1043 if the patient’s sheets and blankets
are
arranged comfor-
tably. Nurses learn to manage them easily, but with unequal tension at the ends, the net may tear. Again, the patient is rather over-confined, but this bed may well make a useful ward acquisition. Beds which constantly 1 rotate the patient from side to side have been devised,’ but the indications for their use are not yet clear and there are some design problems. Assorted supporting fleece, and foam have their advopads of17 jelly, 18 and a resilient polyether foam is now specicates," fied for N.H.S. hospital mattress. 19 Much of the above equipment can be helpful in limiting decubitus ulceration, unless too heavily relied on. But of first importance is an agreed, clearly understood policy of management.12Doctors and nurses are often unsure of the limits of their responsibility in the prevention and treatment of these lesions. If the incidence rises, the nurses are blamed.17 Yet nurses need the doctors’ help in identifying likely pressure-sore subjects, and with their management, as much as for any other serious condition. General nursing guidelines cannot predict the needs of individual wards. Nurses in difficulties over sore prevention and faced with a bewildering array of remedies deserve medical support in working out an effective routine. Pressure-sores represent an ugly and dangerous20 21 and wastefulzz complication of illness, with an incidence of about 2.5% in general hospitals.23’ Where the occurrence-rate is higher, doctors must accept some of the responsibility.
HER SHARE OF THE FOOD
RECOMMENDED values for the energy requirements of diets for men and women are provided by the World Health Organisation and by the British Department of Health and Social Security,2 and cover several levels of physical activity. The recommended values for women lower. Of course women are on average lighter than But when scaled per kg of body-weight, a woman’s ratio still is less than a man’s, by some 10%. It is not in accord either with the remarkable relation that resting energy requirement is proportional to the three-quarter power of body-weight (W-374)3—a relation valid for a range of mammals from the mouse to at least the cow. It is not even explicable on the basis of surface-area calculations, which are in any event precarious. The view that metabolic rate depends on surface area, secure 90 years ago,4 became hardly tenable after 40 further years of observations;3 it survives only because of the air of precision created by time-honoured nomograms, and in spite of its inadequate basis in human are
men.
17. Pinel, C.Nursing Times, 1976, 5, 172. 18. Andrews, J. Association of National Health Service
Supplies Officers;
for 1975-76, p. 4. 19. National Health Service; interim report of the Specification Working on Mattresses and Related Items. 1968. 20. Michocki, R. J., Lamy, P. P. J. Am. Geriat. Soc. 1976, 7, 323. 21. Vasile, J., Chaitin, H. Geriatrics, 1972, 27, 126. 22 Lancet, 1973, ii, 309. 23. Gerson, L.W.Int. J.Nurs. Stud. 1975, 12, 201.
report
Group
1. Tech.Rep.Ser. Wld Hlth Org. no. 522, 1973. 2.Department of Health and Social Security. Recommended Intakes of Nutrients for the United Kingdom. H.M. Stationery Office, 1969. 3.Kleiber, M. The Fire of Life. New York, 1975. 4. Rubner, M.Z.Biol. 1883,19, 535.
