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Personalised nutrition and health

Food for thought, click here to read other articles in this collection.

  • Related content
  • Peer review
  • Jose M Ordovas , professor 1 2 3 ,
  • Lynnette R Ferguson , professor 4 ,
  • E Shyong Tai , professor 5 ,
  • John C Mathers , professor 6
  • 1 JM-USDA-HNRCA at Tufts University, Boston, MA, USA
  • 2 Centro Nacional Investigaciones Cardiovasculares, Madrid, Spain
  • 3 IMDEA Food Institute, CEI UAM + CSIC, Madrid, Spain
  • 4 Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
  • 5 National University of Singapore, Singapore
  • 6 Human Nutrition Research Centre, Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, United Kingdom
  • Correspondence to: J M Ordovas jose.ordovas{at}tufts.edu

Jose Ordovas and colleagues consider that nutrition interventions tailored to individual characteristics and behaviours have promise but more work is needed before they can deliver

Dietary factors are well recognised contributors to common diseases, including heart disease, stroke, type 2 diabetes and cancer. 1 2 3 Despite the known link between dietary patterns and disease, interventions to alter dietary habits and to improve public health and wellbeing have had limited impact. Personalisation of interventions may be more effective in changing behaviour 4 that will affect health outcomes. 5 In this article we consider the evidence for personalised nutrition.

What is personalised nutrition and what is it used for?

There is no agreed definition of personalised nutrition. For the purposes of this review, we define it as an approach that uses information on individual characteristics to develop targeted nutritional advice, products, or services. Gibney et al 6 describe it as an approach that “assists individuals in achieving a lasting dietary behaviour change that is beneficial for health.” Personalised nutrition partially overlaps with related terms such as precision nutrition, nutrigenomics, nutrigenetics, nutritional genomics, etc ( box 1 ).

Descriptors and definitions

In common with other scientific fields in their early development, multiple concepts and descriptors are used in personalised nutrition, sometimes without rigorous definition. In addition to the term personalised nutrition, many other terms are used—for example, precision nutrition, stratified nutrition, tailored nutrition, and individually tailored nutrition. We have attempted to group the descriptors as follows:

• Stratified and tailored nutrition are similar (if not synonymous). These approaches attempt to group individuals with shared characteristics and to deliver nutritional intervention/advice that is suited to each group

• Personalised nutrition and individually tailored nutrition mean similar things and go a step further by attempting to deliver nutritional intervention/advice suited to each individual

• Precision nutrition is the most ambitious of the descriptors. It suggests that it is possible to have sufficient quantitative understanding about the complex relationships between an individual, his/her food consumption, and his/her phenotype (including health) to offer nutritional intervention/advice, which is known to be individually beneficial. The degree of scientific certainty required for precision nutrition is much greater than that required for the other approaches

• Nutrigenetics is an aspect of personalised nutrition that studies the different phenotypic responses (ie, weight, blood pressure, plasma cholesterol, or glucose levels) to a specific diet (ie, low fat or Mediterranean diets), depending on the genotype of the individual

• Nutrigenomics involves the characterisation of all gene products affected by nutrients and their metabolic consequences

• Exposome is the collection of environmental factors, such as stress, physical activity and diet, to which an individual is exposed and which may affect health

As one moves from stratified to personalised to precision nutrition, it becomes necessary to apply more and more dimensions or characteristics to achieve the desired goal. For example, stratification could be undertaken using one, or a few, dimensions such as age, gender, or health status. In contrast, given the complexity of relationships between individual diet and phenotype, deployment of a wide range of dimensions/characteristics, perhaps including “big data” approaches, would be necessary to achieve the goal of precision nutrition. An exception to this broad generalisation is the management of inborn errors of metabolism such as phenylketonuria, where “precision nutrition” can be achieved using information on a single characteristic—that is, genotype.

• Epigenomics is a branch of genomics concerned with the epigenetic changes (methylation, histone modification, microRNAs) that modify the expression and function of the genetic material of an organism

• Metabolomics is the scientific study and analysis of the metabolites (usually restricted to small molecules, ie, <900 daltons) produced by a cell, tissue, or organism

• Microbiomics is the study of the microbiome, the totality of microbes in specific environments (ie, the human gut)

The overall goal of personalised nutrition is to preserve or increase health using genetic, phenotypic, medical, nutritional, and other relevant information about individuals to deliver more specific healthy eating guidance and other nutritional products and services (table 1). Personalised nutrition is equally applicable to patients and to healthy people who may or may not have enhanced genetic susceptibilities to specific diseases.

Personalised nutrition can be applied in two broad areas: firstly, for the dietary management of people with specific diseases or who need special nutritional support—for example, in pregnancy or old age, and, secondly, for the development of more effective interventions for improving public health. It has traditionally focused on maximising the benefits and reducing the adverse effects of dietary changes for the individual. However, this focus on the individual may have limited impact on populations. To have a wider impact, it must be deployed at a scale and in a way that reduces (rather than increases) health disparities. Individuals may also wish to use personalised nutrition to achieve personal goals/ambitions that are less directly related to health—for example, to deal with preferences for, and dislikes of, specific foods, to attempt to achieve a desired body size or shape, or for competitive sports. 7

What are the conceptual bases for personalised nutrition?

Personalised nutrition is based on the idea that individualising nutritional advice, products, or services will be more effective than more generic approaches.

Personalisation can be based on:

• Biological evidence of differential responses to foods/nutrients dependent on genotypic or phenotypic characteristics

• Analysis of current behaviour, preferences, barriers, and objectives and subsequent delivery of interventions, which motivate and enable each person to make appropriate changes to his or her eating pattern.

Personalisation based on biological characteristics of the individual

Differences in the response of people to dietary components have been well documented for almost a century. 8 9 10 This provides the basis, and motivation, for developing personalised nutrition strategies. The trend towards personalisation is the result of: firstly, nutrition research that provides a better understanding of how diet affects health; secondly, new technology that enables better and continuous measurements of markers of individual health and fitness; and thirdly, new analytical tools that interpret this flow of data and transform it into user friendly practical information. Moreover, personal nutrition integrates with the change in bioscience and public health programmes towards preventing rather than mitigating existing disease. Response to food is variable and has multiple forms. These include differential responses in plasma cholesterol concentration to dietary saturated fat intake, food allergies or intolerances (eg, lactose intolerance or gluten sensitivity), or more severe forms such as phenylketonuria and other inborn errors of metabolism. Moreover, personalised nutritional advice may be appropriate for some key factors, such as age (teenager, elderly, child, adult), stage of life (pregnant, lactating, etc), sex, BMI, disease or health status, ethnicity, and cultural or religious backgrounds that dictate particular diets

Nutrigenetics has been defined as “the discipline that studies the different phenotypic response to diet depending on the genotype of each individual.” 11 It is a classic example of an attempt to characterise the response of an individual to a dietary intervention based on genetic factors. To a large extent, this is based on accumulating evidence of the phenotypic consequences of interactions between interindividual differences in genetic make up and nutrition. 12 Nutrigenetics has evolved from using a unique single nucleotide polymorphism at a candidate gene locus to examine interaction with a specific nutrient (eg, saturated fat) to a more comprehensive whole genome approach analysing interactions with dietary patterns. 13

More recently, new technology has enabled multiple endogenous and exogenous factors to be studied at the same time and used to predict the response to intervention. These include epigenomics, metabolomics, microbiomics ( box 1 ), and the individual's environment, 14 also known as the exposome. 15 The ability to measure “everything that matters” is becoming a reality with the increasing availability of fitness trackers, mobile apps, and other devices. These enable individuals to monitor continuously multiple health related factors, such as physical activity, sleep, and vital signs—for example, blood pressure, heart rate, and stress levels. The usefulness of these devices remains controversial. 16 17 However, in theory, such information could be used to develop algorithms that, in combination with genetic and other biological information, may provide a sound basis for personalised recommendations.

