A multidisciplinary reconstruction of Palaeolithic nutrition that holds promise for the prevention and treatment of diseases of civilisation

Abstract

Evolutionary medicine acknowledges that many chronic degenerative diseases result from conflicts between our rapidly changing environment, our dietary habits included, and our genome, which has remained virtually unchanged since the Palaeolithic era. Reconstruction of the diet before the Agricultural and Industrial Revolutions is therefore indicated, but hampered by the ongoing debate on our ancestors' ecological niche. Arguments and their counterarguments regarding evolutionary medicine are updated and the evidence for the long-reigning hypothesis of human evolution on the arid savanna is weighed against the hypothesis that man evolved in the proximity of water. Evidence from various disciplines is discussed, including the study of palaeo-environments, comparative anatomy, biogeochemistry, archaeology, anthropology, (patho)physiology and epidemiology. Although our ancestors had much lower life expectancies, the current evidence does neither support the misconception that during the Palaeolithic there were no elderly nor that they had poor health. Rather than rejecting the possibility of 'healthy ageing', the default assumption should be that healthy ageing posed an evolutionary advantage for human survival. There is ample evidence that our ancestors lived in a land-water ecosystem and extracted a substantial part of their diets from both terrestrial and aquatic resources. Rather than rejecting this possibility by lack of evidence, the default assumption should be that hominins, living in coastal ecosystems with catchable aquatic resources, consumed these resources. Finally, the composition and merits of so-called 'Palaeolithic diets', based on different hominin niche-reconstructions, are evaluated. The benefits of these diets illustrate that it is time to incorporate this knowledge into dietary recommendations.

Full text

A multidisciplinary reconstruction of Palaeolithic nutrition that holds promise
for the prevention and treatment of diseases of civilisation
Remko S. Kuipers
1
, Josephine C. A. Joordens
2
and Frits A. J. Muskiet
1
*
1
Laboratory Medicine, University Medical Center Groningen (UMCG), Groningen, The Netherlands
2
Human Origins Group, Faculty of Archaeology, Leiden University, Leiden, The Netherlands
Abstract
Evolutionary medicine acknowledges that many chronic degenerative diseases result from conflicts between our rapidly changing environ-
ment, our dietary habits included, and our genome, which has remained virtually unchanged since the Palaeolithic era. Reconstruction of
the diet before the Agricultural and Industrial Revolutions is therefore indicated, but hampered by the ongoing debate on our ancestors’
ecological niche. Arguments and their counterarguments regarding evolutionary medicine are updated and the evidence for the long-
reigning hypothesis of human evolution on the arid savanna is weighed against the hypothesis that man evolved in the proximity of
water. Evidence from various disciplines is discussed, including the study of palaeo-environments, comparative anatomy, biogeochemistry,
archaeology, anthropology, (patho)physiology and epidemiology. Although our ancestors had much lower life expectancies, the current
evidence does neither support the misconception that during the Palaeolithic there were no elderly nor that they had poor health. Rather
than rejecting the possibility of ‘healthy ageing’, the default assumption should be that healthy ageing posed an evolutionary advantage for
human survival. There is ample evidence that our ancestors lived in a land –water ecosystem and extracted a substantial part of their diets
from both terrestrial and aquatic resources. Rather than rejecting this possibility by lack of evidence, the default assumption should be that
hominins, living in coastal ecosystems with catchable aquatic resources, consumed these resources. Finally, the composition and merits of
so-called ‘Palaeolithic diets’, based on different hominin niche-reconstructions, are evaluated. The benefits of these diets illustrate that it is
time to incorporate this knowledge into dietary recommendations.
Key words: Palaeolithic nutrition: Disease prevention: Disease treatment: Dietary recommendations: Evolutionary medicine:
Healthy ageing
Introduction
In the Origin of Species
(1)
, Darwin recognised that there
are two forces of evolution, i.e. natural selection and the
conditions of existence, where the latter was considered
the most powerful
(2)
. For example, important steps in evo-
lution are the origin of eukaryotic life approximately
1·6–2·7 billion years ago
(3,4)
and the appearance of photo-
synthetic cyanobacteria that began to oxygenate the
atmosphere about 2400 million years ago (Mya)
(5)
. However,
there was relatively little alteration in the design of life
forms before the Cambrian explosion about 600 Mya. Only
when the oxygen tension in the atmosphere rose above the
Pasteur point did aerobic metabolism become thermo-
dynamically possible
(6)
, resulting in an explosion from
simple prokaryotics to a diversity of eukaryotic life forms
(7)
.
During the past millions of years of evolution, with rela-
tively little alteration in life forms and environmental circum-
stances, the human genome has become optimally adapted
to its local environment
(8 – 11)
. In other words, our genome
may have reached a state of homeostasis, defined as the
‘optimal interaction between environment and genome’ or
‘nature in balance with nurture’, to support optimal survival
for reproductive success. The aetiologies of many typically
Western diseases, also known as diseases of affluence or
civilisation, have been attributed to the disturbance of this
delicate balance, secondary to the rapid changes in the con-
ditions of existence, while our genome has remained basi-
cally unchanged since the beginning of the Palaeolithic
era. The former include changes in physical activity, stress,
sleep duration, environmental pollution and others
(12,13)
,
*Corresponding author: Dr Frits A. J. Muskiet, fax þ31 50 361 2290, email f.a.j.muskiet@umcg.nl
Abbreviations: AA, arachidonic acid; ALA, a-linolenic acid; en%, percentage energy; EQ, encephalisation quotient; Kya, thousand years ago; LA, linoleic
acid; MCSFA, medium-chain SFA; Mya, million years ago; RAR, retinoic acid receptor; RXR, retinoid X receptor; TR, thyroid hormone receptor; VDR,
vitamin D receptor.
Nutrition Research Reviews (2012), 25, 96–129 doi:10.1017/S0954422412000017
qThe Authors 2012
Nutrition Research Reviews

but one of the most rapidly changing conditions of existence
has been the human diet.
Since the onset of the Agricultural Revolution, some 10
thousand years ago (Kya), and notably in the last 200
years following the start of the Industrial Revolution,
humans have markedly changed their dietary habits. Con-
sequently, it has been advocated that the current pandemic
of diseases of civilisation results in part from the mismatch
between the current diet and our Palaeolithic genome. In
other words, ‘we are what we eat, but we should be
what we ate’
(14,15)
. The ensuing poorly adapted phenotype
may find its origin as early as in the fetal period
(16,17)
and
possibly as far back as in the maternal grandmother’s
womb
(18)
. This phenotype might be laid down in, inher-
ently labile, epigenetic marks that are meant for the
short- and intermediate-term adaptation of a phenotype
to the conditions of existence. With clear evolutionary
advantages they may become transmitted to the next
generations as a memory of the environmental conditions
that can be expected after birth
(19)
. They thereby give
rise to a seemingly high contribution of genetics in some
of the associated ‘typically Western’ degenerative diseases,
which are in fact complex diseases that by definition do
not inherit by Mendel’s law, illustrating that epigenetic
marks can also become erased.
From a pathophysiological point of view, the poorly
adapted phenotype in Western countries, ensuing from
the conflict between the changing lifestyle and our Palaeo-
lithic genome, centres on chronic low-grade inflammation
and the metabolic syndrome (also named the insulin resist-
ance syndrome), which are risk factors for many of the dis-
eases and conditions typical for affluent countries, such as
CVD, type 2 diabetes mellitus, osteoporosis, certain types
of cancer (notably colon, breast, prostate), fertility pro-
blems (polycystic ovary syndrome), pregnancy compli-
cations (gestational diabetes, pre-eclampsia), some
psychiatric diseases (major and postpartum depression,
schizophrenia, autism) and neurodegenerative diseases
(Alzheimer’s disease, Parkinson’s disease)
(20 – 22)
. The
genetically determined flexibility to adapt to a changing
environment appears to have been exceeded and the
genetically most vulnerable have become sick first, but ulti-
mately all individuals will become sick with increasing
dose and exposure time.
Environment, nutrients and their interaction with the
genome
Adjustment of the DNA base sequence is a slow process
that in an individual cannot support adaptation to environ-
mental changes occurring at intermediate or rapid pace.
Flexibility for rapid adaptation is provided by genetically
encoded mechanisms that allow adjustment of phenotype
by epigenetics and by the interaction of the environment
with sensors, such as those of the sensory organs, but
also by the many that remain unnoticed
(23 – 25)
. The role
of nutrients in (epi)genetics and their direct interaction
with the genome have become increasingly acknow-
ledged
(26)
. Examples of such nutrients are iodine, Se,
vitamins A and D, and n-3-fatty acids, which are direct or
indirect ligands of the thyroid hormone receptor (TR),
retinoid X receptor (RXR), retinoic acid receptor (RAR),
vitamin D receptor (VDR) and PPAR. Homodimerisation
and heterodimerisation of these receptors facilitate gene
transcription and thereby keep our phenotype optimally
adapted to the reigning conditions of existence. The roles
of these nutrients, their respective receptors and the
interaction between their receptors are indicative of the
importance of their dietary presence and of a certain
balance between their dietary intakes to arrive at optimal
interaction with the genome. Lessons for this optimal
interaction, and hence for the development of randomised
controlled trials aiming at the study of diet or lifestyle,
rather than single nutrients, might derive from knowledge
on human evolution and the conditions of existence to
which our ancestors have been exposed. These lessons
might provide us with valuable information on what we
should genuinely define as a ‘healthy diet’.
Evolutionary medicine
The concept that a thorough understanding of evolution
is important in the prevention and treatment of (human)
diseases has long been recognised. For example, in the
early 1960s it was stated that ‘nothing in biology makes
sense except in the light of evolution’
(27)
, while in ethol-
ogy, a distinction was made between proximate and ulti-
mate (also named evolutionary) causes
(28)
. Proximate
explanations provide a direct mechanism for certain beha-
viour in an individual organism. They explain how biomo-
lecules induce certain behaviour or, for example, an
allergic reaction. Proximate explanations, however, pro-
vide insufficient information to answer the question why
this behaviour or this allergic reaction occurred. Ultimate
explanations provide answers explaining why things
happen from an evolutionary point of view. Many, if not
all, diseases can become explained by both proximate
and ultimate explanations. The science searching for the
latter explanations has become known as ‘evolutionary
medicine’. Unfortunately, modern medicine deals mostly
with proximate explanations
(29,30)
, while ultimate expla-
nations seem more prudent targets for long-time disease
prevention
(29)
.
The term ‘evolutionary medicine’ (also named Darwinian
medicine) was launched by Randolph M. Nesse and George
C. Williams
(31,32)
. They provided evolutionary answers
for the understanding of human diseases. Many diseases
do not result from a single biological, anatomical or phy-
siological abnormality, but rather from a complex web
of interactions. They often reflect the collateral damage
of the survival and reproduction strategies of our genes
and the genes of other organisms in our environment.
Palaeolithic nutrition for disease prevention 97
Nutrition Research Reviews

The resulting disease manifestations include the outcomes
of human defence mechanisms to clear foreign pathogens
and the collateral damage of conflicts and trade-offs
between humans and foreign invaders. Examples often
overlooked are coincidence, in which diseases may result
from imperfections of human evolution, and exaptation, in
which a feature is not acquired in the context of any function
to which it might eventually be put
(33)
. For example, the
equilibrium between the not yet full-grown, but yet relatively
large, brain of a newborn and the small birth canal in its
turn is constrained by an upright posture and provides
an example of a trade-off in human evolution. The location
of the birth canal in its turn provides an example of an
evolutionary coincidence that urges to deal with an, in
retrospect, imperfect evolutionary design. These examples
illustrate that evolution builds on the past: it is not possible
to start a completely new design from scratch, which
argues against ‘intelligent design’. The most important
example of an evolutionary explanation for human disease,
however, comes from the mismatch between our slowly
adapting genome and the rapidly changing environment,
notably our diet.
Evolutionary medicine argues that the chronic degenera-
tive diseases causing most morbidity and mortality in afflu-
ent countries occur because of the current mismatch
between the rapidly changing conditions of existence
and our Palaeolithic genome
(34)
. These mismatches will
persist, notably in the light of our long generation time.
The genetic adjustments needed to adapt to the new
environment are also unlikely to occur, since the mismatch
exerts little selection pressure. That is, they do not cause
death before reproductive age, but rather reduce the num-
bers of years in health at the end of the life cycle
(35)
. Con-
sequently, evolutionary medicine acknowledges a return to
the lifestyle before the onset of the Agricultural Revolution
as translated to the culture of the 21th century and as
popularised by the expression: ‘how to become a 21th cen-
tury hunter–gatherer’
(36)
. Skeptics of evolutionary medi-
cine often raise the intuitive criticism that the human
ancestor had a very short life expectancy compared with
contemporary individuals
(35)
. Consequently, they argue,
there was no selection pressure on longevity or ‘healthy
ageing’, since there were virtually no old people, while
the few individuals reaching old (for example, postmeno-
pausal) age provided no evolutionary benefit to younger
individuals who were still able to reproduce. The counter-
argument is multilevelled.
Arguments and counterarguments in evolutionary health
promotion
It needs to be emphasised that evolutionary medicine pre-
dicts no further increase in life expectancy, but rather a
decrease in the numbers in deteriorating health at the
end of the life cycle. It has been estimated that the com-
plete elimination of nine leading risk factors in chronic
degenerative diseases would increase life expectancy at
birth by only 4 years, since these diseases only affect
late-life mortality
(37)
. Second, the increased life expectancy
at present originates mostly from the greatly diminished
influence of some unfavourable conditions of existence,
including (childhood) infections, famine, homicide and
tribal wars
(34,38)
secondary to the high levels of medical
sciences and continuing civilisation. Thus, to achieve the
average life expectancy of 40 years in a present-day
hunter–gatherer society, for every child that does not sur-
vive beyond 1 year of age, another should reach the age of
80 years. In fact, about 20 % of modern hunter – gatherers
reach at least the age of 60 years
(39 – 41)
. In other words,
the popular argument that very few individuals in these
societies live past 50 years
(35)
is unsupported by ethno-
graphic data. The third, often raised, argument is that
due to the higher life expectancy in present-day humans,
it is invalid to compare the mortality figures for cancer
and degenerative disease of present-day hunter–gatherers
(with low life expectancies) with those of Western popu-
lations (with a life expectancy of 80 years). However,
early biomarkers of degenerative diseases such as obesity,
high blood pressure, atherosclerosis and insulin resistance
are also less common in younger, age-matched, members
of present hunter–gatherer compared with members of
affluent societies
(9,42)
, while measurements indicative for
‘good health’ such as muscular strength and aerobic
power are more favourable in the former
(43)
. Moreover,
even the oldest individuals in hunter–gatherer societies
appear virtually free from chronic degenerative dis-
eases
(44 – 46)
. A fourth counterargument against the assump-
tion that our human ancestors before the Agricultural
Revolution died at a young age derives from archaeological
records. After the transition from hunting and gathering to
farming about 10 Kya, life expectancy dropped from about
40 years (as it is in recently studied hunter –gatherers,
but also was among students of the Harvard College
Class born in 1880
(47)
) to about 20 years
(48 – 50)
. This see-
mingly evolutionary disadvantage, secondary to a decrease
in nutritional quality, is substantiated by a decrease in gen-
eral health that has become noticeable from a decrease
in final height, while skeletal markers of infection and
nutritional stress became more common in archaeological
finds
(49 – 52)
. These setbacks were eliminated by a net
increase in population growth, secondary to an increased
productivity per land area that resulted in more energy
intake per capita. Life expectancy remained stable through-
out the Neolithic until the late 18th century, seldom
exceeding 25 years in ‘civilised’ nations
(35)
. From this
time, improvements in hygiene, food production and
manufacturing, energy generation, per capita income,
shelter, transportation, clothing and energy intakes sub-
stantiated an increase to and beyond the life expectancy
that prevailed before the onset of the Agricultural Revo-
lution. Greater energy availability enhanced, for example,
the energy requirements of the immune system and for
R. S. Kuipers et al.98
Nutrition Research Reviews

reproduction, both improving longevity
(35,53)
. Importantly,
it was concluded that medical treatments had little impact
on mortality reduction, while public health achievements
(sanitation, food and water hygiene, quarantine and
immunisations) have critically improved life expectancy.
The fifth counterargument is that old people do provide
an evolutionary benefit to the younger generations.
Male fertility remains largely intact and male provisioning
might help in the problem of high female reproductive
costs, although the latter is contested
(54,55)
. The benefits
of older females have been put forward in the grand-
mother hypothesis. This hypothesis, in which the presence
of older females within a certain group benefits the
reproductive success of their offspring, is supported by
studies in human hunter–gatherer
(56 – 62)
and primate
societies
(56,60,63)
. Interestingly, the fitness benefits of
grandmothering proved insufficient to fully explain the
evolution of increased longevity
(62)
, suggesting that other
evolutionary benefits, such as grandfathering, might also
be involved in the long reproductive and non-reproduc-
tive lifespan of Homo sapiens. A recent analysis supports
such benefits for both older males and females, since
the presence of post-reproductive women increased the
numbers of newborns by 2·7 %, while 18·4 % of the infants
in a polygamous society in rural Africa were sired by
males aged 50 years and above
(64)
. In support of the state-
ment that ‘nothing in biology makes sense except in the
light of evolution’ we therefore conclude that, unless
proven otherwise, the presence of a substantial pro-
portion of older males and postmenopausal females in
hunter–gatherer, in contrast to primate societies, should
be considered as proof for the evolutionary benefit
that these individuals are to their progeny. Finally, we
propose that this assumption would only be convincible
if these individuals were reasonably fit, thereby support-
ing the concept of healthy ageing. Hence, healthy
ageing seems both supported by ethnographic data and
its benefit to hunter–gatherer societies. Other commonly
raised arguments against the genome–environment mis-
match hypothesis are the potential genetic changes since
the Agricultural Revolution, the heterogeneity of ancestral
environments and innate human adaptabilty
(35)
. Counter-
arguments to these critics have been discussed in great
detail elsewhere
(35)
.
In the present review, a multidisciplinary approach is
used, including palaeo-environmental reconstruction, com-
parative anatomy, biogeochemistry, archaeology, anthro-
pology, (patho)physiology and epidemiology, to assess
the characteristics of the ecosystem that supported
human evolution. Based on this assessment, an approxi-
mation is made of the dietary composition that derives
from this ecosystem. Finally, the potential benefit of a
return to this ‘Palaeolithic diet’ is discussed and an
update is provided for the evidence for the positive
health effects of these diets.
Human evolution
Hominins are defined as members of the taxon Hominini,
which comprises modern Homo sapiens and its extinct
relatives over the past about 7 million years. The oldest-
known hominins (Fig. 1) are Sahelanthropus tchadensis
from Chad (about 7 Mya
(65)
) and Orrorin tugenensis
from Kenya (about 6–5·7 Mya
(66)
). The next oldest are
Ardipithecus kadabba (Ethiopia, about 5·8 Mya
(67)
)and
A. ramidus (Ethiopia, about 4·4 Mya
(68)
), Australopithecus
anamensis (Kenya, about 4·1–3·9 Mya
(69)
), Au. afarensis
(Ethiopia, Tanzania and maybe Kenya, 3·6–3·0
Mya
(70,71)
), Au. bahrelghazali (Chad, about 3·5 Mya
(72)
),
Kenyanthropus platyops (Kenya, about 3·5 Mya
(73)
),
Au. garhi (Ethiopia, about 2·5 Mya
(74)
) and Au. africanus
(South Africa, about 2·9–2·0 Mya
(75)
). From these earliest
hominins evolved the genera Paranthropus (three known
subspecies) and Homo. The earliest species that have
been designated Homo are Homo rudolfensis,Homo
habilis and Homo erectus sensu lato – including H. ergaster
(Eastern Africa, about 2–1.8 Mya): these in turn are the
presumed ancestors of Asian H. erectus,H. heidelbergensis
(Africa, Eurasia 0·6–0·3 Mya), H. neanderthalensis
(Eurasia, 0·4–0·03 Mya) and H. sapiens (from about 0·2
Mya onwards)
(76 – 78)
. The recently discovered H.floresien-
sis (0·095–0·013 Mya
(79)
) and the previously unknown
hominins from Denisova Cave (about 0·05– 0·03 Mya
(80)
)
show that in the recent past several different hominin
lines co-existed with modern humans.
Africa is now generally accepted as the ancestral home-
land of Homo sapiens
(77,81,82)
. In several subsequent out-
of-Africa waves
(83)
, hominins of the genus Homo colonised
Asia, Australia, Europe and finally the Americas (Fig. 2).
Archaic Homo species reached as far as the island of Flores
in South-East Asia, East China and Southern Europe
(Spain). Homo heidelbergensis remains were found in
Africa, Europe and Eastern Asia, while Homo neandertha-
lensis was restricted to Europe, Western Asia and the
Levant. At last, in the later out-of-Africa diaspora starting
about 100 Kya, Homo sapiens finally reached Australia and
the Americas, while probably replacing earlier hominins
in Africa, Europe and Asia that had left during the earlier
out-of-Africa waves. However, there remains some
debate
(82,84 – 86)
whether or not the gene pool of archaic
hominins contributed to that of modern humans. In the
replacement theory, archaic hominins make no contribution
to the gene pool of modern man, whereas in the hybridis-
ation theories (either through assimilation or gene flow),
newly arriving hominins from the later out-of-Africa wave
mixed with archaic predecessors. Current evidence from
DNA analyses supports the concept that the gene pool of
archaic hominins, notably Neanderthals
(87)
, but also Deniso-
vans
(80)
contributed to the gene pool of Homo sapiens.
The African cradle of humankind is supported by
micro-satellite studies
(88)
that reveal that within popu-
lations the genetic variation decreases in the following
Palaeolithic nutrition for disease prevention 99
Nutrition Research Reviews

7
6
5
4
3
2
1
0
7
6
5
4
3
2
1
0
Mya Mya
H. neanderthalensis
H. sapiens
H. heidelbergensis
H. floresiensis
H. erectus
H. mauritanicus/antecessor
H. habilis
Au. sediba
H. rudolfensis
Au. africanus Au. garhi
Au. afarensis
K. platyops
Au. anamensis
O. tugenensis
S. tchadensis
Ar. kadabba
Ar. ramidus
Au. bahrelghazali
P. aethiopicus
P. boisei
P. robustus
H. ergaster
Fig. 1. Scheme of the possible phylogenetic relationships within the family Hominidae. Note that at many time points of evolution, several different hominin species
coexisted. Mya, million years ago; H.,Homo;Au.,Australopithecus;K.,Kenyanthropus;P.,Paranthropus;Ar.,Ardipithecus;O.,Orrorin;S.,Sahelanthropus.q
Ian Tattersall, with permission
(76)
.
R. S. Kuipers et al.100
Nutrition Research Reviews

order: sub-Saharan Africa .Eurasia .East Asia .
Oceania .America, with the hunter–gatherer Hadzabe
of Tanzania separated from the Juj’hoansi (previously
called !Kung) from Botswana by a genetic distance greater
than between any other pair of populations
(89)
, which indi-
cates the chronology of continent inhabitation and points
to South or East Africa as the cradle of humankind
(89,90)
.
Human evolution was characterised by several large-scale
decimations, and it has been estimated that the current
world population derives from only 1000 surviving individ-
uals at a certain time point
(91)
. Such bottlenecks
(92)
, charac-
terised by strong population decrease, or where groups of
hominids were separated due to global climate changes,
volcanic winters or geographic boundaries as mountain
ridges or seas, caused gene flow and genetic drift. As a
result, different phenotypic races emerged in different geo-
graphic regions
(88,92)
. However, differences among these
populations contribute only 3 – 5 % to genetic diversity,
while within-population differences among individuals
account for 93 –95 % of genetic variation
(93)
. In other
words, genetically we belong to one species that originally
evolved in Africa and that for the great majority genetically
still resides in the Palaeolithic era. Most of the current inter-
individual genetic differences were already existent when
Homo sapiens emerged, some 200 Kya
(78)
. Bipedalism,
hairlessness, speech and the ability to store fat differentiate
humans from the closest relatives, the primates, but it is the
uniquely large brain, which allowed for symbolic con-
sciousness and pose ‘what-if’ questions, that finally made
humanity
(76)
.
Changing habitat and increasing brain size
It is assumed that during the early stages of human evol-
ution early hominins introduced more animal food into
their diets, at the expense of plant foods
(94,95)
. Subsequent
hominins further increased the amount of animal food and
consequently the energy density and (micro)nutrient con-
tent of their diet, i.e. the dietary quality. While increasing
their dietary intake from animal food, early hominins
grew taller and increased their brain mass relative to
body mass (encephalisation quotient; EQ). Brain mass in
primates relates to the number of neurons
(96)
and global
cognition
(97)
, while the human cortex also has more
cycles of cell division compared with other primates
(98)
.
During hominin evolution the first significant increase in
EQ occurred about 2 Mya (Table 1). From about 2 Mya
to 200 Kya the human ancestors tripled their brain size
from Australopithecus species with an EQ of 1·23–1·92 to
an EQ of 1·41–4·26 for the genus Homo
(99,100)
. The
increase in brain size and the number of neurons differen-
tiate Homo from their closest primate relatives. However, a
large brain requires an adaptation or an exaptation to
accommodate it, and notably sufficient intake of so-called
‘brain-selective nutrients’
(100,101)
to build and conserve it.
195 000 ya
African origins
125 000 ya
50 000 ya
Homo sapiens
in Europe
85 000 ya
100 000 ya
first humans
travel from
Egypt to Israel 60 000 ya
48 000 ya
33 000 ya
15 000–19 000 ya
4500 ya
25 000 ya
1500 ya
1500 ya
12 500 ya
75 000 ya
40 000 ya
22 000–25 000 ya
Humans cross
the Bering strait
65 000 ya
Humans cross
from Timor
to Australia
Fig. 2. Coasting out of Africa: following the water in the third out-of-Africa diaspora. Assumed dispersal routes of archaic and anatomically modern man out of
Africa and the supportive fossil evidence for hominin presence: (V), Australopithecus sp.; (X), Homo habilis,erectus,ergaster or antecessor;(B), H. heidelbergen-
sis;(w), H. neanderthalensis;((), H. sapiens. ya, Years ago. Source: National Geographic Society 1988, 1997; adapted from www.handprint.com/LS/ANC/
disp.html and Oppenheimer
(83)
.
Palaeolithic nutrition for disease prevention 101
Nutrition Research Reviews

