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ACCESS TO CARE
John B. Youmans, M. D.*
The Medical Department of the Army has always been concerned with the feeding of the soldier as it affects health and effectiveness. This responsibility was given statutory status in 1863 (Act of March 3, 1863, 12 Stat. 744: U. S. Code (10: 104). As revised in 1877 (Rev. Stat. 1174, February 27, 1877, Sec. 1174), it holds today as follows:
The application of the science of nutrition in the Army, both as a part of preventive medicine and as a therapeutic procedure for the sick and wounded, begun in World War I, was expanded in World War II. The developments in nutrition in relation to vitamins A and C, thiamine, minerals (especially calcium and iron), and the acid-base balance to the health of the soldier were appreciated during World War I. In addition, the loss of vitamin C and thiamine by heat, including considerable destruction of the latter in cooking, and the loss of nutrients in milling was known. On the other hand, the requirements of the body for these vitamins, in fact the exact nature and identity of these vitamins, were unknown. Knowledge of the vitamin content of foods was in terms of the relative value of different foods for the various vitamins in general terms. The development in nutrition had increased the number of vitamins identified. It resulted in their isolation and synthesis so that the specificity of their action and the curative effects of some of them had begun to be determined before World War II. A greater appreciation of the effects of a lack or diminished intake of vitamins was more general.
Every war brings many new and unsolved problems, particularly to a country which does not maintain a large preparedness program. Such was the case in nutrition in this country at the beginning of the war. Two avenues of approach were used to solve problems as they arose. The first was to define problems and submit them through the Office of Scientific Research and Development to various university and industrial laboratories for solution. The second was to tackle them in military research organizations.
By precedence since the Spanish-American War and by Army regulations after World War I, one of the duties of The Surgeon General has been to prescribe the basic standards of diet for the Army. By informal agreement between The Surgeon General and The Quartermaster General, the recommended dietary allowances submitted by the Committee on Medicine, National Research Council, and later confirmed in the "Recommended Daily Dietary Allowances" of the National Research Council were accepted as the dietary standards of the Army at the beginning of this war. Although the standards selected were not designed for Army use, they had such a large margin of safety that they were deemed suitable and satisfactory. Later, at the request of The Surgeon General, the Subcommittee on Medical Nutrition, National Research Council, submitted minimum dietary allowances, prepared by the Food and Nutrition Board, for use under emergencies and in times of short supplies.
Upon request by the Office of The Surgeon General the nutrition requirements of troops were studied in detail. The nutritional value of food items being supplied to the Army was studied by the United States Food and Drug Administration and by many university laboratories. Nutrient cooking loss data were accumulated from a large variety of sources among which were the Bureau of Human Nutrition and Home Economics of the United States Department of Agriculture, and the Nutrition Laboratory of the Pentagon Restaurant Association. In addition, much technological work on food in relation to nutrition was done by the Quartermaster Subsistence Research Laboratory. The relation of nutrition to prevention and cure of disease was studied by medical officers in the field.
Many studies of the relationship of protein metabolism to wound healing were done by both civilian and military hospitals in this country. One well-organized group was the Committee of the Josiah Macy Foundation, studying the relationship of metabolism to convalescence. There was also a subcommittee of the National Research Council which studied metabolism in relation to wound healing. The individual projects studied are too numerous to list in this history. Special diets made from Army rations were studied in the Army's Medical Nutrition Laboratory at Chicago, as was the relationship of atabrine and vitamin A deficiency to the development of atypical lichen planus, a serious skin affliction of the Southwest Pacific theater. Nutrition in relation to the healing of acute decubitus ulcers was studied at the Wakeman General Hospital, Camp Atterbury, Indiana, under the direction of the Chief Nutrition Consultant, Fifth Service Command.
Throughout the war, at a large number of
military installations, the energy expenditure of troops in a wide variety of
activities was studied. The method used was usually that of oxygen consumption.
At Wright Field, Ohio, and at many of the subsidiary Air Force physiologic
investigation centers, the
oxygen requirements of pilots and other crew members were determined for all types of aircraft at all altitudes. The Army Signal Corps determined energy expenditure in a variety of field tests at Fort Monmouth, New Jersey. Infantry troop and tank personnel energy expenditure was studied to some extent by the Medical Department in conjunction with the Quartermaster Board at Camp Lee, Virginia, and by the Armored Medical Research Laboratory at Fort Knox, Kentucky. Much work was done by the United States Navy at the Submarine Center in New London, Connecticut, also on board many training ships, and at the Naval Medical Research Institute at Bethesda, Maryland.
To carry out an appraisal of the nutritional state of troops, in relation to the rations which they consumed, a controlled experiment was conducted on 1,000 infantrymen in the mountains of Colorado in the summer of 1944.1 Here the technique for determining the nutritional state were standardized and critically studied. Subsequent to the standardization of these methods, a survey team was sent to the Pacific theater to appraise the nutritional state of carefully selected samples of men from all arms and services in the major Army areas.2 This was done in an effort to determine whether or not the troops who had lived on the B ration, C ration, K ration, and ten-in-one ration for periods of time up to 3 years were, in fact, properly nourished. The findings of this survey indicated that the nutritional state of a vast majority of the troops in this theater, whether they were fresh from the United States or had been there for long periods of time, was satisfactory. The same approach was used in China in the winter of 1944 as a basis for determining the supply requirements of Chinese troops under American supervision.3
Training Camp and Garrison
Formal improvements in the ration have been slow. The training camp and garrison ration was based on the quantities of standard foods consumed by 400 messes, obtained by nutritional surveys between 1917 and 1918. A proposed training ration was presented by the Chief, Food and Nutrition Division, Office of The Surgeon General,4 at the close of World War I, with suggestions for a revision, but no immediate action was taken. As the result of the inability to purchase a satisfactory dietary with the money provided by the garrison
ration, the Quartermaster Corps, with the advice of the Medical Department,5 accomplished a revision in 1927 to increase the money value of the ration. The intent of the changes was to permit the purchase of supplementary food to provide variety. While the nutritive value of the ration was considered by the Office of The Surgeon General, the higher money value of the ration received by the Navy at the time was an important factor in the decisions. A large proportion of the changes in food were in animal products, some of which, particularly meats, were expensive and also beyond the normal consumption by the Army. The normal use of these foods allowed ration savings for the purchase of fresh vegetables, fruits, and milk. The result of this abnormal distribution of foods in calculating the money value of the ration was evident in the depression of the 1930's when the cost of meat decreased out of proportion to vegetables, and the Army was again faced with an unsatisfactory dietary. As the result of nutritional surveys, a proposal was made to the Quartermaster Corps that a ration be set up that would represent fairly satisfactorily the food needs and nutritive requirements of a hard working man. It was also desired to develop some method of determining the money value of the rations from such a ration rather than to obtain additional money by introducing quantities of food out of proportion to those which a suitable dietary should contain. It was indicated that a ration to be successful must have the following characteristics:6
1. A ration must be defensible from a nutritional standpoint.
2. When issued in kind, it must afford sufficient quantities of each item of the various classes of foods to allow the preparation of adequate, varied, and balanced menus. From the standpoint of supply agencies, it must be capable of issue in kind.
3. The relation of the various groups to each other should be such that it can be used to determine the adequacy of the rations actually consumed.
4. When commuted into money, it should furnish sufficient money to buy the various kinds of food necessary to provide nutritionally adequate meals sufficient in quantity and of suitable variety and balance. Providing sufficient money for food purchases does not assure suitable variety, caloric content, vitamin sufficiency, et cetera; only competent personnel can insure this.
The ration approved in 1932, while showing much improvement in the variety, quantities, and distribution of food, still required slight adjustment especially in meat (reduction) and milk (increase) and sources of vitamin C, for adequacy and normal distribution of food. Furthermore, the primary
consideration was still the money value in spite of the recommendation of the Office of The Surgeon General.
During the mobilization of troops for defense in 1940, a "menu" plan of prescribing rations was introduced for trial in 1941 and adopted with changes from time to time.7 The basis of this field ration was a monthly menu to be prescribed for all stations operating on a field ration system within a corps or service command area (the hospital phases of this plan will be discussed later). The menus were required "to indicate the components of each of the three daily meals, and a daily recapitulation of the total quantity of units of purchase of each item required to feed the prescribed menu to 100 men." Provision was made that "care will be exercised to see that the menu is nutritionally balanced," and by implication, adequate, "ample variety provided, and full utilization made of seasonal fresh fruits and vegetables."
The latter statement is the first formal statement in War Department directives that required that the dietary to be fed to the soldier be nutritionally balanced. In the final adoption and revision of War Department circulars relating to the menu plan of field rations, the following was included as the result of suggestion of The Surgeon General: 8 ". . . that consideration be given to evaluation of vitamins and minerals. . . . In its preparation, consideration should be given to the quantities of food necessary to meet nutritional requirements consistent with the prescribed training program."
The concept of the menu plan of prescribing and issuing rations was excellent and generally successful. The chief difficulties arose from the problems of any ration that is prescribed for troops with units having variable degrees of activity and a variety of food habits and operating in areas with different supplies of perishable foods such as meats and vegetables. There are three possibilities that might meet the problem of variable activity to-prescribe food for (1) the maximum activity contemplated; (2) the minimum activity with regard to caloric content and protein, vitamin, and mineral requirements, and additional food for more active units to meet the increased caloric requirements and to carry the additional vitamins associated with the use of carbohydrate or fat; and (3) the average activity of a camp or corps area and provide for adjustment of the distribution of food between organizations with high and low degrees of activity, or extra food for organizations with activity greater than the average. No definite policy was expressed, however, in the various directives relating to field rationing. The tendency was to provide for average activities. War Department Circular 208, 13 September 1943, at the insistence of the Surgeon General's Office, provided for more active troops as follows:
Measures were taken to correct problems that resulted from too much food (because prescribed in greater amounts than some organizations could consume, kinds of food that were not generally eaten, or due to variable attendance at the mess), and that created new problems. A plan introduced to correct variations in attendance was to issue rations in accordance with a count of the number of individuals who actually ate meals, combined with a percentage reduction in the number of rations drawn with increase in the size of the mess. This plan produced a situation in which some organizations would not have received sufficient food had the requirements of the directive been followed explicitly.9
With suitable adjustment at the camp or station level and the resourcefulness of the Army mess sergeants, the menu plan of field rationing in the United States generally supplied adequate and acceptable rations. Master menus were ultimately prepared in the Office of The Quartermaster General, with adjustments made at the corps area, camp, or station level. Medical Department officers, particularly food and nutrition officers at the various levels of command, especially corps area and camp or station, reviewed the adequacy of the quantities of food prescribed to prepare the menus and offered valuable suggestions with regard to changes and adjustment to particular conditions. Nutritional surveys were conducted from time to time to determine whether the soldiers were actually consuming an adequate dietary.
No special provision was made to assure an adequate dietary for troops subsisting on the garrison ration as suggested by The Surgeon General. One step in such a direction was the classification of foods into groups having roughly similar nutritive value and the suggestion that garrison ration accounts provide for nutritional as well as financial accounting of the food purchased with the garrison ration. All foods in nutritional accounts used were listed according to groups instead of only the more perishable foods. Such information reduced to a pound per man per day basis provided an excellent first approximation as to the adequacy of the food used. The foods prescribed in master menus were then classified and properly arranged and offered future possibilities for practical evaluation of the food provided for troops living on garrison rations.
At the end of the war the Army had a variety of rations, all of which met the nutritional requirements of the published basic dietary standards. They were the A ration, which was used in the Zone of Interior and which was made
up of the best fresh and canned food that it was possible for The Quartermaster General to procure. The quantity of food required was so enormous that it was necessary to limit the variety of choices of any given post in terms of the national supply. Hence, the War Department master menu was prescribed, the component parts of which were determined by food availability in the nation. The B ration was essentially the same as the A ration except that nearly all of its components were canned. It was used in communications zones and, as far as practical, in combat zones.
The C ration, K ration, and ten-in-one ration were designed for the various phases of an assault and were intended to be used only for short periods before adequate cooking facilities could be brought forward. It was thought that the K ration should be used in the early days of an assault where no facilities or time for preparation were available. In the next few days, the C ration, which required only heating, and could even be used cold, was indicated. In the next phase, where small groups could eat together, the ten-in-one ration was to be used and finally, when kitchens could be set up, the B ration was indicated.
In practice, however, because of the ease of issue, the lack of necessity for bringing up troop kitchens and other complicated requirements of more normal messing, commanders used these battle rations for much longer periods than that for which they were designed. In many instances the problems of supply necessitated such use. For that reason there was much discontent and often failure to consume the rations because of their monotony and lack of acceptability. The rations themselves were wholly adequate to maintain health and a high degree of combat efficiency when issued and consumed in sufficient amounts to cover the caloric requirements. The rations failed, however, in some campaigns. Most of the defects described were results of improper use rather than defects in the ration itself. From one point of view, these rations were too good because they did permit commanders to use them for too long periods of time.
Troops in training were fed the A ration. Commanders were urged to teach their men the value of eating properly and there is every evidence that this program was generally very effective. Careful nutrition surveys indicate that the American Army was, in fact, the best fed Army in the world and that the nutritional state of troops was far superior to that of American soldiers in previous wars. Also, surveys indicate that it was as optimal as it is possible to measure in our present state of nutritional knowledge.
As indicated above, the packaged rations
were often used for excessive periods of time and the men frequently ate too
little and lost considerable quantities of weight. Satisfactory procedure for
supplying at least one hot meal per day to troops in actual combat in cold
theaters were never well or generally developed. Some units were successful and
others were not. It is apparent, from discussing this matter with infantry
commanders, that success
was a result of the interest of the command. Many tests were devised to study this problem but none of them were satisfactorily carried out. Furthermore, it appeared to be the attitude of the Office of The Quartermaster General at times that combat feeding was one problem with one solution. It is apparent from study of the actual procedures used by units in the various theaters that there were many problems, depending upon the area in which the troops operated. In some cases, it was necessary to supply troops by night (Europe), and in others food could be supplied only by day (New Guinea). For security reasons some units were not permitted to make fires and in others the commanders stated that fire made no difference. There was general agreement among commanders that the morale value of at least one hot meal a day was of real importance in all theaters and that it is imperative in cold theaters.10 This is one of the problems of the future which should not be overlooked.
Because of the emotional stress of battle, troops fail to consume the available food even when other factors, such as acceptability of the food, are satisfactory and lose weight during the very active stages of combat regardless of the ration they are fed. For that reason, the concept of rehabilitation feeding at the end of each active combat period developed in all theaters. Commanders gradually became aware that men could go for days or weeks on slightly inadequate rations provided that they were very well fed during their rest periods. This concept is of real importance and needs additional study.
At the beginning of the war, feeding on troop trains and troopships was very haphazard and men frequently received unsatisfactory meals. By the end of the war, largely as a result of the efforts of the Food Service Program in the Office of The Quartermaster General, troop train and troopship feeding was almost as satisfactory as garrison feeding. In general, the A ration was used for such activities.
There was much interest during the war in the matter of feeding Air Force personnel in flight, particularly at very high altitudes. Investigative work in high altitude chambers indicated that men could not eat at 30,000 feet because unconsciousness occurred as soon as the oxygen mask was removed. However, in practice, it was found that men did eat at such altitudes and that, almost invariably, they carried some kind of lunch in their pockets. The first real study of the problem was made by the nutrition officer of the Eighth Air Force in England. He found that men on bomber missions were happier, remained more alert, and came home less exhausted if they had something to eat while in flight. The first flight lunch which he designed consisted almost exclusively of small bits of candies and it was very well accepted.
This problem was also studied by a medical officer from the headquarters of the Second Air Force at an experimental laboratory, Smoky Hill Airbase,
Salina, Kansas. Here he studied not only the ability of men to eat at high altitudes on long flights but the effectiveness of food on their normal activities under such conditions. His work, also, indicated that food was desirable in flight, particularly for flights which exceeded 5 hours. His work bore out the contention of investigators of the Nutrition Foundation in New York that high carbohydrate diets were better for flight crews than high protein diets, but the differences were of small magnitude. In general, the nutrition requirements of men in flight are identical to those of ground troops and sea troops.
With the beginning of the bombing of Japan by B-29's, in which the duration of flight missions ranged from 8 to 20 hours, feeding of Air Force personnel in flight became imperative. Also, proper management of preflight and post-flight feeding became more important. The men going out on long missions were under severe emotional strain and frequently did not eat well before the takeoff. After such missions men were frequently too tired to eat satisfactorily and the frequency with which such missions were flown sometimes resulted in a gradual decline in the nutritional state of personnel. For the above reasons, preflight and postflight feedings were carefully studied and adequate procedures worked out for them, particularly by the Twentieth Air Force. Records of their experiences and requirements will be found in the Office of the Air Surgeon. In general, in-flight feeding became satisfactory when properly made sandwiches, containing highly acceptable foods, plus hot drinks, were made available. Schedules were altered to permit proper feeding before takeoffs and the frequency of missions was altered to allow adequate rehabilitation after long flights. Feeding of relatively long-mission fighter pilots while in flight was not adequately solved.
OVERSEAS HOSPITAL RATION
In 1942, in connection with the development of expeditionary menus for temperate, tropical, and frigid climates, the medical staff at Headquarters Army Ground Forces suggested that provision should be made for the patients in hospitals. As a result, 10-day rations were planned for regular, light, soft, liquid, and special diets for overseas hospitals. Maximum use was made of foods in the Expeditionary Menu No. 1 (revised 1 June 1942) and No. 2 (revised 27 August 1942). With suitable changes in quantity or the addition of supplementary foods it was possible to provide a reasonably satisfactory diet for patients. It was assumed that hospitals would have the first chance at satisfactory perishable foods whenever available. There were basic menus related to the food supplied. It was assumed and suggested that there could or should be changes in the use of foods in different hospitals.
Data with regard to the preparation of the
different types of diets to be expected were not available. There were no
records of hospital diets used or methods of providing for hospitals in the
history of World War I. As the
result of suggestions from Walter Reed General Hospital, Washington, D. C., a percentage distribution of diets was made for purpose of procurement and issue, as follows:11 regular diets, 85 percent; light diets, 3 percent; soft diets, 6 percent; liquid diets, 4 percent; and special diets, 2 percent.
Copies of the overseas hospital menu were prepared and distributed by The Quartermaster General to port commanders for reproduction and issue to all outgoing task force shipments. This method of distribution was not entirely satisfactory because there was insufficient indoctrination of personnel in the subsistence offices and hospital personnel in the field. Until indoctrination was accomplished and special items reached the hospitals, results were rather unsuccessful. In some instances, especially where some local foods were available, special plans had been developed previously and there was difficulty in obtaining sufficient interest to give the plan a trial.