Potentially just as important is the belief that easy access to indices of health provided frequently, and in real time, will be a driver for beneficial, and sustained behaviour change. Thus, an individual will acquire data on his/her genotype and multiple phenotypic characteristics on which the personalised nutrition is based. Periodic physiological and biochemical analyses and microbiome tests will enable tracking of their health metrics in response to dietary, and other personalised, behavioural changes in real time. Relatively little has been published on the development and validation of the algorithms for personalised nutrition. The Food4Me Study published algorithms to integrate information based on current diet, phenotypic characteristics, and genotypic characteristics. 18 However, other approaches—for example, using machine-learning 19 or artificial intelligence, 20 might offer additional advantages.

For example, Zeevi et al 21 used the connection between a raised concentration of postprandial blood glucose and the risk of type 2 diabetes risk. They monitored glucose concentrations in 800 people continuously for 1 week. They then used the variability in glycaemic response to identical test meals to devise a machine-learning algorithm that integrated blood parameters, dietary habits, anthropometrics, physical activity, and gut microbiota to predict an individual's postprandial glycaemic response to real meals. The predictive algorithm was validated in an independent cohort (n=100). These investigators conducted a small randomised controlled dietary intervention study that suggested that personalised diets may successfully modify raised postprandial blood glucose.

The potential role of microbiome based information in developing personalised nutrition has been emphasised in more recent work from the same group. They used a small intervention study to show that an individual’s glycaemic response to a test meal can be predicted from microbiome data before the intervention. 22 These results highlight the importance of information about individual people in understanding the effects of dietary factors on metabolism and health. The results suggest that interindividual differences in responses to dietary challenges may be particularly informative, but we need evidence from larger scale studies to know whether such personalised interventions based on a “challenge test” offer significant advantages.

This approach was illustrated more recently by Price et al. 23 They collected personal data, including whole genome sequences, clinical tests, blood metabolome and proteome, physical activity, and fecal microbiome, on three occasions over 9 months from 108 people. They used these data to generate correlation networks that disclosed communities of related analytes associated with physiology and disease. They also used some of the personal data (genotype and clinical markers) to implement behavioural coaching to help participants to improve biomarkers of health. This study showed, firstly, that some highly motivated people are willing to collect personal data over extended periods; secondly, that more information can help to confirm existing knowledge about the connectedness of human physiology and to expose new connections; and, thirdly, with intense measurement in highly motivated people, “personalised coaching” may help to change behaviour. However, it is not clear how much of the detailed measurement undertaken in the study was essential in developing the “personalised coaching.” As the participants were self-selected, it is unclear whether this approach would be acceptable to larger populations.

Personalisation based on analysis of current behaviour, preferences, barriers, and objectives

Most researchers, and other stakeholders in personalised nutrition, have focused on the capture of genotypic or phenotypic characteristics. The implicit assumption is that, the more we can measure, the more effective will be the outcomes of personalisation. 24 There is increasing realisation that, unlike with medication, dietary changes require individuals to make daily, sometimes hourly, choices. The adoption of these lifestyle changes (including but not limited to changes in dietary patterns) is highly dependent on effective collaboration with participants who are being helped to take responsibility for their behaviour, and, ultimately, health. Increasing technology is available that can motivate healthy eating. However, such applications usually adopt a “one-size-fits-all” approach that is biased towards specific cultures or population subgroups. Evidence suggests that it is possible to facilitate a change in behaviour using genetic testing or personalised advice as the catalysts. 25 26 More emphasis is needed to develop behavioural approaches that will best motivate particular individual and cultural groups.

There may be benefits in moving from a decision framework based on health professionals’ perspectives of effectiveness to one of shared decision making. An intervention based on shared decision making between the provider and the recipient becomes personalised and may increase acceptance and adherence. In this regard, the Food4Me Study stands out. It was a randomised controlled trial (RCT) involving >1600 participants from seven European countries, which showed that personalised nutrition was more effective than a conventional one-size-fits-all approach as control ( box 2 ). 27 A limitation of the study is that no information is available on outcomes beyond 6 months. However, findings from an earlier systematic review and meta-analysis suggest that, if changes are apparent at 6 months, they are likely to be sustained for at least a year. 28

  • Food4Me Study

The Food4Me Study 27 is the largest randomised controlled trial to have investigated the efficacy of personalised nutrition.

The study asked two key questions:

Is personalised nutrition more effective in changing diet than a conventional one-size-fits-all approach?

Does the basis used for personalisation matter? (With particular interest in the benefit of personalisation based on phenotypic and genotypic characteristics)

After 6 months, the answer was clear. Personalisation of dietary advice assisted and/or motivated consumers to eat a healthier diet and follow a healthier lifestyle (in comparison with “impersonal” (conventional) dietary advice). The Healthy Eating Index was used as the global measure of “healthfulness” of eating patterns and change was measured after 3 and 6 months.

Personalisation based on analysis of current diet was more effective in assisting and/or motivating study participants to make, and to sustain, appropriate healthy changes to their usual (habitual) diet and lifestyle. However, there was no evidence of any additional benefit from using more sophisticated, and expensive, bases for personalisation, such as phenotypic and genotypic information.

The Food4Me Study was implemented as an internet based intervention to emulate commercial personalised nutrition aids. The intervention was delivered to >1600 adults in seven European countries and used several new approaches to collection and validation of data and biological samples. 47 58 This study provides a model for the use of the internet in delivering personalised interventions. It demonstrates the opportunities to scale up and to make potentially significant cost effective improvements in public health.

None the less, many questions remain, and the conceptual framework underpinning this type of personalisation is poorly defined.

