Hidden Hunger 1

Abstract

Malnutrition affects 42 million people in the United States. (Hunger Fight, n.d.) It costs

the country $15.5 billion in healthcare costs and accounts for one-third of all hospitalizations

which makes malnutrition a major public health concern. (Castellucci, 2016) Food insecurity is

the reason that malnutrition is such a widespread yet silent problem. (World Food Programme,

n.d.) The diseases caused by malnourishment can be subdivided into micronutrient deficiencies

and protein-energy deficiencies (Muller,O. & Krawinkel, M., 2005) To test the effects of a

healthy plant-based diet on malnutrition, one nutritious meal a day, three times a week, for six

months, was provided for a group of 215 participants (ages 18-72). Health and wellness tests

were performed monthly to record changes in overall state of health, specifically focusing on

micronutrient levels and waist circumference. Results demonstrated a consistent, steady increase

in micronutrient levels in all participants with ranges below normal at the beginning of the study

and concluding well within normal levels. Waist circumference showed a gradual decrease over

the six months in all participants who were overweight. The sweeping decrease in malnutrition

seen throughout the six-month longitudinal study confirms that the implementation of a

nutritious, plant-based diet improves public health. In order to address the issue of food

insecurity that leads to malnutrition, legislative changes were proposed to ban food waste in the

United States and to provide more government subsidies for specialty crop farmers.
Hidden Hunger 2

When speaking of malnutrition, the image of a skeletal child in a third world country is

recalled for most. In reality, that is not always the case. This vast misconception allows the

problem to be ubiquitous yet remain unknown, even in the United States. The real definition of

malnutrition is an insufficient, excessive, or imbalanced consumption of nutrients and the root

cause can be traced back to food insecurity. (Nordqvist, n.d.)

Food insecurity is not being able to access enough food or nutritious enough food to

maintain health. (World Food Programme, n.d.) Food security is measured by three values: food

availability, access to food, and food utilization. In 2015, almost 16 million homes in the United

States were considered food insecure. (“Definitions of Food Security” n.d.) To put it in

perspective, that is equal to 59.5 million people living with hunger or about 19% of the United

States’ population. (“Definitions of Food Security” n.d.) Because of this, a variety of nutritional

imbalances and conditions develop every day in the population of the United States. The

following will focus primarily on the insufficient consumption of nutrients or undernourishment.

In some rural towns like Jonestown in Mississippi, families sometimes go weeks without

eating a fresh fruit or vegetable because there are none available. (A Place at the Table, 2012) In

Jonestown, only one supermarket has a small selection of fresh fruits and vegetables at high

prices which most people cannot afford on their meager budgets. Any fruits or vegetables that

are available come in cans and the nearest supermarket that does offer a large, varied selection of

fresh fruits, vegetables, and healthy products is thirty-three miles away. (A Place at the Table,

2012) The lack of food availability and difficulty of accessing the necessary healthy foods make

many towns like this one food insecure.

At first glance however, Mississippi may not appear to have a problem with food

availability as they also have the highest rate of obesity in the country. (A Place at the Table,
Hidden Hunger 3

2012) This can be attributed to the fact that people are basically forced to eat empty calories.

They do not have access to affordable, nutritious foods. While they may be eating a lot calorie-

wise, they may not be eating enough of the foods that they need, resulting in obesity along with

other dietary deficiencies which will be discussed.

The type of malnutrition each person suffers from is based on which nutrient or mineral

their diet is missing. The diseases caused by malnourishment can be divided into two types –

those caused by protein-energy deficiency and those caused by micronutrient deficiencies.

(Muller, O., & Krawinkel, M. 2005) Marasmus and kwashiorkor are diseases caused by protein-

energy deficiencies in the diet. Anemia, goiter, pellagra, scurvy, rickets, and beriberi are diseases

caused by the lack of micronutrients being consumed. (Muller, O., Krawinkel, M. 2005)

Marasmus occurs when not enough protein and calories are consumed. The signs of

marasmus include being severely underweight, lethargic, dry skin, saggy skin around the

buttocks and thighs, and brittle hair. Having this disease puts the person at a higher risk for other

conditions such as infections, hypoglycemia, diarrhea, cognitive deficiencies (in children), and

stunted growth. (“Marasmus Treatment & Management” 2017) Blood and fecal tests can be

performed to determine if there is any additional infection or parasites. Usually, the clinical

observation is enough to diagnose the condition. (“Marasmus Treatment & Management” 2017)