The emergency combat rations, C, K, and ten-in-one, proved to be inadequate for sick and wounded soldiers at clearing stations and evacuation hospitals. They were dehydrated rations, in part, and it was difficult to make acceptable liquid and soft diets from them. For that reason two ration supplements were standardized. The first was an aid station beverage pack and consisted of soluble coffee, tea, soup, and fruit juices to make hot drinks for men wounded or in shock. The requirement for it developed in the theaters of operations and many supplements of this sort were used before the official standardization of the pack in 1944. The second pack, the hospital ration supplement, consisted of components for making liquid and soft diets from the C ration and the ten-in-one ration. It contained soups, fruit juices, additional beverages, and some cereal components. To supplement this pack, some investigative work was done in the Medical Nutrition Laboratory in Chicago by the dietetics branch which developed a wide variety of acceptable diets that could be made from the packaged rations plus the hospital supplement. These diets may be found in the records of the Medical Nutrition Laboratory.12
There were several other types of Army food, sometimes erroneously called "rations," which were to be used for special purposes and in the event of severe emergencies. They were not rations in the true sense because they did not contain adequate nutrients for a soldier for 1 day. Examples of these are the D bar which was a type of chocolate bar, the Air Corps flight lunch which was a box of mixed candies, the parachute ration which was a small packaged ration equal to approximately one-third of the K ration, the life raft
ration which appeared in at least five forms, made up mostly of candies and raisins, and a number of others. None of these emergency type, lifesaving rations was satisfactory but their use for the purposes for which they were designed turned out to be infinitesimally small, so the deficiencies in them were of little importance.
At the end of the war representatives of the Office of The Surgeon General, Office of The Quartermaster General, Army Air Forces, and Army Ground Forces met in Chicago on 17 August 1945 to determine the direction which research should take in the future with regard to pure emergency, survival type rations. It was generally agreed that a survival ration should be a part of the equipment of each soldier, just as a first aid pack is a part of his basic equipment. It was agreed that this ration should contain not less than 25 percent of the probable emergency requirements of a soldier for 1 day and that it should be packaged in a watertight container which would fit into a pocket of the soldier's uniform. No consideration need be given to vitamin content because vitamin deficiencies are not a consideration in an acute, lifesaving type of ration. Since most of the use of such a ration is by Army, Navy, and Air Force troops lost at sea, arrangements were made to include apparatus which would supply 800 cc. of water daily with the ration. Careful analysis of all available data indicated that less than 0.05 percent of the troops would ever be required to use such a ration for a period in excess of 48 hours. It was agreed that food was not essential for the maintenance of life in such a short period of time but that its morale value was worthwhile.13
Throughout World War I, the interval of peace, and up until the middle of 1944 there was a strong feeling on the part of the Subsistence Division, Office of The Quartermaster General, that if a nutritionally adequate diet was supplied it naturally followed that men consumed an adequate diet. The Food Division, Office of The Surgeon General, in World War I and the Nutrition Division, Office of The Surgeon General, in World War II have correctly insisted that an appraisal of the dietary of the Army must be on an "as consumed" basis if nutritional adequacy is to be determined. The nutrition officers began early to conduct nutrition surveys of the adequacy of the diet as consumed and indoctrinated troops and commanders in the importance of this concept. This is a proper function of The Surgeon General and supplies essential data to Subsistence Division, Office of The Quartermaster General, upon which to base food procurement.
The nutritional state of troops is an important part of the general responsibility of The Surgeon General for the preservation of health and the prevention of disease. It is also of paramount importance to commanders because it determines much of the fighting efficiency of combat troops. One of the reasons for the reorganization of the Nutrition Division in the spring of 1944, placing at its head a medical officer, was to implement The Surgeon General's responsibility in the maintenance of an optimal nutritional state in all troops. This is a medical officer's job because it requires a physical examination and in some instances a laboratory study of certain body tissues.
Nutrition surveys of messes, lasting from 7 to 10 days, were conducted in various camps and stations for periods usually of 30 days, to supply information on the nutritional adequacy of the food consumed by the soldier as compared with that planned or issued. The factual data obtained gave confidence in the rationing procedures or brought out difficulties and served as a sound basis for recommendation. Particular attention was given to the selection and handling of food because the maltreatment of food in storage, cooking, and serving or the failure on the part of the soldier to consume food because of dislike or poor preparation could render an originally adequate dietary inadequate. Lacking actual data on losses of vitamins in such procedures, such data were obtained through the Office of Scientific Research and Development for the losses under good, poor, and very poor conditions of storage and preparation characteristic of the Army. Corrections were then applied to the calculation of nutritional content of the dietary in accordance with the methods used in a kitchen or with the average of Army methods.
Nutritional surveys had a secondary and often very useful purpose under conditions where the causes of apparent difficulties were hard to detect or where there was some uncertainty as to the success of messing operations. This was true because, in the course of collecting data, food and nutrition officers were in constant contact with the personnel of a mess and were usually able to gain their confidence and thus obtain a background to the problems confronting the mess that was not possible on inspection with its usual formality.
Surveys were made by food and nutrition officers before and upon completion of their training and before assignment and afterwards when required in the course of their duties. A simultaneous survey of 99 Ground Force organizations was made in June 1943,14 when it appeared that the plan of determining the number of rations to be drawn might result in an inadequate dietary for some organizations if followed as prescribed. A second simultaneous survey was conducted in 1945.
The early surveys in 194115 represented roughly the concept of Army personnel with regard to the kinds and quantities found required for a satisfactory dietary based on experience with the garrison ration and information in technical manuals at that time. Subsequently the use of the master menu prepared by the Quartermaster General's Office tended to modify slightly the choice of foods. The chief differences in the quantities of food consumed in 1941 and subsequently were that in the later period there were less meats and citrus fruit and greater quantities of all other classes of food, particularly sugar, cereal grains, and potatoes.
The various types of organizations or units surveyed had a wide range of duties and levels of activity. They included infantry, artillery, cavalry, quartermaster, military police, ordnance, engineering, medical, air, chemical warfare, tank, induction center troops, and others. The number of each type of unit differed widely (from 1 chemical warfare unit to 77 infantry units), and the caloric value of food consumed likewise differed over a wide range (from 3,132 for 5 induction centers to 4,135 for 3 demolition units). The average caloric value of the food consumed in the average mess, when properly weighted, was almost 3,700 calories (3,694) by calculation. This agrees closely with the estimate reported by Murlin and his associates16 during the last war (3,633). As was also observed in World War I reports, the calculated caloric value of food consumed in the ordinary mess rarely lies outside the range of 3,000 to 4,000 calories.
The data examined in terms of seasons gave results that are again similar to those reported in 1919. The caloric intake was highest during the fall (September-November, 3,960 calories), dropping in the spring (March-May, 3,570 calories) and rising slightly during the summer (June-August, 3,790 calories). The observation by Murlin that seasonal variation caused no more than a 400 calorie deviation (in food consumed in the mess only) is corroborated by these data.
The simultaneous surveys carried out in 99 messes at 38 Ground Force stations during the first week of June 1943, represented approximately 130,000 rations consumed. They included a study of: the food planned and consumed; the number of men present for rations (rations due); rations drawn; average number of men eating (the basis on which rations were drawn according to War Department Circular 16, 1943); table waste, i. e., food left on plates and total edible waste; the cooking and standing time for classes of food that might be seriously affected in nutritional value by long cooking and standing.
Table 1 presents composite data on the quantities of food consumed, and wasted, by classes of food having similar nutritive value.17 "Food consumed" represents the average amounts of food eaten in the mess. It does not include waste. The data on waste refer to the quantities of edible food fit for human consumption but not eaten by the soldier, or prepared or discarded in the kitchen. The food waste has been corrected to the equivalent original form, i. e., as purchases, for the purpose of comparison. (The data on waste of individual classes of food represent averages of averages. Such data might be open to serious question because of irregular weighting. It is justified here due to the fact that the kinds and amounts of food and the size of organizations were similar.) Edible table waste is the waste of food, corrected to its purchased form, taken on the soldier's plate and not consumed. Total edible waste, including this waste and all other edible food prepared or discarded, was 0.39 pounds per man per day.
Table 2 is based upon the June 1943 survey of 99 messes and relates to the extent of overcooking or preparation or standing before serving the foods that
TABLE 1. AVERAGE QUANTITIES OF FOOD CONSUMED IN ARMY MESSES (AS DETERMINED IN 455 MESSES DURING 1941-43)
*Average edible food wasted in messhall and kitchen
Source: Howe, P. E., and Berryman, G. N.: Average food consumption in the training camps of the United States Army, 1941-1943. Am. J. Physiol., 144: 588-594, Sep 1945.
TABLE 2. OBSERVATIONS ON LENGTH OF TIME TAKEN
IN PREPARING OR COOKING FOOD
Source: Howe, P. E., and Berryman, G. H.: Average food consumption in the training camps of the United States Army, 1941-1943. Am. J. Physiol. 144: 588-594, Sep 1945.
result in serious destruction of vitamins. The period of "ample cooking or preparing time" is an arbitrary value which may be longer than desirable.
The data on rations drawn were studied in relation to the caloric content of the food planned and consumed. They were divided into two groups as follows:
1. Messes that consumed less calories than were planned. In this group 63 messes consumed an average of 3,440 calories against 3,710 calories planned. They had an average attendance of 161 men and drew 171 rations (10 extra rations per day). The latter represents 106 percent of the attendance. The attendance was 86 percent of the morning strength report. There was 0.15 pound edible table waste and 0.36 pound total edible waste. In addition to the above there were 19 messes that drew fewer rations than indicated by the attendance. These messes consumed 2,780 calories against 3,620 calories planned. They had an average attendance of 176 men and drew 169 rations representing 96 percent of the morning strength report. There was 0.13 pound edible table waste, 0.24 pound total edible waste.
2. Messes that consumed more calories than were planned. In this group15 messes consumed 3,940 calories against 3,690 calories planned. They had an average attendance of 158 and drew 180 rations (22 extra rations per day), representing 120 percent of the attendance. The average attendance was 77 percent of the morning strength report. There was 0.17 pound edible table waste, 0.30 pound total edible waste. Two organizations in this group drew less rations than the number of men eating.
The general conclusions to be drawn from these data are as follows:
1. Organizations drew more rations
than they were entitled to according
to War Department Circular 16, 1943, when followed exactly. In 17 percent of the cases extra food was needed if the caloric intake can be taken as an index of the requirements of the messes. On the average, the organizations were receiving barely enough food for their needs if the rations were drawn according to regulations. In no case were more rations drawn than represented by the number of rations to which the organizations would have been entitled according to the number of men present for rations without the deductions made for strength according to Army Regulations (AR) 30-2210.
2. The total edible waste was fairly high, 0.32, approximating the waste in 1917-18, 0.38 pound per man per day. It is possible under very close supervision to reduce edible waste as it is prepared to 0.1 pound per man per day or even less. Table waste was approximately 50 percent of the total edible waste, indicating that the soldier in his eating habits is not more wasteful than the kitchen personnel. That is, waste that occurs to a considerable extent occurs in the administration and preparation phases of mess operation. Waste did not bear a marked relation either to caloric intake or the excess number of rations drawn. It is obvious, however, that if more perishable food is issued or excessive quantities prepared than can be consumed there will be more waste. Excess issue of staple foods should not have as great effect on waste as perishable foods since the former can be stored for future use or returned to the sales officer. There were indications that the relatively high waste of vegetables was needlessly cutting into civilian supplies of vegetables through a lack of local administration of supply and planning of menus in relation to the dietary habits of the troops.
3. The caloric intake showed a
considerable range and varied from approximately 2,774 to 4,644 calories. The
average caloric consumption, 3,468 calories, was less than the soldier had been
consuming in previous surveys (4,100 calories supplied and 3,888 calories
consumed in 1941-42, and 3,900 calories supplied and 3,633 calories consumed
with approximately 365 calories in the post exchange in 1917-18). Since the
ration was usually planned for the average of a station, some organizations will
require less and some more food. This means that food, particularly the staple
energy foods, should be distributed according to the needs of the various
organizations or additional quantities of these foods be made available to
organizations that need them. The differences between caloric intake observed,
in relation to past experience, indicated that the soldier may depend upon the
food eaten outside the mess to complete his caloric requirements. Troops were
less active than they were formerly, or they ate more food in the past than was
required. It is not possible from these data to determine which factor or
factors were operating. There was considerable use of excess water and
overcooking and the service of food was delayed to such an extent
that serious losses were occurring in the labile vitamins and soluble minerals, which tend to invalidate the careful planning of rations.
A comparison of the food issued and consumed by Negro soldiers as compared with white troops indicates that the consumption of the two sets of soldiers was essentially the same.
Material was developed to aid food and nutrition and Medical Department officers in the evaluation of rations, including data on food consumption. The general principles of an adequate acceptable dietary were prepared in mimeograph form and distributed, and finally published in War Department Technical Bulletin (TB MED) 23, 23 March 1944. A rapid, fairly accurate method of determining the approximate nutritive value of dietaries was developed from the experience of the Bureau of Nutrition and Home Economics, United States Department of Agriculture.18 The weighted average composition of roughly similar classes of foods was represented in tables. It was only necessary to apply the values to the weights of particular classes of food as used or provided. Distributions of food were studied for the fall-winter and spring-summer periods of the year. The tables proved to be very useful and these percentages were used in weighting the composition of the various classes of food. Tables for classifying foods and factors for conversion of unit packages to pounds for use in dietary analysis of rations were also developed and published in TB MED 25, 28 March 1944. The use of the per capita consumption of the various classes of food which follow a given food pattern in relation to the per capita consumption of a given mess may also be used as a first approximation of adequacy of dietaries or rations.
Motorized troop energy expenditure in all varieties of tanks, and to a limited extent also for artillery troops, was determined at Fort Knox, Kentucky. Many universities doing experimental work for the Army made contributions. Much of these data were brought together and summarized by the Chief, Chemical Section, Armored Medical Research Laboratory, and his report was made available to The Surgeon General and to The Quartermaster General.
At the end of 1944 it was possible to make reasonably accurate estimates of the caloric requirements of troops in all kinds of activities and to arrive at a reasonably, properly weighted estimate of a mean value which was applicable to the whole Army. To support this evidence another simultaneous nutrition survey of the actual food intake of troops at a large number of camps scattered over the entire United States was made in the spring of 1945.19
Table 3 shows the average quantities of the various food groups consumed in the mess per man per day during the period under survey; for comparative purposes, food consumption figures as reported in 1943 by Howe and Berryman20 are shown in column 2 of this table. In order to determine the nutritional adequacy of the food consumed it was necessary to estimate not only the amounts of food prepared but also the amount of each food item wasted and subtract the nutrients contained therein from the nutrients in the food prepared. To obtain data on food wastage, all plate waste was segregated by food groups and weighed, and all kitchen waste was also segregated and weighed. The range of food wastage in the different messes was from 0.08 pound to 0.66 pound per man per day, resulting in an overall average of 0.24 pound of edible food per man per day or approximately 5 percent of the food issued by the Quartermaster Corps. This figure, as compared with an average edible food waste of 0.38 pound per man per day reported in 1919, 0.39 pound per man per day in 1941, and 0.32 pound per man per day in 1943, indicates the creditable strides made by the Army in food conservation.
TABLE 3. AVERAGE
QUANTITIES OF FOOD CONSUMED IN 44 ARMY MESSES DURING THE
*For comparative purposes, average food consumption in Army
messes as reported by Howe and Berryman in 1943, Am. J. Physiol. 144: 588-594,
During this study, data were also obtained on messing practices, i. e., total elapsed preparation times. The methods of cooking and preparation of food were satisfactory in the majority of messhalls. In some instances, however, improper preparations and cooking practices were employed, resulting in lowered nutritive value of the food consumed. The most common infraction of good cooking practices was poor timing of food preparation: meat was cooked and salads prepared too far in advance. Another factor, also having bearing upon the amount of food left over, and wasted, was the overdrawing and underdrawing of rations. A comparison was made of rations drawn with the number of men actually fed, based on head counts made by each nutrition officer and a compilation of rations drawn. Of the messes surveyed, 79 percent overdrew rations and 20 percent underdrew rations. Overdrawing rations to the extent of 5 percent was the average for the 44 messes surveyed.
The approximate nutritive value of the food consumed for the period is shown in Table 4. It will be noted that the quantities of essential nutrients as calculated are liberal, and exceed, in every instance, the National Research Council's recommended dietary allowances for moderately active men.
CALCULATED NUTRITIVE VALUE OF AVERAGE FOOD CONSUMED PER MAN PER DAY AS
DETERMINED IN 44 ARMY MESSES DURING THE PERIOD 22-28 MAY 1945
*1945 National Research Council recommended daily allowances
for a moderately active man.
The various organizations and units surveyed were of widely different composition and had a broad range of duties and levels of physical activity. Included were artillery, cavalry, engineer, infantry, medical, military police, quartermaster, signal, tank transportation, replacement center, and miscel-
laneous troop units. The average caloric value of food consumed by the various types of units ranged from 3,471 calories for 2 basic training units to 4,078 calories for 2 quartermaster units, with a total average of 3,744 calories per man per day. These figures, when considered in terms of the strength of the various units, indicate there was no significant variation of the average caloric intake with degree of activity of troops. The estimated average caloric intake (3,744) agrees closely with the estimate of the previous simultaneous survey in World War II in 1943 (3,694) and with Murlin and his associates in World War I (3,633). The observation by Howe and Berryman that the calculated caloric value of food consumed in the mess rarely lies outside of the range of 3,000 to 4,000 calories was corroborated by these data.
Similar surveys were made in isolated camps periodically throughout the war. Nutrition surveys of the actual food consumption of carefully selected representative samples of troops in most of the larger bases of the Pacific theater were made in the spring and summer of 1945. In the summer of 1944 a controlled experiment was carried out in the Tarryall Mountains at Camp Carson, Colorado. Its primary purpose was to test ration acceptability but at the same time very precise records of the actual caloric intake of troops were maintained. These troops (a battalion of infantrymen) were on very rigid advanced infantry training.
There was good, general agreement from all of the sources of information concerning the caloric intake of American soldiers and it was, therefore, possible to write a prescription for the diet of the Army based upon scientific appraisal of soldier requirements.21 There may appear to have been some unnecessary delay in getting this prescription written but as a matter of fact much of the information was used informally by The Quartermaster General in setting up both the master menu of the A ration and the components of the various expeditionary forces' rations for many months before the official prescription was published. The errors in diet construction were always on the high side prior to the publication of these standards
A national food shortage and the tremendous food requirement of Europe and the Orient were in part responsible for the publication of this diet at the relatively low level of 3,600 calories. Previous to this time all of the rations of the Army ranged from 3,750 calories up to over 4,500 calories.