Implementation challenges

Personalised nutrition has raised expectations similar to the excitement that has surrounded other scientific developments in their early stages. Scientists working in this area have expressed concerns about overpromising, 29 30 individually 31 32 as well as through institutional guidelines and statements. 33 34 35 36 37 38 Highest expectations arise from the suggestion that genetic information might be used to define personalised dietary recommendations. For example, the Academy of Nutrition and Dietetics states that “nutritional genomics provides insight into how diet and genotype interactions affect phenotype. The practical application of nutritional genomics for complex chronic disease is an emerging science and the use of nutrigenetic testing to provide dietary advice is not ready for routine dietetics practice.” The consensus is that much research is needed before personalised nutrition can deliver the expected benefits. 36

Gaps in the evidence base Firstly, most studies, many of which are nutrigenetic, have used retrospective or observational approaches. Those studies that have used interventions are small and have focused on intermediate biomarkers. Only a few reports have studied gene-diet interactions in large, randomised, long term dietary intervention studies with clinical events as endpoints. 39 40 Stronger evidence for causality may come from well designed dietary RCTs that use prospective genotyping when randomising participants to treatments, as in the FINGEN Study 41 ( box 3 ). The latter study investigated the effects of supplementation with fish oil on cardiovascular risk markers. For the design and implementation of an RCT, such an approach is much less complex than trials involving whole foods or which attempt to change eating patterns. Randomised controlled trials are essential to providing proof of concept and to giving scientific credibility to the concept of personalised nutrition. We envisage that ethical providers will build delivery systems in which elements of the system are evidence based but for which it would be difficult or impossible to test the whole system with an RCT.

Personalised nutrition

Interindividual variability in response to dietary factors is a real phenomenon

Some studies have shown that personalisation results in greater improvements in diet than universal approaches

Personalisation may foster sustained change in behaviour

The personalised nutrition approach mirrors the rise in personalised, or precision, medicine, which is likely to drive scientific developments beneficial for personalised nutrition, and, therefore, public health

Scientific evidence for personalised nutrition is mostly based on observational studies with a low level of reproducibility

The theoretical basis for personalised nutrition is underdeveloped

The factors responsible for interindividual differences in response to dietary factors, their persistence over time within the same individual, and their heritability are mostly unknown 59

There are few well-designed randomised controlled trial that demonstrate the efficacy and safety of personalised nutrition

Most commercial offerings in the personalised nutrition area are based on direct to consumer tests that are unregulated and have limited published evidence of benefit

Applying evidence for populations to individuals Most of our evidence in populations is probabilistic. The personalised nutrition approach wants to use this evidence for individuals. To take a simple example, there is evidence that an interaction between a variant in APOA2 and intake of saturated fatty acids has an effect on obesity and, by extrapolation, on the risk of cardiovascular disease. 42 43 Lowering saturated fatty acid intake in those carrying this variant would be expected to lower obesity and thus the risk of cardiovascular disease in populations. However, for individuals, there is no guarantee of any benefit. This is because, in common with most health outcomes, the risk of cardiovascular disease is multifactorial and includes the effects of stochastic factors. Available evidence allows us to predict mean outcomes from a given intervention and genotype, but it is impossible to predict health outcomes for individuals. Thus, the current interest is in studies that measure multiple parameters at the same time. Alternatively, others have advocated single subject studies in personalised nutrition. 44 Single subject, or n-of-1, trials can potentially assess the usefulness of personalised interventions by integrating emerging technology and biomarkers. 45 Analytical approaches to n-of-1 studies are being developed in related fields—for example, health psychology, and may be suitable for use in personalised nutrition. 46

Effect on health disparities The use of most new technology (such as n-of-1 trials) for predicting and measuring the response to specific dietary changes may be prohibitively expensive if deployed at scale. 5 This may increase health disparities. The challenge for research will be to define the minimum set of measurements/biomarkers that predicts individual response to personalised nutrition.

Encouraging shared decision making Face-to-face consultations with a health professional or lifestyle coach might enable shared decision making, but is relatively expensive. In the Food4Me Study, personalisation was implemented by nutrition researchers 5 27 47 using decision trees. This guided the personalised advice and ensured that it was standardised across study sites. This process could be used to build algorithms that “tailor” the advice/support offered to an individual, based on preferences, barriers, ambitions, etc. Such algorithms can also incorporate techniques for behaviour change to help maximise the (health) benefit. 48 These algorithms could be automated and could operate in “real time” using the internet. They provide an opportunity for large scale, cost effective shared decision making that may minimise possible increases in health disparities.

Is personalised nutrition more effective than alternative approaches?

Despite studies supporting personalised nutrition, most evidence has come from observational studies with risk factors as outcomes, rather than from RCTs using clinical end points.

There are two key related questions. Firstly, can personalised nutrition produce greater, more appropriate and sustained changes in behaviour than conventional approaches? Secondly, do these changes result in better health and wellbeing?

We have limited information that the answer to the first of these questions is yes. 27 49 However, evidence for the usefulness of communicating genetic risks of a disease itself on risk-reducing health behaviour is weak. 50 A recent systematic review studied genetic testing and lifestyle behaviour change. It concluded that behaviour change can be facilitated using genetic testing as the catalyst. The authors argued that to promote such change the theory of planned behaviour should be deployed when communicating the results of genetic testing. 26

The second question remains unanswered. No personalised nutrition study has been carried out at a large scale, in an appropriate population group and over a sufficiently long time. For this reason, and because of the importance of lifestyle change for large sections of the population, other investigators advocate a universal, rather than targeted, approach to lifestyle intervention for disease prevention and treatment. 51 The logistical complexity, practical challenges, and financial costs of nutrition intervention studies with disease risk as outcomes are large and likely to be increased in personalised nutrition interventions. Thus further testing will probably use outcomes such as changes in diet, adiposity, or established biomarkers of disease such as blood pressure, HbA 1c , or cognitive function. In addition, there are major opportunities to test the usefulness of personalised nutrition in the response to disease management and treatment. This would be cost effective and logistically feasible.

Personalised nutrition in the marketplace

The potential market for personalised nutrition is huge. Firstly: as indicated above, it applies to both diseased and healthy people; secondly, eating is a daily activity, and thus opportunities for personalisation are continuous; thirdly, through personalisation a person may feel able to enhance or maintain health. Most commercial personalised nutrition interventions are provided directly to the consumer through the internet. The reliability of the evidence used by such companies is uncertain. 52 53 The business has developed without regulatory oversight, defined standards, and consumer protection. 54 Moreover, there are no educational resources or guidelines for how the outcomes of research into personalised nutrition should be implemented. To protect the public, advice should be based on robust scientific evidence. A framework for testing evidence for the scientific validity of nutrigenetic knowledge has been published. 38 It is intended to be used for developing transparent and scientifically sound advice to the public founded on nutrigenetic tests. This is based on the assumption that scientifically valid, properly regulated information delivered through the internet will be less expensive and more pervasive and may help to reduce health inequalities.

