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Cover Page: i Half-Title Page: i Title Page: iii Copyright Page: iv Dedication Page: iv Contents Page: vii Preface Page: xxii Acknowledgement Page: xxvi About the author Page: xxviii PART 1 CONCEPTS AND PRINCIPLES Page: xxx 1 Changing priorities in nutrition Page: 2 Ensuring adequacy and use of food groups Page: 3 A new priority – reducing the chronic diseases of ageing populations Page: 6 Plates and pyramids: food guides to reflect modern nutritional priorities Page: 7 Failure to fully implement better nutritional knowledge and understanding Page: 9 The future of nutrition research Page: 12 Yoghurt and ovarian cancer? A case study of unproductive research Page: 14 Key reference Page: 18 2 Food selection Page: 18 Introduction and aims of the chapter Page: 19 The biological model of food Page: 20 Dietary and cultural prejudice Page: 21 Food classification systems Page: 22 Nutritional classification Page: 22 Consumer classification Page: 23 Anthropological classification of foods Page: 25 Non-nutritional uses of food Page: 27 Religion, morality and ethics Page: 27 Status and wealth Page: 27 Interpersonal relationships Page: 27 Political Page: 28 Folk medicine Page: 28 The hierarchy of human needs Page: 28 A model of food selection – “The hierarchy of availabilities model” Page: 30 Physical availability Page: 32 Economic availability Page: 32 International trends Page: 33 The problem of feeding the world Page: 34 Effects of income upon food selection in the UK Page: 36 Cultural availability Page: 37 Dietary taboos Page: 38 Effects of migration upon eating habits Page: 40 “Gatekeeper” limitations on availability Page: 43 A social–ecological model for food and activity decisions Page: 45 Key references Page: 46 3 Methods of nutritional assessment and surveillance Page: 46 Aims and introduction Page: 47 Strategies for nutritional assessment Page: 47 The general lack of valid and reliable measurements in nutrition Page: 48 Measurement of food intake Page: 49 Population or group methods Page: 49 Individual methods Page: 53 Retrospective methods Page: 53 Prospective methods Page: 54 Doubly labelled water (DLW) Page: 56 Tables of food composition Page: 58 Food table problems and errors Page: 58 Dietary standards and nutrient requirements Page: 60 Origins of dietary standards Page: 60 Definitions and explanations Page: 60 The uses of dietary standards Page: 63 Inaccurate standards Page: 64 Defining requirement Page: 65 Deprivation studies Page: 66 Radioactive tracer studies Page: 66 Balance studies Page: 67 Factorial methods Page: 67 Measurement of blood or tissue levels Page: 68 Biochemical markers Page: 68 Biological markers Page: 69 Animal experiments Page: 69 Clinical signs for the assessment of nutritional status Page: 70 Anthropometric assessment in adults Page: 71 Uses of anthropometric assessment Page: 72 Height and weight Page: 73 The Body Mass Index Page: 73 Alternatives to height Page: 74 Skinfold calipers Page: 74 Bioelectrical impedance (BIA) Page: 75 Estimation of fatness from body density Page: 76 An alternative method of measuring body volume (air displacement plethysmography or Bod Pod) Page: 76 Body water content as a predictor of body fat content Page: 76 Mid-arm circumference measures Page: 77 Anthropometric assessment in children Page: 77 Body mass index in children Page: 78 Estimating fatness in animals Page: 80 Biochemical assessment of nutritional status Page: 81 Measurement of energy expenditure and metabolic rate Page: 83 Comparisons of metabolic rates between individuals Page: 85 Key references Page: 86 4 Investigating links between diet and health outcomes Page: 88 Aims and scope of the chapter Page: 89 Observation vs experimentation Page: 89 Range and classification of the methods available Page: 90 About statistics Page: 92 Observational human studies Page: 94 Geographical comparisons