The content of other nutrients which go to make up a diet were arrived at by using the National Research Council standards as a guide but lowering the amounts to what was deemed to be safe but satisfactory levels after carefully studying nutrition survey data in many parts of the world. For example, it will be found that the thiamine requirement of the Army ration is considerably lower than that of the National Research Council. The Army figure was arrived at by studying troops in the Pacific who had lived on a B ration, much
lower in thiamine content than the requirements of the National Research Council, for a period of over 2 years and showed no detectable evidence of thiamine deficiency. The same applied to the other components of vitamin B complex. The figures actually used were also supported by experimental data, particularly that from the University of Minnesota22 and by information obtained from other investigators.
It was the opinion of the officers of the Nutrition Division, Office of The Surgeon General, that a single dietary standard for the Army was a fallacious concept and that the various components of the Army should be fed in the terms of their physiologic needs. Such a procedure would call for a diet of nearly 5,000 calories in some engineering organizations and for approximately 2,500 in many headquarters. However, the administrative mechanism for handling such a plan was not well worked out. Although covered in effect in War Department Circular 208, 13 September 1943, the new concept was never put into effect except as a trial proposition in the feeding of prisoners of war. The actual dietary prescription was a mean value which could be raised or lowered by local commanders with Medical Department approval.
Realizing that under certain circumstances rations may be inadequate because of the inability of troops to consume them or to get all of the normal components, policies were written permitting the supplementation over and above the basic standards as required-the requirement being determined by Medical Department officers.
PRISONER OF WAR FEEDING
Providing food for German prisoners of war in the Zone of Interior created many problems. If the number of prisoners had been small the feeding problem would have been of minor importance. But on V-E Day there were between 300,000 and 400,000 prisoners of war distributed in main and branch camps in the Zone of Interior. The first prisoners of war were received in the United States in May 1942. Their presence in the Zone of Interior posed many questions of feeding. The most important was how much and what items of food should be used in the dietary of the German prisoners of war. Answering this question required the interpretation of that part of the Geneva Convention article pertaining to the feeding of prisoners of war. The Geneva Convention reads, "The food ration of Prisoners of War shall be equal in quantity and quality to that of troops at base camps." The obvious way to conform to this was to feed prisoners the same items and amounts of food as American troops received.
So, from 1942, when the first German prisoners of war were received until 1944 when the first directive on prisoner of war feeding was issued, German
prisoners were fed approximately the same ration as American troops or, namely, the foods listed on the service command menu for troops.
The first circular on prisoner of war feeding was published 1 July 1944.23 This circular was not very forceful. Some of the pertinent provisions contained therein were:
* * * * * *
Thus, it can be seen that no restrictions of consequence were made. As long as the prisoner of war menu did not exceed the value of the garrison ration or the amounts of rationed items on the Office of The Quartermaster General menu, it was satisfactory. Also, it can be seen that in some instances prisoners of war could be fed a ration equal or greater than that of United States enlisted men. This was found to be true in some cases. In 1945 four circulars on prisoner of war feeding were published, namely, Army Service Forces Circulars 39, 72, 150, and 191. Parts of the first three circulars were in effect at the same time; this caused confusion.
It can be safely said that serious, effective attention on a wide scale was never given by anyone to the maximum usage of noncritical foods in prisoner of war feeding until the following occurred: First, the Allied armies overran prison camps in Germany and found in them starving, malnourished prisoners of war, Americans and others; second, civilians in the United States protested vigorously when they learned through newspaper accounts and radio commentators that the German prisoners of war were being fed a diet luxurious in comparison with the one they (housewives) could provide for their families. Response by the War Department to the foregoing protests was immediate: All agencies involved in feeding the prisoners of war were instructed to cut the use of civilian-scarce food to a minimum and to substitute civilian-plentiful food. The Geneva Convention was reinterpreted by joint agreement of the Office of The Surgeon General, Office of The Quartermaster General, and Office of The Provost Marshal General, with concurrence of the Commanding General, Army Service Forces, as follows: The word "equal" does not mean "identical," therefore, if American troops were fed 100 gm. of protein in the form of grade A beef, while German prisoners had to be fed the same amount of protein, it did not have to come from the same part of the carcass. Furthermore, while troops
were authorized from 3,600 to 4,000 calories per day their actual consumption was a function of their energy requirements (the work they did) and might be considerably lower than the authorized figure. It was, therefore, agreed to feed prisoners of war in terms of their energy requirements and to feed them low-cost nonrationed foods which were nutritionally adequate, as determined by accepted American standards. (See Army Service Forces Circular 235, 1945.)
In haste, as a stop-gap measure, Army Service Forces Circular 150, 27 April 1945, was written, principally by the Office of The Quartermaster General, and dispatched to the field accompanied by a menu guide for prisoners of war. This circular and menu required that use be made of the following or similar items: pig's snouts, pig's feet, pig's tails, green bones, hearts, and similar items of meat in amounts not to exceed 4 ounces per man per day (this did not mean inedible meat), bread in amounts up to 130 pounds per 100 men per day and flour in addition. They would not eat this much bread. No substitutions were permitted. This resulted in a sad state of affairs: (1) The items specified in the menu could either not be obtained at all by market centers or in only limited quantities, (2) inability to obtain the foregoing items resulted in an inadequate diet, and (3) some thought the dietary standards were too low when, as a matter of fact, this was not the trouble-the trouble was in the unavailability of foods and a poorly planned menu. Soon there were reports of prisoners of war fainting on the job, inability to meet established work quotas, and loss of weight. Then the public again bombarded the War Department, this time the letters stating, in effect, that to starve the Germans was to lower ourselves to the same level as the Germans who starved their American prisoners in Germany.
At this point, a joint meeting of representatives from the Office of The Quartermaster General, The Surgeon General, and The Provost Marshal General was held to consider what could be done to feed the German prisoners a nutritionally adequate diet with noncritical items of food. This meeting was called by the Office of The Quartermaster General. It marked the first time that joint consideration by all interested agencies was given to the prisoner of war feeding problem. Preceding this first meeting most of the directives on prisoner of war feeding had been written by the Office of The Quartermaster General with the approval of The Provost Marshal General. In this joint meeting several decisions were made:
1. To have teams make brief surveys of the status of prisoner of war subsistence-the teams to consist of representatives of The Surgeon General, The Quartermaster General, and the Director of Food Service from the headquarters of the service command in which the surveys were conducted or, namely, the First, Second, Fourth, Fifth, and Sixth Service Commands;
2. To have a committee review existing directives on prisoner of war feeding and to formulate recommendations concerning them; and
3. To have a committee make a survey of previous surveys of prisoner of war feeding and to render a report thereon.
There were, therefore, three committees at work simultaneously: (1) the survey teams at work in the service commands; (2) the committee to review existing regulations; and (3) the committee to review reports of previous surveys, which had been conducted by both nutrition officers and food service officers. The findings of all these committees were briefly as follows: The committee surveying prisoner of war camps in the Zone of Interior found, in general, noncompliance with the existing directives. The committee which studied existing directives found that specificity was lacking and the mere existence of such a large number of directives confused the officers in the field responsible for implementing the directives. The report of the committee to review previous surveys revealed that the findings of the committee working in prisoner of war camps merely substantiated previously reported findings. These committees brought to a focal point conditions of long standing pertaining to prisoner of war feeding. Not of minor importance was the sale of scarce food items not available to the civilian public from the post exchange to German prisoners.
The second joint meeting of representatives of the interested agencies was held to discuss the results of the survey and to map out the general plan for a single new directive to supersede all existing directives. The real problem was one of policy on nutrition standards for prisoners of war. The Office of The Surgeon General contended that the terms of the Geneva Convention article were met when the standards of the National Research Council were attained and that prisoners of war should be fed according to their degree of activity. These two contentions were upheld and became a part of the directive, Army Service Forces Circular 191, 29 May 1945.
The directive stated specifically the duties of all concerned with the feeding of German prisoners of war. Some of the more important duties to be discharged by the Medical Department through nutrition officers in conformance with Army Service Forces Circular 191 were: to assist in the formulation of a service command prisoner of war menu; determination of the caloric expenditure of energy by prisoners of war-the results would indicate to the sales officer the amounts of food to issue; and frequent inspection of feeding and sanitation. The provisions of this circular were carefully worked out and, with a few exceptions, proved satisfactory.
The Nutrition Division, Office of The Surgeon General, published a set of criteria by which prisoner of war camps could estimate the caloric requirements of troops and by the simple process of periodic weighing could determine the adequacy of the ration issue.
It should be made clear here that the key
to feeding the prisoners properly with food not in short supply was a
well-planned menu composed of food
procurable by market centers in proper amounts. Procurement of food items not commonly used in GI rations was very difficult, as aforementioned, for market centers to effect. For example, to procure enough pig's tails to make one issue of them to German prisoners of war was an almost insurmountable task, particularly when the number of German prisoners of war to be fed was large. Many items of this sort were never used; instead other meats (nonrationed) such as fish, bologna, et cetera, were issued. There was a lag period between the time when the circular was written and when procurement could be effected. As soon as procurement "caught up" with the circular the plan devised jointly by the Office of The Surgeon General, the Office of The Quartermaster General, and Office of The Provost Marshal General worked satisfactorily.
Everyone who assisted in writing the directive was cognizant of the fact that the circular could not possibly be perfect. In order to find out as soon as possible its faults and to correct them, a study was to be conducted in prisoner of war camps by a survey team planned as soon as Army Service Forces Circular 191 was put into effect. The teams consisted of representatives from the Office of The Surgeon General and the Office of The Quartermaster General. Surveys were made and reported but the number of recommendations was small. V-J Day occurred before action could be taken on these recommendations. V-J Day had an immediate effect on the whole outlook of prisoner of war feeding inasmuch as plans were made at once for the return of the entire number to Germany by March 1946.
A record to indicate what the German prisoners of war needed, on the average, is as follows: a ration providing 3,400 calories was usually sufficient; a ration providing as much as 4,000 calories was permitted for prisoners of war laboring in lumber camps, in beet harvest, or in other arduous work whenever it was determined by the proper medical authority that there was a need for it; a low-calorie ration, 2,500 calories, was issued to those German prisoners of war who refused to work. To some it may seem that the German prisoners of war were overfed. The fact that they afforded the primary source of labor in Army camps, harvest fields, pulpwood mills, and other locations should not be overlooked when considering whether prisoners of war were fed too liberally. To produce efficient work any personnel must be well fed and it was on this hypothesis that the Office of The Surgeon General recommended feeding of a ration equal calorically to the caloric expenditure of energy.
CIVILIAN FEEDING IN LIBERATED AND OCCUPIED AREAS
With the cessation of hostilities in
Germany it became the duty of the Army to maintain law and order and to prevent
the spread of disease. The
food problem in Europe was acute. The Office of The Surgeon General supplied five nutrition survey teams for the purpose of appraising the nutritional state of the civil populations in the occupied countries. The purpose of this appraisal was to determine the minimum food requirements for all groups of the population. It was believed that only by this technique could the inadequate supply of food be distributed equitably in the best interest of the Army, and also the quantity of food available through all sources, including the black market, be estimated. Invariably, actual measurement of people showed 500 calories more food intake than agriculture supply surveys indicated was available. Failure of populations to lose weight proved the correctness of the survey findings and saved millions of dollars in rations. By 15 August 1945 more than 40,000 people had been examined in Germany. This group was a carefully selected miniature sample of the population of 20 of Germany's most important cities. A similar procedure was planned for Japan, provided the food supplies of that country were inadequate to meet the needs of the occupying forces. There was no effort to supply an optimal diet to these people but rather to supply a diet which would prevent civil unrest, the spread of disease, and would allow the civil populations to carry out such work as might be necessary for the effective running of the country by American forces. Further details of this program and the nutritional state of civil populations in occupied countries will be found in another volume in this series.
REGIONAL FOOD HABITS AS RELATED TO FOOD ACCEPTANCE
Food acceptance is tied up with many factors which are largely psychological-the strongest is probably the food habits of the family from which an individual comes. Here, unfortunately, methods of food preparation, good or bad, play a significant role. Food habits of a locality in the United States are undoubtedly based on two major factors: (1) the predominating nationality of the country from which the people come, and (2) the food available in the community. Even in the latter case the methods of preparation characteristic of the nationality of origin modify the use of the abundant foods of a region and introduce a secondary factor in the acceptance of the same foods by persons of another region.
Factual evidence of the effect of previous food habits on the acceptance of food in the Army is very limited. The failure to accept new foods or methods of preparation is so much more obvious that it is much easier to notice and relate than the lack of effect or acceptance after a period of exposure to particular foods.
An example is the method of preparation of
a meal at Fort Meade, Maryland, where parts of two companies messed together-one
largely from the New England States with a New England mess sergeant and the
other from the
South with a mess sergeant from the same region. The mess sergeants supervised the cooking on alternate days. In a survey of the mess it was noted that the consumption of food was greater by the men from the region from which the mess sergeant came on the days he was in charge of the kitchen.
There were many cases of failure to accept fresh vegetables other than the standard potatoes, tomatoes, corn, string beans, spinach, and cabbage. In some cases even some of these foods were not accepted. In the case of other vegetables, they were well prepared even when the cook knew that only a small portion of the quantity he was preparing would be eaten, the rest to go into the garbage or elsewhere if the garbage can was under close scrutiny.
Regional food habits are very definite with regard to certain basic carbohydrate foods-rice and potatoes, and individual foods-cornbread and beans. Lamb, or as it is usually called, mutton, is also a regional problem. In the latter case the difficulty in acceptance may be due to the small size of the bulk and consequently the difficulties of getting full-sized slices of meat.
At times variety or greater profusion of so-called acceptable foods was resorted to when all that was needed was a slight variation in method of preparation and good cooking.
The psychological conditions under which food is eaten plays a part in food acceptance. It has been noticed in Army messes that were not consuming certain foods satisfactorily that, while at most of the tables there would be considerable waste, at an occasional table there was no waste and the serving dishes were completely emptied. One possible explanation is that someone showed an interest, no one objected, and the rest fell in line. This is, in effect, the condition that determines the food habits in youth.
From a national point of view, a British officer engaged in studying the nutritional problems of the Royal Air Force told of the delight certain Royal Air Force troops had in our rations when they first lived on them. Later their established habits prevailed and they insisted on returning to British rations.
It is obvious that regional food habits, in the broadest sense, are a factor in the acceptance of foods and that such habits persist for a long time. The opinion has been expressed that the soldier after a year or so gradually becomes accustomed to the foods he obtains in Army messes and accepts them.
There are two or three phases of the
extent to which regional food habits interfere with or promote the eating of
basic foods or unusual foods: (1) when they first are presented or after
they have been presented for a relatively short time, and (2) when they
have been presented for a season or longer. The ultimate test of acceptance
might well be when two foods or methods of preparation are presented
simultaneously and the individual eats the new food or method of preparation in
preference to the one to which he was previously accustomed, or at least 50
percent of the time.
Since previous food habits do influence acceptance of food, at least temporarily, profitable studies might well be conducted with individuals from different regions on such questions as to the best methods to modify acceptance of foods, the classification of foods and methods of preparation that present the least and most difficult problems of acceptance, the extent to which texture (fine, coarse, soft, or hard), color (colorless, colored, and the kind of color), and flavor (acid, sour, sweet, strong, milk, highly flavored, or bland) affect acceptance, and which of the factors have the greatest influence. Along with such studies could well be included studies of the qualities of food that promote the acceptance of the same foods for long periods of time and those that cause early dissatisfaction and even rejection under conditions of monotony. While subjects from the United States are rather well conditioned to variety there is evidence that some types of food are acceptable over longer periods of time than others. Results on studies of the effect of regional food habits in relation to food acceptance can be useful in the development of a sound nutritional program for the country as a whole. They should reveal nutritional deficiencies and their causes. As a member of the Food and Agriculture Organization of the United Nations, the United States agreed, at the first conference at Quebec, Canada, "to take all measures within its power to raise the level of nutrition and the standard of living of the people under their jurisdiction" and "to report to one another . . . on the measures taken and progress achieved."
THEATERS OF OPERATIONS24
The feeding of the soldier in the overseas areas was essentially one of supply, experience of mess personnel in the preparation and serving of the field ration, and the use of the packaged rations, C, K, and five- or ten-in-one. The character of the rations was determined in the Zone of Interior. Supplementation of the ration from sources within or near the field of operations was not the policy of the Army. In the China-Burma-India theater, this policy was modified to some extent before supplies of the B ration reached the authorized level. Troops were fed the British field service ration, supplemented by fresh supplies purchased locally and by available items of the B ration.
The basic major difficulty in the adequacy of the diets was failure to conserve the food available, whether the field or B ration or the packaged rations. The length of the supply line and the rapid movement of troops into new areas, which characterized amphibious operations, resulted in unbalanced rations. The rations were unbalanced in relation to the articles of the ration, more than in actual nutritional adequacy. This was not true of the packaged rations,
which were units in themselves but also restricted in caloric content. The problem of acceptance was more pronounced, however, with the packaged rations, which were planned for short periods of time. Their convenience in transportation, distribution, lack of need for kitchen facilities for preparation, and relative nonperishability or difficulties of supply resulted in their continuous use, without relief with the B ration, for longer periods than contemplated. Under these conditions the soldier chose the parts in which he was most interested and discarded, bartered, or gave away the others. The result was a lowered caloric intake and some slight malnutrition.
Nutrition in North African Theater25
The Consultant in Medicine, Office of the Surgeon, Headquarters, North African Theater of Operations, functioned as the nutrition officer from 3 January 1943 until the responsibility for this subject was transferred to the section of preventive medicine on 1 August 1944. At the time of his arrival at Allied Force Headquarters in Algiers on 3 January 1943, the American forces in North Africa had been engaged for less than 2 months. A short review of the tactical situation as it existed at that time will aid in the understanding of certain of the problems of nutrition encountered by the American forces in forward areas.
In the original planning for the OPERATION TORCH, it was contemplated that while there would be a considerable number of personnel of the Air Forces east of Algiers, the Ground Force component in that area would be relatively small. However, due to changes in operational plans, by January the bulk of the Tactical and Bombing Air Force, one regimental combat team, and numerous smaller units were in Eastern Algeria and in Western and Southern Tunisia; one regimental combat team was guarding the line of communications from Algiers to Souk-Ahras; and II Corps and its attached troops were moving into Southern Tunisia. This meant that a sizable increment of the American forces in North Africa were east or south of Constantine, Algeria. As far as supply lines were concerned, 3 small, frequently bombed ports (Bougie, Philippeville, Bone), 1 single-tracked railroad from Oran to Constantine, and 1 fairly good road from Algiers east were available for supplying this force and for the British First Army and troops along the line of communications. The American supply lines which stretched primarily from Casablanca and Oran were long and tenuous, and it is not strange that during this period of time the combat forces operated on a "shoestring" basis insofar as supplies were concerned.