Suggestions for the future

Advancement of personalised nutrition will be facilitated by a number of factors. Firstly, the development of a strong theoretical basis, including identification of the most important individual characteristics on which to base personalisation. Secondly, the evidence for efficacy and cost effectiveness from well designed intervention studies. Thirdly, the introduction of a regulatory framework designed to protect the public and to give confidence to health professionals and policy makers. This will require a substantial increase in the scientific evidence. This implies:

• More robust study designs ranging from RCTs enrolling participants based on preselected genotypes, to n-of-1 trials and aggregated n-of-1 trials. Such research will benefit from multidisciplinary research teams, comprising, for example, behavioural psychologists, computer scientists, biomedical scientists, and nutritionists.

• Integration of other “omics” to provide greater mechanistic interpretation of the evidence. This is likely to include emphasis on epigenomics, metabolomics, and microbiomics. In this respect, proof of principle of the role of the microbiome in shaping interindividual variability in response to diet has been established.

A first step in developing guidelines for using genotype based advice in personalised nutrition has been proposed by the Food4Me consortium. 38 It will be important for research and regulatory communities to evaluate the proposed guidelines. This may lead to the development of more generic guidelines that could be valuable for national (and international) regulators. However, given the diversity of approaches to personalised nutrition, it is likely to be difficult to agree on the principles for such generic guidelines. Experience shows that commercial providers are keen to proceed before the scientific evidence is established. This would be unimportant if the commercial offerings were harmless. However, inappropriate dietary change may harm the consumer’s health and finances. It will be important to find ways of curbing the more extravagant claims, which are likely to tarnish the emerging science of personalised nutrition.

Key messages

Personalised nutrition uses information on individual characteristics to develop targeted nutritional advice, products, or services to assist people to achieve a lasting dietary change in behaviour that is beneficial for health

Personalised nutrition is based on the concept that individualised nutritional advice, products, or services will be more effective than more traditional generic approaches

This personalisation may be based on biological evidence of differential responses to foods/nutrients dependent on genotypic or phenotypic characteristics, and/or based on current behaviour, preferences, barriers and objectives

Most of the available evidence in support of personalised nutrition has come from observational studies with risk factors as outcomes, rather than from randomised controlled trials using clinical end points

The overall consensus is that much research and regulation is required before personalised nutrition can deliver the expected benefits

Different levels of recommendation for women (not pregnant or lactating)

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Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: JMO is part of Habit advisory board.

Provenance and peer review: Commissioned; externally peer reviewed.

This article is one of a series commissioned by The BMJ . Open access fees for the series were funded by SwissRe, which had no input into the commissioning or peer review of the articles. The BMJ thanks the series advisers, Nita Forouhi and Dariush Mozaffarian, for valuable advice and guiding selection of topics in the series.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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nutrition perspectives (research paper)

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Perspectives in nutrition Waldraw

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fitri rohmatulloh

nutrition perspectives (research paper)

International Journal of Advanced Academic Research

Chinaza G Awuchi , Amagwula Ikechukwu

The systematic review focused on nutritional diseases, nutrient toxicities, nutrients deficiency diseases, and the diets for health living. Nutritional diseases include obesity and eating disorders, and chronic diseases such as protein-energy malnutrition (Kwashiorkor and marasmus), cardiovascular disease, atherosclerosis, hypertension, cancer (colorectal cancer, prostate cancer, breast cancer), diabetes mellitus, dental caries. Others are gastroesophageal reflux disease, heartburn and peptic ulcer, diverticulitis (diverticulosis), constipation, diarrhea, Crohn disease (regional ileitis), ulcerative colitis,etc. Nutritional diseases also include some developmental abnormalities which can be prevented by diet, hereditary metabolic disorders which respond to dietary treatment, food allergies and intolerances, potential hazards in the food supply, and the interactions of foods and nutrients with drugs. The deficiencies or excesses of macronutrients and micronutrients are the cause of many diseases, and also exacerbate others and are acknowledged as having a significant impact on health all over the world. Some important micronutrients include calcium, iodine, iron, zinc, selenium, fluorine, potassium, etc., and vitamins A, D, E, B6, B12, B1, B2, B3, C, among others. Deficiencies of essential vitamins and minerals such as Vitamin A, zinc, and iron may be caused by long-term shortage of nutritious food or by many infections such as intestinal worms. They can also be caused or worsened when illnesses (such as malaria, diarrhoea) cause rapid loss of nutrients through vomit or feces. Dehydration (Water deficiency) may develop if consumption of water fails to satisfy thirst.Because of interactions, high intake of one mineral salt may adversely affect the absorption or the utilization of another. Excessive ingestion from food alone is not likely, but consumption of supplements or fortified foods increases the chance of toxicity. Additionally, occupational or environmental exposure to potentially toxic level of minerals presents additional risks for some populations. The acute effects of large alcohol intake are well known; a mental impairment starts when blood concentration of alcohol is approximately 0.05%. Women who drink during pregnancy stand the risks of physical and mental damage to their babies (known as fetal alcohol syndrome). Many herbal products show sufficient potential in preventing and treating diseases that they are being tested in scientific studies, including clinical and subclinical trials. Maintaining a healthy diet, paleolithic diet, very low carbohydrate diet, low-fat diet, low-calorie diet, raw foodism, and/or ketogenic diet, in addition to proper food hygiene, can help prevent and treat nutritional diseases, food allergies, food intolerance, and nutrient toxicities.

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  • v.361; 2018

Science and Politics of Nutrition

Hunger and malnutrition in the 21st century, patrick webb.

1 Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA

Gunhild Anker Stordalen

2 EAT Forum, Oslo, Norway

Sudhvir Singh

Ramani wijesinha-bettoni.

3 Food and Agriculture Organization of the United Nations, Ringgold Standard Institution, Rome, Italy

Prakash Shetty

4 MS Swaminathan Research Foundation, Ringgold Standard Institution, Chennai, India

Anna Lartey

Despite record food output globally, hunger is still with us. Patrick Webb and colleagues argue that key policy actions are urgently needed to tackle this scourge and must focus on improving diet quality for all

Today’s world is characterised by the coexistence of agricultural bounty and widespread hunger and malnutrition. 1 Recent years have seen a reversal of a decades old trend of falling hunger, alongside the re-emergence of famine. 1 National and global evidence shows that ensuring an adequate food supply is still an important contribution to eradicating hunger. However, generating more food in the form of staple grains or tubers is not enough. Good nutrition and an end to hunger both require everyone to have an appropriate diet. How can that be achieved?

Characterising the problem

A recent report for the World Committee on Food Security argued that “malnutrition in all its forms—not only hunger, but also micronutrient deficiencies, as well as overweight and obesity—is … a critical challenge not only in the developing but also in the developed countries. Resolving malnutrition requires a better understanding of the determinants and processes that influence diets.” 1 Malnutrition ranges from extreme hunger and undernutrition to obesity ( box 1 ). 2 3 Furthermore, malnutrition is found in all countries, irrespective of their economic development, where people lack high quality diets. 4 5 6 Thus, solutions to hunger and to all forms of malnutrition need to focus on ensuring an adequate supply of food, but equally, on the quality of diets.