Page: 94 Anomalous populations Page: 95 Special groups Page: 95 Time trends Page: 95 Migration studies Page: 96 Cross-sectional surveys Page: 96 “Experiments” of nature Page: 97 Case-control studies Page: 97 Cohort studies Page: 98 Association in observational studies does not prove cause and effect Page: 99 Criteria for establishing cause and effect Page: 101 Animal and in vitro experiments Page: 102 Role of animal and in vitro experiments Page: 102 Animal use in UK experiments Page: 104 The rationale for using non-human species in medical research Page: 104 In vitro experiments Page: 104 Animal experiments Page: 105 The potential of animal experiments to mislead human biologists Page: 105 Different strategies of mice and people during cold exposure Page: 106 The nutritional burden of pregnancy in mice and people Page: 107 Species vary in the nutrients they require and their response to foreign chemicals Page: 107 Human experimental studies Page: 108 General design aims of human experimental studies Page: 108 Classifying human experiments Page: 108 Important technical terms Page: 109 Random allocation Page: 109 Double-blind, placebo-controlled Page: 109 Crossover design vs parallel design Page: 110 Risk factors and risk markers Page: 110 Compliance and contamination Page: 111 Some examples of human experimental studies Page: 112 Watercress and cancer Page: 112 Echinacea and cold symptoms Page: 113 Fluoridated water and dental caries in children Page: 113 Folic acid supplements and neural tube defects Page: 113 Vitamin E (alpha-tocopherol), beta-carotene and the risk of lung cancer Page: 113 Scoring clinical trials for quality Page: 114 A warning about uncontrolled trials Page: 114 Key references Page: 116 5 Investigating links between diet and health – amalgamation, synthesis and decision making Page: 116 Aims and scope of the chapter Page: 117 Meta-analysis Page: 117 What is it? Page: 117 Growth of meta-analysis Page: 118 Summarising the results of a meta-analysis Page: 119 Some general problems with meta-analysis Page: 120 Decision-making and hierarchies of evidence Page: 121 The basic dilemma Page: 121 Harm from intervention based on inadequate evidence? Page: 122 Harm from unduly delayed intervention? Page: 122 Evidence hierarchies Page: 123 National Institute for Health and Clinical Excellence (NICE) Page: 126 The need to be critical of the latest published research findings Page: 127 Why are so many research findings irreproducible? Page: 128 Bias Page: 129 The pressure to achieve statistical significance Page: 129 Selective exclusion/inclusion of outlying results Page: 130 Multiple analyses Page: 130 Underpowered studies Page: 131 Small effect size Page: 131 Multiple modelling Page: 132 Randomised controlled trials, the gold standard of evidence? Page: 132 Are meta-analyses the platinum standard? Page: 134 A footnote about research fraud Page: 136 Key references Page: 139 6 Dietary guidelines and recommendations Page: 140 The range of “expert reports” and their consistency Page: 141 Variations in the presentation of guidelines and recommendations Page: 144 “Food” recommendations Page: 145 Energy and body weight Page: 146 Recommendations for fats, carbohydrates, protein and salt Page: 146 UK Targets Page: 146 Rationale Page: 147 Alcohol Page: 148 Changing UK alcohol recommendations Page: 149 What do these guidelines mean in terms of real-life behaviour? Page: 149 How does current consumption compare to the new guidelines? Page: 149 The economic impacts of alcohol Page: 150 The (apparent) alcohol–mortality J-curve? Page: 151 Alcohol increases risk of cancer, liver disease and accidental death Page: 152 Why are the 1995 and 2016 conclusions so different? Page: 153 Summing up the alcohol debate Page: 155 How do current UK diets compare with “ideal” intakes? Page: 156 Willingness to change Page: 157 Some barriers to dietary change Page: 158 Aids