SCNLE Complete Review Guide 2026–2027

4. Do not restrict protein in children with CKD because of the risk of growth impairment; do not transfer adult prescriptions to children. [Source: Practice Point 3.3.1.4, S157]
5. Older adults with CKD and frailty or sarcopenia may need higher protein and energy targets; this practice point does not specify one universal increment. [Source: Practice Point 3.3.1.5, S157]
6. KDIGO suggests sodium below 2 g/day in CKD, approximately below 5 g/day of salt. Grams of sodium and grams of salt are different quantities. [Source: Recommendation 3.3.2.1 (2C), S157]
7. Salt-wasting nephropathy is an important exception: sodium restriction is usually inappropriate in this setting. [Source: Practice Point 3.3.2.1, S158]
8. Encourage a more plant-based pattern with fewer ultraprocessed foods in CKD, with individualization; this does not imply unrestricted potassium intake. [Source: Practice Point 3.3.1, S157]
9. For an adult with little or no intake for more than five days, introduce nutrition at no more than 50% of requirements for the first two days, then increase if monitoring shows no problems. Use the high-risk pathway when applicable. [Source: Recommendation 1.4.5, p13]
10. BMI below 16 kg/m² alone meets one high-risk criterion for refeeding problems in adults. It identifies risk, not an already established syndrome. [Source: Recommendation 1.4.6, Box 1, p14]
11. For adults at high risk of refeeding problems, start at a maximum of 10 kcal/kg/day and increase gradually to full needs over 4–7 days. This is an initiation rate, not a maintenance target. [Source: Recommendation 1.4.8, p14]
12. In extreme cases, such as BMI below 14 or negligible intake for more than 15 days, use 5 kcal/kg/day initially with continuous cardiac rhythm monitoring. [Source: Recommendation 1.4.8, p14]
13. In the NICE adult high-risk pathway, provide oral thiamine 200–300 mg daily immediately before feeding and during the first ten days; use intravenous B-vitamin preparations when necessary. Do not wait for symptoms. [Source: Recommendation 1.4.8, p15]
14. In high-risk refeeding, restore circulatory volume and closely monitor fluid balance; this is not an instruction for unmonitored large-volume fluid administration. [Source: Recommendation 1.4.8, p14]
15. In adults with cancer, regularly assess intake, weight change and BMI from diagnosis; the reassessment interval depends on clinical stability. [Source: Section 3.1, Recommendation 1 (B1-1), p2899]
16. If energy needs are not measured individually in an adult with cancer, generally estimate 25–30 kcal/kg/day and adjust clinically; do not treat the estimate as an exact measurement for everyone. [Source: Section 3.2, Recommendation 3 (B2-1), p2899]
17. For adults with cancer, recommend protein above 1 g/kg/day and, if possible, up to 1.5 g/kg/day. Coexisting cancer and kidney disease require individualization, not automatic selection of the higher number. [Source: Section 3.2, Recommendation 4 (B2-2), pp2899–2900]
18. In adults with cancer, supply vitamins and minerals at approximately recommended daily amounts; discourage high doses without a specific deficiency. Correcting a documented deficiency is a different situation. [Source: Section 3.2, Recommendation 5 (B2-4), pp2900–2901]
19. Avoid energy-restricting diets in a patient with cancer who is malnourished or at risk. Do not generalize this to every cancer patient at every stage. [Source: Section 3.3, Recommendation 8 (B3-2), p2901]
20. When medical nutrition is indicated in cancer, use enteral nutrition if oral interventions remain inadequate, and parenteral nutrition if enteral nutrition is insufficient or infeasible. PN is not routine for every cancer patient. [Source: Section 3.3, Recommendation 9 (B3-3), p2901]
21. Nutrition care process: gather and verify intake, anthropometry, biochemistry, physical findings and context; identify a nutrition problem supported by the assessment. Write the problem related to its etiology as evidenced by measurable signs. A medical diagnosis alone is not the nutrition diagnosis. [Academy Nutrition Diagnosis, PES components]