measurements.5 For example, the usual formula of DuBois is valid for Indian males of typical shape,4but no so valid for Indian males of less typical shape,7 and presumably hardly applicable to females who are not of typical male shape. The rhesus monkey’s surface area is as well-known as human surface area, through the technique of skinning.8 Women may in general be less energetic than men. But the recommended values make allowance for the level of activity. The male in a sedentary job still receives unaccountably more than the comparable female, on any basis except one-the basis of fat-free body mass, since the typical woman contains more fat than the typical man. But, as Durnin points out,9 adipose tissue is not metabolically inert, and, even if it contributes very little to resting melabolic rate, it has to be moved about as its owner moves about, so that the energy cost of, for instance, walking at modest speeds is about the same for a man and for a woman of equal body-weight, despite their differing fat content. The official recommendations are not, of course, the product of male chauvinist gluttony, nor of merely theoretical calculations. They rely on observed dietary intakes. It is, however, very hard to avoid a nutritional counterpart of Heisenberg’s Uncertainty Principlethat the very observations alter the intake being observed. An eater being scrutinised may not eat like himself unscrutinised. The proper method is clearly to provide for each eater an unnoticed observer who surreptitiously measures the food before it is taken, and this method is hardly feasible. One may conjecture that women are more self-conscious than men about their eating, and restrict their intake during a study more than men do. But this is mere conjecture. Another conjecture, equally difficult to establish, and partly for the same reason, is that a woman earning her living through the same occupation as a man does not as a rule exert herself physically as much as he does. If this is so, the woman achieves the same result with less exertion, and shows an enviable economy of effort. If the recommended intakes cannot be faulted, then is it fair for him to get more of every food than she does, since he consumes more energy? There is an important reservation. During her potentially reproductive years, she is in peril of iron deficiency through menstruation, pregnancy, and lactation, while he is not. So she ought to make sure of a more generous iron intake than he needs, and the iron content of the diet usually only just suffices for a woman; 10 it will not suffice if she is engaged in slimming. So an equal share of the readily absorbed iron of meat and fish should be on her plate and his, even if his plateful of food is overall larger than hers. It is true that if she is iron-deficient she will absorb iron better than he, but never having enough is a stiff price to pay for achieving absorption of an equal amount. Only after the menopause can he fairly start plundering some of her beefburger-if he successfully renegotiates their long-standing domestic agreement about food sharing. 5. Gehan, E. A., George, S. L. Cancer Chemother. Reps pt. I, 1970, 54, 225. 6. Mehra, N. C. J. appl. Physiol. 1958, 12, 34. 7. Banerjee, S., Sen, R. ibid. 1955, 7, 585. 8. Liu, C. T., Higbee, G. A. ibid. 1976, 40, 101. 9. Durnin, J. V. G. A. Proc. Nutr. Soc. 1976, 35, 145. 10. Davidson, S., Passmore, R., Brock, J. F., Truswell, A. S. Human Nutrition and Dietetics; p. 504. Edinburgh, 1975.
are
arranged comfor-
tably. Nurses learn to manage them easily, but with unequal tension at the ends, the net may tear. Again, the patient is rather over-confined, but this bed may well make a useful ward acquisition. Beds which constantly 1 rotate the patient from side to side have been devised,’ but the indications for their use are not yet clear and there are some design problems. Assorted supporting fleece, and foam have their advopads of17 jelly, 18 and a resilient polyether foam is now specicates," fied for N.H.S. hospital mattress. 19 Much of the above equipment can be helpful in limiting decubitus ulceration, unless too heavily relied on. But of first importance is an agreed, clearly understood policy of management.12Doctors and nurses are often unsure of the limits of their responsibility in the prevention and treatment of these lesions. If the incidence rises, the nurses are blamed.17 Yet nurses need the doctors’ help in identifying likely pressure-sore subjects, and with their management, as much as for any other serious condition. General nursing guidelines cannot predict the needs of individual wards. Nurses in difficulties over sore prevention and faced with a bewildering array of remedies deserve medical support in working out an effective routine. Pressure-sores represent an ugly and dangerous20 21 and wastefulzz complication of illness, with an incidence of about 2.5% in general hospitals.23’ Where the occurrence-rate is higher, doctors must accept some of the responsibility.
HER SHARE OF THE FOOD
RECOMMENDED values for the energy requirements of diets for men and women are provided by the World Health Organisation and by the British Department of Health and Social Security,2 and cover several levels of physical activity. The recommended values for women lower. Of course women are on average lighter than But when scaled per kg of body-weight, a woman’s ratio still is less than a man’s, by some 10%. It is not in accord either with the remarkable relation that resting energy requirement is proportional to the three-quarter power of body-weight (W-374)3—a relation valid for a range of mammals from the mouse to at least the cow. It is not even explicable on the basis of surface-area calculations, which are in any event precarious. The view that metabolic rate depends on surface area, secure 90 years ago,4 became hardly tenable after 40 further years of observations;3 it survives only because of the air of precision created by time-honoured nomograms, and in spite of its inadequate basis in human are
men.
