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Department of Obstetrics and Gynecology The University of Texas Medical Branch, Galveston, TX
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ABSTRACT |
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 TOP ABSTRACT LITERATURE CITED |
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KEY WORDS: • nutrition surveys • ICNND • NIH Office of International Research • Centers for Disease Control Nutrition Surveys • Alaska
Born of the Korean War during the Eisenhower Administration, the Interdepartmental Committee on Nutrition for National Defense (ICNND) was allowed to die at the end of the Vietnam War during the Nixon Administration. Under three different names (ICNND; Nutrition Section, Office of International Research; and Nutrition Program, National Center for Chronic Disease Control), it conducted 48 nutritional surveys, of which 20 were in North American. Ten focused on military personnel, 18 focused on civilians, and 20 involved both the military and civilians. Nutrition surveys were done "on an invitation only" basis by bilateral teams of nutritional professionals. Team members came from U.S. health departments, universities, military forces, and international agencies. Over the 15 y, 100+ scientists participated in these surveys, with over 60 being involved in two or more. I was around at the beginning (Korea) and at the end (Texas). It was an experience I will never forget, I learned so much and carried it over to my other career of academic obstetrics and gynecology.
Of the 20 North American surveys involving the ICNND, 14 were conducted within the continental United States and 6 were done in partnership with the Institute for Central America and Panama (INCAP) in Guatemala City, Guatemala, Central America. Three native populations were studied in Alaska in 1958 and in Montana in 1961. As the ICNND’s swan song, 10 states, including 1 major city in the United States, were surveyed over a 24-mo period from June 1968 through July 1970. Each of these surveys was performed in partnership with federal, state, and municipal health agencies or academic health universities. They all used the procedures developed by ICNND as published in the "Manual for Nutrition Surveys" (1,2) The findings and the recommendations were published as U.S. Government Printing Office reports (3–7). In addition, the Central American surveys provided the basis for 45 scientific publications and 10 theses, which are listed in the summary report (6) and one scientific publication concerning nutrition of Alaskan Eskimos (8). A recent search of PubMed found 52 citations to the Ten State Nutrition Survey. Nine report data from the survey (9–17) and the remainder cite the survey as a basis for research. These reports are a rich source knowledge concerning the nutritional health status of samples of the North American population from 1958 to 1970. They provide data on representative population samples about the nutritional health of the people and include carefully considered recommendations to address the nutritional problems. They gave direction to future public policy, to educational preparation, and to individual action (18). From these data came major changes in the commodity food, food stamp, and the school feeding programs, as well as the development of our WIC (Women Infants and Children) program. By the early 1970s, we knew much about the nutritional health of our people. In 2004 how do we compare?
The Alaska survey (3,8) was done in March 1958, when it was still winter and the annual dog race (Iditarod) was being run. There were no mosquitoes. Over a 3-wk period, Eskimo and Indian villages were visited, and their native inhabitants were examined during weeks 1 and 3. During week 2, the men were examined while participating in the annual National Guard Training Exercise at one of our U.S. Army military bases in Alaska. A total of 1500 people were examined, 53% were women, children, and elders living in small Eskimo or Indian settlements. The remaining 700 were young men from these communities who were attending National Guard training.
The Montana Indians surveys (4,5) were conducted from late August to late October of 1961. The first snow fell that year in Browning and Cutbank in August. University of Texas Medical Branch-Galveston staff and students and health and nutrition personnel from the Army Medical Laboratory in Denver, CO did the surveys. For many Galvestonians, it was their first experience with snow, their first northern lights, and they were away from home base while Hurricane Carla lashed the Gulf Coast, disabled health and academic operations at the medical school, and caused serious damage to homes through out the area. The Denver-based team members completed a follow-up evaluation survey in the spring of 1962. The Montana Indians were drawn from hospital clinic attendees, well-baby and prenatal clinics, as well as school children from the regional Bureau of Indian Affairs Schools. Over 2000 individuals were evaluated.