Buiding a big brain
Compared with other primates, humans have an extraordi-
narily large brain
(102,103)
. To understand the expansion of
the human brain during evolution, it is important to com-
prehend its composition and its biochemistry. Brain
tissue has a unique profile of long-chain PUFA (LCP)
(99)
.
Comparison of the brain ethanolamine phosphoglycerols
of forty-two studied animal species shows an almost
identical LCP pattern, independent of the grade of ence-
phalisation, containing approximately equal proportions
of arachidonic acid (AA) and DHA. Consequently, for
normal neuronal function, mammalian brain tissue appears
to have an invariant structural requirement for both AA and
DHA. This shows that both these fatty acids are important
building blocks for building a big brain and for encephali-
sation. The weight of a newborn human brain is about
340 g
(104)
and it contains about 9 g lipid
(105)
; the brain of
a 10-month-old infant is 850 g and contains 52 g lipid.
At 3 years, the brain is 1100 g and contains 130 g lipid.
Thus, the major part of the human brain spurt occurs
postnatally
(106)
, implying that especially the newborn
infant has high demands for AA and DHA.
Toothed whales (brain weight 9000 g) and African ele-
phants (4200 g) have brains much larger than humans,
but they have lower cognitive abilities and a lower
EQ
(107)
. These observations substantiate an EQ-centred
approach to explain variation in cognition between
species. Recent analyses, however, have shown remarkable
differences between primate and non-primate brains;
a primate brain contains many more neurons than a non-
primate brain of similar size
(96,108,109)
and the absolute
number of neurons, rather than body relative to brain
ratio (EQ), best predicts cognitive ability
(97)
, although
it still needs to be determined whether humans have
the largest number of brain neurons among all mammals.
From this new neuron-centred view, there seems to
be nothing special about the human compared with the
primate brain, except for its size
(96)
, which basically
determines both the number of neurons and non-
neurons
(110,111)
. Detailed comparisons of human and
primate brains have revealed other differences, such as
different levels of gene expression
(112 – 114)
, secondary to
chromosomal rearrangements
(115)
, differences in the rela-
tive extent of the neocortical areas
(96,116)
, the distribution
of cell types
(117)
and the decrease of brain structure
volumes with increasing age in man in contrast to chim-
panzees
(118,119)
. The best predictor of cognitive ability in
humans compared with non-primates, however, still
needs to be established, but rather than EQ or brain size,
the absolute number of neurons seems a prudent candi-
date
(97,108)
, since there is no clear relationship between
neuron number and the absolute brain size among the
different animal species
(96,108,109)
.
In contrast to intuitive belief, growing a large brain and a
large skull to accommodate it is less difficult to achieve
than it seems at first glance. It was recently shown that
different levels of expression of a single gene might have
resulted in the markedly different beak shapes and lengths
of Darwin’s finches. Experimental overexpression of the
calmodulin gene in chicken embryos resulted in a signifi-
cant increase in the length of their beaks
(120,121)
. These
experiments suggest that small and seemingly insignificant
changes can have profound implications for the evolution
of anatomical size and shape and thereby provide great
potential for explaining the origins of phenotypic vari-
ation
(122)
, including increases in brain and skull size.
Analogously, many mutations in humans are associated
with either microcephaly
(123)
or macrocephaly
(124)
, while
the growth of the skull in hydrocephaly shows that
the increased skull size is secondary to the increase of its
Table 1. The development of brain weight relative to body dimensions*
Species Brain weight (g) Brain:body ratio (%) Relative EQ†
Gorilla gorilla 500 0·3 25
Pongo pygmaeus 400 0·5 32
Pan troglodytes 400 0·9 42
Australopithecus afarensis 455 1·7 41
Australopithecus africanus 450 1·0 44
Paranthropus aethiopicus 405 1·1 44
Paranthropus boisei 510 0·9 46
Paranthropus robustus 520 1·1 50
Homo rudolfensis 750 1·7 59
Homo habilis 600 1·7 57
Homo ergaster 855 –
Homo erectus 863 1·6 63
Homo heidelbergensis 1200 1·8 74
Homo neanderthalensis 1450 1·9 75
Homo sapiens (Cro-Magnon) 1490 2·4 102
Modern Homo sapiens 1360 2·3 100
EQ, encephalisation quotient.
* Adapted from Templeton
(85)
.
† Relative to modern Homo sapiens.
R. S. Kuipers et al.102
Nutrition Research Reviews

contents, suggesting that brain rather than skull size is
the limiting factor here. The evolution of certain genetic
variants associated with brain size has accelerated signifi-
cantly since the divergence from the chimpanzee some
5–6 Mya. A recent variation that occurred 37 Kya has
spread more rapidly through the human population than
could be explained by genetic drift
(125 – 128)
, suggesting
that it conferred evolutionary advantage.
The anatomical and metabolic changes encoded in the
genome (see ‘Comparative anatomy’) might have provided
hominins with the anatomical and energetic opportunity
to, over a period of several million years, steadily increase
their brain size, but these mutations per se did not fulfil
the nutrient requirements for brain expansion
(101,129 – 131)
.
The underlying small number of mutations should rather
have been accompanied, and most probably have been
preceded, by increased availability of ‘brain-specific nutri-
ents’ such as LCP for their ultimate conservation through
the process of mutation and selection, which basically
underlines both Darwin’s concept of the crucial import-
ance of ‘the conditions of existence’ and the secondary
role of mutation. An example may come from current
knowledge on the sources of AA and DHA. In humans,
both AA and DHA can be synthesised from their precursor
essential fatty acids a-linolenic acid (ALA) and linoleic acid
(LA) (Fig. 3), respectively. ALA and LA are present in
various natural food resources. ALA is predominantly
found in plant foods, while LA is mainly found in vegetable
oils such as sunflower-seed oil. Both AA and DHA may
derive from their synthesis from abundantly consumed
precursor fatty acids ALA and LA, but in humans and
especially neonates, these synthetic activities are insuffi-
cient to cope with metabolic demands
(132)
. Consequently
both these LCP, but especially those of the n-3 series,
need to be present in sufficient quantities in our diet. It is
still under debate what dietary resource(s) provided the
LCP that enabled us to grow a large brain
(101,133 – 137)
.
The probability of hunting on the savanna
It has been a longstanding paradigm in palaeoantho-
pology that early human evolution occurred in a dry and
open savanna environment
(138 – 140)
. Recent studies from
the Afar basin
(68,141)
, although recently contested
(142 – 144)
,
indicated that the habitat of Ardipithecus ramidus at
about 4·4 Mya was characterised not by savanna but by
woodland to grassy woodland conditions. Human charac-
teristics, such as poor water-drinking capacity, excessive
urination and transpiration and poor water retention sup-
port the argument that we would be poorly adapted
savanna dwellers
(140)
.
A second long-reigning paradigm was ‘man the hunter’,
which was the standard version of human origins advo-
cated for many years. Washburn & Lancaster
(94)
referred
at most to our most recent antecessors, Homo sapiens
and possibly H. neanderthalensis, when they claimed
that our intellect, interests, emotions and basic social
life are evolutionary products of the hunting adaptation.
The strongest argument against this hunting paradigm
comes from combined studies of past and present-day
hunter–gatherer societies indicating that the role of hunt-
ing is exaggerated, notably (around the campfire) in
hunter–gatherer societies, since the majority of the dietary
protein is in reality obtained by women gathering nuts,
tubers and small animals
(145 – 147)
. Cordain et al.
(148)
showed that only 25–35 % of energy (en%) of subsistence
in worldwide hunter–gatherer communities is derived
from hunting, while the remainder is derived from both
plant and fished food. Thus, while meat from large game
may have been the most valued food, it is highly unlikely
that it was the most valuable (nutritionally important) food
resource from a dietary perspective
(41,149)
. At present, the
niche of early hominins and thus the environment of
human evolution, and, most importantly for the present
review, the nutritional composition of the early human
diet are still heavily debated
(150)
.
Reconstruction of our ancient diet
In the next sections we will discuss various views on
(changes in) the hominin ecological niche that over time
shaped the human genome to what it currently is.
Palaeo-environments
Sahelanthropus, Orrorin and Ardipithecus. In the late
Miocene (up to 5·3 Mya), the African continent became
∆9
∆9
∆6
∆6
∆5
CE
Diet Diet Diet or lipogenesis
CE
CE
CE
CS
22 : 6
n-
3
24 : 6
n-
3
24 : 5
n-
3
22 : 5
n-
3
20 : 5
n-
3
20 : 4
n-
3
18 : 4
n-
3
18 : 3
n-
318 : 2
n-
618 : 1
n-
7
20 : 1
n-
720 : 0
18 : 0
16 : 0
22 : 0
24 : 0
18 : 3
n-
6
20 : 3
n-
6
20 : 4
n-
6
22 : 4
n-
622 : 3
n-
9
20 : 3
n-
9
20 : 2
n-
920 : 1
n-
9
22 : 1
n-
9
24 : 1
n-
9
18 : 2
n-
9
16 : 1
n-
7
n-
3
and n-
6
series n-
7
and n-
9
series
16 : 1
n-
9
18 : 1
n-
9
24 : 4
n-
6
24 : 5
n-
6
22 : 5
n-
6
Fig. 3. Metabolism of the parent essential fatty acids and endogenously
synthesised fatty acids. D9, D9-Desaturase; CE, chain elongation; D6,
D6-desaturase; D5, D5-desaturase; CS, chain shortening through peroxiso-
mal b-oxidation. 18 : 3n-3, a-linolenic acid; 18 : 2n-6, linoleic acid; 18 : 1n-9,
oleic acid; 20 : 5n-3, EPA; 20 : 4n-6, arachidonic acid; 20 : 3n-9, mead acid;
22 : 6n-3, DHA.
Palaeolithic nutrition for disease prevention 103
Nutrition Research Reviews

more arid, which resulted in fragmentation of the (sub)tro-
pical forests and the appearance of more open environ-
ments
(151)
. The widespread dispersal of some of the
earliest hominins such as Sahelanthropus
(65,152)
, and Aus-
tralopithecus bahrelghazali from Chad, might be explained
by the presence of the relatively low-lying humid East –
West corridor constituted by the remnants of the Cretac-
eous Central African and Sudan Rifts between Western
and Eastern Africa
(153,154)
. The reconstructed environment
of Sahelanthropus (about 7 Mya) suggests a mosaic of
gallery forest at the edge of a deep, well-oxygenated lake,
swampy and vegetated areas, and extensive grasslands
(155)
.
Since there is no indication of carnivore modification or
fluvial transport of its bones, Sahelanthropus chadensis
probably lived in this area
(156)
. The palaeo-environment
of Orrorin (about 6 Mya) was probably characterised by
open woodland, with dense stands of trees in the vicinity
and possibly fringing the lake margin and/or streams
that drained into the lake
(157)
.Ardipithecus kadabba
(5·6 Mya) remains are associated with wet and closed,
grassy woodland and forest habitats around lake or river
margins
(158)
.Ardipithicus ramidus (4·4 Mya) lived in or
near a groundwater-supported grassy woodland to
forest
(159)
. Additionally, the abundance of fossilised shal-
low-water aquatic species such as catfish, barbus, cichlidae
and crocodiles additionally suggests an episodically present
flood-plain environment
(159)
.
Early Australopithecus species.Australopithecus ana-
mensis appeared at about 4·2 Mya and its environment
was characterised by a mix of wetlands and terrestrial
environments, such as lacustrine and fluvial floodplains,
woodland and gallery forest
(156,160 – 163)
. The later Australo-
pithecus afarensis survived in a variety of habitats
(164)
, but
apparently thrived better in the more wooded and humid
conditions in the Afar basin than in the relatively dry Lae-
toli area
(165)
. Stewart
(156)
pointed out that in Africa the only
environmental constant in hominin sites throughout the
period from 3·4 to 2·9 Mya was a wetlands habitat, charac-
terised by aquatic herbaceous vegetations around lakes
and rivers, with large populations of wetland fauna such
as reduncines and hippopotami. Hence, these wetlands
could have been refuge for early hominins throughout an
extensive period of human evolution.
Paranthropus, late Australopithecus and Homo species.
About 2·9–2·5 Mya tectonic and global climatic changes
made Africa cooler and drier
(166 – 169)
. The great wet forests
of middle Africa retreated and made place for more
savanna grasslands. It is around this time, from about 2·6
Mya onwards, that the first traces of the new hominin
genus Homo appeared in the archaeological record
(140)
.It
has been suggested that alternating wet and dry periods
after 2·7 Mya could have isolated hominin populations
around sources of potable water, while forcing them to
the extremes of their conditions of existence
(156)
and thus
facilitating specialisation
(170)
, either by adaptation or exap-
tation. Compared with Australopithecus,Paranthropus
existed in slightly more open habitats, including wetlands
and grasslands, but also in woodland and bushland
areas. The habitats of Homo species seem similar to
those utilised by Paranthropus species
(161)
, but Homo
remains at Olduvai Gorge and Koobi Fora are associated
with well-vegetated swamps, lakes and river margins,
and (semi-) aquatic fauna
(171,172)
. Only the later Homo
species are also found in assemblages that indicate extre-
mely arid and open landscapes such as savanna
(161)
.
Also, it has been suggested that hominins and other
(aquatic) species dispersed throughout Africa along water
systems, while even the last out-of-Africa migration might
have occurred via the ‘green Sahara’ that existed during
the last interglacial (125 Kya)
(156,173)
.
In conclusion, the palaeo-environmental evidence
suggests that early hominins lived in the proximity of
water. However, it is frequently argued that bones are pre-
ferentially preserved in lake, river or fluvial sediments,
making their recovery in any other than an aquatic setting
unlikely
(174)
. Alternatively, hominin remains may have
been relocated to the water by carnivores
(162)
, including
crocodiles. Nevertheless, the combined evidence strongly
suggests that early hominins frequented the land–water
ecosystem and thus lived there. Joordens et al.
(154)
pro-
posed, based on comparison with other terrestrial omni-
vores, that the default assumption should be that
hominins living in freshwater or marine coastal ecosystems
with catchable aquatic resources could have consumed
these aquatic resources
(154,175)
.
Comparative anatomy
The diet of our closest relatives. Field studies on our clo-
sest relatives, the extant apes, show that their preferred
food items are primarily fruits and/or leaves and stems
from terrestrial forests. Lowland gorillas, for example,
derive 57 % of their metabolisable energy (en%) from
SCFA derived from colonic fermentation of fibre, 2·5 en%
from fat, 24 en% from protein and 16 en% from carbo-
hydrate
(176)
. ‘Fallback foods’ are consumed when preferred
foods are unavailable
(177)
and are generally composed of
herbaceous plants and high-fibre fruits from aquatic and
terrestrial environments
(156)
. Like our closest rela-
tives
(156,178 – 181)
, hominins might have used foods from
the aquatic environment as fallback foods, while, although
speculative, this niche might eventually have proven
favourable with regard to subsequent encephalisation.
Teeth morphology and dental microwear. Comparative
anatomy (Fig. 4) of the hominins might confer some infor-
mation about these fallback and preferred foods of our
ancestors. Dental studies of Sahelanthropus (Fig. 1) describe
that the teeth had thick enamel
(65)
, similar to orangutans,
suggesting that it could eat hard and tough foods
(182)
, such
as available from the lakeshore vegetation
(156)
.Ardipithecus
ramidus, however, had thin molar enamel and smaller teeth
compared with later hominins. This dental morphology is
R. S. Kuipers et al.104
Nutrition Research Reviews

consistent with a partially terrestrial, omnivorous/frugivor-
ous niche
(183)
. Studies on cranio-dental changes such as
tooth size, tooth shape, enamel structure and jaw biomecha-
nics indicate that Australopithecus and Paranthropus had
prominent jaws, relatively flat molar teeth, small incisors
and thick enamel, suitable for breaking and crushing small
hard, brittle foods such as fruits, nuts and underground
storage organs
(150)
, but unsuitable for breaking down
tough plant foods or tearing meat. Together, this would
allow early hominins to eat both hard and soft, abrasive
and non-abrasive foods, which suits well for life in a variety
of habitats
(184)
.
In addition to studies on teeth morphology, microwear
studies are essential. Dental microwear studies analyse
tooth-wear, showing evidence for where teeth were actu-
ally used for and thus what an animal in reality ate
(185)
.
While adaptive morphology will give important clues
about what a species was capable of eating, microwear
studies reflect what an animal ate during some point in
its lifetime. In these studies, ‘complexity’ is used as an indi-
cator for hard and brittle items, while ‘anisotrophy’ is an
indicator for tough foods
(186)
.
Most primates show either low complexity combined
with high anisotrophy, indicative of consumption of
tough foods such as leaves, stems and meat, or high com-
plexity with low anisotrophy associated with hard-brittle
foods, such as nuts and seeds
(150,187)
.Ardipithecus rami-
dus’s preference for an omnivorous/frugivorous diet was
confirmed by microwear studies
(183)
, suggesting a diet of
fleshy fruits and soft young leaves
(150)
. Conversely, micro-
wear textures of Australopithicus afarensis and anamensis
show striations rather than pits (low complexity and low
anisotrophy), i.e. patterns similar to those of grass-eating
and folivorous monkeys instead of the predicted diets pre-
dominated by hard and brittle foods
(187,188)
.Australopithe-
cus africanus showed microwear patterns that were more
anisotropic, suggestive for consumption of tough leaves,
grasses and stems
(189)
.Paranthropus robustus, also know
as the ‘Nutcracker Man’, has enormous, flat, thickly enam-
elled teeth that are combined with a robust cranium, mand-
ible and powerful chewing muscles, suggestive of breaking
hard and brittle foods
(186)
. After microwear analysis of its
teeth, however, Ungar et al.
(150,186)
showed that P. robustus
had low complexity and anisotrophy; thus Paranthropus
might only have consumed mechanically challenging
items as fallback foods when preferred foods were un-
available. Similarly, microwear studies support the notion
that the diet of P. boisei contained large quantities of
low-quality vegetation, rather than hard objects
(190)
.
Generally, microwear studies confirm earlier dental
topography studies
(191)
, which revealed the incorporation
of more fracture-resistant foods, i.e. tougher foods as
leaves, woody plants, underground storage organs and
animal tissues, in the diet of Australopithecus africanus
compared with Australopithecus afarensis and for
P. robustus compared with Australopithecus africanus
(187)
.
Dental topographic analysis suggested that successive
Homo species emphasised more on tougher and elastic
foods, perhaps including meat
(191)
. The latter suggestion
is in line with the optimal foraging theory, which states
that humans prefer foods with high energy density over
those with low energy density
(192,193)
.
Microwear studies confirmed that early Homo, such as
H. erectus and H. habilis, did not prefer fracture-resistant
foods, although some H. erectus specimens showed more
small pits than H. habilis members, suggesting that none
of the early Homo specialised on very hard-brittle or
tough foods, but rather could consume a varied diet
(194)
.
This does not imply that early Homo had very broad
diets, but rather that early Homo was adapted to subsist
in a range of different environments, providing evolution-
ary advantage in the climatic fluctuations and the mosaic of
habitats in Africa during the late Pliocene
(195)
. A study on
dental microwear of 300 000-year-old H. heidelbergensis
teeth from Sima de los Huesos in Spain showed striation
patterns that indicated a highly abrasive diet, with substan-
tial dependence on poorly processed plant foods such as
roots, stems and seeds
(196)
. Lalueza et al.
(197)
compared
teeth of very recent hunter–gatherers (Inuit, Fueguians,
Bushmen, Aborigines, Andamanese, Indians, Veddahs,
Tasmanians, Laps and Hindus) with Middle and Upper
Pleistocene fossils. Their results indicate that some
Diastema Canine Premolars
Molars
Incisors
Pan Australopithecus Homo
Fig. 4. Lower jaw of a chimpanzee (Pan troglodytes), Australopithecus africanus and Homo sapiens. Note the somewhat human-like shape of the teeth, but ape-
like axis in the jaw of Australopithecus.qAustralian Museum.
Palaeolithic nutrition for disease prevention 105
Nutrition Research Reviews

