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USDA, Agricultural Research Service, Grand Forks Human Nutrition Research Center, Grand Forks, ND 58203
3To whom correspondence should be addressed. E-mail: leslie_klevay{at}und.nodak.edu.
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ABSTRACT |
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 TOP ABSTRACT LITERATURE CITED |
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KEY WORDS: • nutrition survey • ICNND • physical signs of nutrition status • beriberi • pellagra
Nutrition surveys are designed to detect malnutrition by a variety of anatomical, chemical, and physiological criteria that are related to estimates of nutrient intakes and assessments of public health. Related information on agriculture, demographics, economics, food technology, etc., is important to the success of the survey. Successful surveys depend on a wide variety of talent and organizational skill. The people surveyed should be a good statistical sample of the population as a whole. The numerous medical nutrition surveys conducted by the Interdepartmental Committee on Nutrition for National Defense (ICNND) addressed the goals of numerous national and international organizations so that conditions leading to malnutrition could be identified along with means of improvement (1).
The ICNND surveys were based on modern nutritional thought that evolved from concepts developed as scurvy (2), beriberi (3), and pellagra (4) were simplified from their seemingly multifactorial origins (5–7). Pellagra probably was most important in the development of the surveys, because it had been an enormous problem in the United States (8–9), and the work leading to the realization that niacin was both curative and preventive was done in the United States (4). In 1917, the death rate for pellagra in some cotton-mill villages in South Carolina was approximately one-half that for ischemic heart disease in the United States in 1975 (10).
Joseph Goldberger, M.D., was a complete epidemiologist and nutritionist although his background was in infectious disease (11). His multifarious talents led him to correct inferences after examining vital statistics and patients at the bedside. He designed community surveys and clinical trials, evaluated sanitary and social conditions, and experimented with animals. Because few involved in medical and nutritional research have either the interest or the ability to do all of these things, surveys rely on many specialists for success.
Reading Goldberger’s original articles provides a realization that subtle changes in health and metabolism occur before clinical disease is obvious. He relied on the appearance of skin lesions to corroborate the induction of pellagra by diet at a time when laboratory diagnosis was impossible (12).
Dann and Darby defined 5 zones of nutriture (13,14): 1) saturation, 2) unsaturated but functionally unimpaired, 3) potential deficiency disease, 4) latent deficiency disease, and 5) clinically manifested deficiency disease. Laboratory tests usually are used to assign an individual to one of the zones. If intake of a nutrient is insufficient for a long time, a person will move toward, and may reach, zone 5. When body stores are depleted, biochemical changes occur that lead to changes in physiology and morphology, which can be detected as deficiency disease. Emphasis in surveys is on the latter 3 zones.
The initial phase of a medical examination comprises a history and a physical examination, which may reveal some nonspecific physical signs. Laboratory tests then are used to augment the senses of the physician to obtain a correct diagnosis, to evaluate prognosis in a patient with known disease, to detect early manifestations of disease in an apparently healthy person, to assess therapeutic interventions, and to predict future illness. Good tests are positive in diseased people and are negative in healthy people (15); this statement applies to physical signs as well as to laboratory tests.
Galen and Gambino (15) discuss the impossibility of having laboratory tests that are both highly sensitive and highly specific. They illustrate how a higher hemoglobin value can improve sensitivity in the diagnosis of anemia at the expense of specificity. In the survey of Panama, if we were in doubt that a survey subject had marginal redness of the gums (potentially a sign of scurvy), a pale tongue (potentially a sign of anemia), or dermatitis (potentially a sign of pellagra), etc., we would consult one of the other medical examiners. If 2 examiners agreed that a sign was positive, it was recorded as positive. If there was disagreement between examiners, the sign was recorded as negative. This procedure introduced an intentional bias toward larger lesions that improved sensitivity for the survey as a whole. Because there is a fairly extensive literature on differences between observers in the reading of electrocardiograms and x-rays, etc., it is not surprising that skilled examiners may differ.
Physical signs (16) of malnutrition recorded in the surveys were interpreted later in the light of results of the laboratory tests and other data to improve the overall accuracy of the survey. Sometimes comparison of signs with laboratory data can provide new knowledge (17).
