Manual of Dietetic Practice E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 3308

Veröffentlichungsjahr: 2013

Beschreibung

The standard work for all those involved in the field of clinical nutrition and dietetics, The Manual of Dietetic Practice has been equipping health care professionals with the essential foundations on which to build expertise and specialist skill since it was first published in 1988.

The fourth edition responds to the changing demand for multidisciplinary, patient-centred, evidence-based practice and has been expanded to include dedicated chapters covering adult nutrition, freelance dietetics, complementary and alternative therapies.

Compiled from the knowledge of both individual experts and the British Dietetic Association's Specialist Groups, this truly is the essential guide to the principles of dietetics across its whole range.

Leseprobe

Contents

Contributors

Foreword

Introduction

SECTION 1: General dietetic principles and practice

1.1 Diet, health and disease

1.1.1 Diet and health

1.1.2 Diet and health: the global perspective

1.1.3 Diet and health: the UK perspective

1.1.4 UK Dietary targets for health

1.1.5 Monitoring the diet and health of the UK population

1.1.6 Public health policy and health promotion

1.2 Healthy eating, healthy lifestyle

1.2.1 Translating dietary targets into food intake

1.2.2 The national food guide: The Balance of Good Health

1.2.3 Achieving healthy eating

1.2.4 Sensible use of alcohol

1.2.5 Stopping smoking

1.2.6 Physical activity

1.3 Dietary reference values

1.3.1 UK Dietary reference values

1.3.2 Other national and international dietary reference standards

1.3.3 Differences in dietary reference values between countries

1.3.4 Using dietary reference values

1.4 Food composition tables

1.4.1 National food tables

1.4.2 Using food compositional data

1.5 Dietary assessment

1.5.1 Dietary assessment methods

1.5.2 Validity

1.5.3 Reproducibility

1.5.4 Dietary assessment in clinical practice

1.5.5 Research

1.6 Dietary modification

1.6.1 Rationale for dietary modification

1.6.2 Types of dietary modification

1.6.3 Providing dietary advice

1.7 Changing health behaviour

1.7.1 An integrated approach to behaviour change

1.7.2 Foundations underpinning behaviour change

1.7.3 The dietetic consultation in practice

1.7.4 Managing common difficulties

1.7.5 Implications for practice

1.8 Assessment of nutritional status

1.8.1 Clinical considerations

1.8.2 Physical state

1.8.3 Dietary aspects

1.8.4 Anthropometric measurements

1.8.5 Biochemical and haematological markers

1.8.6 Monitoring nutritional status

1.8.7 Assessing nutritional status in children

1.9 Estimating nutritional requirements

1.9.1 Energy requirements

1.9.2 Nitrogen/protein requirements

1.9.3 Fluid requirements

1.9.4 Electrolyte and mineral requirements

1.9.5 Requirements of other micronutrients

1.10 Malnutrition

1.10.1 What is malnutrition?

1.10.2 Prevalence of malnutrition and at-risk groups

1.10.3 Causes of malnutrition

1.10.4 Consequences of malnutrition

1.10.5 Detection of malnutrition

1.10.6 Screening

1.10.7 Malnutrition Universal Screening Tool (‘MUST’)

1.10.8 Treatment of malnutrition

1.10.9 Monitoring progress

1.11 Oral nutritional support

1.11.1 General dietary guidance to improve food intake

1.11.2 Dietary guidance for problems affecting food intake

1.11.3 Food enrichment

1.11.4 Oral nutritional supplements

1.12 Enteral feeding

1.12.1 The role of the Nutrition Support Team in enteral nutrition

1.12.2 Indications for enteral nutrition

1.12.3 Routes of enteral feeding

1.12.4 Enteral feed delivery

1.12.5 Enteral feed formulae

1.12.6 Drug-nutrient interactions

1.12.7 Monitoring of enteral feeding

1.12.8 Complications of enteral feeding

1.12.9 Weaning from enteral nutrition

1.12.10 Home enteral feeding

1.13 Paediatric enteral feeding

1.13.1 General considerations

1.13.2 Indications for enteral feeding in paediatric patients

1.13.3 Choice of enteral feed

1.13.4 Enteral feeding tubes, equipment and feed administration

1.13.5 Home enteral feeding

1.14 Parenteral nutrition

1.14.1 The role of the parenteral nutrition team

1.14.2 Indications for parenteral nutrition

1.14.3 Routes of administration of parenteral nutrition

1.14.4 Formulation of parenteral nutrition

1.14.5 Monitoring parenteral nutrition

1.14.6 Complications of parenteral nutrition

1.14.7 Weaning from parenteral nutrition

1.14.8 Home parenteral nutrition

1.15 Food service in hospitals and institutions

1.15.1 General issues

1.15.2 Guidance and opinion in the UK

1.15.3 How to get more food eaten

1.15.4 The future of food service in the NHS

1.16 Professional practice

1.16.1 Practising the art and science of dietetics

1.16.2 Continuing professional development (CPD)

1.16.3 Professional competence

1.16.4 Healthcare ethics

1.16.5 Professional conduct

1.16.6 Clinical governance

1.16.7 Research

1.16.8 Evidence-based practice

1.16.9 Clinical audit, monitoring and evaluation

1.16.10 Risk management

1.17 Freelance dietetics

1.17.1 Considering becoming a freelance dietetian

1.17.2 Planning the business

1.17.3 Establishing the business

1.17.4 Maintaining and expanding the business

SECTION 2: Foods and nutrients

2.1 Dietary energy

2.1.1 Energy expenditure

2.1.2 Energy intake

2.1.3 Energy balance

2.2 Dietary protein and amino acids

2.2.1 Function

2.2.2 Structure

2.2.3 Protein requirements

2.2.4 Responses to variation in intake

2.2.5 Sources of protein in the UK diet

2.3 Dietary fat and fatty acids

2.3.1 Function

2.3.2 Chemical structure and properties

2.3.3 Dietary fat requirements and intake

2.3.4 Modifying fat intake

2.4 Dietary carbohydrate

2.4.1 Structure and types of carbohydrate

2.4.2 Digestion, absorption and metabolism of carbohydrate

2.4.3 Carbohydrate requirement and intake

2.4.4 Altering carbohydrate intake

2.5 Dietary fibre

2.5.1 Definition

2.5.2 Analysis and labelling

2.5.3 Physiological actions of dietary fibre

2.5.4 Intakes of dietary fibre

2.5.5 Altering fibre intake

2.5.6 Prebiotics, probiotics and synbiotics

2.6 Vitamins

2.6.1 Vitamin A

2.6.2 Vitamin D

2.6.3 Vitamin E

2.6.4 Vitamin K

2.6.5 Thiamin (vitamin B1)

2.6.6 Riboflavin (vitamin B2)

2.6.7 Niacin

2.6.8 Vitamin B6 (pyridoxine)

2.6.9 Vitamin B12 (cobalamin)

2.6.10 Folate

2.6.11 Pantothenic acid

2.6.12 Biotin

2.6.13 Vitamin C (ascorbic acid)

2.7 Minerals and trace elements

2.7.1 Calcium

2.7.2 Phosphorus

2.7.3 Magnesium

2.7.4 Sodium (and chloride)

2.7.5 Potassium

2.7.6 Iron

2.7.7 Zinc

2.7.8 Copper

2.7.9 Chromium

2.7.10 Manganese

2.7.11 Molybdenum

2.7.12 Selenium

2.7.13 Fluoride

2.7.14 Iodine

2.7.15 Other trace elements and contaminants

2.8 Fluid

2.8.1 Regulation of fluid balance

2.8.2 Clinical aspects of fluid balance

2.8.3 Fluid imbalance

2.9 Miscellaneous dietary components

2.9.1 Antioxidant and anticarcinogenic phytochemicals

2.9.2 Caffeine and other methylxanthines

2.9.3 Vasoactive amines

2.9.4 Sweeteners

2.10 Food law and labelling

2.10.1 History of food legislation in the UK

2.10.2 Current UK food legislation

2.10.3 Law enforcement

2.10.4 International food legislation

2.10.5 Food labelling

2.10.6 Labelling regulations

2.10.7 Food additives and E numbers

2.10.8 Nutrition labelling

2.10.9 Guideline daily amounts

2.10.10 Nutrition and health claims

2.10.11 Addition of nutrients to foods

2.10.12 Monitoring food quality and safety

2.11 Complementary and alternative therapies

2.11.1 Complementary and alternative nutritional therapies

2.11.2 Nutritional supplements

2.11.3 Herbal remedies

2.11.4 Dietetic guidance on the use of supplements

2.12 Drug-nutrient interactions

2.12.1 Effects of nutrition on drugs

2.12.2 Effects of drugs on nutrition

2.12.3 Clinical significance of drug-nutrient interactions

SECTION 3: Nutritional needs of population subgroups

3.1 Pregnancy

3.1.1 Preconceptional and periconceptional nutrition in women

3.1.2 Nutritional considerations during pregnancy