22. Plan with the patient: identify a feasible goal, address the cause, consider resources and cultural food preferences, specify the intervention and review interval, then implement. If inability to shop causes inadequate intake, meal access is more directly relevant than another generic food handout. [Academy Nutrition Intervention, Planning and implementation]
23. Screening is not the full assessment. BMI, involuntary weight loss, reduced-intake duration, absorption and nutrient losses matter. Monitor actual delivery against prescription and compare outcomes with goals; reassess when symptoms or clinical status change. Consent, route, benefit, risk and continuing indication must be reviewed. [NICE CG32, 1.2.6, 1.3.1–1.3.2, 1.5.1]
24. Diabetes nutrition is individual and ongoing. Match advice to culture, willingness, quality of life, medicines and skills. Prefer high-fibre carbohydrate sources such as pulses and wholegrains, with vegetables, suitable dairy and controlled saturated fat. A diagnosis does not prescribe a single compulsory meal plan. [NICE NG28 dietary advice, updated 2026, 1.3.1–1.3.3]
25. The diabetes plate allocates half to nonstarchy vegetables, one quarter to protein and one quarter to carbohydrate foods; choose water or an unsweetened low-calorie drink. Milk and fruit still contribute carbohydrate. Count grams per serving multiplied by servings actually eaten, not simply one label serving. [CDC Diabetes Meal Planning, The plate method and Counting carbs]
26. For an alert adult able to swallow, treat low glucose promptly with 15 g rapid carbohydrate, recheck after 15 minutes and repeat if still low. Fatty or high-fibre foods act more slowly. Do not give oral food to an unconscious person; use the prescribed rescue plan and urgent help. Young children need individual doses. [CDC Treatment of Low Blood Sugar, The 15-15 rule and severe hypoglycemia]
27. In type 1 diabetes, coordinate food, insulin and activity within the prescribed regimen. Review snack amount, timing and glucose response; plan religious fasts individually with the diabetes team. Gastroparesis-related vomiting may benefit from small-particle mashed or pureed food. Renal failure, underweight or disordered eating changes priorities. [NICE NG17, 1.4.8–1.4.14, 1.5.2, 1.14.23]
28. Adult weight reduction requires an energy deficit, but dietary quality may improve health without weight loss. Agree a balanced affordable approach the patient can sustain, with follow-up for maintenance. Children require age- and sex-appropriate healthy eating and growth assessment rather than an adult restrictive prescription. [NICE NG246 physical activity and diet, 1.16.1–1.16.6]
29. NG246 defines low-energy diets as 800–1200 kcal/day and very-low-energy diets as below 800. These are selected adult interventions within supported multicomponent care, not long-term maintenance diets. They must be nutritionally complete, supervised and no longer than 12 weeks, with food reintroduction and medicine review. [NICE NG246 physical activity and diet, 1.16.8–1.16.12]
30. Bariatric care includes preoperative nutritional and psychological assessment, postoperative intake and deficiency surveillance, procedure-specific supplements and support. Specialist follow-up is at least two years, followed by at least annual shared-care nutritional monitoring. Normal BMI after surgery does not exclude protein or micronutrient deficiency. [NICE NG246 medicines and surgery, updated 2026, 1.18.7–1.18.18]
31. For high-risk or established CVD, NG238 specifies total fat at 30% or less of energy and saturated fat at 7% or less, replacing saturated fats with unsaturated fats where possible. These are this guideline's targets for this population, not universal limits for every age or disease. Consider medicines and comorbidities. [NICE NG238, 1.3.2–1.3.4]
32. Assess familial patterns and secondary causes such as uncontrolled diabetes or hypothyroidism when evaluating dyslipidaemia. Lifestyle and indicated medicines are complementary. Discuss food and supplement interactions with the pharmacist; do not assume all statins interact identically with grapefruit. [NICE NG238, 1.4.2–1.4.3, 1.5.4, 1.6.2–1.6.5]