Kwashiorkor is a severe protein deficiency. It differs from marasmus in that there may be

an adequate intake of calories but not enough protein. (“Kwashiorkor” 2017) Signs of

kwashiorkor include a skeletal appearance with areas of edema such as the ankles, belly, and

feet, dry hair, brittle hair, loss of hair, diarrhea, lethargy, rash, fatigue, irritability, increased

immune susceptibility, and shock. (“Kwashiorkor” 2017)

Hidden Hunger 4

Anemia is a micronutrient deficiency of iron, folate, or vitamin B12. Signs and symptoms

of this disorder may be fatigue, weakness, pale or yellow skin, arrhythmias, headaches, dyspnea,

and dizziness. Iron, folate, and vitamin B12 is required by the body to make hemoglobin and

healthy red blood cells. When these nutrients are missing in the diet, the body may not be able to

make enough red blood cells which results in all the signs and symptoms associated with the

disease. (“Symptoms and Causes” n.d.) An effective method of prevention for both protein-

energy deficiencies and anemia include having a protein rich diet including beans, lentils,

edamame, tofu, peas, quinoa, steak, turkey, and chicken.

A goiter is caused by an iodine deficiency. Iodine is used by the thyroid gland to make

thyroid hormones: thyroxine (T4) and triiodothyronine (T3). (“Goiter” n.d.) Therefore, with an

iodine deficiency the thyroid cannot make enough thyroid hormones resulting in hypothyroidism.

Thyroid hormones are responsible for regulating the body’s metabolism. The pituitary gland acts

as a feedback mechanism for the thyroid. When the levels of thyroid hormone are too low, the

pituitary releases thyroid stimulating hormone (TSH) to stimulate the thyroid to convert more

iodine into thyroid hormones. TSH also stimulates the thyroid to grow. Once adequate levels of

the hormones are reached, the pituitary stops the release of TSH and the thyroid remains

inactive. In hypothyroidism, TSH continues to be released, overstimulating thyroid growth

resulting in the enlarged appearance of the thyroid gland in the neck. Signs and symptoms of a

goiter are a feeling of pressure in the throat, coughing, and hoarse voice. (thyroid.org) Iodine can

be found in kelp, cranberries, navy beans, strawberries, potatoes, and cheese.

Pellagra is a vitamin B3 (niacin) or tryptophan deficiency. Tryptophan helps the body

make niacin and serotonin. Niacin in turn is responsible for helping to convert food to glucose,

helps to synthesize sex hormones and stress hormones in the adrenal glands, helps improve
Hidden Hunger 5

circulation and suppress inflammation. (“Vitamin B3” n.d.) Signs and symptoms of pellagra are

indigestion, fatigue, vomiting, poor circulation, cracked, dry skin, dementia, and diarrhea.

(Vitamin B3 n.d.) Some sources of niacin in the diet are mushrooms, green peas, turkey, fish,

milk, eggs, and peanuts.

Scurvy is a severe vitamin C deficiency. It causes fatigue, anemia, gum disease, purpura,

skin ulcers, nose bleeds, decreased ability to fight off infection, and broken bones. (A Nightmare

Disease Haunted Ships During Age of Discovery 2017) Vitamin C is essential for the body’s

tissues to grow and repair themselves. It helps the body produce collagen which is a building

block of skin, cartilage, tendons, ligaments, and blood vessels. Without it, the impact on the body

is profound. (“Vitamin C” n.d.) Testing the plasma ascorbic acid level may be helpful in

establishing a scurvy diagnosis. (“Scurvy Workup” 2017) Vitamin C is exclusively from plant

sources - mainly citrus fruits, bell peppers, dark, leafy greens, kiwi, broccoli, tomatoes, and

papaya.

Rickets is a severe vitamin D deficiency which results in the softening and weakening of

bones. Other signs and symptoms of rickets may be muscle weakness, pain in the back or legs,

and stunted growth. Vitamin D is essential in helping the body absorb calcium and phosphorus.

The lack of vitamin D results in the body not being able to maintain healthy bone composition.

Bone x-rays can confirm if any bone deformities are present. (“Overview” n.d.) The body makes

vitamin D when exposed to sun but can also be found naturally in salmon, tuna, or enriched

foods such as milk, some cereals, yogurts, orange juice, and mushrooms that have been exposed

to UV light.

