- Email: [email protected]
PLANNING PRIMARY CARE
560 MEDICAL SCHOOLS IN SOUTH AFRICA
SIR,-Dr Kandela’s report (Jan 18, p 146) directs criticism particularly against the Medical University of Southern Africa (MEDUNSA), though clearly this medical school is only part of the system which until recently strongly influenced universities and medical schools in South Africa.
However, South African universities, including MEDUNSA, have been freed from restrictions on whom they can admit for training, and this change has been widely welcomed. There have been white and black postgraduate students at MEDUNSA since its inception, with a steady increase in the numbers of black postgraduates; and the teaching staff has consisted of both black and white consultants, again with a steady increase in blacks. We hope that white undergraduates will soon be joining the student body. As Dr Saunders points out (March 1, p 505) his rejection of "the call for the devaluation of medical education"] was not referring to MEDUNSA in particular but to issues facing all of South Africa’s medical schools. What sort of doctor should our medical schools produce to deal with the health problems facing South Africa today? He states "We have to increase the numbers of doctors in rural South Africa but they must be first rate doctors". The teaching staff at MEDUNSA strongly support this goal but would define their objectives more broadly-namely, to produce doctors of the highest standard who, at the completion of their internship, would be able to embark on a vocational programme in whatever specialty they might choose and to practise anywhere in South Africa or abroad. The teaching programme at MEDUNSA differs little from that of other medical schools in South Africa, the MEDUNSA is subject to the same requirements laid down by the South African Medical and Dental Council. The external examiners for all examinations are invited from Cape Town, Stellenbosch, Witwatersrand, Natal, Bloemfontein, and Pretoria (ie, those who examine countrywide). The teaching staff at MEDUNSA reject with contempt the outrageous allegation that their aim is to produce some sort of inferior doctor destined to work in some specific area. It speaks volumes for the judgment, fairmindedness, insight, and integrity of the General Medical Council’s delegation led by Prof Joseph Peacock that-despite the inadequacies and deficiencies that are unavoidable in the early years of a new medical school, functioning under difficult circumstances in a hospital not planned as a teaching hospital, and with staffing as yet incomplete-they were nevertheless able to render an unbiased assessment coupled with clear constructive criticism. Their visit and report provided much needed support and encouragement for this medical
university. L. BLUMBERG E. L. KARLSSON I. T. HAY
Faculty of Medicine, MEDUNSA,
SJ. Some challenges
131 Dartmouth Road, LondonNW24ES
DAVID NACHSHEN
SIR,-The Newcastle upon Tyne Local Medical Committee has produced a pragmatic document but has still not grasped the nettle. All definitions I know of general practice concern what GPs perform or should perform. They do not define what he or she should do. If we assume that GPs contribute to the health of a society, and one part of that health is its physical health, we should at least be able to measure some outputs of physical health. Could we not have an organisation similar to that which produces the confidential reports into maternal mortality. There would be several options for discussion. For example: (1) All deaths in the practice under the age of 65 could be investigated to see if the death was preventable and to find out to what extent the patient’s actions were responsible for the death and the part played by the practice team. In our practice of 14 000 there were less than 10 deaths last year under the age of 70, so the work load would not be excessive. (2) Other diseases, for instance strokes under the age of 65 or hospital admissions for severe asthma, could be studied. This would require cooperation with the local hospital, perhaps using Hospital Activity Analysis. These and other diseases could be used as indicators of how well GPs were performing. (3) The FPC might use another, less objective, approach but one that may be just as important. For instance, if they analysed practices with more than average night-visit calls they may discover that there is something easily put right in the practice organisation. When I was responsible for sending medical students to a GP relief service in the late 1970s, the students reported back on what they had seen. Well over half were "second opinion" calls, or calls because the patients had not been able to see their GP in the previous 24 hours. When this is pointed out to a practice it requires little reorganisation to put the matter right. A system for seeing what is going on in practice should be easy and cheap to institute if GPs want it-and I would have thought it better that GPs have a hand in organising this rather than letting the government or FPC force it upon them. Simpson Centre, 70 Gregories Road,
D.W.GAU
Beaconsfield, Bucks HP9 1HL
J.A.L. VAN WYK F. J. PRETORIUS
PO Medunsa 0204, South Africa
1. Saunders
shown me that the professional qualities of practitioners together with as much care as is possible over the selection and appointment of GPs is the first essential of primary care planning. What follows in terms of services provided depends on local facilities and the desire of doctors to pool their resources within their partnership arrangements and (independent) contracts with FPCs.
to
South African
universities.