33. Do not equate a surrogate lipid change with proven event prevention. NG238 does not advise routine plant sterols for CVD prevention or coenzyme Q10 to improve statin adherence. Its specified icosapent-ethyl indication is distinct from general over-the-counter fish-oil supplementation. [NICE NG238, 1.3.12, 1.12.1, 1.12.5–1.12.6]
34. Separate stable nondialysis CKD from maintenance dialysis. The NKF table gives 1.0–1.2 g/kg/day for metabolically stable adults on maintenance HD or PD, with or without diabetes. Do not transfer very-low-protein nondialysis prescriptions to dialysis or acute catabolism. Select energy within the assessed range using age, activity, body composition and goals. [NKF nutrient prescription pocket guide, chapter 4, table, chapter 4 stable CKD nutrition table]
35. Potassium counselling in CKD is individual: consider severity, medicines, laboratory validity, recurrence, food bioavailability, adequacy and quality of life. Highly bioavailable potassium in processed foods deserves attention in recurrent hyperkalemia. Emergent hyperkalemia needs medical treatment alongside dietary assessment, not a diet leaflet alone. [KDIGO CKD 2024, Practice Points 3.3.2, 3.11.5.1–3.11.5.2]
36. Investigate suspected coeliac disease while gluten is still being consumed. NG20 advises gluten in more than one meal daily for at least six weeks before testing for someone on a normal diet. Initial adult tests are total IgA and IgA tTG; use appropriate IgG-based tests in IgA deficiency. Refer persistent clinical suspicion despite negative serology. [NICE NG20, 1.1.3–1.2.3]
37. After coeliac diagnosis, teach gluten-free substitutions, labels and cross-contamination prevention. Gluten-free oats may be used with response review. Annual assessment includes weight or growth, symptoms and adherence; serology alone does not prove gluten exclusion. Persistent symptoms need diagnostic review, dietary investigation and assessment for other disease before a refractory label. [NICE NG20, 1.4.2–1.7.3]
38. IBD requires nutrition screening at diagnosis and regularly, including in patients with obesity. Active adult IBD generally needs 1.2–1.5 g protein/kg/day when no competing contraindication exists; uncomplicated remission generally needs about 1 g/kg/day. Check micronutrients and correct specific deficiencies, remembering inflammatory effects on serum markers. [ESPEN IBD guideline 2023, Recommendations 4–9, pp355–356]
39. Treat confirmed iron-deficiency anemia in IBD. Oral iron may be first-line in inactive disease with mild anemia and no intolerance; active disease, oral intolerance or Hb below 100 g/L favour IV iron consideration. Ferritin can rise with inflammation. No single universal IBD diet induces remission for all patients; avoid unsupported multiple exclusions. [ESPEN IBD guideline 2023, Recommendations 10–15, pp356–357]
40. Acute pancreatitis does not automatically require fasting: allow food unless there is a clear reason such as vomiting. In severe or moderately severe disease offer EN within 72 hours of presentation; use PN if EN fails or is contraindicated. Exocrine insufficiency impairs nutrient digestion because pancreatic digestive enzymes are deficient. [NICE NG104, 1.2.5–1.2.7]
41. In compensated non-malnourished cirrhosis, the protein target is 1.2 g/kg/day; malnutrition with muscle depletion generally calls for 1.5 g/kg/day and 30–35 kcal/kg/day. Minimise fasting with three to five meals and a late snack. Routine protein restriction in hepatic encephalopathy increases catabolism and is not recommended. [ESPEN liver practical guideline 2020, points 67, 71–75, Recommendations 52–54, 57–59, pp3552–3553]
42. Safe oral intake in mild hepatic encephalopathy requires intact cough and swallowing. Nonbleeding varices alone are not an absolute contraindication to a fine-bore NG tube. In overweight fatty-liver disease without decompensation, use an appropriate energy deficit and activity; exercise can reduce liver fat even without weight loss. Do not generalise weight-loss goals to malnourished decompensated cirrhosis. [ESPEN liver practical guideline 2020, points 16, 43–48, 83, pp3542, 3547–3548, 3554]
43. Choose the least invasive effective safe route. Use food fortification, meal changes or ONS when swallowing is safe; EN for inadequate or unsafe oral intake with a functional accessible gut; PN for inadequate or contraindicated enteral delivery or an inaccessible/nonfunctional gut. Review the continuing indication and withdraw support when adequate less-invasive intake is established. [NICE CG32, 1.6.6–1.8.4]
