Anyone who wants to understand the biological nature of humans and their special characteristics must look far back into evolutionary history. Today’s way of life is drastically different from that of our ancestors. For almost 99% of human history, gathering and hunting have been the basis of nutrition. It was not until about 12,000 years ago that humans began domesticating plants and animals. Bioarchaeologically and biochemically, this can be traced back to our earliest roots. Modern living conditions and the quality of human life are better today than ever before. However, neither physically nor psychosocially have we made this adjustment and we are paying a high health price for it. The studies presented allow us to reconstruct food supply, lifestyles, and dietary habits: from the earliest primates, through hunter-gatherers of the Paleolithic, farming communities since the beginning of the Anthropocene, to the Industrial Age and the present. The comprehensive data pool allows extraction of all findings of medical relevance. Our recent lifestyle and diet are essentially determined by our culture rather than by our millions of years of ancestry. Culture is permanently in a dominant position compared to natural evolution. Thereby culture does not form a contrast to nature but represents its result. There is no doubt that we are biologically adapted to culture, but it is questionable how much culture humans can cope with. The fossil representatives of Homo sapiens are now dated to 300,000 years ago [Life on Earth began with the formation of the first molecules and dates back to approximately four billion years ago. As yet, it is unclear how the primordial cell , or LUCA, came into being. Presumably, purely chemical processes were responsible for the beginning of biological evolution . The divears ago ,3.Homo including its habitual upright gait, the freeing of its hands, its large brain as well as its language, thinking and numerous cultural achievements. As far as humans are concerned, it is only through direct comparison with our closest relatives within a long line of ancestors that it is possible to gain a substantial insight into the evolution of Homo sapiens in the context of primate evolution. This limitation also explains why there is no fundamental human–animal dichotomy. Science and scientists are not immune to hubris and egocentrism. Our image of the worldviews and lives of our fossil ancestors is often shaped by our modern cultural perspective. Taking into account its biological origins, the genus Homo seems unique only in the sense that it implemented a revolutionary change out of the “continuum” of evolution by deliberately manipulating its ecological environment [In order to understand the biological nature of humans and their special features, one must deal with their development and look way back into the history of evolution . A diffeironment . This suPhysics can be considered the natural science, as it examines the fundamental principles that determine the processes of life in nature. Chemistry, by contrast, deals with the properties of chemical elements and compounds and with their reactions. Both disciplines together form the framework within which the biological makeup of all organisms, including humans, functions. Biochemistry represents a borderline discipline between biology/medicine and chemistry and, among other things, aims to explore metabolic processes and genetic reproduction. At the species level, two mechanisms in particular are essential: ensuring reproduction for subsequent generations (reproduction) and the physiological functional maintenance of the body in its interactions with the environment (nutrition). The chemistry of life is organised in metabolic pathways . After wThese elements created the living conditions for the first microorganisms on Earth approximately 3.5 billion years ago. But it was not until 350 mya that a particular level of oxygen in the atmosphere had been reached and a stratospheric layer of ozone had developed which enabled higher organisms to evolve under the protection of this UV filter. The atmosphere of the Earth’s recent history was characterised by a high proportion of nitrogen and oxygen and has hardly changed since its formation. The climate was less stable, and extreme climatic crises caused by meteoritic impacts, volcanic eruptions, intense solar activity, continental drift, etc. repeatedly disturbed the balance to such an extent that several mass extinctions occurred. One such global catastrophe, which occurred 65 mya, finally paved the way for the emergence of primates, including humans, and the flora and fauna that exists today .2), heterotrophic organisms  as consumers obtain the carbon required to build their own bodily substances from already synthesised organic COH compounds. Because the chemical elements that are necessary for the formation of organic matter only exist in limited quantities, life on Earth directly depends on the recycling of essential elements. These elements circulate inside organisms, ecosystems, and the biosphere through a constant cycle of build-up and breakdown processes. The driving force behind the cycle of materials is a synergy of biological, geological, and chemical processes involving the ecosystems’ biotic and abiotic components [While autotrophic, photosynthetically active organisms  as primary producers use sunlight as an energy source to obtain carbon from inorganic substrates such as carbon dioxide  is defined as the total amount of chemical energy that is produced within ecosystems through photosynthetic activity. In terrestrial ecosystems, limiting factors include the temperature, the level of humidity and the nutrients available. Secondary production is defined as the rate at which primary consumers within an ecosystem (herbivores) convert the chemical energy of their food into their own new biomass. The importance of the trophic structure for our understanding of the dynamic processes that occur within ecosystems is emphasised by the relationship between herbivores and plants. Nutrients are moved between organic and inorganic reservoirs by means of biological and geological processes. The rate of nutrient cycling is mainly determined by the rate of decay. Nutrient cycles are strongly influenced by the vegetation. From an early phase of the Pleistocene, humans had a profound impact on the natural nutrient cycle and permanently changed the existing flora and fauna ,10,11.The term nutrition combines all processes that ensure the supply of substances that contain energy to a living organism. Accordingly, nutrition is a prerequisite for sustaining the life-force of every living being. Food consists of energy-rich organic compounds in solid or liquid form, which are required for the formation of cells, tissue, bones, and teeth and for maintaining the organism’s energy metabolism. Both animal- and plant-based foods contain nutrients  and supplements . Lipophilic and hydrophilic vitamins flank the metabolic functions by regulating the utilisation of nutrients. Because most of these vitamins are not synthesised by the human body, they must be ingested through food. The same applies to minerals , which regulate the cellular and bodily functions; they cannot be produced by the organism itself and must be supplied through nutrition. These natural inorganic nutrients occur in various chemical compounds, but the body can only ingest them from very specific ones. Major minerals  occur in the body in high concentrations, while essential trace elements  occur in low concentrations. Deficiencies or overdosages of minerals result in impaired bodily functions . Homo sapiens is a relatively recent product of history. Its success since its emergence is illustrated, for instance, by the fact that it has managed to adapt to his environment all over the world [H. sapiens to adapt to any eco-system on Earth [From an evolutionary perspective, he world . It was he world . In addion Earth . While ton Earth . For theThe retrospective reconstruction of our ancestors’ diet is far more difficult than it is for recent populations, offers numerous options and usually depends on a successful transdisciplinary cooperation at the interface between prehistory (archaeology), anthropology (bioarchaeology), chemistry, biochemistry, geology, and evolutionary medicine. In terms of the biohistorical source material, the starting point for the reconstruction of diet in the context of archaeological research are plant, animal, and human remains from archaeological excavations. Archaeobotany and archaeozoology study the environmental, economic, and nutritional history, the human impact on the environment and, since the beginning of domestication, the economic importance of domestic animals and cultivated plants, and also reconstruct the range of plant- and animal-based food consumed. Taking into account the chronology and the archaeological data available, diachronic conclusions can be drawn with regard to the subsistence (procurement) and consumption behaviours and insight can also be gained into social history. Reconstructions of the environment, the technical achievements, and the traces in the landscape  provide indirect evidence of the nutritional situation in different periods.Archaeobotany is the study of plant remains, primarily from anthropogenic deposits from the past . Together with archaeozoology (see below), it is an important cornerstone in the research and reconstruction of the economic, natural and settlement history of past epochs. The source materials studied by archaeobotanists primarily include plant macroremains such as seeds, fruits, wood, leaves, stems and other parts of plants such as tubers, roots, and bulbs . The mosAnimal bones are the primary source material studied by archaeozoologists. The bones mainly derive from the slaughter waste of domestic and/or wild animals consumed by humans . OccasioH. sapiens, represented by more recent populations . The focus of prehistoric anthropology, therefore, is not on the evolutionary process (macroevolution), but rather on recent human history, which is characterised by a gradual emergence of (supra)regional groups . The population concept of biology (microevolution) enters the discussion with the attempt to obtain evidence of the lifestyles and living conditions of past populations from their biological makeup. With that, it is no longer the individual fossil-no matter how spectacular-that is the focus of attention, but the population as a whole, which is analysed by raising questions about the general living conditions and life processes [Direct statements concerning human nutrition in the past are the domain of anthropology and can essentially be inferred from the preserved hard tissue remains of our ancestors such as bones and teeth. While the phylogeny of humankind  as a discipline deal with various species and focuses on the trans-specific course of human evolution, prehistoric anthropology (bioarchaeology) investigates the intraspecific variability of the species rocesses ,23.The human skeleton and teeth provide numerous clues about the type of food consumed and about nutritional deficiencies and malnutrition . The stuAnalyses of stable CN isotope ratios have a broad application potential