3.1.3 Nutrition-related aspects of pregnancy

3.1.4 Dietary guidance in pregnancy

3.1.5 Nutrition-related problems in pregnancy

3.1.6 Pregnancy during adolescence

3.2 Preterm infants

3.2.1 Definitions

3.2.2 Nutritional requirements

3.2.3 Parenteral nutrition

3.2.4 Enteral nutrition

3.2.5 Post-discharge nutrition

3.2.6 Weaning

3.3 Infants (0–1 year)

3.3.1 Current infant feeding recommendations and UK Practice

3.3.2 Breastfeeding

3.3.3 Formula feeding

3.3.4 Weaning

3.4 Pre-school children (1–4 years)

3.4.1 Nutritional aspects of growth and development

3.4.2 Nutritional requirements and dietary intake of pre-school children

3.4.3 Guidance on healthy eating in pre-school children

3.4.4 Nutritional problems in pre-school children

3.5 School-aged children

3.5.1 Growth and development

3.5.2 Nutritional considerations in school-aged children

3.5.3 Current dietary intake of school-aged children

3.5.4 Food within schools

3.5.5 Common dietary problems in school-aged children

3.5.6 Health promotion in school-aged children

3.6 Adolescents

3.6.1 Growth and development

3.6.2 Nutritional considerations in adolescents

3.6.3 Current dietary intake of adolescents

3.6.4 Common dietary problems in teenagers and young adults

3.6.5 Promoting healthy eating in adolescents

3.7 Adults (19–64 years)

3.7.1 The health of the UK population

3.7.2 Nutritional intake of British adults

3.7.3 Health promotion strategies in the UK

3.7.4 Men’s health issues

3.7.5 Women’s health issues

3.8 Older adults

3.8.1 Number and proportion of older people

3.8.2 Nutritional aspects of ageing

3.8.3 Food choice and food selection

3.8.4 Nutritional status and eating habits of older people

3.8.5 General nutritional considerations

3.8.6 Maintaining function in chronic illness

3.8.7 Malnutrition

3.8.8 Nutritional interventions

3.9 People in low-income groups

3.9.1 The links between diet and health

3.9.2 The size and nature of the problem

3.9.3 Nutritional consequences of low income

3.9.4 Low-income issues and dietetic practice

3.9.5 The policy response to low-income issues

3.10 People from Black and minority ethnic groups

3.10.1 South Asian people

3.10.2 Religious influences on diet and lifestyle of South Asian people

3.10.3 Food choices of South Asian people

3.10.4 Meal patterns of South Asian people

3.10.5 Nutritional implications of South Asian diets

3.10.6 Common health problems in South Asian people

3.10.7 Providing dietary guidance to South Asian people

3.10.8 Health promotion in South Asian people

3.10.9 African-Caribbean people

3.10.10 Traditional dietary practices of African-Caribbean people

3.10.11 Health aspects of African-Caribbean diets

3.10.12 Providing dietary guidance to African-Caribbean people

3.10.13 West African people

3.10.14 Chinese people

3.10.15 Vietnamese people

3.10.16 Jewish people

3.11 Vegetarianism and veganism

3.11.1 Types of vegetarian diets

3.11.2 Health implications of vegetarian diets

3.11.3 Nutritional implications of vegetarian diets

3.11.4 Dietary considerations in particular population groups

3.12 People with physical or learning disabilities

3.12.1 Physical disabilities

3.12.2 Learning disabilities

3.12.3 Dietary management of specific learning disabilities

3.13 Sports nutrition

3.13.1 Sport versus exercise

3.13.2 Energy metabolism during exercise

3.13.3 The role of carbohydrate in sport

3.13.4 Protein

3.13.5 Fluid balance

3.13.6 Other considerations

SECTION 4: Dietetic management of disease

4.1 Dental disorders

4.1.1 Dental caries

4.1.2 Dental erosion

4.1.3 Periodontal disease

4.1.4 Dental health promotion

4.2 Dysphagia

4.2.1 The normal swallow

4.2.2 Consequences of dysphagia

4.2.3 The dysphagia care team

4.2.4 Management of dysphagia

4.3 Disorders of the upper aerodigestive tract

4.3.1 Benign disorders of the aerodigestive tract

4.3.2 Head and neck cancers

4.3.3 Oesophageal cancer

4.4 Disorders of the stomach and duodenum

4.4.1 Nausea and vomiting

4.4.2 Indigestion

4.4.3 Gastro-oesophageal reflux disease

4.4.4 Hiatus hernia

4.4.5 Gastritis

4.4.6 Peptic ulcer

4.4.7 Gastric carcinoma

4.5 Disorders of the pancreas

4.5.1 Acute pancreatitis

4.5.2 Chronic pancreatitis

4.5.3 Cancer of the pancreas

4.6 Cystic fibrosis

4.6.1 Features of cystic fibrosis

4.6.2 Nutritional implications of cystic fibrosis

4.6.3 Pancreatic enzyme replacement therapy

4.6.4 Nutritional requirements of people with cystic fibrosis

4.6.5 Devising a dietary strategy to meet nutritional needs

4.6.6 Monitoring dietary effectiveness

4.6.7 Correcting nutritional inadequacies

4.6.8 Specific considerations in the management of cystic fibrosis

4.7 Malabsorption

4.7.1 Diagnostic features of malabsorption

4.7.2 Dietary treatment of malabsorption

4.8 Coeliac disease

4.8.1 Features of coeliac disease

4.8.2 Management of coeliac disease

4.8.3 Diet-related problems

4.8.4 Type 1 diabetes and coeliac disease

4.8.5 Dietary considerations in particular groups

4.9 Inflammatory bowel disease – Crohn’s disease and ulcerative colitis

4.9.1 General aspects of inflammatory bowel disease

4.9.2 Nutritional implications of inflammatory bowel disease

4.9.3 Dietary management of inflammatory bowel disease – general aspects

4.9.4 Dietary management of Crohn’s disease

4.9.5 Dietary management of ulcerative colitis

4.9.6 Other aspects of nutrition and inflammatory bowel disease

4.10 Disorders of the colon

4.10.1 Constipation

4.10.2 Diarrhoea

4.10.3 Diverticular disease

4.10.4 Irritable bowel syndrome

4.10.5 Colorectal cancer

4.11 Intestinal failure and intestinal resection

4.11.1 Nutritional implications of small bowel resection

4.11.2 Nutritional implications of small bowel resection and SBS

4.11.3 Dietary management of short bowel syndrome

4.11.4 Resection of the large intestine

4.12 Liver and biliary disease

4.12.1 Anatomy and function of the liver

4.12.2 Classification of liver disease

4.12.3 Malnutrition

4.12.4 Nutritional assessment in chronic liver disease

4.12.5 Nutritional assessment in fulminant hepatic failure

4.12.6 Nutritional requirements

4.12.7 Nutritional support in chronic liver disease

4.12.8 Nutritional support in fulminant hepatic failure

4.12.9 Management of specific aspects of liver and biliary disease

4.12.10 Hepatic carcinomas

4.13 Renal disease

4.13.1 Kidney function

4.13.2 Chronic renal failure

4.13.3 End-stage renal failure

4.13.4 Acute renal failure

4.13.5 The nephrotic syndrome

4.13.6 Assessing the patient in renal failure

4.14 Gout and renal stones

4.14.1 Gout and hyperuricaemia

4.14.2 Renal stones

4.14.3 Calcium stones

4.14.4 Uric acid stones

4.14.5 ‘Infection’ stones or struvite stones

4.14.6 Cystine stones

4.15 Diabetes mellitus

4.15.1 Features of diabetes

4.15.2 Consequences of diabetes

4.15.3 Aims of management of diabetes

4.15.4 Nutritional recommendations for people with diabetes

4.15.5 Putting nutritional recommendations into practice

4.15.6 Management of type 1 diabetes

4.15.7 Management of type 2 diabetes

4.15.8 Specific considerations in particular circumstances or population groups

4.15.9 Education, follow-up and care

4.15.10 Prevention of diabetes

4.16 Obesity – general aspects

4.16.1 Classification of obesity

4.16.2 Prevalence of obesity

4.16.3 Impact of obesity on health

4.16.4 Aetiology of obesity

4.16.5 Prevention of obesity

4.17 Management of obesity and overweight

4.17.1 Assessment of overweight and obesity

4.17.2 Dietetic approaches to weight loss

4.17.3 Physical activity strategies in the management of obesity

4.17.4 Behavioural modification in weight management

4.17.5 Commercial slimming organisations

4.17.6 Gastrointestinal surgery for weight loss

4.17.7 Who manages overweight and obesity?

4.17.8 Clinical guidelines for management of overweight

4.17.9 Anti-obesity medication

4.17.10 Settings for advice

4.17.11 What reasons do people give for seeking weight loss?

4.17.12 Weight maintenance

4.17.13 Overview and summary

4.18 Eating disorders

4.18.1 General aspects of eating disorders