to food selection Page: 160 Concluding remarks Page: 161 Key references Page: 164 PART 2 ENERGY, ENERGY BALANCE AND OBESITY Page: 164 7 Introduction to energy aspects of nutrition Page: 166 Units of energy Page: 167 How are energy requirements estimated? Page: 168 Variation in average energy requirements – general trends Page: 170 The energy content of foods Page: 172 Sources of dietary energy by nutrient Page: 173 Energy density Page: 176 Nutrient density Page: 178 The sources of dietary energy by food groups Page: 179 Starvation Page: 180 The immediate causes of starvation Page: 180 Physiological responses and adaptations Page: 180 Some adverse consequences of starvation Page: 182 Eating disorders Page: 183 Anorexia nervosa: Characteristics and consequences Page: 183 Bulimia nervosa and binge eating disorder Page: 184 Incidence of eating disorders Page: 185 Causes of eating disorders Page: 185 Cachexia Page: 187 Cancer anorexia cachexia syndrome Page: 187 Key references Page: 190 8 Energy balance and its regulation Page: 190 Concept of energy balance Page: 191 Is there physiological regulation of energy balance? Page: 193 “Set point” theory Page: 193 External influences that affect food intake Page: 194 Physiological regulation of energy intake Page: 194 Early work with experimental animals Page: 194 Hypothalamic centres controlling feeding – a more recent perspective Page: 195 Gut-fill cues Page: 197 The glucostat theory Page: 198 The lipostat or adipostat theory Page: 198 The leptin story Page: 200 Is energy expenditure regulated? Page: 203 Key references Page: 208 9 Obesity Page: 208 Defining obesity Page: 209 Prevalence of overweight and obesity Page: 210 A worldwide perspective Page: 212 Effects of ethnicity and social status upon obesity prevalence Page: 214 Overweight and obesity in children Page: 217 The consequences of obesity Page: 220 The relationship between BMI and life expectancy Page: 220 Obesity and the quality of life Page: 222 Not all body fat is equally bad Page: 224 Weight cycling Page: 225 Does high BMI directly cause an increase in mortality? Page: 225 The metabolic syndrome or “syndrome X” Page: 228 The causes of obesity Page: 228 Nature or nurture? Page: 229 A weakening link between hunger and eating? – The internal/external hypothesis and behaviour therapy Page: 230 Variety of food and sensory specific satiety Page: 232 Is fat more fattening than carbohydrate? Page: 233 Inactivity as a cause of obesity Page: 235 Prevention and treatment of obesity in populations Page: 237 Adopting a “low-risk” lifestyle Page: 237 Targeting anti-obesity measures or campaigns Page: 239 Obesity treatment in individuals Page: 240 Realistic rates of weight loss Page: 240 The reducing diet Page: 241 Alternative diets Page: 241 The role of exercise Page: 242 Are the obese less “vigilant”? Page: 244 More “aggressive” treatments for obesity Page: 245 Drug therapy Page: 245 Appetite suppressants Page: 245 Drugs that block digestion Page: 246 Drugs based on gut hormones Page: 247 Drugs that increase energy expenditure Page: 247 Leptin and leptin analogues Page: 247 Surgical treatment for obesity Page: 247 Very Low Energy Diets (VLEDs) Page: 248 Use of these more extreme treatments Page: 249 Key references Page: 250 PART 3 THE NUTRIENTS Page: 252 10 Carbohydrates Page: 254 Introduction Page: 255 Nature, classification and metabolism of carbohydrates Page: 256 Aerobic metabolism of pyruvic acid Page: 258 Dietary sources of carbohydrate Page: 258 Sugars Page: 259 Lactose or milk sugar Page: 260 Sucrose Page: 260 The new UK “sugar tax” Page: 261 Artificial sweeteners Page: 263 “Calorie-free” sweeteners Page: 263 Sugar replacers Page: 265 Diet and dental health Page: 266 Starches Page: 269 Dietary fibre/NSP Page: 270 Resistant starch Page: 274 The glycaemic index (GI) and glycaemic load (GL) Page: 276 Dietary fibre and other factors in the aetiology of bowel