Table Of ContentAdvanced Nutrition and
Dietetics in Nutrition Support
Advanced Nutrition
and Dietetics in Nutrition
Support
Edited by
Mary Hickson
PhD RD
Sara Smith
PhD RD
Series Editor
Kevin Whelan
PhD RD FBDA
This edition first published 2018 © 2018 by John Wiley & Sons Ltd
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Library of Congress Cataloging‐in‐Publication data applied for
9781118993859
Cover design: Wiley
Set in 9.5/12pt Times by SPi Global, Pondicherry, India
10 9 8 7 6 5 4 3 2 1
ADVANCED NUTRITION AND DIETETICS BOOK SERIES
Nutritional interventions need to be based on solid evidence, but where can you find this information? The
British Dietetic Association and the publishers of the Manual of Dietetic Practice present an essential and
authoritative reference series on the evidence base relating to advanced aspects of nutrition and dietetics in
selected clinical areas. Each book provides a comprehensive and critical review of key literature in the
area. Each covers established areas of understanding, current controversies and areas of future develop-
ment and investigation, and aims to address key themes, including:
• mechanisms of disease and its impact on nutritional status, including metabolism, physiology and
genetics
• consequences of disease and undernutrition, including morbidity, mortality and patient perspectives
• clinical investigation and management
• nutritional assessment, drawing on anthropometric, biochemical, clinical and dietary approaches
• nutritional and dietary management of disease and its impact on nutritional status.
Trustworthy, international in scope and accessible, Advanced Nutrition and Dietetics is a vital
resource for a range of practitioners, researchers and educators in nutrition and dietetics, including
dietitians, nutritionists, doctors and specialist nurses.
Contents
Preface ix
Foreword xi
Editor biographies xii
Contributors xiii
Abbreviations xvii
SECTION 1 Background to undernutrition 1
1.1 Definitions and prevalence of undernutrition 3
1.2 Physiological causes of undernutrition 6
1.3 Socioeconomic causes of undernutrition 15
1.4 Institutional causes of undernutrition 25
1.5 Consequences of undernutrition 33
SECTION 2 Identification of undernutrition 43
2.1 Nutritional screening 45
2.2 Nutritional assessment 50
2.3 Anthropometric assessment of undernutrition 55
2.4 Biochemical assessment in undernutrition 65
2.5 Clinical assessment of undernutrition 74
2.6 Dietary assessment in undernutrition 82
2.7 Advanced imaging techniques for assessment of undernutrition 91
SECTION 3 Nutritional requirements in nutrition support 107
3.1 Fluid requirements and assessment in nutrition support 109
3.2 Energy requirements in nutrition support 117
3.3 Protein requirements in nutrition support 127
3.4 Water-soluble vitamins in nutrition support 135
3.5 Fat-soluble vitamins in nutrition support 144
3.6 Minerals in nutrition support 155
viii Contents
SECTION 4 Nutritional interventions to prevent and treat undernutrition 167
4.1 Population and community interventions to prevent and treat
undernutrition 169
4.2 Institutional interventions to prevent and treat undernutrition 176
4.3 Oral nutrition support to prevent and treat undernutrition 184
4.4 Enteral nutrition to prevent and treat undernutrition 194
4.5 Parenteral nutrition to prevent and treat undernutrition 207
SECTION 5 Undernutrition and nutrition support in clinical specialties 217
5.1 Nutrition support in paediatrics 219
5.2 Nutrition support in anorexia nervosa 231
5.3 Nutrition support in older adults 241
5.4 Nutrition support in neurological disorders 251
5.5 Nutrition support in spinal cord injury 259
5.6 Nutrition support in pulmonary and cardiac disease 270
5.7 Nutrition support in diabetes 278
5.8 Nutrition support in pancreatitis 286
5.9 Nutrition support in inflammatory bowel disease 296
5.10 Nutrition support in intestinal failure 302
5.11 Nutrition support in liver disease 313
5.12 Nutrition support in kidney disease 326
5.13 Nutrition support in critical care 339
5.14 Nutrition support in burn injury 351
5.15 Nutrition support in orthopaedics 358
5.16 Nutrition support in HIV infection 367
5.17 Nutrition support in oncology 376
5.18 Nutrition support in palliative care 389
Index 399
Preface
Undernutrition is a serious condition that occurs relating to undernutrition. It draws on the experi-
when a person’s diet does not contain sufficient ence and expertise of recognised authorities
energy or nutrients for a healthy and active life. from around the world to bring together the
In the past it has been termed malnutrition, but information needed by practitioners, researchers
with the rise of obesity and conditions related to and educators in the area of nutrition and diet.