Terms and definitions 1 2 3

  • Hunger is characterised in many ways. It encompasses individual sensations and household behavioural responses, food scarcity (actual or feared) and national food balance sheets that focus on supply of energy (kilocalories) in any country in relation to a minimum threshold of need. The food balance sheet approach is the only standard of measurement used globally. It is based on data collated by the Food and Agriculture Organization of the United Nations. This organisation has replaced its previous use of the word “hunger” in describing this metric with the phrase “chronic undernourishment”. This today is defined as “a person’s inability to acquire enough food to meet daily minimum dietary energy requirements during 1 year” 1
  • Malnutrition— An all inclusive term that represents all manifestations of poor nutrition. It can mean any or all forms of undernutrition, overweight, and obesity
  • Undernutrition —Refers to any form of nutritional deficiency, particularly those manifest in maternal underweight, child stunting, child wasting, or micronutrient deficiencies. It does not include reference to overweight and obesity
  • Maternal underweight— A body mass index (BMI) of <18.5 among women of reproductive age. This typically reflects chronic energy deficiency coupled with a lack of other key macronutrients or micronutrients, ill health, or energy expenditure higher than consumption. A prevalence >20% indicates a serious public health problem
  • Child stunting —Height for age ≤ −2 standard deviations of the median for children aged 6-59 months, according to World Health Organization child growth standards
  • Child wasting— Weight for height ≤ −2 standard deviations of the median for children aged 6-59 months, according to WHO child growth standards
  • Micronutrient deficiencies— A lack of various key vitamins and minerals leads to a range of symptoms that are of global concern. These include anaemia due to iron deficiency and risk of child mortality associated with clinical vitamin A deficiency. Such deficiencies are measured in several ways, including biomarkers (assessed using blood, serum, urine, etc), clinical manifestations, or proxy measures of diet quality
  • Overweight and obesity —For non-pregnant adults, a BMI ≥25 represents being overweight. The threshold for obesity is a BMI ≥30. Child obesity is of increasing concern and was included in the latest global nutrition goals for 2030 (“no increase in childhood obesity”) 4

Today, risk factors for ill health associated with poor quality diets are the main causes of the global burden of disease. 5 6 Low quality diets lack key vitamins, minerals (micronutrients), and fibre or contain too many calories, saturated fats, salt, and sugar. 7 In 2010, dietary risk factors combined with physical inactivity accounted for 10% of the global burden of disease (measured as disability adjusted life years, which reflect the number of years lost due to ill health, disability, or early death). 8 By 2015, six of the top 11 global risk factors were related to diet, including undernutrition, high body mass index (BMI), and high cholesterol. 9 10 Where governments have invested the economic gains derived from rising productivity in safety nets and services accessible to the poor, this has resulted in national growth. 11 12 13 However, where poverty persists, including in rich nations, hunger also persists.

Several faces of hunger

Hunger is a broad unscientific term that relates to nutrition and health outcomes in various ways. The proportion of people defined as hungry over the long term (usually termed “chronically undernourished”) fell from 18.6% globally in 1990-2002 to under 11% in 2014-16 ( table 1 ). That was a decline of 211 million people while the world’s population increased by 2 billion. 2 Big gains were made in large countries like China and in Brazil, Ethiopia, and Bangladesh ( box 2 ). South America was particularly successful, reducing undernourishment by over 50% in 25 years. 1 Such gains were made possible largely by rapid reduction of poverty, rising levels of literacy, and health improvements that reduced preventable child mortality. 17

Numbers (millions) and prevalence (%) of people with chronic undernourishment, stunting, and wasting* by year and geographical region 2 14

Successful resolution of undernutrition: Brazil, Ethiopia, and Bangladesh

Hunger (chronic undernourishment) has remained static at around 800 million people for several decades. This is largely because of rising populations in fragile states and the escalation of armed conflict in numerous parts of the world. 1 2 Nevertheless, child undernutrition has been falling. In 2000, roughly 200 million children under 5 years of age were stunted, but this has fallen to less than 151 million today. Rapid improvements in nutrition have been concentrated in several large nations, which have shown the way with policy success stories

• Brazil saw its prevalence of child stunting decline from 37% in 1974–1975 to 7% in 2006-7. 17 It achieved these gains through a sustained commitment to expand access to maternal and child health services (reaching into previously underserved geographical regions). This was coupled with large scale investment in social reform and safety net programmes that supported a narrowing of the income gap (through equitable poverty reduction), rising numbers of girls in school, declining fertility, and greater stability in income flows and food consumption among the poor. Stable food consumption was achieved through food supplementation targeted at mothers and children, and with cash transfers targeted at the poorest groups. All of this was helped by improved stability of governance. Few of these actions focused explicitly on nutrition, but many were driven by a policy agenda called “zero hunger.” Even with recent economic challenges and changes of government, the gains made over past decades persist

• Ethiopia has faced famines many times between the 1980s and the early 2000s. It has also reduced child stunting from 58% in 2000 to <40% by 2014. 18 Although this figure is still unacceptably high, it represents a fall of about 1.2% a year. 19 Ethiopia also increased enrolment and retention of girls in schools during this period, increased agricultural productivity, and implemented a huge employment based safety net (one of the largest social protection programmes in Africa). However, two other important drivers improved nutrition in this period. Firstly, a move by government to treat nutrition as a multisector challenge (met by numerous line ministry responsibilities) and, secondly, improved sanitation, focused on eradicating open defecation, which was a major impediment to health and the retention of nutrients in the diet 18 19

• Bangladesh is a modern nutrition superstar. It emerged from famine in the 1970s. Successive governments have worked alongside an unusually vibrant non-governmental sector to deal with underlying problems and visible symptoms of malnutrition. While service delivery remains generally weak, widespread targeted interventions were combined with a variety of nutritional measures that deal with underlying problems. 20 Such actions included economic growth policies aimed at the poor, girls’ education, improved sanitation, and a significant turnaround in the agricultural sector, which moved Bangladesh from being a net importer of food to a significant exporter. 18 21 As a result, child stunting fell from almost 57% in 1997 to around 36% in 2014 18 19

However, despite such progress the world still has unacceptably high numbers of undernourished people. Of the roughly 800 million undernourished, 780 million are in low income countries, especially in sub-Saharan Africa and South Asia. 1 The continents of Africa and Asia have the greatest number of people living in extreme poverty, and it is here that extreme hunger and poverty together present the greatest risk of famine.