cancer and heart disease Page: 277 Background Page: 277 Possible mechanisms by which dietary factors may affect bowel cancer risk Page: 278 Descriptive epidemiology Page: 278 Case-control and cohort studies Page: 280 What about fibre and heart disease? Page: 280 Key references Page: 282 11 Protein and amino acids Page: 284 Traditional scientific aspects of protein nutrition Page: 285 Introduction Page: 285 Chemistry, digestion and metabolism Page: 285 Amino acid metabolism Page: 287 Intakes, dietary standards and food sources Page: 288 Nitrogen balance Page: 289 Estimation of protein content Page: 289 The concept of nitrogen balance Page: 289 Negative nitrogen balance Page: 289 Requirements for balance Page: 290 Positive nitrogen balance Page: 290 Dietary adequacy for protein is not a major issue Page: 291 Protein quality Page: 293 Essential amino acids Page: 293 Establishing the essential amino acids and quantifying requirements Page: 294 Limiting amino acid Page: 294 First- and second-class proteins Page: 294 Mutual supplementation of protein Page: 295 Measurement of protein quality Page: 295 Do children need more protein than adults? Page: 296 Absolute requirement Page: 296 The relative requirement Page: 297 The protein level/concentration needed in the diet Page: 297 Reasons why the past protein needs of children were exaggerated (personal interpretation) Page: 298 Protein quality is probably of little significance in human nutrition Page: 299 Conclusions Page: 299 The protein gap – one of the biggest errors in nutritional science? Page: 299 Overview Page: 299 Aims of this section Page: 300 Past belief in a protein gap and major initiatives taken to close this gap Page: 300 The concept of a protein gap loses credibility Page: 301 What caused the protein gap mistake? Page: 302 Exaggerated estimates of the protein needs of children Page: 302 Kwashiorkor, due to primary protein deficiency, is the dominant form of worldwide malnutrition? Page: 303 Lasting impact of the protein gap myth Page: 303 Concluding remarks Page: 306 Key references Page: 306 12 Fat Page: 306 Nature of dietary fat Page: 307 Types of fatty acids Page: 309 Saturated fatty acids Page: 309 Monounsaturated fatty acids Page: 309 Polyunsaturated fatty acids Page: 309 Cis/trans isomerisation Page: 310 Effects of chain length and degree of unsaturation upon fatty acid melting points Page: 310 Conjugated linoleic acid (CLA) Page: 311 Distribution of fatty acid types in dietary fat Page: 312 Polyunsaturates: saturates (P:S) ratio Page: 313 Sources of fat in the diet Page: 314 UK fat intakes and their food sources Page: 315 Roles of fat in the diet Page: 316 Fat as an energy source Page: 316 Palatability Page: 317 Satiation Page: 318 Fat-soluble vitamins Page: 318 Essential fatty acids Page: 319 Essential fatty acids and eicosanoid production Page: 320 Blood lipoproteins Page: 322 Digestion, absorption and transport of dietary lipids Page: 323 Transport of endogenously produced lipids Page: 324 Fat metabolism Page: 326 Statins Page: 326 The “diet-heart hypothesis” and its implication for dietary fats Page: 329 Current “health images” of different dietary fats Page: 332 What about saturated vegetable fats like coconut and palm oil? Page: 333 Trans-fatty acids Page: 334 Plant sterols Page: 335 Review of the evidence for the diet-heart hypothesis Page: 336 The key tenets of the diet-heart hypothesis Page: 336 Evidence overview Page: 337 Experimental studies Page: 337 “Experiments of nature” Page: 337 Cohort studies Page: 338 Intervention trials and clinical trials Page: 338 Fish oils Page: 340 Overview Page: 340 How might fish oils exert beneficial health effects? Page: 340 Evidence that high fish oil consumption may reduce CHD Page: 341 Conclusions and fish consumption recommendations Page: 342 Other natural oils used as supplements Page: 343 Key references Page: 344 13 Dietary supplements