Book Review

Clinical Nutrition in Gastrointestinal Disease

N Engl J Med 2007; 356:758-759February 15, 2007

Article

Clinical Nutrition in Gastrointestinal Disease
Edited by Alan L. Buchman. 674 pp., illustrated. Thorofare, NJ, SLACK Inc., 2006. $134.95. ISBN: 978-1-55642-697-1

It has been said that a strong gut has more advantages than a good brain. The evolution of the human diet over the past 5 million years demonstrates the spectacular adaptability of our digestive apparatus, as we went from a diet of leaves, stems, shoots, and fruit in the tropical rain forest to one high in meat on the savannah during the Paleolithic period to one high in starches after the dawn of agriculture in the Neolithic period 10,000 years ago. Traditional cultures reflect this diversity, seen in the animal-based fat- and protein-rich diet of the Eskimo and the carbohydrate-based vegetarian diet eaten in parts of India. Meanwhile, changes in the Western diet during the past 100 years have been enormous.

We have grown obese. Allergies with gastrointestinal sequelae are rising. The incidence of celiac disease has increased by a factor of 10 in the past 20 to 40 years, esophageal cancer is increasingly common, and the Japanese, once near the bottom of the international list for colon cancer, are now near the top. Much appears to have gone wrong in the relationship between diet and health.

Scanning Electron Micrograph Showing Part of the Ileum in the Small Intestine and Intestinal Villi.

What is needed is a book on nutrition and gastrointestinal disease that covers causes and treatments in traditional and new areas of interest and that also forges links between gastrointestinal disease and systemic disease. Clinical Nutrition in Gastrointestinal Disease meets this need. Many of the contributors are the founders of the fields they discuss.

The book's stated audience includes gastroenterologists, endocrinologists, surgeons, primary care physicians, pharmacists, dietitians, and nurses. What is unusual is that the book embraces both gastrointestinal and systemic conditions. It covers well what is expected in a textbook on gastrointestinal nutrition, but it also introduces new topics of growing interest to the field. The pros and cons of the Subjective Global Assessment scheme for nutritional assessment, including its potential value for predicting complications, especially from surgical interventions, are discussed in detail. There is an update on the new nutrient requirements under the Dietary Reference Intakes system. The epidemiology and causes of colon cancer are highlighted, and there is a discussion of the type of diet intended to prevent cancer, one rich in fruits and vegetables and low in saturated fat, cholesterol, and red meat. There is also a warning against the use of certain supplements in diets intended to prevent cancer, especially folate and some antioxidants.

Also well covered in this book are prebiotics and probiotics, which have the potential to alter the gut microflora, bind toxins, and stimulate the immune response. Probiotics may attenuate infantile diarrhea among the poor, for whom diarrheal disease is a significant cause of illness and death. In later life, probiotics may reduce autoimmune disease among the more affluent, whose lack of early exposure to a range of bacteria can compromise the immune system. The last section of the book takes on all aspects of obesity, from appetite control to bariatric surgery, and includes discussions of the metabolic syndrome and the treatment of hyperlipidemia.

The chapters are clearly written, and the contributors have used evidence-based medicine to reach conclusions about the treatments discussed. Coverage of some topics could have been a little more detailed — for example, a discussion of the treatment of hypertriglycemia in relation to pancreatitis would have been useful, as would more information about the dietary associations with nonalcoholic fatty liver disease. Likewise, the chapter on nutrient absorption could have included information on the food factors limiting digestibility and bioavailability.

This book covers well the broad range of topics concerning the body's largest endocrine and lymphatic organ, which contains more bacterial cells than the body has eukaryotic cells. The book is likely to be consulted frequently.

David J.A. Jenkins, M.D., Ph.D., D.Sc.
University of Toronto, Toronto, ON M5S 1A8, Canada
david.jenkins@utoronto.ca