4.18.2 Anorexia nervosa

4.18.3 Bulimia nervosa

4.18.4 Binge eating disorder

4.19 Cardiovascular disease – general aspects

4.19.1 Prevalence and costs

4.19.2 Causation

4.19.3 Global risk assessment for cardiovascular disease

4.19.4 Prevention

4.19.5 The cardioprotective (Mediterranean) diet

4.20 Coronary heart disease

4.20.1 Definitions and prevalence

4.20.2 Pathogenesis of CHD

4.20.3 Risk factors for CHD

4.20.4 Role of diet in the development of CHD

4.20.5 Management of CHD

4.20.6 Cardiac rehabilitation

4.20.7 Chronic heart failure

4.20.8 Cardiac cachexia

4.20.9 Public health prevention strategies for CHD

4.21 Dyslipidaemia

4.21.1 Lipid metabolism

4.21.2 Prognostic significance of dyslipidaemia

4.21.3 Diagnosis and classification of dyslipidaemia

4.21.4 Dietary and lifestyle influences on blood lipids

4.21.5 Dietary management of dyslipidaemia

4.21.6 Drug treatment of dyslipidaemia

4.22 Hypertension

4.22.1 Background

4.22.2 Factors affecting the development of hypertension

4.22.3 Management of hypertension

4.22.4 Prevention of hypertension

4.23 Stroke

4.23.1 Types of stroke

4.23.2 Causes and risk factors for stroke

4.23.3 Consequences of stroke

4.23.4 Management of stroke

4.23.5 Nutritional aspects of stroke management

4.23.6 Prevention of stroke

4.24 Parkinson’s disease

4.24.1 Background

4.24.2 Clinical features of Parkinson’s disease

4.24.3 Management of Parkinson’s disease

4.24.4 Nutritional aspects of Parkinson’s disease

4.24.5 Dietary management of Parkinson’s disease

4.25 Motor neurone disease

4.25.1 Types of motor neurone disease

4.25.2 Management of motor neurone disease

4.25.3 Nutritional aspects of management of MND

4.25.4 Artificial nutrition and hydration in MND

4.26 Rare neurological disorders

4.26.1 Huntington’s disease

4.26.2 Myasthenia gravis

4.26.3 Guillain-Barré syndrome

4.26.4 Multiple system atrophy

4.27 Multiple sclerosis

4.27.1 Features of multiple sclerosis

4.27.2 Nutrition and multiple sclerosis

4.27.3 Nutritional status in multiple sclerosis

4.27.4 Clinical management of multiple sclerosis

4.27.5 Dietary management of multiple sclerosis

4.27.6 Alternative diets and complementary therapies in MS

4.28 Chronic fatigue syndrome/myalgic encephalomyopathy

4.28.1 Background

4.28.2 Management of CFS/ME

4.28.3 Nutritional effects of CFS/ME

4.28.4 Dietary management of CFS/ME

4.28.5 Complementary and alternative therapies

4.29 Neurorehabilitation

4.29.1 General principles of neurorehabilitation

4.29.2 The neurological rehabilitation team

4.29.3 Consequences of brain injury

4.29.4 Nutritional implications of brain injury

4.29.5 Nutrition management in neurorehabilitation

4.29.6 The needs of carers

4.30 Dementias

4.30.1 Types of dementia

4.30.2 Symptoms of dementia

4.30.3 Diagnosis and management

4.30.4 Nutritional implications of dementia

4.30.5 Nutritional assessment in patients with dementia

4.30.6 Dietary management of dementia

4.30.7 The needs of carers

4.31 Mental illness

4.31.1 Types of mental illness

4.31.2 Mood disorders

4.31.3 Schizophrenia

4.31.4 Psychiatric co-morbidity (dual diagnosis)

4.31.5 Care of people with mental illness

4.31.6 Management of diet-related problems in mental illness

4.32 Osteoporosis

4.32.1 Bone biology

4.32.2 Skeletal development

4.32.3 Nutritional determinants of bone health

4.32.4 Treatment of osteoporosis

4.33 Arthritis

4.33.1 Osteoarthritis

4.33.2 Rheumatoid arthritis

4.34 Food hypersensitivity

4.34.1 Definition of food hypersensitivity

4.34.2 Prevalence of food hypersensitivity

4.34.3 Mechanisms involved in food hypersensitivity

4.34.4 Symptoms associated with food hypersensitivity

4.34.5 Diagnosis of food hypersensitivity

4.34.6 Food reintroduction and food challenge

4.34.7 Dietary management of food hypersensitivity

4.34.8 Prevention of food allergy

4.34.9 Links between food hypersensitivity and specific disorders

4.35 Food exclusion in the management of food hypersensitivity

4.35.1 General aspects of food exclusion diets

4.35.2 Milk exclusion

4.35.3 Peanut and nut exclusion

4.35.4 Soya exclusion

4.35.5 Wheat exclusion

4.35.6 Egg exclusion

4.35.7 Fish and shellfish exclusion

4.35.8 Other foods

4.36 HIV disease and AIDS

4.36.1 Background

4.36.2 Nutritional aspects of HIV disease

4.36.3 Management of weight-stable individuals and those newly diagnosed with HIV

4.36.4 Management of HIV patients with weight loss and wasting

4.36.5 Symptom management in HIV patients

4.36.6 Drug management of HIV

4.36.7 Complications associated with antiretroviral treatment

4.36.8 Other considerations in the management of people with HIV

4.36.9 Co-infections and complications associated with HIV

4.36.10 Nutritional considerations in particular population subgroups

4.36.11 HIV disease in children

4.36.12 Role of the dietitian in the care of people with HIV disease

4.37 Cancer

4.37.1 Diet and the causation of cancer

4.37.2 Diet and cancer care

4.37.3 Alternative diets and cancer

4.38 Clean diets for immunocompromised patients

4.38.1 Food intake and infection risk

4.38.2 Nutritional status and support

4.38.3 Recommended good practice for immunocompromised patients

4.39 Palliative care and terminal illness

4.39.1 The role of the dietitian in the palliative care team

4.39.2 The effect of progressive illness on nutritional status

4.39.3 Nutritional objectives in palliative care

4.39.4 Practical aspects of dietary guidance

4.39.5 Guidance for carers

4.39.6 Nutritional issues in the latter stages of progressive illness

SECTION 5: Dietetic management of acute trauma

5.1 Critical care

5.1.1 The intensive care unit

5.1.2 The metabolic response to starvation or injury

5.1.3 Nutritional assessment

5.1.4 Nutritional aspects of feeding ICU patients

5.1.5 Practical aspects of feeding critically ill patients

5.2 Traumatic brain injury

5.2.1 Types of traumatic brain injury

5.2.2 Incidence and features of traumatic brain injury

5.2.3 Management and prognosis of traumatic brain injury

5.2.4 Principles of nutritional management

5.2.5 Nutritional management in the acute injury phase (intensive care)

5.2.6 Nutritional management in the post-acute phase (ward-based care)

5.2.7 Nutritional management in the rehabilitation phase

5.3 Spinal cord injury

5.3.1 Consequences of spinal cord injury

5.3.2 Management of spinal cord injury

5.4 Burn injury

5.4.1 Fatal burn injuries

5.4.2 Minor burn injuries

5.4.3 Major burn injuries or ‘shock burns’

5.4.4 Electrical burns

5.4.5 Burn injury in children

5.4.6 Post-discharge

5.5 Surgery

5.5.1 The role of nutrition in surgical patients

5.5.2 Post-surgery complications affecting feeding

5.6 Wound healing, tissue viability and pressure sores

5.6.1 Nutrition and wound healing

5.6.2 Pressure sores

5.6.3 Leg ulcers

SECTION 6: Appendices

6.1 Weights and measures

6.1.1 Height/length

6.1.2 Weight/mass

6.1.3 Volume

6.2 Dietary data

6.2.1 Conversion factors

6.2.2 Food exchange lists

6.2.3 E number classification system

6.3 Body mass index

6.4 Anthropometric data

6.4.1 Demiquet and Mindex

6.4.2 Upper arm anthropometry

6.4.3 Estimating height from ulna length

6.5 Predicting energy requirements

6.5.1 Basal metabolic rate

6.5.2 Stress factors

6.5.3 Factors for activity and dietary-induced thermogenesis

6.6 Clinical chemistry

6.6.1 Millimoles, milligrams and milliequivalents

6.6.2 Osmolarity and osmolality

6.6.3 Biochemical and haematological reference ranges

6.7 Nutritional supplements and enteral feeds

6.8 Abbreviations

6.9 Useful contacts

Index

© 1988, 1994, 2001 by Blackwell Science Ltd, 2007 by Blackwell Publishing Ltd

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First published 1988Second edition 1994Third edition 2001Fourth edition 2007

1 2007

ISBN: 978-1-4051-3525-2

Library of Congress Cataloging-in-Publication Data

Manual of dietetic practice / edited by Briony Thomas and Jacki Bishop in conjuction with The British Dietetic Association. 4th ed.

p. ; cm.