within archaeology. Depending on the initial conditions and study design, they generate relevant information at an individual and collective level that provides an insight into the subsistence conditions and dietary habits of our ancestors. While the results do not allow us to reproduce detailed daily menus from the past, they do enable us to distinguish between food categories such as meat and other animal proteins versus plant-based foods, terrestrial versus aquatic sources of protein, C3 plants versus C4 plants, all of which made up our ancestors’ diet during their lifetime . No otheTannerella forsythia have been detected genetically, which has confirmed the suspected links between host immunity factors, “red complex” pathogens and periodontal disease [Dental calculus, like bones and teeth, remains preserved for millennia  and cont disease . Usually disease ,34 are i disease ,34. In t disease .The diet of non-human primates basically includes a variety of seasonally available plant food components: fruits, nuts, barks, pith, seeds, grasses, stems, flowers, leaves, roots, and tubers . Plant-bPygathrix nemaeus) is a primate species from the group of langurs (Presbytini); it is a pregastric fermenter and is difficult to keep in captivity. As part of a comparative analysis, a group of researchers from the US were able to examine the dietary components of red-shanked doucs with four different lifestyles: wild, semi-wild, semi-captive and captive, which showed that the lifestyle also alters the microbiome [Using isotope data, researchers have been able to decipher the feeding behaviour of wild bonobos from the Congo via biochemical marker substances, allowing them to examine the composition and intake of nutrients . Their dcrobiome .Paranthropus in East Africa even evolved towards a C4/CAM specialisation, which is otherwise unknown in catarrhine primates. Australopithecines, which are considered “pre-humans” and direct ancestors of humans, also deviated in terms of their dietary spectrum from the C3 diet typical of non-human primates, consisting mainly of fruits, leaves, and herbs. Their adaptation to a mixed and diverse C3/C4 diet seems to have occurred as a consequence of changes in their habitat brought about by climate change, which necessitated a partial dietary shift towards grasses, sedges and other plants and probably meat. Diet is considered one of the important factors in human evolution. The food consumed has an influence on the metabolic processes, the nutritional behaviours and the interactions of living beings with their environment. Henry et al. [Australopithecus sediba (two mya) and explore their feeding behaviours by examining phytoliths in their dental calculus.Carbon isotope data from early hominins show that their diet differed significantly from that of today’s great apes . Four myy et al.  was ableNumerous studies have concluded that the freeing of the hands and the associated shift from a plant-based diet to one that relies more on animal protein was crucial for the development of the human brain . Other sPan troglodytes), but it is considered rare in wild populations. As part of a recent study, 11 primate taxa with n = 339 individuals or 7946 teeth were macroscopically examined for the presence of caries [n = 262) of all anterior and posterior teeth, with prevalence varying between 0 to 7%, depending on the primate species. Particular attention was paid to the occurrence of caries in the anterior region because some authors excluded it as a predilection area for caries. The species with the highest rate of caries in the anterior teeth included various species of the genus langur  at 19.5%, guenons (Cercopithecus mitis and Cercopithecus denti) at 18.3%/22.4%, chimpanzees (Pan troglodytes verus) at 9.8% and Gorilla gorilla at 2.6%. The results probably reflected differences between species with regard to their diet and food processing. The processing of cariogenic fruits and seeds in the anterior area probably contributed to the high caries intensity there. However, further studies on living primate populations are required to verify this assumption.Caries can be observed in many species of wild non-human primates, including our closest living relatives, the chimpanzee  far outweighing those in males (1.8%) are extremely interesting. It is likely that the sexual dimorphism in this case reflects behavioural differences in food processing. In terms of lifestyle, the study published by Clayton et al.  mentioneEpidemiological comparisons of the prevalence of caries and periodontitis in great apes and in humans have shown that the prevalence in humans clearly dominates . Human sAustralopithecus were the earliest ancestors of humans. What is not completely clear, however, is how and under what conditions Homo evolved in Africa. Presumably, the onset of changes in the world climate (cooling) 2.8 mya, the effects of which impacted Africa, had a lasting impact on the early development of the genus Homo. Dry savannah landscapes emerged in East Africa, which had a considerable impact on food supplies and required novel consumption habits to make the food digestible. Under these circumstances, new survival strategies and adjustments were the order of the day. Early humans with optimally equipped dentition such as Australopithecus, or those that had developed new behaviours such as the use of primitive tools (H. rudolfensis), possessed a survival advantage. The first representatives of the genus Homo evolved between three and two mya from the genera A. afarensis and A. bahreighazali. The debate still rages with regard to the sequence or even contemporaneity of the early fossil human forms. If H. rudolfensis and H. habilis are considered transitional hominins, the main issues revolve around H. erectus and H. heidelbergensis [There is no question that humans evolved from the group of primates and share a 68-million-year evolutionary history with them. Based on fossil finds from all over the world, it is also certain that all hominids older than two mya exclusively originated from Africa. There is no doubt that the upright species of the genus ergensis .Homo is also seen by researchers as an indication of the fact that the use of fire made food easier to chew and digest [H. erectus as a pioneer species. Migration proved to be the key to the world, which is why the discovery and opening up of new habitats appears to be part of human nature.For the longest period of their history, humans, like all their ancestors, were wholly dependent on nature. The availability of plants and animals in the immediate vicinity and further afield and the availability of water ensured survival in the Pleistocene (beginning 2.6 mya) . The died digest . Even ead digest . It is pd digest . The opeH. sapiens studied, without exception, consumed a very similar, broad range of different plant foods. The results generated suggest that the dietary ecology of Neanderthals was significantly more complex than has been previously portrayed. Thus, the statement is no longer tenable that the coexistence of Neanderthals and anatomically modern humans in central Europe from about 40,000 years ago proves that they obtained their nutrition at least partly from different food sources [Due to the colonisation of a variety of habitats and the adaptation to different climatic zones, it was inevitable that certain groups of our ancestors would begin to differ significantly in terms of their food spectrum, depending on the geographic region they found themselves in. A typical and classic example of this view is the Neanderthals. Despite geographically and ecologically very different environments, they are assumed to have had a dietary strategy largely based on meat. When comparing the diets of Neanderthals and early modern humans in Europe, stable isotope analyses have shown that they differed markedly in terms of their diet . While N sources ,59.Nutrition and reproduction are basic survival strategies for all societies. The question of survival, however, is tied to a certain degree of food security, which was lacking in the Palaeolithic, the longest period in human history . During From a health perspective, the hunter-gatherer lifestyle of Pleistocene groups is generally considered particularly advantageous ,63. In pCarious teeth and other oral diseases were among the singular findings in our Pleistocene ancestors ,69,70 anHomo-specific ability to digest starch thanks to oral streptococci [Although the oral microbiome plays a critical role in human health, little is yet known about its diversity, variation, and evolutionary history. To learn more, analyses of dental calculus samples from Neanderthals and late Pleistocene modern humans were compared to samples from recent humans and non-human primates . Up to aptococci ,75.Hunting, fishing, and the gathering of plants dominated people’s lives throughout the Pleistocene. After the end of the last Ice Age and with the onset of the greatest economic upheaval in human history, the traditional way of life changed dramatically and permanently. During a warm period, and thus favourable climatic conditions, around 12,000 BC, the first permanent settlements were established in the Levant. The appropriative way of life was gradually abandoned in favour of a productive economy and a sedentary lifestyle. The transition from hunting and gathering to crop cultivation and animal husbandry led to drastic social and economic changes as well as to modifications in the material culture . During The shift from a mobile, appropriative way of life to the cultivation of cereals was a slow process, initially driven by individuals, who started it by gathering wild cereal species. The entire process took place over a period of several thousand years and was highly experimental in nature. Cultivation experiments were based on wild forms of grasses and legumes such as natural lentils, from which emmer and einkorn and numerous other varieties were developed. Emmer and einkorn are ideal for arid and lean soils and require a very low level of fertilisation. Alongside the development of cultivated plants, goats and sheep were the species first domesticated; they began to increase the size and fertility of the natural pastures around the settlements. The wild forms of wheat and barley offered the advantage that they were not as easily accessible to birds as the crops with smaller grains . Over the centuries, high-yield varieties of emmer and other cereals began to spread further. Optimal areas were lower-lying mountainous regions, which mitigated the hot and arid summer months and offered abundant precipitation in the winter. Secondary cultivated plants, known as “companion plants”, developed into various vegetables such as carrots, radishes, lettuce plants and herbs . When early farmers from the Near East, having been forced to migrate by climatic events and exponential population growth, reached central Europe 7700 years ago, the new way of life quickly took hold in the new regions. The early farmers settled in the more attractive locations, began to clear the land, plant their fields, and put their livestock to pasture, initially in the surrounding woodland and later on pastureland near the settlements. Virgin landscapes were thus converted to