In the course of a tour of inspection of British hospitals in North Africa made by the consultant in medicine with the British consulting surgeon and physician from 13 to 20 January 1943, complaints were heard from American troops about their rations. Many of them were receiving the British Composite Pack which they stated did not "fill them up" and which contained items foreign to the American dietary and, hence, disliked. The C and K rations also came in for criticism because of the tastelessness and their monotony. However, on this trip no evidence of nutritional disturbances were seen in American troops.
During a tour of inspection in II Corps which was made in February 1943, the Consultant in Medicine, North African Theater of Operations, heard further complaints about the inadequacy of the "Compo," C, and K rations which were being issued to American troops. During this month, reports began to reach the Office of the Surgeon, Headquarters, North African Theater of Operations, from Ground and Air Force units concerning alleged deficiencies in the rations which they were receiving. However, it was not until April 1943 that evidence was obtained by the Consultant in Medicine in the course of a tour of II Corps, in Northern Tunisia, of the development of definite nutritional disturbances in the troops of that Corps. He observed that instances of avitaminosis had been noted in patients received from II Corps. As far as could be ascertained, these disturbances occurred in individuals who were supposed to be on full C rations, but there was no way of telling whether or not they had consumed their rations. There seemed to be general agreement among those concerned that cold C rations were unpalatable for prolonged consumption and if the statements of the enlisted men were correct, cold C rations produced certain digestive disturbances. Because the problem involved various interested sections of the headquarters and because of its importance, he recommended that a board consisting of representatives from G-1, G-4, the Quartermaster, the Surgeon, and an infantry battalion commander from either the 1st or 9th Divisions be created for the purpose of ascertaining the facts and making recommendations concerning the diets of combat troops.
The recommendation in respect to the
forming of a board of officers to survey the rations was favorably considered by
the Surgeon, North African Theater of Operations, and was forwarded as a
memorandum to the Deputy Theater Commander on 15 May 1943. It was returned with
the suggestion that the difficulty lay in the misuse of the C ration, rather
than with the ration itself. In his reply the Surgeon, North African Theater of
Operations, pointed out that this was well understood by him, and that his
proposal was in part made to explore methods by which the responsibility for the
proper use of rations could be impressed upon the command, as well as any other
methods which would result in an improvement of the nutrition of troops in
The Deputy Theater Commander was not impressed by this reply and the board was not appointed.26
Late in May 1943, as a result of discussions which had taken place in the conference of the Chief Administrative Officer (British), Allied Force Headquarters, the Deputy Theater Commander suggested to the Chief Administrative Officer that a joint Anglo-American committee be set up to explore the possibility of devising a common Anglo-American ration scale for Allied Force. The Chief Administrative Officer acceded to this request and the following committee was appointed:
Brigadier H. M. Hinde,
OBE, DST (Chairman)
After a considerable amount of work upon the part of British and American medical officers in the Allied Force Medical Section, an agreement on a common ration scale was reached and presented to the committee. The circumstances surrounding this agreement are perhaps best described in a report entitled "A Personal Memorandum Upon the Nutritive Value of Existing and Proposed Army Rations, Together with Comments upon the Utilization of Rations in NATOUSA and the Adequacy of Existing and Proposed Rations" which was made by the Consultant in Medicine to the Deputy Theater Commander on 29 June 1943. The common ration scale suggested was considered possible of implementation without sacrifice of American dietary standards. The common ration was broken down into its components and was finally approved by the whole committee and forwarded to the Deputy Theater Commander on 28 July 1943. This ration was never adopted because at the time it was made, the two branches of Allied Force were separating into their components, and each was developing its own line of communications and sources of supplies. The introduction of the common ration at this point probably would have increased the difficulties which each force was experiencing in the problem of procuring and distributing rations. It was, however, an interesting idea and one well worth considering, even though it was never realized.
The period between the end of the Tunisian campaign and the amphibian assault upon Sicily was one of intense activity, especially in the Eastern Base Section, as men were being trained and retrained and supplies were being built up in "dumps" for use during the coming attack. It is not surprising therefore, that the B ration became unbalanced during this period of time, and that by July due to "elimination and substitution" of the various items, the caloric
value of this ration had fallen to a level which fluctuated between 1,800 and 2,700 calories per day, with the average daily ration for that month having a value of 2,400 calories. During this time three divisions and attached troops, which had been engaged in Tunisia, were undergoing amphibian training in the course of which emergency C and K rations were used. Thus when II Corps entered Sicily, a number of its component troops had been for a considerable period of time on rations which were deficient in calories.
The troops had better and more varied food during the 38-day campaign in Sicily than at any other period of combat up to that time. This resulted from the fact that five-in-one rations were widely used, a considerable number of first-class German rations were captured, lemons and certain other fresh fruits and vegetables were fairly abundant and were procured in considerable amounts in one way or another. Because the campaign was short and troop reliefs frequent, the individual soldier had an opportunity "to stoke up" in a manner which had been denied him in North Africa.
Despite the fact that there had been some improvement in the level of nutrition in the ground combat troops engaged in the Sicilian campaign, reports of varying degrees of undernutrition were constantly being received from components of the Army Air Forces, together with requests that multivitamin capsules be issued to these units. During the absence of the Consultant in Medicine in Sicily, the Surgeon, North African Theater of Operations, took cognizance of these demands, and upon his recommendations, the issue of such vitamin concentrates was authorized in Section III, NATOUSA Circular 153, 7 August 1943. The phrasing of this section in which it was stated that no requests for vitamin concentrates would be submitted until "a medical officer or nutritionist has analyzed the diet provided from the menu in use," produced many administrative difficulties because it was obvious that a unit medical officer who lacked scales and nutritional charts and tables would have a difficult time in analyzing the diet of his unit. This, coupled with the fact that vitamin concentrates were frequently in short supply, made their distribution a problem. At about this same time, and without consultation with or advice from the Consultant in Medicine, Section III, NATOUSA Circular 164, 29 August 1943, which directed that the part of War Department Circular 208, 1943, dealing with the percentage reduction in rations would be in force in the North African Theater of Operations, was issued. This action was ill-timed and badly conceived because it not only cut down the caloric value of the total rations for any one unit, but also, as it was shown later, penalized the soldier in combat severely.
The opening of the campaign on the
mainland in Italy with its attendant logistic problems created an unbalance in
the rations. This was due to the fact that the bulk of the ground forces was
removed from the neighborhood of the fixed bases in North Africa, large numbers
of service forces were likewise sent
to Italy, the tactical air force, which when Sicily had been secured had moved there, quickly followed the ground forces into Italy, and the strategic air force moved from its bases in North Africa to the eastern side of Italy. These movements of large numbers of men and supplies necessitated the building up of new lines of communications and of new "dumps" in remote and often inaccessible places. It soon became apparent from reports reaching the Office of the Surgeon, Headquarters, North African Theater of Operations, that the rations in certain parts of Italy were badly unbalanced and that nutritional disturbances were occurring. In November 1943, the theater was fortunate in having as its guest Col. Paul E. Howe, SnC, then the nutrition officer in the Office of The Surgeon General. Colonel Howe, in company with the Consultant in Medicine, made a tour of inspection, in the course of which studies upon nutrition were carried out in the base sections, Fifth United States Army and in the Fifteenth Air Force. It was concluded that the ration as issued to troops in the Fifth United States Army during the past 3 months had been inadequate. This was demonstrated from calculations of the nutritive values of the rations as issued and from evidence of weight loss and other nutritional deficiencies which had been noticed especially in forward divisional troops. It was realized that this inadequacy had been in part the result of the tactical situation, in part the result of difficulties and failures in transportation, and in part the result of the increased nutritive requirements associated with cold, wet weather.
The recommendations made on the basis of
these studies reflect the nature of the observations made. In order to improve
conditions found in the Fifth United States Army, it was advised that hot food
be supplied to combat infantry for at least one meal a day whenever the tactical
situation permitted the use of stoves; that unit commanders be impressed with
the necessity for the consumption of "Lemon Juice Powder Synthetic," a
chief source of vitamin C; and that, because of nutritional inadequacy, C and K
rations which were used of necessity under certain combat conditions not be
utilized without supplementation for more than 3 days. Because of the estimated
daily caloric requirement of Fifth United States Army personnel at that time, it
was recommended that five-in-one ration be issued to 4 instead of 5 men per day.
For the same reason, it was suggested that ten-in-one ration be issued to 8 men
daily. Issuance of the full allowances of food for B ration was advised,
including all components necessary to make bread when bread per se could not be
provided. Supplementation of B ration was considered necessary for service
troops involved in strenuous work. It was deemed desirable that a nutrition
officer be provided for duty with army troops and that one be assigned to each
corps. Nutritional rehabilitation was urged for organizations which had been
subsisting continuously or largely on C and K rations when troops were with-
drawn in reserve positions or regrouping areas. For this purpose, B ration, supplemented for strenuous work, was advised.
Problems in nutrition of Army Air Force troops which were disclosed by these studies included those which arose from "improper substitution and eliminations of ration components" of B ration. Heavy bomber groups were voluntarily eliminating "gas-producing components of the diet such as cabbage, beans, etc.," from the ration consumed because of gastrointestinal discomfort during long missions. The caloric value of the ration consumed was thereby lowered, and weight loss ensued. Missions of 7 to 8 hours in length made it impossible for fighter pilots to eat for that period of time; and as for bomber personnel during such lengthy missions, "the cold . . . makes it difficult and dangerous to open 'K' rations because fingers are frost bitten quickly at such altitudes." In areas out of normal lines for supply, Army Air Force units had to subsist on emergency rations for periods up to some 5 months at a time. Menus were scarce in some units, and there were difficulties due to percentage reduction in rations.
Upon receiving the recommendations made on the basis of these studies, the Surgeon, North African Theater of Operations, sent a memorandum outlining the damage which was resulting from the percentage reduction in rations, to the Deputy Theater Commander. The latter, after a careful consideration of all of the factors involved, called a meeting of the Chief of Staff, the Quartermaster, and the Consultant in Medicine, North African Theater of Operations. In the course of the meeting the decision was taken not only to do away with the percentage reduction in rations, but also to activate that part of War Department Circular 208, 1943, which permitted the drawing of excess rations under special conditions. The immediate promulgation of this policy in the theater was welcomed by all who were engaged in heavy work. It was a step in the right direction towards providing a more adequate diet for members of units whose duties were of a strenuous nature.
In January and February 1944, the Chief Nutrition Officer, Office of the Chief Surgeon, European Theater of Operations (Lt. Col. W. H. Griffith, SnC), paid a visit to the North African theater. His observations were recorded in a report made to the Surgeon, North African Theater of Operations, on 18 February 1944.27 "No evidence of nutritional inadequacy (was) observed." However, it should be made clear at this point that when Colonel Griffith was discussing "evidence of nutritional inadequacy" in his report, he was referring to frank nutritional disturbances and not to weight loss, minor anemias, et cetera. It is also of interest to note that the forces on the Anzio Beachhead were subsisting on emergency rations, while along the front west of Cassino, B-type rations were in general use, due to the stalemate in that area.
There can be little doubt about the improvement in the B ration as issued in the North African theater during December 1943 and January 1944. Frozen meat and butter were ordinarily available for three or more meals a week, fresh vegetables, nuts, and a certain amount of fruit became surplus as far as civilian needs were concerned in Italy and North Africa, and hence were procured by the Army. Fresh eggs were also in fairly good supply. Local shortages in certain items existed due to planning mistakes and to transportation failures, but the bulk of the troops who were not actually in frontline duty received a much more nutritious, palatable and varied diet than they had at any previous period in the North African theater. That this was true was shown by a study, initiated by the Consultant in Medicine, North African Theater of Operations, of the nutrition of "trainees" in the North African Disciplinary Training Center. The study was carried out by a board of medical officers during the summer of 1944. The Disciplinary Training Center was at that time located in a very torrid section of North Africa about 25 miles southwest of Oran, and the "trainees" were being put through 16 hours of strenuous exercises each day. One hundred general-service men were studied. The results of this study were of interest because despite very heavy exercise over the 90-day period, the average "trainee" in the group lost only 3 pounds of weight, none developed anemia, and no other evidence of nutritional deficiencies was noted.
The situation in respect to rations for prisoners of war in the North African theater after the surrender in Tunisia, and subsequent to that time, was always relatively good. Of course, local shortages in food did occur from time to time when unexpected numbers of prisoners were taken, but this existed only until they arrived at the permanent cages. The ration for prisoners of war was essentially a modified American B ration with fresh vegetables and fruits added, when such items were in surplus in quartermaster supplies. The ration was modified on a sliding caloric scale so that it provided between 2,500 and 3,000 calories a day for idle prisoners, and up to 4,000 calories a day for prisoners who were engaged in strenuous labor. Sick, wounded, or injured prisoners of war who required hospitalization received the diet provided for American sick, wounded, or injured.
Another problem of rations which was of
considerable interest in the North African theater was that of the hospital
ration. Because of logistic reasons and the tactical situation, the hospital
ration was not widely distributed in the early days of the theater, and was used
only in the Mediterranean and Atlantic Base Sections. The hospitals in Eastern
Base Section were forced to use the B ration. When dysentery and malaria became
prevalent in May and June 1943 it was noted that not only the B ration but also
the hospital ration was inadequate because the content of such components as
fruit juices, custards, and cocoa was not great enough, and the desired special
diets could not be prepared. Coupled with this deficit in the content of the
interesting items of these diets
was the fact that as a result of the supply situation which existed in Eastern Base Section, the B ration was short in calories due to eliminations and substitutions, averaging but 2,500 calories a day during June, July, August, and September 1943. In view of this, and with the knowledge at hand which had been gained during the campaign in Sicily in respect to the difficulties in placing the hospital ration where it was needed, it was decided to abandon this ration in the North African theater, and as a substitute, to provide the B ration, plus a purchase allowance of 35 cents a day per patient with which to purchase from the Quartermaster Corps those items necessary to prepare the required diets. This was authorized in Section III, NATOUSA Circular 179, 13 September 1943, and was amended to include patients occupying beds in dispensaries, by Section IV, NATOUSA Circular 199, 10 October 1943.
In general, it can be said that this plan was satisfactory and especially so in newly created base sections and in forward areas in which, as experience had previously shown, great difficulties were encountered in maintaining the hospital ration. It also provided a means of augmenting the standard B ration for those patients who did not require special diets, but in whom a state of undernutrition had developed because of the prolonged consumption of C, K, ten-in-one, or unbalanced B rations. This system of providing diets for hospitalized personnel, while approved by Col. Paul S. Howe, did come in for a certain amount of criticism from Lt. Col. W. H. Griffith. At the time this criticism was made, part of it was considered valid, but that part which dealt with the automatic issue of the hospital ration was thought unjustifiable because experience within the theater had always demonstrated that the automatic issue system for rations, sooner or later, broke down. It was considered that the plan for building up the ration which had been devised, met the conditions as they existed in the North African Theater of Operations, and that these conditions were different from those encountered by Lt. Colonel Griffith in England.
One of the major disease problems in the
North African and Mediterranean Theaters of Operations was infectious hepatitis,
in which a special problem in nutrition was presented because of the anorexia,
nausea, vomiting, and loss of weight which are characteristic of the disease. It
was noted in the winter of 1943-44 that difficulties were being encountered in
preparing appetizing and tempting diets for these patients out of the items in
the rations which were available, and that most of the patients convalescent
from the disease were definitely underweight. That this should have occurred is
not extraordinary, if one remembers that many of the patients were underweight
at the time they contracted infectious hepatitis. In a planned series of dietary
tests which were carried out early in 1944, it was shown that patients with
hepatitis would consume a diet high in certain proteins and carbohydrates, but
low in fats, with avidity. Further experiments showed that their dislike of fats
was probably based on the fact that under the conditions which existed in the
were very likely to be slightly rancid, and hence not well tolerated by these patients. As a result of these studies a special diet which contained 200 or more grams of protein, 25 to 50 gm. of fat and 400 or more grams of carbohydrate was devised for patients with hepatitis. By special arrangements made with the Quartermaster Corps, amounts of lean frozen beef and of dried skim milk were obtained which were adequate to provide the protein component of the diet, and patients with hepatitis had the first call upon all fresh fruits and vegetables procured by the quartermaster. Proper menus covering a 10-day cycle were prepared for the basic diet, and hospital dietitians throughout the theater were instructed in its preparation. This diet was very successful (if its success can be judged by its consumption) and was relished, with the result that most patients suffering from this disease showed a gain in weight at the time they left the hospital.28
The question of the waste of food was brought out in the report of Lt. Colonel Griffith29 and there can be no question but that much food was wasted in the North African Theater of Operations. Two factors were responsible for this waste: Poor menu planning and preparation of the ration as issued, and the high percentage of unacceptable items within the B ration. Interested members of the staff of the 17th General Hospital conducted a study in 1944 upon the acceptability of the ration as offered to patients. It is of interest that sources of protein showed a very high percentage of waste. Hospital patients were found to waste up to 25 percent of food offered, and ambulatory patients, 17 percent. A fresh educational campaign was found to reduce food wastage markedly. It was concluded that:30
Little can be said about this report because, first, it is true, and secondly, the Quartermaster Corps had been long aware of the unacceptability of certain of the items in the B ration, but had done nothing about them in the period in which the Consultant in Medicine was acting as a nutrition officer in the North African theater.
The general level of the preparation of food in the North African theater was low, and menu planning was essentially a lost art. In the recollections and experiences of the Consultant in Medicine there were but three good messes in the theater, and these were good because they were frequently illegal in respect to the types of food served and because they had capable cooks. The fault for the poor planning and preparation of food can be about equally distributed among command, mess officers, and cooks. The higher echelon of command in this theater, because of military exigencies, had little time to be interested in the details of unit mess operations. Such personnel, because of their position and responsibilities, usually ate in small well-operated messes. On the other hand, many mess officers were inadequately trained for their responsibilities and lacked the fundamental knowledge required for excellent mess operations. Few properly trained cooks were available, and these were most frequently found in kitchens of higher echelons. Poor selection of menus and poor preparation of food was generally responsible for the waste of food which occurred in the North African theater.
In summary, it can be said that many factors contributed to the problem of nutrition in the North African theater. Among these were:
1. The use of canned rations which were unpalatable, monotonous, and nutritionally deficient.
2. The misuse of emergency rations, a factor which was most difficult to eliminate, because logistically the compact emergency ration was the planner's delight, as so much else could be placed in the space which was saved by the use of emergency rations.