17. Pinel, C.Nursing Times, 1976, 5, 172. 18. Andrews, J. Association of National Health Service
Supplies Officers;
for 1975-76, p. 4. 19. National Health Service; interim report of the Specification Working on Mattresses and Related Items. 1968. 20. Michocki, R. J., Lamy, P. P. J. Am. Geriat. Soc. 1976, 7, 323. 21. Vasile, J., Chaitin, H. Geriatrics, 1972, 27, 126. 22 Lancet, 1973, ii, 309. 23. Gerson, L.W.Int. J.Nurs. Stud. 1975, 12, 201.
report
Group
1. Tech.Rep.Ser. Wld Hlth Org. no. 522, 1973. 2.Department of Health and Social Security. Recommended Intakes of Nutrients for the United Kingdom. H.M. Stationery Office, 1969. 3.Kleiber, M. The Fire of Life. New York, 1975. 4. Rubner, M.Z.Biol. 1883,19, 535.
measurements.5 For example, the usual formula of DuBois is valid for Indian males of typical shape,4but no so valid for Indian males of less typical shape,7 and presumably hardly applicable to females who are not of typical male shape. The rhesus monkey’s surface area is as well-known as human surface area, through the technique of skinning.8 Women may in general be less energetic than men. But the recommended values make allowance for the level of activity. The male in a sedentary job still receives unaccountably more than the comparable female, on any basis except one-the basis of fat-free body mass, since the typical woman contains more fat than the typical man. But, as Durnin points out,9 adipose tissue is not metabolically inert, and, even if it contributes very little to resting melabolic rate, it has to be moved about as its owner moves about, so that the energy cost of, for instance, walking at modest speeds is about the same for a man and for a woman of equal body-weight, despite their differing fat content. The official recommendations are not, of course, the product of male chauvinist gluttony, nor of merely theoretical calculations. They rely on observed dietary intakes. It is, however, very hard to avoid a nutritional counterpart of Heisenberg’s Uncertainty Principlethat the very observations alter the intake being observed. An eater being scrutinised may not eat like himself unscrutinised. The proper method is clearly to provide for each eater an unnoticed observer who surreptitiously measures the food before it is taken, and this method is hardly feasible. One may conjecture that women are more self-conscious than men about their eating, and restrict their intake during a study more than men do. But this is mere conjecture. Another conjecture, equally difficult to establish, and partly for the same reason, is that a woman earning her living through the same occupation as a man does not as a rule exert herself physically as much as he does. If this is so, the woman achieves the same result with less exertion, and shows an enviable economy of effort. If the recommended intakes cannot be faulted, then is it fair for him to get more of every food than she does, since he consumes more energy? There is an important reservation. During her potentially reproductive years, she is in peril of iron deficiency through menstruation, pregnancy, and lactation, while he is not. So she ought to make sure of a more generous iron intake than he needs, and the iron content of the diet usually only just suffices for a woman; 10 it will not suffice if she is engaged in slimming. So an equal share of the readily absorbed iron of meat and fish should be on her plate and his, even if his plateful of food is overall larger than hers. It is true that if she is iron-deficient she will absorb iron better than he, but never having enough is a stiff price to pay for achieving absorption of an equal amount. Only after the menopause can he fairly start plundering some of her beefburger-if he successfully renegotiates their long-standing domestic agreement about food sharing. 5. Gehan, E. A., George, S. L. Cancer Chemother. Reps pt. I, 1970, 54, 225. 6. Mehra, N. C. J. appl. Physiol. 1958, 12, 34. 7. Banerjee, S., Sen, R. ibid. 1955, 7, 585. 8. Liu, C. T., Higbee, G. A. ibid. 1976, 40, 101. 9. Durnin, J. V. G. A. Proc. Nutr. Soc. 1976, 35, 145. 10. Davidson, S., Passmore, R., Brock, J. F., Truswell, A. S. Human Nutrition and Dietetics; p. 504. Edinburgh, 1975.
