Borderline Deficiency Diseases

Kai Tiaki : the journal of the nurses of New Zealand, Volume XV, Issue 3, 1 July 1926, Page 101

Borderline Deficiency Diseases

Agnes Bennett

A Lecture delivered to the Massage Association, at the Nurses' Club, Wellington, June 10th, 1926,

by Dr.

Recent dietectic discoveries promise to be of great importance m the development and maintenance of health of our race. In travelling through America I was impressed with the attention paid to nutrition. Many restaurants distribute pamphlets on nutrition to their clients and also state the food value m calories of every item on the menu. When one took time to study these one was impressed with the ease with which one could eat too much. It is, alas, true that half or more of our people eat too much and the remainder too little. In spite of this gastric troubles are all too common m the States — probably more common than among us. But calorie value is not the only essential m a healthy and sufficient diet — the old-time proteid, carbohydrate salts and water, do not represent all the essentials of diet. A new method of experimenting with diets has been introduced since the war, the so-called biological method, which means feeding animals with special diets and carefully observing the results. At first large animals like cows and sheep were the subject of experiment; now it is found that the shorter time of development of smaller animals, e.g., rats and mice, allows of more rapid testing, and one can watch the results of a diet even to the second and third generation. Some of these results were astonishing — it is found, e.g., that where there is definite deprivation of certain factors the animals constantly eat their young; also it has been practically established that some animals fed on undue proportion of proteid not only did not grow to full size but their progeny tended to die young or did not reproduce themselves. These experiments, among many other facts, also proved, that though the caloric value of

a diet may be sufficient that without certain so-called "accessory factors" most animals will develop diseases of which there are exact analogies m man.

Till lately these "accessory factors" or vitamines were looked on as mysterious substances that could not be classified or explained — they were looked upon as being m all probability like the "ferments" or enzymes m the stomach and they could not be separated to be analysed nor could they be synthetized. Now we are within measurable distance of elucidating their character and building them up from other substances with the aid of sunlight.

At present they can be separated into four different classes and they are classified m accordance with the effect they have on the bodies of animals. They are known as A, B, C and D, and the results of feeding animals on diets from which these are absent are known as the "Deficiency Diseases." The commonest of these are Rickets, a certain kind of opthalmia, Beri-beri (or Polyneuritis) and Scurvy, and possibly that other trouble little known to us but common m certain parts of Europe and America — Pellagra. Till lately we have only studied these diseases when fully developed, but the conditions which I wish to talk about to-night are the halfway stations, so to speak, towards them.

The vitamines themselves are all alike m that they disintegrate and disappear with prolonged heating and drying, but fortunately they vary a little m the amount of heating that they can stand. This is most unfortunate m modern civilisation, for it means that from all the tinned and preserved foods sold m such large quantities they are frigeration of food partly destroys

almost completely absent, and even rethem. Yet these vitamines are absolutely essential for our best development and our best health. Possibly the want of these was the main cause of the C 3 population of England demonstrated during the war. Followed to a logical conclusion we are brought up against the fact that a population must live m fairly close proximity to its foodproducing area, and if the British race is to maintain its prestige there must be a re-distribution of population. As the knowledge of dietetics becomes more widely disseminated the cry for fresh food must become more claimant — vegetables deteriorate m value as they lose m freshness, and the man who grows and cooks his own vegetables just as he and his family need them, can rightly claim a superiority m the diet he provides for his household. The more active the part of the plant or animal from which the food substance is derived the richer it is m vitamines, e.g., leaves are more active than seeds, as seeds, till they sprout, are storehouses. Liver, brain, sweetbreads, and other active glands are richer m vitamines than ordinary red muscle meat; whole fish such as whitebait, oysters, crabs, are better than ordinary white fish flesh.

Let us turn to the study of each vitamine separately. "A" is "fat soluble," i.e., it goes into solution m fats and oils. Deficiency of "A" in any marked degree causes a special variety of opthalmia and also rickets. These are common m the slum areas of large cities. The worst feature of rickets is a maldevelopment of bone resulting m stunted growth and twisted, misshapen long bones, because the bone is soft and badly calcified and bends with weight. The recently-discovered fat soluble "D" also plays a part m this disease, and the relationship of "D" with sunlight is most important. The horror of the disease only came home to me when I worked m Glasgow. I have seen a long-limbed bearded youth with limbs so twisted he could only propel himself across the floor like a ten-month-old baby. His legs were broken m four or