3. The utilization for more than a year of the Expeditionary Force Menu No. 1, B ration, which was finally shown in the Camp Lee, Virginia, tests to be a deficient menu.
4. The substitution and elimination of items in the rations.
5. The inexpert procurement of rations by mess officers.
6. The poor preparation of food.
7. The percentage reduction in rations for a 3-month period.
Nutrition in the European Theater of Operations31
A nutrition branch was established in the Division of Preventive Medicine of the Office of the Chief Surgeon, European Theater of Operations, late in August 1942. The branch began activities, therefore, early in the history of the theater and at a period when the ration scale for troops in the European Theater of Operations was still a subject of discussion. From that time it set
the dietary standards for rations provided by the Quartermaster Corps and determined the nutritional needs of the Army personnel. The nutrition branch grew with the theater, as did also the magnitude of its responsibility for the nutritional health of troops and of hospital patients and the variety of its interests in all phases of Army messing. It was recognized that the functions of nutrition officers were investigative and advisory and that the accomplishment of the mission of the nutrition branch depended upon complete coordination with commanding officers, responsible for mess operation, and with officers of the Quartermaster Corps, responsible for the procurement and issue of rations and for the training of mess personnel.
Activities of the nutrition branch
centered on the preventive aspects of sound nutrition but included the
nutritional rehabilitation of malnourished recovered American prisoners
liberated from German stalags, a problem which turned out to be one of the most
important purely medical problems confronted by the Chief Surgeon's Office,
European Theater of Operations. Field tests of the suitability of standard
operational rations for combat troops in Europe were planned and directed, an
activity of especial importance in the case of the new ten-in-one ration which
had not previously been subjected to trial under field conditions. As a result
of these trials and of other accumulated experience, pertinent recommendations
were made concerning the composition of C, K, and ten-in-one rations and
particularly concerning desirable changes in the B ration. The unofficial move
to supply a so-called Americanized version of the British Army ration to
American forces in the United Kingdom was opposed and new ration scales for
troops and hospital patients were pioneered. A troop ration was described in
terms of groups of foodstuffs, in accordance with their nutritive significance,
for the first time in a theater of operations of the United States Army; and,
for the first time, hospitals were issued a type A patients' ration which
did not require an added monetary allowance. The nutritional welfare of troops
in combat was constantly emphasized in theater directives and by personal
contact with officers of combat units. This was doubly necessary because of the
tendency to exaggerate the value of convenience of transport and issue of
operational rations with resulting potential damage to the nutritional fitness
of soldiers. This program, which was actively supported by the Chief
Quartermaster, European Theater of Operations, was so successful that the great
majority of combat units received the modified type A ration rather than C or K
rations, even when in contact with the enemy. Nutrition officers were
particularly prominent in the supervision of special procedures which were
designed to maintain mess operation on a high level in the marshalling areas
from which troops embarked for the liberation of France. Participation in
programs to prevent waste of food and to develop a sense of individual
responsibility for proper eating was encouraged.
TROOP RATIONS IN THE UNITED KINGDOM
British and British-American Rations. The first American units which arrived in Northern Ireland on 26 January 1942 were issued British rations and were loaned British Army cooks who familiarized American cooks with the ration components and with the stoves and other kitchen equipment. The same procedure was used as additional forces reached Ireland and England. The British Home Service ration included a cash element of 2½d (pence) per day which was used by British messes in the purchase of condiments and other items. This dietary was soon found unsuitable for the American Army and the amounts of meat, grain products, sugar, evaporated milk, and dried fruit were increased. Troops engaged in hard labor were authorized a 15-percent increase in this augmented British or so-called British-American ration.
According to American standards and tastes, the British ration was unsatisfactory because of its low caloric value and low content of milk, egg, beef, pork, tomato products, canned fruits and fruit juices, and coffee. On the basis of consumption, it failed to provide the levels of calcium, riboflavin, and ascorbic acid recommended by the National Research Council. The inadequacy of the Home Service ration for British troops was recognized by the British War Office and improvements were made in 1943. The British-American ration was more than adequate in calories but was deficient in tomato products, fruits, and fruit juices. Its nutrient supply was greater than that of the British Home Service ration but, on a consumption basis, it failed to supply the recommended levels of calcium, riboflavin, and niacin.
Early Development of the American
Ration. American rations were authorized on paper in February 1942 but
no menu was published and troops continued to receive either the British ration
or the British-American ration. The components of the authorized type A field
ration were the same as those of the garrison ration except that 4 ounces of
wheat flour and 8 ounces of bread replaced 12 ounces of wheat flour. The listing
of the garrison ration as the basic field ration in an overseas theater is
inexplicable in view of the fact that the garrison ration was designed for the
calculation of the monetary value and not for the issue of a ration. There was
concern over the authorization of this ration because of its weight (4.55
pounds) and caloric value (5,127 calories), and in May a revised ration was
published in which beef was decreased from 7.43 to 5.20 ounces, potatoes from 10
to 8 ounces, sugar from 5 to 4 ounces, bread from 8 to 7 ounces, and flour from
4 to 3 ounces. These changes lowered the caloric value from 5,127 to 4,562 but
still left the ration far in excess of the British Army ration so that pressure
was continued to decrease the difference between the rations of the 2 armies.
Undue attention was paid at this time to the weight of the authorized ration and
to the shipping which would be required to transport it across the Atlantic. No
consideration was given the fact that
the list of components did not constitute an acceptable ration nor the fact that the weights were not significant because boneless meat would be shipped rather than carcass meat, dehydrated potatoes rather than fresh potatoes, evaporated and dried milk rather than fresh milk, et cetera. On 28 July 1942 the first menu was published by the Office of the Chief Quartermaster, European Theater of Operations, and this served as the tentative basis of issue to units adjacent to the relatively few depots which were in operation at that time. The activation of quartermaster depots proceeded rapidly during the early fall and units were transferred from the British-American ration to the American ration accordingly. This changeover was nearly complete by the end of October except for those units of the Army Air Forces which shared stations with the Royal Air Force. At these stations either British or American rations were issued depending upon which force was numerically greater. It is interesting that neither group was satisfied with the ration to which it was unaccustomed. American Air Force enlisted personnel at stations issued the British ration (not the British-American ration) were particularly unhappy and requests for supplementation of the ration with canned fruits and fruit juices were not infrequent. Supplementation in these instances was impracticable and was not approved. Fortunately this situation did not continue long because incoming Air Force personnel made possible the general issue of American rations.
The first menu for the type A field ration (Table 5), which was published on 28 July 1942 as a tentative basis of issue, was authorized by the Commanding General, European Theater of Operations, United States Army, on 6 September 1942. The letter of authorization directed that the services of the newly assigned nutrition officer would be utilized to make the best possible use of subsistence and that the contents of the proposed menu should be modified when justified by further study. It became the first duty, therefore, of the nutrition branch to determine the adequacy of the ration prescribed by menus prepared by the Subsistence Division, Office of the Chief Quartermaster, European Theater of Operations, and to recommend improvements, if necessary. The reports of the resulting studies of the first menu authorized on 6 September 1942 and of the second menu (Table 5) authorized on 12 October 1942 paved the way for the subsequent complete revision of the ration scale upon which these menus were based. The reports, which were forwarded to the Chief Quartermaster and which served as a basis for the first of many regularly occurring conferences at which theater rations were discussed and evaluated during the ensuing 3-year period, emphasized the following points:
1. The caloric levels of the first
and second menus were approximately 4,800 and 4,500 respectively, both of which
were in excess of the actual energy requirement of troops. Adjustment of this
level should not be accomplished at the expense of the nutrients of the ration.
TABLE 5. NUTRITIVE VALUE OF TROOP RATIONS IN THE UNITED KINGDOM, WITH AND WITHOUT CORRECTION FOR MINIMUM LOSSES DURING ISSUE, STORAGE, PREPARATION, AND SERVICE OF FOOD1
1Uncorrected and corrected values represent
"as issued" and "as consumed" values respectively.
Corrected, or "as consumed" values, are estimated by making the
following deductions from "as issued" values:
2. Forty percent of the calories were from fat, a large part of which would not be eaten. Special measures to salvage unused fat were therefore necessary.
3. The substitutive table which was patterned after the one described for the garrison ration listed vegetables, in general, as substitutes for plant sources of vitamin A. In order to safeguard the adequacy of the ration it was essential that substitutes for leafy, green and yellow vegetables should be limited to
vegetables in that category. Similarly, substitutes for tomatoes should be limited to tomato or citrus fruit products.
4. Increased issues of fresh cabbage and potatoes, milk and tomato products were necessary in order to provide an acceptable ration.
5. Menus should be used as an instructional medium for mess personnel and should include data on methods of conserving nutrients during the preparation of food, on the necessity of complete utilization of the nutritionally important foodstuffs, and on other pertinent phases of mess operation.
Waste of Food in 1942. During November 1942 an extensive survey of American units in the United Kingdom was made by representatives of the Nutrition Branch, Office of the Chief Surgeon, of the Subsistence Division, Office of the Chief Quartermaster, and of the British Army Catering Corps. This investigation demonstrated that the issue of excess food was resulting in widespread wastage because of failure to use the ration economically and to return unused items to depots. It not only represented financial loss and the futile transportation of supplies across the Atlantic but also had an unfortunate effect on the British who were campaigning for the maximum prevention of waste.
Revision of Ration Scale. On 12 December 1942 the chief of the Nutrition Branch, Office of the Chief Surgeon, was specifically ordered to recommend whatever changes in the current directives on rations were deemed appropriate as a result of his investigations in the theater. As a matter of fact, the third menu, published 22 December 1942, was satisfactory in most respects because most of the earlier recommendations of the branch had been approved by the Subsistence Division, Office of the Chief Quartermaster, and incorporated in the menu. The caloric level had been decreased temporarily to 3,800 as a means of emphasizing the necessity of complete utilization of the ration. None of these changes were in accordance with the theater ration directive so that there was need of a restatement of the basic components and allowable substitutive items of the rations. Advantage was taken, therefore, of this opportunity to describe the field ration in terms of food classes composed of nutritionally similar foodstuffs. Substitutive items were rigidly restricted to those of nutritional equivalence and both basic components and substitutes were limited to those known to be available. The proposed new directive on rations was published on 11 February 1943. Only minor changes in the troop ration scale were necessary in subsequent revisions of this circular.
Average Type A Menu in the United
Kingdom. The composition of the average type A field ration issued in
the United Kingdom between 1 January 1943 and 1 February 1945 was adequate in
all nutrients except riboflavin which was 10 percent less than the recommended
allowance. This was not believed significant and there was no evidence of
ariboflavinosis in the troops. It is highly probable that 2.0 mg. of riboflavin
daily are more than sufficient. From
a practical standpoint it is very difficult to provide this level even in a varied diet containing meat, milk, and eggs without occasional servings of liver and without riboflavin-enriched flour and bread. Worthy of emphasis is the fact that United States Army rations in the United Kingdom contained neither white flour (70 percent extraction) nor white bread. British flour (85 percent extraction) and British bread were used and the consumption by the troops was very satisfactory (0.424 pound daily). The average intakes of evaporated milk and of dried egg were the equivalent of one pint of whole milk and of one egg daily. Servings of cabbage and of brussels sprouts were in excess of American food habits. The average daily issue of all fresh vegetables, other than tomatoes and potatoes, amounted to 0.375 pound, 28 percent of which consisted of cabbage and sprouts.
Hospital (Patients' ) Ration. The first theater directive on hospital rations in February 1942 authorized one field ration plus a monetary allowance of one shilling (approximately 20 cents) for the feeding of patients. Quartermasters were directed to procure the extra foodstuffs, requisitioned by hospital commanders, from "any available source." Later, hospitals were allowed to purchase food supplies for patients from local civilian sources as well as from the quartermaster. The monetary allowance was unsatisfactory in the United Kingdom because of the very limited number of foodstuffs which could be procured by local purchase. The theater abolished the monetary supplement in February 1943 and adopted a special patients ration at the same time that the revised troop ration was authorized.
In November 1943, the availability of supplies permitted revision of the hospital ration scale and small increases were authorized in meats, milk products, fruit juices, and potatoes. These additions were offset by decreases in legumes and grain and the energy content remained approximately 4,000 calories. Up to this time the majority of patients consisted of sick individuals without particularly hearty appetites. As more and more wounded Air Force personnel arrived in the hospitals, the ration which heretofore had been adequate required supplementation. Provision was therefore made for significant augmentation whenever necessary. Prior to D-day, increases were authorized in the hospital ration in anticipation of the expected change in the type of hospital patient. The greater appetite and food consumption of average battle casualties compared with average patients is noteworthy.
The hospital ration in the United Kingdom
was never the same as that issued on the Continent because of the greater supply
of fresh meat and vegetables in England. Menus described the regular patients'
diet only. Provision was made for modification of the ration issue whenever the
need for special diets increased above 20 percent. This was the case if certain
hospitals specialized in specific types of patients, such as those with
hepatitis, with jaw injuries, et cetera. Provision was also made for the feeding
of soup, sandwiches, egg-
nog, fruit juices, and coffee at airstrips receiving casualties by plane from the Continent. Similar arrangements were made at so-called "transit hospitals" receiving casualties transported by water.
The special hospital ration used in the United Kingdom was composed of the items appearing in the troop ration, plus skimmed milk powder (for fat-free diets), malted milk powder, egg noodles, brown sugar, canned soups, purees, et cetera. It supplied 100 percent more chicken and fruit juices, 65 percent more milk, 20 percent more eggs, and 40 percent more fruit than the troop ration.
Planning for Rations in Combat. The continuation on the Continent of the excellent ration supplied in the United Kingdom was impossible for many months after the establishment of a beachhead. The enormity of the problem of transport across the channel and from beach depots to rapidly moving armies demanded the temporary use of nonperishable, conveniently packed, and easily prepared rations. Operational rations, such as C, D, and K, and the nonperishable type B ration were already stocked in depots in the United Kingdom. Because the latter ration consisted of more than 100 different foodstuffs in as many different containers, the Chief Quartermaster, European Theater of Operations, proposed the preparation of a so-called twelve-in-one ration which would supply in a single box an assortment of type B components sufficient for 1 day's supply of food for 12 men. Before more than a few units of the twelve-in-one had been assembled, the theater was informed of the availability of the new ten-in-one ration in the United States. The ten-in-one appeared to fill the need for a ration intermediate between C and K and the type B ration, and plans for the twelve-in-one were therefore dropped.
In order to familiarize the theater with the advantages or possible disadvantages of operational rations, a ration board headed by the chief of the Nutrition Branch, Office of the Chief Surgeon, was appointed in 1943 and directed to conduct comprehensive field tests on rations which would be used later in combat. In the first of these field tests it was noted that troops remained in reasonably good physical condition during a 10-day period on C, K, and five-in-one rations but that the rations were deficient in calories, especially for large men. The report listed the following recommendations: The use of the D ration as a supplement only; the restriction of the use of C and K rations to 5-day periods unless supplemented; the replacement of the wholly unsatisfactory dextrose and malted tablets of the K ration with a desirable confection; the replacement of the fruit powder component of C and K rations with a source of ascorbic acid which would guarantee the utilization of this nutrient; and, the addition of cigarettes, gum, matches, and toilet tissue to the rations which lacked these articles.
The report of the second trial noted the
acceptable quality of the majority of the components of the recently developed
ten-in-one ration and the excellence
of its packaging but emphasized its marked inadequacy in calories (3,300-3,400) for troops during 15-day maneuvers in moderately cool weather (35°-55° F.). The following recommendations were made: An increase in caloric value to 3,900 calories; a limitation of 30 days in its issue and of a total of 40 days in the issue of ten-in-one and unsupplemented B rations; the replacement of the dehydrated baked beans, the fortified fruit powders, the K-1 biscuits, and the dextrose and malted milk tablets; and the addition of cocoa beverage powder, pea or bean soup powder, extra cereal mixture with increased sugar in the mixture, components for hot drinks twice daily, heating units, and extra paper tissues.
The conception of the ten-in-one ration was basically sound but it was obvious that it was developed for use in warmer areas than Western Europe. Because of the demonstration of the marked caloric deficiency of this ration, the theater decided to use it on an 8-man basis or to supplement it with additional food if it was issued on a 10-man basis.
Specific recommendations were made to the Chief Quartermaster, European Theater of Operations, with respect to feeding troops on the Continent: Shipment of bakery units and of fresh meat to the Continent at the earliest possible moment after D-day so that the maximum period for subsistence of troops on wholly processed rations (D, C, K, ten-in-one, and B) would not exceed 40 days; substitution of canned roast beef or canned meats for less desirable components of the B ration; replacement of the butter substitute; modification of the ten-in-one ration; supplementation of C and K rations with miscellaneous nonperishable foodstuffs (sardines, peanuts, jam, et cetera) as a means of avoiding monotony; supplementation of C and K rations with multivitamins after 15 days in the event these were the only rations available; and provision of individual heating units, preferably tablets of the hexamine type.
These efforts to improve the quality of processed operational rations were supported by the Chief Quartermaster and were successful insofar as the ten-in-one ration was concerned. The theater was informed in April 1944 that the caloric value of the ten-in-one had been increased from 3,400 to 3,700 and that in future procurement in the United States the ration would provide 3,900 calories. These improved types were received before the termination of hostilities on the Continent but improved C and K rations were not available until the later spring of 1945. Additional type B meat components, such as canned beef and gravy, pork and gravy, sardines, et cetera, were received but not until after the type B ration had been replaced by the A ration with its fresh foodstuffs. Individual heating units of the wax candle type were received but were little used because of their unsatisfactory character.
A supplementary ration for the nourishment
of casualties in beachheads was essential because C or K rations were wholly
unsatisfactory for this purpose. The procurement of such "patient's
operational ration" was one of the
first activities of the Nutrition Branch, Office of the Chief Surgeon. The Office of the Chief Quartermaster agreed to prepare cases, each containing fruit juice, milk, sugar, and coffee for 20 men, if an equivalent ration could not be procured from the United States. Subsequently, the 25-in-1 hospital supplement was developed in the United States and was used with great benefit in Italy and in France. Procurement of this supplement from the United States became impossible in the spring of 1945 so that an additional quantity was assembled from supplies in the United Kingdom for use by the armies in Europe.
In addition to the 25-in-1, a second supplement, the B-C pack, was requested by the theater and supplied from the United States. This unit contained bouillon cubes and cigarettes and was designed for issue to aid stations. These components were selected following a survey of battalion medical officers in experienced divisions which had arrived in England from the North African theater. The value of this supplement was questionable, mainly because of the successful provision of other nourishment to frontline units.