44. Gastric feeding is usual without upper-GI dysfunction; consider post-pyloric access when upper-GI function prevents gastric use. Consider gastrostomy when feeding is expected for at least four weeks. Acute stroke dysphagia often begins with a 2–4-week NG trial. Confirm tube position by the appropriate protocol; initial post-pyloric position requires radiographic confirmation unless placed radiologically. [NICE CG32, 1.7.6–1.7.18]
45. Calculate delivered energy as kcal/mL × mL/hour × actual hours; protein from concentration × delivered volume; and water from the labelled water fraction plus flushes, medicines and other inputs. Review losses separately. Low albumin during illness is not proof of inadequate protein intake. Monitor electrolytes, glucose and clinical tolerance according to stability and route. [NICE CG32, 1.4.1–1.4.3, Tables 1–2]
46. In resuscitated critically ill adults who cannot eat, early EN within 48 hours is preferred when feasible. Delay EN during uncontrolled shock or inadequate perfusion. Use indirect calorimetry for ventilated patients. Early acute feeding is hypocaloric with progressive delivery; do not immediately add full external calories to ongoing endogenous production. [ESPEN ICU practical revised guideline 2023, points 6, 11, 19–25, pp1675–1679]
47. Revised ICU guidance supports progressive protein-equivalent delivery around 1.3 g/kg/day, with specific assessment in obesity. Measure potassium, magnesium and phosphate at least daily in the first week. Refeeding hypophosphatemia requires more frequent tests, replacement and temporary energy restriction before cautious progression. Adult ICU numbers are not paediatric targets. [ESPEN ICU practical revised guideline 2023, points 25, 52, 57–59, pp1679, 1685–1686]
48. The 2025 surgery update emphasises preoperative nutritional assessment. Severe malnutrition or high metabolic risk may justify 10–14 days of preoperative nutrition even if elective surgery is delayed. Start appropriate postoperative EN early when oral requirements cannot be met and continue indicated assessment and support after discharge. [ESPEN surgery guideline update 2025, Recommendations 6, 20, 28, 33]
49. Major burns cause marked metabolic and protein demands. Use calorimetry when available and individualise delivery to avoid both underfeeding and overfeeding. The endorsed adult burn protein range is 1.5–2.0 g/kg/day, distinct from paediatric recommendations. Apply current ICU safety principles and specialist burn-team monitoring. [ESPEN major burns endorsed recommendations 2013, section 3, Table 1]
50. Abnormal cancer screening warrants quantitative intake, symptom, muscle, function and inflammation assessment. Weight-losing insulin-resistant patients may benefit from a higher fat-to-carbohydrate energy ratio. Pair nutrition with appropriate activity and resistance exercise. Appetite stimulants require medical benefit-risk review; short-term steroid appetite benefit does not imply restored muscle. [ESPEN cancer practical guideline 2021, points 2, 6, 12–16, pp2899–2904]
51. Head-and-neck radiotherapy needs early individual counselling, intake support and dysphagia management. Severe mucositis may require tube feeding; retain supervised swallowing rehabilitation. During HSCT monitor intake and metabolism repeatedly. Prefer EN when the gut is usable, but severe ileus, malabsorption or gut graft-versus-host disease may favour PN. [ESPEN cancer practical guideline 2021, points 26–28, 35–38, pp2906–2908]
52. Insufficient evidence for routine low-bacterial diets or glutamine after HSCT does not abolish standard food safety. Stable survivors need a healthy dietary pattern and activity. In advanced cancer, choose artificial nutrition only after assessing prognosis, achievable benefit, burdens and wishes. During active dying, comfort is the primary goal. [ESPEN cancer practical guideline 2021, points 37–43, pp2908–2910]