Famine is the most acute face of hunger. Over 70 million people died in famines during the 20th century. 22 23 24 Most deaths occurred in human induced crises, in which political mismanagement, armed conflict, and discrimination of marginalised political or ethnic groups compounded the effects of environmental shocks, such as droughts or locust invasions. 25 Deaths from famine fell from the mid-1980s onwards. However, as of 2017 four countries were again struggling to cope: Somalia, Yemen, South Sudan, and Nigeria. 26 In each case, instability induced by conflict, terrorism, drought and decades of failed governance have left over 20 million people facing famine, including 1.4 million children “at imminent risk of death.” 27

A major cause of mortality in famines is children becoming severely wasted. Around 52 million children were wasted in 2016, of whom around 70% (36 million) resided in Asia ( table 1 ). 14 Roughly 12.6% of deaths among children under 5 are attributed to wasting worldwide. 28 Although wasting has declined, progress has been slow and some countries have seen a rise, including Pakistan and India. 29 Many of the drivers of wasting are often the same as for stunting—namely, low birth weight, lack of exclusive breast feeding, poor hygiene and sanitation, and infectious disease. 30 While wasting is one sign of acute hunger, stunting (being too short for one’s age) represents chronic distress. Around 151 million preschool children were stunted in 2017, down from 200 million at the turn of the 20th century. 14 Improvements were made in east Asia, including China (today reporting a prevalence of only 6% compared with the global mean of 23%) and Bangladesh as well as in Latin America ( table 1 ). 31 Nevertheless, South Asia and East and Central Africa all still had rates over 32% in 2017.

Coexisting forms of malnutrition related to diet

The coexistence of multiple forms of malnutrition is a global phenomenon. That is, wasting often coexists with stunting in the same geographical areas, and can be found simultaneously in children. 32 For example, around 9% of children in India exhibit both conditions, while the rate in parts of Ghana is reported to be >3%. 32 33 Many countries with a high prevalence of stunting have made limited progress in achieving annual average rates of reduction required to meet global targets. For example, Timor Leste needs an annual reduction of around 5% to reduce stunting by 40% by 2030, but its current reduction rate is barely above zero. 9 Ethiopia also needs an annual average rate of reduction of 5%, but continues to remain at 3%.

Part of the reason for slow progress lies in overlapping micronutrient deficiencies. Inadequate supply of energy and protein both impair a child’s growth, but micronutrient deficiencies also have a role. It has been estimated that roughly 2 billion people, or about 29% of the world’s population, faced micronutrient deficiencies in 2010. 34 35 36 37 Micronutrient deficiencies are also widely present in high income countries. For example, childhood anaemia in 2010 was 26% in the Russian Federation and in Georgia, and 16%, on average, across the European Union. 38

Obesity is conventionally associated with food excess, but it is also associated with micronutrient deficiencies and even with daily hunger, as shown for Malaysia, 39 Canada, 40 and Iran. 41 Indeed, people with obesity can be prone to deficiencies of micronutrients, such as zinc, iron, and vitamins A, C, D, and E. 42 43 44 45 46 Between 1990 and 2010, the prevalence of adults with a high BMI in sub-Saharan Africa tripled. At the same time, hypertension increased by 60%, and the prevalence of high blood glucose rose nearly 30%. 47 The prevalence of overweight and obesity among South Asian women is almost the same today as the prevalence of underweight. 6 Pacific and Caribbean islands and countries in the Middle East and Central America have reached extremely high rates of adult overweight and obesity. Some have a prevalence as high as 80% (eg, Tonga, 84% for men, 88% for women). 48

Many countries today face the dual burden of rising rates of female obesity with continuing high rates of maternal underweight. The latter matters because of ill effects on the mother and on the unborn child. Roughly 30% of stunting by a child’s 3rd birthday can be attributed to being born small for gestational age, which is linked to nutrition before birth and health problems of the mother. 28 Not only is maternal underweight still more prevalent than overweight in rural parts of South Asia and sub-Saharan Africa but adult female underweight rose recently in Senegal, Madagascar, and Mali, mainly in urban settings. 49

Thus, actions are needed in all countries around the world to deal with undernutrition, micronutrient deficiencies, and overweight and obesity simultaneously. No country is exempt. “Triple duty” investments are needed everywhere because wealth and food sufficiency will not in themselves resolve the problems of low quality of diets.

Effective actions to tackle hunger and malnutrition

In 2016, the world hit a new record by producing over 2.5 billion metric tons of cereal grains—up from 1.8 billion tons 20 years earlier. 50 But hunger persists because an increased supply of food alone is neither the solution to hunger nor an answer to malnutrition. Countries that have made recent progress in reducing hunger and improving nutrition have a core set of common characteristics. Firstly, they tend to be politically stable countries that have pursued relatively equitable growth policies (not only increasing wealth for some but reducing poverty overall). Secondly, they employ targeted safety nets for the poor and invest in accessible services (education, clean water, healthcare). Thirdly, they assume responsibility for responding to shocks (economic, environmental, or due to conflict) in timely ways that mitigate human suffering.

Successful actions typically include a mix of targeted so called nutrition specific programming (aimed at preventing or resolving defined nutrition and health problems in individuals) and nutrition sensitive interventions for the whole population that deal with the underlying causes. 9 32 35 Table 2 provides details of evidence based policies and programmes in a variety of sectors, which are known to reduce hunger and deal with malnutrition. 32 In food and agriculture, these may include national price support interventions that increase the supply and accessibility of nutrient rich foods (often perishables, like dairy, fruits and fresh meats), coupled with technical and financial support for women farmers to produce nutrient rich vegetables in their gardens. In health, national policies to support accessible high quality services are critical to ensuring antenatal and postnatal care, particularly combined with targeted nutrition, exclusive breast feeding, and infant feeding messaging. Measures directed at underweight mothers are important for good birth outcomes, as well as varied forms of micronutrient supplementation. 1 In other words, the quality of services, scale of coverage, and the singling out of nutritionally vulnerable demographic groups are all keys to success. 20 47

Examples of actions to tackle hunger and malnutrition across sectors 3 20 47 51

Good nutrition and eradication of hunger comes at a price, but pays for itself in the longer term. Donor funding for nutrition sensitive programmes rose between 2003 and 2015, from 11.8% to 19.4%, reaching around $19bn (£14bn, €16bn) in 2015. 48 Such assistance is deemed to be effective, in that a 10% increase in overall nutrition sensitive aid delivers an estimated 1.1% “decrease in hunger” (measured as chronic undernourishment). 48 The World Bank has argued that a “priority package” of evidence based nutritional interventions that could be readily scaled up would require roughly $23bn over a decade, or $5 per child. 51 52 The World Bank emphasises that while international donor agencies should increase spending to achieve global nutrition goals, national governments and citizens themselves need to increase spending and act appropriately. The role of individuals and families comes largely in the form of preferences and constraints. 52 People make choices that shape dietary patterns and physical activity but also the uptake of healthcare services, spending on smoking and hygiene, as well as investments in schooling for their children and agricultural productivity (if farmers).