cultivated land. While the newcomers had a certain level of know-how, they encountered different landscapes and soils, which meant that they probably experienced some setbacks and went through another lengthy phase of learning in central Europe. Based on valid palaeogenetic data, it has been shown that it was the infiltration and assimilation of foreign populations from the Carpathian Basin and later from the Eurasian steppe that resulted in the settlement of Europe by farming populations ,82,83,84In retrospect, the Neolithic was an irreversible revolution that, besides with the apparent advantages , also had numerous disadvantages  . In addiWith the increase in settlement density, however, new forms of human dependence on nature emerged, which became manifest not so much through weather and climatic events but through their consequences , and ultimately led to food shortages and even famine, which still occur in some parts of the world today. With the Neolithic way of life, culture replaced nature as a way of ensuring human subsistence and nutrition, and new forms of human-nature interaction developed. Rising population densities, increasing social hierarchisation, controlled access to natural resources , human impact on nature and armed conflicts increased with each successive cultural epoch and economic and social pressures intensified within and between communities, especially in times of crisis. However, volatile supply situations, food crises, famine and violence are not just a spectre of the past, but since the Neolithic Revolution have become increasingly established as permanent threats . Our knowledge about what people consumed after the introduction of farming and animal husbandry is based on evidence of crop cultivation, stockpiling and waste disposal from archaeological remains of houses, ditches, and pits. The main sources are remnants of cereals, legumes, and vegetables, either charred or from wetland preservation, as well as waste from the slaughtering of animals. As societies became more differentiated, the range of implements and tools also became more diverse and the variety of materials such as pottery, copper, bronze, and iron increased, leading to an array of sources that provide us with evidence of the production, processing, and consumption of food. The main crops cultivated by Bandkeramik farmers in central Europe were einkorn, emmer, barley, flax, lentils, peas, and opium poppies. Due to the predominance of some of the cereal varieties, which had proved to be most robust and provide the highest yields, the general variety of plants consumed declined sharply from the Neolithic onwards in favour of just a few varieties. While the appropriative lifestyle in earlier periods only allowed for the consumption of edible plants that were seasonally available, the farming way of life led to a stockpiling economy based on just a small number of food resources, which in times of crisis posed quite a risk. The reduction in food diversity is highly likely to have culminated in a reduction in the diversity of the human microbiome, which in turn can be linked to the occurrence of various diseases .The consumption of carbohydrates in the central European Neolithic was mainly covered by the wheat varieties of emmer and einkorn, which were originally domesticated in the Near East, and to a lesser extent by barley. We can assume that the use of certain varieties of cereals was based on experience gathered from certain soils and climatic conditions. Hulled cereals were ground to groats using stone querns, while finely ground flour was required to make bread; bread-baking is attested to by the discovery of ovens. Over the course of the Neolithic, cereal porridge and flat breads were quickly replaced by a variety of breads and pastries. Protein-rich legumes such as lentils and peas were primarily used as dry goods, except during the harvest season; flax and poppy seeds provided fat-rich food and were therefore suitable alternatives to animal-based food . The typNumerous archaeological findings have been made with regard to soil cultivation, the range of domesticated, cultivated field and garden crops, the ways in which the plant- and animal-based foods were prepared and how milk was used ,91,92. TUsing the plant remains recovered from the Neolithic lakeside settlement of Arbon Bleiche 3 on Lake Constance in Switzerland, it was shown how the inhabitants were able to cover their calory requirements over the 14 years during which they lived there . AccordiAfter the introduction of stable isotope analysis of carbon and nitrogen in the late 20th century had paved the way for comprehensive nutritional studies from a methodological point of view, it became possible, in conjunction with diachronically designed bioarchaeological and palaeogenetic studies, to obtain representative results across all cultural stages ,98. The n = 482 ind.; 26 sites) from a period of over 4000 years from the Early to the Late Neolithic in central Europe, a slow but continuous increase in the consumption of animal proteins can be identified, which must have been linked to an increase in the consumption of dairy [This development was not without its problems or conflicts. Early fisher-hunter-gatherer communities on the transition to the Holocene, for instance, exhibited marked differences in their burial customs and the number of individual grave goods, which seem to point to social differentiation but have not been confirmed by any other archaeological evidence or by the CN isotope data that allow us to reconstruct their diet. The discrepancy in the data is reflected by the fact that material possessions were destroyed in the context of the funerary rites, which points to a conflict between traditional egalitarian concepts and the emerging social differentiation . Based oof dairy . In the of dairy ,102,103.of dairy  also ledof dairy . Until tIn principle, however, we can assume that until well into the early modern period, access to a balanced diet was largely linked to a person’s social standing. The Three Estates system  of the Middle Ages was also reflected in the dietary habits. The most significant dietary aspects that help to distinguish between the social classes are the types of meat, fish and cereals consumed, as well as the frequency and type of spices used; the latter were primarily reserved for the nobility and, with certain restrictions, the clergy. The peasants, on the other hand, mainly lived on cereal porridge or mash with lard, cabbage and bacon or pork as well as locally grown vegetables. This social order, which had emerged during the Middle Ages, remained in place relatively unchanged for many centuries and was only replaced by new patterns of social behaviour at the beginning of the industrial age ,107.While the beginning of the metal ages saw an increase in the range of cereals due to the addition of varieties such as oat and millet, there was also a decline in naked wheat. Beans were the most important new crop. In general, the consumption of legumes continuously increased, and this is generally attributed to population growth. In terms of livestock and meat supplies, the large Iron Age sites of Manching in Germany  and Basel-Gasfabrik in Switzerland  yielded large quantities of bones, which allowed archaeologists to calculate the ratio of animals present at any one time. Cattle clearly dominated over sheep/goats and pigs ,109,110.Besides cereal varieties such as rye and wheat for bread, which accounted for approximately 60% of the overall diet, there were special cereals such as millet, buckwheat and green spelt, which were used to make groats and porridge (c. 15% of the diet). Because of this dependence on cereals, crop failures could not be compensated by any other foodstuffs until the potato conquered Europe in the 17th century. Before the year 1000 and after 1300, climatic crises led to considerable levels of famine. These can be identified through climate proxies as stabilising or destabilising factors in cultural history . Within There is no doubt today that the transition from an appropriative economy, which prevailed for about 99% of human evolution, to a productive economy based on farming in the Neolithic represented a step that was radical in every respect, which is why it has also been termed a revolution. Beyond the consequences of Neolithisation described above, which were undeniably positive in the medium and long term, there were also various negative effects in terms of health and mortality, which were obviously closely related to the lifestyle change . In ordeIn the past and up to the present, plagues and pandemics have had a greater impact on the world and have reduced population numbers more than armed conflicts, famine and natural disasters combined . Many diThe communicable diseases of these early farmers that still threaten our health today ,120 inclIn principle, humans are omnivores by biological design. Unlike other species, they are food generalists, which means that they do not make any specific demands on their diet. This allows them to survive under diverse conditions in almost all geographical regions by consuming a wide range of organic substances provided by the animal and plant worlds. However, this does not always make for the best conditions with regard to human health. Until a few thousand years ago, our ancestors largely covered their nutritional needs by exploiting the seasonal supply in their natural environments and were therefore perfectly adapted to this way of life. The onset of the Neolithic brought a radical change. From the point of view of nutritional physiology, the transition to an agrarian way of life, which we have now been practising for at least 480 generations, has had considerable consequences for our health, the full extent of which have only recently become apparent. As long as people lived from gathering and hunting and were highly mobile, they were physically very fit, rather tall and muscular and had a balanced diet rich in protein and vitamins from wild plants, meat, nuts and fruits, though they also had to withstand occasional periods of undernourishment. While intermittent fasting is now considered beneficial, this is a deliberate and voluntarily practice which can be abandoned at any stage ,128. EpiAt the beginning of the Neolithic, the consumption of animal proteins initially decreased, the variety of food plants was reduced and the proportion of starchy cereals in the diet rose sharply . The chaMilk, today a foodstuff of global importance, has a very complex history. Animal milk has been used by humans almost since the beginning of animal domestication , and if H. sapiens in a radical way, but also induces diseases like dietary metabolic disorders and intolerances [From an evolutionary point of view, humans were well adapted to their environments prior to the Neolithic. Mobile lifestyles and natural diets met the physiological and metabolic requirements of our species in an ideal way. This prevents the occurrence of non-communicable diseases which we count among today’s diseases of civilization ,144. Duelerances ,145,146 lerances ,148,149.lerances . Today, lerances .The caesura in the development of nutrition which occurred with the onset of industrial food production