Book Review

Primary and Secondary Preventive Nutrition

N Engl J Med 2001; 345:71July 5, 2001

Article

Primary and Secondary Preventive Nutrition
(Nutrition and Health.) Edited by Adrianne Bendich and Richard J. Deckelbaum. 465 pp., illustrated. Totowa, N.J., Humana Press, 2001. $125. ISBN: 0-89603-758-4

This book is the second in a Nutrition and Health series, planned as resources for physicians and nutritionists with a view to answering the questions of their patients and clients. The series highlights and reviews recent research and is said to be intended not only for professionals but also for their clients, students, and educated consumers — a wide audience, indeed. In the first book in the series, Preventive Nutrition: The Comprehensive Guide for Health Professionals (1997), Bendich and Deckelbaum covered broad, disease-oriented themes — cancer and cardiovascular disease, among others — and closed with some ideas about nutrition and prevention in both the developed and developing world. In this new book, with “Primary and Secondary” in the title, there appears to be a similar thematic structure and a final section on critical issues for the 21st century.

There are strengths to this book, some of which may be in tension with the notion of teaching professionals and their clients. It is easy to forget, when one lives in the developed world (and this is a very United States–centered book), that nutrition in the developing world is not a matter of professionals and their clients but a matter of economics, bureaucrats, and climate. The chapter by Underwood, for instance, reminds us strongly that not all nutritional problems are to be found in the developed world and that understanding childhood blindness, for instance, requires a solid grasp of social epidemiology — of “poverty, environmental deprivation, and social disparity.” Underwood outlines local solutions to vitamin A deficiency, such as homestead gardening, but reminds us that plant breeding and fortification immediately set up a conflict between individual and community need and the ability to pay. She argues that no single, vertically implemented intervention is likely to be sustainable; that female literacy is critical; and that local leaders, the poor, and women are all part of the solution.

In contrast, the chapter by Fournier and colleagues fails to tackle the current lack of consistent evidence that soy is really important for protection against cancer. There is considerable enthusiasm among health-food advocates and members of the soy industry for soy as the explanation for differences in cancer rates between the United States and Asia. Even if this is true, it is not necessarily a solution that can be translated into disease prevention; there is a substantial difference between a Japanese woman who has been exposed to high levels of soy and its isoflavones since she was in utero and a North American woman who is beginning to take a genistein supplement at the age of 52; the uncontrolled experiment is already well under way. We need a stronger message that much research is still needed. The authors are careful, nonetheless, to remind readers that any recommendation is for the consumption of soy foods, not soy extracts.

Discussing the use of supplements more generally, Patterson and colleagues explain how surprisingly little evidence there is to support the use of supplements to prevent cancer. Given the size of the supplement industry and thus the widespread use of supplements, now might be a good time for nutritionists to advise clients on the benefits of vegetables and fruits, which have a much wider variety of potential (and yet unidentified) phytochemicals than any pill.

Lands, reporting on alcohol, reminds us that the consequences of alcohol consumption are mostly deleterious and even that to lower the risk of cardiovascular disease, “alternate preventive nutrition tactics other than alcohol drinking are available.” However, he does note that the median intake of one or two drinks per week in the U.S. population is much lower than the one to two drinks per day that is suggested as the upper limit of consumption that may lower the risk of cardiovascular disease. Still, this ignores the fact that most studies of consumption understate population intake by about half.

The section on issues for the 21st century is perhaps the most problematic. There is no mention of several of the principal areas of nutritional deficiency (iodine, iron, and vegetables and fruit), the problem of lack of physical activity, the growing sentiment against genetically modified food, and the increasing problem of bacterial contamination of the food supply, particularly in the United States. Furthermore, economic and environmental issues — discussions of food security, malnutrition, global climate change, and environmental degradation — are nowhere to be found. The chapters on issues for the future would have benefited from the useful, if iconoclastic, thinking of the nutritionist George Blackburn or the historical perspective and scholarship of Henry Blackburn.

The book is splendidly free of almost all inappropriate nutritional claims (for instance, claims for trans fatty acids, alcohol, and supplements) but suffers from disorganization: some section headings in the index do not match the layout of the book, and there appear to be missing pieces — chapters that were never received, perhaps.

In short, this is a book with some very useful, carefully crafted chapters that may indeed inform several groups of readers. However, there is no real sense of coherence around the topic of primary and secondary prevention. Perhaps the next book in this series will be both well structured and well written.

John D. Potter, M.D., Ph.D.
Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024
jpotter@fhcrc.org