Includes bibliographical references and index.

ISBN : 978-1-4051-3525-2 (pbk. : alk. paper)

1. Diet in disease. 2. Diet therapy. I. Thomas, Briony. II. Bishop, Jacki.

III. British Dietetic Association.

[DNLM: 1. Diet Therapy. 2. Dietetics. 3. Nutrition. WB 400 M294 2007]

RM216.M295 2007

615.8′54—dc22

2006032269

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Contributors

Editor and principal contributor

Briony Thomas BSc PhD RD Nutrition Scientist and Registered Dietitian, Dorking, Surrey

Address for correspondence: c/o The British Dietetic Association, 5th Floor Charles House, 148/9 Great Charles Street Queensway, Birmingham B3 3HT

Editor and contributor

Jacki Bishop PhD RD Formerly Senior Lecturer in Nutrition and Dietetics, Dietetics Programme Director, University of Surrey, Guildford

Contributors

Dianne Boaden MSc RD Freelance Dietitian, London

Fran Bryan BSc MSc PGDipDiet RD Chief Dietitian, University Hospital of North Staffordshire, Stoke-on-Trent

Catherine Collins BSc RD Chief Dietitian, St George’s Hospital, London

Lucy Collins BSc RD Principal Paediatric Dietitian, Barts and the London NHS Trust

June Copeman BSc PGDipDiet MSc MEd RD Principal Lecturer in Nutrition and Dietetics, Leeds Metropolitan University, Leeds

Jeanette Crosland MSc RD Accredited Sports Dietitian, Lancashire

Alison Culkin BSc RD Research Dietitian, St Mark’s Hospital, Harrow, Middlesex

Ingrid Darnley BSc Clinical Effectiveness and Quality Officer, The British Dietetic Association, Birmingham

Lucy Eldridge BSc DipADP RD Senior Oncology and Palliative Care Dietitian, Barts and The London NHS Trust

Ann Fehily BSc PhD RD RNutr Consultant Nutritionist, Tinuviel Software, Anglesey, UK

Elaine Gardner BSc RD Freelance Dietitian, London

Karen Glynn BSc MSc RD Senior 1 Dietitian (Neurosciences), The National Hospital for Neurology and Neurosurgery, London

Catherine Hankey BSc MSc PhD RD RPHNutr Senior Lecturer in Human Nutrition, University of Glasgow Division of Developmental Medicine, Glasgow Royal Infirmary, Glasgow

Judith Harding BSc RD Community Dietitian, Basildon PCT, Basildon, Essex

Kathryn Hart PhD RD Lecturer in Nutrition and Dietetics, School of Biomedical and Molecular Sciences, University of Surrey

George Hartley BSc MPhil RD Lead Renal Dietitian, Freeman Hospital, Newcastle upon Tyne

Lee Hooper PhD RD Lecturer in Research Synthesis and Nutrition, Department of Medicine, Health Policy and Practice, University of East Anglia

Lynne Hubbard BSc RD Senior Dietitian in Burns and Plastic Surgery, University Hospitals Birmingham NHS Foundation Trust

Paula Hunt BSc RD Independent Nutrition Consultant and Registered Dietitian, Ilkley, West Yorkshire

Karen Hyland DipDiet PGDip MHM RD Service Manager – Nutrition and Dietetics, Edgware Community Hospital, Barnet PCT, Middlesex

Susan Jebb PhD RD MRC Scientist and Head of Nutrition and Health, MRC Human Nutrition Research, Cambridge

Jill Johnson BSc RD Chief Dietitian/Clinical Leader, Queen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust

Nicola Kerr BSc RD Specialist Dietitian, Department of Dietetics and Nutrition, Southern General Hospital, Glasgow

Caroline King BSc RD Chief Dietitian (Paediatrics), Hammersmith Hospital, London

Janet Lambert PhD RD RPHN Director, Lambert Nutrition Consultancy Ltd

Julie Lanigan BSc RD Specialist Dietitian, MRC-Childhood Nutrition Research Centre, Institute of Child Health and HIV Family Clinic Dietitian, Great Ormond Street Children’s Hospital, London

Norma McGough BSc RD Head of Diet and Health, Coeliac UK, High Wycombe, Bucks

Sue McQuire RD Advanced Dietetic Practitioner, Leeds Mental Health NHS Trust

Nicky Mendoza BSc RD Dietitian, Coeliac UK, High Wycombe, Bucks

Joe Millward PhD DSc RPHNutr Professor of Human Nutrition, University of Surrey, Guildford

Judy More BSc Dip Nutn & Diet RD Freelance Paediatric Dietitian, London

Alison Morton BSc RD Clinical Specialist Dietitian, The Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds

Linda Murray BSc RD Senior Dietitian, Surgical Nutritional Support, Department of Nutrition and Dietetics, Glasgow Royal Infirmary

Kate Nancekivell BSc DipDiet RD Gastroenterology Dietitian, Addenbrooke’s Hospital, Cambridge

Jaana Nurmi-Lawton MSc PhD RD Research Fellow, School of Biomedical and Molecular Sciences, University of Surrey, Guildford

Anne Payne BSc PhD RD Principal Lecturer/Lead in Dietetics, School of Health Professions, University of Plymouth

Dympna Pearson RD Consultant Dietitian and Freelance Trainer, Leicester

Helen Powell MSc, MSc, BSc, DipADP, RD Hospital Director, The Priory Highbank Neuro-Rehabilitation Centre, Bury, Lancs

Jane Power BSc RD Senior Dietitian, North East Wales NHS Trust

Vivian Pribram BA BSc MSc RD Advanced Dietitian, Dept of Sexual Health and HIV Medicine, King’s College Hospital, London

Joanna Prickett BSc RD PGDip. Chief Renal Dietitian, North Bristol NHS Trust

Lorna Rapoport BSc RD Advanced Dietetic Practitioner – Mental Health, Dennis Scott Unit, Edgware Community Hospital, Middlesex

Wendy Rees MSc RD Senior Dietitian – Nutrition Support, Gastroenterology Surgery and Critical Care, Gloucestershire Hospitals NHS Foundation Trust

Clare Reid PhD RD Research Dietitian, Critical Care, University of Cambridge and Addenbrooke’s Hospital

Alan Rio BSc DipADP RD Specialist Dietitian – Neurosciences, King’s College Hospital London

Maria Ross BSc PGDipDiet RD Neuroscience Dietitian, National Hospital for Neurology and Neurosurgery, London

Ella Segaran BSc, PGDipDiet, MSc, RD Clinical Dietetic Services Manager, National Hospital for Neurology and Neurosurgery, London

Clare Shaw PhD RD Consultant Dietitian, The Royal Marsden NHS Foundation Trust, London and Sutton

Toni Steer PhD RD Nutritionist, MRC Human Nutrition Research, Cambridge

Rebecca Stratton BSc PhD RNutr RD Senior Research Fellow, Institute of Human Nutrition, University of Southampton

Diane Talbot DipDiet RD MPH Acting Director of Public Health, South Leicestershire PCT

Bella Talwar BSc DipADP RD Clinical Lead Dietitian: Head and Neck Cancer, University College London Hospitals NHS Foundation Trusts

Carolyn Taylor BSc RD Specialist Dietitian, Dietetic Department, Northern General Hospital, Sheffield Teaching Hospital NHS Trust, Sheffield

Aruna Thaker BSc PGDipDiet RD Chief Dietitian, Wandsworth NHS Teaching Primary Care Trust

Denise Thomas MPhil RD Chief Dietitian, Portsmouth Hospitals NHS Trust

Anthony Twist BSc RD Senior Dietitian, Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, Oswestry, Shropshire