53. PAH deficiency therapy controls phenylalanine while meeting essential nutrient needs. Measured natural protein and Phe-free medical food are balanced using biochemical monitoring; Phe itself is essential. ACMG-based guidance supports lifelong treatment when untreated Phe exceeds 360 µmol/L. Pregnancy planning requires control before conception because maternal Phe is teratogenic. [GeneReviews PAH deficiency, incorporating ACMG 2025, Management and Table 3]
54. MSUD management restricts leucine, uses BCAA-free medical foods and adjusts isoleucine and valine to avoid essential-amino-acid deficiency. Catabolic illness releases endogenous amino acids; urgent specialist sick-day treatment provides energy and appropriate amino acids with frequent monitoring. Infant natural protein including expressed milk must be quantified. [GeneReviews Maple Syrup Urine Disease, Treatment, Tables 5 and 8]
55. Classic galactosemia requires prompt removal of lactose/galactose-containing milk and an appropriate replacement formula. Lactose hydrolysis releases galactose, so lactose-free dairy is not automatically safe. Follow metabolic-team guidance and monitor biochemical response rather than generalising the same restrictions to every sugar disorder. [GeneReviews Classic Galactosemia, Treatment Table 8]
56. GSD I nutrition prevents fasting hypoglycemia using scheduled feeds and individually dosed uncooked cornstarch. Heat changes the intended slow-release effect. Overnight feeding interruption can be life-threatening, requiring alarms and a response plan. Excess carbohydrate and unmeasured dosing can also worsen metabolic control. [GeneReviews Glycogen Storage Disease Type I, Management, cornstarch and overnight feeding]
57. Hyperammonemic encephalopathy from a suspected urea-cycle disorder is an emergency: lower ammonia urgently through specialist treatment rather than waiting for genetic confirmation. Nutrition must limit nitrogen burden while supplying nonprotein energy to reduce catabolism; prolonged total protein deprivation is not a safe long-term strategy. [GeneReviews Urea Cycle Disorders, updated 2025, section 5, Management]
58. Before pregnancy and during its first 12 weeks, routine folic acid is 400 micrograms/day. NG247 specifies 5 mg/day for listed higher-risk factors such as pre-existing diabetes or a prior neural-tube-defect pregnancy. BMI of 25 or above alone does not require a higher dose under the 2025 recommendation. After bariatric surgery seek specialist advice. [NICE NG247 maternal and child nutrition 2025, 1.1.3–1.1.8]
59. Pregnancy advice prioritises a healthy diet and suitable activity; intentional weight loss is not recommended. Weight includes fetal, placental and fluid components. Breastfeeding support should be respectful, practical and individualised; a special restrictive maternal diet is not routinely required. Consider food access and safe medicine use. [NICE NG247 maternal and child nutrition 2025, 1.2.11–1.3.8]
60. For healthy infants without a contraindication, WHO recommends breastfeeding initiation within one hour, exclusive breastfeeding for six months, then adequate safe complementary food with continued breastfeeding to two years or beyond. Feed responsively to hunger and satiety and adapt texture and variety to developmental abilities. [WHO infant and young child feeding, updated August 2026, Key facts and Complementary feeding]
61. For older adults, 30 kcal/kg/day is a guiding value and at least 1 g protein/kg/day a general starting point, adjusted for illness, tolerance and competing disease. Offer adequate drinks unless a condition changes the plan. Avoid unnecessary restriction in frailty. For malnourished older adults, prescribed ONS should generally provide at least 400 kcal and 30 g protein/day. [ESPEN geriatrics practical guideline 2022, points 1–5, 10, 29, pp960–962, 968]
62. Assess neonatal loss over 10% for dehydration, illness and feeding problems. Later faltering-growth thresholds depend on birth centile and downward crossing; current weight below the 2nd centile is concerning regardless of birth weight. Measure weight and length under two years or height thereafter, and interpret longitudinally on appropriate charts. [NICE NG75, 1.1.2–1.2.6]
