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ABC OF NUTRITION Fourth edition
Truswell
Written by A Stewart Truswell
General practice,
Dietetics & Nutrition
ABC
OF
NUTRITION
FOURTH EDITION
44100 ABC of Nutrition 27/6/03 2:16 pm Page 1
ABC OF
NUTRITION
Fourth Edition
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ABC OF
NUTRITION
Fourth Edition
A STEWART TRUSWELL
Emeritus Professor of Human Nutrition,
University of Sydney, Australia
with contributions from
PATRICK G WALL
CIARA E O’REILLY
the late CHRISTOPHER R PENNINGTON
NIGEL REYNOLDS
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© BMJ Publishing Group 1986, 1992, 1999, 2003
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted, in any form or by any means, electronic, mechanical, photocopying,
recording and/or otherwise, without the prior written permission of the publishers.
First published in 1986
by BMJ Books, BMA House, Tavistock Square,
London WC1H 9JR
www.bmjbooks.com
First edition 1986
Second edition 1992
Third edition 1999
Fourth edition 2003
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
ISBN 0 7279 1664 5
Typeset by Newgen Imaging Systems (P) Ltd., Chennai, India
Printed and bound in Spain by Graphycems, Navarra
Cover shows halved apple, with permission
from Gusto productions/Science Photo Library
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Contents
Contributors vi
Preface vii
1 Reducing the risk of coronary heart disease 1
2 Diet and blood pressure 10
3 Nutritional advice for some other chronic diseases 15
4 Nutrition for pregnancy 20
5 Infant feeding 24
6 Children and adolescents 32
7 Adults young and old 37
8 Malnutrition in developing countries 43
9 Other nutritional deficiencies in affluent communities 52
10 Vitamins and some minerals 59
11 Overweight and obesity 69
12 Measuring nutrition 78
13 Therapeutic diets 87
14 Food poisoning 94
Patrick G Wall, Ciara E O’Reilly
15 Food sensitivity 108
16 Processing food 113
17 Nutritional support 120
Nigel Reynolds, Christopher R Pennington
18 Some principles 125
Index 133
v
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Ciara E O’Reilly PhD
Technical Executive, Food Safety Authority of Ireland, Dublin,
Ireland
Christopher R Pennington MD, FRCPEd
Late Professor of Gastroenterology,
Ninewells Hospital and Medical School, Dundee, Scotland
Nigel Reynolds MB, ChB, MRCP
Medicine and Cardiovascular Group, Department of
Digestive Diseases and Clinical Nutrition, Ninewells Hospital
and Medical School, Dundee, Scotland
A Stewart Truswell AO, MD, DSc, FRCP, FRACP
Emeritus Professor of Human Nutrition, University of Sydney,
Australia
Patrick G Wall MB, BCh, BAO, MRCVS, MFPMM
Chief Executive, Food Safety Authority of Ireland, Dublin,
Ireland
vi
Contributors
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vii
Preface to 3rd edition
Nutrition is one of those subjects which comes up every day in general practice—or should do—yet in most undergraduate medical
schools it is crowded out by the big clinical specialities and high technology procedures. It is for subjects like nutrition that the British
Medical Journal’s ABC series is extremely useful.
This book was started when Dr Stephen Lock, previous editor of the BMJ asked me to write a series of weekly articles for an
imagined general practitioner, in an unfashionable provincial town who had been taught almost no nutrition at medical school. They
now felt the need to use nutrition in the practice, but could spare only 15 to 20 minutes a week to read about it.
The brief was that the writing must be practical and relevant; about half the page was to be for tables, figures, photographs or
boxes (that is, not text) and these have to tell part of the story. The writing was to “come down off the fence”, to make up its mind
on the balance of evidence and state it plainly. The first edition had no references but some reviewers asked for them and now in
the era of evidence-based medicine some well chosen references seem indispensable when writing about nutrition.
Nutritional concepts, of course, are not as tightly evidence-based as information about drugs because randomised controlled
trials, so routine for drug therapy, are rare for nutrition.
This book does not deal with all aspects of human nutrition, only those that are useful in everyday medical practice. The latest
fads and controversies are not here either. This is the ABC of Nutrition, not the XYZ.
