Giardiasis is the most common waterborne diarrheal disease in the United States and is highly prevalent throughout the world. The clinical spectrum of disease ranges from asymptomatic infection to persistent severe malabsorption. The precise interaction between Giardia and its human host remains conjectural because of the paucity of published studies that address the details of its pathogenesis. The immune system of the host responds to this protozoan parasite, and the intestinal epithelium is a site of interaction between parasite and host. Possible mechanisms whereby Giardia may alter the host's absorption of nutrients at the epithelial level include direct physical interference, toxin secretion, direct physical alteration of the epithelium, competition for nutrients, induction of an inflammatory response, and coincidental infection of the host with a second organism. The host's immune system may play both a protective and a pathogenic role.