five places and set m splints m the hope of getting a functionating limb. I am thankful to be able to say that rickets is being gradually stamped out m Britain, and now that the cause is known we hope that one day it may be as rare as scurvy. Quite one-half, if not more, of the children brought to the outpatients' departments of the large city hospitals are ricketty — one sees it rarely m New Zealand. Ido notice one or two ricketty children m the streets of Wellington, but they are mostly the children of foreigners. Because "A" and "D" are preventive of this they are called anti-rachitic — it is quite probable that our good butter largely saves us from rickets. The sources of "A" and "D" are milk (careful pasteurisation does not destroy "A"), butter, eggs (yolk), animal fats, kidneys, sweetbreads, brains, lettuce, spinach, cabbage, carrots (especially very young carrots uncooked), fresh ripe fruit, and also cod liver oil. "B," which is soluble m water and therefore often lost m cooking, is much more difficult to get m sufficient quantities. Formerly it was thought that these substances were probably like ferments and therefore a very small amount of them sufficed for almost any amount of work. This is disproved. The diet must be balanced and it appears as if no amount of food over a certain proportion of "B" did much good. In an experiment with rats where (1) a deficient all-round diet was provided, the rats grew and developed normally and reproduced themselves; (2) with a diet rich m proteids and carbohydrates and the same amount of vitamine the rats developed irregularly and especially showed bad development m their teeth, and their progeny tended to die young; (3) with a diet rich m both the rats became much stronger and bigger and more prolific than m (1) and (2). Rats deprived of vitamine "B" develop a shyness, nervousness and a restless tension like our highly-strung children, and finally they go on to a neuritis analogous to "beri-beri" m man which is really a multiple — or polyneuritis.

I did not realise the ravages of beriberi till last year, when during my return journey to New Zealand I picked up a Singapore paper and saw that beriberi was the second commonest cause of death m the Straits Settlements. The cause of this tragic death-roll is that the natives have taken a liking to rice as eaten by the Western nations — what is technically called "polished" rice, and this is almost their only food. "Polished" rice has had both husk and germ taken off the grain. The natives after removing the grain from the ear "stamp" it: this means pounding it m strong wooden troughs or vessels, and then only the husk is taken off — the dark-coloured germ is left attached to the white part or endosperm. This gives the rice a browny-red hue as contrasted with our white rice, and it is known as red rice. To cure beri-beri the natives are given red-rice and also "rice polishings" which consist principally of the germ. The over-refinement of the food has reduced it m nutrition value.

We are m almost an analogous position with regard to our flour. I say "almost" because fortunately for us flour is not our only food, but rice is almost the only food m many Eastern countries. Our white flour is wheat without germ, and with the germ has gone all our valuable vitamin "B," but yeast contains quite a good proportion of vitamin "B" and some of the deficiency is thus made up. Certain kinds of bread are made without yeast — a kind often termed "Vienna" bread — very palatable but much poorer from nutrition standpoint than yeast bread.

We may not suffer from beri-beri, but are not some of us "borderline cases"? It is now established that the first sign of "B" deficiency is an atrophy of the nerves and the wall generally of the bowel bringing about an intestinal stasis and along with this an absorption of substances that never should be absorbed. Certainly part of the very common complaint, constipation, is due to this deficiency, and quite likely also the nervous tendency of our

nervous children, who among other weaknesses are so liable to contract T.B. We may yet find a method of building up our nervous children into adults who are more fit to stand the wear and tear of civilisation — or if not eradicating the weakness m them we may succeed m making them the parents of a stronger generation. There are other diseases that come to us from faulty absorption from the alimentary canal — among others arthritis and high blood pressure, and possibly, goitre. ■ It is folly to say we are eating the same as our forefathers — think of the old windmills and watermills, the wrecks of which one sees everywhere m the old countries. Most of these meant that the local farmers were getting their grain "milled" m the locality m which it was eaten, and there was no necessity to refine it for export. We could not easily ship whole wheat flour overseas because the germ contains an oil which may become rancid. Because absence of this "B" is actually known to be the cause of polyneuritis it is described as "antineuritic, water-soluble *B\" As with "A", it is the most active cells that contain the vitamine — the cells immediately under the skin of most fruit and vegetables are the active cells which keep up respiration: we should not peel fruit or vegetables more than is absolutely necessary. Potatoes should be cooked m their skins and the thin outer cuticle can be taken off if not eaten, but m itself this cuticle is clean after the boiling and not unwholesome. Steaming is a far better method of cooking than boiling. The other sources of "B" are the pulses — i.e., peas, lentils, all nuts and leafy vegetables, especially lettuce and celery eaten raw. Tomato, cabbage, spinach and very young carrots have a high percentage of "B," and remembering that "B" is water-soluble we should if possible cook leafy vegetables m minimum amount of water. Spinach, cabbage and even cauliflower can be cooked with no water but just a little fat, and long boiling is not an advantage. There are many people now who add finely-chopped cabbage to

salads, and it is a wise plan. Brain, liver and sweetbread all contain some "B," and so does milk, but not m very large amounts. Unfortunately the majority of these foods are not those that appeal to children, but at all events milk is a sheet anchor with them.