Beriberi is a vitamin B1 (thiamine) deficiency. Thiamine helps to catabolize

carbohydrates into energy for the brain and nervous system. It also functions to conduct nerve
Hidden Hunger 6

signals, help with muscle contraction, and in pyruvate metabolism. A person suffering from this

disease may have trouble in many motor functions such as walking, feeling numbness, tingling,

vomiting, nystagmus, speech difficulties, paralysis of the lower legs, increased heart rate and

swelling of the lower legs. The signs and symptoms depend on which form of beriberi the person

is afflicted with. The two types of beriberi are wet or dry. The wet beriberi affects the

cardiovascular system while the dry beriberi affects the nervous system. (“Beriberi” n.d.) Blood

and urine tests may be done to check for thiamine levels. Thiamine can be found in rice, oranges,

oats, nuts, peas, and legumes.

For several of these conditions, the examinations are similar. A physical exam may be

done to detect hepatomegaly which is indicative of the metabolic disorder. Arterial blood gas test

may be ordered to measure lung function, kidney function, and to detect the presence of any

metabolic disorders. A blood, urea, nitrogen (BUN) test helps to check kidney function. A

complete blood count helps to monitor and check for numerous conditions and complications

that may accompany or arise from kwashiorkor such as anemia, infections, kidney failure, etc.

Creatinine clearance test and creatinine blood test may help to check kidney function. A

potassium test may be ordered to check kidney function and metabolic efficiency. A total protein

test checks for normal levels of protein in the blood. Low levels are indicative or malnutrition. A

urinalysis can also check for hyperglycemia, kidney function, infections, etc.

Treatment depends on the severity of the condition but is similar for both protein-energy

deficiencies and anemia. It must be gradual to prevent complications. (Hearing, S.D., 2017,

p.908-909) In any case where starvation is present, the body begins to catabolize fat reserves for

energy instead of catabolizing carbohydrates as usual which signals the body to slow the

metabolism including the production of insulin. While the body is under stress, aldosterone, a
Hidden Hunger 7

hormone, is released which promotes the retention of sodium and water, while potassium and

phosphate are lost. Phosphate is essential in the production of ATP at the cellular level and for

smooth and skeletal muscle contraction (Duggan, C., Watkins, J. B., & Walker, W. A., 2009,

p.129)

If a person with severe malnutrition under these conditions is fed very rich and high

calorie foods all at once, the body faces complications in switching from fat metabolism to

carbohydrate metabolism. The rapid ingestion of food would promote insulin secretion and

cellular uptake of already low levels of phosphate for use in digestion. Hypokalemia can result in

respiratory failure, cardiac failure, arrhythmias, seizures, and sudden death. This fatal

phenomenon is known as refeeding syndrome. It was first described in the cases of severe

malnutrition seen in the war prisoners of World War II after they were fed large amounts of food

after their starvation. (Hearing, S.D., 2017, p.908-909).

To avoid refeeding syndrome, restoring these electrolyte balances and rehydration are

often the first step of treatment through oral rehydration solutions (ORSs). If there is any

infection, the appropriate antibiotics or anti-parasitic medicine should be administered

simultaneously. Electrolyte levels are monitored constantly for the first four days after refeeding

has commenced. Intravenous phosphate is administered and feedings are small and often, every

few hours until caloric needs are met. (Hearing, S.D., 2017, p.908-909)

Treatment for micronutrient deficiencies is not so rigorous and mostly involves just

reintroducing the missing vitamin or nutrient into the diet. Prevention of the micronutrient

deficiencies includes maintaining a healthy, balanced diet with generous fresh fruits, vegetables,

nuts, seeds, beans, and whole grains.

Hidden Hunger 8

Of these conditions, anemia and micronutrient deficiencies are most common in the

United States because of food insecurity. (“Parentingliteracy.com” n.d.) Populations that are at

an elevated risk are those who live in food insecure areas. (“Definitions of Food Security” n.d.)

Other conditions such as cancer, burn victims, and people that have existing metabolic diseases

are at risk for developing some form of malnutrition. Cancer and burn victims are at risk because

as bodies repair themselves they require a higher than normal caloric and micronutrient intake.

Awareness is the key to prevention for malnutrition.