Neanderthals resemble carnivorous groups, while archaic
H. sapiens show a more abrasive diet, partly dependent on
vegetable materials.
Overall, remarkably few studies have related microwear
patterns to hominin diet for the period between 1·5 Mya
and 50 Kya (PS Ungar, personal communication). Studies
in more recent hominins, such as from an Upper Palaeo-
lithic site in the Levant (22 500 – 23 500 before present;
BP) showed a high frequency of long narrow scratches
and few small pits, suggesting a tough abrasive diet of
aquatic foods rather than a diet with hard foods that
needed compressive force
(198,199)
. A study of subsequent
local hunter–gatherer (12 500–10 250 BP) and farmers
(10 250 –7500 BP) living in the Levant showed larger
dental pits and wider scratches among the farmers com-
pared with the hunter–gatherers, suggesting that the
implementation of agriculture led to a more fracture-
resistant diet
(199)
.
Gut morphology, energy expenditure and muscularity.
Gut morphology studies
(200,201)
support the introduction
of animal foods, at the expense of vegetable foods, in
the diet of early Homo. The dominance of the colon
(.45 %) in apes indicates adaptation to a diet rich in
bulky plant material, such as plant fibre and woody
seeds. In contrast, the proportion of the human gut domi-
nated by the small intestine (.56 %) suggests adaptation to
a diet that is highly digestible, indicating a closer structural
analogy with carnivores than to folivorous or frugivorous
mammals. Importantly, the shorter gut in Homo, as com-
pared with primates, might have had some other advan-
tage. During the evolution from Ardipithecus and
Australopithecines to early Homo, the improvement of diet-
ary quality coincided with an increase in height, the size of
our brain and its metabolic activity. However, an increase
in body size coincides with increased daily energy
demands, notably during gestation
(202)
and lactation
(203)
.
It was, for example, calculated that daily energy expendi-
ture for a Homo erectus female is about 66 % higher com-
pared with an Australopithicine female, while being
almost 100 % higher in a lactating Homo erectus female
compared with a non-lactating, non-pregnant Australo-
pithicine
(204)
. These high energy demands might have
been met by increased female fat reserves
(205,206)
, such as
demonstrated by the presence of female steatopygia in
some traditional human populations, such as the Khoisan
of southern Africa.
Apart from the extra energy need for reproduction and
increasing height, the human brain of a modern adult uses
20–25 en% of the total RMR, while this value is 8 –9 en%
for a primate
(207)
. It has been postulated that the extra
energy needs did not derive from a general increase in
RMR, but partly from a concomitant reduction of the gastro-
intestinal tract
(208)
and a reduction in muscularity
(207)
. These
features are combined in the ‘expensive tissue hypothesis’ of
Aiello & Wheeler
(208)
that points at the observation that the
mass of the human gastrointestinal tract is only 60 % of that
expected for a similar-sized primate and that humans are
relatively under-muscled compared with other primates
(207)
.
Interestingly, the negative relationship between gut and
brain size across anthropoid primates
(209)
was confirmed
in a study with highly encephalised fish
(210)
, whereas it
became falsified in mammals
(102)
. Unfortunately, however,
the latter study did not include marine mammals
(102)
, while
it is questionable whether with respect to brain development
humans adhere to general mammalian rules
(103)
. Other
adaptations might have saved energy expenditure as well.
The short human inter-birth interval
(204)
, compared with
inter-birth intervals of 4–8 years in the gorilla, chimpanzee
and orangutang
(211)
, reduces the most expensive part of
reproduction, i.e. lactation
(212,213)
, while the shift from quad-
rupedal to bipedal locomotion also reduced daily energy
expenditure
(214)
. Together, all of these adaptations allow
for an increased daily energy expenditure, including the
reallocation of energy to the metabolically active brain, but
were only possible after Homo included more energy-
dense foods into its diet. Brain mass in primates is positively
related to dietary quality and inversely to body weight
(207)
.
Generally, a shift towards more energy-dense foods includes
a shift from primarily carbohydrate-rich vegetables to fat-
and protein-rich animal foods. However, it has also been
suggested that a shift from the complex carbohydrates in
leafy vegetables towards underground storage organs,
such as tubers, might have provided easy-to-digest carbo-
hydrates
(200,215)
to support a larger hominin body mass.
A phenotypic specialisation on non-preferred resources,
without compromising the ability to use preferred
resources, is also known as Liem’s paradox
(216)
. This para-
dox is important to keep in mind during attempts to recon-
struct the preferred diet from the available evidence.
Interestingly, Stewart
(156)
recently noted that in the case
of Paranthropus’s phenotype with regard to its fallback
food, there is just as much evidence to talk about a ‘Nut-
cracker Man’ as there is to talk about a ‘Shellcracker
Man’. Thus, a phenotypic characterisation needs support
from other studies to confirm adaptation to preferred
rather than fallback foods. In other words, it should be
noted that not all physical characteristics might be taken
as unambiguous proof for the preferred diet of early homi-
nins (Liem’s paradox). The increasing absolute body size
and brain size and the reduction in gut size, however, do
indicate a shift from low- to high-dietary-quality foods for
more recent hominins.
Biogeochemistry
Evidence from the strontium:calcium ratio. Based upon
the principle ‘you are what you eat’
(217)
several techniques
have been developed to study early hominin diets
(218)
.
Trace element studies first started with Sr:Ca ratios, which
decrease as an animal moves up the food chain, secondary
to the biological discrimination against strontium
(219)
. A first
study
(220)
suggested that Paranthropus robustus (Fig. 1)
R. S. Kuipers et al.106
Nutrition Research Reviews

had lower Sr:Ca ratios compared with contemporaneous
Papio (baboon) and Procavia (hyrax), suggesting that
Paranthropus was not an exclusive herbivore. However,
a subsequent study showed that two Homo specimens
had a higher Sr:Ca ratio than Paranthropus
(221)
. Since
Homo had been assumed to consume more animal foods
than Paranthropus and thus have a lower Sr:Ca ratio,
these higher Sr:Ca ratios needed explanation. For example,
consumption of specific foods with a high Sr:Ca ratio
might have increased the ratio in Homo compared with
Paranthropus. Foods in the area of research with elevated
Sr:Ca ratios were mainly geophytes. These are notably
perennial plants with underground food storage organs,
such as roots, bulbs, tubers, corms and rhizomes. Conse-
quently, this discrepancy has been attributed to the
consumption of underground storage organs by early
Homo
(215,221)
. The use of these underground storage
organs may have become necessary from the start of a
first period of aridity about 2·8 Mya, when forest was
replaced by drier woodlands, forcing hominins to search
for available resources around water margins
(222)
.
Although promising at first, the use of Sr:Ca ratios was
found to suffer from several limitations. For example, a
problem is that hominin Sr:Ca ratios in fossilised bones
alter with time
(223)
, a process that is known as diagenesis.
This problem can be circumvented by the use of tooth
enamel, which is less susceptible to diagenesis than
bone
(223)
. Subsequent studies showed that Australopithe-
cus africanus had a higher Sr:Ca ratio in its enamel
compared with Paranthropus and contemporaneous
browsers, grazers, baboons and carnivores
(224 – 226)
. The
interpretation of these findings, however, remains a subject
of debate. For example, a group of brown seaweeds and
some aquatic plants discriminate against Ca, resulting in
an increase in the Sr:Ca ratio, and likewise in the Sr:Ca
ratio of the fish feeding on them
(226,227)
. Similarly, leaves
from trees have lower Sr:Ca ratios compared with grasses,
which becomes subsequently reflected in the Sr:Ca ratios
of browsers and grazers, respectively
(228)
. Thus, it might
be argued that the relatively high Sr:Ca ratios in Australo-
pithicines and Homo reflect their consumption of aquatic
resources or of animals such as insects or other small
animals feeding on grasses. For now, the exploration of
especially Sr:Ca ratios as a dietary proxy method has
largely been stalled
(229)
.
Evidence from the barium:calcium ratio. Another trace
element ratio that might provide information on the
composition of the early hominin diet is the Ba:Ca ratio,
particularly when used in a multiple-element analysis
with Sr:Ca and Sr:Ba ratios
(224,230)
. Combined Ba:Ca and
Sr:Ba ratios clearly differentiate grazers from browsers
and carnivores in both modern and fossil mammals
(230)
.
Hominins have a lower Ba:Ca and higher Sr:Ba ratio
compared with grazers and browsers. Paranthropus
shows considerable similarity for both ratios with both car-
nivores and Papionins (baboons), while Australopithecus
shows an even higher Sr:Ba ratio. The unusual combi-
nation of a high Sr:Ca and low Ba:Ca ratio in hominins
(and baboons) has been further observed for some animals
such as warthogs and mole rats that make extensive use of
underground resources
(231)
. Finally, the high Sr:Ba ratio,
as observed in Australopithecus, might derive from the
consumption of grass seeds, which have Sr:Ba ratios
three to four times higher than grass straw, while consump-
tion of these grasses is also consistent with stable-isotope
evidence (see below) showing that Australopithecus
derived a substantial part of its diet from C
4
resources.
Although not included in any study so far, Sr:Ba ratios
in aquatic foods might add to the understanding of the
unusual combination of low Ba:Ca and high Sr:Ba ratios.
Evidence from the
13
C:
12
C ratio. Fractionation studies
of carbon isotopes differentiate between different routes
of photosynthesis. While most tropical African woody
plants from forests (like fruits, leaves, trees, roots,
bushes, shrubs and forbs) use the C
3
photosynthetic path-
way, some South African
(232)
and East African
(233)
grasses
and sedges use the C
4
photosynthetic pathway. C
4
plants
such as sedges (for example, Cyperus papyrus) typically
occur in a mosaic of extensive seasonal and perennial shal-
low freshwater wetlands that can also be found in savanna
and ‘bushvelds’ receiving summer rainfall
(234)
. The real
impact of C
4
plants occurred with their spread into Eastern
and Southern Africa during the Pliocene
(235)
. Tissues of
plants that utilise the C
4
pathway have a relatively high
content of the stable carbon isotope
13
C (about 1·1 % of
carbon), since C
3
plants discriminate more strongly against
13
CO
2
during photosynthesis. As a result C
3
and C
4
plants
have quite different
13
C:
12
C ratios in their tissues, as have
the herbivorous animals that feed on these plants
(228,232)
and the carnivores that prey on these herbivores
(193,206)
.
Differences are expressed as d
13
C values (d
13
C¼
((
13
C:
12
C)
sample
2(
13
C:
12
C)
standard
)£1000/(
13
C:
12
C)
standard
)
in parts per thousand (‰) relative to the
13
C:
12
C ratio in
the reference standard (named Pee Dee Belemnite; PDB),
i.e. the carbonate obtained from the fossil of a marine
Cretaceous cephalopod (Belemnitella americana) which
is highly enriched in
13
C(
13
C:
12
C ratio ¼0·0112372). Con-
sequently, most animals have negative d
13
C values (Fig. 5).
The d
13
C ranges from 235 to 221 ‰ (mean 226 ‰) in C
3
plants and from 214 to 210 ‰ (mean 212 ‰) in C
4
plants
(225)
. Studies that attempted to reconstruct mamma-
lian food webs indicated that carbon is slightly enriched
(1 –2 ‰) with each trophic step
(193,206)
. To facilitate com-
parison of current and historical animals, d
13
C analyses
are predominantly performed in hard tissues, such as
bone collagen and enamel (notably apatite), since these
constitute the majority of the fossil record. It was shown
that enamel mineral is enriched by about 13 ‰ compared
with dietary d
13
C
(238)
, while collagen is enriched by
about 5 ‰ compared with dietary d
13
C
(225)
. Collagen
from terrestrial mammal C
3
herbivores shows a value
of 221 ‰ (range 222 to 214 ‰), while in collagen of
Palaeolithic nutrition for disease prevention 107
Nutrition Research Reviews

C
4
herbivores this value is 27‰ (212 to 26 ‰). Their
respective carnivores show collagen values of 219 ‰
(221 to 214 ‰) and 25‰ (28to22 ‰), respect-
ively
(225)
. Marine phytoplankton, which uses the C
3
path-
way, shows an average value of 222 ‰
(239)
. Collagen of
marine fish shows a range from 215 ‰ to 210 ‰, while
the values in collagen of reef fish range from 28to
24‰
(240)
. Marine carnivores have, similar to terrestrial
carnivores, intermediate values of 214 ‰, ranging from
210 ‰ in collagen of sea otters to 215 ‰ in collagen of
the common dolphin
(239,240)
. Thus, also the d
13
C values
of marine carnivores compare well with those of their
prey. Finally, d
13
C values for the muscle of freshwater
fish species range from 224 to 213 ‰, but considerable
variation may exist between different lakes
(241)
. Unfortu-
nately, no d
13
C data are available for terrestrial piscivorous
carnivores, but the consistency of the other data suggests
that these might be between 224 and 213 ‰, i.e. compar-
able with their prey (Fig. 5).
Consistent with the data above, Schoeninger et al.
(242)
showed that European agriculturalists consuming C
3
grasses had much lower d
13
C values in bone collagen
(221 to 219 ‰) compared with Mesoamerican agricultur-
alist consuming C
4
maize (27to25 ‰), while North
American and European fisher–gatherers had intermediate
values (215 to 211 ‰). However, bone collagen proved
less reliable to study early hominin diets. For that purpose
the
13
C:
12
C ratio is preferably measured in tooth enamel.
To compare collagen d
13
C values with enamel d
13
C
values, an additional (8 ‰) correction has to be made.
Similar to the clear distinctions between bone collagen of
modern grazers, browsers and their carnivores, tooth
enamel data from fossilised fauna from South Africa
showed similar differences for Plio-Pleistocene C
3
feeders
(211·5 ‰) and C
4
feeders (20·5 ‰), with Australopithe-
cus,Paranthropus and Homo taking intermediate positions
(210 to 24‰)
(231,234,237,243)
, which compared well with
the values for contemporaneous felids (210 to
20·5 ‰)
(231,237,244)
(Fig. 5). These results clearly demon-
strated that a significant proportion of the diets of the
early hominins from Swartkrans, Makapansgat and Sterk-
fontein derived from C
4
resources. Using these data it
Freshwater fish
C4 agriculturalist*
Reef fish*
C4 carnivore*
C4 herbivore*
Sea grasses
–35 –25 –15 –5
Marine fish*
C4 plants
Fisher–gatherer*
Marine carnivore*
Crustacean*
Marine mammal hunter*
C3 herbivore*
Freshwater carnivore§
C3 agriculturist*
C3 carnivore*
Marine plankton‡
C3 plants
Baboon sp.†
Termites
Paranthropus
sp.†
Australopithecus
sp.†
Homo
sp.†
Normalised d 13C values (%)
Fig. 5. Normalised collagen d
13
C values (mean and range; in per thousand (‰)) in plankton, crustaceans, sea grasses, C
3
and C
4
plants; of marine crustaceans,
fish and freshwater fish and their respective carnivores; of terrestrial C
3
and C
4
herbivores and their carnivores; and of human groups in historic and prehistoric
times. * Corrected
(229)
for collagen (25 ‰). † Corrected
(238)
for enamel (213 ‰). ‡ Arbitrary range of ^1 ‰ due to a lack of data. § As predicted from other
predator– prey relationships and after correction
(239)
for tropic level (þ1 ‰). Adapted from Ambrose & Deniro
(228)
, Sponheimer et al.
(231,247)
, Peters & Vogel
(234)
,
Lee-Thorp et al.
(237,244)
, Kelly
(239)
, Schoeninger & Deniro
(240)
, Mbabazi et al.
(241)
, Schoeninger et al.
(242,246)
, Sponheimer & Lee-Thorp
(243,248,249)
and van der
Merwe et al.
(245)
.
R. S. Kuipers et al.108
Nutrition Research Reviews

was calculated that South African Paranthropus derived
14 –47 % of its diet from C
4
sources, compared with
5–64 % in Australopithecus and 20–35 % in Homo
(245)
.
A second study in Olduvai showed that the Tanzanian
Paranthropus boisei derived 77 – 81 % and Homo 23 –49 %
from its diet from C
4
resources
(245)
. The low nutritional
value of grasses, and microwear studies (see above)
render it unlikely that humans were directly eating
grass
(231,243)
. Analogously, the sizeable carnivory of C
4
-
consuming mammals (such as cane rats, hyraxes or juven-
ile bovis) was argued to be practically impossible and thus
unable to leave a strong C
4
signature
(243)
. However, at
about 1·8 Mya, there were extensive wetlands in the Oldu-
vai area, where a river from the Ngorongoro mountains
entered the area, while at 1·5 Mya the Peninj river pro-
duced wetlands near Lake Natron
(156)
. Some researchers
investigated the edible plants in a present-day wetland
(Okavango Delta) and found that the rhizomes and
culms of three species of C
4
sedges were edible, the
most common one of which is Cyperus papyrus
(245)
. How-
ever, it seems unlikely that the C
4
signature in all early
hominins derived from the consumption of papyrus. It
was recently suggested that P. robustus and especially
P. boisei had a diet of primarily C
4
resources, most probably
grasses or sedges, from savanna or wetland environments,
respectively
(190)
. Theoretically, a good source of C
4
foods would be a seasonal freshwater wetland with flood-
plains and perennial marshlands, with an abundance of
easy accessible aquatic foods, large aggregations of nesting
birds and calving ungulates
(234)
. Consumption of termites
could have contributed to the high C
4
signature observed
in hominin fossils (Fig. 5), but it seems unlikely that termites
could explain values as high as 50 % of the diet from C
4
( 243)
.
Finally, an enamel C
4
signature of 210 to 24 ‰ in hominins,
which translates into a soft tissue signature of 223 to 217 ‰
and a collagen signature of 218 to 212 ‰ (see above),
might also derive from the consumption of small
freshwater aquatic animals or fish, since they compare well
with the d
13
C values of 224 to 213 ‰ for freshwater
fish
(241)
and 218 to 29 ‰ in collagen of crustaceans and
anthropods
(240)
, respectively. Moreover, d
13
C values for
hominins are similar to those reported for marine mammal
hunters, freshwater fish, crustaceans, fisher–gatherers,
marine and freshwater carnivores and marine fish (Fig. 5).
In agreement with the variability selection hypothesis
of Potts
(170)
, which states that large disparities in
environmental conditions were responsible for important
episodes of adaptive evolution, the wide range in d
13
C
values in particularly Australopithecus suggests that early
hominins utilised a wide range of dietary sources, includ-
ing C
4
resources. This contrasts with chimpanzees,
which, even in the most arid and open areas of their
range, are known to consume negligible amounts of C
4
resources, despite their local abundancy. Consequently,
chimpanzees show very little variability in their d
13
C
carbon signature
(246,247)
. This underscores that even if
contemporaneous chimpanzees and early hominins
inhabited similar habitats, hominins had broadened their
dietary range sufficiently to survive in habitats uninhabita-
ble by chimpanzees. The latter assumption provides an
interesting perspective on the recent data, which suggest
that C
4
foods were absent in the diet of Ardipithecus
ramidus at 4·4 Mya. Consequently, it has been proposed
that the origins of the introduction of C
4
foods into the
hominin diet lie in the period between 3 and 4 Mya
(229)
.
Limited evidence from the
15
N:
14
N ratio. Another
stable-isotope ratio that has received considerable attention
is the N isotope (
15
N:
14
N) ratio. A number of food web
studies have shown that each step in the food chain is
accompanied by 3–4 ‰ enrichment in d
15
N
(228,239)
and
that d
15
N can therefore be useful as a trophic level indi-
cator. Additionally, animals feeding in marine ecosystems
have higher values compared with animals feeding on ter-
restrial resources
(242)
. For example, North American and
European fisher–gatherers and North American marine
mammal hunters and salmon fishers had much higher
d
15
N values (þ13 to þ20 ‰) compared with agricultural-
ists (þ6toþ12 ‰). Analyses of phyto- and zooplankton
suggest that freshwater organisms have d
15
N values inter-
mediate to terrestrial and marine organisms
(242)
.d
15
N
values are routinely measured in bone collagen, but it
has been shown that good-quality collagen (preserving
the original d
15
N value) can, and only under favourable
conditions, survive up to a maximum of 200 000
years
(225)
. This limits d
15
N isotopic studies to Late Pleisto-
cene hominins (see below), but with improved technology,
future studies using collagen extracted from tooth enamel
may expand their application to early hominins
(238)
.
Limited evidence from the
18
O:
16
O ratio. A final iso-
tope that might provide information about an animal’s
diet and thermophysiological adaptations is the oxygen
isotope ratio (
18
O:
16
O). More energy is needed to vaporise
H
2
18
O than H
2
16
O. When ocean water evaporates and during
evapotranspiration, i.e. the sum of evaporation and plant
transpiration from the earth’s land surface to the atmos-
phere, more of the lighter isotope evaporates as
H
2
16
O. The ensuing
18
O enrichment of transpiring leaves
results in
18
O enrichment in typical browsers such as
kudu and giraffe who rely less on free drinking water
and derive most of their water from the consumption of
the
18
O-enriched plant water. As the
16
O-enriched water
vapour in clouds moves inland, some of it condenses as
rain, during which more of the heavier isotope (as H
2
18
O)
rains out, making the d
18
O of coastal rain only slightly
less enriched than the original vaporated ocean water,
while the d
18
O of the remaining water vapour that even-
tually comes down is highly negative (i.e. more
18
O
depleted). Consequently, river water from rain and melting
ice is more d
18
O negative than seawater. Roots derive their
water from meteoric or underground water that is thus
relatively depleted from
18
O and so become animals that
are consuming these roots
(248,249)
. Browsers of leaves
Palaeolithic nutrition for disease prevention 109
Nutrition Research Reviews

undergoing evapotranspiration and consumers of roots
may thus be expected to have high and low d
18
O values,
respectively.
Australopiths showed lower d
18
O values compared with
Paranthropus, but the meaning of this difference remains
uncertain. However, one might argue that Australopithecus
preferred less arid conditions compared with Paranthropus
or was more dependent on seasonal drinking water
(231)
.
Low d
18
O was additionally found in primates and suids,
which might be linked to frugivory, although this is not
supported by the higher
18
O values found in Ardipithecus
ramidus compared with Australopithicines
(68,229)
. Taken
together, the use of d
18
O for exploration of ancient
human diets is still in its infancy, but might, especially in
combination with other isotope ratios, become more
appreciated in the future.
Isotopic data for more recent hominins. It would be of
high interest to explore the hominin diet during the last
spurt of encephalisation between 1·9 Mya to 100 Kya,
when brain size tripled in size to volumes between 1200
and 1490 cm
3
for Homo erectus,H. heidelbergensis,
H. neanderthalensis and modern H. sapiens
(100)
. Isotopic
data for this period are, however, absent. Due to the lim-
ited preservation of collagen beyond 200 000 years, and
the near absence of C
4
plants in Europe, these answers
will have to come from further studies with tooth enamel
in Africa and Asia. So far, there is no isotope evidence
for the diet of Homo between 1·5 Mya up to 50 Kya
(MP Richards, personal communication).
Dietary information from more recent humans comes
from data on d
13
C, supplemented with data on d
15
N and
the
13
C:
15
N ratio. The
15
N-isotope values of bone col-
lagen
(242)
for differentiation between aquatic and agricul-
tural diets were additionally verified by the study of the
sulfur isotope ratios (
34
S:
32
S), since high intakes of
marine organisms also result in higher d
34
S values
(250)
.
Combined isotope studies reveal high intakes of animal
protein, with substantial proportions derived from fresh-
water fish by Upper and Middle Palaeolithic (40–12 Kya)
humans in Eurasia, indicating that in some populations
about 30 % of dietary protein came from marine
sources
(250 – 256)
. In contrast, isotopic evidence indicates
that Neanderthals were top-level carnivores that obtained
most of their dietary protein from large terrestrial herbi-
vores, although even Neanderthals certainly exploited
shellfish such as clams, oysters, mussels and fish on
occasion
(250 – 252)
. At the onset of the Neolithic period
(5200 years ago), there was a rapid and complete change
from aquatic- to terrestrial-derived proteins among both
coastal and inland Britons compared with Mesolithic
(9000–5200 years ago) British humans
(254)
, which
coincides precisely with the local onset of the Agricultural
Revolution in Europe.
Conclusions from isotope studies. The isotope systems
that have been studied thus far in hominin bone and teeth
provide evidence that early hominins were opportunistic
feeders
(257)
. The spread of C
4
foods in East Africa, and sub-
sequently in the hominin food chain between 3 and 4 Mya,
is in agreement with a niche of early hominins that locates
close to the water. This conception is in agreement with
the palaeo-environmental evidence. However, many ques-
tions still remain unanswered. With regard to the possible
niche in the water–land interface, it seems interesting to
include aquatic as well as terrestrial piscivorous animals
into future studies. The data of combined studies of early
hominins and the more recent hominins suggest a gradual
increase in dietary animal protein, a part of which may
derive from aquatic resources. In the more recent human
ancestors, a substantial part of the dietary protein was irre-
futably derived from marine resources, and this habit was
only abandoned in some cases after the introduction of
agriculture at the onset of the Neolithic
(254)
.
Archeology
The oldest stone tools found so far are dated to 2·6
Mya
(258,259)
and it has been suggested that these were
used for flesh removal and percussion on long bones for
marrow access. From this time onward stone tools were
apparently used for defleshing and butchering of large ani-
mals. However, again there is a pitfall in putting too much
emphasis on the association between stone tools and hunt-
ing and butchering of large animals as the sole food source
of the human ancestors, especially with regard to brain
foods such as LCP. As stated by Liem’s paradox; the appar-
ently overwhelming evidence for the consumption of bone
marrow, or even brain from cracked skulls, by the findings
of cut marks on animal bone may not be evidence for the
primary food resources of human ancestors, but only for its
fallback food. Bones, especially long bones, are also better
preserved than vegetable material. Moreover, cut marks on
bone are easier ascribed to human utilisation than any
nearby found fossilised fish bones or molluscan shells
that only seldomly bear cut marks
(260,261)
and are often
not even examined. Hence, while human remains are
nearly always found in the vicinity of water and the fossil
record of nearby found fish is extensive
(74,262)
, the exploi-
tation of aquatic resources is difficult to relate to early
man
(263)
.
The present review is about the diet that allowed early
humans to increase their brain size and thereby become
intelligent enough to develop, for example, symbolic
thinking and the controlled use of fire. Hunting and/or
scavenging is often invoked as an important source of
LCP, but, as pointed out by Crawford
(2)
, even in the
more recent certainly ‘hunting’ ancestors ‘a [scavenged]
small brain was not going to go far among the ladies
[and children] even if it was still in an edible condition
when they [the male hunters] got it back [from the
savanna]’
(2)
, not even in the scenario
(264)
that we were
specialised, as suggested
(265)
, in endurance running.
Apart from organ tissue (liver and brain) and bone
R. S. Kuipers et al.110
Nutrition Research Reviews