in the second half of the 18th century was similar in its severity to the change that occurred at the beginning of the Neolithic. Both events have been characterised by terms that can be understood as process-centred and epoch-defining terms and are politically influenced: the ‘Neolithic (urban) revolution’  and the However, the cultural evolution of our consumption habits was far from over. Eating habits change along with lifestyles and under the influence of social developments. Increased globalisation and the emergence of multicultural communities led to further changes in dietary habits. In the second half of the 20th century, ready-made meals (TV dinners) first came to Europe from the US. Other trends included healthy food and fast food, which are still popular today, as are convenience food on the one hand and nouvelle cuisine on the other. With the rising numbers of migrant workers, traditional dishes from faraway countries such as India, China, Japan, Spain, Italy, the Near East, and South America conquered the central European cuisine. At the end of the 20th century, a number of food scandals and various animal diseases such as bovine spongiform encephalopathy (BSE), avian flu, swine fever, paratuberculosis caused by ruminants, etc opened up a broad public discussion about meat consumption  and modeIn the 21st century and the era of fast-food chains and snacks, which are now the first choice particularly for younger people when it comes to their daily food intake, behaviours that used to be crucial for survival are taking a back seat. Also, the natural components are now hardly recognisable in many of our “foods”. The main components of plants that act as nutrients are their primary constituents such as carbohydrates, proteins, and fats. The secondary constituents of plants  perform protective and defence functions. The importance of the secondary plant nutrients is subject to debate. Little is known about how they can be identified and how they work. It is generally assumed that these substances prevent diseases and are therefore necessary for human health. The focus of investigation is the question of whether the health-promoting effects of a plant-based diet are actually due to their secondary components and what role they could play as food supplements. The concept of food synergy is based on the idea that the interactions between the different food components are significant. The balance between the individual components, the metabolic processes that occur during digestion and the biological activity at the cellular level are all important. Instead of favouring food supplements, the concept involves intensifying basic nutritional research with the aim of identifying the foods that are best suited to promoting human health .From a health perspective, most foods sold in supermarkets today are dispensable. Paradoxically, consumer insecurity is increasing despite the availability of an abundance and variety of foods. The clearest sign of this development is the range of diets, which have long since shattered all standards and can no longer be simply reduced to vegan, vegetarian and omnivorous. What can we still eat and what should we avoid? Does the solution lie in a return to our ancestors’ diet, as promised by the proponents of the “paleo diet”? The fact is that the increase in allergic reactions to certain foodstuffs, the rise in diet-related diseases , food scandals, the use of pharmaceuticals in livestock breeding, the dominance of industrial food and the massive increase in obesity and deficiency symptoms have unsettled the general public, as have various new diagnostic techniques which can uncover previously unknown risks. Since we are supposed to be “learning for life” from kindergarten or at least from primary school, healthy eating should be made part of the curriculum, and advertising for products that are harmful to our health should be curtailed .For approximately 99% of human history, our ancestors lived with and from nature, while the period when we gradually became farmers only covered roughly 1% of human evolution, or in other words, only a blink of an eye. Our biological origins were based on tried and tested predispositions, which in our modern industrial society, however, have become risk factors, as our behaviour and lifestyles have changed drastically and are no longer in line with our biological heritage . InsightHomo later evolved into an omnivorous species. In herbivores the enzymatic digestion begins through saliva in the mouth. Carnivores, on the other hand, gulp down their food, which is digested only in the stomach. In addition, fermentation chambers exist in the large intestine of both herbivores and omnivores, where the indigestible food components are broken down. The intestine of a typical carnivore also differs from that of an herbivore with regard to its length. Carnivores have a very short intestine, herbivores have a very long one, while omnivores are somewhere in between. The intestinal length in humans can be explained in terms of evolutionary history over the course of hominisation and is generally associated with an increase in meat consumption [Many of the common health problems today stem from the fact that we do not adapt our food consumption to what is most beneficial for our digestive system. We use only a fraction of the plants consumed by our ancestors and have almost reversed the original ratio between plant-based food (75%) and meat/fish (25%). The result is overnutrition, malnutrition and undernourishment , which isumption . The interactions between the intestinal microbiome and the metabolic system, the immune system, the cognitive development, and the brain also point to indirect links with nutrition ,169. TheThe second basic health-risk factor is our pronounced lack of physical activity . From a The medical relevance in the study of our evolutionary past is not just aimed at energy sources. Vitamin C is a prime example. It supports vital bodily functions and is involved in numerous metabolic reactions in the body. As an antioxidant, it guards against cell damage and plays an essential role in the synthesis of collagen. Because the human body cannot synthesise vitamin C to a sufficient extent, it must be ingested with food. Its importance as an essential vitamin for various metabolic processes shows why most vertebrate species are capable of synthesising vitamin C. While bats and birds can reactivate their ability to synthesise vitamin C if this is needed, a few recent genera such as humans, great apes, guinea pigs and some species of fish have irreversibly lost it . With reThe global increase in chronic non-communicable diseases (CNCDs) is a result of the rapid and incomplete human adaptation to recent lifestyles over the last 10,000 years and is mainly related to the areas of exercise and nutrition . The latIn recent decades, the number of deaths from chronic non-communicable diseases (CNCDs) worldwide has been steadily rising. According to current data provided by the WHO, approximately 41 million (72%) out of 71 million deaths are caused by non-communicable diseases every year, making them by far the most common cause of death worldwide . CNCDs aThe classification of cardiovascular diseases, chronic respiratory diseases, certain types of cancer, type 2 diabetes, dementia and others as common CNCDs or civilisation diseases is undisputed scientifically and their socio-political significance is widely recognised. However, CNCDs do not only affect older people. Many of these diseases have their roots in a person’s childhood and adolescence. In recent decades there has been a rapid increase in the number of young people with colon cancer and immune diseases. This is believed to have been caused mainly by the consumption of highly processed foods over several years ,187. UntIn terms of the nutritional mismatch discussed above, numerous clinical studies carried out in recent decades have gone far beyond the ongoing media discussion to highlight the importance and significance of various different diets  with regard to CNCDs and public health, and we now have a broad body of relevant data ,197,198.Promoted by the WHO  and the From this point of view health and disease must be re-evaluated. Fundamental facts must be questioned, including the fact that pathogenic genes and mechanisms like uninhibited cell growth were never eliminated by natural selection over the course of evolution. What might be the evolutionary benefit or advantage of the existence of cancer, inflammatory processes or immune diseases for individuals or populations? Our current way of life is increasingly determined by culture rather than by our origins millions of years ago (nature) . Compared to natural evolution, cultural evolution is forever in the fast lane. Evolution does not strive for perfection, nor does it give priority to quality of life and longevity. Culture is not the opposite of nature; it is a result of our nature . WithoutAlong with reproduction, nutrition ensures human survival and represents a basic need . Eating The long-term consequences for our health and morbidity rates of the unhealthy diet, which is widespread in the West despite the boom in organic produce, cannot be determined, nor can we say how quickly the situation will evolve. Theories and models describing the epidemiological transition  attempt Our recent way of life, as far as nutrition is concerned, originated in the beginning of the Anthropocene (Holocene) about 14,000 years ago with the domestication of plants and animals. During the period preceding this revolutionary transition, which accounts for 99 percent of human history, subsistence and nutrition were completely different. The basis of nutrition for non-human primates and prehistoric humans alike was the gathering of wild plants and hunting terrestrial and aquatic animal species. Thus, human beginnings are characterized by an exclusive exploitation of wild dietary resources, similar to that of wild primates. By increasing their cognitive and technical abilities, humans then tapped into further food sources, enabling production but permanently changing the environment. According to data updated in 2021 by the US Population Reference Bureau, based on Haub , an estiH. sapiens has become increasingly biologically and culturally detached from nature and, in the industrialized world, has to spend little time organizing daily meals. Little more than 250 years ago, 95% of humanity lived in the countryside, with most people providing for themselves from their gardens, fields and stables and where the only way to buy or barter food for sustenance was at markets. With the end of the Middle Ages, trade relations intensified, but only satisfied the needs of a small upper class. Industrialization gradually put an end to the agrarian life for the majority of the population. The populations were increasingly concentrated in the industrial centres and the countryside became a supplier of foodstuffs. New ways of food preservation as well as an increasing food processing becam widespread. These cultural developments have moved us further and further away from our natural diet. Nutrition ensures the basis of metabolism and serves to generate energy and maintain vital functions. Although