In the context of ICNND and its origins, angular oral fissures were common among Chinese troops in 1945 (18) and Republic of Korea Army troops in 1953 (19) when examined by J. B. Youmans, M.D., and H. R. Sandstead, M.D., respectively. The relation of angular oral fissures to riboflavin deficiency was reported by Sebrell and Butler in 1938 (20). Later, in 1953, Vilter et al. (21) reported an association with pyridoxine deficiency. Angular oral fissures also are found with acrodermatitis from zinc deficiency (22–24). The apparently dissimilar origins of this lesion may be the result of the essentiality of zinc for the activity of flavokinase and pyridoxal kinase (25). The association of one lesion with deficiencies of 3 different nutrients illustrates the lack of specificity of physical signs.
It generally is agreed that accuracy in measurement is desirable. When we were being instructed in survey methods before we approached the equator, Edwin B. Bridgeforth, M.S., told us that on a statistical basis, too many blood pressure readings end in the digits 0 or 5, although sphygmomanometers are calibrated in units of 2. He also said that some individual examiners have a statistical tendency, e.g., to record readings that end in 2 or 4, etc., and admonished us to be as accurate is possible.
Accuracy and sensitivity are for naught if people do not come to be surveyed. I remember a town in eastern Panama where we had far less than the usual number of examinees; the annual melon festival had been the previous day and many were still celebrating or were recovering. These absences decreased the reliability of the statistical sample. Some of us did the Harvard step test on this slow day to give us the experience of those being surveyed.
Finally, I have a fairly extensive collection of close-up photographs that I have taken of various lesions related to nutritional deficiency. Most of these were taken in Panama, but many were taken in hospitals and clinics in the United States. You do not have to travel by DC-3, motorized canoe, or Land Rover5 to find evidence of malnutrition (26–27), even if you do not count ischemic heart disease, obesity, and osteoporosis as malnutrition.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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2 The U.S. Department of Agriculture, Agricultural Research Service, Northern Plains Area, is an equal opportunity/affirmative action employer and all agency services are available without discrimination.
4 Leslie M. Klevay worked as a physician in the survey of the Republic of Panama and co-authored the clinical report with Harold H. Sandstead. He later instructed physicians how to do nutritional examinations in five states of the Ten State Nutrition Survey in the U.S. and advised the National Center for Health Statistics about appropriate laboratory tests for the earliest phases of HANES. Samples for his first paper on copper (28) were collected in Panama; see (29) for a map of survey locations. He is a Fellow of the American Society of Nutritional Sciences and of the American Association for the Advancement of Science.
5 Names are necessary to report factually on available data; however, the USDA neither guarantees nor warrants the standard of the product, and the use of the name by USDA implies no approval of the product to the exclusion of others that may also be suitable.
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LITERATURE CITED |
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TOPABSTRACTLITERATURE CITED |
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1. Interdepartmental Committee on Nutrition for National Defense (1963) Manual for Nutrition Surveys 2nd ed. 1963 U.S. Department of Health, Education and Welfare, Public Health Service, NIH, U.S. Government Printing Office Washington, DC.
2. Lind, J. (1980) A Treatise on the Scurvy (1772) 3rd ed. 1980 The Classics of Medicine Library Birmingham, AL. S. Crowder and Co., London, Special Edition.
3. Williams, R.R. (1961) Toward the Conquest of Beriberi 1961 Harvard University Press Cambridge, MA.
4. Terris, M. (1964) Goldberger on Pellagra 1964 Louisiana State University Press Baton Rouge, LA.
5. Klevay, L. M. (1984) The role of copper, zinc, and other chemical elements in ischemic heart disease. Rennert, O. M. Chan, W. Y. eds. Metabolism of Trace Metals in Man 1:129-157 CRC Press Boca Raton, FL. .
6. Klevay, L. M. (1990) Some environmental aspects of ischaemic heart disease. Environ. Management Health 1:9-17.
7. Klevay, L. M. (1977) The role of copper and zinc in cholesterol metabolism. Draper, H. H. eds. Advances in Nutritional Research 1:227-252 Plenum New York, NY. .