The highest rate of food insecurity in the entire United States can be found in Apache

County, Arizona, where the population is predominantly Native American. Almost 42% of

Apache County is considered food insecure. (Scalise, 2016) This is a common trend among

Native American reservations nationwide. (Lee, 2016) Many of the residents in the reservation

suffer from obesity, diabetes, heart disease, and other nutritional deficiencies because of

consuming mainly processed, unhealthy food. (Apache County Public Health Services District

2015) These factors make Apache county a perfect location to perform a longitudinal study on

the beneficial effects of nutrition on an individual’s health.

In order to demonstrate the significant impact a nutritious diet can have on health,

nutrient-dense meals were provided once a day, three times a week over the course of six months

for the 215 willing participants of the most food insecure population in the country. The

participants received a full physical examination with laboratory work to evaluate and record

their initial health. Changes in the participants’ overall health were then measured and evaluated

at the end of the study for comparison.

For this experiment, the independent variable was the adjusted diet (the provided meals).

The dependent variables were the nutritional imbalances that were monitored which were
Hidden Hunger 9

anemia, scurvy, pellagra, and obesity. Because this study is done on an at-will basis for a group

of people that are in need, it was determined by the Institutional Review Board to be unethical to

provide nutritious foods to one group while depriving another group of the same opportunity at

the cost of their health. For this reason, the control group was the collective set of data consisting

of the participants’ initial health exam results. The experimental group was made up of the

participants – 215 in total, ages 18-72. There was no inclusion criteria, participants were allowed

to participate as long as they were willing.

The materials that were used for the experiment were the 215 participants who were fed

nutritious meals, a kitchen to heat up the meals, a cafeteria, the meals provided, a laboratory to

perform physical examinations and to analyze the blood work of participants. Plant- based meals

were chosen because they are rich in all essential vitamins and nutrients. (Russell, T., 2017)

Three meal options were provided: sweet potato chili, vegetarian ajiaco, and vegetarian refried

bean tacos. For the sweet potato chili the ingredients needed are: cooking oil, red bell peppers,

green peppers, onions, sweet potatoes, garlic cloves, salt, pepper, chili powder, cumin, red

pepper flakes, dried basil, bay leaves, tomatoes, vegetable stock, black beans, and jalapeno. For

the vegetarian ajiaco, the ingredients are: potatoes, carrots, peas, navy beans, corn, vegetable

stock, salt, pepper, and cilantro. For the vegetarian refried bean tacos, the ingredients used were:

black beans, garbanzo beans, water, olive oil, cumin, ground coriander, paprika, chili powder,

salt, garlic, sweet peppers, corn tortillas, onion, spinach, vegan cheese, lime juice, and cilantro.

The portions of all ingredients were calculated for 215 servings.

For the physical examinations and blood tests for the participants, the following was

needed: tape measure to evaluate waist circumference, scale to weigh participant, height chart to

measure stature, blood tests for anemia– complete blood count (CBC) to measure hemoglobin,
Hidden Hunger 10

hematocrit, and ferritin, tests for scurvy– physical examination for usual signs and symptoms and

blood test for serum ascorbic acid levels, tests for pellagra- physical examination for

characteristic signs and symptoms and blood tests to measure serum levels of niacin and

tryptophan.

One dinner was provided a day, three times per week over the period of six months in a

cafeteria. To measure the effect of diet on micronutrient malnutrition, consistent attendance to

the meals was crucial. The participants were accounted for by showing photo ID at the entrance

to keep track of attendance. To mark the beginning of the study, physical examinations and

blood work was done on all participants for reference. At the end of the study, the same

examinations were performed on all subjects and the results were compared to the initial results.

Waist Circumference (in inches)

50
40
30
20
10
0
Initial Avg Month 2 Avg Month 3 Avg Month 4 Avg Month 5 Avg Final Avg
Waist Circumference (in inches)

The most notable difference that was the decrease in waist circumference by the end of

the study. The above chart shows how the average waist circumference decreased over time. The

average waist circumference at the beginning of the study was 43 inches. At the end of the six

months, the average waist circumference amongst the participants went down to 35 inches.