S Afr Med J 1985; 67:
932-33.
PLANNING PRIMARY CARE
SiR,-The laudable aims of the Newcastle upon Tyne Local Medical Committee (Feb 15, p 370) are to be commended in principle as a planning exercise in primary care. Your accompanying editorial highlights the pitfalls of the Newcastle ideals. The committee fails to appreciate that the contract between general practitioners (GPs) and their family practitioner committee (FPC) is an individual one personal to a practitioner rather than a collective contract between a practice or partnership and an FPC. Moreover, the nature of the contract is defined in National Health Service legislation as a contract for service not a contract of service. A change in this definition would be unlikely to gain the support of the Local Medical Committees Conference or the General Medical Services Committee. Twelve years experience of the administration and organisation of manpower in a London surburban FPC has
SIR,-The reason we are still waiting for the green-paper on general practice is that the more the DHSS tries to find out what represents quality and value for money in general practice the more complex the problem becomes. I am glad about this because I feel that the debate on quality has not yet been broad enough. As your editorial says, good general practice requires the qualities of kindness and understanding. Traditionally patients have been the judge of these qualities. If the doctor was unkind they could, with difficulty, change their doctor. Assessment of these qualities may be impossible, but to judge a kind and caring GP as being of poor
quality because of his immunisation audit is plainly wrong. In the race for quality it may appear that all GPs start at the same mark and run over an observed fixed distance. They do not. The course
is
more
like the
sort
of marathon where
we start at
different
places than a 400 metre race. If, as I did, you join a traditional family practice with no room for a practice nurse, secretary, or office equipment you have, before all else, to provide a building to achieve improved quality. Whereas if you start in a purpose-built surgery which has an age-sex register and a developed prevention programme you have
can
constructing
studying
scheme.
a
a head start and measles audit rather than
devote time to a cost/rent
561
Before
we
individually,
measure we
start
performance
from and what
we
must
qualities
define where, we
wish
general
practice to have. DAVID STEPHENS FUTURE OF NORTHWICK PARK
SIR,-The director of the Medical Research Council’s Clinical Research Centre at Northwick Park, Sir Christopher Booth (Feb 15, p 372), supports the establishment of a new national centre for postgraduate education and research. Is any consideration being given to establishing this centre outside London? There would be several advantages to such a move. (1) It is surely sensible to set up the proposed centre in a region where the toll of disease is high, rather than in a part of the UK where almost every index of disease incidence is comparatively low. (2) If, as Sir Christopher argues, clinical research workers will increasingly need access to many body systems while investigating the molecular basis of disease, an association with a provincial university serving one NHS region and providing access to the full range of disease would be preferable to a centre in London where too many institutions already compete for the patients available. (3) The new centre would need to establish links not only with traditional medical subjects but also with other biological disciplines to maintain a flow of new ideas into medicine. This would be easier at one of the newer and smaller universities with single departments of biological science. (4) Modest academic salaries would provide a higher standard of living outside London, and this could go some way to attracting the best research brains back into academic medicine. Are there any reasons, other than inertia, for retaining this centre in London? Department of Pathology, Lancaster Moor Hospital,
JAMES A. MORRIS
Lancaster LA1 3JR
HYGIENE IN HOSPITAL KITCHENS
SIR,-Considerable publicity has lately been given to hygiene standards in National Health Service hospital kitchens. As a cleaning company specialising in hygiene maintenance and providing a service to central government, local authorities, and British companies we have been surprised by an apparent disparity in approach between two Government departments-namely, the Department of the Environment’s Property Services Agency (PSA) and the Department of Health and Social Security (DHSS). The PSA is responsible for the maintenance of many buildings occupied by Government departments and the military. In 1975 it published a Government specification on the maintenance of hygienic conditions in catering facilities under its care.Almost as a routine the PSA has retained specialist contractors to provide a hygiene maintenance service. In contrast, surprisingly few people in the NHS are aware of this specification and even fewer have applied its disciplines. Nor have I heard it mentioned by DHSS spokesmen in the recent spate of publicity. Whilst I would not claim (nor, I think, would the PSA) that use of this specification automatically guarantees clean kitchens, its application clearly denotes a genuine awareness of the importance of proper hygiene standards. One Government Department seems to be much more aware of a fundamental problem and the means of controlling it than another. Is this yet another instance of one Department not knowing what the other is doing? Surely when lives could be at risk there should be collaboration between Departments. For anyone in the NHS or outside it, wishing to have a copy of the specification I am sure the PSA would be glad to help, or we will. Indepth Hygiene Services Ltd, Sandown Lodge,
A. R. NORMAN
Epsom, Surrey KT18 7QY Department M&E
of the Environment
in your Feb 1 issue (p 281) states that "since food open to distortion by the manufacturer... every effort must be made to get it right before it becomes mandatory". Manufacturers go to great lengths to check their labelling against the requirements of the law before selling, and they frequently consult with their local authority’s trading standards department, which may refer the matter to the Local Authorities Co-Ordinating Body on Trading Standards. We cannot be held responsible for what the law says. We would agree that mandatory fat labelling alone may lead to undue emphasis on fat-which is why we have argued that the other three major elements of nutrition should be added alongside where fat has to be declared. But labelling is not the whole answer: it needs education as well.