The value of such large investments to future human and economic development has long been understood in high income countries, such as Europe and the United States. European countries deploy a wide range of policies to combat residual hunger. These include promoting more diverse local food production and diversified diets, the latter “encouraged through nutrition education targeting school children and mothers of young children.” 38 The United States also supports large state food provisioning through nutrition programmes aimed at women and children. For example, spending on the federal food stamp programme in 2017 reached $68bn ($126 per person). 53 Similarly, spending on the Women Infants and Children programme, which targets low income families nutritionally at risk with food supplements, nutrition education, and health system referrals, reached $6.5bn in 2017. 54

Conclusions

The sustainable development goals require all countries and their citizens to act together to end hunger and all forms of malnutrition by 2030. 13 Setting targets is a good first step, but actions need to follow quickly. Urgent attention to achieve such goals is seriously overdue. Policy action must be designed to reduce malnutrition in all its forms, and be adequately funded. Measures must be evidence based, implemented at scale, and include both broad based and targeted actions aimed at the most nutritionally vulnerable people. The evidence to support such actions is growing, but it is already plentiful and compelling; there is no need for delay. The rapidly escalating threats posed by malnutrition represent a planetary challenge on a par with poverty and climate change. An appropriate response at the required scale is top priority for decision makers globally. It cannot wait.

Key messages

  • Despite record levels of food production globally, hunger and many forms of malnutrition still affect billions of people
  • While traditionally associated with a lack of food, hunger, and malnutrition (which includes overweight and obesity as well as undernutrition) are associated with low quality diets
  • Poor diet quality is a problem in every country—high and low income alike. A high quality diet meets most key nutrient needs, mainly through nutrient rich foods
  • Securing high quality diets for all, comprising sufficiency, diversity, balance, and safety, is necessary to resolve hunger and malnutrition in all its forms
  • Policy makers must urgently implement evidence based, cost effective actions that have a triple purpose: eradicate hunger, resolve all forms of undernutrition, and tackle obesity
  • Governments must consider how policies across multiple sectors influence the functioning of food systems from farm to fork. They must identify changes that will help all consumers to have healthy diets
  • The challenge is huge, but the urgency has never been so great

Contributors and sources: The authors have diverse subject expertise and policy experience relating to hunger, food insecurity, diets and nutrition. Some authors have a medical or agriculture background, while others have training and experience in policy analysis, nutrition and humanitarian action. PW and GAS were both members of the Global Futures Council on Food Security and Agriculture of the World Economic Forum. PW and AL advise the Global Panel on Agriculture and Food Systems for Nutrition. SS is a contributing author to the upcoming EAT Lancet Commission on Healthy Diets from Sustainable Food Systems. Data used are all in the public domain, and are derived from nationally representative surveys, United Nations agency analyses, or peer reviewed publications. PW, GAS and AL were involved in manuscript concept and design. All authors were involved in drafting and editing the manuscript; critically revised the manuscript for important intellectual content and approved the final manuscript and the authorship list. PW is the guarantor.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: Commissioned; externally peer reviewed.

This article is one of a series commissioned by The BMJ . Open access fees for the series were funded by Swiss Re, which had no input into the commissioning or peer review of the articles. The BMJ thanks the series advisers, Nita Forouhi and Dariush Mozaffarian, for valuable advice and guiding selection of topics in the series.

Sports Nutrition for Optimal Athletic Performance and Health: Old, New and Future Perspectives

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  • Published: 06 November 2019
  • Volume 49 , pages 99–101, ( 2019 )

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This supplement examines several sports nutrition topics related to the optimisation of athletic performance and health. Some of the research areas have been examined for many years but are presently being examined with new methods and perspectives, while others are very new and some may be seen as approaches for the future. The authors have provided an excellent explanation of these new approaches and perspectives, as well as outlining where additional sports nutrition research is needed—especially with athletic populations and the long-term health of athletes. This collection of papers makes it very clear how important adequate nutrition is to the performance and well-being of athletes and how far reaching the negative effects of low energy availability can be, with these topics being discussed in five out of the eight papers in this supplement.

The Gatorade Sports Science Institute (GSSI) has been bringing sports nutrition and sports science researchers together for over 30 years to address and discuss many topics that relate to the health and performance of athletes. Since 2012, these meetings have been known as the GSSI Expert Panel. The latest meeting in March of 2019 was held to discuss old, new and future perspectives related to athlete nutritional, performance and health issues. Following the meeting, the authors summarized the recent work in their topic area, resulting in the manuscripts in this Sports Medicine supplement (the seventh in a series supported by GSSI).

The initial two papers highlight areas relevant to athletic performance that are difficult to study—does hypohydration really impair endurance performance [ 1 ] and what causes muscle cramping [ 2 ]? In the former situation, how does the experimenter effectively blind the research subject from knowing their hydration status? In addition, inducing hypohydration can be uncomfortable and unfamiliar to the subjects, with both problems potentially leading to performance decrements that are unrelated to hypohydration. The authors discuss recent attempts to rectify these problems using blinded hydration methods and conclude that hypohydration of ~ 2–3% body mass decreases endurance cycling performance in the heat, at least when no/little fluid is ingested [ 1 ]. In the muscle cramping situation, the authors have carefully described that water and salt balance are involved in cramping, using data from early studies in industrial settings with many subjects and also more recent work with smaller numbers of athletes [ 2 ]. In other situations, however, sustained abnormal spinal reflex activity seems to be the cause. Since no laboratory experimental models appear to be applicable to whole body exercise situations where muscle cramps occur, the authors argue that a single strategy for prevention or treatment will not be found.

In the next paper, De Souza et al. [ 3 ] provide a brief overview of the Female Athlete Triad and an update on the current thinking regarding energy availability. They also discuss the available literature relevant to a similar syndrome in males that is referred to as the Male Athlete Triad. To date, it appears that the energetic, reproductive and bone systems in men are more resilient to the effects of low energy availability compared to those of women, requiring more severe perturbations before alterations are observed. In addition, recovery of the hypothalamic pituitary gonadal axis occurs more quickly in men than in women. However, far more research with males experiencing low energy availability is needed.

The paper on nutrition and athlete bone health [ 4 ] also stresses the need for more athlete-specific research, especially as it relates to longer-term bone health (e.g., risk of osteopenia and osteoporosis) and shorter-term risk of bony injuries. Bone is a nutritionally modified tissue and generally benefits from weight-bearing activities, although not all athletes engage in weight-bearing sports. While nutritional requirements to support bone health may not be different between athletes and the general population, the authors highlight situations that may be relevant for athletes, including low energy availability, low carbohydrate availability, protein intake, vitamin D intake and dermal calcium and sodium losses. The paper by Walsh [ 5 ] outlines a new perspective on nutrition and athlete health to better understand how sick an athlete will become when they get an infection. This paradigm includes the concepts of immune resistance (destroying microbes) and immune tolerance (dampening defence but controlling infection to a non-damaging level). It also suggests that research efforts on nutritional supplements that may provide immunological tolerance and reduce the infection burden in athletes are needed.