A Stewart Truswell
1999
Preface to 4th edition
When the first edition of this ABC was written in 1985 there was no “evidence-based medicine”, no human genome, no BSE or
nvCJD, no epidemic of obesity and associated type II diabetes; there were no statins to lower plasma cholesterol and no genetically
modified foods. Helicobacter pylori had just been discovered. The role of folate in neural tube defects had not been established, or
raised plasma homocysteine as a risk factor for heart disease. The Barker hypothesis had not been propounded. These recent
discoveries and ideas affect nutritional practice and they appear or influence what is in this new edition.
A Stewart Truswell
2003
Preface
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For some doctors in affluent countries the first question about
prevention of coronary heart disease (CHD) nowadays is
whether to write a prescription for one of the statins
(simvastatin, pravastatin, fluvastatin, atorvastatin, etc) which
inhibit an early step of cholesterol biosynthesis in the body (see
p 7). Tables are available to show whether the 5- or 10-year risk
justifies the cost of long term statin medication, but the
relation of diet and CHD is still of primary importance for the
majority of people. What we eat is bound up with the aetiology
of CHD. Many people do not know their current plasma
cholesterol, many coronary deaths occur before medical help
and most countries cannot afford these expensive drugs.
Coronary heart disease is the largest single cause of death
in Britain and the disease that causes most premature deaths,
but it is only one-seventh as common in industrial Japan and
rare in the masses in most developing countries. Its incidence
must be environmentally determined because immigrant
groups soon take on the incidence rate of their new country
and there have been large changes in mortality over time.
Coronary heart disease was uncommon everywhere before 1925
and then increased steadily in Western countries until the
1970s, except for a dip during the Second World War.
Age-standardised mortality rates from coronary heart disease in
the United States of America and Australia started to decline
from 1966 and have reduced by more than 70%. In Britain
rates are higher in Scotland and Ireland than in England, and
higher in the north of England than the south. They have been
declining since 1979 and have fallen by about 25%. Most
EU countries have shown similar recent modest reductions of
coronary mortality, but in the countries of eastern Europe
coronary mortalities have risen. They have, however, recently
fallen in Poland and the Czech Republic.
Coronary heart disease is a multifactorial disease, but diet is
probably the fundamental environmental factor. The
pathological basis is atherosclerosis, which takes years to
develop. Thrombosis superimposed on an atherosclerotic
plaque, which takes hours, usually precipitates a clinical event.
Then whether the patient dies suddenly, has a classic
myocardial infarct, develops angina, or has asymptomatic
electrocardiographic changes depends on the state of the
myocardium. Each of these three processes is affected by
somewhat different components in the diet.
The characteristic material that accumulates in
atherosclerosis is cholesterol ester. This and other lipids in the
plaque, such as yellow carotenoid pigments, come from the
blood where they are carried on low density lipoprotein (LDL).
In animals, including primates, atheroma can be produced by
raising plasma cholesterol concentrations with high animal fat
diets. Much of this cholesterol is present in modified
macrophages that have the histological appearance of foam
cells. Experimental pathology studies indicate that these cells
only take up large amounts of LDL if it has been oxidised.
2
This
oxidation probably occurs within the artery wall.
People with genetically raised LDL-cholesterol
(familial hypercholesterolaemia) tend to have premature coronary
heart disease. This is accelerated even more in homozygotes who
have plasma cholesterols four times normal and all develop
clinical coronary heart disease before they are 20.
Thousands of papers have been written on diet and CHD.
Since early in the century scientists have suggested links
1
1 Reducing the risk of coronary heart disease
80-84
Year
Deaths per 100 000
75-79
70-74
65-69
60-64
55-59
50-54
92
91
93
90
89
88
87
86
0
90
180
270
360
450
Finland
USA
Australia
UK
Hungary
Japan
Coronary heart disease death rates in six countries, for men aged 25-74,
1950-83. (Adapted from Heart and Stroke Facts published by the National
Heart Foundation of Australia, from WHO data.) CHD mortality in USA
and Australia started to fall 10 years before any decline in UK coronary
deaths and fell more profoundly. Smoking rates and medical treatments
cannot explain these phenomena. They may have been due to dietary
changes (increased polyunsaturated and decreased saturated fatty acids)
1
Photomicrograph of coronary artery with atherosclerosis
Evidence linking diet and CHD
This comes from:
• animal experiments
• pathology studies
• genetic polymorphisms
• epidemiology: ecological and cohort/prospective studies
• randomised controlled trials with dietary changes.
