Introduction

The interface between normal and abnormal nutrition can be difficult to define. There is no

universally accepted definition of malnutrition, but a reasonable definition is as follows:

‘Malnutrition is a state of nutrition in which a deficiency, excess or imbalance of energy,

protein and other nutrients causes measurable adverse effects on tissue/body form (body shape,

size and composition) and function, and on clinical outcome.’

In developing countries, the lack of food and poor usage of the available food, often in

association with ongoing inflammatory processes, result in what has traditionally been called

protein–energy malnutrition (PEM). However, nutrient deficiencies often accompany PEM and

they may contribute to its development. Worldwide, in 2011, 165 million children under

5 years of age were affected by stunting, and at least 52 million by wasting. Obesity has also

been a growing problem in developing countries and the combination of stunting with obesity

has been increasing. In developed countries, excess food is available, and overweight and

obesity are the most common nutritional problems. However, under-nutrition (often referred to

as ‘malnutrition’) continues to remain a major clinical and public health problem worldwide.

Diet and disease are inter-related in many ways:

• Excess energy intake contributes to a number of diseases, including ischaemic heart

disease and diabetes, particularly when high in animal (saturated) fat content.

• There is a relationship between food intake and cancer, as found in many epidemiological

studies. An excess of energy-rich foods (i.e. those containing fat and sugar), often combined

with physical inactivity, plays a role in the development of certain cancers, while diets high

in vegetables and fruits reduce the risk of most epithelial cancers. Numerous carcinogens,

intentional additions (e.g. nitrates for preserving foods) or accidental contaminants (e.g.

moulds producing aflatoxin and fungi) may also be involved in the development of cancer.

• The proportion of processed foods eaten may affect the development of disease. Some

processed convenience foods have a high sugar and fat content and therefore predispose to

dental caries and obesity, respectively. They also have a low fibre content, and dietary fibre

can help in the prevention of a number of diseases (see p. 188).

• Long-term under-nutrition is implicated in disease by some epidemiological studies; for

example, low growth rates in utero are associated with high death rates from cardiovascular

disease in adult life.

In the UK, dietary reference values for food, energy and nutrients are stated as reference

nutrient intakes (RNIs), on the basis of data from the Food and Agriculture Organization

(FAO-WHO), United Nations University (UNU) expert committee and elsewhere. The RNI is

sufficient, or more than sufficient, to meet the nutritional needs of 97.5% of healthy people in a

population. Most people's daily requirements are less than this, and so an estimated average

requirement (EAR) is also given, which will certainly be adequate for most. A lower

reference nutrient intake (LRNI), which fails to meet the requirements of 97.5% of the

population, is also given. The RNI figures quoted in this chapter are for the age group 19–

50 years. These represent values for healthy subjects and are not always appropriate for

patients with disease