SiR,-A
note
labelling is
5 Red Posr Hill, London SE21 7BX
1.
FOOD LABELLING
Property
Services
Agency.
Standard
specification
142, March, 1975: Hygienic cleaning of kitchens and catering equipment.
Food & Drink Federation, 6 Cathenne Street, London WC2B 5JJ
D. M. WALKER
CASSAVA TOXICITY is used as a main source of energy, it SIR,-Wherever would be sensible to use the protein in the leaves. They are used more widely than Dr Hall suggests (Jan 11, p 95). Scepticism may be justified about the claim that 500 g of leaves are often eaten daily in Zaire;l evidence for 200 g is firmer, and such an amount should supply 5-10 g protein daily.2Despite the chronic fuel shortage in regions where cassava is grown, prolonged boiling is the usual method of removing hydrogen cyanide (HCN).3,4 But HCN and its precursors are soluble in water. There is no reason to think that more fuel would be used if the leaves were boiled briefly in a considerable volume of water, squeezed by hand, and boiled again. The second cooking water would be discarded also. Negligible HCN would probably remain, though this assumption needs experimental verification. Minerals, vitamin C, and the B vitamins would be removed, but protein and (3-carotene (provitamin A) would remain in the boiled leaf. An alternative procedure would be pulping and pressing, and then curdling the expressed juice to make edible leaf protein.55 Unfortunately, yields from cassava leaves, taken when the tubers are harvested, have been smaller than from many other species of leaf. There are, however, many thousands of cassava varieties. Perhaps cassava varieties will be found from which leaf protein extraction is more satisfactory. As a result of encouraging feeding experiments in India, Nigeria, and Jamaica, leaf protein is now in small-scale but regular use in five or six countries. cassava
Rothamsted
Experimental Station, Harpenden, Herts AL5 2JQ
N. W. PIRIE
1. Terra GJA. The significance of leaf vegetables, especially cassava, in tropical nutrition. Trop Geogr Med 1964; 16: 97. 2. Lancaster PA, Brooks JE. Cassava leaves as human food. Econ Bot 1983; 37: 331. 3 Raymond WD, Jojo W, Nicodemus Z The nutritive value of some Tanganyika foods II: Cassava E Afr Agric J 1941; 6: 154. 4. Caldwell M, Gim-Sai Y The effect of cooking method and storage on the ascorbic acid content of Malaysian leaf vegetables. Ecol Fd Nutr 1973; 2: 35. 5. Pirie NW. Leaf protein and other aspects of fodder fractionation. Cambridge. Cambridge University Press, 1978
DIGESTIBILITY AND PROTEIN FROM LEGUMES
SIR,-Your Dec 7 editorial on the new FAO/WHO report on energy and protein requirements points out that it is no longer thought necessary to take into account the quality of the dietary protein. However, a correction is needed for digestibility since this is low in vegetable sources. This applies particularly to legumes, a useful source of protein in many developing countries and one which could probably be further exploited for infant feeding, but which have a digestibility as low as 70-75% compared with 9507o for many other foods. True digestibility is measured by the difference between endogenous output of nitrogen (measured on a protein-free diet) and total nitrogen excretion. It has been suggested that the increase after feeding dietary fibre (and legumes provide fibre) is of endogenous
SIR,-Dr Kandela’s report (Jan 18, p 146) directs criticism particularly against the Medical University of Southern Africa (MEDUNSA), though clearly this medical school is only part of the system which until recently strongly influenced universities and medical schools in South Africa.
