280 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 17, NO. 5, 2004 Correspondence Dilemmas in planning diets using existing food nutrient content of foods across (FCTs).5 There is an urgent need to composition tables critically evaluate current FCTs. This will allow nutritionists to make an appropriate selection of foods when planning diets and counselling patients. In the interim, where large disparities exist, it Nutritionists use food composition tables (FCTs) to calculate the may be useful to use the mean of the nutritional values closest to each amount of nutrients while making dietary recommendations. A other for a particular food across the major FCTs available. Match- variety of FCTs including the National Institute of Nutrition (NIN) ing of foods is best done by using the scientific name (Genus; tables are widely used in India.1 Other tables that nutritionists use species). Although we specifically highlight the problems associ- include McCance and Widdowson’s composition of foods2 and the ated with estimation of potassium in the diet, similar problems exist United States Department of Agriculture (USDA) FCTs.3 While the to varying extents for other micronutrients. NIN tables were updated in 1989, and McCance and Widdowson’s tables in 1991, the USDA has regularly revised its tables in its online 25 August 2004 A. V. Bharathi database from 1995 to as recently as 2004. Mario Vaz Nutrient data across these tables are not always comparable for Division of Nutrition Department of Physiology similar foods and this has created problems for nutritionists while St John’s Medical College prescribing diets. In Table I, we compare the potassium content of Sarjapura Raod certain foods across these tables. The above FCTs largely use the Bangalore technique of flame photometry for potassium estimation. McCance Karnataka and Widdowson’s data, in addition, have been derived using other [email protected] techniques such as emission spectrometry and atomic absorption spectrophotometry. The values of potassium vary widely across the REFERENCES tables, and for some foods the difference is more then 20-fold. In 1 Gopalan C, Ramshastri BV, Balasubramanian SC. Nutritive value of Indian foods. certain renal conditions, potassium intake is restricted and nutri- Hyderabad:National Institute of Nutrition; 1989. tionists often need to prescribe diets with a specified potassium 2 Holland B, Welch AA, Unwin ID, Buss DH, Paul AA, Southgate DAT. McCance and Widdowson’s The Composition of foods, 5th ed. Cambridge:Royal Society of Chemistry; 4 content. The difficulty faced by nutritionists is the uncertainty 1995. while prescribing an accurate potassium content in the diet. Table I 3 United States Department of Agriculture. Nutrient data laboratory. http:// shows that some foods considered to have low levels of potassium in www.nal.usda.gov/fnic/foodcomp/ (accessed on 4 January 2004). one FCT are shown to have substantially higher levels of potassium 4 Alpers DH, Stenson WF, Bier DM. Dietary management of diabetes, renal disease, and hyperlipidemia. In: Alpers DH, Stenson WF, Bier DM (eds). Manual of nutritional in another. therapeutics. 3rd ed. Boston:Little Brown; 1995:435-75. Many factors are known to cause differences in nutrient compo- 5 Mugford DC. Nutrition labeling: Concern for precision of analysis. Food Australia sition such as the genetic make-up of foods, environmental condi- 1993;45:216-23. tions in which foods are grown, moisture content of foods and the stage of ripening of fruits, among others. Differences in the methods of biochemical estimation can also contribute to variations in the TABLE I. Potassium content in foods according to different food composition tables (FCTs). Communication skills: Is there a need for training? Food NIN McCance and USDA USDA/ (mg/100 g) Widdowson’s (mg/100 g) NIN Good communication plays a pivotal role in the medical profession. (mg/100 g) It is especially important for doctors who need to communicate with Radish (pink) 10 240 233 * 23 patients regarding the disease, and with nurses and other members Orange 9.3 150 181 19 of the healthcare team to carry out the planned treatment. Good Beetroot 43 380 325 8 communication with patients is even more important today, when Banana 88 400 358 4 litigations against doctors are on the rise. It is generally believed that Papaya 69 200 257 4 good communication can decrease the number of litigations against Bitter gourd 152 330 608 4 doctors. There are three main settings where doctors need to utilize Peas (green) 79 330 244 3 their communication skills: (i) informing the patients of the diagno- Ladies finger 103 330 303 3 sis (especially of untreatable or terminal illnesses), (ii) explaining Cucumber 50 140 136 3 about the diagnostic or therapeutic procedures, and modes of treat- Plantain 193 500 499 3 Spinach 206 500 558 3 ment and their side-effects before obtaining informed consent, and Carrot 108 240 320 3 (iii) communicate to relatives about death. It is important