RATIONS ON THE CONTINENT
Type C and K rations, supplemented with the D chocolate bar, were used on the Continent until D-day plus 5, at which time ten-in-one rations were available for issue to troops in rear areas. The latter ration was widely used until D-day plus 33 when type B components were distributed. By D-day plus 40 fresh bread and meat were issued in limited quantities. The supply of bread increased rapidly as new bakery companies arrived and went into production. The early establishment of bakeries on the Continent and the movement of these with the armies contributed immeasurably to the maintenance of the nutritional health of the troops.
Operational rations were supplemented with
captured enemy foodstuffs and with fresh vegetables and eggs which were surplus
in many districts of Normandy and Brittany. Shipments of potatoes and carrots
were received from the United Kingdom after D-day plus 90 and, at the same time,
arrangements were made with French authorities to obtain tomatoes, onions,
celery, and cabbage whenever these were in surplus of civilian requirements. The
listing of fresh meat and vegetables in monthly menus of the modified type A
ration was possible starting with the September menu. It is estimated that about
one-half of the meat and vegetable issue during the fall and winter consisted of
fresh items. Combat troops and hospital patients were given first priority on
fresh meats. The meat issue in the armies was augmented by the capture of large
cold storage plants well stocked with carcass beef. As an illustration, the
After-Action Report of the Third United States Army, 1 August 1944 to 9 May
1945, states that the army captured 2,600,000 pounds of frozen beef and 500,000
pounds of canned beef, property of the German Army, and issue to frontline
troops was started at once.
Vigorous efforts were made by the Nutrition Branch, Office of the Chief Surgeon, and by many Quartermaster Corps officers to minimize the use of operational rations, except as emergency rations for frontline troops. Supply officers were inclined to overemphasize the convenience of transport and issue of the C, K, and ten-in-one rations at times when convenience was not a tactical necessity. The justification for the use of the modified A ration with its hot, varied meals did not depend on a theoretical effect upon physical fitness and morale. These positive effects were real and were recognized by the personnel of experienced divisions. The contrast between old and new combat divisions in this respect was most enlightening. Table 6 shows the proportional use of operational rations on the Continent. The extent of issue of nonoperational rations to combat, as well as service troops, was most gratifying. It is significant that the Battle of the Bulge, which occurred in an area easily supplied with A rations, did not increase the issue of operational rations (December 1944 and January 1945, Table 6). This is in contrast to the requirement of these rations in the period of rapid movement away from supply depots during the overrunning of Germany (April-May 1945).
TABLE 6. ISSUE OF OPERATIONAL RATIONSPERCENT OF RATIONS ISSUED
Source: Data supplied to author by Office of the Chief Quartermaster, Headquarters, European Theater of Operations, United States Army.
Troops were on a diet practically devoid of ascorbic acid whenever they subsisted on unsupplemented C, K, or ten-in-one rations in the cold weather which was general in Europe. This resulted from the refusal to prepare and drink the lemonade which may be made from the fortified lemon or other fruit powders. Revised forms of the improved C and K rations were on hand late in the war but the bulk used between D-day and April 1945 consisted of unimproved types. These were unpopular and were poorly utilized. Limited experience with the newest C ration indicated that troops preferred it to the K ration. The K ration appeared more desirable than the unimproved C ration except in units which made provision for heating the C ration. These units set up field ranges as close to the front as was feasible, heated the meat components of the C ration in boiling water, repacked the hot cans in cases and sent them forward for distribution. The taste of the C ration meat component was greatly improved if warmed.
The deficiency in thiamine and the questionable deficiency in riboflavin in the type B ration was corrected as quickly as fresh items became available. The ration was adequate by October 1944 and by February 1945 was superior in its content of nutrients to that supplied in the United Kingdom before D-day. The difference was primarily due to enriched flour, which was used on the Continent and which had a higher content of thiamine and riboflavin than the British National flour.
Extra ration allowances were authorized combat units occupying positions in contact with the enemy. These augmentations included a 10-percent overall increase for units receiving the A or B ration and additional meat, jam, bread, and coffee ingredients for troops receiving operational rations. Full advantage was taken of these authorizations and the service of sandwiches and coffee to frontline troops as supplements to C and K rations was a common occurrence.
In June 1945, rations for personnel engaged in nonarduous duties, except patients, were automatically decreased 10 percent. Fortunately the ration was rich enough in nutrients so that minimum allowances were still supplied. Overall deductions are hazardous because of the failure to distinguish between foods of high and low nutrient content. The decrease in June was necessitated by the theater shortage in rations. It should be noted in this connection that the average ration was insufficient for units performing very heavy labor and required augmentation.
Hospital Rations. The feeding
of battle casualties was quite satisfactory. The rapid evacuation to the
hospitals in the United Kingdom, both by air and by water, materially eased the
load on the medical units which preceded general hospitals to the Continent. The
result was that operation hospital rations were only required in the early
stages of the invasion. Most of the casualties arrived very quickly in areas
where type B or A components were
available. The hospital ration on the Continent differed from that in the United Kingdom in that the continental ration consisted of the troop ration plus a supplementary list of foodstuffs, whereas patients in the United Kingdom were supplied a separate special ration. The continental issues were generally excessive unless hospital mess officers refused components of the troop ration which were not needed. The authorization for the use of the special hospital ration on the Continent was refused by Headquarters, European Theater of Operations, United States Army, for the reason that depots would find it too difficult to provide 2 rations rather than 1 ration plus a supplement.
AUGMENTATION AND REDUCTION OF RATIONS
In August 1942 authority was granted the Commanding General, Services of Supply, European Theater of Operations, to increase the augmented British ration (British-American ration) 15 percent if not less than 75 percent of an organization was engaged in hard physical labor for 10 or more hours daily, 6 days per week. This augmentation ceased as troops received the American ration in September and October of 1942.
Early in 1943, upon the request of the Air Surgeon, members of air combat crews on operational status were authorized 3 fresh eggs and 3 oranges per man weekly and 0.0625 pounds of powdered whole milk daily. Later, Air Force combat and repair crews on operational status were allowed an additional augmentation. The request for shell eggs and oranges was approved by the Office of the Chief Surgeon, European Theater of Operations, as a morale measure and not because of nutritional necessity. The request for components for a fourth meal was granted without the reference of the matter to the Chief Surgeon for investigation and recommendation.
In view of the increasing number of
requests for augmentation of rations, mainly from port and engineer battalions,
an extra allowance for units performing arduous tasks was written into the
theater directive on rations. Nutrition officers had been assigned to the staffs
of base section surgeons by this time so that it was possible to make the
augmentation contingent upon an investigation which "shows that the
authorized ration issue is properly prepared, served and eaten and that a need
for additional food still exists." The augmentation, which supplied
approximately 400 calories, was purposely limited to bread or flour, potatoes
and lard, although most units which requested extra food desired more meat. The
basic ration was adequate in nutrients and generous in its meat components and
it was believed to be sound policy, therefore, to confine supplements to
reasonably available foodstuffs which provided the necessary calories. Units
which were not interested in eating more bread and potatoes were not considered
to be suffering from a shortage of food. As a matter of fact, few of the
requests for augmentation were found to be justified.
These investigations by nutrition officers did prove to be excellent opportunities for instruction of untrained or careless mess personnel.
The above procedure which provided for a thorough survey of the physical well-being of troops as well as a determination of the adequacy of the quantity of the ration issue was a most satisfactory method of controlling the vexing problem of insuring that soldiers were well-fed without incurring the risk of waste of food because of oversupply. Unfortunately, it became necessary in July 1944 to replace this system with one which liberalized the issue of augmented rations and recognized the fact that it was easier to supply extra food to a unit than it was to insist upon efficient mess operation. Prior to the invasion of France requests for augmentation of the ration increased enormously due to the number of depot and port units which ran day and night shifts. Some units attempted to feed sandwich meals at night rather than hot meals prepared by a night shift in the mess. The ration was not adapted for sandwich meals. Night feeding was poor, therefore, and vegetables, canned fruits, et cetera, accumulated in storerooms. In other units, which served regular hot meals at midnight, men on the night shift were permitted to get up and eat the midday meal with the day shift. The total daily food intake of these men was no greater but this practice did deprive the day shift of its normal share of the more desirable components of the ration, especially of its share of the meat issue. Artificial shortages of certain ration items developed from these failures of mess officers to insist upon mess discipline and proper mess operation. During this period the Commanding General, Services of Supply, European Theater of Operations, believed it necessary to authorize many augmentations without the usual preliminary survey. All investigations were therefore discontinued and augmentation requests were approved as they were received. As soon as the emergency created by the main invasion operations had passed, the augmentation procedure was brought under control again by a new directive which rescinded all previous written and verbal authorizations for extra rations and which described the specific types of augmentation which might be requested. The ration increases for the Air Forces, referred to above, were reaffirmed. An automatic increase of 10 percent was allowed messes serving less than 50 men in order to provide adequately for the many isolated antiaircraft and similar groups consisting of 5 to 20 men. The Chief Quartermaster, European Theater of Operations, was authorized to grant extra food to troops engaged in hard labor, to noncombat sectors, to troops returned to rest camps after combat, and to troops operating under exceptional circumstances provided the Chief Surgeon recommended the augmentations as essential for the maintenance of physical fitness.
In June 1945 the theater ration and
augmentation directives were drastically revised. The new directive, which took
into consideration the cessation
of hostilities and the critical shortage of rations within the theater, included the following provisions:
1. All augmentations were discontinued except the 10-percent increase for small messes (under 50) and increases for crews of small watercraft. The way was left open for augmentations which were approved by the Chief Surgeon, European Theater of Operations, but it was emphasized that nutritional necessity, and not convenience in mess operation, would be the sole factor governing the approval of an augmentation request.
2. Decreases in normal ration issues were authorized for the first time in the theater:
a. Rations for all military personnel engaged in sedentary duties were automatically reduced by 10 percent.
b. Base section and other commanders were directed to review constantly troop lists in their respective commands and to apply reductions up to 10 percent for all troops engaged in light or moderately active duties.
c. A percentage reduction, as follows, was directed for all messes not affected by the provisions of paragraphs a and b, above:
None of the above reductions applied to ration items, such as shell eggs or fruit, issued on the basis of one per man. Furthermore, personnel in the following categories were exempted from all reductions: Hospital patients, troops undergoing vigorous training or engaged in hard labor, troops on leave or in officially designated rest areas, messes serving less than 50 men, and recovered Allied military personnel (RAMP's).
Vitamin Supplementation. The supplementation of rations with multivitamins was a relatively unimportant feature of rationing in the European Theater of Operations except in the case of hospital patients and Air Force personnel. The former required extra vitamins if the food intake was insufficient to provide the necessary levels of these nutrients. Combat crews were supplied multivitamins at the request of the Air Surgeon. This may have been justified as a preventive measure related to a possible greater need of certain nutrients by aviators. The basis of such a need was never demonstrated.
In February 1944 a survey of the dietary
histories of the personnel of small detachments (1-15 men) of the Corps of
Military Police, Finance Department, and Transportation Corps, located in
cities, towns, and villages throughout the United Kingdom, showed that the
intake of vitamins was well below the minimum standards. These men were isolated
from United States Army messes and received a monetary allowance in lieu of
rations. Obviously no control of their purchase of food was possible except that
of the British rationing
regulations. Arrangements were made to supply multivitamins to these detachments although no evidence of nutrient deficiency was uncovered.
Provision was made for distribution of vitamins to combat troops in the event subsistence on unsupplemented rations continued for periods in excess of 15 days. Fortunately, few units were ever in this category. Conferences with division surgeons disclosed that few believed that vitamin supplementation was necessary. These conferences always served the purpose of reemphasizing the desirability of extending even more the common practice of augmenting operational rations with sandwiches and other items.
The initial survey of German stalags at Limburg, Zigenheim, and Heppenheim by the Nutrition Branch, Office of the Chief Surgeon, revealed the magnitude of the RAMP problem. It furnished the background for the measures adopted to insure nutritional rehabilitation of the men who required immediate hospitalization, or who were hospitalized during or after evacuation to the camps in the rear areas, and of the men who, although suffering from malnutrition, were not hospitalized and remained under the control of the Provost Marshal, European Theater of Operations. A directive was immediately distributed to hospitals outlining therapeutic dietary procedures for the various categories of malnourished patients. The nutritional care of nonhospitalized RAMP's was effected by the authorization of a special bland, high protein, high calorie ration for use in RAMP camps. Conferences were held with base section surgeons and with medical officers in these camps in order to guarantee the proper use of the bland diet. This dietary regime was necessary because of the extreme gastrointestinal sensitivity which characterized RAMP's. Diarrhea was almost universal before corrective measures were instituted. It was necessary to prohibit the distribution to RAMP's of peanuts, candy bars, doughnuts, et cetera, by the Army Exchange Service and by the Red Cross because it was evident that these well-intended measures were in reality harmful. Studies of nutritional rehabilitation in the RAMP camps were not undertaken because it was the original policy of the theater to evacuate these troops to the United States immediately. Provision was made for the continuance of the bland ration on the ships carrying them home.
OTHER RATION PROBLEMS
Milk and Ice Cream. Milk
issues consisted almost exclusively of evaporated and dried whole milk. Small
amounts of skimmed milk powder were included in the hospital ration for use in
low-fat diets. One shipment of 3,200 quarts of frozen whole milk was received in
good condition in the United Kingdom in March 1945, and was distributed to
hospitals. Beverage milk and eggnog were prepared and served in hospitals but no
serious attempt was made to popularize the use of beverage milk in troop messes
although suitable instructions for its preparation were published in mess
bulletins. The dried whole milk was very
acceptable, however, and yielded a reasonably good fluid milk if care was used in its rehydration and particularly if the product was flavored with chocolate or vanilla. In view of the lack of apparatus for the large-scale reconstitution of fluid milk from milk powder, emphasis was placed on the utilization of dried and evaporated milk in cooking, in cocoa, on cereal, and in similar ways. Consumption of the milk component of the ration was satisfactory. This would not have been the case in the absence of an intensive educational program.
Early ration directives authorized the daily issue of the equivalent of 5 ounces of evaporated milk per man. This was not considered sufficient and the Nutrition Branch, Office of the Chief Surgeon, was instrumental in having the allowance increased to 7 and 10 ounces, and later to 8 and 12 ounces, for troops and hospital patients, respectively. Thus, troops received the equivalent of 1 pint of whole milk daily. The additional milk added greatly to the acceptability of the ration and assisted materially in assuring satisfactory intake of calcium and riboflavin. The use of fresh milk from local sources in the United Kingdom and on the Continent was restricted and later prohibited because of the medical hazard involved and because of the scarcity of the supply for civilian use.
The manufacture of ice cream by British concerns was prohibited by governmental order as a means of conserving materials and of insuring a uniform distribution of available milk. The American Army supported this policy and ice cream was not supplied except as it was prepared by hand freezing in small quantities in a few messes. The British restriction was removed after the liberation of France and Belgium, and in January 1945 the use of ice cream by United States Army units in England and on the Continent was authorized and encouraged. It was specified, however, that ice cream would be prepared from ration components exclusively and that civilian manufacturing agencies must maintain United States Army standards of sanitation. In August 1945, ice cream mix became a normal component of the ration issue.
Dehydrated Foods. The issue
of dehydrated foods was not a serious problem in the European theater because
these items never predominated in the ration. Dried milk was acceptable. Dried
egg was not received enthusiastically but it was a useful item if used as an
ingredient. The wastage was excessive whenever it was served as an omelet or as
scrambled egg because of the inability or refusal of cooks to prepare it
properly. Onion was very satisfactory if used with ground beef. It was
unsatisfactory if used as a vegetable. Potato was acceptable if reconstituted
properly. Sweet potato was a good product but the amount in the B ration was
excessive for the average soldier. Carrots and beets were reasonably
satisfactory. Obviously, none of these dried foodstuffs was a good substitute
for the canned product. The problem of dehydrated foods was worsened by the fact
that relatively few cooks had received sufficient training on the handling of
this type of foodstuff.
Local Procurement of Foodstuffs. The general policies governing the procurement of foodstuffs from sources within the theater were designed to save transoceanic shipping by the maximum use of local surpluses and, at the same time, to protect the food rationing programs of the British and other Allied governments by restrictions on miscellaneous purchases by individuals and units of the American forces. The British Ministries of Food and of Agriculture made available large quantities of such foodstuffs as flour, bread, prepared cereals, rolled oats, tea, marmalade, syrup, condiments, potatoes, and vegetables. Procurement through authorized quartermaster purchasing officers was also authorized on the Continent but this was limited largely to fresh vegetables and the supply permitted only occasional issue. The supply of potatoes, cabbage, carrots, beets, rutabagas, and brussels sprouts was practically unlimited in England. Tomatoes and lettuce were only abundant during short seasons so that the dietary was generally lacking in fresh salad components. Fresh fruits were notably lacking in the American ration. Seasonal apples and pears were unrationed in England and the same was true of apricots and grapes in France, but the former were of inferior quality and the latter were readily available only in southern France. Shipments of oranges, which were received occasionally in 1944 and 1945, were therefore especially appreciated by the troops.
The purchase of meals in public restaurants was prohibited on the Continent. No such restriction prevailed in the United Kingdom although the demand for meals sometimes exceeded the supply. The American Red Cross provided snack bars which were well patronized. These were limited to British sources of supply and to British rationing in the United Kingdom but were allowed to purchase quartermaster subsistence supplies on the Continent.
RATIONS FOR PRISONERS OF WAR
A small number of German and Italian prisoners of war were brought to the United Kingdom from North Africa in 1943. Prisoners captured in Normandy in 1944 increased the number but the total in the United Kingdom under the control of the United States Army was never large. These prisoners of war were issued a ration which did not differ greatly from that supplied American troops. No distinction was made in the rations for working and nonworking prisoners.
Prisoners of war on the Continent were
issued a similar ration until 7 December 1944, except that nonworkers received
20 percent less than workers. At this time the worker's ration was reduced from
3,860 to 3,258 calories; non-workers received 10 percent less. Another reduction
was made in April 1945. For the first time separate rations were authorized
nonworkers because it was not feasible to make an overall percentage deduction
in the worker's ration to bring the caloric level down to the 2,000 calorie
level ordered by the theater
for nonworkers. These ration decreases were the result of the disparity between tremendous numbers of captured prisoners and the relatively small stocks of available foodstuffs. Furthermore, the 2,000-calorie ration was authorized as the theater ration for displaced persons and others whose subsistence was the responsibility of Allied Military Government. The earlier rations supplied nonworkers were in accordance with the Geneva Convention and were in excess of the actual requirements of the prisoners. This original policy was bitterly criticized by Allied civilians because nonworking prisoners had more to eat than Allied workers. Following the German surrender in May 1945, practically all the prisoners held by the armies inside of Germany were classified as "disarmed forces" and their subsistence became the responsibility of the civilian food administration. Prisoners of war in the communications zone remained on the prisoner of war ration.