However, South African universities, including MEDUNSA, have been freed from restrictions on whom they can admit for training, and this change has been widely welcomed. There have been white and black postgraduate students at MEDUNSA since its inception, with a steady increase in the numbers of black postgraduates; and the teaching staff has consisted of both black and white consultants, again with a steady increase in blacks. We hope that white undergraduates will soon be joining the student body. As Dr Saunders points out (March 1, p 505) his rejection of "the call for the devaluation of medical education"] was not referring to MEDUNSA in particular but to issues facing all of South Africa’s medical schools. What sort of doctor should our medical schools produce to deal with the health problems facing South Africa today? He states "We have to increase the numbers of doctors in rural South Africa but they must be first rate doctors". The teaching staff at MEDUNSA strongly support this goal but would define their objectives more broadly-namely, to produce doctors of the highest standard who, at the completion of their internship, would be able to embark on a vocational programme in whatever specialty they might choose and to practise anywhere in South Africa or abroad. The teaching programme at MEDUNSA differs little from that of other medical schools in South Africa, the MEDUNSA is subject to the same requirements laid down by the South African Medical and Dental Council. The external examiners for all examinations are invited from Cape Town, Stellenbosch, Witwatersrand, Natal, Bloemfontein, and Pretoria (ie, those who examine countrywide). The teaching staff at MEDUNSA reject with contempt the outrageous allegation that their aim is to produce some sort of inferior doctor destined to work in some specific area. It speaks volumes for the judgment, fairmindedness, insight, and integrity of the General Medical Council’s delegation led by Prof Joseph Peacock that-despite the inadequacies and deficiencies that are unavoidable in the early years of a new medical school, functioning under difficult circumstances in a hospital not planned as a teaching hospital, and with staffing as yet incomplete-they were nevertheless able to render an unbiased assessment coupled with clear constructive criticism. Their visit and report provided much needed support and encouragement for this medical
university. L. BLUMBERG E. L. KARLSSON I. T. HAY
Faculty of Medicine, MEDUNSA,
SJ. Some challenges
131 Dartmouth Road, LondonNW24ES
DAVID NACHSHEN
SIR,-The Newcastle upon Tyne Local Medical Committee has produced a pragmatic document but has still not grasped the nettle. All definitions I know of general practice concern what GPs perform or should perform. They do not define what he or she should do. If we assume that GPs contribute to the health of a society, and one part of that health is its physical health, we should at least be able to measure some outputs of physical health. Could we not have an organisation similar to that which produces the confidential reports into maternal mortality. There would be several options for discussion. For example: (1) All deaths in the practice under the age of 65 could be investigated to see if the death was preventable and to find out to what extent the patient’s actions were responsible for the death and the part played by the practice team. In our practice of 14 000 there were less than 10 deaths last year under the age of 70, so the work load would not be excessive. (2) Other diseases, for instance strokes under the age of 65 or hospital admissions for severe asthma, could be studied. This would require cooperation with the local hospital, perhaps using Hospital Activity Analysis. These and other diseases could be used as indicators of how well GPs were performing. (3) The FPC might use another, less objective, approach but one that may be just as important. For instance, if they analysed practices with more than average night-visit calls they may discover that there is something easily put right in the practice organisation. When I was responsible for sending medical students to a GP relief service in the late 1970s, the students reported back on what they had seen. Well over half were "second opinion" calls, or calls because the patients had not been able to see their GP in the previous 24 hours. When this is pointed out to a practice it requires little reorganisation to put the matter right. A system for seeing what is going on in practice should be easy and cheap to institute if GPs want it-and I would have thought it better that GPs have a hand in organising this rather than letting the government or FPC force it upon them. Simpson Centre, 70 Gregories Road,
D.W.GAU
Beaconsfield, Bucks HP9 1HL
J.A.L. VAN WYK F. J. PRETORIUS
PO Medunsa 0204, South Africa
1. Saunders
shown me that the professional qualities of practitioners together with as much care as is possible over the selection and appointment of GPs is the first essential of primary care planning. What follows in terms of services provided depends on local facilities and the desire of doctors to pool their resources within their partnership arrangements and (independent) contracts with FPCs.
to
South African
universities.