marrow (whether scavenged or hunted), fish, shellfish and
other aquatic foods are also mentioned as rich sources
of the nutrients involved in brain expansion
(99,130,266)
.
Therefore, the question arises whether the archeological
evidence for human habitation in the land–water ecosys-
tem only represents facilitated fossilisation or indicates
the true ecological niche. The following section will
focus on comparable evidence for the concurrent exploi-
tation of aquatic resources.
Living in the water–land ecosystem. Because sea
levels have risen up to 150 m in the past 17 000 years, a
substantial part of the evidence for the exploitation of
aquatic resources is hidden below sea level, if not perma-
nently destroyed by the water
(267,268)
. However, in Kenya,
a site in East Turkana provides solid evidence that at about
1·95 Mya hominins enjoyed carcasses of both terrestrial and
aquatic animals including turtles, crocodiles and fish,
which were associated with Oldowan artifacts
(261)
. More
ambiguous evidence for the exploitation of freshwater
fish, crocodiles, turtles, amphibians and molluscs by
Homo habilis in the Olduvai Gorge in Tanzania goes
back as far as 1·8–1·1 Mya
(267,269)
. Subsequent tentative
evidence from the Olduvai Gorge dates the use of similar
aquatic resources by Homo erectus to 1·1 – 0·8
Mya
(267,269)
. Also the out-of-Africa diaspora probably took
place largely via the coastlines
(81)
, even after the crossing
of the Bering Strait into North America
(270)
(Fig. 2). In
Koa Pah Nam, Thailand, 700 000-year-old piles of fresh-
water oyster shells were associated with Homo erec-
tus
(271,272)
. In Holon, Israel, freshwater turtles, shells and
hippopotamus bones were associated with Homo erectus
and dated to 500–400 Kya
(273)
.Homo erectus fossils associ-
ated with seal remains in Mas del Caves (Lunel-Viel,
France) were dated to 400 Kya
(274)
.
The archeological evidence for aquatic resource use
increases with the appearance of archaic Homo
sapiens
(267)
. Although dominated by land mammal
bones, 400 000– 200 000-year-old remains from penguin
and cormorants in Duinefontein, South Africa were associ-
ated with early Homo
(275)
. Shellfish and possibly fish
remains, dated 300–230 Kya, were associated with the
French coastal campsite at Terra Amata
(276,277)
, while
marine shellfish and associated early human remains,
dated 186–127 Kya, were found in Lazaret, France
(274)
.
Marean et al.
(278)
found evidence for the inclusion of
marine resources, at 164 Kya, in the diet of anatomically
modern humans from the Pinnacle Point Caves (South
Africa). At the Eritrea Red Sea coast, Middle Stone Age arti-
facts on a fossil reef support the view that early humans
exploited near-shore marine food resources by at least
125 Kya
(279)
. In several North African sites, dated to
40–150 Kya
(267)
, human remains were associated with
shell middens and aquatic resources such as aquatic
snails, monk seals, mussels and crabs. Several European
sites, dated to 30–125 Kya, are comparable with archeolo-
gical sites that reveal evidence ranging from thick layers of
mussels and large heaps of marine shells in Gibraltar
(267)
to
diverse marine shells in Italy
(280)
, and to a casual descrip-
tion of the presence of marine shells of unknown density
in Gruta da Figueira in Portugal
(267)
. Further evidence for
the use of shellfish, sea mammals and flightless birds
comes from: Klasies River Mouth (South Africa) dated
between 130 and 55 Kya
(267,281,282)
; from Boegoeberg,
where 130 000 – 40 000-year-old shell middens and cormor-
ant bones were associated with Homo sapiens
(267,283)
; from
Herolds Bay Cave, where 120 000 – 80 000-year-old shell
middens, shellfish, mussels and otter remains were associ-
ated with human hearths
(267)
; from Die Kelders (75–55
Kya), where abundant remains of sea mammals, birds
and shellfish were found in cave deposits
(267,284)
; and
from Hoedjies Punt (70–60 Kya), Sea Harvest (70–60
Kya) and Blombos Cave (60–50 Kya) for the use of shell-
fish, sea mammals and fish
(267,285)
. From this period
onwards, human settlements are strongly associated with
the exploitation of aquatic resources
(267,268,282,286 – 288)
. Evi-
dence for more sophisticated fishing by use of barbed
bone harpoon points dates back to 90–75 Kya in Katanda,
Semlike River, Zaire
(289,290)
and to 70 Kya in South
Africa
(291)
. Finally, indications for seafaring are dated to
42–15 Kya
(292 – 294)
. Possibly, seafaring dates as far back
as 800 Kya, as indicated by the finding of Homo erectus
stone tools at the Indonesian island of Flores, which is
located on the other side of a deep sea strait
(79,295 – 299)
.
In general, many archeological sites are found along chan-
nels, lake- and seashores
(99,266,267,282)
and reveal aquatic
fauna, such as catfish, crocodile and hippopotamus
(300)
,
but its proves difficult to relate their possible utilisation
to our early ancestors.
Several events within the time span of the past about 2
million years have been attributed to the increase in
brain size and intelligence. The introduction of meat in
the hominin diet, which resulted in a higher dietary quality,
has been discussed above. Claims for controlled fire in the
Olduvai Gorge (Tanzania) and Koobi Fora (Kenya) go as
far back as 1·5 Mya
(215,301,302)
. Evidence for cooking is as
old as 250 Kya
(301)
, but possibly dates back to 800
Kya
(303)
, when indications of controlled fire were found
to be present. However, recently it has been concluded
that solid evidence for systematic use of fire is only
found from 400 to 300 Kya onwards
(304)
. Evidence that
cooking provided increased dietary quality was recently
provided by Wrangham et al.
(215)
. According to archeo-
logical evidence, this could only have played an important
role since the appearance of Homo sapiens
(215,301)
and
Neanderthals
(305)
. Also, the inclusion of aquatic resources
as an attributor to human brain evolution has been
suggested
(2,99 – 101,130,266,306 – 308)
, but remains a matter of
debate
(134,135,268,309)
.
From hunting–gathering to agriculture. The hunter–
gatherer lifestyle continued worldwide for several millions
of years and ended quite abruptly with the introduction
of agriculture. The first indications for the abandonment
Palaeolithic nutrition for disease prevention 111
Nutrition Research Reviews

of the hunter–gatherer lifestyle towards settlement come
from a 23 000 year-old fisher – hunter– gatherer’s camp at
the shore of the Sea of Galilee
(310,311)
. The associated
return from diets containing substantial amounts of protein
(from hunting and gathering) back to substantial amounts
of carbohydrates is supported by indications for the
ground collecting of wild cereals
(312)
. This was slowly fol-
lowed by the large-scale utilisation of cereals starting with
the onset of the Agricultural Revolution some 10 Kya.
As indicated above (see ‘Biogeochemistry’), there is
much controversy about the diet of the earliest humans
and until now it is often stated that fishing was only intro-
duced until more recently. From an anthropological per-
spective this might be true, since certain types (for
example, deepwater) of fishing require advanced tech-
niques
(294)
. However, from a nutritional point of view,
‘fishing’ might include anything from collecting sessile
shellfish to the seasonal hand capture or clubbing of
migrating or spawning fish in very shallow water. Since
fresh drinking water is the single most important aquatic
resource for humans, hominins probably observed preda-
tors and scavengers feeding on aquatic animals. This
makes it unlikely that they would not have participated
in opportunistic harvesting of the shallow-water flora and
fauna, such as molluscs, crabs, sea urchins, barnacles,
shrimp, fish, fish roe or spawn, amphibians, reptiles,
small mammals, birds or weeds
(175,267)
. There are many
indications suggesting that the evolution of early Homo
and its development to Homo sapiens did not take place
in the ‘classical’ hot, arid and waterless savanna, but
occurred in African ecosystems that were notably located
in places where the land meets the water (with the land
ecosystem possibly consisting of – depending on rainfall
– wooded grasslands). Compared with terrestrial hunting
and/or scavenging in the savanna, food from this land –
water ecosystem is relatively easy to obtain and is rich in
the aforementioned combination of haem-Fe, iodine, Se,
vitamins A and D, and long-chain n-3-fatty acids
(100,101,266)
.
In conclusion, there is ample archeological evidence for
a shift from the consumption of plant towards animal
foods. Second, although there is an extensive archeological
record for aquatic fossils (representing possible food) in
the vicinity of human remains, their co-occurence is
usually attributed to the preferential conservation of
human remains in the vicinity of water. The present
review provides support for the notion that the exploita-
tion of these aquatic resources by hominins in coastal
areas should be the default assumption, unless proven
otherwise
(154)
. For a long time period in hominin evol-
ution, hominins derived large amounts of energy from
(terrestrial and aquatic) animal fat and protein. This habit
became reversed only by the onset of the Neolithic
Revolution in the Middle East starting about 10 Kya.
Anthropology
The hunter–gatherer diet. The Homo genus has been on
earth for at least 2·4 million years
(313)
and for over 99 % of
this period has lived as hunter –gatherers
(314)
. Surprisingly,
very little information is available on the macro- and micro-
nutrient compositions of their diet in this extended and
important period of human evolution
(34,148)
. Since the
onset of agriculture, about 10 Kya, agriculturalists and
nomadic pastoralists have been expanding at the expense
of hunter–gatherers
(314)
, with agricultural densities increas-
ing by a factor of 10 –1000 compared with the highest
hunter densities. For this reason, present-day hunter–
gatherers are often found in marginal environments,
unattractive for crop cultivation or animal husbandry.
In order to study the original hunter–gatherer way of
life, it is appropriate to aim at the few hunter –gatherer
communities living in the richer environments that bear
closer resemblance to those in which the evolution of the
genus Homo probably took place. Most studies on
hunter–gatherers and their diets are, however, performed
by anthropologists
(315)
, whose primary interests are differ-
ent from those of nutritionists. Anthropologists would, for
example, conclude that ‘fishing was so unimportant as to
be a type of food collection’
(316)
, or consider collecting
both small land fauna and shellfish
(314)
as part of ‘gather-
ing’, whereas from a nutritional point of view considerable
differences exist in energy density, macro- and micro-
nutrient composition between plants, terrestrial and
aquatic animal foods.
Hunting v. gathering. Studies on food procurement of
present-day hunter–gatherer societies show, in terms of
energy gain v. expenditure, the advantage of hunting com-
pared with plant foraging
(192)
. Nevertheless, three distinct
studies
(41,148,314)
showed that hunting makes up only
about 35 % of the subsistence base for worldwide
hunter–gatherers, independent of latitude or environment.
However, collection of small land fauna and shellfish was
included as gathering in these studies. While gathering evi-
dently played an important role over the whole of human
evolution, hunting, although introduced later, coincided
with ‘a major leap for mankind’ and has ever since
played the most dominating cultural role. While hunting
may have overtaken gathering in cultural importance, gath-
ering continued to play a very important nutritional role,
because: (i) gathering still contributes about 65 % to the
subsistence base; (ii) many micronutrients derive only
from plant sources; (iii) gathering of, for example, shellfish
provides a substantial amount of LCP and other nutrients
essential for brain development; and (iv) gathering plays
an important cultural role since women, children and
grandparents can participate
(56,57,317)
.
Contrary to common belief, hunting in present-day
hunter–gatherers is still not very successful: the probability
for a kill in !Kung bushmen is only 23 %
(314)
and the sub-
sistence of Hadza, as described by Marlowe
(41)
and
R. S. Kuipers et al.112
Nutrition Research Reviews

Woodburn
(145)
, is composed of 75–80 % of plant foods.
Conversely, studies of North American hunting–gathering
societies describe the dietary role of shellfish as similar to
‘bread and butter’, being the staple food
(318)
in these
societies. The anthropological remark
(314)
that for many
studied hunter–gatherer tribes ‘fishing was only a type of
food collection’ also adds to the notion that the collection
of aquatic foods might have preceded scavenging and
hunting. Collecting aquatic foods is still daily practice in
Eastern Africa and picking up, clubbing or spearing
stranded aquatic animals seems much easier and safer
than either scavenging or hunting game on the Serengeti
plains.
We conclude that gathering plays, and most likely always
played, the major role in food procurement of humans.
Although hunting doubtlessly leaves the most prominent
signature in the archaeological record, gathering of veg-
etables and the collection of animal, notably aquatic,
resources (regardless of whether their collection is con-
sidered as either hunting or gathering), seems much
easier compared with hunting on the hot and arid savanna.
We suggest that it seems fair to consider these types of
foods as an important part of the human diet, unless
proven otherwise
(154)
. Conversely, while hunting might
have played a much more important role at higher lati-
tudes, dietary resources in these ecosystems are rich in
n-3-fatty acids (for example, fatty fish and large aquatic
mammals), while the hominin invasion of these biomes
occurred only after the development of more developed
hunting skills.
(Patho)physiology
Brain-selective nutrients. Nutrients and other environ-
mental factors are increasingly recognised to influence epi-
genetic marks
(319 – 323)
, either directly or indirectly via many
bodily sensors. Food from the diverse East African aquatic
ecosystems is rich in haem-Fe, iodine, Se, vitamins A and
D, and n-3 fatty acids from both vegetable origin and
fish
(101)
. All of these nutrients seem to act at the crossroad
of metabolism and inflammation
(24)
. For example,
PPAR
(324,325)
are lipid-driven nuclear receptors with key
cellular functions in metabolism and inflammation
(26)
.
TR
(326)
, VDR
(327)
, RXR and RAR
(328)
are other examples of
nuclear transcription factors that serve functions as
ligand-driven sensors. The iodine- and Se-dependent hor-
mone triiodothyronine (T
3
)
(329 – 331)
is a ligand of TR
(326)
,
many fatty acids and their derivatives are ligands of
PPAR
(332)
, the vitamin D-derived 1,25-dihydroxyvitamin D
hormone is a ligand of the VDR
(333)
,9-cis-retinoic acid
and the fish oil fatty acid DHA are ligands of RXR
(328)
,
while RAR interacts with vitamin A (retinol) and many of
its derivatives such as all-trans-retinoic acid, retinal and
retinyl acetate
(328)
. The ligated nuclear transcription factors
usually do not support transcription by themselves, but
need to homodimerise or heterodimerise notably with
RXR to facilitate gene transcription. Examples of the latter
are TR/RXR, PPAR/RXR, VDR/RXR and RAR/RXR. It has
become clear that their modes of action illustrate the
need of balance between, for example, iodine, Se, fish
oil fatty acids and vitamins A and D, a balance that is nota-
bly found in the land–water ecosystem.
Deficiencies of the above ‘brain-selective nutrients’ are
among the most widely encountered in the current world
population
(101,334)
. While iodide is added to table salt in
many countries, margarines and milk have become popu-
lar food products for fortification with vitamins A and
D. After discussing some general health differences
between traditionally living individuals and those living
in Westernised countries, we focus on the importance of
LCP and notably those of the n-3-series, as examples of
the above-mentioned nutrients that are especially abun-
dant in the land–water ecosystem.
Hunter–gatherer v. ‘Western’ physiology. There are
many differences in health indicators between traditionally
living individuals and those living in Western societies. For
instance, primary and secondary intervention trials with
statins indicate lowest CHD risk at an LDL-cholesterol of
500 –700 mg/l (1·3– 1·8 mmol/l), which is consistent with
levels encountered in primates in the wild and hunter–
gatherer populations with few deaths from CVD
(335 – 339)
.
Another example of the healthy lifestyle of present-day
hunter–gatherers comes from the observed ‘insulinopenia’
or ‘impaired insulin secretion’ following an oral glucose
tolerance test (Fig. 6) in Central African Pygmies and
Kalahri Bushmen
(340,341)
, respectively. As opposed to the
‘impairments’ noted by these authors, it may also be
argued that these researchers were actually witnessing an
insulin sensitivity that has become sporadic in Western
countries as a consequence of the decrease in physical
activity and fitness, increase in fat mass and as a result of
the quantity and quality of the foods consumed
(36,133,342)
.
The current consensus is that ‘fat is bad’ and especially
saturated fats have become associated with CVD
(343 – 345)
.
However, traditional Maasai consumed diets high in protein
and fat (milk and meat) and low in carbohydrates
(346,347)
.
They had high intakes of saturated fat and cholesterol,
showed extensive atherosclerosis with lipid infiltration and
fibrous changes, but had very few complicated lesions,
and were virtually devoid of CVD
(348)
. The average total
and LDL-cholesterol in these societies was low and did not
increase with age
(348)
. Finally, the physical fitness of indi-
viduals in such traditional societies, such as the Maasai,
is often remarkable
(337)
.
In Kalahari Desert Bushmen and Central African
Pygmies, observers could not find any case of high blood
pressure and blood pressure did not increase with
age
(335,349)
. Dental surveys of Kalahari Bushmen
(350)
and
other hunter–gatherers
(49)
showed a remarkable absence
of caries. The absence was explained by the repe-
titive annual abstinence of fermentable sugars in their
diet, with a consequent inability to build a cariogenic oral
Palaeolithic nutrition for disease prevention 113
Nutrition Research Reviews

Lactobacillus flora
(350)
. Inhabitants of Kitava (Trobriand
Islands, Papua New Guinea) have high intakes (70 en%)
of carbohydrates from yams, high intakes of SFA from
coconuts, and a high fish intake
(44,45,351)
. Although both
high intakes of carbohydrates and saturated fat have
been related to the metabolic syndrome and CVD, these
traditional Kitavians do not show symptoms of either the
metabolic syndrome and are virtually free from the Western
diseases that ensue from it.
Evidence-based medicine as applied to long-chain
PUFA in CVD and depression. Despite some compelling
examples of the healthy lifestyles of traditional populations,
current dietary recommendations derive preferably from
randomised clinical trials with single nutrients and pre-
ferably hard endpoints
(352)
. This approach clearly over-
simplifies the effects of dietary nutrients
(353)
, since neither
macronutrients, nor micronutrients, are consumed in iso-
lation and their effects may be the result of a complex web
of interactions between all the nutrients present in the
biological systems that we consume, such as a banana
or a fish.
The current recommendations from many nutritional
boards for a daily intake of 450 mg EPA þDHA in adults
derive from epidemiological data that demonstrated a nega-
tive association of fish consumption with CHD
(354 – 357)
that
has subsequently become supported by landmark trials
with ALA
(358)
and fish oil
(359 – 361)
in CVD. However, not all
trials in CVD have been positive
(362)
. In addition, a negative
association was observed for fish consumption and
depression
(363 – 365)
and for homicide mortality
(366)
. The
causality of these relationships was supported by some,
but not all, trials with fish oil in depression
(367 – 371)
, while a
recent meta-analysis demonstrated the beneficial effect of
EPA supplements with $60 % EPA of total EPA þDHA in
a dose range of 200 –2200 mg/d of EPA in excess of DHA
(372)
.
The influence of polymorphisms in the genome is
increasingly recognised, but seldom interpreted in an evol-
utionary context. As argued above, most polymorphisms
were already amongst us when Homo sapiens emerged,
some 200 Kya, while that also holds true for most, if
not all, currently identified ‘disease susceptibility genes’
that are usually abundant but confer low risk
(373)
.
10·0
9·0
8·0
7·0
6·0
5·0
4·0
3·0
2·0
1·0
0·0
0 20406080100
100
90
80
70
60
50
40
30
20
10
0
120
Time after glucose intake (min)
Plasma glucose (mmol/l)Plasma insulin (µU/l)
140 160 180 200
0204060
(b)
(a)
80 100 120
Time after glucose intake (min)
140 160 180 200
Fig. 6. ‘Abnormal’ insulin response but normal glucose response after oral glucose tolerance test in African Bushmen and Pygmies, compared with Western con-
trols. (a) Plasma glucose response after an oral glucose load of 50 g (Bushmen (V) and white controls (W)) or 100 g (Pygmy (B), Pygmy with 2 weeks’ daily sup-
plementation of 150 g carbohydrates before testing (O), Bantu (X) and American controls ( )). Of note is that Bushmen and Pygmies have significantly lower body
weights as compared with Bantu and white and American controls (average weight Bushmen/Pygmy males 46 kg, females 38 kg; controls 65 kg), while each
group received the same unadjusted loading dose of 50 g or 100 g glucose. (b) The so-called ‘abnormal’ insulin response or ‘impaired’ insulin secretionas
observed by the authors in both Bushmen and Pygmies
(340,341)
.
R. S. Kuipers et al.114
Nutrition Research Reviews

A loss-of-function mutation in a specific biosynthetic path-
way might be an evolutionary advantage if the specific
endproduct has been a consistent part of the diet, such
as is probably applicable to all vitamins, for example,
vitamin C
(374,375)
. Applied to our LCP status, it is nowadays
well established that all humans synthesise DHA with
difficulty
(376,377)
. Analogously, the recently discovered
polymorphisms of fatty acid desaturases 1 (FADS1; also
named D-5 desaturase) and FADS2 (D-6 desaturase) with
lower activities in their conversion of the parent essential
fatty acid to LCP suggest that from at least the time of
their appearance, the dietary intakes of AA, EPA and
DHA have been of sufficient magnitude to balance the
LCP n-3:LCP n-6 ratio
(378,379)
to maintain good health.
Long-chain PUFA benefits in pregnancy and early life.
Another indication for the importance of LCP comes from
the higher LCP contents in the fetal circulation compared
with the maternal circulation, a process named biomagnifi-
cation
(380 – 382)
, which occurs at the expense of the maternal
LCP status
(383,384)
. The decreasing maternal n-3 LCP status
during pregnancy in Western countries is associated with
postpartum depression
(363,364)
, although intervention
studies with LCP in postpartum depression have been
negative so far
(370,371,385,386)
. However, a positive effect
was seen for n-3 LCP supplementation on depression
during pregnancy
(387)
and it has been advocated to start
supplementation earlier in pregnancy and with higher
dosages
(388)
.
Maternal LCP intakes have also been related to infant
health. AA and DHA in premature and low-birth-weight
infants correlated positively with anthropometrics, AA
to increased birth weight
(389)
and DHA to prolonged
gestation
(390 – 392)
. Studies with supplementation of DHA
during pregnancy yielded, for example, evidence for:
(i) the maturation of the brain, visual system and retina
of the newborn at 2·5 and 4 months, but not at
6 months
(393 – 397)
; (ii) increased problem solving at 9
months but no difference in memory
(398)
; and (iii) superior
eye–hand coordination at 2·5 years
(399)
and higher intelli-
gence quotient at 4 years
(400)
but not at 7 years of
age
(401)
. In contrast to the inconclusive human studies,
animal studies and combined human and animal studies
showed abnormal behaviour together with disturbed cog-
nition at lower brain DHA levels
(402)
. The importance of
dietary AA during pregnancy seems less pronounced, but
a positive association between umbilical AA and neonatal
neurological development
(389)
and a lower venous AA for
those with slightly abnormal neurological development
(403)
has been shown. A reduced DHA status in the brain is
associated with a mildly increased AA status
(404)
, which is
in its turn associated with low-grade inflammation
(405)
.
Infant health starts with maternal health; thus dietary
recommendations issued for pregnant women indirectly
also apply to their infants. The recommendation for
adults to consume 450 mg DHA þEPA per d translates into
a DHA composition in breast milk of about 0·79 %
(406)
.
However, current recommendations for the composition
of infant formulae derive mainly from the range of
human milk fatty acid compositions as observed in Western
countries, which in their turn derive from women with
recorded intakes below the 450 mg recommended daily
intake of EPA þDHA
(407,408)
.
The same paradox holds for other fatty acids in breast
milk. For instance, there are few recommendations for
the medium-chain SFA (MCSFA) content of human milk.
High MCSFA contents in some traditional societies derive
from their high intakes of 12 : 0 and 14 : 0 from coco-
nuts
(409)
. Conversely, the high MCSFA contents in
Western populations are primarily influenced by maternal
carbohydrate intakes
(410)
, since the mammary gland
has the unique ability to convert glucose into MCSFA
(6 : 0 –14 : 0), mainly lauric (12 : 0) and myristic (14 : 0)
acids. However, women with regular consumption of coco-
nuts have a much higher 12 : 0:14 : 0 ratio compared with
women with high carbohydrate intakes. Both MCSFA are
readily absorbed in the gastrointestinal tract, while antiviral
as well as antibacterial properties have been attributed to
some MCSFA, but mainly to 12 : 0
(411,412)
.
The PUFA content of Western milk has increased over
the last decades
(413,414)
. While the human milk LA content
in the USA increased by at least 250 %, its DHA content
decreased by almost 50 %
(414)
. The (from an evolutionary
point of view) abnormally high LA intake is, despite a
lack of evidence
(415)
, advocated for cardiovascular
health
(416)
. The resulting high LA status is likely to interfere
with both the incorporation of AA and DHA into phospho-
lipids and also inhibits their synthesis from their parent
essential fatty acid
(417)
. Major differences are noted in the
comparison of the human milk fatty acid compositions of
Western mothers compared with some traditional African
women
(409,418)
, with unknown consequences for infant
health or the occurrence of disease at adult age (i.e. the
‘Barker hypothesis’)
(16,419)
. It has been proposed that the
high concentrations of EPA, DHA as well as AA in human
milk, such as described for many fish-consuming
societies
(409,420,421)
, might be a more appropriate reflection
of the Palaeolithic breast milk composition and may
therefore constitute a better reference for infant formulae
than do Western human milks
(422)
.
The influence of environment. It is estimated that 70 %
of all cases of stroke and colon cancer, 80% of all CVD and
90 % of all cases of type 2 diabetes mellitus have been
caused by lifestyle and could have been prevented by
paying more attention to modifiable behaviour factors,
including specific aspects of diet, overweight, inactivity
and smoking
(423)
. The mismatch between the human diet
and the Palaeolithic genome might therefore be respon-
sible for many typically Western diseases. In addition to
the evidence from many other disciplines, evidence from
(patho)physiology and epidemiology adds to the notion
that a great deal of information on healthy diets might
derive from the study of the diets of the early human
Palaeolithic nutrition for disease prevention 115
Nutrition Research Reviews