this important connection was not known to prehistoric humans, survival or self-preservation is achieved by satisfying the urge to eat. This begins in mammals after birth and consists in the instinctive sucking of their mother’s milk. The use of further food sources is enormously important and is acquired via learning effects. Changes of habitat due to changing environmental conditions involves adaptation to new foodstuffs and animals must what is edible and what is not. The preferred sources of energy for our omnivorous ancestors were primarily plant foods, complemented by fat and proteins from animals. In order to sustain life in the long term, essential nutrients such as vitamins were also necessary in the diet. The energy requirements of humans vary according to strain, and it is likely that they were at a high level for our ancestors. However, due to lack of food security, people may have suffered from deficiencies for short or long periods of time. What was normal was not so much abundance as recurring scarcity. Because of food insecurity, our ancestors therefore often met their energy needs above the minimum so as not to endanger their existence. The first clear nutritional change in mankind begins in the Neolithic. In its beginnings, the farming way of life can be seen as a crisis . With thThe present food situation-both in the industrialized nations and globally-is not comparable with the past. Demographic aspects are primarily responsible for this. World population and world nutrition are directly interdependent in a complex way. More people automatically mean a higher demand for food and water. More high-quality food means more factory farming, overexploitation of land and water, decrease in biodiversity and destruction of natural habitats. In agrarian societies from ancient to early modern times, mortality was high, flanked by famine, war, and epidemics. Population growth and decline alternated. In central Europe, the Little Ice Age and the plague reduced the population ; in the Perhaps the most significant aspect of the present concerns the relationship between nutrition and health. Increasingly, more and more people around the world are suffering from various diseases of civilization, from diet-related intolerances, and are suffering from malnutrition despite the wide range of food available. At least in Western countries, there are fewer and fewer people in recent decades who must perform strenuous physical labor, but they still eat as if they worked in heavy industry. In addition, the calories supplied from processed foods have a high energy density but provide hardly any fiber and micronutrients. The failure to adapt diet and caloric intake to predominantly sedentary lifestyles and lack of exercise has consequences, the roots of which today often lie in childhood. Nutrition today is about its quality. Food should predictively promote health and help avoid diseases. This is why countless food trends and concepts are promoted, such as the veggie boom, the paleo diet, volumetrics, the Mediterranean diet and superfoods. Healthy living means consistently decimating or eliminating risk factors. But far too often we end up eating highly processed fast-food dishes and are addicted to sugar. However, the medical effects of our current diet in the form of CNCDs are much more extensive than the most common diseases such as diabetes, cardiovascular disease, and stroke, as well as caries, periodontal disease, and others. For example, the consumption of predominantly soft, highly processed food has made the teeth’s job of grinding food almost obsolete, with fatal consequences that have not really been recognized. Since we no longer abrade our teeth, like we do all other body tissues, they may be causing diseases whose causes remain unrecognized because we lack a view into the past . BruxismEverything in nature is in a constant state of change, including the food sector, but this change is taking place much more slowly than the accompanying cultural evolution in humans. Our origins lie in the distant past, but a look back into phylogenesis and the stages of human development is worthwhile. Optionally, evolutionary medicine provides a forum to look more closely at our biological origins and development . A bio-e


Retinopathy of prematurity (ROP) is an ophthalmologic condition that is one of the leading causes of preventable childhood blindness. Due to the premature nature of blood vessels in preterm infants, retinal vessels are prone to damage. The incidence of ROP ranges with great variation across countries, and this study aims to identify the incidence and its related risk factors.A compilation of studies investigating the incidence of ROP was acquired through the PubMed and Google Scholar databases with a full free text in English filter set. All members of the study were involved in designating studies based on continent and arranging them into a table format. Following this, reasons for the variation in the incidence of ROP were investigated by individually assessing each study.The variation of an increased incidence of ROP seen in low-income countries (LICs) was most likely due to the availability of resources. As a preterm birth can give rise to further complications such as the development of sepsis, it is important to manage preterm birth with the utmost caution. Evidence has suggested that the two key variables in reducing the morbidity and mortality of ROP are the implementation of a screening and treatment protocol with controlled use of oxygen and the availability of resources in hospitals to adequately identify and manage ROP as early as possible.Through a comprehensive overview of the incidence of ROP, it is vital to review screening and treatment protocols in each hospital for ROP, which would aid in preventing its occurrence and initiating early treatment. Retinopathy of prematurity (ROP) is identified by the World Health Organization (WHO) as a major cause of preventable childhood blindness worldwide . It is aApproximately 14,000 preterm infants in the United States alone develop retinopathy of prematurity, and between 1,100 and 1,500 cases of them progress into moderate to severe stages of the disease that requires medical attention and treatment . Long-teThere are multiple risk factors affecting the development and progression of retinopathy of prematurity, including low birth weight, preterm gestational age, appearance, pulse, grimace, activity, and respiration (APGAR) score, and especially the use of supplemental oxygen, which causes downregulation of the vascular endothelial growth factor (VEGF) due to oxidative stress and death of endothelial cells, intraventricular hemorrhage, sepsis, blood transfusions, and most importantly, lack of timely screening . RetinopManagement strategies vary depending on the ICROP classification system. Current treatment guidelines include laser peripheral retinal ablation for the early stages of the disease. Anti-VEGF inhibitors such as bevacizumab have also recently emerged with promising results, especially in the early stages of the disease. Further information and research are needed on this novel therapy as there are insufficient data on its long-term effects on infants . It is cThis study is conducted to estimate the incidence of retinopathy of prematurity and evaluate the pattern, prevalence, risk factors, and complications to achieve a better understanding of the disease and its burden to help healthcare professionals design efficient preventive measures and authorize setting basic minimum requirements for screening preterm and low-birth-weight infants for this condition to decrease its associated morbidity to accomplish a high and healthy quality of life for future babies.Worldwide incidence and prevalenceThe worldwide prevalence of ROP can be difficult to estimate due to not only a large number of patients but also a lack of standardized ROP screening protocols worldwide, which would enable a global registry to collect more accurate data. As seen in Table Risk factorsRetinopathy of prematurity has several risk factors that determine its course and presentation. These risk factors can be interlinked with the pathogenesis of the development of the different stages of the condition. Two key identifiable risk factors are infants being born at an early gestational age of less than 30-32 weeks and a low birth weight of less than 1-1.5 kg .The amount of oxygen received by the child and the duration of ventilation are examples of interlinked risk factors. This could be due to the prolonged use of nasal continuous positive airway pressure (CPAP). Exposure to oxygen for longer than seven days with a saturation of greater than 50% leads to the formation of oxygen free radicals, which in turn leads to the development of ROP . There hPulmonary conditions such as neonatal respiratory distress syndrome (NRDS), if left untreated, can lead to advanced stages of ROP. NRDS, along with early gestational age, is associated with the development of aggressive posterior ROP . In respLate-onset sepsis, including perinatal infection and inflammation, affects retinal angiogenesis via the formation of cytokines and endotoxins, which leads to retinal ischemia due to the impairment of tissue perfusion . The incThe two other factors associated with retinopathy of prematurity are poor postnatal weight gain and slower growth velocity. Slow weight gain causes a lower increase of an anabolic hormone used in the development of blood vessels called insulin-like growth factor (IGF-1) . TherefoChorioamnionitis is a bacterial infection that occurs before or during labor, which affects the chorion and the amniotic fluid. It also induces a fetal inflammatory response causing the release of the inflammatory cytokines that affect retinal angiogenesis. If this occurs in the presence of funisitis , then this increases the chance of developing ROP. Infants exposed to chorioamnionitis are found to be born preterm, have a lower birth weight, be exposed to antenatal corticosteroids, have development of early- or late-onset sepsis, and be subjected to higher rates of partial rupture of membranes (PROM). All of these are contributing factors to the development of ROP .Pre- and postnatal risk factors are very significant in the development and progression of retinopathy of prematurity. Some of these have already been mentioned and discussed above. Postnatal factors include prolonged oxygen exposure, sepsis, necrotizing enterocolitis, and intraventricular hemorrhage . NecrotiPrenatal risk factors include prolonged rupture of membranes, preterm premature ruptures of membranes, hypertensive disorders of pregnancy, and chorioamnionitis. Hypertensive disorders of pregnancy are known to cause an increase in antiangiogenic factors, which antagonizes the action of vascular endothelial growth factor 1 (VEGF-1) responsible for the growth and permeability of the blood vessels. The use of beta-blockers and antihistamines in the later stages of pregnancy are also known risk factors.The care given in higher-level hospitals or study centers of large clinical trials has shown lower rates of retinopathy of prematurity. This is due to the availability of more experienced staff able to manage premature infants . Race alGlobal