S Afr Med J 1985; 67:
932-33.
PLANNING PRIMARY CARE
SiR,-The laudable aims of the Newcastle upon Tyne Local Medical Committee (Feb 15, p 370) are to be commended in principle as a planning exercise in primary care. Your accompanying editorial highlights the pitfalls of the Newcastle ideals. The committee fails to appreciate that the contract between general practitioners (GPs) and their family practitioner committee (FPC) is an individual one personal to a practitioner rather than a collective contract between a practice or partnership and an FPC. Moreover, the nature of the contract is defined in National Health Service legislation as a contract for service not a contract of service. A change in this definition would be unlikely to gain the support of the Local Medical Committees Conference or the General Medical Services Committee. Twelve years experience of the administration and organisation of manpower in a London surburban FPC has
SIR,-The reason we are still waiting for the green-paper on general practice is that the more the DHSS tries to find out what represents quality and value for money in general practice the more complex the problem becomes. I am glad about this because I feel that the debate on quality has not yet been broad enough. As your editorial says, good general practice requires the qualities of kindness and understanding. Traditionally patients have been the judge of these qualities. If the doctor was unkind they could, with difficulty, change their doctor. Assessment of these qualities may be impossible, but to judge a kind and caring GP as being of poor
quality because of his immunisation audit is plainly wrong. In the race for quality it may appear that all GPs start at the same mark and run over an observed fixed distance. They do not. The course
is
more
like the
sort
of marathon where
we start at
different
places than a 400 metre race. If, as I did, you join a traditional family practice with no room for a practice nurse, secretary, or office equipment you have, before all else, to provide a building to achieve improved quality. Whereas if you start in a purpose-built surgery which has an age-sex register and a developed prevention programme you have
can
constructing
studying
scheme.
a
a head start and measles audit rather than
devote time to a cost/rent
561
Before
we
individually,
measure we
start
performance
from and what
we
must
qualities
define where, we
wish
general
practice to have. DAVID STEPHENS FUTURE OF NORTHWICK PARK
SIR,-The director of the Medical Research Council’s Clinical Research Centre at Northwick Park, Sir Christopher Booth (Feb 15, p 372), supports the establishment of a new national centre for postgraduate education and research. Is any consideration being given to establishing this centre outside London? There would be several advantages to such a move. (1) It is surely sensible to set up the proposed centre in a region where the toll of disease is high, rather than in a part of the UK where almost every index of disease incidence is comparatively low. (2) If, as Sir Christopher argues, clinical research workers will increasingly need access to many body systems while investigating the molecular basis of disease, an association with a provincial university serving one NHS region and providing access to the full range of disease would be preferable to a centre in London where too many institutions already compete for the patients available. (3) The new centre would need to establish links not only with traditional medical subjects but also with other biological disciplines to maintain a flow of new ideas into medicine. This would be easier at one of the newer and smaller universities with single departments of biological science. (4) Modest academic salaries would provide a higher standard of living outside London, and this could go some way to attracting the best research brains back into academic medicine. Are there any reasons, other than inertia, for retaining this centre in London? Department of Pathology, Lancaster Moor Hospital,
JAMES A. MORRIS
Lancaster LA1 3JR
HYGIENE IN HOSPITAL KITCHENS
SIR,-Considerable publicity has lately been given to hygiene standards in National Health Service hospital kitchens. As a cleaning company specialising in hygiene maintenance and providing a service to central government, local authorities, and British companies we have been surprised by an apparent disparity in approach between two Government departments-namely, the Department of the Environment’s Property Services Agency (PSA) and the Department of Health and Social Security (DHSS). The PSA is responsible for the maintenance of many buildings occupied by Government departments and the military. In 1975 it published a Government specification on the maintenance of hygienic conditions in catering facilities under its care.Almost as a routine the PSA has retained specialist contractors to provide a hygiene maintenance service. In contrast, surprisingly few people in the NHS are aware of this specification and even fewer have applied its disciplines. Nor have I heard it mentioned by DHSS spokesmen in the recent spate of publicity. Whilst I would not claim (nor, I think, would the PSA) that use of this specification automatically guarantees clean kitchens, its application clearly denotes a genuine awareness of the importance of proper hygiene standards. One Government Department seems to be much more aware of a fundamental problem and the means of controlling it than another. Is this yet another instance of one Department not knowing what the other is doing? Surely when lives could be at risk there should be collaboration between Departments. For anyone in the NHS or outside it, wishing to have a copy of the specification I am sure the PSA would be glad to help, or we will. Indepth Hygiene Services Ltd, Sandown Lodge,
A. R. NORMAN
Epsom, Surrey KT18 7QY Department M&E
of the Environment
in your Feb 1 issue (p 281) states that "since food open to distortion by the manufacturer... every effort must be made to get it right before it becomes mandatory". Manufacturers go to great lengths to check their labelling against the requirements of the law before selling, and they frequently consult with their local authority’s trading standards department, which may refer the matter to the Local Authorities Co-Ordinating Body on Trading Standards. We cannot be held responsible for what the law says. We would agree that mandatory fat labelling alone may lead to undue emphasis on fat-which is why we have argued that the other three major elements of nutrition should be added alongside where fat has to be declared. But labelling is not the whole answer: it needs education as well.
