except tyramine, caused a drop in blood pressure. Tyramine has been
associated with hypertension and headaches in sensitive individuals, especially those
who suffer from migraine headaches. In foods containing nitrite, such as cured meat
products, putrescine and cadaverine may react with nitrate and produce carcinogenic
compounds.
From a legal perspective, safe legal limits are set for histamine in certain fish and
seafood products, mainly from fish species associated with high levels of histidine
(e.g. 50 mg.kg-1 in USA, 100 mg.kg-1 in EU, 200 mg.kg-1 in Australia). Although there are
no legal guidelines that restrict the presence of biogenic amines in wine, it has been
reported that different countries have applied specific histamine thresholds to reject
wine imports: 2 mg.l-1 in Germany, 5–6 mg.l-1 in Belgium, 8 mg.l-1 in France, and 10 mg.l-1
in Switzerland.

15.2.5 Environmental Contaminants

Dioxins, Furans, and Dioxin-like Polychlorinated Biphenyls
Polychlorinated dibenzo-p-dioxins, polychlorinated dibenzofurans, and dioxin-
like polychlorinated biphenyls (PCDD/Fs and dl-PCBs) are ubiquitous environmental
contaminants, having been found in soil, surface water, sediments, plants, and animal
tissue worldwide (Fig. 10).

108
Str. 107, 2. odstavec odspodu: výraz mg.kg-1in USA upraviť na mg.kg-1 in USA (vložiť
medzeru pred in).
Str. 108, Fig. 10: vzorce sú vo vrchnej časti orezané a substituenty nenadväzujú na väzby.
Prosím, opraviť podľa nasledujúceho vzoru:
O O Clx Cl x
Cl x Cl x
Clx
O
Cl x

PCDD PCDF PCB

Str. Figure
108, 7.10 Structures
riadok of PCDDs,
odspodu: PCDFs,
upraviť and
vetu PCBs.
The WHO/FAO Joint Expert Committee on Food
Additives (JECFA) established a provisional tolerable monthly intake (PTMI) of 70 pg World
Dioxins are often man-made contaminants and are –1
formed as unwanted by-products
Health Organization
of industrial toxicprocesses,
chemical equivalents (WHO-TEQ).kg
such as the manufactureof bodyweight perpesticides
of paints, steel, month in June
and
2001. na vetu
other The WHO/FAO
synthetic Joint Expert
chemicals, wood pulp andCommittee on Foodand
paper bleaching, Additives (JECFA) from
also in emissions
established a provisional
vehicle exhausts tolerable monthly
and incineration. intake
Dioxins (PTMI)
are also of dioxins
produced to 70during
naturally pg of World
volcanic
–1
Health Organization toxic equivalents (WHO-TEQ).kg of bodyweight in June 2001.early
eruptions and forest fires. PCBs have been used in manufacturing industry since the
1930s, mainly as cooling and insulating fluids in electrical equipment. The manufacture
and general use of PCBs was banned in the 1970s because of environmental and health
concerns. The EU has prohibited the use of most PCBs since 1978 and for certain
applications since 1986. A deadline of 2010 was set for removing all PCB-containing
equipment from service. Dioxins, on the other hand, cannot be banned owing to their
formation as unwanted by-products of many industrial processes. Dioxins and PCBs are
highly stable and they persist in animal tissues, especially fatty tissue, for long periods.
They are not generally affected significantly by food processing such as heat treatments,
or fermentation.
There are many different dioxins, of which 17 are known to be toxic to humans.
The most toxic known dioxin is 2,3,7,8-tetrachlorodibenzo-p-dioxin (2,3,7,8-TCDD).
Significant concentrations of this compound can be measured in parts per trillion
(ppt). PCBs, or polychlorinated biphenyls, are chlorinated aromatic hydrocarbons
produced by the direct chlorination of biphenyls. There are about 209 related PCBs,
known as congeners of PCBs, of which 20 reportedly have toxicological effects. Some
of the PCBs have toxicological properties similar to those of dioxins and are therefore
often referred to as ‘‘dioxin-like PCBs.’’
Dioxins are carcinogenic and can also cause adverse developmental and reproductive
effects. Their negative health impacts are linked to their metabolic resistance and their
capacity to accumulate in fat tissue in animals and humans. More than 90% of human
exposure to dioxins typically occurs through the food supply, mainly fish, meat, and
dairy products.
Because of the need to assess the risk from complex mixtures of dioxins, an approach
has been adopted that assigns a factor relating to the relative potency of each congener,
based on a comparison with the toxicity of 2,3,7,8-TCDD. Each chemical is assigned a
toxic equivalency factor (TEF) related to the most toxic of the dioxins, 2,3,7,8-TCDD,
which is given a TEF of 1. The total toxic equivalency (TEQ) of a mixture is the sum of
the TEF weighed concentration of each compound in the mixture. The WHO/FAO Joint
Expert Committee on Food Additives (JECFA) established a provisional tolerable monthly
intake (PTMI) of dioxins to 70 pg of World Health Organization toxic equivalents (WHO-
TEQ).kg–1 of bodyweight in June 2001. EC Regulation No. 1881/2006 sets maximum levels
for certain contaminants, including dioxins and dioxin-like PCBs in foods. These limits
for dioxins and PCBs are in the following range: 1.5-12.0 pg per g of fat for meat products,
1.5-10.0 pg per g of fat for oils, fats, eggs, and milk products.

109
 Environmental Estrogens
Environmental estrogens are compounds ingested in the diet, which can mimic or
interfere in estrogen action and have the potential to alter hormonal homeostasis in
both women and men. The ability of compounds in the diet to influence reproductive
functions was first noted in the 1920s by pig farmers after feeding their animals on
mouldy grain, and concern was further stimulated in the 1940s by reports that sheep
grazing on certain types of clover in western Australia became infertile (‘clover disease’).
More recent research has identified the estrogenic compounds in the mouldy grain
to be of microbial origin and these have been termed mycoestrogens. The estrogenic
compounds in the clover have been identified as of plant origin and have been termed
Str.phytoestrogens. Thereestrogens
109, 1. riadok: výraz are also many man-madeupraviť
arecompounds chemicals, which can
na estrogens are mimic estrogen
compounds
action and enter the food
(vložiť medzeru za slovo are). chain from environmental contamination (xenoestrogens).
There are four main phytoestrogens classes: the isoflavones (genistein, daidzein), the
Str.coumestans
109, Fig. 11: vzorce sú voprenylated
(coumestrol), vrchnej časti orezané a(8-prenylnaringenin),
flavonoids substituenty nenadväzujú na väzby.
and the lignans
Prosím, opraviťenterolactone)
(enterodiol, podľa nasledujúceho vzoru:
(Fig. 11).

O
OH OH OH
OH O O O

HO O HO O
HO

genistein daidzein coumestrol

O OH O
HO HO
OH
O

HO O
OH
OH
OH
OH H3C CH3

enterodiol enterolactone 8-prenylnaringenin

OH

HO
OH

trans-resveratrol

Figure 11 Chemical structures of some environmental estrogens

Str. 110, Fig. 12:and

Genistein vzorce sú vo vrchnej
daidzein časti orezané
are isoflavones founda in
substituenty
leguminousnenadväzujú na väzby.
plants, especially not
Prosím, opraviť podľa
only soybeans nasledujúceho
but also vzoru:
lentils and chickpeas. Other isoflavones in food include glycitein,
biochanin A, Oand formononetin. Coumestrol is a coumestan found in young sprouting
legumes such as clover and alfalfa sprouts and CHis
3
therefore found in many animal feedstuffs.
O
OR
Prenylated flavonoids, includingH8-prenylnaringenin
O and
OH 6-prenylnaringenin,
HO are found in
OR
hops and products made from hops such as beer. CH3 Resveratrol is a polyphenolic compound
OR
found in grapesO and therefore red wine. The lignans are found in many cereals especially
linseedester
phthalate (flaxseed)
(R = alkyland many fruits and bisphenol
group) vegetables.A paraben (R = alkyl group)
Xenoestrogens are synthetic chemicals released into the environment as pollutants.
The main classes of xenoestrogens are alkyl esters of p-hydroxybenzoic acid (parabens),
PCBs and dioxins, bisphenol A and some phthalate esters (Fig. 12).
Str. 110, 2. odstavec, str. 111, 2. riadok v prvom odstavci a 3. riadok v druhom odstavci:
výraz mg kg-1 opraviť na mg.kg-1 (vložiť bodku ako znamienko násobenia).
Str.110
111, v strede strany: výraz Cu, Zn, Sn, Cr, Ni,and Al. opraviť na Cu, Zn, Sn, Cr, Ni, and
Al. (vložiť medzeru pred slovo and).
Str. 112, Fig. 13: vzorce sú vo vrchnej časti orezané a substituenty nenadväzujú na väzby.
Prosím, opraviť podľa nasledujúceho vzoru:
OH OH Cl Cl
 trans-resveratrol

Str. 110, Fig. 12: vzorce sú vo vrchnej časti orezané a substituenty nenadväzujú na väzby.
Prosím, opraviť podľa nasledujúceho vzoru:
O

CH3 O
OR
HO OH HO
OR
CH3 OR
O

phthalate ester (R = alkyl group) bisphenol A paraben (R = alkyl group)

Figure 12 Chemical structures of some xenoestrogens.