The Central American survey (6) activities began in February 1965 in Guatemala. The survey of the final country, Panama, was completed by Easter of 1967. Two countries were evaluated each year during 3 mo each of survey activities. Directors of the survey were Drs. Guillermo Arroyave and Werner Ascoli from the Institute of Nutrition for INCAP. INCAP provided the key field and laboratory personnel, as well as statistical and logistical support. Dr. Walter Unglaub in 1965 and Dr. William J. McGanity in 1966–1967 directed the U.S. contingent that came from U.S. health related academic and government agencies. In each country, 30–40 localities were selected in stratified manner, 40% rural, 30% small town, and 30% major urban centers. In each of the 190 localities, 20 families were randomly selected. Military personnel or police were also examined but were not included in the published regional summary. Over 15,000 civilian individuals participated in these studies.
The Ten State Survey (7) began field activities in Texas in late May 1968 (19). During the 6 mo before the survey "vested interested parties" expressed concerns as to how the population sampling and the survey operation would be implemented. Remember, the Vietnam War was in chaos; Lyndon Baines Johnson gave his "I chose not to seek election" speech at the end of March 1968, and Hunger USA (20) had just been published. Before the year 1968 was closed, five state surveys had begun; another five were started in 1969; and the final one was done in Massachusetts in 1970.
Surveys were from 4- to 6-mo duration. Sometimes work was scheduled to coincide with significant local events. For instance, in the lower Rio Grande Valley of Texas, studies were done in November 1968 and again in April 1969 to evaluate migrant workers families during their comings and goings to and from their home bases. In the New York State survey, the field team was immobilized in Buffalo for 10 d by a 30-inch snowfall.
In 1954 health affairs among Native Americans were transferred from the Bureau of Indian Affairs to the U.S. Public Health Service. During summer of 1955, a nutrition survey of the Navajo Indians was conducted for the Arizona Department of Health (21). The Alaska (3,8) and the Montana (4,5) surveys were conducted 4–6 y later. In 1964 and 1965, the Civil Rights Act, Medicare and Medicaid had become law. In Galveston 1967–1968 was the 1st y of public school integration, voluntary for us, but court ordered throughout most of Texas. Our Texas nutrition survey team was multi-ethnic and bilingual. It created quite a stir and some tension as we all ate together and slept at the same hotels during our travels about the state.
In 1967 at Lyndon Baines Johnson’s urging Congress authorized that a nutrition survey be conducted of the population of the United States to ascertain the extent of our country’s malnutrition. The Ten State Sample was designed by the National Center for National Health Statistics (7). The design was a 3-step random sample of 20–30 families who lived in enumeration districts that fell in the lowest quartile of each state’s economic stratum. The actual sample turned out to be bimodal, with 5 states below and 6 states above the national poverty ratio of 1.0. Participation rates of selected families ranged from 70% to as low as 46%. Participant families had incomes ranging from <$2000 (24%) per year to >$8000 per (20%) year. A few families reported annual income exceeding $40,000 per year. This was a working not a welfare population.
The methods of sampling the populations studied by the ICNND, with the exception of the Ten States and the Central American studies, would probably not pass serious statistical scrutiny. Ethiopia (22), surveyed in 1958, was a mob scene until we requested that each local community governor provide a random sample of 200 men, 200 women and 200 children for evaluation. Then, we scheduled our arrival to coincide with their weekly market day.
A constant challenge for all of the North American surveys was the logistics of providing team and equipment transportation to and from examinations sites, housing, and feeding (23). How do you find young civilian male drivers without a moving traffic violation written in the past 3 y? How do you find motel housing for > 40 people in San Antonio during the 4th of July weekend, when "Hemisphere" has just opened? How do you get all your laboratory specimens stabilized and transported from the field to the base laboratory that is 400 to 800 miles away, be it in Texas, Montana, Honduras, or Ethiopia? Can you imagine bus drivers and airline crews carrying an icebox in their cockpit each morning or afternoon, from north, south, or west Texas, back to Houston or Galveston, sometimes even including en route transfer in Dallas or Austin? In the more remote parts of Honduras and Nicaragua, the only way to cross small rivers was by barge ferry. The dried up riverbeds were the highways. We learned how layers of newspapers will maintain cold, are excellent separators of racks of specimens, and will prevent hemolysis. We also learned to accommodate families and to maximize participation by providing transportation to and from the work site and by working from 1600 to 2400 h.