The blood test results also showed a great improvement across all values.
Hidden Hunger 11

The preceding table lists all the tests, in the first column, that were performed on the test

subjects along with their corresponding normal ranges for reference. The tests with their normal

ranges, in order from top to bottom are: RBC– 4.2-6.2 mill/mm3, Hemoglobin- 12-17.5 g/dL,

Hematocrit- 35%-50%, Ferritin- 18-270 mcg/L, Ascorbic Acid- 0.6-2 mg/dL, and Niacin- 0.5-

8.45 ug/mL. (Pathophysiology 2013 p.256-260; Mayo Clinic 2016) The second column shows

the initial average amongst the 215 participants for each test from the beginning of the study.

The numbers that are written in red are considered low when compared to the normal range. The

initial average results are as follows, RBC- 4.1 mill/mm3, Hemoglobin- 10 g/dL, hematocrit-

33%, ferritin- 20 mcg/L, ascorbic acid- 0.7 mg/dL, niacin- 2 ug/mL. The last column shows the

average of all the results of the final blood work for each test. The results written in green are

indicative of normal levels according to the normal ranges. The results for the blood tests taken

at the end of the study are: RBC- 6.0 mill/mm3, hemoglobin- 17 g/dL, hematocrit- 49%, ferritin-

220 g/mL, ascorbic acid- 1.9 mg/dL, niacin- 8 ug/mL.

At the beginning of the longitudinal study, the population was averaging on the low end

of the normal ranges for almost all values. At the end of the six-month study however, all the

values were well within the normal range.

Hidden Hunger 12

Throughout the six month long experimental study, health and wellness tests were

performed every month on all 215 participants. At the beginning of the longitudinal study, the

population was averaging on the low end of the normal ranges for all values. At every juncture,

the average results showed improvement from the previous tests for: red blood cell count,

hemoglobin, hematocrit levels, ferritin, ascorbic acid, niacin, and vitamin A. At the end of the

six-month study, all values were well within the normal range. This research data could also aid

colleagues who are working towards finding successful treatments for different types of

malnourishment or even for research on how a nutrient-dense, plant-based diet can reduce the

risk of many serious diseases such as heart disease, type 2 diabetes, and high blood pressure.

(Nutrition Facts, 2016)

This research is already being used by colleagues to benefit the environment. One of the

public health educators from the Environmental Protection Agency (EPA) is using this research

to encourage the implementation of community gardens. Community gardens aim to improve

public health, mostly in places where there is food insecurity, while simultaneously benefitting

the environment. By incorporating fruit and vegetable gardens into the community where they

can be shared by everyone, nutritious produce would be more accessible for members of the

community and the environment would be positively impacted. (American Community Garden

Association, n.d.).

Although food insecurity and malnutrition in France is only seen in 5% of the population,

less than half the percentage of the United States’ rate, France makes food security a priority.

(Knoema, 2016) In 2016, France passed a law that would require supermarkets larger than 4000

square feet to donate all food that was still usable but would usually be disposed of. (Frej, 2016)

Instead, supermarkets must donate or compost their unsold, nearly-expired products or pay a
Hidden Hunger 13

hefty fine that ranges from about $4,200-$84,000 or two years in jail. (Gore-Langton, 2017)

Those who comply are compensated with a tax incentive of 60% of the eligible food value.

(Mourad, 2015) Carrefour, a large chain retailer in France, alone donates the equivalent of about

320,000 meals a year to local charities. (Bryant, 2016)

63 million tons of food are wasted every year in the United States. (ReFED, n.d.) Yet,

12.7% of the country’s population- that is 42 million people - are suffering from food insecurity.

(Hunger Fight, n.d.) Enforcing laws like France’s food waste law would make a tremendous

difference in lowering the United States’ food insecurity rate. The bill would require any

supermarket over 4,000 square feet to sign contracts with local charities to donate unsold food.

Donations could benefit soup kitchens, homeless shelters, or other hunger-fighting charities that

make meals available to low-income and struggling families.

Reducing food waste would not only benefit the public but the environment as well. Food

waste releases methane as it decomposes. (Environmental Protection Agency, 2016) Methane is

a greenhouse gas that is about 20 times more potent than carbon dioxide in terms of retaining

heat in the atmosphere. (Jones, 2016) It is estimated that food waste contributes 1.5% of all

greenhouse gas emissions in the United States which is equal to 135 million tons of gases.

(Barclay, 2011) Therefore, reducing the amount of food waste would also benefit the

environment by reducing the country’s carbon footprint.