Str. 110, 2. odstavec, str. 111, 2. riadok v prvom odstavci a 3. riadok v druhom odstavci:
All these compounds have been shown to possess estrogenic properties in assays in
výraz mg kg-1 opraviť na mg.kg-1 (vložiť bodku ako znamienko násobenia).
vitro and in vivo. Because of concern for endocrine disruption following exposure in
Str.
young 111,children,
v strede use
strany: výraz Cu, A
of bisphenol Zn,
inSn,
theCr, Ni,and Al. of
manufacture opraviť na Cu, Zn,
baby bottles has Sn,
beenCr,ceased
Ni, and
Al. (vložiť medzeru
in Europe, Canada, pred slovo
and the and).
USA.
Soy-based infant formulae have been used since the 1960s in the UK and have
Str. 112, Fig.
become 13: vzorce
popular sú vo vrchnej
as an alternative časti orezané
to cow’s milk for ababies
substituenty nenadväzujú
with milk na väzby.
allergy. Daily intake
Prosím, opraviť by
of isoflavones podľa
thisnasledujúceho
route has beenvzoru:
estimated at up to 4 mg.kg-1 of body weight in
infants, giving
OH plasma isoflavone levels
OH 10,000-fold higherClthan their own endogenous
Cl

estrogen levels. Questions still exist as to whether there may be adverse reproductive
consequences associated with use of soy-based infant formulas for baby boys, especially
in Clthe context of
OHmale reproductive
Cl health.
Cl HO OH HO Cl

Exposure to some persistent

3-MCPD organic pollutants,2-MPCD
1,3-DCP phthalates, and bisphenol A can
2,3-DCP
give rise to obesity in animal models, and such compounds are increasingly implicated
in the rapid rise in obesity, metabolic syndrome, and diabetes in young people.

Nitrate and Nitrite

Nitrate and nitrite are widely consumed from food and water by animals and
humans, and are formed to a limited extent endogenously. Nitrate is used in agriculture
as a fertilizer and in food processing as an approved food additive (antimicrobial agents,
preservatives, and colour fixatives in meat and fish). Nitrate’s toxicity is low, but the
metabolites, nitrite, nitric oxide, and N-nitroso compounds make these substances
of regulatory importance because of the potential for adverse health implications in
humans and animals.
International efforts have been put in place to reduce and limit the occurrence of
nitrate in water. In drinking water the maximum permitted levels are 50 mg nitrate
and 0.5 mg nitrite per litre. Human exposure to nitrate is mainly exogenous whereas
exposure to nitrite is mainly endogenous via nitrate metabolism. In Europe, the main
dietary sources of nitrate are vegetables, preserved meat, and drinking water, with
vegetables being the most important source. The acceptable daily intake (ADI) values for
nitrate and nitrite were in 2002 established by the Joint FAO/WHO Expert Committee
on Food Additives (JECFA): 0–3.7 mg.kg–1 of bodyweight for nitrate and 0–0.07 mg.kg–1
of bodyweight for nitrite.

Perchlorate
The most common perchlorate salts are ammonium perchlorate (NH4ClO4), lithium
perchlorate (LiClO4), potassium perchlorate (KClO4), and magnesium perchlorate
(Mg(ClO4)2). Ammonium perchlorate and potassium perchlorate are used as an
oxidizing agent in rocket propellants and with the remaining salts are found in other
items (e.g. explosives, road flares, fireworks, and car airbags), occur naturally in some
fertilizers, and potash. The use of these perchlorate salts and the disposal of these
salts provide a pathway for them to enter into the soil and ground and surface water
allowing solvation to occur.

111
 Perchlorate is one of several chemicals that has the ability to disrupt thyroid gland
function at pharmacological doses (0.02, 0.1, and 0.5 mg.kg-1 per day). Perchlorate at
these doses can competitively inhibit iodide uptake from the blood by the sodium–
iodide symporter and reduces the amount of iodide that is available for organification.
If the reduction of iodine is continuous and the uptake of iodine is hindered, it may
cause the thyroid to become enlarged (goiter) and may result in hypothyroidism. In
children, hypothyroidism leads to delays in growth and intellectual development,
which is called cretinism in severe cases. In adults, it can cause a number of symptoms,
such as tiredness, poor ability to tolerate cold, and weight gain.
In 2010, the Joint FAO/ WHO Expert Committee on Food Additives (JECFA) of the
World Health Organization (WHO) derived a provisional maximum daily tolerable
intake (PMDTI) for perchlorate: 0.01 mg.kg-1 of bodyweight per day.

15.2.6 Toxic Metals

Foods of animal and plant origin contain many chemical elements, which depending
on their amount are termed either macroelements or microelements. Macroelements,
as well as basic elements, are the building materials that support tissue, teeth, skin, and
hair, play an important role in water-electrolyte management and pH regulation, and
are parts of many active compounds vital for metabolic processes. Some microelements
are essential for the normal functions of organisms. They participate in numerous
important processes, e.g. enzymatic reactions (Zn, Co, Ni, Mn, Fe, Cr, Al), glycolysis (Mn,
Zn), nucleotide synthesis (Mg, Fe), erythropoesis (Fe, Cu), organic acid transformation
(Fe, Zn, Ni, Mn), nitrogen exchange (Fe, Mo, Cu, Mn, V, Co), photosynthesis (Fe, Ti, Mg,
Mn), and their lack or excess may be a cause of many serious diseases. Trace elements,
which are not considered essential, may cause severe poisonings if administered in
amounts equal to or higher than the minimal dose. Due to toxicity of some trace heavy
metals and the possibility of environmental contamination, the potential for high risk
is linked mainly to Hg, Cd, As, and Pb. Some others are Cu, Zn, Sn, Cr, Ni,and Al. All
elements are present in the environment as salts or as metalo-organic compounds,
and only in such forms they are biologically active. To limit the possibilities of food
poisoning in humans caused by ingestion of excessive amounts of trace elements via
food and water, the highest allowable concentrations of trace elements are fixed as the
PTWI (permitted tolerable weekly intake).
• Mercury. The main source of mercury in the diet is fish, followed by fruit
and vegetables. The other source is dental amalgam. It is highly toxic and can
cause disruption of the nervous system, brain damage, damage to DNA and
chromosomes, allergic reactions and adverse reproductive effects. The PTWI for
mercury is 0.35 mg for a person weighing 70 kg.
• Cadmium. The main sources of cadmium in the diet are cereals, fruit and
vegetables. The other sources include meat, and large fish shellfish. Long-term
exposure to Cd may lead to kidney damage, as cadmium tends to accumulate in
the kidneys. Other adverse health effects include diarrhoea, stomach pains and
sickness, bone defects, immune system damage, possible infertility, possible
damage to DNA and carcinogenic effects. The PTWI is 0.49 mg for a person
weighing 70 kg.
• Arsenic. The major source of arsenic in the diet is fish and other seafood. Arsenic
is one of the most toxic elements found, and is present in foods in organic or
inorganic forms, with the latter being considered to be far more toxic than the
former (100 mg of arsenic oxide is considered to be lethal). Illnesses associated
with excessive inorganic arsenic intake include skin, lung and heart conditions,

112
 gastrointestinal
gastrointestinaldiseases,
diseases,and
andpossible
possiblecarcinogenic
carcinogenic effects.
effects. The
The PTWI
PTWI forfor arsenic
arsenic
should not exceed 1.05 mg for a person weighing
should not exceed 1.05 mg for a person weighing 70 kg. 70 kg.
• • Lead.
Lead.Lead
Leadenters
entersthe
the human
human body
body via
via food,
food, water,
water, and
and air.
air. Its
Its adverse effects
adverse effects
include disruption of haemoglobin synthesis, kidney damage, increased
include disruption of haemoglobin synthesis, kidney damage, increased blood blood
pressure, miscarriage, nervous system disruption, reduced fertility, and
pressure, miscarriage, nervous system disruption, reduced fertility, and learning learning
disabilities
disabilitiesand
andbehavioural
behavioural problems
problems in in children.
children. Lead
Lead can cross the placenta
placenta
and may damage the nervous system and brain
and may damage the nervous system and brain of the of the developing foetus. The
The
PTWI for lead in the EU is 1.75 mg for a person weighing
PTWI for lead in the EU is 1.75 mg for a person weighing 70 kg.

15.2.7
15 .2 .7Processing
ProcessingContaminants
Contaminants
Processing
Processingcontaminants
contaminantsare aregenerated
generatedduring
during the
the processing
processing of foods (e.g. heating,
heating,
fermentation). They are absent in the raw materials,
fermentation). They are absent in the raw materials, and and are formed by chemical
chemical
reactions
reactionsbetween
betweennatural
naturaland/or
and/oradded
addedfood
foodconstituents
constituents during
during processing. Examples
Examples
are:
are:advanced
advancedglycationend
glycationendproducts
products(AGEs),
(AGEs),chloropropanols
chloropropanols (3-monochloropropane-
(3-monochloropropane-
1,2-diol,1,3-dichloropropane-2-ol,
1,2-diol, 1,3-dichloropropane-2-ol,2-monochloropropane-1,3-diol,
2-monochloropropane-1,3-diol, 2,3-dichloropropane-
2,3-dichloropropane-
1-ol),acrylamide,
1-ol), acrylamide,polycyclic
polycyclicaromatic
aromatichydrocarbons
hydrocarbons(PAH)
(PAH) and
and N-nitrosodimethylamine
N-nitrosodimethylamine
Str. 112, Fig.
(NDMA)
(NDMA) 13:13).
(Fig.
(Fig. vzorce sú vo vrchnej časti orezané a substituenty nenadväzujú na väzby.
13).
Prosím, opraviť podľa nasledujúceho vzoru:
OH OH Cl Cl