to commu- Cauliflower 138 380 303 2 nicate in a language that the patient understands, bereft of technical French beans 120 230 209 2 terms. Extra care is required while dealing with untreatable condi- Beef (muscle) 214 350 297 * 1.5 tions. It is advisable to tell the truth about the diagnosis, as any Green gram (whole) 843 1250 * 1246 * 1.5 uncertainty regarding the diagnosis is bad for the patient. However, Celery leaves 210 320 260 1.2 one should not be ‘brutal’ while telling the truth. It is imperative to Yam (ordinary) 237 380 - - be gentle and give time to the patient to ask questions. It is generally NIN National Institute of Nutrition USDA United States Department of Agriculture useful to give all the information about the patient’s disease (as * Description of foods vary in detail across tables desired by her/him). However, the patient’s personality and premorbid 13-Corres.pmd 280 12/3/04, 11:39 AM CORRESPONDENCE 281 mental condition might modify the manner in which it is done. For REFERENCES example, in a patient with obsessive–compulsive disorder, it is better 1 McCormack D, Evoy D, Mulcahy D, Walsh M. An evaluation of patients’ comprehension to concentrate on facts rather than on feelings while breaking bad of orthopaedic terminology: Implications for informed consent. J R Coll Surg Edinb news. 1997;42:33–5. 2 Sanwal AK, Kumar S, Sahni P, Nundy S. Informed consent in Indian patients. J R Soc Getting informed consent for a diagnostic procedure or therapeu- Med 1996;89:196–8. tic modality is another challenging area. The legal doctrine of 3 Chan D, Goh LG. The doctor–patient relationship: A survey of attitudes and practices informed consent requires that all patients must be informed of the of doctors in Singapore. Bioethics 2000;14:58–76. procedures, risks and benefits of any recommended treatment and 4 Schumacher JE, Ritchey FJ, Nelson LJ 3rd, Murray S, Martin J. Malpractice litigation available alternatives, and that patients’ decisions must be in- fear and risk management beliefs among teaching hospital physicians. South Med J 1995;88:1204–11. formed, voluntary and competent. This appears simple but in reality 5 Marco CA, Bessman ES, Schoenfeld CN, Kelen GD. Ethical issues of cardiopulmonary it is not so. As a rule, all patients are assumed to be competent. resuscitation: Current practice among emergency physicians. Acad Emerg Med However, certain groups of patients are not so, such as those with 1997;4:898–904. psychosis, mentally challenged individuals, minors, patients with severe/terminal illness and the elderly. Though we are expected to present all known information to patients, are all patients capable of understanding this information? In Ireland, it was found that most of the patients who had recently signed consent forms containing terms such as ‘fracture reduction’ or ‘internal fixation’ were unsure of their meaning.1 In India, with its high rates of illiteracy, it is commonly believed that patients need not be told about their ‘Rule of 80’ for coronary disease? operations as they are unable to understand the complexities and likely to forget the important facts quickly. In an Indian study by Recent studies in patients with coronary artery disease are changing 2 Sanwal et al., it was found that about 70% of patients could recall established perceptions regarding the goals for reduction of low- the relevant data regarding abdominal operations five days postop- density lipoprotein (LDL) cholesterol levels.1 The evidence for con- eratively; however, less educated, poorer and older patients per- tinuing benefit at levels below the recommended goal of 100 mg/dl formed badly. It was also interesting that 98% of the patients reiterates the broadly valid concept that variables, which vary appreciated being given the information as it reduced their anxiety continuously in the population, do not lend themselves to arbitrary regarding the operation. Patients are expected to make an autono- cut-offs. This is because the risk of coronary events varies continu- mous decision based on the information presented to them. But the ously with increasing levels, beginning from those that are consid- truth is often otherwise. This might be because doctors feel that their ered normal. Similar relationships are seen between adverse event 3 patients are incapable of making a rational choice. On the other rates, and blood sugar levels2 and blood pressure.3 It appears that hand, a number of patients would like their doctors to be involved soon a ‘rule of 80’ might begin to apply, at least in the treatment of in the decision-making. This is due to several reasons. First, patients patients after an acute coronary syndrome. Patients should receive are overloaded with information from a host of sources including 80 mg of atorvastatin with a goal to reduce the levels of LDL healthcare providers, journals, books and the internet, which are cholesterol to perhaps 80 mg/dl; blood pressure to (<130 mmHg often conflicting, confusing and complex.