63. Use clinical, developmental, social and detailed feeding assessment, with observed meals when indicated. Target investigations to findings. Agree goals with carers; promote relaxed regular meals, self-feeding and noncoercive support. Match textures and nutrient density to development. Excess milk or energy drinks may suppress appetite for other foods. [NICE NG75, 1.2.6–1.2.22]
64. If feeding support and fortification fail, a reviewed ONS trial may help. Tube feeding requires serious concern, specialist multidisciplinary assessment and failed less-invasive measures, plus goals and withdrawal planning. Monitor growth at intervals appropriate to age and concern; unnecessary frequent weighing can increase anxiety. Rapid loss or new symptoms warrants escalation. [NICE NG75, 1.2.23–1.2.32]
65. Take an allergy-focused history before testing: onset, speed, amount, reproducibility, organ systems, feeding history and atopy matter. For suspected IgE-mediated disease use targeted skin-prick or specific-IgE tests interpreted with history; a positive test alone is not clinical allergy. Skin testing requires anaphylaxis facilities; oral challenges need appropriate specialist settings. [NICE CG116 under-19 food allergy, 1.1.3–1.1.11]
66. Non-IgE suspicion may need a 2–6-week elimination trial with planned reintroduction and dietetic review. Teach labels, safe alternatives, nutritional adequacy and the limits of elimination. Do not diagnose allergy using food IgG, hair analysis, kinesiology or vega tests. Systemic reactions, growth faltering or multiple suspected allergies warrant specialist referral. [NICE CG116 under-19 food allergy, 1.1.11–1.1.19]
67. Eating disorders need coordinated medical, psychological and nutritional treatment. Severe dehydration, electrolyte disturbance or organ compromise requires acute care. Do not decide admission from BMI alone. Support age-appropriate growth and micronutrient adequacy; use a trained refeeding team and avoid both underfeeding and refeeding complications. [NICE NG69 eating disorders, 1.3.20–1.3.23, 1.10.3, 1.11.2]
68. For bone-related calcium inadequacy, assess food intake and supplement only the appropriate gap. Calcium citrate is less acid-dependent than carbonate; carbonate is better taken with food when gastric acid is low. Elemental calcium is the relevant label amount, and divided doses of 500 mg or less favour fractional absorption. Consider vitamin D status and medicine interactions. [NIH ODS Calcium Health Professional Fact Sheet, updated June 2026, Dietary supplements]
69. COPD nutrition assessment includes BMI and its trend; NG115's stated range is 20 to below 25 kg/m². Low BMI may call for dietetic advice, supplements and suitable exercise. Unintentional weight change, especially over 3 kg in older people, deserves attention even when a single BMI appears acceptable. [NICE NG115, 1.2.103–1.2.105]
70. Before organ transplantation, optimise malnutrition using a structured individual nutrition plan, adding ONS or EN when needed. Principles resemble major abdominal surgery but comorbid organ dysfunction changes the prescription. A transplant does not itself prove nutritional recovery; subsequent clinical status, intake and tolerance guide continued support. [ESPEN surgery guideline update 2025, Recommendations 37–39]

Common mistakes in this chapter

• ✕ Do not equate 2 g sodium with 2 g salt or apply restriction to salt-wasting nephropathy.
• ✕ Low BMI alone does not diagnose an established refeeding syndrome; it can identify risk.
• ✕ Do not use 10 kcal/kg/day as a maintenance target or transfer adult guidance to children.
• ✕ Do not combine kidney and cancer protein targets without considering comorbidity, or treat an estimate as an individual measurement.
• ✕ KDIGO practice points are not all graded recommendations; retain the source type and number when reviewing.
• ✕ Do not treat a positive food-IgE test alone as a clinical allergy diagnosis.
• ✕ Do not substitute low-protein nondialysis CKD targets for maintenance dialysis or acute catabolism.
• ✕ Do not infer adequate micronutrients, muscle or safe swallowing from normal BMI.
• ✕ An elimination diet, a bariatric procedure and an energy deficit each require a separate adequacy and follow-up plan.
• ✕ UK guideline recommendations here are clinical evidence, not Saudi administrative or prescribing law.