Cl OH Cl Cl HO OH HO Cl

3-MCPD 1,3-DCP 2-MPCD 2,3-DCP

NH2 H3C
H2C
N N
O H3C O

acrylamide benzo[a]pyrene benzo[a]anthracene NDMA

Str. 112,13
Figure
Figure 2. riadok
13Chemicalodspodu:
Chemical výraz
structures
structures grillingof
ofofsome
some opraviť
processing
processing na grilling of (vložiť medzeru).
contaminants.
contaminants.
Str. 113, 2. Odstavec: vložiť medzeru medzi slová Chloropropanols.Chloropropanols
• • Acrylamide.
a opraviť Acrylamide. Acrylamide
na Chloropropanols.
Acrylamide infood
food isis formed
Chloropropanols.
in formed at
at temperatures
temperatures above
above 120
120 °C
°C via
via the
the
Maillardreaction
Maillard reactionbetween
between the
the reducing
reducing sugars
sugars (glucose
(glucose and
and fructose)
fructose) and
and the
the
Str. 117, v strede
amino
amino acid
stránky:
acid asparagine.
asparagine.
200.mg l-1 opraviť
výraz Acrylamide
Acrylamide na 200
has been
has been found
found
-1
mg.lat
at(vymazať bodku
microgram
microgram per za 200 a
per kilogram
kilogram
vložiť bodku
levelsako
in znamienko
a wide násobenia
range of za jednotku
heat-treated mg).
foods, for example, potato
levels in a wide range of heat-treated foods, for example, potato products, products,
breakfast cereals, bread, cookies, and coffee. Acrylamide is a neurotoxin at high
breakfast cereals, bread, cookies, and coffee. Acrylamide -1
isopraviť
a neurotoxin at high
Str. 118, posledný
levels of riadok 3.
exposure odstavca
and may odspodu:
cause a výrazof0–0.07
range mg kg
symptoms such na 0–0.07
as numbness in the
-1levels of exposure and may cause a range of symptoms such as numbness in the
mg.kg (vložiť bodku
hands and zaHowever,
feet. mg). it is considered unlikely that the levels found in foods
hands and feet. However, it is considered unlikely that the levels found in foods
Str. 118,could result odspodu:
2. odstavec in sufficient exposure
ak exposure
sa to cause neurological
dá, tak opraviť damage or reproductive
could result in sufficient to causerozdelenie slova
neurological bod-yweight
damage na body-
or reproductive
toxicity. Acrylamide is carcinogenic in animal experiments (mainly
weight.toxicity. Acrylamide is carcinogenic in animal experiments (mainly its its metabolite
metabolite
glycidamide), but epidemiological studies have not shown any evidence of
glycidamide),
Str. 119, but epidemiological
v strede stránky: studies
kg-1 opraviť 5have
mg.kgnot
-1 shown any evidence of
increased cancervýraz 5 mg
risk in humans due tonaacrylamide (vložiť bodku
in food. Thezacancer
mg). risk
increased cancer risk in humans due to acrylamide in food. The cancer risk
Str. 120,associated
2. odstavec with acrylamide
– druhý in foods should
riadok odspodu, be validated by the Joint FAO/WHO
associated with acrylamide in foods 3. odstavec
should – druhý riadok
be validated by theodspodu a 4.
Joint FAO/WHO
Expert Committee on Food Additives (JECFA).
odstavec – tretíCommittee
Expert riadok odspodu: 4 výrazy
on Food (mg per
Additives kg bw) opraviť na (mg per kg of bw)
(JECFA).
• Advanced Glycation End Products (AGEs). These compounds are a heterogeneous
(vložiť of za kg). Glycation End Products (AGEs). These compounds are a heterogeneous
• Advanced
group of chemical compounds (also referred to as glycotoxins), which occur
group of chemical compounds (also referred to as glycotoxins), which occur
Str. 120,naturally
druhý odstavec odspodu
in animal – vand
tissues strede:
are výraz (approximately
also produced 30temperature
by high per kg bw) opraviť
cookingna
naturally in such
animal tissues roasting
and are also produced by highfoods.
temperature cooking
(approximately 30 mg
processes, peraskgfrying,
of bw). and grilling of certain They are highly
processes, suchare
oxidative and as known
frying, to
roasting and grilling
be involved of certainoffoods.
in the pathology Theyofare
a number highly
diseases,
Str. 121, druhý odstavec
oxidative and are–known
posledný a tretí
to be riadokin
involved odspodu, tretí odstavec
the pathology – tretí of
of a number riadok
diseases,
odspodu,
112 štvrtý odstavec – druhý riadok odspodu, piaty odstavec – druhý riadok odspodu: 5
výrazov mg per kg bw opraviť na mg per kg of bw (vložiť of za kg). 113
Str. 128, druhý odstavec odspodu – štvrtý riadok: výraz 1.2mm opraviť na 1.2 mm (vložiť
medzeru).
 including diabetes, cardiovascular disease, the metabolic syndrome, insulin
resistance, obesity, and Alzheimer’s disease. Although a number of different
AGEs have been identified, three types have been studied in some detail and
have been used in studies as markers for AGEs. These are N6-(carboxymethyl)
lysine (also known as CML), pentosidine and derivatives of methylglyoxal.
AGEs levels in the blood tend to increase with age because kidney function
in older people is reduced and less able to remove substances from the body.
The recommendations to reduce the production of AGEs in cooked foods are
as follows: Cook meat and fish at temperatures of less than 200 °C and avoid
prolonged cooking times. Use indirect cooking methods, such as stewing,
poaching and steaming, rather than grilling, frying or barbecuing. Apply acidic
marinades incorporating lemon juice or vinegar to meat before cooking.
• Chloropropanols. Chloropropanols are a group of related chemical contaminants
that may be produced in certain foods during processing. They are formed during
the manufacture of acid-hydrolysed vegetable protein (used as a savoury ingredient
in soups, sauces, especially soy sauce) and have been detected in refined edible
oils and fats (palm oil, margarine and spreads), but not in unrefined oils. The
most common and the best studied is 3-monochloropropane-1,2-diol (3-MCPD).
Chloropropanols are potentially carcinogenic and their presence in food, even at
low levels, is therefore undesirable. A provisional maximum tolerable daily intake
(PMTDI) for 3-MCPD is 2 micrograms per kg of bodyweight.
• Polycyclic Aromatic Hydrocarbons (PAHs) are a large group of lipophilic organic
chemical contaminants containing two or more fused aromatic rings. They can
be produced during the partial combustion or pyrolysis of organic material
(wood) including the processing and preparation of food. The occurrence of
PAHs in food is mainly due to food smoking, roasting, grilling (which includes
barbequing), frying, drying, and steaming. The most studied PAH is benzo[a]
pyrene (BaP), which is often used as a marker compound for all PAHs in food, and
also in environmental studies. The maximum levels of B[a]P (micrograms per kg
of wet weight) in some types of food are as follows: Foods for infants (1.0), oils
and fat (2.0), smoked meats (2.0), cocoa beans and derived products (5.0), heat
treated meat (5.0), bivalve mollusks smoked (6.0).
• N-Nitrosamines are formed by the reaction of nitrite with secondary amines. Nitrite
is traditionally used for developing the pink, heat-stable pigment of cured meat. Its
other important role is the inhibition of the outgrowth of Clostridium botulinum
spores in pasteurized products. Nitrite also serves as an antioxidant and contributes
to the development of the flavour of cured meat. The undesirable side effect,
however, is the formation of N-nitrosamines. Many N-nitrosamines are strongly
carcinogenic. The N-nitrosamine of most importance is N-nitrosodimethylamine
(NDMA). Nitrates may also form N-nitrosamines through reduction to nitrites
by saliva or enzymes in the intestinal tract. N-nitrosamines were found in beer,
cured meats, and smoked fish. Only a few countries have imposed limits on
the N-nitrosamine content of foods and these have been restricted to certain
commodities.

15.2.8 Food Contact Materials

There are approximately 80,000 chemicals currently in commerce, and 2,000 new
chemicals are thought to be added to this list each year. A large number of these chemicals
come into contact with food.

114
 Bisphenol A and Endocrine Disruption
Some chemicals have the potential to disrupt the endocrine system of animals,
including humans. This class of chemicals is referred to as “endocrine disruptors’’ or
“endocrine-disrupting chemicals’’ (EDCs). The EDCs can be natural, i.e. plant-based
(phyto) estrogens, or artificial, such as herbicides, insecticides, and fungicides on food
crops. Another group of EDCs are the environmental toxins (PCBs and dioxins) and
a final source is the packaging itself. Epoxy resins, plastics, and other food contact
materials contain chemicals with endocrine activity, and these chemicals can leach
from these food contact materials into the food itself.
Bisphenol A (BPA) (Fig. 7) is a synthetic compound, which has been known since
1891 and exhibits hormone-like properties that raise concern about its suitability in
some consumer products and food containers. The products using bisphenol A-based
plastics have been in commercial use since 1957 and at present 3.6 million tonnes of BPA
are used by manufacturers yearly. It is a key monomer in production of epoxy resins and
polycarbonate plastic. BPA-based plastic is clear and tough, and is made into a variety of
common consumer goods, such as baby and water bottles, sports equipment, medical
and dental devices, dental fillings sealants, CDs and DVDs, household electronics,
eyeglass lenses, foundry castings, and the lining of water pipes. BPA is also used in the
synthesis of polysulfones and polyether ketones, as an antioxidant in some plasticizers,
and as a polymerization inhibitor in PVC. Epoxy resins containing bisphenol A are used
as coatings on the inside of almost all food and beverage cans and they are also used to
line water pipes and in making thermal paper such as that used in sales receipts.
BPA is an endocrine disruptor and may have an effect on fertility, development, the
brain, behaviour, and prostate gland in foetuses, infants, and young children. BPA may be
carcinogenic, possibly leading to the precursors of breast cancer. Some reports indicate
that it has liver toxicity and may even be linked to obesity by triggering fat-cell activity.
Some countries have recently considered banning, or have banned the use of BPA in
plastics used for baby feeding bottles. The chemical industry over time responded to
criticism of BPA by promoting “BPA-free” products. Some “BPA-free” plastics are made
from epoxy containing a compound called bisphenol S (BPS), but BPS like BPA has been
found to be an estrogen hormone disruptor even at extremely low levels of exposure.
In 2002, EU legislation was introduced setting a Specific Migration Limit (SML) of 3
mg BPA per kg of food. This was amended in 2004 to set a SML(T) of 0.6 mg BPA per
kg of food. In January 2011, use of bisphenol A in baby bottles was forbidden in all
EU countries. By October 2008, the EFSA issued a statement concluding that the study
provided no grounds to revise the current Tolerable Daily Intake (TDI) level for BPA of
0.05 mg/kg bodyweight. In January 2015, EFSA’s experts reduced the safe level of BPA
from 50 micrograms per kilogram of body weight per day to 4 micrograms/kg of bw/
day, the highest estimates for dietary exposure and for exposure from a combination
of sources (diet, dust, cosmetics, and thermal paper) are three to five times lower than
the new TDI.