ancestors. The metabolic syndrome, characterised by
impaired insulin sensitivity, is at the centre of many dis-
eases of civilisation. High intakes of refined carbohydrates
as well as low intakes of LCP have been implicated in the
development of insulin resistance. As such, low carbo-
hydrate intakes
(424,425)
and high LCP
(8,34,426,427)
intakes
by the early human ancestor might explain in part the
low incidence of diseases of civilisation in current
hunter–gatherer societies. The available evidence from
pathophysiology and epidemiology supports the hypoth-
esis that the land–water ecosystem contributed important
and indispensable nutrients to evolving hominins.
Dietary reconstruction of the nutrients available
in Eastern Africa
The debate on the ecological niche of human ancestors is
unlikely to reach a consensus shortly. The millions of years
of human evolution concurred with marked and abrupt cli-
matic changes, which renders a single ecological niche of
human ancestry unlikely. However, it is at the same time
clear that in a short period of time humans have made
tremendous changes in their lifestyle, their diet included,
that lie at the basis of the diseases of Western civilisation.
This prompted various investigators to reconstruct the
possible compositions of diets that could have been
consumed by our Palaeolithic ancestors. Their studies
are, for example, based on the plausibility that before the
Agricultural Revolution, when humans lived as hunter–
gatherers, cereals were no appreciable part of the diet
and that wild animals living in the Eastern African savanna
and in Eastern African aquatic ecosystems have different
fatty acid compositions compared with the domesticated
animals that have now become staple foods. For example,
the lean savanna animals that inhabit the Eastern African
plains have much lower fat contents, and the available
fat is much more enriched in PUFA
(428)
. Similarly, high-
latitude (fatty) fish have much higher EPA and DHA con-
tents, but lower AA contents compared with low-latitude
(lean) fish from tropical waters
(429 – 432)
.
Eaton & Konner
(8)
where the first to use this approach in
reconstructing a Palaeolithic diet; their pioneer study was
published in the New England Journal of Medicine in
1985. The authors estimated that late Palaeolithic humans
consumed diets containing 35 % meat and 65 % vegetable
foods, containing 34 en% from protein, 45 en% from carbo-
hydrate and 21 en% from fat, while the ratio between poly-
unsaturated and saturated fat equalled 1·41 and their fibre
intake amounted to 46 g/d
(8)
. These outcomes contrasted
with the average American diet at the time, that consisted
of 12 en% protein, 46 en% carbohydrate and 42 en% fat,
with a polyunsaturated:saturated fat ratio of 0·44 and a
fibre intake of 20 g/d. After 25 years of additional study,
Konner & Eaton confirmed their previous findings by esti-
mating that the Palaeolithic diet provided 25–30 en% pro-
tein, 35–40 en% carbohydrate and 20– 35 en% fat
(433)
,
while the polyunsaturated:saturated fat ratio was 1·40
(434)
.
Moreover, they concluded that ‘it has become clear since
our initial publications that marine, lacustrine, and riverine
species were important sources of animal flesh during the
evolution of modern Homo sapiens, and may have played
a role in the evolution of brain ontogeny’
(433)
. In addition
to the earlier studies, they also estimated the vitamin and
mineral composition of a Palaeolithic diet, showing
higher contents of folate, riboflavin, thiamin, vitamins A
and E, Ca, Mg, P, Zn, and notably ascorbate, vitamin D
(sunlight), Cu, Fe, Mn and K, while the Palaeolithic diet
contained much lower Na compared with contemporary
US intakes and recommendations
(433 – 435)
. In a subsequent
study they estimated that in different ancient hunting and
gathering populations, fatty acid intakes would have
ranged from 5·19 to 20·6 g LA/d, 0·26 to 4·8 g AA/d, 3·45
to 25·2 g ALA/d and 0·03 to 1·52 g DHA/d, which contrasted
with the much higher LA (22·5 g/d) and lower ALA (1·2 g/d),
AA (0·6 g/d) and DHA (0·08 g/d) intakes as observed in
current Western populations
(34)
.
In a meticulous analysis of worldwide hunter–gatherer
diets, Cordain et al.
(148,436)
estimated that the most plaus-
ible percentages of total energy from dietary macronutri-
ents would be 19–35 en% from protein, 22–40 en% from
carbohydrate and 28–58 en% from fat, which reflects a
markedly higher contribution of dietary fat, a similar
amount of protein, but a lower contribution of carbo-
hydrates, compared with earlier estimates from Eaton &
Konner
(8,434)
. The main differences were explained by
the assumption that, wherever it was ecologically possible,
hunter –gatherers would have consumed 45 – 65 % of
total energy from animal foods
(148)
, while in the earlier
estimations
(8,434)
only 35 % derived from animal foods.
These higher animal food intakes were explained by
their inclusion of both worldwide hunting and fishing
hunting–gathering societies into their new calculation
models
(148)
, also including mounted and arctic hunters.
Those latter possibilities, however, seem insignificant
with regard to early human evolution, which explains
why they seem to overestimate the amount of the
diet that is derived from animal foods. For example,
Marlowe
(41)
estimated that in a warm-climate sample
about 53 % of the diet derives from gathering, 26 % from
hunting and 21 % from fishing (i.e. about 47 % from hunting).
To subsequently investigate the nutrient compositions of
such diets, fish consumption was incorporated as a separ-
ate variable to plant and meat consumption in the earlier
models, since aquatic and terrestrial animals have mark-
edly different fatty acid compositions. In this most recent
analysis
(437)
, 12 500 kJ (3000 kcal) Palaeolithic diets were
investigated with plant:animal food intake ratios ranging
from 70:30 to 30:70 en%/en% under the conditions
of four different foraging strategies in which the animal
part ranged from exclusive meat consumption including
the selective consumption of energy- and LCP-rich fat
from bone marrow and brain, respectively
(427)
, to the
R. S. Kuipers et al.116
Nutrition Research Reviews

consumption of an entirely aquatic diet in an Eastern Afri-
can water–land ecosystem
(438,439)
. It was found that that
the energy intakes from the macronutrients were: 25– 29
en% (range 8–35) from protein, 39 – 40 en% (range
19–48) from carbohydrate and 30 –39 en% (range 20–72)
from fat. Dietary LA ranged from 1·7 to 6·2 en%/d, AA
from 1·15 to 10·7 g/d, ALA from 2·1 to 5·8 en%/d and
EPA þDHA intakes from 0·87 to 28·3 g/d
(437)
. From
these data, despite their wide range in outcomes, it can
again be concluded that there are substantial differences
with respect to the average composition of the current
Western diet, notably because of its higher proportions of
carbohydrates and LA, and its much lower protein and
ALA and LCP contents. It became also conceivable that
ancestors living in the East African water–land ecosystem
had daily intakes of gram amounts of EPA þDHA. As
such, these n-3 LCP intakes were comparable with those
of the traditionally living Eskimos in Greenland, who
because of their low CVD risk
(354,355)
initiated the current
interest in the role of n-3 LCP in both primary and second-
ary prevention of CVD. In addition to these n-3 fatty acids,
the water–land ecosystem is also a rich source of haem-Fe,
iodine, Se and the vitamins A and D
(101)
, which have
important functions and interactions in gene transcription
and metabolism
(24,26,440)
.
Dietary changes since the Agricultural Revolution
Whatever the specific composition and wide range of
early hunter–gatherer diets, the current consensus is that
our diet has changed markedly from the time of large-scale
utilisation of cereals and animal domestication (i.e. the
Agricultural Revolution) starting some 10 Kya. Contrary to
earlier belief, the advent of agriculture coincided with an over-
all decline in nutrition and general health, but at the same
time provided an evolutionary advantage since it increased
birth ratesand thereby promotednet population growth
(49,50)
.
While the decline of nutritional quality and general
health started with the onset of the Agricultural Revolution,
these processes became even more pronounced with the
advent of the Industrial Revolution some 100–200 years
ago
(9,11,133)
. Among the many dietary and lifestyle changes
(Fig. 7) are: a grossly decreased n-3:n-6 fatty acid ratio, the
combined high intakes of SFA and carbohydrates
(441 – 443)
,
the introduction of industrially produced trans-fatty acids,
reduced intakes of n-3 and n-6 LCP, reduced exposure to
sunlight, low intakes of vitamins D and K, disbalanced anti-
oxidant status and high intakes of carbohydrates with high
glycaemic indices and loads, such as sucrose and indus-
trially produced high-fructose maize syrup
(36,133,444,445)
.
Many of these changes act in concert, which points at
the serious limitations of conclusions from contemporary
investigations that study the many nutrients in isolation
and form the basis of modern nutritional guidelines.
An example is the interaction of dietary carbohydrates
with SFA
(441 – 443,446)
.
Potential benefits of a Palaeolithic diet
Evidence for the beneficial effects of Palaeolithic diets may
derive from their influence on weight reduction and classi-
cal coronary artery disease risk factors. In an uncontrolled
study with healthy adults, Osterdahl et al.
(447)
showed a
decrease in weight, BMI and waist circumference after
3 weeks ad libitum consumption of a Palaeolithic-like
diet (i.e. 6627 kJ/d (1584 kcal/d); carbohydrate 40, protein
24, fat 36 en%), compared with their baseline usual diet
(10 368 kJ/d (2478 kcal/d); carbohydrate 54, protein 14,
fat 30 en%). Additionally, they showed favourable effects
on systolic blood pressure and plasminogen activator
inhibitor-1. Jo
¨nsson et al.
(448)
performed a cross-over
study of 2 £3 months in type 2 diabetic patients receiving
a Palaeolithic diet (6615 kJ/d (1581 kcal/d), carbohydrate
32, protein 24, fat 39 en%) or a diabetes diet (7858 kJ/d
(1878 kcal/d), carbohydrate 42, protein 20, fat 34 en%).
They showed a reduction of body weight, BMI and waist
circumference and lower HbA
1c
, TAG and diastolic blood
pressure, and higher HDL-cholesterol after consumption
of the Palaeolithic diet.
In a randomised trial in patients with IHD plus glucose
intolerance or type 2 diabetes, Lindeberg et al.
(449)
showed a reduced energy intake after ad libitum con-
sumption of a Palaeolithic diet (5623 kJ/d (1344 kcal/d);
carbohydrate 40, protein 28, fat 27 en%) as compared
with an ad libitum Mediterranean-like Consensus diet
(7510 kJ/d (1795 kcal/d); carbohydrate 52, protein 21, fat
25 en%). They also observed a larger improvement in glu-
cose tolerance in the Palaeolithic diet group, independent
of decreased waist circumference. The most convincing
evidence so far derives from an uncontrolled trial
(450)
showing that 10 d consumption of an isoenergetic Palaeo-
lithic diet (11 301 kJ/d (2701 kcal/d); carbohydrate 38,
protein 30, fat 32 en%) improved blood pressure, arterial
distensibility, insulin sensitivity and total, HDL- and LDL-
cholesterol in healthy sedentary human subjects, when
compared with their baseline usual diet (9924 kJ/d
(2372 kcal/d), carbohydrate 44, protein 18, fat 38 en%).
Dietary characteristics
that have changed
since the Agricultural and
Industrial Revolutions
Macronutrient
composition
Fatty acid
composition
Glycaemic
load
Fibre
content
Na:K
ratio
Acid–base
balance
Macronutrient
density
Fig. 7. The seven dietary characteristics that have been changed since the
Agricultural and Industrial Revolutions. Adapted from Muskiet
(24)
.
Palaeolithic nutrition for disease prevention 117
Nutrition Research Reviews

Importantly, there were no changes in energy intakes,
activity levels and body weight, which indicates that the
improved coronary artery disease risk profile was unrelated
to weight reduction or other well-known determinants.
Conclusions
The optimal nutrient combination to support good health
can be expected to reflect a certain balance. This balance
is present in the foods that were consumed by Palaeolithic
and possibly by pre-Palaeolithic ancestors, because it is this
balance on which the human genome has evolved. This
genome has been shaped by millions of years of evolution,
during which it adapted to the conditions of existence,
including the diet. There are ample indications from
many disciplines that the human ancestors evolved in a
water–land interface that provided food from both terres-
trial and aquatic resources. For instance, the availability
of both n-3 and n-6 LCP from the aquatic food chain was
one of the many factors that provided early humans with
the unique combination of brain-selective nutrients for
brain growth
(2)
. The recent deviation from this Palaeolithic
diet and lifestyle in general might be at the basis of many, if
not all, current diseases of civilisation. Detailed studies
with respect to the health effects of the diets of these earlier
ancestors are therefore warranted.
Acknowledgements
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
R. S. K. wrote the initial manuscript. After finishing a first
outline, all authors contributed to their specific fields of
knowledge, i.e. R. S. K. and F. A. J. M. refined the sections
‘Environment, nutrients and their interaction with the
genome’, ‘Evolutionary medicine’, ‘Arguments and counter
arguments in evolutionary health promotion‘, ‘Human
evolution’, ‘Dietary changes since the Agricultural Revolu-
tion’ and ‘Potential benefits of a Palaeolithic diet’ and the
sub-sections ‘Comparative anatomy’, ‘Biogeochemistry’,
‘Anthropology’, ‘(Patho)physiology’ and ‘Dietary recon-
struction of the nutrients available in Eastern Africa’; J. C. A. J.
refined the section ‘The probability of hunting on the
savanna’ and the sub-sections ‘Palaeo-environments’ and
‘Archeology’.
The authors thank Matt Sponheimer, Mike Richards and
Peter Ungar for their willingness to answer their questions.
There are no conflicts of interest.
References
1. Darwin C (1979) The Illustrated Origin of Species. Ede:
Zomer & Keuning Boeken B.V.
2. Crawford MA (2010) Long-chain polyunsaturated fatty
acids in human brain evolution. In Human Brain Evol-
ution. The Influence of Freshwater and Marine Food
Resources, pp. 13–31 [SC Cunnane and KM Stewart, edi-
tors]. Hoboken, NJ: Wiley-Blackwell.
3. Knoll AH, Javaux EJ, Hewitt D, et al. (2006) Eukaryotic
organisms in Proterozoic oceans. Phil Trans R Soc Lond B
Biol Sci 361, 1023–1038.
4. Brocks JJ, Logan GA, Buick R, et al. (1999) Archean molecu-
lar fossils and the early rise of eukaryotes. Science 285,
1033–1036.
5. Buick R (2008) When did oxygenic photosynthesis evolve?
Phil Trans R Soc Lond B Biol Sci 363, 2731– 2743.
6. Holland HD (2006) The oxygenation of the atmosphere and
oceans. Phil Trans R Soc B Biol Sci 361, 903 –915.
7. Crawford MA & Marsh DE (1995) Nutrition and
Evolution: Food in Evolution and the Future. New
Canaan, CT: Keats.
8. Eaton SB & Konner M (1985) Paleolithic nutrition. A con-
sideration of its nature and current implications. N Engl J
Med 312, 283–289.
9. Eaton SB, Konner M & Shostak M (1988) Stone Agers in the
fast lane: chronic degenerative diseases in evolutionary per-
spective. Am J Med 84, 739–749.
10. Eaton SB, Eaton SB III, Konner MJ, et al. (1996) An evol-
utionary perspective enhances understanding of human
nutritional requirements. J Nutr 126, 1732–1740.
11. Eaton SB & Cordain L (1997) Evolutionary aspects of diet:
old genes, new fuels. Nutritional changes since agriculture.
World Rev Nutr Diet 81, 26– 37.
12. Egger G & Dixon J (2009) Should obesity be the main
game? Or do we need an environmental makeover to
combat the inflammatory and chronic disease epidemics?
Obes Rev 10, 237–249.
13. Egger G & Dixon J (2010) Inflammatory effects of nutri-
tional stimuli: further support for the need for a big picture
approach to tackling obesity and chronic disease. Obes Rev
11, 137–149.
14. Wood B & Brooks A (1999) Human evolution. We are what
we ate. Nature 400, 219 –220.
15. Muskiet FAJ (2005) Evolutionaire geneeskunde. U bent wat
u eet, maar u moet weer worden wat u at (Evolutionary
medicine. You are what you eat, but you must again be
what you ate). Ned Tijdsch Klin Chem Labgeneesk 30,
163–184.
16. Barker DJ (1990) The fetal and infant origins of adult dis-
ease. BMJ 301, 1111.
17. Godfrey KM & Barker DJ (2000) Fetal nutrition and adult
disease. Am J Clin Nutr 71, 1344S–1352S.
18. Drake AJ & Walker BR (2004) The intergenerational effects
of fetal programming: non-genomic mechanisms for the
inheritance of low birth weight and cardiovascular risk.
J Endocrinol 180, 1–16.
19. Gluckman PD, Hanson MA, Morton SM, et al. (2005) Life-
long echoes – a critical analysis of the developmental ori-
gins of adult disease model. Biol Neonate 87, 127 –139.
20. Cordain L, Eades MR & Eades MD (2003) Hyperinsulinemic
diseases of civilization: more than just syndrome X. Comp
Biochem Physiol A Mol Integr Physiol 136, 95–112.
21. Reaven GM (2005) The insulin resistance syndrome: defi-
nition and dietary approaches to treatment. Annu Rev
Nutr 25, 391–406.
22. Pasinetti GM & Eberstein JA (2008) Metabolic syndrome
and the role of dietary lifestyles in Alzheimer’s disease. J
Neurochem 106, 1503–1514.
23. Muskiet FA & Kemperman RF (2006) Folate and long-chain
polyunsaturated fatty acids in psychiatric disease. J Nutr
Biochem 17, 717–727.
24. Muskiet FA (2010) Pathophysiology and evolutionary
aspects of dietary fats and long chain polyunsaturated
R. S. Kuipers et al.118
Nutrition Research Reviews

fatty acids across the life cycle. In Fat Detection. Taste, Tex-
ture, and Post Ingestive Effects, pp. 19 –79 [JP Montmayeur
and J le Coutre, editors]. Boca Raton, FL: CRC Press Taylor
& Francis Group.
25. Muskiet FAJ & Kuipers RS (2010) Lessons from shore-based
hunter–gatherer diets in East Africa. In In Human Brain
Evolution. The Influence of Freshwater and Marine Food
Resources, pp. 77 –103 [SC Cunnane and KM Stewart,
editors]. Hoboken, NJ: Wiley-Blackwell.
26. Feige JN, Gelman L, Michalik L, et al. (2006) From molecu-
lar action to physiological outputs: peroxisome proliferator-
activated receptors are nuclear receptors at the crossroads
of key cellular functions. Prog Lipid Res 45, 120 –159.
27. Dobzhansky T (1964) Biology, molecular and organismic.
Am Zool 4, 443–452.
28. Tinbergen N (1963) On the aims and methods of ethology.
Zeit Tierpsy 20, 410–463.
29. Harris EE & Malyango AA (2005) Evolutionary explanations
in medical and health profession courses: are you answer-
ing your students’ ‘why’ questions? BMC Med Educ 5, 16.
30. Purushotham AD & Sullivan R (2010) Darwin, medicine and
cancer. Ann Oncol 21, 199– 203.
31. Williams GC & Nesse RM (1991) The dawn of Darwinian
medicine. Q Rev Biol 66, 1–22.
32. Nesse RM & Williams GC (1994) Why We Get Sick. The New
Science of Darwinian Medicine. New York: Times Books,
Random House, Inc.
33. Gould SJ & Vrba ES (1982) Exaptation – a missing term in
the science of form. Paleobiology 8, 4–15.
34. Eaton SB, Eaton SB III, Sinclair AJ, et al. (1998) Dietary
intake of long-chain polyunsaturated fatty acids during
the Paleolithic. World Rev Nutr Diet 83, 12– 23.
35. Eaton SB, Cordain L & Lindeberg S (2002) Evolutionary
health promotion: a consideration of common counterargu-
ments. Prev Med 34, 119 –123.
36. O’Keefe JH Jr & Cordain L (2004) Cardiovascular
disease resulting from a diet and lifestyle at odds with our
Paleolithic genome: how to become a 21st-century
hunter–gatherer. Mayo Clin Proc 79, 101 –108.
37. Hahn RA, Teutsch SM, Rothenberg RB, et al. (1990) Excess
deaths from nine chronic diseases in the United States,
1986. JAMA 264, 2654–2659.
38. Hill K, Hurtado AM & Walker RS (2007) High adult mortality
among Hiwi hunter–gatherers: implications for human
evolution. J Hum Evol 52, 443–454.
39. Howell N (2001) Demography of the Dobe !Kung, 2nd ed.
Piscataway: Aldine Transaction.
40. Hill K & Hurtado A (1995) Ache Life History: the Ecology
and Demography of a Foraging People. Piscataway:
Aldine Transaction.
41. Marlowe FM (2010) The Hadza Hunter – Gatherers of
Tanzania. Los Angeles: The University of California Press.
42. Eaton SB & Eaton SBI (1999) The evolutionary context of
chronic degenerative diseases. In Evolution in Health and
Disease, pp. 251–259 [SC Stearns, editor]. Oxford: Oxford
University Press.
43. Shephard RJ & Roy J (1996) The Health Consequences of
Modernization: Evidence from Circumpolar Peoples.
Cambridge: Cambridge University Press.
44. Lindeberg S & Lundh B (1993) Apparent absence of
stroke and ischaemic heart disease in a traditional Melane-
sian island: a clinical study in Kitava. J Intern Med 233,
269–275.
45. Lindeberg S, Nilsson-Ehle P, Terent A, et al. (1994) Cardio-
vascular risk factors in a Melanesian population apparently
free from stroke and ischaemic heart disease: the Kitava
study. J Intern Med 236, 331 –340.
46. Trowell HC & Burkitt DP (1981) Western Diseases: Their
Emergence and Prevention. Cambridge, MA: Harvard
University Press.
47. Blacklow RS (2007) Actuarially speaking: an overview of
life expectancy. What can we anticipate? Am J Clin Nutr
86, 1560S–1562S.
48. Angel JL (1984) Health as a factor in the changes from hunting
to developed farming in the eastern Mediterranean. In Paleo-
pathology at the Origins of Agriculture, pp. 51 – 73 [MN Cohen
and GJ Armelagos, editors]. New York: Academic Press.
49. Larsen CS (1995) Biological changes in human populations
with agriculture. Annu Rev Anthropol 24, 185 –213.
50. Larsen CS (2003) Animal source foods and human health
during evolution. J Nutr 133, 3893S–3897S.
51. Larsen CS (2000) Dietary reconstruction and nutritional
assessement of past peoples: the bioanthropological
record. In The Cambridge World History of Food, pp.
13–34 [KF Kiple and KC Ornelas, editors]. Cambridge:
Cambridge University Press.
52. Cohen MN (1984) Editors summation. In Paleopathology at
the Origins of Ariculture, pp. 585 –601 [MN Cohen and GJ
Armelagos, editors]. New York: Academic Press.
53. McKeown T, Brown RG & Record RG (1972) An interpret-
ation of the modern rise of population in Europe. Popul
Stud (Camb) 26, 345–382.
54. Blurton-Jones NG, Marlowe FW, Hawkes K, et al (2000)
Paternal investment and hunter–gatherer divorce. In Adap-
tation and Human Behavior: An Anthropological
Perspective, pp. 61–90 [L Cronk, N Chagnon and W Irons,
editors]. New York: Aldine de Gruyter.
55. Hawkes K, O’Connell JF & Blurton-Jones NG (2001)
Hunting and nuclear families: some lessons from the
Hadza about men’s work. Curr Anthropol 42, 681 –709.
56. Hawkes K, O’Connell JF, Jones NG, et al. (1998) Grand-
mothering, menopause, and the evolution of human life
histories. Proc Natl Acad Sci U S A 95, 1336 –1339.
57. O’Connell JF, Hawkes K & Blurton Jones NG (1999)
Grandmothering and the evolution of Homo erectus.
J Hum Evol 36, 461–485.
58. Sear R, Mace R & McGregor IA (2000) Maternal grand-
mothers improve nutritional status and survival of children
in rural Gambia. Proc Biol Sci 267, 1641 –1647.
59. Bogin B (2009) Childhood, adolescence, and longevity: a
multilevel model of the evolution of reserve capacity in
human life history. Am J Hum Biol 21, 567 –577.
60. Hawkes K (2010) Colloquium paper: how grandmother
effects plus individual variation in frailty shape fertility and
mortality: guidance from human–chimpanzee comparisons.
Proc Natl Acad Sci U S A 107, Suppl. 2, 8977 –8984.
61. van Bodegom D, Rozing M, May L, et al. (2010) When
grandmothers matter. Gerontology 56, 214– 216.
62. Kachel AF, Premo LS & Hublin JJ (2011) Grandmothering
and natural selection. Proc Biol Sci 278, 384 –391.
63. Strier KB, Chaves PB, Mendes SL, et al. (2011) Low
paternity skew and the influence of maternal kin in an
egalitarian, patrilocal primate. Proc Natl Acad Sci U S A
108, 18915–18919.
64. van Bodegom D (2011) Selection for longevity in a poly-
gamous society in rural Africa. In Post-Reproductive
Survival in a Polygamous Society in Rural Africa,
chapter 7, pp. 125– 140. Doctoral Thesis, Leiden University.
65. Brunet M, Guy F, Pilbeam D, et al. (2002) A new hominid
from the Upper Miocene of Chad, Central Africa. Nature
418, 145–151.
66. Senut B, Pickford M, Gommery D, et al. (2001) First
hominid from the Miocene (Lukeino Formation, Kenya).
C R Acad Sci IIA 332, 137–144.
Palaeolithic nutrition for disease prevention 119
Nutrition Research Reviews