In February and March 1945 the Nutrition Branch, Office of the Chief Surgeon, was directed to investigate the nutritional status of prisoners of war in American custody. The survey team, consisting of 2 medical and 2 nutrition officers examined 800 prisoners in representative work camps and enclosures. The results showed that the nutrition of prisoners who had been in American hands for 50 days or more was satisfactory and considerably superior to that of newly captured Germans. This indicated that the prisoner of war ration in use during the early part of 1945 was superior to the ration of the German Army.
In August 1945 the Nutrition Branch, Office of the Chief Surgeon, was directed to make a second theater survey of the adequacy of the feeding of prisoners of war and of German disarmed forces. The 2,000-calorie ration was found to be insufficient for German prisoners under 21 years of age and for others who were classed as nonworkers but whose caloric needs were significantly increased by fatigue duties, calisthenics, or marching. The 2,000-calorie ration was adequate for individuals who were inactive in fact. The German civilian ration issued to disarmed forces varied from 1,200 to 1,500 calories at that time and was inadequate. This was especially true because there was no opportunity for the men in the enclosures to supplement their rations as German civilians were able to do from gardens, household supplies, et cetera.
Nutrition in the Persian Gulf Command
In the noncombat or less active areas such
as the Persian Gulf Command and China-Burma-India theater, the problems in
nutrition were of a different nature. In the Persian Gulf Command, troops were
stationed primarily in fixed installations. The field ration was used throughout
1943, and supplemented by vitamin tablets up to June of that year when the
practice was discontinued because the ration was felt to be nutritionally
produce could not be fed to soldiers because of the native's custom of using night soil for fertilizer. No fresh meat was provided for the command until just prior to the Teheran conference. No master menu was ever prepared in this command, the menu being largely dependent upon the arrival of reefer ships. There was some inequitable distribution of food; however, no vitamin deficiency diseases were known to have existed.
The problem of feeding Army employees who were local inhabitants of various religious faiths and food habits was encountered in the Persian Gulf Command. For example, Mohammedans were provided goat meat in lieu of pork. The problem also arose in the China-Burma-India theater, where nutritional deficiency disease developed among Chinese troops stationed in a training center at Ramgarh, India.
Nutrition in the China-Burma-India Theater32
The establishment of a theater of operations by the United States Army in India and Burma presented peculiar subsistence problems. Our forces were not invading a hostile country where subsistence could be requisitioned from the populace and where supply lines could be appropriated and set up without regard for the native population. They came as "guests" to a densely populated, Allied country in the throes of political unrest. Furthermore, a large proportion of the population was on the brink of a great famine which was to destroy by starvation a million and a half people in 1943. The United States troops could not be concentrated within a few well-consolidated areas, but because of military necessity were scattered in small groups separated by thousands of miles. The existing ground lines of communication between these areas were extremely primitive or nonexistent. Rations of the British or Indian Armies were not acceptable to our troops. It was intended, however, for these troops to "live off the land."
When the first contingent of troops arrived in India from the United States early in 1942, no provision had been made for the continuous supplying of these troops with subsistence from the Zone of Interior. A reserve stock of B rations was sent to the theater, but these were not to be used except in emergencies. It was intended that these troops should be fed on supplies obtained from local markets and on rations obtained through the British Army. In October 1942, a theater policy was adopted governing the subsistence of United States troops in India and Burma.33 The ration consisted of the British troops field service ration obtained through the Royal Indian Army Service Corps, supplemented by local purchase of fresh supplies and by the issue of excess stocks of the reserve B ration. These reserves were augmented from time to time by ship-
ments from the Zone of Interior which permitted rotation of stocks to prevent spoilage and which provided a reserve for subsequent incoming troops.
Unfortunately the excess stocks of B-ration reserve were slow to accumulate and confusion existed as to what constituted an emergency. It was often difficult to maintain the reserve at the authorized level because of the rapid expansion of the theater. The British troops field service ration was found to be unsuitable for United States troops because many items such as pork and soya links, corned beef and mutton, were not acceptable and hence were not eaten. The milk allowance received from the British Army amounted to only 2 ounces of tinned milk per man per day, which is not considered to be adequate for United States troops. Practically no fresh milk was available because of the insanitary conditions under which it was produced. Fresh meat was scarce and of inferior quality, because of the Government of India law which prohibits the slaughter of bullocks in good state of health under 10 years of age, pregnant cows, or cows in milk. Other fresh meats were not available. Difficulty was also encountered in obtaining sufficient quantities of high quality fresh fruits and vegetables. These were available to troops in the metropolitan areas such as Karachi, New Delhi, and Calcutta, but were scarce in isolated regions such as the Brahmaputra River Valley. Menus were prepared in the various section headquarters located in the above mentioned cities but these could only be used in the immediate vicinity because of difficulty of distribution.
Numerous complaints were received by the Surgeon of the theater that the dietary of the troops was deficient in calcium, thiamine, riboflavin, and vitamin C. Medical officers reported a reduction in the efficiency of the command which they attributed to malnutrition. A large proportion of the troops reporting for sick call complained of weakness, insomnia, lassitude, and gastric complaints which were suggestive of a deficiency state. An increase in the occurrence of gingivitis was also observed which may have been precipitated by a vitamin C deficiency.34
The situation became serious enough to warrant careful study of the adequacy of the ration and means of improving the nutritional status of the troops. In midyear of 1942 a nutrition officer, Capt. (later Maj.) M. J. Babcock, SnC, was assigned to the theater as Nutrition Consultant to the Surgeon, Headquarters, Services of Supply, China-Burma-India. He made a thorough study of the dietary of the troops and concurred in the opinion that the ration was deficient in calcium, thiamine, and riboflavin. Dietary studies of the troop ration continued throughout the autumn and winter and were summarized in a report in January 1943.35 On the basis of these studies, the Surgeon recommended that:
1. The allowance of canned milk obtained from the United States be increased to supplement the 2 ounces received from the British Army;
2. Troops in Base Section No. 3 (Ledo area) be issued the B ration instead of the British Troops Field Service Ration; and
3. The ration of other troops stationed in Assam be supplemented with canned fruits and vegetables.
Troops in the forward areas deserved preference in subsistence because they were fighting and doing heavy work under very adverse conditions and because local supplies were not available. These recommendations were put into effect. Stocks of B rations which were beginning to accumulate in excess of the authorized reserve were diverted to the use of hospitals and combat aircrews. The Surgeon, China-Burma-India, recommended that the Expeditionary Force Menu No. 1 (Tropical and Temperate Climate) be adopted as the field ration for this theater. No action was taken on this recommendation at that time and the policy of "living off the land" was continued except in the Ledo area.
As a result of the complaints that the ration was nutritionally inadequate, many requests for the issue of multivitamin tablets to supplement the ration were received by the Surgeon's Office. Since this item was in critical supply at that time, it was necessary to establish a theater policy governing the issue of multivitamin tablets to supplement the ration in order to insure expeditious use of available supplies. The issue of multivitamin tablets was authorized to supplement the ration of troops only upon certification by the unit medical officer that a specific deficiency existed and that no foods were available to correct this deficiency. Requisitions accompanied by the certificate were required to be submitted to the Surgeon, Headquarters, Services of Supply, China-Burma-India, for final approval. Later in 1943 this policy was liberalized to include the issue of multivitamin tablets to combat aircrews and units subsisting on emergency rations.
At this time an outbreak of nutritional deficiency disease occurred in the form of beriberi among Chinese troops at the Chinese Training Center at Ramgarh, India. This outbreak was investigated by the nutritional consultant.36 Between 8 August and 25 September 1943, 199 patients were hospitalized with beriberi as the primary cause of hospitalization. Many patients were not admitted to hospitals but were treated as outpatients at dispensaries. Other symptoms of deficiency diseases such as night blindness, cheilosis, glossitis, and osteomalacia were also observed. These troops had recently arrived from China and most of them had a background of chronic malnutrition. The rice eaten by some of them had spoiled and required much washing which
caused the extraction and loss of
nutrients. The diet prescribed for Chinese enlisted men in India at that time
had the following composition:
A nutritional analysis of this ration made at that time showed the following daily allowances of nutrients:
This dietary was obviously deficient in calcium, vitamin A, thiamine, riboflavin, and ascorbic acid. The ration was changed as follows: 1½ pounds of undermilled rice was substituted for the 2 pounds of polished rice, and one-half instead of one-third of the vegetable allowance was prescribed as green. The following ingredients were added: 2 ounces of dried beans, 2 ounces of peanuts, and 4 ounces of atta (whole wheat flour). Subsequent to these changes, no further widespread incidence of nutritional disease occurred among troops of the Chinese Army in India or Burma.
With large numbers of troops moving into Assam during the latter part of 1943 and in early 1944, the problem of supplying subsistence from the port of Calcutta became acute. The Bengal-Assam Railway system was sorely overtaxed and since the trip from Calcutta to Assam took 12 days, only nonperishable items were so shipped. Barges carrying supplies up the rivers of East Bengal were often stranded for days because of the great variations in the flow of water. There were no roads connecting Calcutta with Assam, so motor transport could not be used. Because of the uncertainty of supply, it was impractical to prepare a menu in advance for the forward areas. The local markets were quickly depleted of foods, and the reserve of B rations was seriously unbalanced. It was necessary, therefore, to employ airlift to transport much of the subsistence from Calcutta to Assam.
As the combat troops and those engaged in
the construction of the Ledo Road, petroleum pipeline, and signal communications
moved forward from Ledo into Burma, many of the units had to be supplied by
airdropped ration was formulated of B-ration components which was nutritionally adequate yet light in weight. This was accomplished by the full use of dehydrated products. C and K rations were also used for this purpose. Airdropped rations were always supplemented with multivitamin tablets.
Supply to the forward areas was always uncertain under optimum conditions, but it became precarious during the spring-summer season of 1944. It became necessary, therefore, to liberalize the theater policy on the issue of multivitamin tablets to supplement the ration. This was done by authorizing the issue of one tablet per man per day to all troops stationed in Assam and Burma until such time as transportation would allow the supplying of adequate subsistence to all units.
Early in 1944 Col. Paul E. Howe, Chief of the Nutrition Division, Office of The Surgeon General, visited the theater and studied the ration problems. In his report Colonel Howe attributed the inadequacy of the ration to the attempt to "live off the land," to dependence on British supplies which were often not available or acceptable, and to inadequacy or failure of transportation. He recommended that the theater adopt the Expeditionary Force Menu No. 1 (revised 1 October 1943) as the basic field ration. He also recommended that additional nutrition officers be assigned to the theater to work with the troops in the field.37
In March 1944, four nutrition officers were assigned to this theater. The following were their assignments: (1) Air Transport Command installations in India and China; (2) Services of Supply installations around Ledo and the Ledo Road as far as Myitkyina; (3) the eastern half of India; and (4) the Air Force installations in Northern Burma. The duties of these nutrition officers were to conduct nutritional surveys in troop masses in the field to determine the nutritional adequacy of the dietary consumed by the troops, to advise the surgeon in matters pertaining to nutrition, and to assist the quartermaster in preparing menus and in selecting nutritionally equivalent substitutes for unavailable items.
In July 1944, the Expeditionary Force Menu No. 1 was adopted as the basic field ration for this theater in accordance with Colonel Howe's recommendation. Such components as were available from the British were procured in bulk from the Royal Indian Army Service Corps under reverse lease-lend agreement. These items included flour, salt, sugar, condiments, fresh eggs, meats, fruits, and vegetables. Components not available locally were imported from the Zone of Interior and a 90-day reserve stock level maintained. The indigenous products were of low quality compared with United States Army standards. The flour was particularly subject to criticism by United States troops. It was not enriched and therefore was low in vitamin content, was heavily infested with weevils, and, because of its low gluten content, it was
unsuitable for breadmaking. The fruits were of fair quality, but many species were previously unknown to the troops and were not well received, for example, mangoes, papayas, and leechie nuts. The vegetables were generally of poor quality, picked after the optimum stage of maturity and were usually wilted or spoiled upon arrival at their destination. As in the case of fruits, many of the vegetables were unknown to the cooks who were at a loss to know whether a new botanical specimen issued to the mess should be boiled, fried, or baked; or whether it should be seasoned with salt or sweetened with sugar. The resulting product was usually highly unpalatable.
The troops in this theater subsisted for several months on the ration as prescribed by the Expeditionary Force Menu No. 1, supplemented with such indigenous fresh produce as could be obtained from the Royal Indian Army Service Corps. During that time complaints about the quality and quantity of the ration became more and more numerous. The following were the most commonly expressed complaints: (1) the caloric value of the ration was inadequate; (2) the canned meat components became monotonous, were unacceptable, and were not eaten by the troops; (3) the dried eggs and whole milk powder were rancid and therefore were not consumed; (4) insufficient bread and spreads were issued; and (5) cereal products were heavily infested with weevils.
The complaint that the caloric value of the ration was inadequate as prescribed by the Expeditionary Force Menu No. 1 was justified in many instances. The food prescribed by this ration contained 3,945 calories whereas nutritional surveys conducted in hard-working units such as port battalions and truck companies revealed that food actually consumed exceeded 4,000 calories if it were available. The port battalions and aviation engineer battalions, which worked three 8-hour shifts daily, often served as many as 6 meals a day. This was very difficult to accomplish with the food prescribed by the Expeditionary Force Menu No. 1. The canned meat components of the B ration were highly spiced and quickly became monotonous and therefore unacceptable. Much of the meat was not consumed, and therefore the ration as consumed was lowered in nutritional value.
The dried eggs and powdered whole milk
components of the B ration were too perishable to be sent to a tropical theater
so far from the source of supply. It required from 60 to 90 days' travel time to
ship subsistence from the Zone of Interior to India and for most of that time
the temperature was around 100° Fahrenheit. An additional 30 days
were required to unload and transport the supplies to the various subdepots
where they were stored for an additional 90 days at a temperature of 100º
F. or higher. This latter storage was necessary for the proper rotation of the
90-day reserve stocks. Thus it was necessary to subject these products to high
temperatures for a minimum of 6 months before they could be used. Actually they
were from 1 to 2 years old before they were issued. The powdered eggs were
discolored and had a disagreeable taste
which was difficult to disguise; consequently the mess personnel seldom bothered to prepare them as a breakfast dish and when they did, most of them were discarded. The powdered eggs, however, were extensively used in baking and cooking. The whole milk powder could not be made into a palatable beverage unless it was mixed with chocolate or some other flavoring to mask its disagreeable taste. It could be used satisfactorily, however, in cooking and baking.
Because of the long storage at high temperature, the dehydrated vegetables had deteriorated considerably. Many of the cooks in the theater had not had previous experience in the preparation of dehydrated vegetables and, therefore, were not adept in preparing appetizing dishes from them. Consequently the dehydrated vegetables were not acceptable and considerable waste resulted. This had a deleterious effect on the nutritional adequacy of the ration. The surgeon recommended that a food service program be established in this theater to correct these difficulties, but the recommendation was not favorably considered at that time.
The hospitals found it difficult to operate on the field ration and hospital supplement ration as prescribed by the Issue Chart to Expeditionary Force Menu No. 1. The hospital ration did not furnish adequate subsistence for patients under the climatic and epidemiologic conditions of this theater. The high proportion of patients admitted with febrile and diarrheal diseases resulted in the use of a large percentage of special or restricted diets. The subsistence issued was particularly deficient in fruit juices and the more acceptable canned meat items. An attempt to correct this was made in Base Section No. 2 (eastern half of India) by issuing one field ration for each patient and allowing the hospital a monetary credit with the quartermaster equal to one-half the cost of the field ration for each patient in lieu of the automatic issue of the hospital supplemental ration. This did not work out satisfactorily because the purchase of certain items of the hospital supplemental ration in excessive quantities by some hospitals quickly depleted stocks of these items, which were being sent to the theater on the basis of troop strength as prescribed by the Issue Chart to Expeditionary Force Menu No. 1. Thus, many hospitals were not able to obtain the subsistence items required for the formulation of the special or restricted diets.
In September 1944, the Surgeon,
Headquarters, United States Forces, India-Burma Theater, requested that the
ration scale for troops in the theater be revised, that a more liberal hospital
supplemental ration be provided, and that a uniform ration system be adopted for
all hospitals. The Nutrition Consultant to the Surgeon assisted by the nutrition
officers of the base sections and hospital dietitians, in cooperation with the
Quartermaster, drew up a new ration scale in the form of the Basic Subsistence
Issue Chart for India and Burma and also set up a uniform ration system for
hospitals. This was accomplished in October 1944, and the new policy submitted
to the Commanding
General, India-Burma Theater, for approval in November. It was put into effect 1 January 1945.38
The revised ration provided a maximum of 4,500 calories with a greater variety of meats including canned ham (to increase the thiamine content of the ration), canned pork and gravy, frozen boneless beef, and lamb carcass. The frozen and fresh meats provided more of the B vitamins than the canned beef components of the Expeditionary Force Menu No. 1. An increase in juices, fruits, bread, and spreads were also provided.
All hospitals in the theater were authorized to draw one field ration for each patient plus an automatic issue of the revised hospital supplemental ration prescribed by the Basic Subsistence Issue Chart for India and Burma. This revised hospital supplemental ration prescribed more liberal allowances of canned meats, milk, fruit juices, and canned vegetables than the Expeditionary Force Menu No. 1. The quantities of the less useful items such as dehydrated soups and vegetables purees were reduced.
Early in November 1944, Captain Babcock was returned to the Zone of Interior under the theater rotation policy and he was replaced by Capt. (later Lt. Col.) K. J. Koehn, SnC, as Nutrition Consultant to the Surgeon.
With the adoption of the Basic Revised Subsistence Issue Chart for India and Burma it became necessary to publish a monthly master menu for the theater. The preparation of this menu was undertaken jointly by the Quartermaster and the Surgeon, India-Burma. The menu was used as the basis of issue of subsistence to all unit messes in the theater. This was necessary to insure equitable distribution of all ration items, particularly the fresh and frozen meat components. The menu was also used to exercise control over the stock levels of subsistence items. For example, if it appeared that the supply of a certain item was diminishing at such a rate that it would be exhausted before the supply could be replenished from the Zone of Interior, the quantities prescribed by the menu would be reduced so that the supply would last until replenished. Conversely, if stocks of an item greatly exceeded the reserve level, an increased issue would be prescribed. If stocks of certain items began to accumulate in the messes, the rate of issue would be reduced in the menu. The master menu was subjected to nutritional analysis each month before publication to insure that the optimum quantities of nutrients were prescribed with the available foods.