Food Packaging Contaminants

Food packaging contaminants are organic or inorganic chemicals that originate
from the food packaging. Chemical contamination of food from food packaging
material largely depends on the type of material in contact with the packaged food.
Polymers are the most important food packaging materials constituting approximately
70% of the market share, namely: low-density polyethylene (LDPE), polypropylene (PP),
polyethylene terephthalate (PET), high-density polyethylene (HDPE), polystyrene (PS)
and expanded PS, and polyvinylchloride (PVC). Food packaging contaminants with their
very diverse chemistry are the largest single source of chemical food contaminants. The

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process of chemical partitioning from the packaging into food is called migration. The
types of chemicals that can migrate from packaging into food are highly diverse and
depend on the type of packaging material, the food properties (e.g. fat content) as well
as the temperature and duration of storage. For example, heavy metals those are used
in ceramic glazing, or are naturally present in glass raw materials, can transfer from
the inner surface to the food by surface exchange. For non-inert materials, like plastics,
elastomers, and paper and board, migration can occur either from the packaging
material itself or from the outside of the packaging. Paper-based materials have a large
pore size and this permits migration of smaller molecules from the outside to the food
inside. To reduce or prevent food contamination, barrier materials can be used (a carton
with an inner bag made of aluminium foil). Another source of chemical contaminants is
from the degrading polymer, when small-sized monomers are released and can migrate
into the food. Chemical contamination by release is relevant mainly for reusable food
contact materials, like plastic baby bottles or plastic kitchenware.
The major contaminants in food packaging materials are:
• in PET (formaldehyde, acetaldehyde, antimony, ultraviolet stabilizers),
• in LDPE (polyolefin oligomeric saturated hydrocarbons, nonylphenol),
• in PVC (vinyl chloride, phthalates, organotins),
• in PS (styrene and its trimers),
• in PP (polyolefin oligomeric saturated hydrocarbons, erucamide, oleamide,
butylated hydroxytoluene),
• in polycarbonate (bisphenol A),
• in cellulose (triacetin),
• in metal with inner coating (bisphenol A, Sn, Al),
• in paper and carton (polyolefin oligomeric saturated hydrocarbons, benzophe­
nones),
• in Tetrapack carton (polyolefin oligomeric saturated hydrocarbons, benzophe­
nones, isopropyl thioxanthone),
• in glass with closure (phthalates, lead, UV stabilisers),
• in ceramic (heavy metals).
Important food packaging contaminants are phthalates. Phthalates are esters of
phthalic acid and are used to impart flexibility to plastic products. A number of food
packaging materials can contain phthalates, including PVC and other plastics, printing
inks used on flexible food packaging, adhesives used for paper and board, regenerated
cellulose film (cellophane), aluminium foil–paper laminates, and closure seals in
bottles. Phthalates are known to migrate from packaging into foods, especially high-
fat products and oils, and the rate of migration into food from packaging rises with
increasing temperature. Phthalates could cause adverse effects on the developing
human male reproductive system, adverse effects on fertility and birth defects and
cause kidney and liver damage. Phthalates may be potential carcinogens, endocrine
disruptors and may also be linked to neurological and behavioural disorders such as
attention deficit hyperactivity disorder and autism. The most used phthalates are di-(2-
ethylhexyl) phthalate (DEHP), dibutyl phthalate (DBP), di-isononyl phthalate (DINP),
di-isodecyl phthalate (DIDP) and benzyl butyl phthalate (BBP). The European Union
has also restricted the use of BBP, DBP, and DEHP to food contact surfaces only for non-
fatty foods up to 0.1%, 0.05%, and 0.1%, respectively, in the final product. It should be
noted that many PVC “cling film“ food wraps are no longer made with phthalates, but
are now manufactured using other plasticisers.
In Europe, food-packaging contaminants are regulated by the European Commission,
Directorate General Health and Consumers under the Food Packaging Framework
Regulation. Migration of chemicals from packaging into food is usually assessed using

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food simulants, which represent different groups of food in terms of their chemical
properties. Overall migration to any of the food simulants should not exceed 10 mg.dm-2
of food contact surface for plastics and multi-layered materials such as beverage cartons
consisting of several layers of different materials.

15.2.9 Food Additives

In the EU, a food additive is defined in law (Regulation 1333/2008) as:
• “any substance not normally consumed as a food by itself and not normally
used as a typical ingredient of the food, whether or not it has nutritive value, the
intentional addition of which to food for a technological (including organoleptic)
purpose in the manufacture, processing, preparation, treatment, packing,
packaging, transport or holding of such food results, or may be reasonably
expected to result (directly or indirectly) in it or its by-products becoming a
component of or otherwise affecting the characteristics of such foods“.
The definition excludes processing aids, including enzymes and extraction
solvents, flavourings, substances added as nutrients, such as vitamins and minerals,
and substances migrating from food contact materials (food packaging, utensils, etc.)
which do not exert a technological function in the food. The term does not include
contaminants and sodium chloride. Today, the use of food additives is regulated by
national legislation in most countries and only additives, which are shown to be safe,
can be used. Therefore, food additives are regulated as a positive list, which means
that only food additives specifically listed in the regulations of a country can legally be
added to food products, and the maximum levels (MLs) in food must not be exceeded.
This is in contrast to chemical and microbiological contaminants, which are regulated
as a negative list.
Every food additive is assigned a unique number in the International Numbering
System (INS), adopted and extended by the Codex Alimentarius. The INS assigns a
unique three- or four-digit reference number to each additive (e.g. ascorbic acid is 300).
Within the European Union and Switzerland these numbers (prefixed by the letter
E) are known as E-numbers (the “E” stands for “Europe”). Number ranges have been
preassigned to food additive classifications, so also give information on the primary
purpose of the additive, even without knowing the name:
• E100–E199 (colours)
• E200–E299 (preservatives)
• E300–E399 (antioxidants, acidity regulators)
• E400–E499 (thickeners, stabilizers, emulsifiers)
• E500–E599 (acidity regulators, anti-caking agents)
• E600–E699 (flavour enhancers)
• E700–E799 (antibiotics)
• E900–E999 (glazing agents and sweeteners)
• E1000–E1599 (additional chemicals)
Possibly the principal concern currently expressed by consumers in relation to
food additives, both natural and synthetic, is the belief that their consumption may
be associated with unwanted behavioural effects such as hyperactivity, especially in
children. Another concern is that they may be linked to food allergies and insensitivities.
The implicated food additives include:
• food dyes and colourings (such as tartrazine, ponceau 4R, quinoline yellow,
sunset yellow),
• antioxidants (such as butylated hydroxy anisole (BHA) and butylated hydroxy
toluene (BHT)),

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 • flavourings and taste enhancers (such as monosodium glutamate (MSG), spices,
and artificial sweeteners),
• preservatives (such as benzoates, nitrates, nitrites and sulphites).
The majority of these and other food additives have undergone reevaluation based
on their human health risk assessments.

Colourants
The use of synthetic colours in foods has been an area of debate in recent years
due to a proposed linked between behavioural disturbances, especially hyperactivity,
in children and dietary exposure to colours in food. Some colourants are no longer
approved for use in food, but are still used in some countries illegally, and may pose
health risks. One of these is Sudan Red, which is a suspected carcinogen. Some other
colours are of public interest: Ponceau 4R, Quinoline Yellow, and Sunset Yellow.
• Tartrazine (E102) is a synthetic lemon yellow azo dye primarily used as a food
colouring. The European Food Safety Authority (EFSA) allows for tartrazine to be
used in processed cheese, canned or bottled fruit or vegetables, processed fish or
fishery products, and wines and wine-based drinks. Tartrazine appears to cause
the most allergic and intolerance reactions of all the azo dyes, particularly among
asthmatics and those with an aspirin intolerance.
• Ponceau 4R(E124) is a synthetic red azo dye used in a range of alcoholic and
non-alcoholic beverages, and a variety of foodstuffs including confectionary,
desserts, cheeses, meats, preserved fruits, and sauces. Known are its possible
effects on children’s behaviour, especially hyperactivity. In Europe, the
maximum permitted levels (MPLs) in food and beverages range up to 500 and
200 mg.kg-1, respectively.
• Quinoline Yellow (E104) is a synthetic colourant used in confectionery, soft
drinks, as well as other food and beverages. Quinoline Yellow in food causes
behavioural problems such as hyperactivity in children. In the EU, Quinoline
Yellow is permitted in beverages, with a maximum level of 200 mg.l-1 for alcoholic
and 100 mg.l-1 in non-alcoholic beverages. It is also used in a variety of foods, with
MPLs ranging from 50 mg.kg-1 in complete weight control formulas to 500 mg.kg-1
in sauces, decorations, and coatings.
• Sunset Yellow FCF (E110) is a synthetic azo dye used as a colouring for beverages
and variety of foods, including confectionary, desserts, soups, cheeses, savoury
snacks, sauces, and preserved fruits. It has been claimed that Sunset Yellow
FCF causes intolerance reactions in sensitive individuals and adverse effects on
children’s behaviour. In Europe, the MPLs in food and beverages range from 50
to 500 mg.kg-1.