Carina Venter BSc PhD RD PGDipAllergy Senior Allergy Dietitian, The David Hide Asthma and Allergy Research Centre, St. Mary’s Hospital, Newport, Isle of Wight

Rachel Vine BSc RD Dip ADP Community CHD Advanced Dietetic Practitioner, South Leeds Primary Care Trust

Avni Vyas MPhil RD Research Associate, Department of Medicine, Manchester Royal Infirmary

Bridget Wardley MS RD Community Paediatric Dietitian, Bromley PCT and Freelance Paediatric Dietitian, Kent

Kate Williams BSc MA RD Head of Nutrition and Dietetics, The South London and Maudsley NHS Trust

Richard Wilson BSc RD Director of Nutrition and Dietetics, King’s College Hospital NHS Trust

Sarah Woodman BSc RD Diabetes Lead Dietitian, Southampton University Hospitals NHS Trust

Additional contributors and acknowledgements

Karen Allan Dietitians in Obesity Management UK (DOM UK)

Chetali Agrawal Specialist Cardiology Dietitian – Ethnic Health, Westminster Primary Care Trust

Mary Ann Ampong Clinical Nurse Specialist, Kings MND Care and Research Team, King’s College Hospital, London

Heidi Ball Senior Specialist Dietitian, Leicestershire Nutrition and Dietetic Service, Leicester Royal Infirmary

Penny Blacker Senior Paediatric Dietitian, Frimley Park Hospital Trust, Surrey

Rachel Broughton Registered Dietitian, Maidenhead, Berkshire

Robyn Boyce Clinical Pharmacist, Leeds Mental Health Trust

Helen Brown Accredited Sports Dietitian, Nutrition and Dietetic Service, Bedfordshire Heartlands PCT

Jane Brown Chair of the Clinical Governance Committee of the British Dietetic Association

Burns Interest Group of the British Dietetic Association

Elaine Cawadias Registered Dietitian, Ottawa, Canada

Bernice Chiswell Senior Dietitian, Bedford Hospitals NHS Trust and Bedfordshire and Northamptonshire MS Therapy Centre

Mary Chong Research Dietitian, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford

Vicky Cook Advanced Dietetic Practitioner, South Leeds Primary Care Trust

Lyndel Costain Dietitians in Obesity Management UK (DOM UK)

Janeane Dart Lecturer, Department of Nutrition and Dietetics, School of Biomedical and Health Sciences, King’s College, London

Hilary Davies Community Dietitian, Wandsworth Primary Care Trust

Anne Dear Chief Dietitian, Oldchurch Hospital, Romford, Essex

Auline Delisser Primary Care – Prescribing Lead Dietitian, Wandsworth NHS Teaching Primary Care Trust

D-Liver Interest Group of the British Dietetic Association

DHIVA (Dietitians in HΓV and AIDS) Group of the British Dietetic Association

Julie Dehavillande Neurosciences Specialist Dietitian, Oxford City Primary Care Trust

Jane Eaton Formerly Professional Affairs Officer, British Dietetic Association

Dietitians of Southampton University Hospitals NHS Trust

Marinos Elia Professor of Clinical Nutrition and Metabolism, Institute of Human Nutrition, University of Southampton

Helen Finch Head of Dietetics, Royal Hospital for Neuro-disability, Putney, London

Freelance Dietitians Group of the British Dietetic Association (Committee and Fact Sheet authors)

Simon Gabe Consultant Gastroenterologist, St Mark’s Hospital, Harrow, Middlesex

Muriel Gall Senior Community/Rehabilitation Dietitian, Dartford and Gravesham NHS Trust

Carole Gant Senior Allergy Dietitian, The David Hide Asthma and Allergy Research Centre, Isle of Wight

Juliet Gellateley Founder and Director of Viva! and The Vegetarian and Vegan Society

Margaret Gellatly Independent PWS Dietary Adviser, Chelmsford, Essex

Lynn Harbottle Consultant Dietitian, Princess Elizabeth Hospital, Guernsey

Elizabeth Harding CFS/ME sufferer, Brentwood, Essex

Dr Gillian Harris Senior Lecturer in Applied Developmental Psychology, School of Psychology, University of Birmingham and Consultant Paediatric Clinical Psychologist, The Children’s Hospital, Birmingham

Hilary Hartley Paediatric Dietitian, North Tyneside Hospital, North Shields, Tyne & Wear

Rebecca Hartley Senior Dietitian Critical Care, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge

Mary Hickson Research Committee of the British Dietetic Association

Rhona Hobday Senior Dietitian, Royal London Hospital

Elaine Isherwood Dietetic Team Leader (Primary Care), Stafford Central Clinic, North Walls, Stafford

Helena Jackson Senior Renal Dietitian, St George’s Hospital NHS Trust

Rose Jackson Senior Dietitian – Beta Cell, Queen Mary’s Hospital, Wandsworth NHS Teaching Primary Care Trust

Cherry-Ann James PD Clinical Nurse Specialist, The National Hospital for Neurology and Neurosurgery, London

Joint Working Party of the British Dietetic Association and Royal College of Speech and Language Therapists

Ruth Kander Senior Renal Dietitian, Hammersmith Hospital NHS Trust

Deepa Kariyawasam Senior Renal Dietitian, King’s College Hospital NHS Trust

Sue Kellie Education and Professional Development Section of the British Dietetic Association

Alison Kirkby Senior Dietitian, County Durham & Darlington Acute Hospitals NHS Trust

Judy Lawrence Chair of the Research Committee of the British Dietetic Association

Anne Laverty Senior Dietitian – Learning Disability, Causeway Health and Social Services Trust, Northern Ireland.

Wilma Leslie Researcher, Division of Developmental Medicine, University of Glasgow

Sue Luscombe Senior Dietitian, Bedford Hospital

Linda Main Freelance Dietitian, Berkshire and British Dietetic Association Weightwise Website Co-ordinator

Renuka McArthur Community Dietitian, Bedfordshire Heartlands Primary Care Trust

Helen McCabe Clinical Specialist Paediatric Dietitian, Royal Victoria Infirmary, Newcastle upon Tyne

Helen McCarthy Senior Paediatric Dietitian, Manchester Royal Infirmary

Camilla McGough Research Dietitian, The Royal Marsden NHS Foundation Trust, London and Sutton

Alison Mead Chief Dietitian, Cardiovascular Medicine, National Heart and Lung Institute, Charing Cross Hospital, London

The Mental Health Group (MHG) of the British Dietetic Association

Carole Middleton MBE Dietetic Services Manager, Oxford City PCT

Judy Molyneux Senior Dietitian Burns and Plastics, St Andrew’s Centre for Burns and Plastic Surgery, Mid-Essex Hospitals Services NHS Trust, Chelmsford

Mairi Murray Renal Dietitian, Freeman Hospital, Newcastle upon Tyne

Sally Naylor Freelance Dietitian

Susan New Reader in Nutrition, School of Biomedical and Molecular Sciences, University of Surrey

Allison Nightingale IBD Specialist Nurse, Addenbrooke’s Hospital, Cambridge

Chris Olivant Information and Customer Services Manager, The Vegetarian Society of the UK

Michelle Pang Senior Dietitian, Huntington’s Disease Unit, Royal Hospital for Neuro-disability, Putney, London

Parenteral and Enteral Nutrition Group (PENG) of the British Dietetic Association

Gopi Patel Senior Critical Care Dietitian, Royal Free Hospital NHS Trust

Ruple Patel Senior Renal Dietitian, St Helier Hospital, Carshalton, Surrey

Katherine Paterson Specialist Dietitian, Norfolk & Norwich University Hospital

Morag Pearson Senior Dietitian, Northwick Park Hospital, London

Frankie Phillips National Public Relations Officer, British Dietetic Association

Najia Qureshi Education and Professional Development Section of the British Dietetic Association

Pragna Raval Community Dietitian, North and Central Manchester Primary Care Trust

Pauline Rigby Calon Lân Dietitian, Anglesey Local Health Board

Sally Sandford Advanced Dietetic Practitioner, Leeds Mental Health Trust

Tahira Sarwar Senior Diabetes Specialist Dietitian, Central Derby Primary Care Trust

Nicola Schonfelder Specialist Mental Health Dietitian, South West Essex PCT

Susan Shandley Clinical Governance Committee of the British Dietetic Association

Vanessa Shaw Head of Nutrition and Dietetics, Great Ormond Street Hospital for Children NHS Trust

Lauren Sheldrick Speech and Language Therapist, The National Hospital for Neurology and Neurosurgery, London