relevance of retinopathy of prematurityRetinopathy of prematurity is a condition in which it has been shown that with adequate screening and timely management, the progression of the disease and mortality can be drastically reduced. One of the most commonly identified reasons for increased mortality for this condition was a lack of screening protocols and utilities in certain countries. In a study conducted by Onyango et al. in 2018 [There has been a significant progress in the reduction of neonatal mortality rates for ROP as Wang et al. in 2019 mentioned that there was a 53% reduction in mortality, especially in the first year of life, from 1990 to 2015 . Wang etA study conducted by Braimah et al. in 2020  in GhanaAs mentioned earlier, one of the major risk factors identified for the development of ROP is an early gestational age, specifically neonates born before the gestational age of 32 weeks. It was reported by Edy Siswanto and Sauer in 2017  that theIt is imperative to note that with the advancement of neonatal care, better-implemented screening protocols, and newer treatment modalities being developed for managing ROP, mortality rates have decreased since the disease was first identified. However, in countries such as low- and middle-income countries, implementing a screening protocol means the incidence of diseases such as ROP will increase; however, a sustainable method of management that is economic, effective, and easily implementable must be put into action to actively reduce both the incidence and mortality of ROP.Current management strategiesIn recent times, promising developments have been made with regard to treatment modalities and efficacies for ROP. Many large-scale studies such as the CRYO-ROP, Early Treatment for Retinopathy of Prematurity Study (ETROP), and Bevacizumab Eliminates the Angiogenic Threat of Retinopathy of Prematurity (BEATROP) have led to the formation of current guidelines for managing infants with this disease. For prethreshold type 1 disease, they recommend that laser therapy is a suitable initial step; however, as the condition progresses to an aggressive zone 1 type, anti-VEGF inhibitors such as intravitreal bevacizumab have been shown to provide the most benefit . They arDue to the extensive research and understanding of ROP progression, the current standards of care in the United States emphasize a screening program, in which at-risk infants undergo retinal examinations at specific intervals so that timely treatment can commence. These assessments would ideally be scheduled in accordance with the preterm child’s gestational age at birth, as well as the nature of the disease. The objective of this plan is to detect infants who can benefit from treatment and highlight the need for future appropriate interventions. Such a system would employ the use of wide-angle retinal images and binocular indirect ophthalmoscopes in conjunction with clinical data. The presence of skilled and experienced ophthalmologists is vital for this program, as well as the contributions of neonatologists and imaging staff. Despite the implementation of such screening protocols, there will always remain a small portion of ROP infants that still progress to blindness; however, it should not come as a surprise that presenting late to screening is the most common reason for ROP-related blindness ,28.Retinopathy of prematurity is a preventable disorder of retinal blood vessels that has caused blindness in millions of preterm children throughout the globe. Once it advances into later life, ROP can lead to several complications that include severe myopia, strabismus, cataracts, glaucoma, and retinal detachment. Due to the numerous risk factors of ROP being related to the delivery and early development of preterm infants, this disease can provide interesting insight into the quality of perinatal and postnatal services in a given health center. It should then come as no surprise that poorly developed countries continue to lag behind with regard to ROP prevalence. Fortunately, intriguing breakthrough studies have paved the way for current treatment strategies involving the use of laser therapy and low-dose intravitreal bevacizumab. These emerging methods for the management of ROP provide a considerable reason for optimism moving forward. However, the significance of implementing consistent and strict screening protocols worldwide needs to be highlighted to successfully halt the progression of this potentially debilitating disease.


Background: Long-term care (LTC) services help the elderly maintain their functional ability and live with dignity. In China, the establishment of an equitable LTC system is a primary focus of the current public health reform. This paper assesses levels of equality in resources for and utilization of LTC services between urban and rural areas and economic regions in China. Methods: We use social services data from the China Civil Affairs Statistical Yearbooks. Gini coefficients against elderly population size are calculated for the number of institutions, beds, and workers, and the concentration index (CI) against per capita disposable income is calculated for the number of disabled residents per 1000 elderly people and the number of rehabilitation and nursing services per resident. Results: The Gini coefficients against the elderly population in urban areas indicate relatively good equality. In rural areas, the Gini coefficients have increased rapidly from relatively low values since 2015. The CI values in both urban and rural areas are positive, indicating that utilization is concentrated in the richer population. In rural areas, the CI values for rehabilitation and nursing have remained above 0.50 for the last three years, implying high levels of income-related inequality. The negative CI values for rehabilitation and nursing services in urban areas in the Central economic region and rural areas in the Western region imply a concentration of resource utilization toward poorer groups. The Eastern region shows relatively high internal inequality. Conclusion: Inequalities exist between urban and rural areas in the utilization of LTC services, despite similar numbers of institution and bed resources. Resource distribution and healthcare service utilization are more equal in urban areas, creating a low level of equilibrium. This urban-rural split is a source of risk for both formal and informal LTC. The Eastern region has the largest number of resources, the highest level of utilization, and the greatest internal variation. In the future, the Chinese government should enhance support for the utilization of services for the elderly with LTC needs. With the increasing level of population aging globally, access to long-term care (LTC) to ensure functional capacity and live with dignity is critical for older adults with declining physical functional status. Therefore, how to develop a sustainable and equitable LTC system has become one of the key policy issues of concern for many countries . Such a The first concern has been adequately explained by existing research. LTC is effective in compensating for functional decline in older adults and reducing the burden of home care, demonstrating its effectiveness for survival assurance . AccordiFor the second concern, people have not found a reliable LTC system that can guarantee the fairness of LTC services at present. But for LTC, as a system with greater public resource distribution and breadth of population coverage than the traditional health care system, the availability, and accessibility of LTC’s resources must be equitable for all older adults . When LTIn terms of resource distribution, many believe that the higher the distribution of public resources, the less inequality there will be in LTC. However, Fernandez finds that because the central government leaves too much leeway to local governments in allocating public resources and setting service standards, it breeds geographic inequality in the LTC system . Rich arOn the utilization of LTC services, the most striking finding is the socioeconomic gradient in LTC use. In most European countries, LTC services have a clear pro-rich tendency, and their use is closely related to personal savings, family income, and housing ownership. Even after controlling the health differences of the elderly, this tendency is still significant ,13,14. IIn addition to developed countries, the demand for LTC in many emerging countries is also growing rapidly, and the rate has even far exceeded that of developed countries. These countries are trying to establish their LTC systems. However, informal care (mainly home care) still occupies a central position in developing countries. Almost all developing countries do not have an established LTC policy and system, and there is also a lack of research on the state of LTC provision in these countries ,18. ChinAt present, China has established an LTC system covering almost all the elderly at a low level. Its LTC system includes two levels: financial protection and service protection. Financial protection is the main funding and payment system for LTC, which provides all ADL-assessed elderly with the necessary funds for LTC services. It takes the form of social insurance, commercial insurance, and social relief. In terms of coverage, such a financial security system includes almost all urban elderly people. For rural elderly people, only those in financial difficulty can be supported through social relief. Social insurance is mainly paid for by residents and/or their employers and is available to all insured people with long-term disability status. In 2016, the Chinese government launched a pilot long-term care insurance system (LTCI) in 15 cities . It attempts to address the costs required for basic living care and medical care closely related to basic living for severely disabled people. Commercial insurance is paid by the residents themselves, and residents who pass the ADL assessment are entitled to a subsidy for the cost of care. Social relief is borne by the government and mainly covers elderly people in financial difficulties . For example, in 2014, the Chinese Ministry of Finance and the Ministry of Civil Affairs together introduced the “Subsidy System for Elderly People with Disabilities in Financial Difficulties”, which aims to provide financial subsidies for these elderly people to access elderly care services. In addition, the purpose of the service protection is to guarantee LTC services in professional institutions that residents can enjoy nearby, and a subsidy system for elderly care institutions was implemented in 2014. It mainly consists of subsidies for the construction and operation of LTC institutions, as well as economic subsidies for the elderly to receive LTC services. The exact amount of which is determined by each province according to its economic development, and there is no uniform standard.However, unlike most countries where LTC systems cover both institutions and households, LTC in China is currently only for institutions. LTC institutions provide the majority of formal LTC services and play an important role in the LTC system . It is wBecause of these specific issues related to LTC, an increasing number of elderly people are being excluded from