Antioxidants
Antioxidants are a group of food preservatives that delay or prevent the deterioration
of foods by oxidative mechanisms. Some of these (BHA and BHT) attract public
controversy regarding their safety to human health.
• BHA (E320) is a mixture of the two chemical isomers – 85% of 3-tertiary-butyl-4-
hydroxyanisole (3-BHA) and 15% of 2-tertiary-butyl-4-hydroxyanisol (2-BHA) and
is an effective antioxidant in animal fats used in baked products. The National
Toxicological Program (NTP) has listed BHA as “reasonably anticipated to be a
human carcinogen.’’ In 2011, the EFSA established an ADI for BHA of 1.0 mg.kg-1
of bodyweight per day.

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 • BHT (E321), also known as butylhydroxytoluene (2.6-di-tert-butyl-4-methyl­
phenol), is primarily used as a food additive. BHT at high doses can exert liver
and lung tumour-promoting effects in some animal models. In 2012, the EFSA
established an ADI for BHT of 0.25 mg.kg-1 of bodyweight per day.

Flavourings and taste enhancers

Flavourings are substances used to impart taste and/or smell to food, and/or to
intensify the existing flavours of products. Flavour enhancers activate receptors for the
umami or savoury taste (the four other tastes are sweet, salt, sour, and bitter) and, thus,
introduce a new taste to products. General method for the safety evaluation of flavouring
agents takes the approach that in most cases, dietary exposure to these substances is
low, and the majority of flavours are metabolized rapidly to innocuous end products.
The most contentious flavour enhancer added to food from the perspective of a safety
to human health is monosodium L-glutamate (MSG).
• Monosodium L-glutamate (E621) is used as flavour enhancers for over a century.
MSG is now considered to be one of the most intensively scrutinized food additives
because it has been reported to trigger minor adverse reactions now called the
“MSG symptom complex’’ (headaches, general weakness, palpitations, and pain at
the back of the neck starting about an hour after eating food containing MSG, and
lasting for 2 h with no apparent long-term effect). However, studies to date have
failed to prove an unequivocal link between MSG and the reported symptoms.
The largest palatable level for humans is approximately 60 mg.kg-1 of bodyweight
with higher doses causing nausea.

Preservatives
The efficiency of preservatives depends primarily on the concentration of the
preservative, the composition of food, and the type process to be inhibited. There are
food preservatives that inhibit microbes (nitrites, benzoates, ascorbates, and sorbates),
preservatives that act as antioxidants (BHA, BHT) and some can be used for both
(sulphites and sulfur dioxide). The safety of certain preservatives has been the subject
of debate among the consumer groups, academics, and food regulators.
• Potassium nitrite (E249), sodium nitrite(E250), sodium nitrate(E251),
potassium nitrate (E252) have been used as food additives in cured meats for
many years primarily to prevent growth and toxin production by Clostridium
botulinum. The use of nitrite to cure meat was also seriously questioned in the
1970s due to the potential for the presence of preformed N-nitrosamines, which
may have a carcinogenic potential. The toxicology of nitrate and nitrite has been
comprehensively reviewed by the Joint FAO/WHO Expert Committee on Food
Additives (JECFA), which established acceptable daily intakes (ADIs) of 0–3.7
mg.kg-1 of bodyweight for nitrate and 0–0.07 mg.kg-1 of bodyweight for nitrite.
• Benzoic acid (E210) and sodium benzoate (E211) have inhibitory effects on
the yeast growth and their ADIs were established by the JECFA at 0–5 mg.kg-1 of
bodyweight.
• Sodium and Potassium Sulphites (E221, E225) and Suphfur dioxide (E220) are
used as antioxidants to prevent the discolouration of light-coloured fruits and
vegetables, such as dried apples and dehydrated potatoes. They are also used in the
wine-making process because they inhibit bacterial growth without interfering
with the development of yeasts. The use of sulphites in foods that are important
sources of thiamine (vitamin B1) is prohibited because of their ability to destroy
thiamine. The ADIs for sulphites were established by the JECFA at 0–0.7 mg.kg-1
of bodyweight.

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 • Sorbic acid (E200), sodium sorbate (E201), potassium sorbate (E202) are
antimicrobial agents often used as preservatives in food and drinks to prevent the
growth of mould, yeast, and fungi without affecting the taste, colour, or flavour.
The ADI for sorbic acid is 0–25 mg/kg of bodyweight.

Sweeteners
Sweeteners are food additives used as substitutes for sugar, mainly sucrose and
fructose. Some of them have a relative sweetness many times that of sugar, which
means they can be used in much smaller amounts. The most widely approved intensely
sweet sugar substitutes are stevia, aspartame and its derivative neotame, sucralose,
acesulfame, and saccharin. The toxicology of two of them (aspartame and saccharin)
was intensively studied.
• Aspartame (E951) is one of the most widely used non-nutritive, intense
sweeteners in the world. It is approximately 200 times sweeter than sugar and
is used in a range of foods (desserts, carbonated soft drinks, yoghurt, weight-
control products, and confectionary). The food safety issue in relation to the
consumption of aspartame is for a very small proportion of the population that
has the rare genetic disorder, phenylketonuria. In 2002,the Scientific Committee
on Food (SCF) established the ADI of aspartame as 40 mg.kg-1 of bodyweight.
• Saccharin (E954) is approximately 300–500 times sweeter than sugar and can
be used in cooking and baking, as well as a sweetener for foods and beverages.
Although saccharin has been in use for more than a century, its safety has
repeatedly been questioned. The epidemiological studies on saccharin did not
show any evidence that saccharin ingestion increases the incidence of bladder
cancer in human population. The ADI of 5 mg.kg-1 of bodyweight was allocated
by the JECFA to saccharin and its calcium, potassium, and sodium salts. In a
December 14, 2010 release, the EPA stated that saccharin is no longer considered
a potential hazard to human health.
• Steviol Glycosides (E960) are compounds extracted from the leaves of the plant
Stevia rebaudiana. Two of the major steviol glycosides contributing to the sweet
taste of stevia extracts, namely stevioside and rebaudioside A, are reported
to be 100–400 times as sweet as sucrose. Steviol glycosides were approved as
food additives in Europe in 2011 and are permitted in a large variety of foods
and beverages. The ADI of 4 mg.kg-1 of bodyweight for steviol glycosides was
established by the EFSA in 2011.

Some special analytical methods are used today for regulatory purposes to ensure
that food additives do not exceed their maximum levels or are not being used for
unapproved uses or in unapproved foods. These methods can be found in a number of
internationally published sources of monographs:
• Combined Compendium of Food Additive Specifications, FAO JECFA,
• Food Chemicals Codex,
• European Union (EU) directives on food additives specification.
Food additives are among the safest chemicals present in food because of the
rigorous testing that is required before they may legally be used in food.

15.2.10 Pesticide Residues

The term pesticides includes all chemical, natural or synthetic substances used to fight
parasites on crops. Though pesticides are used mainly for this purpose, they can also
be used to fight the carriers of illnesses such as malaria, yellow fever, typhoid fever, etc.,

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or even against domestic insects. About 20% of the production of insecticides is used
for this purpose. They are normally classified according to their target as insecticides,
fungicides, and herbicides.

Conazoles
The conazole fungicides (bitertanol, cyproconazole, diniconazole, epoxiconazole,
flusilazole, propiconazole, triadimefon, etc.) represent a large group of compounds
widely used in agriculture for protection and treatment of fungal diseases in crop plants
(cereals, oil seeds, fruit trees, grapes, vegetables, sugar beets). A number of adverse effects
have been observed in laboratory animals after repeated administration of conazoles:
developmental effects, effects on reproduction, hepatotoxicity, hepatocarcinogenicity
in mice, and production of other types of tumours (thyroid, testis), via non-genotoxic
mechanisms. There are no reported effects in humans similar to those described in
experimental animals. Risks from long-term and short-term dietary intakes of residues
of conazole fungicides have been assessed by the Joint FAO/WHO Meeting on Pesticide
Residues. The ADIs values (mg per kg of bw) for long-term intake of conazoles residues
are from 0.007 (flusilazole) to 0.07 (propiconazole).

Dithiocarbamates
Dithiocarbamates are sulphur compounds of which 21 known compounds are
employed as pesticides to protect fruits and vegetables. Most of these compounds are
rapidly degraded in the environment to yield thioureas such as ethylenethiourea (ETU),
ethyleneurea (EU), and propylenethiourea. ETU is of toxicological concern due to its
carcinogenicity, teratogenicity, and antithyroid properties. Maneb, mancozeb, and
metiram can induce thyroid cancer in laboratory animals possibly via the formation of
ETU. The hazard associated with the use of dithiocarbamates for the general population
is the residue left on the foodstuff, which can be conveniently reduced or eliminated
by washing or peeling fruit and vegetables before eating or cooking. Recommended
ADIs values (mg per kg of bw) for dithiocarbamates are from 0.0003 (ethylenethiourea,
propylenethiourea) to 0.05 (maneb, mancozeb).