Jevanjot Kaur Sihra Registered Dietitian, Sandwell Primary Care Trust

Rosemarie Simpson Formerly Education and Professional Development Section of the British Dietetic Association

Isabel Skypala Director of Rehabilitation and Therapies, The Royal Brompton & Harefield NHS Trust

Sarah Tabrizi Consultant Neurologist, Institute of Neurology, London

Pat Taylor Network Co-ordinator for West Midlands CFS/ME Service

Katie Thomas Senior Dietitian – Learning Disabilities and Paediatrics, Coventry

Helen Truby Research Fellow, Discipline of Paediatrics and Child Health, University of Queensland, Australia

UK Heart Health and Thoracic Dietitians Group of the British Dietetic Association

Sunita Wallia Senior Research Dietitian, University of Edinburgh

Stephen Walsh Science Co-ordinator for the International Vegetarian Union

Ruth Watling Chief Paediatric Dietitian, Royal Liverpool Children’s NHS Trust, Liverpool

Helen Watson Clinical Specialist Dietitian, Papworth Hospital, Cambridge

Carol Weir Public Health Dietitian, Calderdale PCT, Halifax

Helen White Senior Dietitian, St James’s University Hospital, Leeds

Sue Wolfe Chief Paediatric Dietitian, St James’s University Hospital, Leeds

Christopher Woodage Regulatory Affairs Consultant, UK

Linda Wray Specialist Cardiology Dietitian, Belfast City Hospital Trust

Tanya Wright Specialist Dietitian, Department of Dermatology, Amersham Hospital, Bucks

Suzy Yates Senior Dietitian, National Hospital for Neurology and Neurosurgery, London

Foreword

It once again gives me great pleasure to have been invited to write the Foreword for the Fourth Edition of the Manual of Dietetic Practice. Previous editions are recognised as an invaluable resource for dietitians, appreciating the input from colleagues who are experts in their field. The Manual is also an excellent source of information for other health professionals and demonstrates the expertise of the dietitian.

The solid contribution of Dr Briony Thomas ably assisted by Dr Jacki Bishop, with their time and diligence in managing the collation and editing of this very comprehensive Manual, is not to be underestimated. There must also be an acknowledgement of all who have contributed to this vast resource.

The Manual has been consistently and meticulously updated and expanded in line with changing healthcare and advances in nutrition to ensure the information remains relevant. Indeed in some cases, new areas, ranging from clinical to professional developments, have been addressed to ensure the practising dietitian has the resources to meet the complex challenges they face.

With the ever-evolving health agenda, dietitians have an important role to play in health promotion and disease management. This edition once again supports dietitians in the delivery of a professional, evidence based approach to the population and its well-being.

Dame Barbara Clayton DBE

Honorary Research Professor in Metabolism,

University of Southampton

Honorary President, The British Dietetic Association

Introduction

First published in 1988, the Manual of Dietetic Practice is a comprehensive guide to the principles and practice of dietetics across its entire spectrum – from health promotion to disease management. This is the fourth edition. The book aims to equip the student or novice dietitian with the solid foundations on which skills and expertise can be built, to provide dietitians moving into a new area of practice with the basic knowledge from which specialist skills can be developed, to update those returning to the profession after a career break with changes in practice and to act as a point of reference for all dietitians.

Unlike other multi-author textbooks, the Manual of Dietetic Practice is not just a collection of isolated chapters but a cohesive whole, with considerable interlinking between different subject areas. The text is divided into six main parts:

Section 1: General dietetic principles and practice

Section 2: Foods and nutrients

Section 3: Nutritional needs of population subgroups

Section 4: Dietetic management of disease

Section 5: Dietetic management of acute trauma

Section 6: Appendices.

The Manual of Dietetic Practice has evolved considerably since its inception to reflect the many changes in dietetic practice that have occurred in recent years. Healthcare is increasingly required to be patient-centred, multidisciplinary in nature, evidence-based, compatible with national standards, clinically effective and subject to audit and evaluation. While principles of care can be standardised, the way in which they are applied has to vary to take account of individual needs, problems, habits, lifestyle, associated health risks and readiness to change. In order to provide effective care, the dietitian has to exercise considerable clinical judgement in deciding how a specific set of circumstances may most appropriately be managed. This requires more than just nutritional knowledge. The modern-day dietitian has to be able to assess individual nutritional priorities, have an understanding of human behaviour in order to achieve dietary change, acquire the interviewing and counselling skills necessary for meaningful dialogue between patient and professional and have the ability to evaluate whether objectives have been achieved.

This edition of the Manual of Dietetic Practice continues to reflect these changes and also recent advances in nutritional knowledge. All the chapters in the last edition have been updated and new chapters have been added on adult nutrition, freelance dietetics, complementary and alternative therapies and chronic fatigue syndrome. Other topics, such as malnutrition, obesity management, motor neurone disease and Parkinson’s disease, have been expanded to become stand-alone chapters. I am indebted to the time and effort people have put into the revision or creation of these chapters. I know many have given up precious evenings, weekends and even annual leave in order to do so.

Many other people have played a part in the creation of this book. Some have had a major role in the revision of chapters in previous editions and parts of their work remain. Others have played a smaller but no less vital part by providing information, advice or comments during the various stages of manuscript preparation. All have been crucial to the creation of the final product and I am enormously grateful to everyone who has provided assistance.

I wish to thank the British Dietetic Association for its continued support for this project and for the assistance of Andy Burman, Ruth Redman and other members of staff. I also wish to thank the staff at Blackwell Publishing for their friendliness and efficiency and in particular to pay tribute to the late Richard Miles, who was closely involved with this and previous editions of the Manual. I shall greatly miss his advice, encouragement and sense of humour.

It is now over 20 years since I first began the task of creating a comprehensive textbook on dietetic practice. It is gratifying to know that the book has become so popular and that, although primarily written from a British perspective, it now has a worldwide readership. For the last three editions, the responsibility for revising and editing the Manual of Dietetic Practice has largely been mine alone. For this edition, it has been an enormous help to have Jacki Bishop working with me and being a constant source of support. Producing a book of this nature is a huge undertaking and, without her input, my task would have been much harder. We hope that people find our endeavours useful.

Briony Thomas

February 2007

SECTION 1

General dietetic principles and practice

1.1

Diet, health and disease

Key points

Much of the world’s disease burden results from a few largely preventable risk factors, most of which are related to diet and lifestyle.

It is an oversimplification to assume that developing countries only have problems associated with undernutrition while developed countries only have those associated with overnutrition. Globally, there is a rapidly increasing prevalence of obesity, type 2 diabetes and cardiovascular disease, much of which is occurring in the world’s poorer nations.

Within all societies, there are inequalities in health related to socioeconomic circumstances. Developing countries have pockets of affluence; developed nations (including the UK) have pockets of poverty.

Nutrition, along with strategies to combat inactivity, tobacco use and excessive alcohol consumption, should be at the forefront of public health policies.

Health promotion needs to start early in life and continue throughout the life-span.

Food is essential for health and survival. Without sufficient energy and nutrients, the body’s ability to function normally is impaired. If the body is starved completely, life can only be sustained for a matter of weeks.

Over the last century, much has been learnt about the role of nutrients in maintaining health and the requirements for them to prevent deficiency diseases such as scurvy, pellagra and anaemia. In more recent decades, the focus of research has shifted to the role of diet in preventing disease. There has been increasing recognition that nutrition is a major, and modifiable, determinant of many chronic diseases, and that diet has both positive and negative influences on health throughout life.

It is also being increasingly acknowledged that ‘health’ is more than just the absence of disease. Good health requires both physical and mental well-being and hence encompasses quality of life. Improving health requires consideration of issues such as education, employment, housing, poverty and social isolation, in addition to dietary objectives and healthcare provision.

1.1.1 Diet and health

A healthy diet has to fulfil two objectives:

1. It must provide sufficient energy and nutrients to maintain normal physiological functions and permit growth and replacement of body tissues.

2. It must offer the best protection against the risk of disease.

Meeting the needs for energy and nutrients

A healthy diet needs to provide the following.

Energy

The fundamental need of the human body is for a supply of energy. Without this, death will occur within weeks. Most of this energy is derived from the metabolism of carbohydrate, fat and protein, the amount of energy released being measured in kilocalories (kcal) or kilojoules (kJ). Fat is the most energy-dense nutrient, providing 9 kcal (39 kJ) per gram. Protein [4kcal (17 kJ) per gram] and carbohydrate [3.75 kcal (16 kJ) per gram] each provide less than half of this amount of energy. Other dietary constituents such as alcohol [7 kcal (29 kJ) per gram] can also be a source of energy.