Another proposed legislation that would help to reduce malnutrition in food deserts is to

encourage an increase in Community Supported Agriculture (CSA) by providing subsidies for

farmers who run the CSA farm. A Community Supported Agriculture farm is a type of farm that

allows local people to become a “member” of the farm by contributing money (amount is

determined by the farmer) in exchange for a “share” of the harvest from the farm. (Just Food,
Hidden Hunger 14

n.d.) The money collected from members is used to cover the costs of maintaining the farm,

buying equipment, buying seeds, making repairs if necessary, etc. (Just Food, n.d.) CSA farms

benefit communities and help to prevent malnutrition by making fresh, locally-grown produce

available to members of the community who choose to participate. Some CSA farms may even

offer eggs, meat, and flowers as part of each member’s share. (Just Food, n.d.) CSAs make

having a wholesome diet easier because fresh, nutritious food choices are readily available.

Current legislation provides many incentives for commodity crop farming, which is

harmful for the public and for the environment. (Food and Water Watch, 2015) Commodity

crops are corn, soy, and wheat, which are widely used for highly-processed, harmful foods.

(Food and Water Watch, 2015) Fruits, vegetables, nuts, dried fruits, culinary herbs and spices,

and more that are used for food, medicine, and even for aesthetic purposes are considered

specialty crops. (USDA, n.d.) Providing greater subsidies for small farmers such as those who

run CSA farms would be steering the agricultural policies of the country in a direction that favors

the production of specialty crops rather than commodity crops, thereby increasing the availability

of healthy, affordable food for more people.

Currently, malnutrition costs the healthcare industry about $15 billion a year and

accounts for one-third of all patients admitted to hospitals. (Castellucci, 2016) The goal of these

legislative changes is ultimately to improve public health and decrease the rate of malnutrition in

the United States. With these changes, obtaining one nutritious meal once a day, three times a

week would be more realistically obtainable even for those located in food deserts such as the

participants who were part of the longitudinal study, improving public health, reducing

healthcare costs and hospitalization, and benefitting the environment.

Hidden Hunger 15

References

American Community Gardens Association. (n.d.). Growing Community Across the U.S. and

Canada. Retrieved from https://communitygarden.org/mission/

A Nightmare Disease Haunted Ships During Age of Discovery. (2017, April 14). Retrieved from

http://news.nationalgeographic.com/2017/01/scurvy-disease-discovery-jonathan-lamb/

Apache County Public Health Services District (2015). COMMUNITY HEALTH

IMPROVEMENT PLAN FINAL ANALYSIS (Rep.). Retrieved from

http://www.co.apache.az.us/wp-content/uploads/2015/09/CHIP.pdf

Barclay, E. (2011, October 07). How That Food You Throw Out Is Linked To Global Warming.

Retrieved from http://www.npr.org/sections/thesalt/2011/10/07/141123243/how-that-

food-you-throw-out-is-linked-to-global-warming

Beriberi. (n.d.). Retrieved from https://medlineplus.gov/ency/article/000339.htm

Bryant, E. (2016, April 19). France battles food waste by law | DW Environment | DW |

19.04.2016. Retrieved from http://www.dw.com/en/france-battles-food-waste-by-law/a-

19148931

Castellucci, M. (2016, September 23). Malnutrition causes $15.5 billion in healthcare spending

per year. Retrieved from

http://www.modernhealthcare.com/article/20160923/NEWS/160929940

Copstead, L. E., & Banasik, J. L. (2013). Pathophysiology. St. Louis, MO: Elsevier.

Duggan, C., Watkins, J. B., & Walker, W. A. (2009). Nutrition in pediatrics basic science,

clinical applications. Shelton, CT: PMPH.

Environmental Protection Agency. (2016, July 26). America's Food Waste Problem. Retrieved

from https://www.epa.gov/sciencematters/americas-food-waste-problem
Hidden Hunger 16

Food and Water Watch. (2015, October 21). Farm Bill 101. Retrieved from

https://www.foodandwaterwatch.org/insight/farm-bill-101

Frej, W. (2016, February 05). It's Now Illegal For Supermarkets To Waste Food In France.

Retrieved from http://www.huffingtonpost.com/entry/france-supermarkets-food-

waste_us_56b4ba4de4b04f9b57d93f53

Gore-Langton, L. (2017, March 24). France's food waste ban: One year on. Retrieved from

http://www.foodnavigator.com/Policy/France-s-food-waste-ban-One-year-on

Goiter. (n.d.). Retrieved from http://www.thyroid.org/goiter/

Hearing, S. D. (2004). Refeeding syndrome: Is underdiagnosed and undertreated, but treatable.