Herbicides
Herbicides represent a diverse group of chemicals, which are used to control weeds.
The European Union pesticides database lists 324 herbicides. The toxicity of herbicides
varies between classes as well as individual chemicals. Some of them (paraquat, 2,4-D,
glyphosate) have been involved in a number of human poisoning cases. The primary
target organs are the kidney and the heart. For example, the lethal oral dose of paraquat
is approximately 2 g for an adult (approximately 30 per kg bw). Genetically modified,
herbicide resistant crops permit the use of certain herbicides (e.g. glyphosate in
Monsanto’s Roundup herbicide formulation) while crops are growing. This can result in
significant residues of the herbicide and/or metabolites. Dietary exposures to herbicides
are generally well below reference doses; however, if the herbicides are not degraded
in the environment they might be transported to water sources resulting in human
exposures via drinking water. The ADIs values (mg per kg of bw) for herbicides are from
0.002 (diquat, terbutylazine) to 0.3 (2,4-D). The TDI value for glyphosate was established
as 1.75 mg per kg of bw, but some recent studies have recommended the re-evaluation of
this value.

Inorganic and Other Metal-Containing Compounds

At present, in most developed countries, only copper compounds are used in
significant amount as fungicides. It is believed that some organotins are still used in

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some developing countries. The others have been banned for either toxicological or
environmental reasons.
• Copper is present in almost all foods, and most human diets naturally include
between 1 and 2 mg per person per day of copper. Copper is included in
fungicidal formulations as oxychloride (Cu2Cl(OH)3), sulphate (CuSO4·5.H2O) or
hydroxide (Cu(OH)2). Copper hydroxide and the Bordeaux mixture may cause
toxic effects by inhalation and present a risk of serious damage to eyes. Target
organs of excess copper after oral administration are the liver and kidneys. The
upper limit of copper intake without adverse effect is not well defined, but is well
recognised to be between 10 and 12 mg Cu per person per day. In the EU, the
following maximum residue level (MRL) have been set: 5 mg.kg-1 for tomatoes, 20
mg.kg-1 for table grapes, and 50 mg.kg-1 for wine grapes.
• Tin. Organic tin compounds, such as triphenyltin (fentin) acetate and triphenyltin
(fentin) hydroxide, are used as fungicides, whereas others such as cyhexatin
and the closely related azocyclotin are also used as acaricides in several crops.
Azocyclotin and cyhexatin have moderate acute toxicity by the oral route and
their ADIs values were established of 0–0.003 mg per kg of bw. Fentin showed
immunosuppressive properties in toxicity studies and the US EPA established for
it an ADI of 0–0.00003 mg per kg bw.

Organophosphates and Carbamates

Organophosphates(OPs) and carbamates (CAs) are the most used insecticides
after the banning of most organochlorines such as DDT. They are also used in public
health against vectors of diseases such as the malaria mosquitoes even indoors. Some of
them are used for the treatment of human diseases such as parasitosis, myasthenia, or
glaucoma. The toxicity of OPs and CAs is due to the accumulation of acetylcholine at
nerve terminals because of acetylcholinesterase inhibition. The ADIs values (mg per kg
bw) for long-term intake of OPs and CAs residues are from 0.0006 (Terbufos (OP)) to
0.3 (pirimiphos-methyl (OP), malathion (OP)).

Organochlorines
Organochlorinated pesticides (OCPs) have broad-spectrum insecticidal activity and
primarily act as excitatory neurotoxins. They have been used for several applications
and have been widely dispersed into the environment over the past 50 years. Now, many
of these compounds (aldrin, chlordane, chlordecone, diendrin, endrin, heptachlor,
lindane, etc.) are ubiquitously found as trace contaminants in soil, sediment, air, biota,
and food, even in places where they were never used, including Antarctica. DDT has
been employed as an insecticide in agriculture and public health. Banned for use in
agriculture, its only permitted use is for indoor spraying of walls to control the malaria
vector mosquito. Human exposure mainly occurs through trace environmental
contamination of food (meat and meat products, fish, milk, and other dairy products).
The toxicity of OCPs in humans differs significantly and the CNS is the main target
organ, where they cause either depression or stimulation. The ADIs values (mg per kg
of bw) for intake of OCPs are from 0.0005 (Chlordane) to 0.02 (Chlorobenzilate).

Pyrethroids
Pyrethroids are synthetic insecticides derived from the naturally occurring pyrethrins,
the six insecticidal compounds of pyrethrum isolated from the Chrysanthemum
genus of plants. The insecticidal properties of pyrethroids (cyfluthrin, cyhalothrin,
etofenprox, cypermethrin, bifenthrin, deltamethrin, esfenvalerate, tefluthrin, etc.) are

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due to their ability to disrupt the electrical signalling in the nervous system, an effect
that is also relevant to mammals. The ADIs values (mg per kg bw) for long-term intake
of pyrethroids are from 0.01 (bifenthrin) to 0.04 (cyfluthrin).

15.2.11 Veterinary Drugs Residues

The Codex Alimentarius Commission defines a veterinary drug as any substance
applied or administered to any food-producing animal for therapeutic, prophylactic, or
diagnostic purposes, or for modification of physiological functions or behaviour. This
broad definition includes drugs for:
• treatment of diseases or other pathological conditions,
• prevention of diseases or other pathological conditions,
• diagnosis of diseases,
• zootechnical purposes such as oestrus synchronization, induced ovulation,
chemical castration, etc.,
• improved production such as increase in growth rate, feed efficiency, milk
production, etc.,
• behaviour modification, such as tranquilizers.
In the European Union, some substances such as anticoccidial compounds
administered in animal feed are regulated as feed additives; however, these substances
are considered to be veterinary drugs within the Codex Alimentarius Commission. The
Codex Alimentarius Commission has examined the most commonly used veterinary
drugs and established appropriate MRLs for meat, poultry, fish, milk, eggs, and honey.
Toxicological testing for veterinary drugs is based on the same battery of tests used in
evaluating food additives and pesticides.

Antibacterials
To assure the long-term care, health, and welfare of food-producing animals,
antibacterial compounds (aminoglycosides, amphenicols, tetracyclines, streptogramins,
sulfonamides, etc.) are used for three purposes:
• therapeutic use to treat sick animals,
• prophylactic use to prevent infection in flocks/herds of food-producing animals,
• as growth promoters to improve feed utilization and reduce production time.
On 1 January 2006, the EU banned the feeding of all antimicrobials and related
drugs to food-producing animals for growth-promoting purposes. Currently, in Europe
no antimicrobial agents can be used in farm animals for growth promotion purposes.
Several different classes of antibacterials are now recognized and many of these are used
in both animal and human medicine. It has been suggested that those antibacterials that
are important in human medicine should not be used therapeutically in food-producing
animals (to avoid the resistance problems). Residues of antimicrobial compounds in
foods of animal origin could also negatively affect some food-processing procedures
(they could inhibit the activity of starter cultures used in the production of certain
fermented meats, yogurt, and cheeses, leading to economic losses for food producers).
In Europe, tests are regularly performed to detect the presence of antibacterial residues
in food. Before the animal or animal products can be sold for slaughter/consumption,
a withholding period must be observed which is of sufficient duration to allow any
residues to be eliminated, such that antibacterial residues are no longer detected at
concentrations above the maximum residue limit (MRL).

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 Anthelmintics
Anthelmintics (also called parasiticides, endectocides, and nematocides) are usu­
ally used to treat parasitic worm infections. Three main families of anthelmintics
are known as follows: benzimidazoles, nicotinic receptor agonists, and macrocyclic
lactones. Moreover, the presence of anthelmintic residues (albendazole, fenbendazole,
flubendazole, abamectin, doramectin, emamectin, levamisole, morantel, etc.) in
livestock may have serious consequences on consumers, so in order to assure food
safety maximum residue limits (MRLs) of these compounds in several matrices were
established. For example, the MRLs values (micrograms per kg) for muscle are from
10 (levamisole in bovine, ovine, porcine, and poultry) to 225 (triclabendazole in all
ruminants).

Anabolics
The use of hormonally active steroids as growth promoters in farm animals can
increase the production of veal and beef significantly (up to 15%), but very few issues
involving veterinary medicines have resulted in more controversies over the years than
those surrounding the use in animals of drugs that promote anabolism and the safety of
food produced from those treated animals. Here is an example: the USA and a number
of other countries worldwide have approved some of these substances for use in beef
cattle. In 1985 the EU prohibited the use of synthetic hormones and imports of meat
from animals that had been administered these hormones and in 1989, the EU banned
the import of US beef produced with the six FDA-approved hormones (estradiol,
progesterone, testosterone, trenbolone acetate, zeranol, and melengestrol acetate).
This action dramatically reduced beef exports to the EU Member States. In April 2012,
after prolonged trade dispute, an agreement was reached when the EU Member States
agreed to increase the quota of “no hormone added’’ beef permitted to be imported
into the EU and the USA agreed to drop its ad valorem punitive duties on EU products
exported to the USA. Another problem is illegal use of anabolics in food-producing
animals and sale of “hormone cocktails’’ by a “hormone mafia’’ in the EU as well as
several reports of serious health effects from consuming the meat from treated animals.
Very popular are so called “beta-agonists’’ (ractopamine hydrochloride, clenbuterol,
etc.), which have the ability to increase muscle mass. Ractopamine has been approved
for use as a veterinary drug in swine in 21 countries, but the EU and China have not
approved ractopamine for domestic use and do not allow residues of ractopamine in
imported food.