Because the body’s priority for energy is so high, if insufficient energy is obtained from the diet it will start to ‘cannibalise’ its own tissues in order to meet energy needs. Initially it will make use of its fat stores but, as the energy deficit increases, muscle and other tissues will be broken down and used as a fuel supply.

Carbohydrate, protein and fat

Enzymatically digestible carbohydrate (sugars and starches) is rapidly broken down to glucose and is the most readily available source of energy to the body. Dietary fat is a concentrated form of energy and also provides essential fatty acids necessary for the construction of cell membranes and many other functions. Protein provides amino acids, which are essential for the growth and continuous replacement of body tissues and enzymes. However, in conditions of energy shortage, the body’s need for a source of energy will take precedence and protein will be used as a fuel supply rather than for anabolic purposes.

Vitamins, minerals and trace elements

Many different substances are required by the body for the operation of enzyme systems, transport mechanisms, structural synthesis and regulatory processes. Most are only required in very small or even trace amounts. None provide energy and so cannot sustain life alone, but without them metabolism will be impaired, body systems will malfunction, disease may result and life can be threatened.

Dietary fibre (‘non-starch polysaccharide’)

These terms refer to the undigested residues of plant foods, their value being in the fact that they are not absorbed (although components of them can be fermented to short-chain fatty acids in the colon and used as a source of energy). Dietary fibre is not a uniform substance but a mixture of plant materials, the effects of some of which have yet to be evaluated. Dietary fibre helps maintain normal bowel function, increases satiety value of a diet and may influence the absorption of nutrients and, indirectly, their metabolic effect.

Fluid

Fluid is also a vital component of a healthy diet and, without fluid, survival time is limited to a matter of a few days, or even hours. Chronic dehydration can result in a number of ill-effects such as constipation, increased risk of renal stone formation and mental confusion. Acute dehydration (e.g. due to severe vomiting or diarrhoea) is life-threatening.

The requirements and function of each of these dietary constituents are discussed in more detail in Section 2. Dietary requirements for health and disease prevention are set out in Dietary Reference Values for the UK (DH 1991) (see Section 1.3, Dietary reference values).

Offering the best protection against disease

What people eat affects not only their current health but also their risk of future disease. The consequences of diet in terms of obesity, hypertension and dyslipidaemia have a major influence on the development of cardiovascular disease (CVD). Obesity also increases the risk of type 2 diabetes and exacerbates other health problems such as arthritis and respiratory disease. As many as one-third of cancers may be associated with diet. Other conditions, such as osteoporosis, constipation and dental caries, can also be diet-related.

There is now broad consensus (WHO/FAO 2003; DH 1991, 1994) that the type of diet which minimises the risk of chronic disease is one which:

Has an energy content which maintains normal body weight

. Both underweight and overweight increase the risk of morbidity and mortality.

Provides a relatively low proportion of energy in the form of saturated fat

. Most dietary fat should be comprised of monounsaturates, together with sufficient

n

-6 and

n

-3 polyunsaturates.

Provides a relatively high proportion of energy in the form of starchy, fibre-containing carbohydrate and a low proportion as refined sugars

.

Is low in sodium

.

Is rich in fruit and vegetables

.

Is balanced in overall terms

. The impact of diet on all aspects of health, not just one or two, must be borne in mind. For example, people with coeliac disease require a gluten-free diet but, like the rest of the population, they also require a diet which provides protection against cardiovascular disease, cancer and other diseases.

Does not inadvertently cause harm

. Advice to increase or decrease the intake of one type of nutrient or food should not create another health risk. For example, advice to increase consumption of oily fish to reduce the risk of heart disease should not create other health risks from environmental contaminants such as dioxins or mercury.

In addition, diet should not be considered in isolation. Lifestyle factors such as physical activity are increasingly being recognised as having an important role alongside diet in the maintenance of health and prevention of disease.

1.1.2 Diet and health: the global perspective

There are still many differences in the health problems of the poorer parts of the world and those of more affluent areas. In many less developed regions, famine and chronic undernutrition remain a constant threat, mortality from infectious diseases (particularly AIDS and tuberculosis) is high and childbirth still poses considerable risks to mother and child. Nearly 30% of the world’s population is affected by one or more forms of malnutrition. Some 60% of the 10.9 million deaths each year among children under 5 years old in the developing world are associated with malnutrition, and many more suffer disability and stunted mental and physical growth as a result of deficiencies of nutrients such as iodine, vitamin A and iron (WHO/FAO 2003). There are major differences in child mortality and life expectancy between rich and poor nations.

In contrast, in more affluent areas of the world the health problems associated with overnutrition are the primary concern. The consumption of energy-dense diets, high in saturated fat and low in unrefined carbohydrate and micronutrients, coupled with a sedentary lifestyle and use of tobacco, impact on many aspects of the process of atherogenesis, thrombogenesis or carcinogenesis, either directly or via their influence on other risk factors such as obesity, hypertension, hyperlipidaemia and type 2 diabetes.

However, the nutritional differences between rich and poor nations are by no means clear-cut as rapid changes in diets and lifestyle due to industrialisation and urbanisation have also occurred in developing countries. Although this has led to improved standards of living, greater food availability and wider food choice, there have also been significant negative consequences in terms of inappropriate dietary patterns (due to the increasing availability of energy-dense high-fat, high-sugar foods), decreased physical activity (due to increasing availability of motorised transport and heavy manual work being replaced by machinery) and increased tobacco use. As a result, there is a rapidly increasing incidence of obesity, type 2 diabetes and diet-related chronic diseases, particularly CVD, in the developing world (WHO/FAO 2003). It has been projected that by 2025, three-quarters of all deaths from CVD will occur in developing countries (WHO 2004).

It is therefore no longer appropriate to assume that countries either have problems of ‘undernutrition’ or ‘diseases of affluence’. Within all societies, there are major inequalities in health (and in healthcare provision). Developing countries have pockets of affluence; developed nations (including the UK) have pockets of poverty. Public health nutrition policies therefore need to address the nutritional needs of all sectors of a society, not just those at one extreme of the undernutrition/overnutrition spectrum. In many developing countries, food policies remain focused only on malnutrition and are not addressing the growing problem of chronic disease (WHO 2004).

1.1.3 Diet and health: the UK perspective

In Britain, life expectancy has doubled over the last 150 years as a result of improvements in hygiene, safety and infection control. In 1841, 25% children died before the age of 5 years, often from diseases such as scarlet fever, typhoid and whooping cough; in the population as a whole, one-third of deaths resulted from tuberculosis (ONS 1997). By the end of the 20th century, these problems had drastically reduced in scale but new ones had emerged to take their place. Coronary heart disease (CHD) and cancer had become the major causes of death, with the UK having one of the highest CHD mortality rates in the world, many of the deaths occurring at a relatively young age. Stroke also accounted for significant mortality and morbidity. There was also growing realisation that much of this mortality and morbidity was attributable to diet and lifestyle factors and hence preventable.

At the beginning of the 21st century, CVD remains the most common cause of death in the UK, about half of which results from CHD and one-quarter from stroke (Peterson et al. 2005). CHD by itself is the principal cause of premature death. Although CHD mortality has fallen in the UK over the last two decades, it is still relatively high compared to other Western nations, much of the recent fall being attributable to smoking cessation and better CHD treatment rather than to dietary change (Unal et al. 2004).

The current major health concern in the UK is the rapidly rising prevalence of obesity in both adults and children. Obesity has many negative influences on health and, on average, reduces life expectancy by 9 years (Wanless 2004). More than half of the population in England (66% of men and 53% of women) is currently either overweight or obese (Ruston et al. 2004). Levels of obesity in England have almost trebled in the past 20 years and this trend shows little sign of abating (Wanless 2004). Of particular concern is the rapid rise in childhood obesity. Over one in five boys (22%) and one in four girls (28%) aged 2–15 years are now either overweight or obese (Sproston and Primatesta 2003). The prevalence and severity of the problem increase throughout childhood; 8% of 6-year olds are clinically obese, a figure which increases to 15% in 15-years olds (Jotangia et al. 2005). Many of these children are likely to become overweight or obese adults. The cost, both in human terms and to the NHS, of treating the direct and indirect consequences of obesity is already considerable. The rising prevalence of childhood obesity has been described as a ‘public health time bomb’, which, if unchecked, will create enormous problems in terms of both human health and the economic health of the country (CMO 2003).