overnutrition, it is important to make a clear Specialist dietitians and nutritionists will find
distinction between the two extremes. This book this to be an essential text, but it will also be
focuses particularly on undernutrition in eco- valuable for doctors, nurses and other health pro-
nomically developed regions of the world, and as fessionals with a specialist interest in nutrition.
such does not cover in any detail undernutrition The chapters provide a comprehensive and
relating to famine, conflict and long‐term food critical review of the key literature and are split
insecurity prevalent in developing countries. into five sections.
Undernutrition can result from inadequate
consumption of nutrients, failure to absorb nutri- • The background to undernutrition, which
ents, impaired metabolism, excessive loss of examines in detail the causes and conse-
nutrients or increased requirements. It generally quences of undernutrition. Chapters cover
develops gradually but rapid deterioration in how and why physiological, psychological,
nutritional status can occur in acute disease or socioeconomic and institutional factors can all
starvation. The first changes are to nutrient con- play a role in the development of undernutri-
centrations in blood and tissues, followed by tion, and the consequences of these.
intracellular changes in biochemical functions • Identification of undernutrition, which covers
and structure. Later, overt symptoms and signs the range of methods available for screening
appear, enabling diagnosis by history, physical and assessing levels of undernutrition, includ-
examination, body composition and dietary ing anthropometric, biochemical, clinical
analysis, and laboratory tests. The causes of and dietary assessment. This section ends
undernutrition can be complex and may involve with a look at the cutting‐edge advanced
several interacting factors including physiologi- imaging techniques now available to assess
cal, psychological, socioeconomic and institu- undernutrition.
tional. The consequences can be far reaching and • Nutritional requirements in nutrition support,
affect the optimal functioning of individuals, as which includes fluid, energy, protein, vitamins
well as exacerbating and precipitating disease. and minerals in the context of deficiency or
Undernutrition commonly occurs concurrently when increased requirements exist.
with disease and particular life stages make peo- • Nutritional interventions to prevent and
ple more vulnerable to it: childhood, during treat undernutrition, exploring population‐
pregnancy and lactation, and during older age. level, community‐wide and institutional
Advanced Nutrition and Dietetics in Nutrition interventions, as well as looking in detail at
Support aims to provide an essential and authori- oral, enteral and parenteral approaches to
tative reference and review of the evidence base managing individuals.
x Preface
• Undernutrition and nutrition support in a This book is the fourth title in a series commis-
range of clinical specialties. This section sioned as part of a major initiative between the
incorporates both life stages and clinical British Dietetic Association and the publishers
conditions where the risk of undernutrition Wiley. Each book in the series provides a com-
is increased. prehensive and critical review of the key litera-
ture in a clinical area. Each book is edited by one
The authors have focused on established areas or more experts who have themselves under-
of understanding, current controversies and taken extensive research and published widely in
areas of future development and investigation, the relevant topic area. Chapters are written by
and drawn extensively upon the research lit- experts drawn from an international audience
erature, particularly systematic reviews and and from a variety of disciplines as required of
meta‐analyses. Efforts have been made to the relevant chapter (e.g. dietetics, medicine,
highlight the gaps in the literature and specific biomedical sciences).
issues relating to the quality of the evidence in The editors and I are proud to present this
a given specialty. Importantly, the authors title: Advanced Nutrition and Dietetics in
have sought to discuss the implications of Nutrition Support. Undernutrition can have
research findings for practice and the issues profound impacts on a range of outcomes,
to consider when translating research into including clinical (e.g. mortality, morbidity,
practice. complications), patient‐centred (e.g. quality
of life, patient experience) and economic out-
comes (e.g. length of stay, readmission rates,
Mary Hickson PhD RD costs). Approaches are needed to both screen
Professor of Dietetics and assess undernutrition and to appropriately
Plymouth University prevent and manage it, using interventions
ranging from public health approaches to par-
Sara Smith PhD RD enteral nutrition. We hope that this book will
Senior Lecturer in Dietetics improve health professionals’ understanding
Queen Margaret University and application of nutrition and dietetics in
these areas and improve outcomes for the
Editors patients affected.