Coccidiostats
Coccidiosis is a parasitic disease, which can occur wherever animals are housed
in small areas that are contaminated with coccidial oocysts. Coccidiosis has affected
historically all species of wild and domestic birds. Coccidia are without question the
most important parasites of poultry in terms of distribution, frequency, and economic
losses. The main method of controlling coccidiosis is through the addition of drugs used
as anticoccidial drugs or coccidiostats in the feed at the authorized levels and observing
the prescribed hygiene requirements. The coccidiostats or anticoccidial drugs can be
grouped into two major classes:
• polyether ionophore antibiotics - monensin sodium, lasalocid sodium, madura­
micin ammonium, narasin, salinomycin sodium, and semduramicin sodium
• non-polyether ionophores – decoquinate, robenidine, amprolium, halofuginone,
diclazuril, sulfonamides, etc.

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 The maximum content of coccidiostats in food was in 2012 established in the EU.
These values (micrograms per kg of wet weight) are from 1 (lasalocid sodium, narasin,
halofuginone in milk) to 300 (nicarbazin in eggs or liver).

Ectoparasiticides
Food-producing animals are infected by a number of ectoparasites, including
lice, ticks, mange mites, myiasis larvae, and nuisance flies. Control of the parasites
is largely based on the use of chemicals that are usually applied topically to the
skin and have a direct effect on the parasite. Most ectoparasiticides are neurotoxins
(organochlorines, organophosphates and carbamates, pyrethrins and pyrethroids,
formamidines, macrocyclic lactones, etc.). The chronic effects of ectoparasiticides
from food intake on human health are not well defined, but there is increasing
evidence of carcinogenicity, disruption in hormonal function, and genotoxicity.
Restrictions are therefore applied to many of the ectoparasiticides indicated for use
in food-producing animals to ensure that unacceptable residues are not present in
products intended for human consumption.

15.2.12 Prevention and Control of the Chemical Contamination of

Food
For the prevention and control of the chemical contamination of food, three lines of
defence are available:
• The first line of defence is the production of food in which the quantities of
added chemicals and their quality lie within the limits permitted by legislation.
For this purpose, the primary industry as agriculture and processing industries
have to comply with laws and observe the principles of good agricultural and
manufacturing practices.
• The second line of defence is the application of technologies, which can prevent
or reduce the use of chemicals in food (e.g. pesticides).
• The third line of defence is the strict control and monitoring of levels of chemicals
in food, the responsibility for which is laid on governments’ food control agencies.

15.3 Physical Hazards

Physical hazards are foreign matter that accidentally gets into food. This can be
the result of environmental contamination during production, processing, storage,
packaging, and transport, or from fraudulent practices. It is important to identify foreign
objects and to locate the source as far as possible, in order to determine when, where,
how, and why the object got into the food. Illness complaints from the ingestion of
foreign matter include nausea and vomiting, diarrhoea, headache, fever and dizziness,
and chest pain. These may be due to chemical hazards, microbiological contamination,
or a psychosomatic response to the belief that foreign matter has been ingested.
Potential hazards caused by foreign matter can be grouped into several classes.

15.3.1 Physical Objects

Hard objects such as glass fragments, metal, and bone pose the biggest food safety
concern because they can cause injuries such as cuts, broken teeth, choking, and intestinal
perforation. There is a risk of cuts or lacerations to the hands during food preparation
and to the mouth, oesophagus, stomach, or intestines. There is also a risk of chipped
teeth, broken dental fillings, and damage to prosthetics (dentures). Approximately 80%
of reported foreign matter ingestions occur in children, and 80–90% of such ingested

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foreign objects will pass through spontaneously over the following 4–7 days. It was
estimated that only 1–5% of ingested foreign objects resulted in actual injury. There are
three main factors, which determine whether an object may be hazardous:
• size – foreign particles greater than 20 mm (e.g. bones) have the potential to be a
food safety hazard and may cause injury to consumers,
• shape – spherical or cylindrical objects present a greater risk for choking, whereas
slender and sharp objects (e.g. fish bones) present a greater risk of laceration or
perforation,
• consistency of the object – rigid objects such as coins caused most choking deaths
in 3-year and older children, whereas conforming objects such as balloons caused
more choking deaths in children under the age of 3 years.

15.3.2 Chemicals
Some foreign objects may represent possible chemical hazards to a person consuming
them:
• poisonous products, which may be accidentally harvested with field crops (e.g.
ergots),
• medical tablets or capsules in food,
• pests, which have been killed by commercial pesticides,
• food ingredients from other recipes (nuts – risk of causing an allergic reaction).

15.3.3 Biological Objects

Foreign matter with potential biological hazards (such as blood, used wound
dressings, etc.) can be found in food products which may evoke fear that diseases (such
as AIDS) may be transmitted to them by such means. In fact, most of these diseases are
quite difficult to transmit indirectly by such means, and if the offending item has been
subjected to heat processing, any infective agent has been killed.

The foreign matter that can be found in foods includes:

• insects (domestic flies) or pests (caterpillars) that feed either on the food product
or on something closely connected with it, mould spores, insect eggs, animal
droppings,
• plant material (bits of leaf or stalk) is frequently found in vegetables and fruits,
• other hard material – stones, sand, soil may be incorporated when soil-based
crops are harvested, material from production line and packaging like plastics,
paperboard, pieces of metals, fragments of glass (but most of the glass fragments
originate from end-use of the product rather than from its manufacture).

References
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Ltd., Cambridge 2015, 244 p. ISBN 978-1-78242-076-7.
Blackburn, C. deW., McClure, P. J. eds: Foodborne Pathogens. Hazards, Risk Analysis and Control.
Woodhead Publishing Ltd., Cambridge 2009, 1227 p. ISBN 978-1-84569-362-6.
Botana, L. M., Alfonso, A. eds: Phycotoxins: Chemistry and Biochemistry, 2nd Ed. John Wiley &
Sons, Ltd, Chichester 2015, 531 p. ISBN 978-1-118-50036-1.
Brimer, L.: Chemical Food Safety. CAB International, Cambridge 2011, 296 p. ISBN 978-1-84593-
676-1.

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Chen, C. I., Yan, X., Jackson, C. R. eds: Antimicrobial Resistance and Food Safety. Methods and
Techniques. Academic Press, London 2015, 457 p. ISBN: 978-0-12-801214-7.
D’Mello, J. P. F. ed.: Food Safety. Contaminants and Toxins, CABI Publishing, Wallingford UK 2003,
469 p. ISBN 0-85199-607-8.
Dabrowski, W. M., Sikorski, Z. E. eds: Toxins in Food, CRC Press, London 2005, 344 p. ISBN 0-8493-
1904-8.
de Vries, J. ed.: Food Safety and Toxicity. CRC Press, Boca Raton 1997, 334 p. ISBN 0-8493-9488-0.
Gurtler, J. B., Doyle, M. P., Kornacki, J. L. eds: The Microbiological Safety of Low Water Activity
Foods and Spices. Springer Science + Business Media, New York 2014, 437 p. ISBN 978-1-4939-
2061-7.
Khan, M. A. ed: Food Safety. Researching the Hazard in Hazardous Foods, Apple Academic Press,
CRC Press, Toronto 2014, 496 p. ISBN: 978-1-4822-2353-8.
Labbé, R. G., García, S. eds: Guide to Foodborne Pathogens. John Wiley & Sons, Ltd., Chichester
2013, 482 p. ISBN 978-0-470-67142-9.
Lawley, R., Curtis, L., Davis, J.: The Food Safety Hazard Guidebook, 2nd Ed., The Royal Society of
Chemistry, Cambridge UK 2012, 546 p. ISBN: 978-1-84973-381-6.
McElhatton, A., Marshall, R. J.: Food Safety . A Practical and Case Study Approach. Springer Science,
New York 2007, 322 p. ISBN 978-0387-33509-4.
Morris, J. G. Jr., Potter, M. E. eds: Foodborne Infections and Intoxication, 4th Ed. Academic Press,
Elsevier, London 2013, 576 p. ISBN : 978-0-12-416041-5.
Motarjemi, Y. ed.: Encyclopaedia of Food Safety. Academic Press, Elsevier, London 2014, 2356 p.
ISBN 978-0-12-378612-8.
Ortega, Y. R. ed.: Foodborne Parasites. Springer Science + Business Media, LLC, New York 2006,
300 p. ISBN 978-0387-30068-9.
Pongratz, I., Bergander, L. V. eds: Hormone-Disruptive Chemical Contaminants in Food. Royal
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Püssa, T.: Principles of Food Toxicology. CRC Press, Boca Raton 2014, 404 p. ISBN 978-1-4665-
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2015, 542 p. ISBN 978-1-4665-9307-7.
Rasco, B. A., Bledsoe, G. E.: Bioterrorism and Food Safety. CRC Press, Boca Raton 2005, 404 p.
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 16 FOOD SAFETY MANAGEMENT

Food quality and safety can only be insured through the application of quality-
control systems throughout the entire food chain. They should be implemented at farm
level with the application of good agricultural practices and good veterinary practices
at production, good manufacturing practice at processing, and good hygiene practices
at retail and catering levels.

16.1 HACCP and Food Safety Management Systems

HACCP is an acronym for Hazard Analysis Critical Control Point, a science-based
food safety management system that has its origins in the USA manned space flight
programme of the 1960s and 1970s. The HACCP approach to food safety is based on a
detailed examination of every stage in the production process for an individual food
product. The objective is to identify where and when hazards could occur and to design
effective controls for each hazard.