the LTC system. The resulting impact not only has a significant impact on the quality of life of older adults but also affects the effectiveness and efficiency of the LTC system. It is regrettable that current research on LTC, especially in emerging countries such as China, still focuses primarily on the LTC needs of older adults and approaches to LTC system construction. However, research on the more basic and necessary LTC resource distribution and utilization inequities that precede these issues is rare. The purpose of this research is therefore to examine the evolution and equality of LTC resource distribution and service utilization in China to uncover its urban-rural and regional disparities and the socioeconomic factors that contribute to them. To our knowledge, this is the first study to assess and examine inequalities in LTC resources and service utilization at a national level, specifically introducing an urban-rural perspective in a Chinese context. Drawing on official national data, we use the Gini coefficient and the concentration index (CI) to assess inequalities in resource and service utilization. We hope that our findings will not only provide new reform ideas for China but also warn countries trying to build new LTC systems to intervene moderately in their resource distribution and utilization.This study uses social services data from the China Civil Affairs Statistical Yearbook from 2014 to 2018, which records statistics related to social elderly service institutions in 31 provinces of China from 2013 to 2017, covering municipalities directly under central government authority and autonomous regions in mainland China. Data for Taiwan, Hong Kong, and Macao are not included in this study. The 31 provinces were divided into three regions according to their geographical distribution and GDP per capita: the Western (undeveloped) region covering Inner Mongolia, Ningxia, Gansu, Shaanxi, Sichuan, Chongqing, Guizhou, Yunnan, Guangxi, Qinghai, Xinjiang, and Tibet; the Central (developing) region covering Heilongjiang, Jilin, Shanxi, Henan, Anhui, Hubei, Jiangxi, and Hunan; and the Eastern (developed) region covering Beijing, Tianjin, Hebei, Liaoning, Shandong, Jiangsu, Zhejiang, Shanghai, Fujian, Guangdong, and Hainan . PopulatMost LTC institutions are under the supervision of the Chinese civil affairs authorities. In the civil affairs statistics, institutions affiliated with elderly and disabled people that provide residential services include urban LTC institutions, rural LTC institutions, honorary homes, honorary military rehabilitation hospitals, demobilized military sanatoriums, and military rest homes. The first two are managed by the civil affairs departments, while the rest are managed by the military. Honorary homes are living care institutions exclusively for military personnel and their families. Honorary military rehabilitation hospitals, demobilized military sanatoriums, and military rest homes provide living care and rehabilitation care accommodation for disabled military personnel, demobilized military personnel, and retired cadres of the army, respectively. These four types of institutions provide resources only to military personnel (not to other personnel), and all care costs are covered by the military. According to Chinese media reports, the number of all elderly military cadres in mainland China in 2022 is about 267,000, accounting for only 0.10% of the overall elderly population, and we, therefore, do not include them in our study. Since the 2015 statistical yearbook does not provide separate data for urban and rural areas, we use the five-year average results as a proxy. Four provinces, namely, Hainan , Tibet and Inner Mongolia , and Jilin , have serious missing data for resource utilization, and they are therefore excluded from our measurements of inequality of utilization.S is the area between the Lorenz curve and the horizontal axis, i depends on the number of provinces considered. G, the Gini coefficient, takes a value from 0 to 1. Referring to the critical value of the Gini coefficient given by the China national bureau of statistics and the classification of the Gini coefficient threshold value in existing literature [G less than 0.3 denotes a preferred equality status; a value greater than 0.4 triggers an inequality alert; and a value exceeding 0.6 reflects a highly inequitable distribution of resources.The Gini coefficient and the CI are instruments commonly used to measure inequality. The Gini coefficient is a well-known general measure of inequality , and theterature ,34. We dCI algebraic expressions are not unique. Drawing on the application of CI in health services, we adopt the formula used in a previous study [CI ranges from −1 to +1. A value of 0 indicates absolute equality; a negative value indicates a concentration of LTC resources or services in poorer populations; and a positive value represents a concentration of LTC resources or services in richer populations [n depends on the number of provinces considered.us study :(4)CI=2nulations . n depenLong-term care is a relatively new concept in China. As for the specific service categories, according to the classification in the government report and the Statistical Yearbook, institutional LTC in China generally includes a range of services such as daily living care (assistance with daily care such as bathing and dressing), professional care (non-therapeutic care and rehabilitation services), and other services aimed at providing long-term support for people who have lost their daily living abilities and cognitive functions. In terms of specific data selection, we refer to previous literature ,35,36,37Most LTC is low-tech, especially in late-developing countries, where greater availability of institutions, beds, and workers plays a key role in securing LTC and quality of life . TherefoPrevious studies on LTC utilization have generally considered whether the service has been used as an indicator of service utilization ,36. In CIn rural areas, the size of the elderly population was also growing, but the development of LTC resources was quite different from urban areas, with an obvious decline over the same period . SpecifiThe Gini coefficient for urban areas relative to the elderly population was less variable, ranging from 0.168 to 0.294 . The GinG-values are less than 0.3 and decreasing). Thus, urban LTC resources have basically reached a low level of equilibrium. The rate of decline in G values, representing rural LTC resources, has slowed. Distributional inequality has increased significantly with the end of policies that tilted resources toward rural areas. The urban-rural differences are shrinking, obviously at the expense of increasing inequality in rural areas. This implies a risk of inequality between urban and rural areas in terms of the size of the distribution of LTC resources as policy interventions wane.The development of the Gini coefficient from 2013 to 2017 shows that LTC resource distribution in urban areas is improving, but that the distribution in rural areas gives cause for concern. The distribution of urban LTC institutions and beds is relatively equal and improving relative to the size of the aging population , whereas the number of rural disabled residents declined and then rebounded slightly (from 0.80 to 1.16 per 1000 elderly people). Rehabilitation and nursing services per resident in urban areas increased and then decreased (ranging between 2.62 and 3.13 per capita), while rehabilitation and nursing services per resident in rural areas maintained a steady increase (1.30–1.96 per resident). However, this change is not the same as the trend in the number of workers between urban and rural areas. While the number of services is rising in both urban and rural areas, the number of workers in rural areas is declining. This may be closely related to the difference in government purchase of services policies between urban and rural areas.LTC resources and healthcare service utilization in the Eastern region were much higher than in the Central and Western regions, and the gap widened. In urban areas, the Central region scored lower than the Western region for both LTC resources and healthcare service utilization; in rural areas, the Central economic region scored only slightly higher than the Western region. From 2016, the number of rehabilitation and nursing services per resident in the Western region surpassed that in the Central region. It is worth noting that the above changes exhibit the opposite of the regional economic level status. The central region has a higher level of economic development than the western region, but the western region has a higher utilization of services. The reason for this may be that the lower economic level makes it more common for the young population in the west to work outside their hometowns. This leaves western households with less capacity for services, forcing older adults to seek services in the marketplace.CI values for LTC resources and services in both urban and rural areas were positive, implying that LTC resources and healthcare service utilization were concentrated among the richer population in both cases. The CI values for disabled residents in urban areas continued to decline (from 0.483 to 0.329), implying an improvement in equality. The CI values for disabled residents in rural areas increased, remaining above 0.50 for the last three years of the period under study, implying a high level of income-related inequality. Such a time series with a decreasing trend of urban inequality and an increasing trend of rural inequality. There is a similar change to the trend in the Gini coefficient, implying that the improvement in LTC utilization in urban areas is built on the premise of increasing inequality in rural areas. The CI values for urban and rural rehabilitation and nursing services fluctuated but were low overall (ranging from 0.185 to 0.384), indicating reasonable income-related equality . The CI values for rehabilitation and nursing services per resident were negative in urban areas in the Central region and rural areas in the Western region, indicating a concentration of resource utilization toward poorer groups. The CI values for rehabilitation and nursing services per resident in urban areas of the Central and Western regions gradually exceeded those in the Eastern region. However, for all other indicators, the Eastern region had higher (absolute) CI values than the Central and Western regions.Within different economic zones, more complex income-related inequalities of LTC resources and healthcare service utilization were found . The CI CI values, the inequality of resources and utilization exhibited in different economic zones shows a phenomenon of increasing inequality as the socioeconomic level increases. In other words, the differential allocation of resources by the government across regions has not substantially narrowed the gap in the level of services received by the elderly.From the evolution of This study examines LTC resource distribution and healthcare service utilization in China, in both urban and rural areas, and from the perspectives of the Eastern, Central, and Western economic regions. On the whole, under the influence of reform path