Team composition had to be different during the Ten State Surveys (7). For ICNND surveys, we had well-trained professionals working alongside host country health professionals, most of whom were fluent in English. Robust operational support came from one or more branches of the host country’s military or health agencies. Work facilities and vehicle transportation were also provided.
For the Ten State Survey, three surveys were contracted to academic health centers in Texas, Louisiana, and Washington State. The remainder were directed and conducted by state health departments. Four of the directors had prior experience as members of ICNND surveys. Staff from earlier surveys participated in surveys of later states and helped train staff for those studies. Logistical support from federal, state, and local health agriculture and educational agencies was crucial. However, on a day-to-day basis, we were on our own for operations in the field and at the base laboratory.
In addition to our 25 survey professionals in Texas, there were 63 other health- and nutrition-related personnel. Fifty-one were undergraduate or recent graduates of state universities; 80% of our team were Texans; 35% were bilingual in Spanish and English. They were teenagers and Medicare recipients. They were black, brown, and white. We had 6 physicians and 3 dentists. The summer and the fall of 1968 was a time we have all remembered with pride. It was truly a team effort.
At each examination site we had 10 workstations for the evaluation process, from registration to biochemistry (19). Initially, each member of the team was trained to do a specific task. However, as time went on, by mid July 1968, we moved to a two-field team operation, and all of us learned at least one other aspect of the field operation. We all ended up with two new skills be it "door knocking," driver, audio–visual tester, or registrar. We followed the procedures, definitions, and standards as outlined in the ICNND Manual for Nutritional Surveys (2).
Consultants developed the ICNND manual after evaluation of existing American, WHO, and FAO guidelines for nutrition assessment. Standard procedures and definitions were prepared for all phases of nutrition surveys. After completion of a survey, reports were developed that began with an executive summary and recommendations, presented detailed findings and definitions, and ended with an appendix of additional pertinent information and references.
In several surveys, we added special studies that were easily fitted into the flow of the fieldwork. Parasitologic, hematologic, bone age, cardiovascular, and diabetic studies were done in Central America. Hearing and vision testing were added in Texas. Excess blood, serum, and urine samples were frozen and stored for more detailed analysis and further studies. Water samples from the 124 Texas examination sites provided a cross section of the state’s water fluoride and lithium concentrations that were correlated with the incidence of dental caries and certain types of mental illness (24–26). When a given clinical finding in children appeared to be significant, we expanded our number and verified occurrence rates. By visiting local schools, one could give all of the children a quick screening for enlarged thyroid or angular fissures of the mouth. With the international surveys, the team leaders of each section had a major role in the analysis, interpretation, findings, and recommendations. Final sign-off was by the ICNND Committee, and its consultant panel. All 38 ICNND/Office of International Research surveys permit some comparisons. In contrast, the Ten State survey’s implementation, operations, analysis, interpretation and recommendations from planning to publication had a thick layer of federal executive and congressional oversight (27). As far as I am aware, an executive summary with a list of specific recommendations was not published.
In the field, data were collected on McBee Cards for the first 10 y and later the data were entered on IBM forms that were optically scanned and sorted by machine.
I must acknowledge Edwin Bridgforth of Pickens, MS. Ed was the primary statistician for the ICNND though out its existence. He first worked with William J. Darby at Vanderbilt University Medical School in Nashville, TN, and later with me at the University of Texas Medical Branch in Galveston, TX. Ed was responsible for the sections concerning experimental design and statistics in the Manual for Nutrition Surveys (2). He supervised processing of all data from the ICNND surveys through 1969, including data from the Texas survey, and his "seal of approval" was essential for all reports. All of us knew that this was the key to the validity of our findings. He was our "most valuable team member."
Christine Wilson and her staff at the ICNND Secretariat provided writing of reports and editorial review. Each country’s report was published by the U.S. Government Printing Office and ran from a 100 to 900 pages.