HACCP consists of seven principles that outline how to establish, implement, and
maintain a quality assurance plan for a food establishment:
1. Conduct a hazard analysis. (Prepare a list of steps in the process where significant
hazards occur and describe the preventive measures. Assess the likelihood of
occurrence of the hazard(s) and identify the measures for their control).
2. Identify the critical control points (CCPs) in the process. (Determine the points,
procedures or operational steps that can be controlled to eliminate the hazard(s)
or minimize its (their) likelihood of occurrence).
3. Establish critical limits for preventative measures associated with each identified
CCP.
4. Establish CCP monitoring requirements. (Establish procedures from the results
of monitoring to adjust the process and maintain control).
5. Establish corrective actions to be taken when monitoring indicates a deviation
from an established critical limit.
6. Establish effective record-keeping procedures that document the HACCP system.
7. Establish procedures for verification that the HACCP system is working correctly.

Over the last 25 years, HACCP has become the preferred method of ensuring safe
food all over the world. The widespread adoption of HACCP in the food industry has led
to the development of a number of formal standards and less formal codes of practice
designed to facilitate the integration of HACCP principles and practice into the overall
management of food safety. The International Organization for Standardization (ISO)
has developed the ISO 22000:2005 Food Safety Management Systems Standard (ISO
22000, Food safety management systems – Requirements for any organization in the
food chain) that utilizes HACCP principles to outline methods for controlling food
safety hazards and brings together many of the other key elements in an effective food

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safety management system. Since 2005, several other standards were published by ISO
concerning the food safety:
• ISO/TS 22002-1:2009 – Prerequisite programmes on food safety. Part 1: Food
manufacturing.
• ISO TS 22003:2007 – Food safety management systems for bodies providing audit
and certification of food safety management systems.
• ISO TS 22004:2005 – Food safety management systems. Guidance on the
application of ISO 22000:2005.
• ISO 22005:2007 – Traceability in the feed and food chain. General principles and
basic requirements for system design and implementation.

16.2 Food Safety Legislation in the EU

Food safety legislation in the countries of the EU originates from the European
Commission (EC). There are two main legal instruments by which the Commission can
introduce new food legislation:
• The first instrument is the Directive, which sets out an objective, but allows
national authorities to determine how that objective is to be achieved, and
cannot be enforced in individual Member States until implemented into national
legislation.
• The second instrument is the Regulation, which is ‘directly applicable’ and
becomes law in all Member States as soon as it comes into force, without the need
to change national legislation.
It is usual for the EC to submit a request for a risk analysis to be undertaken by the
European Food Safety Authority (EFSA) before legislative proposals are drawn up. On
1st January 2006 there came into force the “Food Hygiene Package“ of EU legislation,
which consists of three main Regulations:
• EC Regulation No. 852/2004 on the hygiene of foodstuffs,
• EC Regulation No. 853/2004 setting out specific hygiene requirements for foods
of animal origin,
• EC Regulation No. 854/2004 setting out specific requirements for organising
official controls on products of animal origin intended for human consumption.

16.3 Labeling and Information for Consumers

Starting from 13 December 2014 there is a new Regulation (EU) No. 1169/2011
concerning consumer information on foodstuff. The mandatory particulars must be
easy to understand and visible, clearly legible, and, where appropriate, indelible. The
height of «x» the characters must be at least 1.2 mm (except for small-sized packaging
or containers).
The mandatory particulars concern: the name, the list of ingredients, the substances
causing allergies or intolerances (nuts, milk, mustard, fish, grains containing gluten,
etc.), the quantity of certain ingredients or categories of ingredients, the net quantity
of the food, the date of minimum durability or the ‘use by’ date, any special storage
conditions and/or conditions of use, the name or business name and address of the
food business operator or importer, the country of origin or place of provenance for
certain types of meat, milk or where failure to indicate this might mislead the consumer,
instructions for use where it would be difficult to make appropriate use of the food in
the absence of such instructions, for beverages containing more than 1.2% by volume of
alcohol, the actual alcoholic strength by volume, and a nutritional declaration.

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 Information provided voluntarily must meet the following requirements: it shall
not mislead the consumer, it shall not be ambiguous, or misleading, it shall, where
appropriate, be based on the relevant scientific data.

16.4 Institutions Involved in Food Safety

There are many institutions involved in food safety. The most important ones are as
follows:
• FAO –Food and Agricultural Organization of the United Nations
• WHO– World Health Organization
• CAC FAO/WHO –Codex Alimentarius Commission
• JECFA –Joint FAO/WHO Expert Committee on Food Additives
• JEMRA –Joint FAO/WHO Expert Meetings on Microbiological Risk Assessment
• JMPR –Joint FAO/WHO Meetings on Pesticide Residues
• EC –European Commission (European Union)
• EFSA –European Food Safety Authority
• ISO –International Standards Organization

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 17 FOOD QUALITY ASSURANCE

The main actors in the food quality assurance include the government, consumers,
and the food industry.
Food quality is determined by organoleptic (sensoric), nutritional, functional, and
hygienic properties.
In order to ensure or stimulate food preparation at home, it is important to realize
that the general public, especially in the industrialized world, has a different perception
on food related health risks as compared to the ranking order of food hazards based
on objective scientific criteria. The difference in ranking order between consumers
and scientists is a cause of concern, especially as risk prevention is also partly the
responsibility of the consumer. The observed difference is partially attributable to
information in the media as well as to psychological factors.
The household is perhaps the most relevant place for development measures to
combat food-borne illnesses, as it is the location where the consumer can exert the
mostly control over what he or she eats.
Illness due to contaminated food is a widespread health problem; in infants and the
elderly, its consequences can be fatal. WHO data indicate that only a small number of
factors are responsible for a large proportion of food-borne disease episodes.
Common errors include:
− preparation of food too far ahead of consumption;
− prepared food being left too long at a temperature that permits bacterial
proliferation;
− inadequate heating;
− cross-contamination;
− an infected or “colonized” person handling with the food.

17.1 The Golden Rules of Food Safety

The Ten Golden Rules presented below offer advice that can reduce the risk that
food-borne pathogens will be able to contaminate, to survive, or to multiply. The rules
have been drawn up by the World Health Organization to provide guidance to members
of the community on safe food preparation in the home. They should be adapted, as
appropriate, to local conditions.
1. Choose foods processed for safety
While many foods, such as fruits and vegetables, are best in their natural state,
others simply are not safe unless they have been processed. For example, always buy
pasteurized as opposed to raw milk and, if you have the choice, select fresh or frozen
poultry treated with ionizing radiation. When shopping, keep in mind that food
processing was invented to improve safety as well as to prolong shelf life. Certain foods
eaten raw, such as lettuce, need thorough washing.
2. Cook food thoroughly
Many raw foods, most notably poultry, meats, and unpasteurized milk, are very often
contaminated with disease-causing pathogens.

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 Thorough cooking will kill the pathogens, but remember that the temperature of all
parts of the food must reach at least 70 °C. If cooked chicken is still raw near the bone,
put it back in the oven until it is done-all the way through. Frozen meat, fish, and poultry
must be thoroughly thawed before cooking.
3. Eat cooked foods immediately
When cooked foods cool to room temperature, microbes begin to proliferate. The
longer they wait, the greater is the risk. To be on the safe side, eat cooked foods as soon
as they come off the heat.
4. Store cooked foods carefully
If you must prepare foods in advance or want to keep leftovers, be sure to store them
under either hot (near or above 60 °C) or cool (near or below 10 °C) conditions. This
rule is of vital importance if you plan to store foods for more than four or five hours.
Foods for infants should preferably not be stored at all. A common error, responsible
for countless of foodborne disease, is to put too large a quantity of warm food in the
refrigerator. In an overburdened refrigerator, cooked foods cannot cool to the core as
quickly as they must. When the centre of food remains warm (above 10 °C) too long,
microbes thrive, quickly proliferating to disease-producing levels.
5. Reheat cooked foods thoroughly
This is your best protection against microbes that may have developed during storage
(proper storage slows down microbial growth but does not kill the organisms). Once
again, thorough reheating means that all parts of the food must reach at least 70 °C.
6. Avoid contact between raw foods and cooked foods
Safely cooked food can become contaminated through even the slightest contact
with raw food. This cross-contamination can be direct, as when raw poultry meat comes
into contact with cooked foods. It can also be more subtle. For example, do not prepare
a raw chicken and then use the same unwashed cutting board and knife to carve the
cooked bird. Doing so can reintroduce all the potential risks for microbial growth and
subsequent illness present prior to cooking.
7. Wash hands repeatedly
Wash hands thoroughly before you start preparing food and after every interruption–
especially if you have to change the baby or have been to the toilet. After preparing raw
foods such as fish, meat, or poultry, wash again before you start handling with other
foods. Moreover, if you have an infection on your hand, be sure to bandage or cover it
before preparing food. Remember too, that household pets – dogs, birds, and especially
turtles–often harbour dangerous pathogens that can pass from your hands into food.
8. Keep all kitchen surfaces meticulously clean
Since foods are easily contaminated, any surface used for food preparation must be
kept absolutely clean. Think of every food scrap, crumb or spot as a potential reservoir
of germs. Cloths that come into contact with dishes and utensils should be changed
every day and boiled before reuse. Separate cloths for cleaning the floors also require
frequent washing.
9. Protect foods from insects, rodents, and other animals
Animals frequently carry pathogenic microorganisms, which cause food-borne
disease. Storing foods in tightly sealed containers is your best protection.
10. Use pure water
Pure water is just as important for food preparation as for drinking. If you have any
doubts about the water supply, boil water before adding it to food or making ice for
drinks. Be especially careful with any water used to prepare an infant’s meal.

133
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Acknowledgements

This publication is the result of the research supported by the ESF-OPV project “MPH
study programme development at Comenius University in Bratislava in English lan-
guage (Master of Public Health).“ ITMS code of the project: 26140230009

Moderné vzdelávanie pre vedomostnú spoločnosť/

Projekt je spolufinancovaný zo zdrojov EÚ