The strongest body of evidence comes from cohort studies which
demonstrate environmental factors that are either associated with
increased subsequent risk of CHD events (risk factors) or
decreased subsequent risk (protective factors).
ABCN-01 7/19/03 3:33 PM Page 1
[...]... first pass metabolism N Engl J Med 1990; 322: 95-9 Department of Health Nutritional aspects of the development of cancer Report of the Working Group on Diet and Cancer of the Committee on Medical Aspects of Food and Nutrition Policy The Stationery Office, 1998 Doll R, Peto R The causes of cancer: qualitative estimates of avoidable risks of cancer in the United States today J Natl Cancer Inst 1981;... Kalbfleisch JM Influence of nutritional factors on prevalence of diabetes Diabetes 1971; 20: 99-108 8 Report of a WHO Study Group Prevention of diabetes mellitus WHO Tech Rep Ser 844 Geneva: WHO, 1994 9 Ohlson LO, Larsson B, Svarsudd K et al The influence of body fat distribution on the incidence of diabetes mellitus 13.5 years of follow up of the participants in the study of men born in 1913 Diabetes... Randomised controlled trials are under way % of animals ABC of Nutrition 100 80 60 40 Dangerous arrhythmias Dangerous arrhythmia is one of the two major causes of death in CHD Over half the deaths occur before the arrival of paramedical or medical help Then in the ambulance or coronary care unit the treatment of ventricular fibrillation saves lives Developments in nutrition research are showing, with animal... an allergic (IgE) reaction occasionally occurs in the baby (5) The amount of caffeine in the milk after a cup of coffee is only about 2% of the maternal dose Likewise, the alcohol concentration of breast milk is about the same as that of plasma so single drinks of coffee or alcohol, well spaced out, are harmless, but the babies of alcoholics can be affected Beer stimulates prolactin secretion (at least... restriction? BMJ 1985; 290: 110-13 20 Ministry of Agriculture, Fisheries and Food The Dietary and Nutritional Survey of British Adults—Further Analysis London: HMSO, 1994 21 Bucher HC, Cook RJ, Guyatt GH et al Effects of dietary calcium supplementation on blood pressure A meta-analysis of randomised controlled trials JAMA 1996; 275: 1016-22 13 ABC of Nutrition 22 Sever P, Beevers G, Bulpitt C et al... 0.93 1.02 1.08 1.22 1.38 * 12-year follow up of cohort of 276 802 US men by stated alcohol habits at entry Reduced risk of CHD brought down total mortality at 1 and 2 drinks/day but not above Reproduced from Boffeta and Garfinkel11 Reducing the risk of coronary heart disease The management of hypertriglyceridaemia consists of looking for and dealing with any of the common associations The non-pharmacological... Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel of Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) JAMA 2001; 285: 2486-97 Department of Health Nutritional Aspects of Cardiovascular Disease Report on the Cardiovascular... Department of Health Nutritional aspects of cardiovascular disease Report of the Cardiovascular Review Group Committee on Medical Aspects of Food Policy London: HMSO, 1994 12 Law MR, Frost CD, Wald NJ By how much does dietary salt reduction lower blood pressure? III Analysis of data from trials of salt reduction BMJ l991; 302: 819-24 13 Beard TC, Cooke HM, Gray WR, Barge R Randomised controlled trial of a... analyses of 24-hour sodium excretion and blood pressure within and across populations BMJ 1996; 312: 1249-53 9 Department of Health Dietary reference values for food energy and nutrients for the United Kingdom Report of the Panel of the Committee on Medical Aspects of Food Policy London: HMSO, 1991, pp 152-5 10 Denton D, Weisinger R, Mundy NI et al The effect of increased salt intake on blood pressure of. .. Lancet 1991; 338: 131-7 3 Department of Health Folic Acid and the prevention of disease Report of the Committee on Medical Aspects of Food and Nutrition Policy London: Stationery Office, 2000 4 Forrest F, Florey du VC The relation between maternal alcohol consumption and child development: the epidemiological evidence J Publ Health Med 1991; 13: 247-55 [Review by members of the Dundee prospective team.] .
44100 ABC of Nutrition 27/6/03 2:16 pm Page 1
ABC OF
NUTRITION
Fourth Edition
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ABC OF.
www.bmjbooks.com
ABC OF NUTRITION Fourth edition
Truswell
Written by A Stewart Truswell
General practice,
Dietetics & Nutrition
ABC
OF
NUTRITION
FOURTH EDITION
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