Over the 17 y, 35 foreign governments invited the ICNND to conduct nutritional surveys of their military and civilian populations. We left behind a blue print to improve their people’s health and nutritional needs; a cadre of well-trained nutrition personnel of their own, and a well-equipped, trained, and functional biochemical laboratory. U.S. academic scientific professionals and their counterparts in the respective countries established long-term personal links.
In the beginning, when our focus was mainly military populations, the international agencies and nongovernmental organizations stood aside. In 1958, that changed when civilian populations were added. WHO, FAO, UNRWA, UNICEF, and USAID then became colleagues. Our findings helped document the needs of the civilian and refuges populations in many countries. For each U.S. team members, the surveys provided an opportunity to see respective countries or states, and learn about the people, their history, and nutrition problems in a manner few foreign visitors would be permitted. Even the Ten State Survey gave 51 young Texas students a view of their state that left a permanent imprint on them.
Analysis of data from all 20 North American surveys revealed similarities in the general pattern of nutritional problems encountered and the populations at risk.
Survey recommendations also followed common themes.
By the time of the 2nd White House Conference in December of 1969 (28,29), when Richard Nixon was president, 8 of the Ten State Surveys had been completed. The preliminary report of the Nutrition Survey in Texas had been published in March of 1969 (30). It took until 1972 for the 4 volume, 928 pages of the Ten State Report findings to be released (7). In late 1970 and early 1971, the final and the summary reports of the White House Conferences were completed. So in a sense, the Ten State Survey findings were a part of the discussion and recommendations developed by the conferences 25 panels and task force.
In going through my old slides last fall, I discovered unpublished comparative data of all the North American Surveys 1961–1970. I compiled some of these data in a compact disk PowerPoint presentation on file in the History of Nutrition collection at the Eskind Library of Vanderbilt University Medical Center in Nashville, TN. The presentation provides a quick look at some of the unpublished data from the surveys in North America in which I was involved. The data were compiled and analyzed by Ed Bridgforth and his team from our own database and from extra printouts of data from the Ten State Survey data files. Included are comparative data concerning:
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FOOTNOTES |
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2 This manuscript is also available as a CD PowerPoint Presentation by McGanity and Mathew S. Reinhart (my grandson) on file in the History of Nutrition collection at the Eskind Library at the Vanderbilt University Medical Center, Nashville, TN.
3 Deceased. Address reprint requests to Guest Editor. E-mail: hsandste{at}utmb.edu.
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LITERATURE CITED |
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TOPABSTRACTLITERATURE CITED |
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1. Interdepartmental Committee on Nutrition for National Defense (1957) Manual for Nutrition Surveys 1st ed. 1957 U.S. Government Printing Office Washington, DC.
2. 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.
3. Interdepartmental Committee on Nutrition for National Defense (1959) Alaska, an Appraisal of the Health and Nutrition Status of the Eskimo 1959 U.S. Department of Health, Education and Welfare Bethesda, MD.
4. Interdepartmental Committee on Nutrition for National Defense and Division of Indian Health, USPHS (1964) Blackfeet Indian Reservation: Nutrition Survey 1964 U.S. Department of Health, Education and Welfare Washington. DC.
5. Interdepartmental Committee on Nutrition for National Defense and Division of Indian Health, USPHS (1964) Fort Belknap Indian Reservation: Nutrition Survey 1964 U.S. Department of Health, Education and Welfare Bethesda, MD.
6. Interdepartmental Committee on Nutrition for National Development (1971) Nutritional Evaluation of the Population of Central America and Panama Summary 1971 U.S. Department of Health, Education, and Welfare Washington, DC.
7. Centers for Disease Control (1972) Ten States Nutrition Survey 1972 U.S. Department of Health, Education and Welfare Atlanta, GA.
8. Mann, G., Scott, E., Hursh, L., Heller, C., Youmans, J., Consolazio, C., Bridgforth, E., Russell, A. & Silverman, M. (1962) The health and nutritional status of Alaskan Eskimos. Am. J. Clin. Nutr. 11:31-76.[Abstract]
9. Trowbridge, F. L. (1972) Selected findings of the Ten-State Nutrition Survey. Ill. Med. J. 142:473-478.
10. Trowbridge, F. L., Hand, K. E. & Nichaman, M. Z. (1975) Findings relating to goiter and iodine in the Ten-State Nutrition Survey. Am. J. Clin. Nutr. 28:712-716.