and food fortification Page: 346 An overview of food fortification Page: 347 Definitions Page: 347 Early successes Page: 348 Fortification in the UK Page: 348 Folic acid (vitamin B9) in flour – a modern fortification success story Page: 348 Time to update UK food fortification policy Page: 351 An overview of dietary supplements Page: 353 Definition and categories of dietary supplements Page: 353 Size and breakdown of the supplement market Page: 354 Overview of uses and potential hazards Page: 354 Some rules and regulations Page: 355 Vitamin and mineral supplements Page: 357 Do vitamin and mineral supplements ensure adequacy? Page: 357 Do micronutrient supplements reduce cancer, cardiovascular disease and increase life expectancy? Page: 359 Do individual micronutrient supplements offer specific benefits? Page: 359 Strategies for improving micronutrient adequacy Page: 363 Natural fats and oils Page: 364 The main “natural oil” supplements Page: 364 Evening primrose and starflower/borage oils Page: 364 Fish oils Page: 365 Dietary supplements or natural medicines? Page: 366 Natural metabolites as dietary supplements Page: 368 Conditionally essential nutrients Page: 368 L-Carnitine Page: 369 Glucosamine and Chondroitin sulphate Page: 369 Co-enzyme Q10(CoQ10) or ubiquinone Page: 370 Creatine Page: 371 Alpha (α)-lipoic acid Page: 371 Lecithin and choline Page: 372 s-Adenosylmethionine Page: 372 Natural extracts as dietary supplements Page: 373 Secondary metabolites in plant extracts Page: 373 Role of plant secondary metabolites in preventing/treating disease Page: 375 Phytoestrogens Page: 376 Garlic supplements Page: 377 Others Page: 378 Antioxidants and the oxidant theory of disease Page: 379 The nature and effects of free radicals Page: 379 Origins of free radicals Page: 379 Physiological mechanisms to limit free radical damage Page: 380 Situations that might increase damage by free radicals Page: 381 Do high antioxidant intakes prevent heart disease, cancer and other chronic diseases? Page: 384 Key references Page: 388 14 Food as medicine Page: 390 Fruit and vegetables five, seven, ten or even three portions per day? Page: 391 Background Page: 391 A flavour of the evidence underpinning the 5-a-day recommendation Page: 392 Calls to change the 5-a-day recommendation Page: 393 Can we justify increasing the 5-a-day recommendations? Page: 397 Is 10-a-day a realistic recommendation? Page: 397 Superfoods Page: 398 What are “superfoods”? Page: 398 What is the theoretical basis of claims for superfoods? Page: 399 Examples of superfoods Page: 400 The choice of which foods to classify as superfoods is biased Page: 402 Conclusions Page: 402 Functional foods Page: 403 Phytoestrogens Page: 404 Probiotics, prebiotics and synbiotics Page: 405 Plant sterols or phtyosterols Page: 408 Key references Page: 410 15 The vitamins Page: 412 Some general concepts and principles Page: 413 What is a vitamin? Page: 413 Classification Page: 414 Vitamin deficiency diseases Page: 415 Precursors and endogenous synthesis of vitamins Page: 416 Circumstances that precipitate deficiency Page: 416 A note about individual vitamins Page: 417 Vitamin A – retinol Page: 417 Key facts Page: 417 Nature and sources of vitamin A Page: 418 Functions Page: 419 Requirements and assessment of vitamin A status Page: 420 Deficiency states Page: 420 Risk factors for deficiency Page: 421 Benefits and risks of high intakes Page: 421 Vitamin D – cholecalciferol Page: 421 Key facts Page: 421 Nature, sources and requirements for vitamin D Page: 422 Functions of vitamin D Page: 424 Acute deficiency states Page: 425 Vitamin D, osteoporosis and non-bone conditions Page: 426 Safely improving the vitamin D status of the population Page: 426 Vitamin E – α-tocopherol Page: 426 Key facts Page: 426 Overview Page: 427 Vitamin K – phylloquinone Page: 427 Key facts Page: 427 Overview Page: 428 Thiamin – vitamin B1 Page: 429 Key