The paper on nutrition and health at altitude [ 6 ] has been written by several scientists renowned for their work examining strategies to enhance adaptation, improve performance and maintain health in athletes living and training at low-to-moderate altitudes (1600–2400 m). Much of the existing altitude research was conducted at high to extreme altitudes (> 3000 m) and not the lower altitudes that athletes typically train at. While the authors highlight several nutritional issues that must be monitored at altitude, they stress that special attention must be given to the possibility of poor energy availability and increased iron requirements limiting the adaptations to altitude. Also, to deal with the possibility of increased oxidative stress at altitude, foods rich in antioxidants are recommended rather than high-dose antioxidant supplements.

The final two papers examine approaches to athlete nutrition and performance that might be called futuristic. The examination of blood test data, as a physiological profiling and monitoring tool, is becoming more routinely used in professional and elite high-performance athletes [ 7 ]. Much useful information can be obtained from blood tests, including the identification of iron, vitamin and energy deficiency, the identification of oxidative stress and inflammation status and the characteristics of red blood cell populations. Such data can be used to identify the effectiveness of training interventions, nutritional strategies and training load tolerance. The authors discuss perspectives, limitations and recommendations for sports science and sports medicine practitioners, who may use athlete blood profiling and monitoring for nutrition and performance purposes. In the final paper, Joyner [ 8 ] discusses the physiological determinants of human endurance performance, maximal oxygen uptake, the lactate threshold and running economy or effciency. He examines the genetics of endurance performance, as many of us may assume that individual differences in our genetic endowment would account for differences in endurance performance. However, he concludes that at present, interindividual differences in DNA sequence explain only a small fraction of the physiology underpinning sports performance.

The papers of this supplement have identified several areas of sports nutrition research that need to be studied or restudied to optimize sports performance and health for athletes. While we study groups of athletes, it is also clear that there are large individual variations between athletes and that we lack research in many areas for female athletes and in some cases male athletes. It is hoped that these papers have provided interesting perspectives on old, new and future areas of sports nutrition research and will spur additional research in these areas.

James LJ, Funnell MP, James RM, Mears SA. Does hypohydration really impair endurance performance? Methodological considerations for interpreting hydration research. Sports Med. 2019. https://doi.org/10.1007/s40279-019-01188-5 (Suppl) .

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Maughan RJ, Shirreffs SM. Muscle cramping during exercise: causes, solutions and questions remaining. Sports Med. 2019. https://doi.org/10.1007/s40279-019-01162-1 (Suppl) .

De Souza MJ, Koltun KJ, Williams NI. The role of energy availability in reproductive function in the female athlete triad and extension of its effects to men: an initial working model of a similar syndrome in male athletes. Sports Med. 2019. https://doi.org/10.1007/s40279-019-01217-3 (Suppl) .

Sale C, Elliott-Sale KJ. Nutrition and athlete bone health. Sports Med. 2019. https://doi.org/10.1007/s40279-019-01161-2 (Suppl) .

Walsh NP. Nutrition and athlete immune health: new perspectives on an old paradigm. Sports Med. 2019. https://doi.org/10.1007/s40279-019-01160-3 (Suppl) .

Stellingwerff T, Peeling P, Garvican-Lewis LA, Hall R, Koivisto AE, Heikura IA, Burke LM. Nutrition and altitude: strategies to enhance adaptation, improve performance and maintain health: a narrative review. Sports Med. 2019. https://doi.org/10.1007/s40279-019-01159-w (Suppl) .

Pedlar CR, Newell J, Lewis NA. Blood biomarker profiling and monitoring for high performance physiology and nutrition: current perspectives, limitations and recommendations. Sports Med. 2019. https://doi.org/10.1007/s40279-019-01158-x (Suppl) .

Joyner MJ. Genetic approaches for sports performance: how far away are we? Sports Med. 2019. https://doi.org/10.1007/s40279-019-01164-z (Suppl) .

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Acknowledgements

This supplement is supported by the Gatorade Sports Science Institute (GSSI). The supplement was guest edited by Dr. Lawrence L. Spriet, who attended a meeting of the GSSI Expert Panel in March 2019 and received honoraria from the GSSI, a division of PepsiCo, Inc., for his participation in the meeting and the writing of this preface. Dr. Spriet received no honorarium for guest editing the supplement. Dr. Spriet suggested peer reviewers for each paper, which were sent to the Sports Medicine Editor-in-Chief for approval, prior to any reviewers being approached. Dr. Spriet provided comments on each paper and made an editorial decision based on comments from the peer reviewers and the Editor-in-Chief. Where decisions were uncertain, Dr. Spriet consulted with the Editor-in-Chief.

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  12. [PDF] Artificial intelligence in nutrition research: perspectives on

    Artificial intelligence in nutrition research: perspectives on current and future applications. Mélina Côté, B. Lamarche Published in Applied physiology, nutrition… 15 September 2021 Medicine, Computer Science, Agricultural and Food Sciences Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme TLDR

  13. Nutrition Research

    About the journal. Original research articles presenting hypothesis-driven studies performed in humans, or in animal models or cellular systems with physiological relevance to humans. Narrative and systematic reviews and meta-analyses focusing on fundamental and applied nutrition. Research methodology and study design of human clinical trials.

  14. Nutrition Perspectives Research Paper

    1 Nutrition Perspectives (Research Paper) Cassy L. Boyd NUTR 1020 Salt Lake Community College 2021 f 2 Abstract In this paper, I will be exploring the concepts of the book, In Defense of Food: An Eater's Manifesto, written by Michael Pollan. I will also be presenting information about the

  15. Frontiers in Nutrition

    Editorial: Sugar reduction strategies in foods: sensory, nutritional and safety evaluation. Dipendra Kumar Mahato. Emmanuela Magriplis. Nitya Sharma. Shirani Gamlath. Frontiers in Nutrition. doi 10.3389/fnut.2024.1370781. Perspective. Published on 07 Feb 2024.

  16. Nutrition Perspectives Research Paper

    nutrition perspectives research paper - Free download as PDF File (.pdf), Text File (.txt) or read online for free. Scribd is the world's largest social reading and publishing site.

  17. Sports Nutrition for Optimal Athletic Performance and Health ...

    The paper on nutrition and athlete bone health [] also stresses the need for more athlete-specific research, especially as it relates to longer-term bone health (e.g., risk of osteopenia and osteoporosis) and shorter-term risk of bony injuries.Bone is a nutritionally modified tissue and generally benefits from weight-bearing activities, although not all athletes engage in weight-bearing sports.

  18. Nutrition Perspectives Research Paper

    Nutrition Perspectives Research Paper - Supersize Me. For my Research Report, I chose to analyze the documentary Supersize Me. I chose this. documentary because topics about eating experiments interest me, such as thirty days or a week. of food challenges on YouTube. I've also heard of this documentary before in middle school,

  19. Nutrition Perspectives Paper

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