67. Haile-Selassie Y, Suwa G & White TD (2004) Late Miocene
teeth from Middle Awash, Ethiopia, and early hominid
dental evolution. Science 303, 1503–1505.
68. White TD, Asfaw B, Beyene Y, et al. (2009) Ardipithecus
ramidus and the paleobiology of early hominids. Science
326, 75–86.
69. Leakey MG, Feibel CS, McDougall I, et al. (1998) New
specimens and confirmation of an early age for Australo-
pithecus anamensis.Nature 393, 62 –66.
70. Kimbel WH & Delezene LK (2009) “Lucy” redux: a review
of research on Australopithecus afarensis.Am J Phys
Anthropol 140, Suppl. 49, 2 –48.
71. Harrison T (2011) Hominins from the Upper Laetolil and
Upper Ndolanya beds, Laetoli. In Paleontology and
Geology of Laetoli: Human Evolution in Context: Volume
2: Fossil Hominins and the Associated Fauna, pp.
141–188 [T Harrison, editor]. Dordrecht: Springer.
72. Brunet M, Beauvilain A, Coppens Y, et al. (1995) The first
australopithecine 2,500 kilometres west of the Rift Valley
(Chad). Nature 378, 273 –275.
73. Leakey MG, Spoor F, Brown FH, et al. (2001) New hominin
genus from eastern Africa shows diverse middle Pliocene
lineages. Nature 410, 433–440.
74. Asfaw B, White T, Lovejoy O, et al. (1999) Australopithecus
garhi: a new species of early hominid from Ethiopia.
Science 284, 629–635.
75. Herries AI, Hopley PJ, Adams JW, et al. (2010) Letter
to the Editor: Geochronology and palaeoenvironments of
Southern African hominin-bearing localities – a reply to
Wrangham et al., 2009. “Shallow-water habitats as sources
of fallback foods for hominins”. Am J Phys Anthropol
143, 640–646.
76. Tattersall I (2010) Macroevolutionary patterns, exaptation,
and emergence in the evolution of the human brain and
cognition. In Human Brain Evolution. The Influence of
Freshwater and Marine Food Resources, pp. 1 –11
[SC Cunnane and KM Stewart, editors]. Hoboken, NJ:
Wiley-Blackwell.
77. Stringer C (2003) Human evolution: out of Ethiopia. Nature
423, 692–693, 695.
78. White TD, Asfaw B, DeGusta D, et al. (2003) Pleistocene
Homo sapiens from Middle Awash, Ethiopia. Nature 423,
742–747.
79. Brown P, Sutikna T, Morwood MJ, et al. (2004) A new
small-bodied hominin from the Late Pleistocene of Flores,
Indonesia. Nature 431, 1055 –1061.
80. Reich D, Patterson N, Kircher M, et al. (2011) Denisova
admixture and the first modern human dispersals into
Southeast Asia and Oceania. Am J Hum Genet 89, 516 –528.
81. Stringer C (2000) Palaeoanthropology. Coasting out of
Africa. Nature 405, 24–25, 27.
82. Templeton A (2002) Out of Africa again and again. Nature
416, 45–51.
83. Oppenheimer S (2009) The great arc of dispersal of modern
humans: Africa to Australia. Quat Int 202, 2–13.
84. Templeton AR (2005) Haplotype trees and modern human
origins. Am J Phys Anthropol 128, Suppl. 41, 33 –59.
85. Templeton AR (2007) Genetics and recent human
evolution. Evolution 61, 1507–1519.
86. Templeton AR (2010) Coherent and incoherent inference
in phylogeography and human evolution. Proc Natl Acad
Sci U S A 107, 6376–6381.
87. Green RE, Krause J, Ptak SE, et al. (2006) Analysis of one
million base pairs of Neanderthal DNA. Nature 444,
330–336.
88. Zhivotovsky LA, Rosenberg NA & Feldman MW (2003)
Features of evolution and expansion of modern humans,
inferred from genomewide microsatellite markers. Am
J Hum Genet 72, 1171–1186.
89. Knight A, Underhill PA, Mortensen HM, et al. (2003) African
Y chromosome and mtDNA divergence provides insight
into the history of click languages. Curr Biol 13, 464 –473.
90. Henn BM, Gignoux CR, Jobin M, et al. (2011)
Hunter–gatherer genomic diversity suggests a southern
African origin for modern humans. Proc Natl Acad Sci
USA108, 5154–5162.
91. Behar DM, Villems R, Soodyall H, et al. (2008) The dawn of
human matrilineal diversity. Am J Hum Genet 82,
1130–1140.
92. Ambrose SH (1998) Late Pleistocene human population
bottlenecks, volcanic winter, and differentiation of
modern humans. J Hum Evol 34, 623–651.
93. Rosenberg NA, Pritchard JK, Weber JL, et al. (2002) Genetic
structure of human populations. Science 298, 2381 –2385.
94. Washburn SL & Lancaster CS (1968) The evolution of
hunting. In Man the Hunter, pp. 293– 303 [RB Lee and I
DeVore, editors]. New York: Aldine Publishing Company.
95. Sailer LD, Gaulin SC, Voster JS, et al. (1985) Measuring the
relationship between dietary quality and body size in
primates. Primates 26, 14–27.
96. Herculano-Houzel S (2009) The human brain in numbers: a
linearly scaled-up primate brain. Front Hum Neurosci 3, 31.
97. Deaner RO, Isler K, Burkart J, et al. (2007) Overall
brain size, and not encephalization quotient, best predicts
cognitive ability across non-human primates. Brain Behav
Evol 70, 115–124.
98. Hill RS & Walsh CA (2005) Molecular insights into human
brain evolution. Nature 437, 64 –67.
99. Broadhurst CL, Cunnane SC & Crawford MA (1998) Rift
Valley lake fish and shellfish provided brain-specific
nutrition for early Homo.Br J Nutr 79, 3–21.
100. Cunnane SC (2010) Human brain evolution: a question of
solving key nutritional and metabolic constraints on
mammalian brain development. In Human Brain
Evolution. The Influence of Freshwater and Marine Food
Resources, pp. 33–76 [SC Cunnane and KM Stewart,
editors]. Hoboken, NJ: Wiley-Blackwell.
101. Cunnane SC (2005) Origins and evolution of the Western
diet: implications of iodine and seafood intakes for the
human brain. Am J Clin Nutr 82, 483–484.
102. Navarrete A, van Schaik CP & Isler K (2011) Energetics and
the evolution of human brain size. Nature 480, 91 –93.
103. Potts R (2011) Evolution: big brains explained. Nature 480,
43–44.
104. Blinkov SM & Glezer II (1968) The Human Brain in Figures
and Tables. New York: Basic Books, Inc.
105. White DR, Widdowson EM, Woodard HQ, et al. (1991)
The composition of body tissues (II). Fetus to young
adult. Br J Radiol 64, 149–159.
106. Dobbing J & Sands J (1973) Quantitative growth and
development of human brain. Arch Dis Child 48, 757–767.
107. Roth G & Dicke U (2005) Evolution of the brain and
intelligence. Trends Cogn Sci 9, 250 –257.
108. Herculano-Houzel S (2011) Scaling of brain metabolism
with a fixed energy budget per neuron: implications for
neuronal activity, plasticity and evolution. PLoS One 6,
e17514.
109. Herculano-Houzel S (2011) Not all brains are made the
same: new views on brain scaling in evolution. Brain
Behav Evol 78, 22–36.
110. Azevedo FA, Carvalho LR, Grinberg LT, et al. (2009) Equal
numbers of neuronal and nonneuronal cells make the
human brain an isometrically scaled-up primate brain.
J Comp Neurol 513, 532 –541.
R. S. Kuipers et al.120
Nutrition Research Reviews

111. Herculano-Houzel S (2010) Coordinated scaling of
cortical and cerebellar numbers of neurons. Front
Neuroanat 4, 12.
112. King MC & Wilson AC (1975) Evolution at two levels in
humans and chimpanzees. Science 188, 107–116.
113. Gu J & Gu X (2003) Induced gene expression in human
brain after the split from chimpanzee. Trends Genet 19,
63–65.
114. Caceres M, Lachuer J, Zapala MA, et al. (2003) Elevated
gene expression levels distinguish human from
non-human primate brains. Proc Natl Acad Sci U S A 100,
13030–13035.
115. Marques-Bonet T, Caceres M, Bertranpetit J, et al. (2004)
Chromosomal rearrangements and the genomic distribution
of gene-expression divergence in humans and chimpan-
zees. Trends Genet 20, 524 –529.
116. Finlay BL & Darlington RB (1995) Linked regularities in the
development and evolution of mammalian brains. Science
268, 1578–1584.
117. Stimpson CD, Tetreault NA, Allman JM, et al. (2011)
Biochemical specificity of von economo neurons in
hominoids. Am J Hum Biol 23, 22–28.
118. Sherwood CC, Subiaul F & Zawidzki TW (2008) A natural
history of the human mind: tracing evolutionary changes
in brain and cognition. J Anat 212, 426–454.
119. Sherwood CC, Gordon AD, Allen JS, et al. (2011) Aging of
the cerebral cortex differs between humans and chimpan-
zees. Proc Natl Acad Sci U S A 108, 13029 –13034.
120. Abzhanov A, Kuo WP, Hartmann C, et al. (2006) The calmo-
dulin pathway and evolution of elongated beak mor-
phology in Darwin’s finches. Nature 442, 563 –567.
121. Patel NH (2006) Evolutionary biology: how to build a
longer beak. Nature 442, 515 –516.
122. Schneider RA (2007) How to tweak a beak: molecular
techniques for studying the evolution of size and
shape in Darwin’s finches and other birds. Bioessays 29,
1–6.
123. Kaindl AM, Passemard S, Kumar P, et al. (2010) Many roads
lead to primary autosomal recessive microcephaly. Prog
Neurobiol 90, 363 –383.
124. Williams CA, Dagli A & Battaglia A (2008) Genetic disorders
associated with macrocephaly. Am J Med Genet A 146A,
2023–2037.
125. Evans PD, Anderson JR, Vallender EJ, et al. (2004) Adaptive
evolution of ASPM, a major determinant of cerebral cortical
size in humans. Hum Mol Genet 13, 489 –494.
126. Evans PD, Anderson JR, Vallender EJ, et al. (2004) Recon-
structing the evolutionary history of microcephalin, a
gene controlling human brain size. Hum Mol Genet 13,
1139–1145.
127. Evans PD, Gilbert SL, Mekel-Bobrov N, et al. (2005) Micro-
cephalin, a gene regulating brain size, continues to evolve
adaptively in humans. Science 309, 1717–1720.
128. Evans PD, Vallender EJ & Lahn BT (2006) Molecular
evolution of the brain size regulator genes CDK5RAP2
and CENP. J Gene 375, 75–79.
129. Speth JD (1989) Early hominid hunting and scavenging – the
role of meat as an energy-source. J Hum Evol 18, 329 –343.
130. Crawford MA, Bloom M, Broadhurst CL, et al. (1999) Evi-
dence for the unique function of docosahexaenoic acid
during the evolution of the modern hominid brain. Lipids
34, Suppl., S39–S47.
131. Gibbons A (2002) American Association of Physical Anthro-
pologists meeting. Humans’ head start: new views of brain
evolution. Science 296, 835–837.
132. Crawford MA (2002) Cerebral evolution. Nutr Health 16,
29–34.
133. Cordain L, Eaton SB, Sebastian A, et al. (2005) Origins and
evolution of the Western diet: health implications for the
21st century. Am J Clin Nutr 81, 341–354.
134. Carlson BA & Kingston JD (2007) Docosahexaenoic acid,
the aquatic diet, and hominin encephalization: difficulties
in establishing evolutionary links. Am J Hum Biol 19,
132–141.
135. Joordens JC, Kuipers RS & Muskiet FA (2007) Preformed
dietary DHA: the answer to a scientific question may in
practice become translated to its opposite. Am J Hum
Biol 19, 582–584.
136. Joordens CA, Kuipers RS & Muskiet FAJ (2005) On breast
milk, diet, and large human brains. Curr Anthropol 46,
122–124.
137. Langdon JH (2006) Has an aquatic diet been necessary
for hominin brain evolution and functional development?
Br J Nutr 96, 7–17.
138. Dart RA (1925) Australopithecus africanus: the man-ape of
South Africa. Nature 115, 195 –199.
139. Tobias PV (1998) Water and human evolution. Out There
35, 38–44.
140. Tobias PV (2010) Foreword: evolution, encephalization,
environment. In Human Brain Evolution. The Influence
of Freshwater and Marine Food Resources, pp. vii – xii
[SC Cunnane and KM Stewart, editors]. Hoboken, NJ:
Wiley-Blackwell.
141. White TD, Ambrose SH, Suwa G, et al. (2009) Macroverte-
brate paleontology and the Pliocene habitat of Ardipithecus
ramidus.Science 326, 87–93.
142. Cerling TE, Levin NE, Quade J, et al. (2010) Comment on
the paleoenvironment of Ardipithecus ramidus.Science
328, 1105.
143. Feibel CS (2011) Anthropology: shades of the savannah.
Nature 476, 39–40.
144. Cerling TE, Wynn JG, Andanje SA, et al. (2011) Woody
cover and hominin environments in the past 6 million
years. Nature 476, 51 –56.
145. Woodburn J (1968) An introduction to Hadza ecology. In
Man the Hunter, [RB Lee and I DeVore, editors]. New
York: Aldine Publishing Company.
146. Tanner NM & Zihlmann AL (1976) Women in evolution,
part 1: innovation and selection in human origins. Signs
1, 585–608.
147. Stanford CB (1999) The hunting people. In The Hunting
Apes: Meat Eating and the Origins of Human Behaviour,
chapter 5, pp. 136–162. Princeton: Princeton University
Press.
148. Cordain L, Miller JB, Eaton SB, et al. (2000) Plant-animal
subsistence ratios and macronutrient energy estimations in
worldwide hunter–gatherer diets. Am J Clin Nutr 71,
682–692.
149. Stanford CB (1999) Man the hunter and other stories. In The
Hunting Apes: Meat Eating and the Origins of Human
Behaviour, chapter 2, pp. 15– 51. Princeton: Princeton Uni-
versity Press.
150. Ungar PS & Sponheimer M (2011) The diets of early homi-
nins. Science 334, 190–193.
151. Bernor RL (2007) New apes fill the gap. Proc Natl Acad Sci
USA104, 19661–19662.
152. Lebatard AE, Bourles DL, Duringer P, et al. (2008)
Cosmogenic nuclide dating of Sahelanthropus tchadensis
and Australopithecus bahrelghazali: Mio-Pliocene
hominids from Chad. Proc Natl Acad Sci U S A 105,
3226–3231.
153. Bosworth W & Morley CK (1994) Structural and strati-
graphic evolution of the Anza rift, Kenya. Tectonophysics
236, 93–115.
Palaeolithic nutrition for disease prevention 121
Nutrition Research Reviews

154. Joordens JC (2011) The Power of Place: Climate Changes as
Driver of Hominin Evolution and Dispersal over the Past
Five Million Years. Amsterdam: Vrije Universiteit.
155. Vignaud P, Duringer P, Mackaye HT, et al. (2002) Geology
and palaeontology of the Upper Miocene Toros-Menalla
hominid locality, Chad. Nature 418, 152 –155.
156. Stewart KM (2010) The case for exploitation of
wetlands environments and foods by pre-sapiens
hominins. In Human Brain Evolution. The Influence
of Freshwater and Marine Food Resources, pp. 137 –171
[SC Cunnane and KM Stewart, editors]. Hoboken, NJ:
Wiley-Blackwell.
157. Pickford M & Senut B (2001) The geological and faunal
context of Late Miocene hominid remains from Lukeino,
Kenya. C R Acad Sci IIA 332, 145–152.
158. WoldeGabriel G, Haile-Selassie Y, Renne PR, et al. (2001)
Geology and palaeontology of the Late Miocene Middle
Awash valley, Afar rift, Ethiopia. Nature 412, 175 –178.
159. WoldeGabriel G, Ambrose SH, Barboni D, et al. (2009) The
geological, isotopic, botanical, invertebrate, and lower
vertebrate surroundings of Ardipithecus ramidus.Science
326, 65e1–65e5.
160. Feibel CS, Harris JM & Brown FH (1991) Paleoenvironmen-
tal context for the late Neogene of the Turkana basin. In
Koobi Fora Research Project, pp. 321 –346 [JM Harris,
editor]. Oxford: Clarendon Press.
161. Reed KE (1997) Early hominid evolution and ecological
change through the African Plio-Pleistocene. J Hum Evol
32, 289–322.
162. Ward C, Leakey M & Walker A (1999) The new hominid
species Australopithecus anamensis.Evol Anthropol 7,
197–205.
163. Schoeninger MJ, Reeser H & Hallin K (2003) Paleoenviron-
ment of Australopithecus anamensis at Allia Bay, East Tur-
kana, Kenya: evidence from mammalian herbivore enamel
stable isotopes. J Anthropol Archaeol 22, 200 –207.
164. Reed KE (2008) Paleoecological patterns at the Hadar
hominin site, Afar Regional State, Ethiopia. J Hum Evol
54, 743–768.
165. Su DF & Harrison T (2008) Ecological implications of the
relative rarity of fossil hominins at Laetoli. J Hum Evol 55,
672–681.
166. Veldkamp A, Buis E, Wijbrands JR, et al. (2007) Late
Cenozoic fluvial dynamics of the River Tana, Kenya, an
uplift dominated record. Quat Sci Rev 26, 2897 –2912.
167. Sepulchre P, Ramstein G, Fluteau F, et al. (2006) Tectonic
uplift and Eastern Africa aridification. Science 313,
1419–1423.
168. Trauth MH, Maslin MA, Deino AL, et al. (2007) High- and
low-latitude forcing of Plio-Pleistocene East African climate
and human evolution. J Hum Evol 53, 475–486.
169. Bartoli G, Sarnthein M, Weinelt M, et al. (2005) Final closure
of the Panama and the onset of northern hemisphere
glaciation. Earth Planetary Sci Lett 237, 33–44.
170. Potts R (1998) Environmental hypotheses of hominin
evolution. Yearb Phys Anthropol 41, 93–136.
171. Pobiner BL, Rogers MJ, Monahan CM, et al. (2008) New
evidence for hominin carcass processing strategies at 1.5
Ma, Koobi Fora, Kenya. J Hum Evol 55, 103–130.
172. Ashley GM, Tactikos JC & Owen RB (2009) Hominin use of
springs and wetlands: paleoclimate and archaeological
records from Olduvai Gorge (,1.79 –1.74 Ma). Palaeo-
geogr Palaeoclimatol Palaeoecol 272, 1–16.
173. Drake NA, Blench RM, Armitage SJ, et al. (2011) Ancient
watercourses and biogeography of the Sahara explain the
peopling of the desert. Proc Natl Acad Sci U S A 108,
458–462.
174. Sikes NE (1994) Early hominid habitat preferences in
East-Africa – paleosol carbon isotopic evidence. J Hum
Evol 27, 25–45.
175. Joordens JC, Wesselingh FP, de Vos J, et al. (2009)
Relevance of aquatic environments for hominins: a case
study from Trinil (Java, Indonesia). J Hum Evol 57,
656–671.
176. Popovich DG, Jenkins DJ, Kendall CW, et al. (1997) The
western lowland gorilla diet has implications for the
health of humans and other hominoids. J Nutr 127,
2000–2005.
177. Marshall AJ & Wrangham RW (2007) Evolutionary conse-
quences of fallback foods. Int J Primatol 28, 1218 –1235.
178. Nishida T (1980) Local differences in responses to water
among wild chimpanzees. Folia Primatol 33, 189–209.
179. Sakamaki T (1998) First record of algae-feeding by a female
chimpanzee at Mahale. Pan Afr News 5,1–3.
180. Kempf E (2009) Patterns of water use in primates. Folia
Primatol (Basel) 80, 275–294.
181. Wrangham R, Cheney D, Seyfarth R, et al. (2009) Shallow-
water habitats as sources of fallback foods for hominins.
Am J Phys Anthropol 140, 630 –642.
182. Vogel ER, van Woerden JT, Lucas PW, et al. (2008) Func-
tional ecology and evolution of hominoid molar enamel
thickness: Pan troglodytes schweinfurthii and Pongo pyg-
maeus wurmbii.J Hum Evol 55, 60 –74.
183. Suwa G, Kono RT, Simpson SW, et al. (2009) Paleobiologi-
cal implications of the Ardipithecus ramidus dentition.
Science 326, 94–99.
184. Teaford MF & Ungar PS (2000) Diet and the evolution of the
earliest human ancestors. Proc Natl Acad Sci U S A 97,
13506–13511.
185. Walker A, Hoeck HN & Perez L (1978) Mecrowear of mam-
malian teeth as an indicator of diet. Science 201, 908 –910.
186. Ungar PS, Grine FE & Teaford MF (2008) Dental microwear
and diet of the Plio-Pleistocene hominin Paranthropus
boisei.Plos One 3, e2044.
187. Ungar PS, Scott RS, Grine FE, et al. (2010) Molar microwear
textures and the diets of Australopithecus anamensis and
Australopithecus afarensis.Philos Trans R Soc B Biol Sci
365, 3345–3354.
188. Grine FE, Ungar PS, Teaford MF, et al. (2006) Molar micro-
wear in Praeanthropus afarensis: evidence for dietary stasis
through time and under diverse paleoecological conditions.
J Hum Evol 51, 297–319.
189. Scott RS, Ungar PS, Bergstrom TS, et al. (2005) Dental
microwear texture analysis shows within-species diet
variability in fossil hominins. Nature 436, 693 –695.
190. Cerling TE, Mbua E, Kirera FM, et al. (2011) Diet of
Paranthropus boisei in the early Pleistocene of East
Africa. Proc Natl Acad Sci U S A 108, 9337 – 9341.
191. Ungar P (2004) Dental topography and diets of Australo-
pithecus afarensis and early Homo.J Hum Evol 46,
605–622.
192. Ulijaszek SJ (2002) Human eating behaviour in an evol-
utionary ecological context. Proc Nutr Soc 61, 517 –526.
193. Goldstone AP, de Hernandez CG, Beaver JD, et al. (2009)
Fasting biases brain reward systems towards high-calorie
foods. Eur J Neurosci 30, 1625 –1635.
194. Ungar PS, Grine FE, Teaford MF, et al. (2006) Dental
microwear and diets of African early Homo.J Hum Evol 50,
78–95.
195. Ungar PS, Grine FE & Teaford MF (2006) Diet in early
Homo: a review of the evidence and a new model of
adaptive versatility. Annu Rev Anthropol 35, 209 –228.
196. Perez-Perez A, De Castro JMB & Arsuaga JL (1999) Nonoc-
clusal dental microwear analysis of 300 000-year-old Homo
R. S. Kuipers et al.122
Nutrition Research Reviews