facts Page: 429 Nature and sources Page: 429 Functions Page: 429 Requirements and assessment of status Page: 430 Deficiency states Page: 430 Riboflavin – vitamin B2 Page: 431 Key facts Page: 431 Nature and sources Page: 432 Functions Page: 432 Requirements and assessments of status Page: 432 Riboflavin deficiency Page: 432 Niacin – vitamin B3 Page: 432 Key facts Page: 432 Nature and sources Page: 433 Functions Page: 434 Dietary requirements and assessment of status Page: 434 Niacin deficiency Page: 434 Vitamin B6 – pyridoxine Page: 435 Key facts Page: 435 Nature and sources Page: 435 Functions Page: 436 Requirements and assessment of status Page: 436 Deficiency and toxicity Page: 436 Vitamin B12 – cobalamins Page: 437 Key facts Page: 437 Nature and sources Page: 437 Functions Page: 438 Requirements and assessment of status Page: 438 Deficiency of B12 Page: 438 Folate or folic acid (vitamin B9) Page: 438 Key facts Page: 438 Nature and sources Page: 439 Functions Page: 440 Requirements and assessment of folate status Page: 440 Folate deficiency Page: 440 Folic acid and birth defects Page: 441 Potential hazards of high folic acid intake Page: 441 Biotin Page: 441 Key facts Page: 441 General overview Page: 441 Pantothenic acid Page: 442 Key facts Page: 442 Vitamin C – ascorbic acid Page: 442 Key facts Page: 442 Nature and sources Page: 443 Functions Page: 443 Requirements and assessment of status Page: 443 Deficiency states Page: 443 Benefits and risks of high intakes Page: 444 Key references Page: 446 16 The minerals Page: 446 Introduction Page: 447 Chromium Page: 448 Key facts Page: 448 Overview Page: 449 Copper Page: 449 Key facts Page: 449 Overview Page: 449 Fluoride Page: 450 Magnesium Page: 451 Key facts Page: 451 Overview Page: 451 Manganese Page: 451 Overview Page: 452 Molybdenum Page: 452 Key facts Page: 452 Overview Page: 452 Phosphorus Page: 452 Potassium Page: 453 Key facts Page: 453 Overview Page: 453 Selenium Page: 454 Key facts Page: 454 Overview Page: 454 Zinc Page: 455 Key facts Page: 455 Overview Page: 455 Iodine and iodine deficiency diseases Page: 457 Key facts Page: 457 Distribution and physiological function of body iodine Page: 457 Iodine deficiency Page: 457 Epidemiology of iodine deficiency across the world Page: 458 Iodine in the UK and other affluent countries Page: 459 High intakes and goitrogens in food Page: 460 Iron and iron deficiency anaemia Page: 461 Iron nutrition Page: 461 Key facts Page: 461 Distribution of body iron Page: 462 Requirement for dietary iron Page: 462 Regulation of iron balance and iron overload Page: 463 Determination of iron status Page: 463 Iron deficiency Page: 464 Prevalence of iron deficiency and anaemia Page: 464 Preventing iron deficiency Page: 465 Calcium, diet and osteoporosis Page: 467 Key facts Page: 467 Distribution and functions of body calcium Page: 467 Hormonal regulation of calcium homeostasis Page: 468 Requirement and availability of calcium Page: 468 Calcium and bone health Page: 470 The nature of bone Page: 470 Effects of age and sex upon bone density and fracture risk Page: 470 Incidence of osteoporosis Page: 472 General and lifestyle risk factors for osteoporosis Page: 472 Dietary risk factors for osteoporosis Page: 474 Prevention and treatment of osteoporosis Page: 474 Diet and lifestyle conclusions Page: 476 Salt and hypertension Page: 477 Key facts Page: 477 Overview Page: 477 Historical importance of salt Page: 477 The problems with salt Page: 478 Requirement for salt Page: 479 Amount and sources of dietary salt Page: 480 A review of the evidence for a salt–hypertension link Page: 482 Observational evidence Page: 482 Experimental studies Page: 484 Relationship between salt intake and morbidity and mortality Page: 485 Other factors involved in the aetiology of hypertension Page: 486 Conclusions Page: 487 Key references Page: 488 PART 4 VARIATION IN NUTRITIONAL REQUIREMENTS AND