Advanced Nutrition and Dietetics in
Nutrition Support Kevin Whelan PhD RD FBDA
Professor of Dietetics
King’s College London
Series Editor
Advanced Nutrition and Dietetics Book Series
Foreword
I am delighted to present the foreword for community interventions to prevent and treat
Advanced Nutrition and Dietetics in Nutrition undernutrition. The various routes that can be
Support, edited by two eminent British dietitians used to provide nutritional support have an entire
and clinical nutritionists, Professor Mary section of their own. A particularly valuable
Hickson and Dr Sara Smith. Both of the authors section of the book is its coverage of over a
have the advantage of considerable clinical and dozen of the most common diseases and
research experience in actually providing nutrition conditions requiring nutrition support. They
support as well as a gift for communicating are tackled in sufficient detail to provide the
their knowledge of the science and art to practitioner with the specific considerations to
others. Together with the experts writing each adequately deal with the patient’s problem.
chapter, they nicely define and set out the Paediatric as well as older adults are considered.
problem of undernutrition, the tools for deciding In addition to the diseases involving various
what needs to be done and then what to do, all in organ systems and metabolic disease, special
a single volume. and rarely covered problems such as anorexia
This is a book that I, and many other practi- nervosa, HIV, burns, orthopaedics and spinal
tioners throughout the world, will welcome as an cord injury are discussed. The special issues
addition to their core reference libraries that they arising in delivering nutrition support in critical
will turn to repeatedly in their daily work care and palliative care are also covered.
because it manages to convey the essentials I look forward to reading and using this
succinctly and authoritatively. The information book, and congratulate the authors on a job well
it provides is useful not only in Europe but done.
globally since the comprehensive and critical
review of the key literature in nutrition support Johanna T. Dwyer DSc RD
covers not only basic concepts but current
Professor of Medicine and Community
controversies and likely directions for future
Health, School of Medicine and Friedman
developments in the field.
School of Nutrition Science and Policy
The book is well suited to both beginners and
master practitioners. Early sections provide a Senior Nutrition Scientist, Jean Mayer
succinct background on undernutrition and how USDA Human Nutrition Research Center,
to identify it, followed by a section describing Tufts University
nutritional requirements. In addition to artificial
Director, Frances Stern Nutrition Center,
nutrition support (e.g. parenteral, enteral), a
Tufts Medical Center, Boston, USA
welcome addition is a chapter on population and
Editor biographies
Mary Hickson Kevin Whelan
Mary Hickson is Professor of Dietetics at the Kevin Whelan is the Professor of Dietetics and
University of Plymouth, UK, and leads the Head of Department of Nutritional Sciences
Dietetics, Human Nutrition and Health Research at King’s College London. He is a Principal
group in the Institute of Health and Community. Investigator leading a research programme
Her research interests include sarcopenia and exploring the interaction between the gut micro-
frailty, hospital nutritional care, and nutrition in biota, diet in health, disease and in patients
older people. Professor Hickson is on the edito- receiving artificial nutrition support. In 2012 he
rial board of the Journal of Human Nutrition and was awarded the Nutrition Society Cuthbertson
Dietetics. Medal for research in clinical nutrition and in
2017 was appointed a Fellow of the British
Sara Smith Dietetic Association. Professor Whelan is on the
Sara Smith is a Senior Lecturer in Dietetics and editorial boards of Alimentary Pharmacology
Nutrition at Queen Margaret University in and Therapeutics and the Journal of Human
Edinburgh, Scotland, UK. She is particularly Nutrition and Dietetics.
interested in nutritional assessment, undernu-
trition and the effects of treatment interventions
on nutritional status. Her own PhD explored the
effects of an intradialytic exercise programme
on quality of life, functional and nutritional
status of individuals receiving haemodialysis
therapy. Dr Smith works with the National
Health Service in a number of capacities and is
actively engaged in the work of the British
Dietetic Association. She won the BDA IBEX
award in 2016 in recognition of her significant
contribution to the dietetic profession.