Within the UK, health and life expectancy are still linked to social circumstances and childhood poverty. Mortality and morbidity from chronic diseases are greatest in those who are least advantaged, much of it attributable to adverse diet and lifestyle influences (Acheson 1998; DH 2003a). Despite improvements, the gap in health outcomes between those at the top and bottom ends of the socioeconomic scale remains large and some parts of the country have the same life expectancy as the national average for the 1950s (DH 2003a). There is increasing recognition that, in order to improve the health of the nation as a whole, the needs and problems of its most vulnerable sectors have to be addressed (DH 2005a).

1.1.4 UK Dietary targets for health

Numerical dietary targets for the UK population were first set out in the 1980s by the Committee on Medical Aspects of Food Policy (COMA) and the National Advisory Committee of Nutrition Education (NACNE) (NACNE 1983; DHSS 1984). The 1991 COMA report on Dietary Reference Values (DH 1991) forms the basis of current guidelines, together with some additional recommendations from the COMA report Diet and Cardiovascular Disease (DH 1994). More recently, the Scientific Advisory Committee on Nutrition (SACN), which replaced COMA in 2003, has issued additional targets on salt intake for both adults and children (SACN 2003). UK dietary targets are summarised in Table 1.1.1.

The figures are population targets and are not necessarily what each person should consume. They simply represent changes in dietary composition which, if achieved on a population basis, would result in a significant improvement in the nation’s health. Individuals within the population have varying needs, and a diet of this composition is not necessarily suitable for those who are old, young or ill. Nevertheless, most people would benefit if the composition of their diet moved in the direction of these targets.

Although useful for governments and health professionals to assess and monitor the nation’s health and plan health strategies, numerical compositional targets are of limited value to the individual wishing to eat a healthy diet. People eat ‘food’ rather than ‘nutrients’ and hence there has been increasing emphasis on food-based guidelines such as The Balance of Good Health and promotion of the ‘Five a Day’ message to increase consumption of fruit and vegetables. Guidance on the consumption of alcohol (DH 1995), oily fish (SACN/COT 2004) and physical activity level (DH 2004a) has also been issued (Table 1.1.1; see also Section 1.2, Healthy eating, healthy lifestyle).

Dietary targets are extrapolated from the observed relationships between diet, risk factors and the development of disease, and the effect of dietary modification on primary or secondary disease prevention. However, the relationships between diet and disease are complex and hard evidence from randomised controlled intervention trials on large populations is limited. Unequivocal proof of benefit from dietary intervention is therefore often lacking and dietary guidelines simply reflect the best available evidence and scientific knowledge available at the time.

Table 1.1.1 Dietary targets for the adult UK population

Dietary component

Target intake

References

§

Total fat

<35% energy*

1

Saturated fat

<11% energy

1

Monounsaturated fatty acids

13% energy

†

2

n

-6 polyunsaturated fatty acids

6.5% energy (individual intake <10%)

1

n

-3 polyunsaturated fatty acids

0.2 g/day (minimum)

1

Trans

fatty acids

<2% energy

1

Total carbohydrate

50% energy

1

Non-milk extrinsic sugars

<11% energy

1

Fibre (non-starch polysaccharide)

18g/day

‡

1

Salt

6 g/day

2

Fruit and vegetables

400 g/day (5 portions/day)

3

Oily fish

2 portions fish/week, one of which should be oily fish

4

Alcohol

<3–4 units/day in men; <2–3 units/day in women

5

Physical activity

≥30 min of moderate intensity activities on ≥5 days/week

6

* % food energy intake (i.e. excluding alcohol).

† Monounsaturates can comprise a higher proportion of dietary energy provided that intake of saturates remains low and total energy intake does not exceed requirement (RCP 2000).

‡ Figures expressed as NSP (DH 1991). The recommended daily intake has been estimated to be equivalent to 24 g when estimated by the AOAC method that is now used on most food labelling (see Section 2.5, Dietary fibre).

§ 1, DH 1991, 1994; 2, SACN 2003; 3, DH 2003b; 4, SACN/COT 2004; 5, DH 1995; 6, DH 2004a.

More work is needed to identify better biomarkers of health and disease. For example, human observational and interventional studies consistently show health benefits from a diet rich in fruit and vegetables, but as yet little is known about which nutrients or bioactive substances are responsible for the protective effect. For the time being, public health advice can only advocate increased fruit and vegetable consumption.

Much also remains to be learnt about the genetic basis of chronic disease and how nutritional and other environmental factors influence gene expression in individual cells and tissues. At present, research into ‘nutritional genomics’ is still in its infancy but in time it may become possible to identify gene polymorphisms that predispose individuals to specific diseases and to define the optimal nutritional measures that may help prevent them (Elliott and Ong 2002). In the future, rather than devising blanket dietary targets for a population, it may be possible to construct optimal nutritional targets for particular individuals based on their genotype.

1.1.5 Monitoring the diet and health of the UK population

Sources on information on the UK diet

There are three main sources of information on the diet of the UK population.

The National Diet and Nutrition Survey (NDNS) Programme

This is a rolling programme of surveys carried out on behalf of the Food Standards Agency and Department of Health. The surveys provide comprehensive nutritional information on a representative group of about 2000 subjects drawn from a particular age band of the British population. Each survey includes weighed and other assessments of dietary intake in conjunction with anthropometric, biochemical and physiological measures of nutritional status together with socioeconomic and demographic data. Reports which have been published to date are summarised in Table 1.1.2. The most recent reports can be downloaded from the Food Standards Agency website.

The Expenditure and Food Survey (formerly the National Food Survey)

The Expenditure and Food Survey (EFS) is an annual survey of household expenditure, food consumption and income commissioned by the Office of National Statistics (ONS) and the Department of Environment, Food and Rural Affairs (DEFRA). Since 2001, this has replaced the former National Food Survey (NFS) and the Family Expenditure Survey, which had been carried out on an annual basis since 1950.

Information is collected from a sample of about 8000 households in the UK using self-reported diaries of all food purchases, including food eaten out, over a 2-week period. Where possible, quantities are recorded in the diaries but otherwise estimated. Energy and nutrient intakes are calculated using standard profiles for about 500 types of food.

Estimates of food consumption from the EFS are likely to be higher than in the former NFS as the new survey includes all food eaten outside the home. In addition, all members of a household over 7 years old now complete a food diary.

Table 1.1.2 Reports from the National Diet and Nutrition Survey (NDNS)

Population group

Reports published

Children 1

1

/

2

to 4

1

/

2

years

Volume 1: Report of the Diet and Nutrition Survey

(Gregory

et al

. 1995).

Volume 2: Report of the Dental Survey

(Hinds and Gregory 1995).

Young people 4–18 years

Volume 1: Report of the Diet and Nutrition Survey

(Gregory

et al

. 2000).

Volume 2: Report of the Oral Health Survey

(Walker 2000).

Adults 19–64 years*

2000/1 Survey

Volume 1: Types and Quantities of Food Consumed

(Henderson

et al

. 2002).

Volume 2: Energy, Protein, Carbohydrate, Fat and Alcohol Intake

(Henderson

et al

. 2003a).

Volume 3: Vitamin and Mineral Intake and Urinary Analytes

(Henderson

et al

. 2003b).

Volume 4: Nutritional Status (Anthropometry and Blood Analytes), Blood Pressure and Physical Activity

(Ruston

et al

. 2004).

Volume 5: Summary Report

(Hoare

et al

. 2004).

1986/7 Survey (adults 16–64 years)

The Dietary and Nutritional Survey of British Adults

(Gregory

et al

. 1990).

The Dietary and Nutritional Survey of British Adults – Further Analyses

(MAFF 1994).

Adults 65 years and over

Volume 1: Report of the Diet and Nutrition Survey

(Finch

et al

. 1998).

Volume 2: Report of the Oral Health Survey

(Steele

et al

. 1998).

* The most recent (2000/1) NDNS surveyed adults aged 19–64 years. The previous survey (1986/7) covered the age band 16–64 years.

Results of the food and nutrition component of the EFS are published annually as Family Food, a National Statistics publication by DEFRA. In terms of individual nutritional intake, the EFS is less accurate than the nutrition information obtained from the NDNS Programme. Its strength is that it is conducted every year and so provides a valuable guide to trends in food purchases and expenditure.

The Total Diet Study

The Total Diet Study (TDS) provides additional government information on the level of some micronutrients, natural toxicants and contaminants such as heavy metals, dioxins and pesticide residues in the average UK diet. The TDS has been run on a continuous annual basis since the early 1960s and hence is a valuable source of information on trends over time. Based on consumption data from the EFS and from trade statistics, samples of food which are representative of the UK diet are purchased from a variety of retail outlets in 24 towns in the UK and analysed for constituents considered to be of current interest or concern. The findings are published as Food Survey Information Sheets on the Food Standards Agency website.

Sources of information on UK health

Health Survey for England