PRIORITIES Page: 490 17 Nutrition and the human lifecycle Page: 492 Introduction Page: 493 Nutritional aspects of pregnancy Page: 495 Pregnancy overview Page: 495 Effects of malnutrition in pregnancy Page: 495 The scale of increased nutritional needs in pregnancy Page: 495 RNI and RDA for pregnancy Page: 496 Pregnancy outcomes Page: 497 Estimating the extra nutritional needs of pregnancy Page: 498 Preconception Page: 498 Energy aspects of pregnancy Page: 499 Protein in pregnancy Page: 502 Minerals in pregnancy Page: 503 Calcium Page: 503 Iron Page: 504 Folic acid/folate and NTDs Page: 505 Other vitamins in pregnancy Page: 505 Alcohol and pregnancy Page: 506 Lactation Page: 506 Infancy Page: 507 Breastfeeding versus bottle-feeding Page: 507 Prevalence of breastfeeding Page: 508 Factors influencing choice of infant feeding method Page: 510 The benefits of breastfeeding Page: 513 Weaning Page: 517 When to wean? Page: 517 What are weaning foods? Page: 518 The priorities for weaning foods Page: 518 Childhood and adolescence Page: 520 Data from the rolling NDNS programme Page: 521 The elderly Page: 525 Demographic and social trends Page: 525 The effects of ageing Page: 527 Nutritional requirements of the elderly Page: 529 The diets and nutritional status of elderly people Page: 531 Energy and macronutrients Page: 531 Levels of overweight, obesity and other risk factors Page: 533 Diet and disease risk in the elderly Page: 535 Key references Page: 538 18 Nutrition as treatment Page: 540 Diet as a complete therapy Page: 541 Overview and general principles Page: 541 Food allergy (including coeliac disease) Page: 542 Immediate hypersensitivity reactions Page: 542 Coeliac disease (gluten-induced enteropathy) Page: 543 Phenylketonuria Page: 545 Diet as a specific component of therapy Page: 546 Diabetes mellitus Page: 546 Classification and aetiology Page: 546 Diagnosis Page: 547 Symptoms and long term complications Page: 547 Principles of management Page: 548 Can type-2 diabetes be reversed? Page: 549 Cystic fibrosis Page: 551 Chronic renal failure Page: 553 Malnutrition in hospital patients Page: 554 Overview Page: 554 Prevalence of hospital malnutrition Page: 555 Consequences of hospital malnutrition Page: 555 The traditional causes of hospital malnutrition Page: 557 Improving the nutritional care of hospital patients Page: 560 Aims of dietetic management of general hospital patients Page: 560 Aids to meeting nutritional needs Page: 560 Measures that could improve the nutritional status of hospital patients Page: 561 Impact of nutritional support Page: 562 The Malnutrition Universal Screening Tool Page: 563 NICE quality standards and guidelines Page: 563 Key references Page: 564 19 Some other groups and circumstances Page: 566 Vegetarianism Page: 567 Introduction Page: 567 Prevalence of vegetarianism Page: 568 The risks and benefits of vegetarian and vegan diets Page: 569 Adequacy of vegetarian diets Page: 569 Vegetarian diets and nutritional guidelines Page: 573 Racial minorities Page: 574 Introduction and overview Page: 574 The health and nutrition of particular minority groups Page: 575 Dietary comparison of ethnic groups in Britain Page: 577 Nutrition and physical activity Page: 580 Fitness Page: 580 Guidelines Page: 582 Current levels of physical activity and fitness Page: 582 Long-term health benefits of physical activity Page: 585 Introduction Page: 585 Diet as a means to improving physical performance Page: 587 Key references Page: 590 PART 5 FOOD SAFETY AND QUALITY Page: 592 20 The safety and quality of food Page: 594 Aims of the chapter Page: 595 Consumer protection Page: 595 Food law Page: 595 Food labelling Page: 597 Labelling in the UK Page: 597 Labels in the US Page: 598 An overview of health claims Page: 599 Food poisoning and the microbiological safety of food Page: 601 Introduction Page: 601 The causes of food-borne diseases Page: 602 The causative