heilderbergensis teeth from Sima de los Huesos (Sierra de
Atapuerca, Spain). Am J Phys Anthropol 108, 433 –457.
197. Lalueza C, PerezPerez A & Turbon D (1996) Dietary infer-
ences through buccal microwear analysis of middle and
upper pleistocene human fossils. Am J Phys Anthropol
100, 367–387.
198. Mahoney P (2007) Human dental microwear from Ohalo II
(22 500 –23 500 cal BP), Southern Levant. Am J Phys Anthro-
pol 132, 489–500.
199. Mahoney P (2006) Dental microwear from Natufian hunter –
gatherers and early neolithic farmers: comparisons within
and between samples. Am J Phys Anthropol 130, 308 –319.
200. Milton K (1999) Nutritional characteristics of wild primate
foods: do the diets of our closest living relatives have les-
sons for us? Nutrition 15, 488–498.
201. Milton K (2003) The critical role played by animal
source foods in human (Homo) evolution. J Nutr 133,
3886S–3892S.
202. Gittleman JL & Thompson SD (1988) Energy allocation in
mammalian reproduction. Am Zool 28, 863–875.
203. Oftedal TO (1984) Milk composition, milk yield and energy
output a peak lactation: a comparative review. Symp Zool
Soc Lond 51, 33–85.
204. Aiello LC & Key C (2002) Energetic consequences of being
aHomo erectus female. Am J Hum Biol 14, 551 –565.
205. Aiello LC & Wells JCK (2002) Energetics and the evolution
of the genus Homo.Annu Rev Anthropol 31, 323 –338.
206. Cunnane SC & Crawford MA (2003) Survival of the fattest: fat
babies were the key to evolution of the large human brain.
Comp Biochem Physiol A Mol Integr Physiol 136, 17 –26.
207. Leonard WR, Robertson ML, Snodgrass JJ, et al. (2003)
Metabolic correlates of hominid brain evolution. Comp Bio-
chem Physiol A Mol Integr Physiol 136, 5–15.
208. Aiello LC & Wheeler P (1995) The expensive-tissue
hypothesis – the brain and the digestive system in
human and primate evolution. Curr Anthropol 36, 199 –221.
209. Aiello LC (2007) Notes on the implications of the expensive
tissue hypothesis for human biological and social evolution.
In Guts and Brains. An Integrative Approach to the Homi-
nin Record, pp. 17 –28 [W Roebroeks, editor]. Leiden:
Leiden University Press.
210. Kaufman JA, Hladik CM & Pasquet P (2003) On the expens-
ive-tissue hypothesis: independent support from highly
encephalized fish. Curr Anthropol 44, 705 –707.
211. Galdikas BM & Wood JW (1990) Birth spacing patterns in
humans and apes. Am J Phys Anthropol 83, 185 –191.
212. Isler K & van Schaik CP (2009) The expensive brain: a fra-
mework for explaining evolutionary changes in brain size. J
Hum Evol 57, 392–400.
213. Isler K (2011) Energetic trade-offs between brain size and
offspring production: marsupials confirm a general mam-
malian pattern. Bioessays 33, 173–179.
214. Pontzer H, Raichlen DA & Sockol MD (2009) The metabolic
cost of walking in humans, chimpanzees, and early homi-
nins. J Hum Evol 56, 43–54.
215. Wrangham RW, Jones JH, Laden G, et al. (1999) The raw
and the stolen. Cooking and the ecology of human origins.
Curr Anthropol 40, 567 –594.
216. Robinson BW & Wilson DS (1998) Optimal foraging,
specialization, and a solution to Liem’s paradox. Am Nat
151, 223–235.
217. Harris WS (2008) You are what you eat applies to fish, too. J
Am Diet Assoc 108, 1131–1133.
218. Sponheimer M & Dufour DL (2009) Increased dietary
breadth in early hominin evolution: revisiting arguments
and evidence with a focus on biogeochemical contri-
butions. In The Evolution of Hominin Diets: Integrating
Approaches to the Study of Palaeolithic Subsistence,
chapter 18, pp. 229–240 [J-J Hublin and MP Richards,
editors]. Dordrecht: Springer.
219. Sillen A & Kavanagh M (1982) Strontium and paleodietary
research: a review. Am J Phys Anthropol 25, 67 –90.
220. Sillen A (1992) Strontium calcium ratios (Sr/Ca) of Australo-
pithecus robustus and associated fauna from Swartkrans.
J Hum Evol 23, 495–516.
221. Sillen A, Hall G & Armstrong R (1995) Strontium calcium
ratios (Sr/Ca) and strontium isotopic-ratios (
87
Sr/
86
Sr) of
Australopithecus robustus and Homo sp. from Swartkrans.
J Hum Evol 28, 277–285.
222. Conklin-Brittain NL, Wrangham RW & Hunt KD (1998) Diet-
ary response of chimpanzees and cercopithecines to seaso-
nal variation in fruit abundance. II. Macronutrients. Int J
Primatol 19, 971–998.
223. Lee-Thorp J & Sponheimer M (2003) Three case studies
used to reassess the reliability of fossil bone and enamel
isotope signals for paleodietary studies. J Anthropol
Archaeol 22, 208–216.
224. Sponheimer M, de Ruiter D, Lee-Thorp J, et al. (2005) Sr/Ca
and early hommin diets revisited: new data from modern
and fossil tooth enamel. J Hum Evol 48, 147–156.
225. Lee-Thorp J & Sponheimer M (2006) Contributions of bio-
geochemistry to understanding hominin dietary ecology.
Yearb Phys Anthropol 49, 131–148.
226. Balter V & Simon L (2006) Diet and behavior of the Saint-
Cesaire Neanderthal inferred from biogeochemical data
inversion. J Hum Evol 51, 329–338.
227. Ophel IL & Fraser CD (1970) Calcium and strontium dis-
crimination by aquatic plants. Ecology 51, 324–327.
228. Ambrose SH & Deniro MJ (1986) The isotopic ecology of
East-African mammals. Oecologia 69, 395–406.
229. Lee-Thorp JA, Sponheimer M, Passey BH, et al. (2010)
Stable isotopes in fossil hominin tooth enamel suggest a
fundamental dietary shift in the Pliocene. Phil Trans R
Soc Lond B Biol Sci 365, 3389–3396.
230. Sponheimer M & Lee-Thorp JA (2006) Enamel diagenesis at
South African Australopith sites: implications for paleoeco-
logical reconstruction with trace elements. Geochim Cosmo-
chim Acta 70, 1644–1654.
231. Sponheimer M, Lee-Thorp J, de Ruiter D, et al. (2005)
Hominins, sedges, and termites: new carbon isotope data
from the Sterkfontein valley and Kruger National Park.
J Hum Evol 48, 301–312.
232. Vogel JC (1978) Isotopic assessment of dietary habits of
ungulates. S Afr J Sci 74, 298–301.
233. Cerling TE, Harris JM, MacFadden BJ, et al. (1997) Global
vegetation change through the Miocene/Pliocene bound-
ary. Nature 389, 153 –158.
234. Peters CR & Vogel JC (2005) Africa’s wild C-4 plant foods
and possible early hominid diets. J Hum Evol 48, 219–236.
235. Segalen L, Lee-Thorp JA & Cerling T (2007) Timing of C-4
grass expansion across sub-Saharan Africa. J Hum Evol
53, 549–559.
236. Sponheimer M, Reed KE & Lee-Thorp JA (1999) Combining
isotopic and ecomorphological data to refine bovid
paleodietary reconstruction: a case study from the Makapans-
gat Limeworks hominin locality. J Hum Evol 36, 705–718.
237. Lee-Thorp J, Thackeray JF & van der Merwe N (2000)
The hunters and the hunted revisited. J Hum Evol 39,
565–576.
238. Sponheimer M, Lee-Thorp JA & de Ruiter DJ (2007) Icarus,
Isotopes, and Australopith Diets. In Evolution of the
Human Diet: The Known, the Unknown, and the Unknow-
able, pp. 132–149 [P Ungar, editor]. Oxford: Oxford Univer-
sity Press.
Palaeolithic nutrition for disease prevention 123
Nutrition Research Reviews

239. Kelly JF (2000) Stable isotopes of carbon and nitrogen in
the study of avian and mammalian trophic ecology. Can J
Zool 78, 1–27.
240. Schoeninger MJ & Deniro MJ (1984) Nitrogen and carbon
isotopic composition of bone-collagen from marine and
terrestrial animals. Geochim Cosmochim Acta 48, 625–639.
241. Mbabazi D, Makanga B, Orach-Meza F, et al. (2010) Intra-
lake stable isotope ratio variation in selected fish species
and their possible carbon sources in Lake Kyoga
(Uganda): implications for aquatic food web studies. Afr J
Ecol 48, 667–675.
242. Schoeninger MJ, Deniro MJ & Tauber H (1983) Stable
nitrogen isotope ratios of bone-collagen reflect marine
and terrestrial components of prehistoric human diet.
Science 220, 1381–1383.
243. Sponheimer M & Lee-Thorp JA (2003) Differential resource
utilization by extant great apes and australopithecines:
towards solving the C-4 conundrum. Comp Biochem
Physiol A Mol Integr Physiol 136, 27 –34.
244. Lee-Thorp JA, Sponheimer M & Luyt J (2007) Tracking
changing environments using stable carbon isotopes in
fossil tooth enamel: an example from the South African
hominin sites. J Hum Evol 53, 595–601.
245. van der Merwe NJ, Masao FT & Bamford MK (2008)
Isotopic evidence for contrasting diets of early hominins
Homo habilis and Australopithecus boisei of Tanzania.
S Afr J Sci 104, 153–155.
246. Schoeninger MJ, Moore J & Sept JM (1999) Subsistence
strategies of two ‘savanna’ chimpanzee populations: the
stable isotope evidence. Am J Primatol 49, 297–314.
247. Sponheimer M, Loudon JE, Codron D, et al. (2006) Do
“savanna” chimpanzees consume C-4 resources? J Hum
Evol 51, 128–133.
248. Sponheimer M & Lee-Thorp JA (1999) Oxygen isotopes in
enamel carbonate and their ecological significance.
J Archaeol Sci 26, 723–728.
249. Sponheimer M & Lee-Thorp JA (2001) The oxygen isotope
composition of mammalian enamel carbonate from Morea
Estate, South Africa. Oecologia 126, 153–157.
250. Hu Y, Shang H, Tong H, et al. (2009) Stable isotope dietary
analysis of the Tianyuan 1 early modern human. Proc Natl
Acad Sci U S A 106, 10971–10974.
251. Richards MP, Pettitt PB, Trinkaus E, et al. (2000)
Neanderthal diet at Vindija and Neanderthal predation:
the evidence from stable isotopes. Proc Natl Acad Sci
USA97, 7663–7666.
252. Richards MP, Pettitt PB, Stiner MC, et al. (2001) Stable
isotope evidence for increasing dietary breadth in the
European mid-Upper Paleolithic. Proc Natl Acad Sci U S A
98, 6528–6532.
253. Richards MP (2002) A brief review of the archaeological evi-
dence for Palaeolithic and Neolithic subsistence. Eur J Clin
Nutr 56, 1270–1278.
254. Richards MP, Schulting RJ & Hedges RE (2003) Archaeology:
sharp shift in diet at onset of Neolithic. Nature 425, 366.
255. Richards MP, Jacobi R, Cook J, et al. (2005) Isotope evi-
dence for the intensive use of marine foods by Late
Upper Palaeolithic humans. J Hum Evol 49, 390–394.
256. Richards MP & Trinkaus E (2009) Isotopic evidence for the
diets of European Neanderthals and early modern humans.
Proc Natl Acad Sci U S A 106, 16034 – 16039.
257. van der Merwe NJ, Thackeray JF, Lee-Thorp JA, et al. (2003)
The carbon isotope ecology and diet of Australopithecus
africanus at Sterkfontein, South Africa. J Hum Evol 44,
581–597.
258. Semaw S, Rogers MJ, Quade J, et al. (2003) 2.6-Million-
year-old stone tools and associated bones from
OGS-6 and OGS-7, Gona, Afar, Ethiopia. J Hum Evol 45,
169–177.
259. McPherron SP, Alemseged Z, Marean CW, et al. (2010) Evi-
dence for stone-tool-assisted consumption of animal tissues
before 3.39 million years ago at Dikika, Ethiopia. Nature
466, 857–860.
260. Willis LA, Eren MI & Rick TC (2008) Does butchering fish
leave cut marks? J Archaeol Sci 35, 1438 –1444.
261. Braun DR, Harris JW, Levin NE, et al. (2010) Early hominin
diet included diverse terrestrial and aquatic animals 1·95 Ma
in East Turkana, Kenya. Proc Natl Acad Sci U S A 107,
10002–10007.
262. de Heinzelin J, Clark JD, White T, et al. (1999) Environment
and behavior of 2.5-million-year-old Bouri hominids.
Science 284, 625–629.
263. Leonard WR, Robertson ML & Snodgrass JJ (2007) Ener-
getics and the evolution of brain size in early Homo.In
Guts and Brains. An Integrative Approach to the Hominin
Record, pp. 29–46 [W Roebroeks, editor]. Leiden: Leiden
University Press.
264. Simpson SW, Quade J, Levin NE, et al. (2008) A female
Homo erectus pelvis from Gona, Ethiopia. Science 322,
1089–1092.
265. Bramble DM & Lieberman DE (2004) Endurance running
and the evolution of Homo.Nature 432, 345 –352.
266. Broadhurst CL, Wang Y, Crawford MA, et al. (2002) Brain-
specific lipids from marine, lacustrine, or terrestrial
food resources: potential impact on early African Homo
sapiens.Comp Biochem Physiol B Biochem Mol Biol 131,
653–673.
267. Erlandson JM (2001) The archaeology of aquatic adap-
tations: paradigms for a new millennium. J Archaeol Res
9, 287–350.
268. Marean CW (2010) Coastal South Africa and the co-evol-
ution of the modern human lineage and the coastal adap-
tation. In Trekking the Shore: Changing Coastlines and
the Antiquity of Coastal Settlement, pp. 421–440 [N Bicho,
JA Haws and LG Davis, editors]. New York: Springer.
269. Stewart KM (1994) Early hominid utilization of fish
resources and implications for seasonality and behavior.
J Hum Evol 27, 229–245.
270. Wang S, Lewis CM, Jakobsson M, et al. (2007) Genetic vari-
ation and population structure in native Americans. PLoS
Genet 3, e185.
271. Pope GG (1989) Bamboo and human-evolution. In Natural
History, pp. 48–57, October 1989.
272. Fagan BM (1990) The Journey from Eden: The Peopling of
Our World. London: Thames and Hudson.
273. Bar-Yosef O (1994) The lower Paleolithic of the Near East.
J World Prehist 8, 211–265.
274. Cleyet-Merle J & Madelaine S (1995) Inland evidence of
human sea coast exploitation in Palaeolithic France. In
Man and Sea in the Mesolithic, pp. 303 –308 [A Fischer,
editor]. Oxford: Oxbow Books.
275. Klein RG, Avery G, Cruz-Uribe K, et al. (1999) Duinefontein
2, an Acheulean Site in the Western Cape Province of South
Africa. J Hum Evol 37, 153–190.
276. de Lumley H (1969) A Paleolithic camp at Nice. In Scientific
American, vol. 220, pp. 42–50.
277. Villa P (1983) Terra Amata and the Middle Pleistocene
Archaeological Record of Southern France (University of
California Publications in Anthropology). Berkeley: Uni-
versity of California Press.
278. Marean CW, Bar-Matthews M, Bernatchez J, et al. (2007)
Early human use of marine resources and pigment in
South Africa during the Middle Pleistocene. Nature 449,
905–908.
R. S. Kuipers et al.124
Nutrition Research Reviews

279. Walter RC, Buffler RT, Bruggemann JH, et al. (2000) Early
human occupation of the Red Sea coast of Eritrea during
the last interglacial. Nature 405, 65 –69.
280. Stiner MC (1993) Honor Among Thieves: A Zooarchaeologi-
cal Study of Neandertal Ecology. Princeton, NJ: Princeton
University Press.
281. von den Driesch A (2004) The Middle Stone Age fish fauna
from the Klassies River main site, South Africa. Anthropo-
zoologica 39, 33–59.
282. Erlandson JM (2010) Food for thought: the role of coastlines
and aquatic resources in human evolution. In Human
Brain Evolution: The Influence of Freshwater and Marine
Food Resources, pp. 125–136 [SC Cunnane and KM Stewart,
editors]. Hoboken, New Jersey: Wiley-Blackwell.
283. Klein RG, Cruz-Uribe K, Halkett D, et al. (1999) Paleoenvir-
onmental and human behavioral implications of the Boe-
goeberg 1 late pleistocene hyena den, Northern Cape
Province, South Africa. Quatern Res 52, 393 –403.
284. Marean CW, Goldberg P, Avery G, et al. (2000) Middle Stone
Age stratigraphy and excavations at Die Kelders Cave 1
(Western Cape Province, South Africa): the 1992, 1993,
and 1995 field seasons. J Hum Evol 38, 7–42.
285. Henshilwood C & Sealy J (1997) Bone artifacts from the
Middle Stone Age at Blombos Cave, southern cape, South
Africa. Curr Anthropol 38, 890 –895.
286. Klein RG, Avery G, Cruz-Uribe K, et al. (2004) The Yster-
fontein 1 Middle Stone Age site, South Africa, and early
human exploitation of coastal resources. Proc Natl Acad
Sci U S A 101, 5708–5715.
287. Avery G, Halkett D, Orton J, et al. (2008) The Ysterfontein 1
Middle Stone Age rock shelter and the evolution of coastal
foraging. S Afr Archaeol Soc Goodwin Ser 10, 66 –89.
288. Henshilwood C, d’Errico F, Vanhaeren M, et al. (2004)
Middle Stone Age shell beads from South Africa. Science
304, 404.
289. Harris JW, Williamson PG, Morris PJ, et al (1990) Archaeol-
ogy of the Lusso beds. In Evolution of Environments and
Hominidae in the African Western Rift Valley, pp.
237–272 [NT Boaz, editor]. Martinsville: Virginia Museum
of Natural History.
290. Meylan P (1990) Fossil turtles from the upper Semliki, Zaire.
In Evolution of Environments and Hominidae in the Afri-
can Western Rift Valley, pp. 163– 170 [NT Boaz, editor].
Martinsville: Virginia Museum of Natural History.
291. Henshilwood CS, Sealy JC, Yates R, et al. (2001) Blombos
Cave, Southern Cape, South Africa: preliminary report on
the 1992–1999 excavations of the Middle Stone Age
levels. J Archaeol Sci 28, 421–448.
292. Wickler S & Spriggs M (1988) Pleistocene human occu-
pation of the Solomon-Islands, Melanesia. Antiquity 62,
703–706.
293. Allen J, Gosden C, Jones R, et al. (1988) Pleistocene dates
for the human occupation of New Ireland, northern Mela-
nesia. Nature 331, 707–709.
294. O’Connor S, Ono R & Clarkson C (2011) Pelagic fishing at
42 000 years before the present and the maritime skills of
modern humans. Science 334, 1117 –1121.
295. Morwood MJ, O’Sullivan PB, Aziz F, et al. (1998) Fission-
track ages of stone tools and fossils on the east Indonesian
island of Flores. Nature 392, 173 –176.
296. Morwood MJ, Aziz F, O’Sullivan P, et al. (1999) Archaeolo-
gical and palaeontological research in central Flores, east
Indonesia: results of fieldwork 1997–98. Antiquity 73,
273–286.
297. Morwood MJ, Brown P, Jatmiko, et al. (2005) Further evi-
dence for small-bodied hominins from the Late Pleistocene
of Flores, Indonesia. Nature 437, 1012 –1017.
298. Westaway KE, Morwood MJ, Roberts RG, et al. (2007) Estab-
lishing the time of initial human occupation of Liang Bua,
western Flores, Indonesia. Quat Geochronol 2, 337 –343.
299. Brumm A, Jensen GM, van den Bergh GD, et al. (2010)
Hominins on Flores, Indonesia, by one million years ago.
Nature 464, 748–752.
300. Sept JM (1986) Plant foods and early hominids at Site Fxjj
50, Koobi-Fora, Kenya. J Hum Evol 15, 751 –770.
301. Gibbons A (2007) Paleoanthropology. Food for thought.
Science 316, 1558–1560.
302. Wobber V, Hare B & Wrangham R (2008) Great apes prefer
cooked food. J Hum Evol 55, 340–348.
303. Goren-Inbar N, Alperson N, Kislev ME, et al. (2004) Evi-
dence of hominin control of fire at Gesher Benot
Ya’aqov, Israel. Science 304, 725– 727.
304. Roebroeks W & Villa P (2011) On the earliest evidence for
habitual use of fire in Europe. Proc Natl Acad Sci U S A 108,
5209–5214.
305. Henry AG, Brooks AS & Piperno DR (2011) Microfossils
in calculus demonstrate consumption of plants and
cooked foods in Neanderthal diets (Shanidar III, Iraq;
Spy I and II, Belgium). Proc Natl Acad Sci U S A 108,
486–491.
306. Crawford MA, Bloom M, Cunnane S, et al. (2001) Docosa-
hexaenoic acid and cerebral evolution. World Rev Nutr
Diet 88, 6–17.
307. Parkington J (2003) Middens and moderns: shellfishing and
the Middle Stone Age of the Western Cape, South Africa. S
Afr J Sci 99, 243–247.
308. Parkington J, Roggenpoel C, Halkett D, et al (2009) Initial
observations on the Middle Stone Age coastal settlement
in the Western Cape, South Africa. In Settlement Dynamics
of the Middle Paleolithic and Middle Stone Age, pp. 5–22
[NJ Conard, editor]. Tubingen: Tubingen Publications in
Prehistory.
309. Cordain L, Eaton SB, Sebastian A, et al. (2005) Origins and
evolution of the Western diet: implications of iodine and
seafood intakes for the human brain – reply. Am J Clin
Nutr 82, 483–484.
310. Nadel D, Weiss E, Simchoni O, et al. (2004) Stone Age hut
in Israel yields world’s oldest evidence of bedding. Proc
Natl Acad Sci U S A 101, 6821 –6826.
311. Weiss E, Wetterstrom W, Nadel D, et al. (2004) The broad
spectrum revisited: evidence from plant remains. Proc
Natl Acad Sci U S A 101, 9551 –9555.
312. Kislev ME, Weiss E, Hartmann A & Hartmann A (2004)
Impetus for sowing and the beginning of agriculture:
ground collecting of wild cereals. Proc Natl Acad Sci U S
A101, 2692–2695.
313. Kimbel WH, Walter RC, Johanson DC, et al. (1996) Late
Pliocene Homo and Oldowan tools from the Hadar for-
mation (Kada Hadar Member), Ethiopia. J Hum Evol 31,
549–561.
314. Lee RB (1968) What hunters do for a living, or, how to
make out on scarce resources. In Man the Hunter, pp.
30–48 [RB Lee and I DeVore, editors]. New York: Aldine
Publishing Company.
315. Murdock GV (1967) Ethnographic Atlas. Pittsburgh: Univer-
sity of Pittsburgh Press.
316. Stewart JH (1968) Causal factors and processes in the
evolution of pre-farming societies. In Man the Hunter,
pp. 321–334 [RB Lee and I DeVore, editors]. New York:
Aldine Publishing Company.
317. Meehan B (1982) Shell Bed to Shell Midden. Canberra:
Humanity Press.
318. Moss ML (1993) Shellfish, gender, and status on the North-
west Coast – reconciling archaeological, ethnographic, and
Palaeolithic nutrition for disease prevention 125
Nutrition Research Reviews