SiR,-A
note
labelling is
5 Red Posr Hill, London SE21 7BX
1.
FOOD LABELLING
Property
Services
Agency.
Standard
specification
142, March, 1975: Hygienic cleaning of kitchens and catering equipment.
Food & Drink Federation, 6 Cathenne Street, London WC2B 5JJ
D. M. WALKER
CASSAVA TOXICITY is used as a main source of energy, it SIR,-Wherever would be sensible to use the protein in the leaves. They are used more widely than Dr Hall suggests (Jan 11, p 95). Scepticism may be justified about the claim that 500 g of leaves are often eaten daily in Zaire;l evidence for 200 g is firmer, and such an amount should supply 5-10 g protein daily.2Despite the chronic fuel shortage in regions where cassava is grown, prolonged boiling is the usual method of removing hydrogen cyanide (HCN).3,4 But HCN and its precursors are soluble in water. There is no reason to think that more fuel would be used if the leaves were boiled briefly in a considerable volume of water, squeezed by hand, and boiled again. The second cooking water would be discarded also. Negligible HCN would probably remain, though this assumption needs experimental verification. Minerals, vitamin C, and the B vitamins would be removed, but protein and (3-carotene (provitamin A) would remain in the boiled leaf. An alternative procedure would be pulping and pressing, and then curdling the expressed juice to make edible leaf protein.55 Unfortunately, yields from cassava leaves, taken when the tubers are harvested, have been smaller than from many other species of leaf. There are, however, many thousands of cassava varieties. Perhaps cassava varieties will be found from which leaf protein extraction is more satisfactory. As a result of encouraging feeding experiments in India, Nigeria, and Jamaica, leaf protein is now in small-scale but regular use in five or six countries. cassava
Rothamsted
Experimental Station, Harpenden, Herts AL5 2JQ
N. W. PIRIE
1. Terra GJA. The significance of leaf vegetables, especially cassava, in tropical nutrition. Trop Geogr Med 1964; 16: 97. 2. Lancaster PA, Brooks JE. Cassava leaves as human food. Econ Bot 1983; 37: 331. 3 Raymond WD, Jojo W, Nicodemus Z The nutritive value of some Tanganyika foods II: Cassava E Afr Agric J 1941; 6: 154. 4. Caldwell M, Gim-Sai Y The effect of cooking method and storage on the ascorbic acid content of Malaysian leaf vegetables. Ecol Fd Nutr 1973; 2: 35. 5. Pirie NW. Leaf protein and other aspects of fodder fractionation. Cambridge. Cambridge University Press, 1978
DIGESTIBILITY AND PROTEIN FROM LEGUMES
SIR,-Your Dec 7 editorial on the new FAO/WHO report on energy and protein requirements points out that it is no longer thought necessary to take into account the quality of the dietary protein. However, a correction is needed for digestibility since this is low in vegetable sources. This applies particularly to legumes, a useful source of protein in many developing countries and one which could probably be further exploited for infant feeding, but which have a digestibility as low as 70-75% compared with 9507o for many other foods. True digestibility is measured by the difference between endogenous output of nitrogen (measured on a protein-free diet) and total nitrogen excretion. It has been suggested that the increase after feeding dietary fibre (and legumes provide fibre) is of endogenous