Egg yolk is valuable and also yeast, which is a fundamental part of "marmite." Germinated pulses are of great value, and most people have heard of the wonderful benefit that accrued to our soldiers m Mesopotamia who were suffering very badly from the want of fresh foods from the bright idea of the man, who, instead of issuing a ration of dried peas* caused them to sprout first. It is easily done by keeping them moist m a sieve and cooking when the little rootlets are about three-quarters of an inch long.

The third of our series "C" is "antiscorbutic water-soluble *C\" It was the want of this that caused the scurvy among the old navigators. I saw lots of cases of it m the Balkans during the war, and it was only then I realised what a serious disease it could be. Apart from the intense and wearing pains, especially m the legs, the haemorrhages into muscles were so big that they seriously injured the muscle fibres and the resulting cicatricial tissue so impaired the muscle that many men became permanently disabled. The Italian army knew wisdom when it issued a ration of lemons or oranges, and when we could barter other goods for these we considered we were lucky, for lemon and orange juice are worth their weight m gold to the sufferer from scurvy. A curious case of scurvy m a Plunket fed baby came to my notice here: the very conscientious mother took enormous pains over the preparation of the food and the child appeared to be gaining weight and was passed by the nurse as healthy when it developed an acute bronchitis and I was summoned. To my surprise, I found the child suffering from scurvy, and it was with some difficulty I discovered that m her wish to be accurate the mother was sterilising the orange * juice as well as

the milk, thereby destroying the very vitamines for which the orange juice is given. The want of fresh food told on us all very seriously m winter m the Balkans during the war — few of us escaped without boils and many, m spite of a healthy, open-air life became anaemic and flabby, a sort of mild "war oedema." The first leaves to appear m early spring were the grape leaves, and I fear many a peasant thought we were cruelly punishing his vines, when we insisted upon having them. We boiled them like spinach, and undoubtedly they made a great change for the better m both the patients and staff of the hospital. Another interesting occurrence during the war took place among the prisoners m Russia. A batch of English prisoners could not make up their minds to take the horrible cabbage soup dealt out to them, so they avoided it altogether; they became the victims of scurvy and other troubles, while their fellow-prisoners maintained quite a fair standard of health. It proves to us that probably valuable food factors get into the water that vegetables are boiled m: let us copy the French, who never throw away vegetable water but make their soup stock with it.

It almost seems as if we must "catch sunbeams" and put them inside ourselves. Milk that comes from stall-fed cows is not as good an anti-scorbitic as milk from the cow fed m the open. Think of this deprivation m the children of Great Britain m winter; we hardly possess stall-fed cows m New Zealand. The sources of our "antiscorbutic 'C " then are juices of fruit, fresh vegetables, carrot and tomato juice are specially potent; sun-dried fruits, e.g., raisins and dates, these latter are also valuable for the iron they contain. An Eastern adage is, "Eat raisins and discard the rouge pot" ; but unfortunately the raisins must not be heated to the extent necessary to cook a pudding or cake — it is the "sun drying" that preserves them with very little destruction of their food value.

Vitamine "D" is particularly interesting because it has been made with the aid of the ultra-violet rays of the sun from a substance called cholesterol. We have this substance m small quantity both m our livers and skins. "D" is strongly "anti-rachitic." This may be the explanation of the well-known fact that the deprivation of sunlight predisposes towards rickets. I would just add one word about the value of the direct sun's ray, and by this I mean sunlight that has not come through glass. Glass cuts out the ultra-violet rays ; never be satisfied with glassed-in verandahs especially for babies. We are too apt to cut off sunlight m the attempt to cut off wind. Ultra-violet rays will probably prove to be much more important than we yet know: they certainly have some kind of stimulating effect on the metabolism of our bodies and the recent discoveries about their action on cholesterol seems to be a partial explanation of their importance.

The thoughts and ideas that I should like you to carry away from this lecture can be summed up as follows: —

(1) That though we have not among us the Deficiency Diseases we have minor degrees of them that are sapping the vitality of the race.

(2) That to think just a little of these valuable vitamines can do all that is required is wrong: the amount required is m a direct proportion to the amount of food we eat. It is better to take less food altogether than to take more than the vitamines m that food can deal with. (3) That we require a mixed diet which is not too refined, and must include fresh food, especially leafy vegetables and milk (the so-called "protectives"). (4) That the effects of bad diet extend to succeeding generations. (5) That we can readily improve our diet by cooking root vegetables without peeling them ; by eating more raw fruit and vegetables ; by using more of the gland substances, e.g., sweetbreads, brains, etc. ; by having a garden and growing our own vegetables especially, for instance, cress and lettuces. (6) That the nearer we get to soil and sun the better developed we are likely to be.