organisms Page: 602 How bacteria make us ill Page: 603 Circumstances that lead to food-borne illness Page: 603 Principles of safe food preparation Page: 606 Requirements for bacterial growth Page: 606 Some specific causes of food poisoning outbreaks Page: 607 Some practical guidelines to avoid food poisoning Page: 608 Minimise the risks of bacterial contamination of food Page: 608 Maximise killing of bacteria during home preparation of food Page: 609 Minimise the time that food is stored under conditions that permit bacterial multiplication Page: 609 A note about treatment of food-borne disease Page: 610 Pinpointing the cause of a food poisoning outbreak Page: 610 A review of some common food poisoning organisms and foodborne illnesses Page: 612 The Campylobacter Page: 612 Salmonella Page: 612 C. perfringens Page: 613 E. coli 0157 and the VTEC bacteria Page: 613 S. aureus Page: 613 B. cereus Page: 614 C. botulinum Page: 614 L. monocytogenes Page: 614 Bovine spongiform encephalopathy (BSE) Page: 615 Overview Page: 615 The nature of prion diseases Page: 616 The infective agent Page: 616 Causes of prion disease Page: 616 The cattle epidemic of BSE Page: 617 Time course of the epidemic Page: 617 What caused the cattle epidemic? Page: 617 Measures taken to limit vCJD and eliminate BSE Page: 617 The human vCJD epidemic Page: 618 The costs of this crisis Page: 619 Food processing Page: 620 Some general pros and cons of food processing Page: 620 Specific processing methods Page: 622 Canning Page: 622 Pasteurisation Page: 622 Ultra-high temperature treatment Page: 622 Cook chill processing Page: 622 Food irradiation Page: 623 The chemical safety of food Page: 625 Overview of chemical hazards in food Page: 625 Natural toxicants and contaminants Page: 625 Circumstances that may increase chemical hazard Page: 625 Some natural toxicants in “Western” diets Page: 626 Residues of agricultural chemicals Page: 627 Food additives Page: 629 Uses Page: 629 Some arguments against the use of food additives Page: 629 Some counter-arguments Page: 629 Food additive regulation Page: 630 Testing the safety of food additives Page: 631 Key references Page: 634 Index Page: 635

Following the tradition of its predecessor, the fifth edition of Nutrition: Maintaining and Improving Health continues to offer a wide-ranging coverage of all aspects of nutrition while providing new information to this edition including: Increased coverage of experimental and observational methods used in nutrition In-depth focus on the nutritional implications of the increased adoption of vegetarian and vegan lifestyles Streamlined referencing - a short selected list of key references at the end of each chapter with URL links to free additional resources where possible Discussion of nutrition debates Critical coverage of "medicinal uses of food" including superfoods, functional foods and dietary supplements Updated bullet point summaries of key points after each major topic within each chapter The author provides an evidence-based evaluation of many key nutrition beliefs and philosophies. The book contains in-depth and critical reviews of the methods used to evaluate nutritional intakes/status and the observational and experimental used to investigate putative links between dietary factors and health outcome. It covers the role of food as a source of energy and nutrients while discussing the non-nutritional roles of food and the social and psychological factors that influence food choice. Presenting a critical discussion on the value of nutrition research linking specific foods or nutrients to specific diseases which encourages students to question the value of some current nutrition research. This is essential reading for all nutrition and dietetics students with different backgrounds who are studying nutrition as a specific discipline for the first time.
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