BMJ : British Medical Journal, 328(7445), 908–909.

Hunger Fight. (n.d.). About HungerFight.org. Retrieved from

http://hungerfight.org/about-us/about-hunger-fight?

gclid=EAIaIQobChMIy6aClZf90wIVUFt-

Jones, E. (2016, July 15). EPA Issues Final Actions to Cut Methane Emissions from Municipal

Solid Waste Landfills. Retrieved from https://www.epa.gov/newsreleases/epa-issues-

final-actions-cut-methane-emissions-municipal-solid-waste-

landfillsCh0aoQ9eEAAYAiAAEgIiHvD_BwE

Just Food. (n.d.). WHAT IS CSA? Retrieved from http://www.justfood.org/csa

Knoema. (2016, June 19). Global Food Security Index, 2016. Retrieved from

https://knoema.com/GFSIEIU2015R1/global-food-security-index-2016?

country=1000350-france

Lee, T.H. (2016, July 12). 7 Foods That Cost More on the Rez, and One Junk Food That Costs

Less. Indian Country Today. Retrieved from

Hidden Hunger 17

https://indiancountrymedianetwork.com/culture/health-wellness/7-foods-that-cost-more-

on-the-rez-and-one-junk-food-that-costs-less/

Mayo Clinic (2016, October 18). Complete Blood Count (CBC). Retrieved from

http://www.mayoclinic.org/tests-procedures/complete-blood-count/details/results/rsc-

20257186

Medline plus. (n.d.). Kwashiorkor. Retrieved from

https://medlineplus.gov/ency/article/001604.htm

Medscape (2017, April 04). Marasmus Treatment & Management. Retrieved from

http://emedicine.medscape.com/article/984496-treatment?src=refgatesrc1

Mourad, M. (2015, September) France Moves Toward A National Policy Against Food Waste.

Retrieved from https://www.nrdc.org/sites/default/files/france-food-waste-policy-

report.pdf

Müller, O., & Krawinkel, M. (2005, August 02). Malnutrition and health in developing countries.

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1180662/

Nordqvist, C. (n.d.). Malnutrition: Causes, Symptoms and Treatments. Retrieved from

http://www.medicalnewstoday.com/articles/179316.php

Nutrition Facts (2016, November). Plant-based Diets. Retrieved from

https://nutritionfacts.org/topics/plant-based-diets/

Overview. (n.d.). Retrieved from

http://www.mayoclinic.org/diseases-conditions/rickets/home/ovc-20200467

Russell, T. (2017, April 24). Plant-Based Nutrition: Everything You Need To Know To Thrive

On Plants. Retrieved from

https://www.incrediblesmoothies.com/plant-based-diet/nutrition/
Hidden Hunger 18

Scalise, S. (2016, October 05). Apache County had worst 'food insecurity' in U.S.; state also bad |

Cronkite News. Cronkite News. Retrieved from

https://cronkitenews.azpbs.org/2016/09/16/apache-county-had-worst-food-insecurity-in-

u-s-state-among-worst/

Scurvy Workup. (2017, April 05). Retrieved from

http://emedicine.medscape.com/article/125350-workup

Silverbush, L., & Jacobson, K.(2012). A Place at the Table. Participant Media. Retrieved from

https://youtu.be/KRK1c8GnYfY

Symptoms and causes. (n.d.). Retrieved from

http://www.mayoclinic.org/diseases-conditions/anemia/symptoms-causes/dxc-20183157

USDA (n.d.). Definitions of Food Security. Retrieved from

https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/

definitions-of-food-security/

USDA. (n.d.). What is a Specialty Crop? Retrieved from

https://www.ams.usda.gov/services/grants/scbgp/specialty-crop

Vitamin B3 (Niacin). (n.d.). Retrieved from

http://www.umm.edu/health/medical/altmed/supplement/vitamin-b3-niacin

Vitamin C (Ascorbic acid). (n.d.). Retrieved from

http://www.umm.edu/health/medical/altmed/supplement/vitamin-c-ascorbic-acid

World Food Programme. (n.d.). Retrieved from https://www.wfp.org/node/359289