8. Elmore, J. G. & Feinstein, A. R. (1994) Joseph Goldberger: an unsung hero of American clinical epidemiology. Ann. Intern. Med. 121:372-375.
9. Rajakumar, K. (2000) Pellagra in the United States: a historical perspective. South Med. J. 93:272-277.[Medline]
10. Klevay, L. M. (1997) And so spake Goldberger in 1916: pellagra is not infectious! J. Am. Coll. Nutr. 16:290-292.
11. Klevay, L. M. (1997) Pellagra is not infectious! (Goldberger, 1916). J. Nutr. 127:1032S-1034S.
12. Goldberger, J. & Wheeler, G. A. (1964) The experimental production of pellagra in human subjects by means of diet. Terris, M. eds. Goldberger on Pellagra 1964:54-94 Louisiana State University Press Baton Rouge, LA. .
13. Dann, W. J. & Darby, W. J. (1945) The appraisal of nutritional status (nutriture) in humans; with especial reference to vitamin deficiency disease. Physiol. Rev. 25:326-346.
14. Klevay, L. M. (1987) Dietary requirements for trace elements in humans. Brätter, P. Schramel, P. eds. Trace Element-Analytical Chemistry in Medicine and Biology 4:43-60 Walter de Gruyter Berlin, Germany. .
15. Galen, R. S. & Gambino, S. R. (1975) Beyond Normality: the Predictive Value and Efficiency of Medical Diagnoses 1975 Wiley New York, NY.
16. Interdepartmental Committee on Nutrition for National Defense (1963) Clinical and dental apraisal of Nutrition. Manual for Nutrition Surveys 2nd ed. 1963:31-83 U.S. Department of Health, Education and Welfare, Public Health Service, NIH, U.S. Government Printing Office Washington, DC.
17. Klevay, L. M. (1992) Clinical signs of iron deficiency. Eur. J. Clin. Nutr. 46:607-608.[Medline]
18. Pollack, H. (1956) Studies on nutrition in the Far East. I. the problem and outline of the test protocol. Metabolism 5:203-218.[Medline]
19. Sandstead, H. R. & Koehn, C. J. (1963) Nutrition of the Korean army. Field studies May-June 1953. Am. J. Clin. Nutr. 13:25-34.
20. Sebrell, W. & Butler, R. (1938) Riboflavin deficiency in man. Public Health Rep. 53:2282-2284.
21. Vilter, R. W., Mueller, J. F. & Glazer, H. S. (1953) The effect of vitamin B6 deficiency induced by desoxypyridoxine in human beings. J. Lab. Clin. Med. 42:335-357.[Medline]
22. Kay, R. G., Tasman-Jones, C., Pybus, J., Whiting, R. & Black, H. (1976) A syndrome of acute zinc deficiency during total parenteral alimentation in man. Ann. Surg. 183:331-340.[Medline]
23. Arakawa, T., Tamura, T., Igarashi, Y., Suzuki, H. & Sandstead, H. H. (1976) Zinc deficiency in two infants during total parenteral alimentation for diarrhea. Am. J. Clin. Nutr. 29:197-204.
24. Okada, A., Takagi, Y., Itakura, T., Satani, M. & Manabe, H. (1976) Skin lesions during intravenous hyperalimentation: zinc deficiency. Surgery 80:629-635.[Medline]
25. McCormick, D. (2002) Micronutrient cofactor research with extension to applications. Nutr. Res. Rev. 15:245-262.[Medline]
26. Kertesz, S. G. (2001) Pellagra in two homeless men. Mayo Clin. Proc. 76:315-318.[Abstract]
27. Friedli, A. & Saurat, J. H. (2004) Images in clinical medicine. Oculo-orogenital syndrome-a deficiency of vitamins B2 and B6. N. Engl. J. Med. 350:1130.
28. Klevay, L. M. (1970) Hair as a biopsy material II. Assessment of copper nutritive. Am. J. Clin. Nutr. 23:1194-1202.[Medline]
29. Klevay, L. M. (1973) Hair as a biopsy material. 3. Assessment of environmental lead exposure. Arch. Environ. Health 26:169-172.[Medline]
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