dependence, the current promotion policy of LTC in China, although formally including the reform of social insurance and the establishment of LTCI and other measures, remains mainly in the substance of single financial support. But the adoption of these instruments by the Chinese government has led to unintended consequences. These instruments have promoted market enthusiasm for building long-term care resources, but have led to a large number of idle resources due to different policy inputs on the distribution and utilization sides. At the same time, such policy instruments have made the current LTC service utilization in China appear pro-poor phenomenon between the regions and a pro-rich phenomenon between urban and rural areas at the same time, and have not well improved the service utilization of economically disadvantaged elderly people in rural areas. This reform trap is worthy of caution for other countries attempting to build new LTC systems. We find that rural areas have more institution and bed resources compared to urban areas. The higher base number of institutions and beds in rural areas cannot be explained in terms of economic level and is actually due to continuous policy support dedicated to increasing the number of beds in rural areas. During the 11th Five-Year Plan (2006–2010), the government proposed adding 2.2 million beds in rural institutions for the elderly. In the 12th Five-Year Plan period (2011–2015), the government set a requirement of 30 beds per 1000 elderly people nationwide, with 3.42 million new beds of all types, and increased policy support and resource distribution for rural areas and the Central and Western regions. The 13th Five-Year Plan period (2016–2020) again called for improvements to the supply of services for the elderly but without an emphasis on tilting resources to rural areas. Urban areas have more resources for workers, although they have fewer bed spaces. There are no regulations on worker numbers in China in terms of policy, and the distribution of workers is influenced by labor market mechanisms, with higher wages in urban areas likely to attract more workers. Appropriate staffing is critical in the provision of care for the elderly , and staThe level of utilization of LTC resources and healthcare services is low, with large variations between urban and rural areas with different levels of economic development. On the one hand, not only is the level of utilization of LTC resources and services in rural areas much lower than in urban areas but the rise in utilization in urban areas is accompanied by a decline in utilization in rural areas . On the In addition, the LTC service protection system and LTCI system introduced by the Chinese government may have a potential role in guiding the widening gap between the rich and the poor in LTC service utilization. In Jiangsu province, for example, which is one of the leading economies in China, the LTC service protection system in Jiangsu provides a financial subsidy ranging from 300–800 RMB per month for each elderly person admitted to an LTC institution. However, this is a far cry from the average monthly cost of admission of 3600 RMB for an elderly person in Jiangsu. With this lack of targeted subsidies, the CI of LTC institutionalized seniors in urban areas decreased by 0.07 in 2015 under the service protection policy, while in rural areas it increased by 0.27. That is, urban seniors with generally good social security and rural seniors with good financial conditions are more willing to receive LTC services in institutions. China’s LTCI system, which is being piloted, also shows an imbalance between urban and rural payment capacity. For example, the LTCI pilot in Qingdao includes both urban and rural areas, with urban workers covering 10% of the cost and others covering 20% or 40% . This prIn addition, the current government subsidies in the Chinese LTC system include both the construction subsidy and operating subsidy. The construction subsidy is based on the number of beds built by the institution at the time of construction. The operating subsidy is based on the actual number of residents. We believe that the large subsidy has been used to support the expansion of facility investment by service production entities in LTC institutions, which is consistent with government practices in other service areas . And yetGeographic disparities in healthcare resources are prevalent in most countries and contribute indirectly to the unequal spatial distribution of individual healthcare. The study of the key mechanisms responsible for this phenomenon is an important area of public health research . AnalysiThe results of our study suggest that service utilization is affected not only by economic factors but also by macro policy regulations. We find that resource utilization is indeed higher in the Eastern region than in the Central and Western regions. The reason for this discrepancy may be related to the operating subsidy policies. Apart from the previously mentioned operating subsidy based on the number of residents, the government also provides implicit operating subsidies consisting of tax breaks and institutional water, electricity, and gas cost discounts. However, the central government has not clearly defined the target, scope, and amount of these subsidies. Cities have a relatively large degree of discretion in setting the subsidies. For example, Jiangsu province in the eastern region stipulates that LTC institutions don’t need to pay corporate income tax. At the same time, the institution is allowed to pay for the use of water, electricity, and gas at the civilian standard. In Shanxi Province, located in the central region, institutions are only exempted from 50% of corporate income tax. Meanwhile, in some western provinces, there is no water, electricity, or gas usage fee concession policy. This policy disparity allows the wealthier east to have more policy incentives, which is opposed to the inter-regional pressure to operate LTC. This ultimately leads to higher financial expenses for seniors in the central and western regions to access services, which aggravates the differences in service utilization among regions.Furthermore, a comparison between the Central and Western regions shows that the number of services per resident in the Western region was higher than in the Central region in 2017, but that the economic situation is lower overall. This finding is inconsistent with earlier studies’ characterization of elderly care services as pro-rich . Adding Based on the findings of this paper, to promote the LTC system as equitable as possible and create an age-friendly society. The government needs to contribute at both ends of resource distribution and support for utilization.(1)Moving away from unconditional encouraging an influx of capital into the LTC system. An effective response to low bed capacity in China is to encourage institutions with occupancy rates that meet certain standards to expand. It will help to prevent the construction of institutions that meet policy needs but do not meet the needs of the elderly. At the same time, the government needs to reform the nationally planned standard for the number of beds. Allow cities to adjust the number of beds based on regional conditions flexibly. On the other hand, the type of institutional beds should be subdivided into nursing and general beds. The LTC institutions’ bed construction and the government’s LTC subsidy should focus on nursing beds. Under the premise of clear subsidy direction, the amount of subsidy for service utilization of the elderly is appropriately adjusted according to their different situations . In addition, the government needs to unify the implicit operating subsidies and try to establish rules for subsidy standards. In this way, the government can ensure that institutions in different regions are treated as fairly as possible in terms of the types of subsidies. On this basis, the government should clarify the requirements for institutional care staffing and encourage investment in caregivers in rural areas.(2)A mechanism for the dynamic adjustment of institutional beds and a verification mechanism for government subsidies should be established. Current subsidy policies are not well directed toward the economically disadvantaged elderly to ensure that every elderly person has equitable access to LTC services. Adjustments are needed to meet the needs of disabled elderly and to increase support for service users. By guiding the merging, transformation, and withdrawal of institutions with excessive bed idleness, and investigating the eligibility of institutionalized elderly. Not only can the pressure on LTC system operations be reduced, but also the inpatient health care costs derived from the physician-induced demand can be prevented as much as possible. Under this premise, by including the elderly with nursing care needs in the scope of government-purchased services, encouraging nursing care beds in rural nursing facilities can cooperate with community hospitals to provide rehabilitation care services to improve bed utilization and enhance service quality.This study analyzes equality in LTC resources and healthcare services utilization in China from 2013 to 2017. Due to changes in the availability of statistics, we were unable to use the most recent data. At the same time, due to the objective lack of data for the four provinces, the sample used in this study is actually based on the territory of mainland China other than these areas and may not be fully representative of the whole country. Nevertheless, developments in the level of equality of disabled residents are obvious, and the Chinese government should release more recent data so that this phenomenon can be better understood. In addition, the discussion of service utilization needs to be more detailed than has been possible in the present study; future work should refine the indicators to explore causal relationships in greater depth, for example by constructing broader indicators of institutional financial inputs or staff salary levels to analyze whether and how LTC services in China are skewed in favor of richer groups. Indicators such as urban–rural geographic space and gender could also be constructed to clarify other factors that impact resource distribution and utilization of LTC services.China has a very low utilization rate of LTC resources and a large number of unused beds. There are obvious inequalities between urban and rural areas in the utilization of LTC resources and services, although institution and bed resource distributions are similar. Equality of resource distribution and utilization is better in urban areas, creating a low level of equilibrium; inequality in resource distribution and service utilization is more marked in rural areas. This ultimately leads to the phenomenon of poor rural elderly being considered in LTC resource input policies but excluded from LTC utilization policies. From a regional perspective, the Eastern region has the largest number of institutional LTC resources, the highest level of utilization, and the greatest internal variation. The Chinese government should enhance the support for the utilization of services for the elderly with LTC needs in the future.