11. Lowe, C. U., Forbes, G., Garn, S., Owen, G. M., Smith, N. J., Weil, W. B., Jr & Nichaman, M. Z. (1975) Reflections of dietary studies with children in the Ten-State Nutrition Survey of 1968–1970. Pediatrics 56:320-326.
12. Garn, S. M. & Clark, D. C. (1975) Nutrition, growth, development, and maturation: findings from the Ten-State Nutrition Survey of 1968–1970. Pediatrics 56:306-319.
13. Garn, S. M. & Clark, D. C. (1976) Trends in fatness and the origins of obesity Ad Hoc Committee to Review the Ten-State Nutrition Survey. Pediatrics 57:443-456.
14. Guthrie, H. A. & Guthrie, G. M. (1976) Factor analysis of nutritional status data from Ten State Nutrition Surveys. Am. J. Clin. Nutr. 29:1238-1241.
15. Anon (1973) American Academy of Pediatrics Committee Statement. The Ten-State Nutrition Survey: a pediatric perspective. Pediatrics 51:1095-1099.
16. Schwerin, H. S., Stanton, J. L., Riley, A. M., Jr, Schaefer, A. E., Leveille, G. A., Elliott, J. G., Warwick, K. M. & Brett, B. E. (1981) Food eating patterns and health: a reexamination of the Ten-State and HANES I surveys. Am. J. Clin. Nutr. 34:568-580.
17. Kuczmarski, M. F., Moshfegh, A. & Briefel, R. (1994) Update on nutrition monitoring activities in the United States. J. Am. Diet. Assoc. 94:753-760.[Medline]
18. Anonymous, (1970) Workshops on problems of assessment and alleviation of malnutrition in the United States 1970 DHEW Washington, DC.
19. Anonymous (1968–69) Texas Nutrition Survey film presentation available at Vanderbilt University Eskind Medical Library, Nutrition Collection 1968–69 Nashville, TN.
20. Citizens’ Board of Inquiry into Hunger and Malnutrition (1968) Hunger USA 1968 New Community Press Washington DC.
21. Adams, C. M., Bridgforth, E. B., Dalton, E., Darby, W. J., Efner, J. A., Houk, N., Johnson, H. F., McGanity, W. J. & McKinley, P., et al (1956) A study of the dietary background and nutriture of the Navajo Indian. J. Nutr. 60:1-85.
22. Interdepartmental Committee on Nutrition for National Defense (1959) Ethiopia nutrition survey 1959 U.S. Department of Health, Education and Welfare, Public Health Service, NIH Bethesda, MD.
23. Schubert, E. P. (1969) Suggested Procedures for Local Support to Nutrition Survey Teams 1969:3 Nutrition Program, National Center for Chronic Disease Control Altanta, GA.
24. Dawson, E. B., Moore, T. D. & McGanity, W. J. (1972) Relationship of lithium metabolism to mental hospital admission and homicide. Dis. Nerv. Syst. 33:546-556.[Medline]
25. Dawson, E. B., Moore, T. D. & McGanity, W. J. (1970) The mathematical relationship of drinking water lithium and rainfall to mental hospital admission. Dis. Nerv. Syst. 31:811-820.[Medline]
26. Dawson, E. B., Frey, M. J., Moore, T. D. & McGanity, W. J. (1978) Relationship of metal metabolism to vascular disease mortality rates in Texas. Am. J. Clin. Nutr. 31:1188-1197.
27. Kotz, N. (1969) Let Them Eat Promises 1969 Prentice-Hall Englewood Cliffs, NJ.
28. Anon (1969) White House Conference on Food Nutrition and Health: Final Report. Mayer, J. eds. White House Conference on Food Nutrition and Health 1969 U.S. Government Printing Office Washington, DC. .
29. Anon (1969) Mayer, J. eds. White House Conference on Food Nutrition and Health: Summary Report 1969 U.S. Government Washington, DC. .
30. McGanity, W. J. (1969) Preliminary Report: Nutrition Survey in Texas. Tex. Med. 65:40-49.
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