ethnohistorical records of the Tlingit. Am Anthropol 95,
631–652.
319. Godfrey KM, Lillycrop KA, Burdge GC, et al. (2007)
Epigenetic mechanisms and the mismatch concept of the
developmental origins of health and disease. Pediatr Res
61, 5R–10R.
320. Burdge GC, Hanson MA, Slater-Jefferies JL, et al. (2007)
Epigenetic regulation of transcription: a mechanism for
inducing variations in phenotype (fetal programming) by
differences in nutrition during early life? Br J Nutr 97,
1036–1046.
321. Waterland RA & Jirtle RL (2004) Early nutrition, epigenetic
changes at transposons and imprinted genes, and enhanced
susceptibility to adult chronic diseases. Nutrition 20,
63–68.
322. Lillycrop KA & Burdge GC (2010) Epigenetic changes in
early life and future risk of obesity. Int J Obes (Lond) 35,
72–83.
323. Godfrey KM, Sheppard A, Gluckman PD, et al. (2011)
Epigenetic gene promoter methylation at birth is associated
with child’s later adiposity. Diabetes 60, 1528–1534.
324. Bensinger SJ & Tontonoz P (2008) Integration of
metabolism and inflammation by lipid-activated nuclear
receptors. Nature 454, 470 –477.
325. Castrillo A & Tontonoz P (2004) PPARs in atherosclerosis:
the clot thickens. J Clin Invest 114, 1538–1540.
326. Song Y, Yao X & Ying H (2011) Thyroid hormone action in
metabolic regulation. Protein Cell 2, 358 –368.
327. Bouillon R, Bischoff-Ferrari H & Willett W (2008) Vitamin D
and health: perspectives from mice and man. J Bone Miner
Res 23, 974–979.
328. McGrane MM (2007) Vitamin A regulation of gene
expression: molecular mechanism of a prototype gene.
J Nutr Biochem 18, 497–508.
329. Venturi S, Donati FM, Venturi A, et al. (2000) Role of iodine
in evolution and carcinogenesis of thyroid, breast and
stomach. Adv Clin Path 4, 11–17.
330. Kohrle J & Gartner R (2009) Selenium and thyroid. Best
Pract Res Clin Endocrinol Metab 23, 815 –827.
331. Gilbert ME, McLanahan ED, Hedge J, et al. (2011) Marginal
iodide deficiency and thyroid function: dose–response
analysis for quantitative pharmacokinetic modeling. Toxi-
cology 283, 41–48.
332. Desvergne B & Wahli W (1999) Peroxisome proliferator-
activated receptors: nuclear control of metabolism. Endocr
Rev 20, 649–688.
333. Norman AW & Bouillon R (2010) Vitamin D nutritional
policy needs a vision for the future. Exp Biol Med
(Maywood) 235, 1034–1045.
334. Holick MF & Chen TC (2008) Vitamin D deficiency: a
worldwide problem with health consequences. Am J Clin
Nutr 87, 1080S–1086S.
335. Mann GV, Roels OA, Price DL, et al. (1962) Cardiovascular
disease in African Pygmies. A survey of the health status,
serum lipids and diet of Pygmies in Congo. J Chron Dis
15, 341–371.
336. Mann GV, Shaffer RD, Anderson RS, et al. (1964)
Cardiovascular disease in the Masai. J Atheroscler Res 4,
289–312.
337. Mann GV, Shaffer RD & Rich A (1965) Physical fitness and
immunity to heart disease in Masai. Lancet ii, 1308–1310.
338. Shaper AG, Leonard PJ, Jones KW, et al. (1969) Environ-
mental effects on the body build, blood pressure and
blood chemistry of nomadic warriors serving in the army
in Kenya. East Afr Med J 46, 282–289.
339. O’Keefe JH Jr, Cordain L, Harris WH, et al. (2004) Optimal
low-density lipoprotein is 50 to 70 mg/dl: lower is better
and physiologically normal. J Am Coll Cardiol 43,
2142–2146.
340. Joffe BI, Jackson WP, Thomas ME, et al. (1971) Metabolic
responses to oral glucose in the Kalahari Bushmen. Br
Med J 4, 206–208.
341. Merimee TJ, Rimoin DL & Cavalli-Sforza LL (1972) Meta-
bolic studies in the African pygmy. J Clin Invest 51,
395–401.
342. Ramsden CE, Faurot KR, Carrera-Bastos P, et al. (2009)
Dietary fat quality and coronary heart disease prevention:
a unified theory based on evolutionary, historical, global,
and modern perspectives. Curr Treat Options Cardiovasc
Med 11, 289–301.
343. Keys AB (1980) Seven Countries: A Multivariate Analysis
of Death and Coronary Heart Disease. Cambridge, MA:
Harvard University Press.
344. Clarke R, Frost C, Collins R, et al. (1997) Dietary lipids and
blood cholesterol: quantitative meta-analysis of metabolic
ward studies. BMJ 314, 112–117.
345. Kuipers RS, de Graaf DJ, Luxwolda MF, et al. (2011) Satu-
rated fat, carbohydrates and CVD. Neth J Med 69, 22–28.
346. Ho KJ, Biss K, Mikkelson B, et al. (1971) The Masai of East
Africa: some unique biological characteristics. Arch Pathol
91, 387–410.
347. Biss K, Ho KJ, Mikkelson B, et al. (1971) Some unique
biologic characteristics of the Masai of East Africa. N Engl
J Med 284, 694–699.
348. Mann GV, Spoerry A, Gray M, et al. (1972) Atherosclerosis
in the Masai. Am J Epidemiol 95, 26–37.
349. Kaminer B & Lutz WPW (1960) Blood pressure in Bushmen
of the Kalahari Desert. Circulation 22, 289 –295.
350. Clement AJ, Fosdick LL & Plotkin R (1956) The formation of
lactic acid in dental plaques. II. Oral conditions of primitive
Bushmen of the Western Kalahari Desert. J Dent Res 35,
786–791.
351. Lindeberg S, Berntorp E, Nilsson-Ehle P, et al. (1997) Age
relations of cardiovascular risk factors in a traditional Mela-
nesian society: the Kitava Study. Am J Clin Nutr 66,
845–852.
352. Sackett DL, Rosenberg WM, Gray JA, et al. (1996) Evidence
based medicine: what it is and what it isn’t. BMJ 312,
71–72.
353. Blumberg J, Heaney RP, Huncharek M, et al. (2010)
Evidence-based criteria in the nutritional context. Nutr
Rev 68, 478–484.
354. Dyerberg J, Bang HO & Hjorne N (1975) Fatty acid compo-
sition of the plasma lipids in Greenland Eskimos. Am J Clin
Nutr 28, 958–966.
355. Bang HO, Dyerberg J & Sinclair HM (1980) The compo-
sition of the Eskimo food in north western Greenland.
Am J Clin Nutr 33, 2657–2661.
356. Burr ML, Fehily AM, Gilbert JF, et al. (1989) Effects of
changes in fat, fish, and fibre intakes on death and myocar-
dial reinfarction: diet and reinfarction trial (DART). Lancet
ii, 757–761.
357. Mozaffarian D & Rimm EB (2006) Fish intake, contami-
nants, and human health: evaluating the risks and the ben-
efits. JAMA 296, 1885–1899.
358. de Lorgeril M, Salen P, Martin JL, et al. (1999) Mediterranean
diet, traditional risk factors, and the rate of cardiovascular
complications after myocardial infarction: final report of
the Lyon Diet Heart Study. Circulation 99, 779–785.
359. Anonymous (1999) Dietary supplementation with n-3
polyunsaturated fatty acids and vitamin E after myocardial
infarction: results of the GISSI-Prevenzione trial. Gruppo
Italiano per lo Studio della Sopravvivenza nell’Infarto
miocardico. Lancet 354, 447–455.
R. S. Kuipers et al.126
Nutrition Research Reviews

360. Marchioli R, Barzi F, Bomba E, et al. (2002) Early protection
against sudden death by n-3 polyunsaturated fatty acids
after myocardial infarction: time-course analysis of the
results of the Gruppo Italiano per lo Studio della
Sopravvivenza nell’Infarto Miocardico (GISSI)-Prevenzione.
Circulation 105, 1897–1903.
361. Yokoyama M, Origasa H, Matsuzaki M, et al. (2007) Effects
of eicosapentaenoic acid on major coronary events in
hypercholesterolaemic patients (JELIS): a randomised
open-label, blinded endpoint analysis. Lancet 369,
1090–1098.
362. Kromhout D, Giltay EJ, Geleijnse JM, et al. (2010) n-3 Fatty
acids and cardiovascular events after myocardial infarction.
N Engl J Med 363, 2015–2026.
363. Hibbeln JR (1998) Fish consumption and major depression.
Lancet 351, 1213.
364. Hibbeln JR (2002) Seafood consumption, the DHA content
of mothers’ milk and prevalence rates of postpartum
depression: a cross-national, ecological analysis. J Affect
Disord 69, 15–29.
365. Hibbeln JR (2009) Depression, suicide and deficiencies of
omega-3 essential fatty acids in modern diets. World Rev
Nutr Diet 99, 17–30.
366. Hibbeln JR (2001) Seafood consumption and homicide
mortality. A cross-national ecological analysis. World Rev
Nutr Diet 88, 41–46.
367. Lin PY & Su KP (2007) A meta-analytic review of
double-blind, placebo-controlled trials of antidepressant
efficacy of omega-3 fatty acids. J Clin Psychiatry 68,
1056–1061.
368. Ross BM, Seguin J & Sieswerda LE (2007) Omega-3 fatty
acids as treatments for mental illness: which disorder and
which fatty acid? Lipids Health Dis 6, 21.
369. Sinclair AJ, Begg D, Mathai M, et al. (2007) Omega 3 fatty
acids and the brain: review of studies in depression. Asia
Pac J Clin Nutr 16, Suppl. 1, 391–397.
370. Freeman MP (2000) Omega-3 fatty acids in psychiatry: a
review. Ann Clin Psychiatry 12, 159–165.
371. Freeman MP, Hibbeln JR, Wisner KL, et al. (2006) Omega-3
fatty acids: evidence basis for treatment and future research
in psychiatry. J Clin Psychiatry 67, 1954–1967.
372. Sublette ME, Ellis SP, Geant AL, et al. (2011) Meta-analysis
of the effects of eicosapentaenoic acid (EPA) in clinical
trials in depression. J Clin Psychiatry 72, 1577 –1584.
373. Wellcome Trust Case Control Consortium (2007) Genome-
wide association study of 14 000 cases of seven common
diseases and 3,000 shared controls. Nature 447, 661 –678.
374. Challem JJ (1997) Did the loss of endogenous ascorbate
propel the evolution of Anthropoidea and Homo sapiens?
Med Hypotheses 48, 387–392.
375. Nishikimi M, Fukuyama R, Minoshima S, et al. (1994) Clon-
ing and chromosomal mapping of the human nonfunc-
tional gene for L-gulono-g-lactone oxidase, the enzyme
for L-ascorbic acid biosynthesis missing in man. J Biol
Chem 269, 13685–13688.
376. Burdge GC & Wootton SA (2002) Conversion of a-linolenic
acid to eicosapentaenoic, docosapentaenoic and docosa-
hexaenoic acids in young women. Br J Nutr 88, 411 –420.
377. Burdge GC (2006) Metabolism of a-linolenic acid in humans.
Prostaglandins Leukot Essent Fatty Acids 75, 161 –168.
378. Kuipers RS, Luxwolda MF, Janneke Dijck-Brouwer DA, et al.
(2011) Intrauterine, postpartum and adult relationships
between arachidonic acid (AA) and docosahexaenoic acid
(DHA). Prostaglandins Leukot Essent Fatty Acids 85,
245–252.
379. Luxwolda MF, Kuipers RS, Smit EN, et al. (2011) The
relation between the omega-3 index and arachidonic acid
is bell shaped: synergistic at low EPA þDHA status and
antagonistic at high EPA þDHA status. Prostaglandins
Leukot Essent Fatty Acids 85, 171–178.
380. Crawford MA, Hassam AG, Williams G, et al. (1976)
Essential fatty acids and fetal brain growth. Lancet i,
452–453.
381. Kuhn DC & Crawford M (1986) Placental essential fatty acid
transport and prostaglandin synthesis. Prog Lipid Res 25,
345–353.
382. Crawford MA, Hassam AG & Rivers JP (1978) Essential fatty
acid requirements in infancy. Am J Clin Nutr 31, 2181–2185.
383. Hornstra G (2000) Essential fatty acids in mothers and their
neonates. Am J Clin Nutr 71, 1262S–1269S.
384. Hornstra G (2005) Essential fatty acids during pregnancy.
Impact on mother and child. Nestle Nutr Workshop Ser
Pediatr Program 55, 83–96.
385. Makrides M, Gibson RA, McPhee AJ, et al. (2010) Effect of
DHA supplementation during pregnancy on maternal
depression and neurodevelopment of young children: a
randomized controlled trial. JAMA 304, 1675–1683.
386. Doornbos B, van Goor SA, Dijck-Brouwer DA, et al. (2009)
Supplementation of a low dose of DHA or DHA þAA does
not prevent peripartum depressive symptoms in a small
population based sample. Prog Neuropsychopharmacol
Biol Psychiatry 33, 49–52.
387. Su KP, Huang SY, Chiu TH, et al. (2008) Omega-3 fatty acids
for major depressive disorder during pregnancy: results
from a randomized, double-blind, placebo-controlled trial.
J Clin Psychiatry 69, 644–651.
388. Wojcicki JM & Heyman MB (2011) Maternal omega-3 fatty
acid supplementation and risk for perinatal maternal
depression. J Matern Fetal Neonatal Med 24, 680 –686.
389. Koletzko B & Braun M (1991) Arachidonic acid and early
human growth: is there a relation? Ann Nutr Metab 35,
128–131.
390. Szajewska H, Horvath A & Koletzko B (2006) Effect of n-3
long-chain polyunsaturated fatty acid supplementation of
women with low-risk pregnancies on pregnancy outcomes
and growth measures at birth: a meta-analysis of random-
ized controlled trials. Am J Clin Nutr 83, 1337 –1344.
391. Olsen SF, Osterdal ML, Salvig JD, et al. (2006) Duration of
pregnancy in relation to seafood intake during early and
mid pregnancy: prospective cohort. Eur J Epidemiol 21,
749–758.
392. Olsen SF, Osterdal ML, Salvig JD, et al. (2007) Duration of
pregnancy in relation to fish oil supplementation and habit-
ual fish intake: a randomised clinical trial with fish oil. Eur J
Clin Nutr 61, 976–985.
393. Malcolm CA, McCulloch DL, Montgomery C, et al. (2003)
Maternal docosahexaenoic acid supplementation during
pregnancy and visual evoked potential development in
term infants: a double blind, prospective, randomised
trial. Arch Dis Child Fetal Neonatal Ed 88, F383 –F390.
394. Malcolm CA, Hamilton R, McCulloch DL, et al. (2003) Sco-
topic electroretinogram in term infants born of mothers
supplemented with docosahexaenoic acid during preg-
nancy. Invest Ophthalmol Vis Sci 44, 3685–3691.
395. Judge MP, Harel O & Lammi-Keefe CJ (2007) A docosahex-
aenoic acid-functional food during pregnancy benefits
infant visual acuity at four but not six months of age.
Lipids 42, 117–122.
396. Birch EE, Carlson SE, Hoffman DR, et al. (2010) The DIA-
MOND (DHA Intake And Measurement Of Neural Develop-
ment) Study: a double-masked, randomized controlled
clinical trial of the maturation of infant visual acuity as a
function of the dietary level of docosahexaenoic acid. Am
J Clin Nutr 91, 848–859.
Palaeolithic nutrition for disease prevention 127
Nutrition Research Reviews

397. Smithers LG, Gibson RA, McPhee A, et al. (2008) Higher
dose of docosahexaenoic acid in the neonatal period
improves visual acuity of preterm infants: results of
a randomized controlled trial. Am J Clin Nutr 88, 1049 –1056.
398. Judge MP, Harel O & Lammi-Keefe CJ (2007) Maternal con-
sumption of a docosahexaenoic acid-containing functional
food during pregnancy: benefit for infant performance on
problem-solving but not on recognition memory tasks at
age 9 mo. Am J Clin Nutr 85, 1572–1577.
399. Dunstan JA, Simmer K, Dixon G, et al. (2008) Cognitive
assessment of children at age 2(1/2) years after maternal
fish oil supplementation in pregnancy: a randomised con-
trolled trial. Arch Dis Child Fetal Neonatal Ed 93, F45 –F50.
400. Helland IB, Smith L, Saarem K, et al. (2003) Maternal sup-
plementation with very-long-chain n-3 fatty acids during
pregnancy and lactation augments children’s IQ at 4 years
of age. Pediatrics 111, e39–e44.
401. Helland IB, Smith L, Blomen B, et al. (2008) Effect of sup-
plementing pregnant and lactating mothers with n-3 very-
long-chain fatty acids on children’s IQ and body mass
index at 7 years of age. Pediatrics 122, e472–e479.
402. McCann JC & Ames BN (2005) Is docosahexaenoic acid, an
n-3 long-chain polyunsaturated fatty acid, required for
development of normal brain function? An overview of evi-
dence from cognitive and behavioral tests in humans and
animals. Am J Clin Nutr 82, 281–295.
403. Dijck-Brouwer DA, Hadders-Algra M, Bouwstra H, et al.
(2005) Lower fetal status of docosahexaenoic acid, arachi-
donic acid and essential fatty acids is associated with less
favorable neonatal neurological condition. Prostaglandins
Leukot Essent Fatty Acids 72, 21–28.
404. Moriguchi T, Loewke J, Garrison M, et al. (2001) Reversal of
docosahexaenoic acid deficiency in the rat brain, retina,
liver, and serum. J Lipid Res 42, 419– 427.
405. Rao JS, Ertley RN, DeMar JC Jr, et al. (2007) Dietary n-3
PUFA deprivation alters expression of enzymes of the ara-
chidonic and docosahexaenoic acid cascades in rat frontal
cortex. Mol Psychiatry 12, 151–157.
406. van Goor SA, Smit EN, Schaafsma A, et al. (2008) Milk of
women with lifetime consumption of the recommended
daily intake of fish fatty acids should constitute the basis
for the DHA contents of infant formula. J Perinat Med 36,
548–549.
407. Brenna JT, Varamini B, Jensen RG, et al. (2007) Docosahexae-
noic and arachidonic acid concentrations in human breast
milk worldwide. Am J Clin Nutr 85, 1457–1464.
408. Koletzko B, Lien E, Agostoni C, et al. (2008) The roles of
long-chain polyunsaturated fatty acids in pregnancy,
lactation and infancy: review of current knowledge and
consensus recommendations. J Perinat Med 36, 5–14.
409. Kuipers RS, Smit EN, van der Meulen J, et al. (2007) Milk in
the island of Chole [Tanzania] is high in lauric, myristic, ara-
chidonic and docosahexaenoic acids, and low in linoleic
acid reconstructed diet of infants born to our ancestors
living in tropical coastal regions. Prostaglandins Leukot
Essent Fatty Acids 76, 221–233.
410. Hachey DL, Silber GH, Wong WW, et al. (1989) Human lac-
tation. II: Endogenous fatty acid synthesis by the mammary
gland. Pediatr Res 25, 63–68.
411. Kabara JJ (1980) Lipids as host-resistance factors of human
milk. Nutr Rev 38, 65–73.
412. Bergsson G, Steingrimsson O & Thormar H (2002)
Bactericidal effects of fatty acids and monoglycerides
on Helicobacter pylori.Int J Antimicrob Agents 20, 258 –262.
413. Widdowson EM, Dauncey MJ, Gairdner DM, et al.
(1975) Body fat of British and Dutch infants. Br Med J 1,
653–655.
414. Ailhaud G, Massiera F, Weill P, et al. (2006) Temporal
changes in dietary fats: role of n-6 polyunsaturated fatty
acids in excessive adipose tissue development and relation-
ship to obesity. Prog Lipid Res 45, 203 –236.
415. Ramsden CE, Hibbeln JR, Majchrzak SF, et al. (2010) n-6
Fatty acid-specific and mixed polyunsaturate dietary
interventions have different effects on CHD risk: a meta-
analysis of randomised controlled trials. Br J Nutr 104,
1586–1600.
416. Harris WS, Mozaffarian D, Rimm E, et al. (2009) Omega-6
fatty acids and risk for cardiovascular disease: a science
advisory from the American Heart Association Nutrition
Subcommittee of the Council on Nutrition. Circulation
119, 902–907.
417. Gibson RA, Muhlhausler B & Makrides M (2011) Conver-
sion of linoleic acid and a-linolenic acid to long-chain poly-
unsaturated fatty acids (LCPUFAs), with a focus on
pregnancy, lactation and the first 2 years of life. Matern
Child Nutr 7, Suppl. 2, 17–26.
418. Koletzko B, Thiel I & Abiodun PO (1992) The fatty acid
composition of human milk in Europe and Africa. J Pediatr
120, S62–S70.
419. Godfrey K, Robinson S, Barker DJ, et al. (1996) Maternal
nutrition in early and late pregnancy in relation to placental
and fetal growth. BMJ 312, 410–414.
420. Innis SM & Kuhnlein HV (1988) Long-chain n-3 fatty acids
in breast milk of Inuit women consuming traditional foods.
Early Hum Dev 18, 185–189.
421. Ruan C, Liu X, Man H, et al. (1995) Milk composition in
women from five different regions of China: the great diver-
sity of milk fatty acids. J Nutr 125, 2993 –2998.
422. Muskiet FA, Kuipers RS, Smit EN, et al. (2007) The basis of
recommendations for docosahexaenoic and arachidonic
acids in infant formula: absolute or relative standards? Am
J Clin Nutr 86, 1802–1803.
423. Willett WC (2002) Balancing life-style and genomics
research for disease prevention. Science 296, 695–698.
424. Yudkin J (1963) Dietary carbohydrate and ischemic heart
disease. Am Heart J 66, 835–836.
425. Yudkin J (1967) Evolutionary and historical changes in diet-
ary carbohydrates. Am J Clin Nutr 20, 108–115.
426. Eaton SB (1992) Humans, lipids and evolution. Lipids 27,
814–820.
427. Cordain L, Watkins BA & Mann NJ (2001) Fatty acid compo-
sition and energy density of foods available to African
hominids. Evolutionary implications for human brain devel-
opment. World Rev Nutr Diet 90, 144– 161.
428. Crawford MA (1968) Fatty-acid ratios in free-living and
domestic animals. Possible implications for atheroma.
Lancet i, 1329–1333.
429. O’Dea K & Sinclair AJ (1982) Increased proportion of ara-
chidonic acid in plasma lipids after 2 weeks on a diet of tro-
pical seafood. Am J Clin Nutr 36, 868–872.
430. Sinclair AJ, O’Dea K & Naughton JM (1983) Elevated levels
of arachidonic acid in fish from northern Australian coastal
waters. Lipids 18, 877–881.
431. Gibson RA, Kneebone R & Kneebone GM (1984) Compara-
tive levels of arachidonic acid and eicosapentaenoic acid in
Malaysian fish. Comp Biochem Physiol C 78, 325–328.
432. Naughton JM, O’Dea K & Sinclair AJ (1986) Animal foods in
traditional Australian aboriginal diets: polyunsaturated and
low in fat. Lipids 21, 684–690.
433. Konner M & Eaton SB (2010) Paleolithic nutrition: twenty-
five years later. Nutr Clin Pract 25, 594– 602.
434. Eaton SB, Eaton SB III & Konner MJ (1997) Paleolithic nutri-
tion revisited: a twelve-year retrospective on its nature and
implications. Eur J Clin Nutr 51, 207–216.
R. S. Kuipers et al.128
Nutrition Research Reviews

435. Eaton SB & Eaton SB III (2000) Paleolithic vs. modern diets
– selected pathophysiological implications. Eur J Nutr 39,
67–70.
436. Cordain L, Miller JB, Eaton SB, et al. (2000) Macronutrient
estimations in hunter–gatherer diets. Am J Clin Nutr 72,
1589–1592.
437. Kuipers RS, Luxwolda MF, Dijck-Brouwer DA, et al. (2010)
Estimated macronutrient and fatty acid intakes from an East
African Paleolithic diet. Br J Nutr 104, 1666–1687.
438. Morgan E (1997) The Aquatic Ape Hypothesis. London:
Souvenir Press.
439. Horrobin DF (2001) The Madness of Adam and Eve. How
Schizophrenia Shaped Humanity. Reading: Cox & Wyman
Ltd.
440. Hotamisligil GS & Erbay E (2008) Nutrient sensing and
inflammation in metabolic diseases. Nat Rev Immunol 8,
923–934.
441. Forsythe CE, Phinney SD, Fernandez ML, et al. (2008) Com-
parison of low fat and low carbohydrate diets on circulating
fatty acid composition and markers of inflammation. Lipids
43, 65–77.
442. Volek JS, Phinney SD, Forsythe CE, et al. (2009)
Carbohydrate restriction has a more favorable impact on
the metabolic syndrome than a low fat diet. Lipids 44,
297–309.
443. Forsythe CE, Phinney SD, Feinman RD, et al. (2010) Limited
effect of dietary saturated fat on plasma saturated fat in the
context of a low carbohydrate diet. Lipids 45, 947–962.
444. Simopoulos AP (1999) Essential fatty acids in health and
chronic disease. Am J Clin Nutr 70, 560S–569S.
445. Simopoulos AP (2001) Evolutionary aspects of diet
and essential fatty acids. World Rev Nutr Diet 88, 18– 27.
446. Feinman RD & Volek JS (2006) Low carbohydrate diets
improve atherogenic dyslipidemia even in the absence of
weight loss. Nutr Metab (Lond) 3, 24.
447. Osterdahl M, Kocturk T, Koochek A, et al. (2008) Effects of
a short-term intervention with a Paleolithic diet in healthy
volunteers. Eur J Clin Nutr 62, 682–685.
448. Jo
¨nsson T, Granfeldt Y, Ahre
´nB,et al. (2009) Beneficial
effects of a Paleolithic diet on cardiovascular risk factors
in type 2 diabetes: a randomized cross-over pilot study.
Cardiovasc Diabetol 8, 35.
449. Lindeberg S, Jonsson T, Granfeldt Y, et al. (2007) A Palaeo-
lithic diet improves glucose tolerance more than a Mediter-
ranean-like diet in individuals with ischaemic heart disease.
Diabetologia 50, 1795–1807.
450. Frassetto LA, Schloetter M, Mietus-Synder M, et al. (2009)
Metabolic and physiologic improvements from consuming
a Paleolithic, hunter–gatherer type diet. Eur J Clin Nutr
63, 947–955.
Palaeolithic nutrition for disease prevention 129
Nutrition Research Reviews