The increase in the ration, particularly for hospital patients was very well received in the field. Some difficulties were encountered, however, in making adjustments to the new ration scale. Subsistence supplies due in to replenish stocks depleted by the increased issues failed to arrive when expected. Shipments of canned ham were cancelled. This deficiency of supply was apparently
related to increased demands by other more
active theaters. Fortunately the shortage of subsistence was confined to staple
and nonperishable items. The supply of frozen boneless and imported carcass beef
was uninterrupted. This issue of fresh meat boosted the morale of the troops
more than any other factor connected with food. It served to break the monotony
of an otherwise tiresome ration.
Some difficulty was encountered in the
feeding of Chinese patients in American hospitals in the forward areas. The
basic ration for Chinese enlisted patients was the revised Chinese troop ration
described earlier in this discussion. The components of this ration were
obtained through the Royal Indian Army Service Corps and were prepared by the
Chinese themselves. Cooking was done in large drums or tubs over an open fire
where they prepared their rice, stews, and soups. An attempt was made to
exercise supervision over the cooking and serving of the food by United States
personnel, but it was almost impossible to change centuries' old customs. For
example, when fresh meat was issued, it was necessary to cut it up and issue it
to each patient. The patient then cooked it himself according to his particular
custom or entrusted its cooking to some friend. Because of their customs of
cooking their foods in large volumes of water, many of the water soluble
nutrients were lost. In order to prevent the occurrence of deficiencies,
Marmite, a brewers yeast preparation, was added to the soups. To
supplement the ration further, all of the hospital comfort items of the British
troops field service ration were made available to hospital commanders who
decided which items were necessary for the welfare of the patients. These items
consisted of canned milk, meats, fruits, sugar, et cetera. Upon the insistence
of the Chinese, these items were issued individually to each patient by an
American in order to insure equitable distribution. It was over the issue of
these comfort items that trouble arose. It was natural that hospital commanders
had different ideas as to just which comfort items were necessary and in what
quantities. A Chinese patient would find out that a neighboring hospital was
issuing an item he was not receiving; he would then
complain that he was not getting what he was entitled to. This became widespread among the patients of all hospitals in this area and no hospital escaped criticism on one score or another. The Chinese found these tactics very useful in playing one hospital against another to secure more comfort items than were necessary. A patient would insist on going to one particular hospital and would boycott the others. Since all of the patients were well fed, this situation was absurd, but rapidly became intolerable. A meeting was called by the Surgeon, Advance Section, which was attended by the nutrition officer and the hospital commanders concerned. A uniform scale of hospital comforts was evolved which was put into effect in all hospitals caring for Chinese patients. After the Chinese were made to understand that the food was the same in all hospitals, the trouble subsided.
Nutritional surveys conducted in Advance Section in 1945 showed that in spite of the more liberal ration prescribed, it was still deficient in thiamine, the average daily intake being 1 mg. per man. The riboflavin intake was also low. The ration as prescribed was low in these vitamins because of two factors; the lack of fresh pork, and the use of unenriched, indigenous flour which comprised 40 percent of the issue. Although few cases of clinical avitaminoses were ever seen in United States troops in this theater, an increasing number of patients were seen in the forward areas who complained of vague symptoms suggestive of subclinical thiamine deficiency, i. e., anorexia, nervousness, indigestion, or fatigue. Some of these patients responded to therapy with thiamine hydrochloride although it was not proved that other factors coincident to hospitalization were not the cause of improvement. The use of thiamine preparations by hospitals in the forward areas increased considerably in 1945 indicating that the long continued low intake of thiamine was beginning to show effects.
Since lean pork products contain approximately five times as much thiamine as lean beef, the Surgeon recommended that pork loins and hams be requisitioned in lieu of half of the beef being procured monthly from the Zone of Interior. He further recommended that the use of unenriched flour be discontinued and that 100-percent enriched flour be procured from the Zone of Interior. The former recommendation was acted upon and the first shipment of boneless pork loins and hams arrived in the theater in July 1945. This pork not only substantially increased the thiamine content of the ration but relieved the monotony of the previously predominantly beef dietary. The second recommendation was not favorably considered at that time because of the theater policy to procure as many items locally as possible to conserve shipping space.
In April 1945 the War Department directed
that the ration scale for this theater be reduced so that the total quantities
of foods within the various food groups (with several exceptions) conformed with
the quantities prescribed
by the Issue Chart to Expeditionary Force Menu No. 1. The revised ration provided approximately 4,150 calories, 2.06 mg. of thiamine, and 2.78 mg. of riboflavin daily. The increase in thiamine content of the ration in spite of the decrease in calories resulted from the inclusion of 0.13 pound per man per day of lean pork products. It was necessary to reduce the total weight of issue of leafy, green, and yellow vegetables, but this was compensated for by reducing the weight of the canned vegetables and increasing the dehydrated. Since fresh vegetables were usually substituted for the dehydrated, the net result was an increase in this group. The reduction in calories was caused by the decrease in the issue of fats and potatoes. Adjustments were made between the various food groups so that the overall decrease in the ration could be accomplished without seriously affecting its nutritional value.
The limitations placed upon the ration by the War Department also applied to the hospital supplemental ration. It was necessary, therefore, to place the hospitals back on the ration prescribed by the Issue Chart to Expeditionary Force Menu No. 1. Within 1 month, reserve stocks of supplemental items on hand in the hospitals were exhausted and the subsistence issued was insufficient to allow for the proper dietary management of patients. The Nutrition Consultant to the Surgeon and the quartermaster subsistence officer studied the situation very carefully in order to determine how the hospitals could be furnished adequate subsistence without exceeding the overall allotment of subsistence to this theater. They arrived at the following conclusions: Hospital supplemental ration items were allocated to this theater on the basis of troop strength, assuming 15-percent hospitalization of the command. Under the existing theater policy the hospital ration items received with 10,000 rations were, therefore, issued to 1,500 patients. Statistics revealed, however, that in this theater only 5 percent of the command was hospitalized. Thus, two-thirds of the items earmarked for hospitals remained in the depots unused. The problem could be solved, therefore, by prorating the essential hospital items received with 10,000 rations among 500 patients without exceeding the quantities of food allotted this theater. The hospital supplemental ration was revised, therefore, to increase the allowances of fruit juices, canned meat, and other essential items effective 1 August 1945.
During the summer monsoon of 1945,
nutritional surveys conducted in the forward areas indicated that the
consumption of thiamine and riboflavin was not optimum. This was attributable to
lack of fresh foods in the ration and to the impossibility at times of
transporting fresh or frozen meats to the forward units along the road.
Transportation failure resulted from temporary washouts of the Stilwell Road
caused by torrential rains and from low visibility which grounded aircraft. The
Surgeon, therefore, requested that the Commanding General, United States Forces,
India-Burma Theater, obtain authority from the War Department either to procure
containing thiamine, riboflavin, and niacin for the enrichment of the indigenous flour or to procure 100-percent enriched flour from the Zone of Interior. The authority for the procurement of bulk vitamins or 100-percent enriched flour was granted.
The enriching of the indigenous flour appeared to be the most practicable means of increasing the vitamin content of the ration. Before requisitions were placed for the vitamins, theater headquarters was requested to allow the United States Army to provide bulk vitamins to the Indian mills furnishing us flour for the purpose of enriching this flour. This request was not favorably considered since the flour for United States troops and for the British and Indian troops all came from a common stockpile, and they considered it impracticable to enrich the flour for the United States troops without enriching all of the flour. The project, therefore, had to be dropped. Before the question of procuring 100-percent enriched flour from the Zone of Interior could be considered, the end of the war with Japan had occurred. Since early evacuation of the theater was contemplated, reserve stocks of enriched flour were released for issue which were sufficient to provide 100-percent flour for the troops until evacuation of the theater had been accomplished.
The difficulty in maintaining an adequate dietary arising from the use of unenriched flour is just one example of the problems encountered in an attempt to feed troops in a foreign country on indigenous foods. This applies not only to flour but to such foods as fresh vegetables, which are raised from undeveloped strains on infertile land, and meat from malnourished animals. A comprehensive nutritional survey of India and Burma prior to the entry of the troops into these areas would have allowed our forces to anticipate the difficulties later encountered and steps could have been taken to prevent them. The obvious course that would have been followed is the continuous supplying of these forces from the beginning with the balanced B ration. In case such items of this ration as flour were required to be obtained locally, arrangements could have been made to correct the resulting deficiencies. The most practical means of accomplishing this is by furnishing tablets containing thiamine, riboflavin, and niacin for use in enriching bread. The proper quantities and proportion of each vitamin could be incorporated into a tablet to be used for each unit of flour used in making bread. This can be dissolved in the water so that uniform distribution throughout the bread can be accomplished.
Experience in this theater has shown that
it is impracticable to send such dehydrated products as powdered eggs, whole
milk powder, and dehydrated vegetables to a tropical climate unless a quick
turnover can be arranged or facilities provided to store these items under
relatively cool conditions. Surveys conducted in this theater showed that over
50 percent of all dehydrated vegetables prepared in the messes were discarded,
which represents a waste of effort in their manufacture and waste of the
original product which could have been
used to feed the civilian population. If at all possible only canned foods should be sent to theaters in tropical climates.
Although it may be economical to feed relatively small forces on the rations of Allied troops, this procedure was found to be highly unsatisfactory in this theater. There is a great difference in food habits between various countries, even between such closely Allied countries as the United States and England. The United States troops almost unanimously condemned the British rations. This is attributable to their dislike of such items as mutton, corned beef, and pork and soya links, and to the inferior quality of many foods. Since the United States standards and specifications for foodstuffs are the highest in the world, it appears unwise to attempt to subsist American troops on the inferior rations of other countries.
Another cause of dissatisfaction with the ration among the United States troops in this theater was the lack of skill on the part of the cooks in preparing the B-ration components. Many of the men serving as cooks had no training in cooking and many of those who had, had left the Zone of Interior without learning how to prepare such foods as dehydrated eggs, vegetables, and the various stew and hash components of the ration. The Surgeon repeatedly recommended that a food service program be established in this theater to correct this deficiency. This recommendation was not favorably considered by the theater general staff, which was unfortunate because such a program would have allowed the training of competent mess personnel in the theater and would have provided competent supervision over the preparation of food for the enlisted men. It is strongly recommended that in future operations, a food service program be made an integral part of the organization of every theater of operations.
In summary, it may be said that the history of nutrition in the India-Burma theater is one of constant struggle against odds to improve the nutritional adequacy of the ration. The difficulties encountered were the inability of India and Burma to supply appreciable quantities of acceptable subsistence to sustain our Army, the length of the supply line from the Zone of Interior which was the longest in the world, the priority in subsistence given the more active theaters of operations, the adverse climatic conditions encountered, and the inadequate transportation facilities in the interior. In spite of these difficulties, a slow but steady improvement in the nutritional quality of the ration was obtained. Except for the outbreak of beriberi among Chinese troops, there were no significant indications of malnutrition in this theater.
Nutrition in the Pacific Area
The problems experienced in Europe and
Asia were often accentuated during amphibious landings in the Pacific area.
Americans found the food provided them by other nations to be often unacceptable
and, in turn, met difficulties
in feeding their Allies an American ration unpalatable to those with different food habits. Varying local situations made procurement of native food difficult or inadvisable and supply lines not infrequently embraced great distances. Limitation of refrigeration for transport and storage resulted in spoilage, and the lack of ability to obtain perishables at times resulted in a monotonous diet. This situation was sometimes aggravated by climatic differences between source of food and forward bases. As in other parts of the world, problems at times arose on the basis of lack of personnel, or of their skill in the preparation of food, with the attendant complaints of unpalatability and failure to consume the ration served. Inspection was not always all it might have been under the circumstances, and there were occasional unfavorable comments on mess management.
Difficulties were sometimes encountered in the preflight and in-flight feeding of Air Force personnel on long missions. Refusal by troops of certain items in the diet occurred. Dried and evaporated milk, and lemon crystals, were mentioned as such items. Comment was made on the loss of water-soluble vitamins during the handling and preparation of food, and the requirements for certain of them were felt to be in excess of supply in areas where troops were subjected for long periods of time to excessive heat and humidity.
Special problems arose in respect to the hospital ration, the feeding of oriental laborers and troops of Allied countries, and in the provision of food to prisoners of war. Here, as elsewhere, hospitals received priority in the ration scale and hospital diet was supplemented by special purchase of food. However, the need for hospital dietitians was at times keenly felt. An unfavorable reaction on the part of troops from the Philippine Islands to a special ration scale was recorded. Nausea and vomiting among Philippine civilians was at one time felt to be due to the Army diet.
However, in spite of not infrequent
untoward circumstances in respect to food supplied or consumed which resulted
chiefly from the great problem of supplying a nutritious and acceptable diet to
troops operating in areas at long distances over water from the source of
supply, and in tropical or semitropical areas where geographic and climatic
factors considerably enhanced the problem, there was remarkably little severe
disability due to malnutrition. Weight loss by troops was often considerable.
However, it should be remembered that psychic as well as dietary factors may
affect the intake of food by troops under combat conditions or even during
acclimatization in tropical areas. In addition to dietary inadequacy in
calories, inadequacy of calcium and the water-soluble vitamins was most often
commented upon in the Pacific area, as it was in other theaters of operations.
Apparently, slow clotting time was encountered in at least one instance, and
chronic fatigue, skin infection, untoward oral conditions, and other signs and
symptoms suggestive of avitaminosis were noted by various observers. Beriberi
and pellagra were regarded as principal causes of mor-
bidity and mortality due to disease among our citizens who were prisoners of the Japanese.
Some of the observations of individual commentators on nutrition in the Pacific theater are recorded as examples of the type and number of problems in feeding troops and of their dispersal throughout the area. An interview with the Surgeon, 37th Division, stationed on Guadalcanal and New Georgia islands is illustrative of the situation in regard to nutrition encountered early in operations in the Pacific area.39 The surgeon believed that very few clinical signs of vitamin deficiency had been seen in troops of that division and that their supply of multivitamin capsules prior to combat had been adequate. However, he recounted that the weight loss of the individual soldier during the battle of Munda had been in the neighborhood of 20 to 30 pounds.
The C ration was used by this division in combat, and it was supplemented by D (chocolate) bars. Logistic difficulties arose out of the tactical situation, and the diet became unpalatable. On the whole, the surgeon thought that the ration had been low in calcium and inadequate in perishables, including fresh fruits, vegetables, meat, and fish. It was his impression that inspection of food obtained in New Zealand and the Fiji Islands had not met American desired standards, and that problems in refrigeration resulted in its improper freezing. Up to 40-percent spoilage of evaporated milk obtained from New Zealand was attributed to climatic factors. As a result of this experience, the division surgeon believed that the use of powdered milk was preferable to that of evaporated in such a geographic area. Fish were simply not available. There was a relative shortage of water due to porous ground and no rivers, and it was necessary to collect rainwater or to obtain it from the United States Navy.
Historical reports provide information on problems in nutrition related to island warfare, to meeting the special problems of hospitals, and to feeding natives of other countries. During the assault of Saipan, K, C, and B rations were used. The first fresh food received by troops on this island was a shipment arriving on D plus 136, a striking example of the adverse relation of the tactical situation to the feeding of soldiers. From 15 June to 31 December 1944, only about 10 days' supply of fresh food per man was provided, yet no nutritional disease was observed among troops in spite of their uniform weight loss. After the latter date, fresh food became available for a meal daily. Troops on the islands gradually took advantage of the fresh fish, vegetables, and fruits that were available from native and Foreign Economics Administration sources. On Saipan fresh fish were accepted from native fishermen beginning in June 1945 and an average of 40 tons of fish was issued per month. Fresh fruits and vegetables produced under Foreign Economics Administration supervision were accepted for quartermaster issue and the supply was adequate. Ice cream manufactured from standard ice cream mixture was a
welcomed addition to the menu. The quartermaster bakery began functioning early and furnished good bread for all troops. Food poisoning which occurred was attributed to faulty handling of food and not to food defective when issued.
An example of the priority for fresh food enjoyed by hospitals was that provided by USASOS Regulations 30-16, 20 February 1945. This regulation provided for a supplemental list of foods for special diets required in hospitals. Nutritional analysis of hospital diets so insured found them to meet National Research Council standards for nutritional adequacy.
The regular Army menu was unpalatable to civilians in the Philippines, and many developed acute episodes of nausea and vomiting believed to be related to the high fat content of their unaccustomed diet.40
Reports of inspection trips in the Pacific area provide information on nutrition there from persons variously oriented to the situation. Reports included comment on the adequacy of the Australian ration when perishables were obtainable, and the monotony of the diet when they were not. Weight loss but little clinical avitaminosis was seen in troops in forward areas. The transfer of procurement and distribution of food from Australian to American control was noted.41
The report of another inspection trip made in 1943 by Brig. Gen. Charles C. Hillman, (MC), USA, included an account of the complaints which he heard in respect to hospital rations.42 These included reference to the inadequacy of the number and use of hospital dietitians, to the limited facilities for refrigeration available in hospitals, and to nutritional inadequacy of certain diets. Based on his observations, General Hillman advised provision of the Southwest Pacific and Pacific areas with more officers of the Veterinary Corps for the purpose of augmenting local meat and dairy inspection.
Nutrition was often a subject of discussion in regularly recurring reports received from the Pacific area. In one, the problems in feeding which were encountered in New Guinea in 1942 and 1943 were described in some detail. As for nutritional adequacy of the diet, comment was made only on the probable loss of ascorbic acid and thiamine during the handling of food products. Problems in the handling of food included unsatisfactory inspection, lack of cool and cold storage, pilfering, spoilage in containers due variously to the geographical environment, distribution of food products, and mess management. On the whole, however, nutrition officers found the quantity and quality of food "very satisfactory" at the time of writing the report.
At that time, fresh meats, fruits, and vegetables were being obtained from Australia, and a few gardens had been planted locally. Ninety percent of the
troops were receiving bread from field bakeries, although there was spoilage of flour. Canned fruits and corned beef, fresh boneless meat, ham, and bacon were readily available, but there was little fish. Army rations used included C ration, which had been shipped to New Guinea in large quantities in 1942 and early in 1943. Large amounts of this ration had deteriorated in cans which had been stored in the open and subjected to high temperatures. D ration of both American and Australian origin had deteriorated in open storage save when stored in sealed metal containers. There was pilferage of peanuts from the bulky jungle ration. Troops had found K ration just palatable and soon tired of it. Mountain ration had been issued in New Guinea only on a trial basis. It is evident that these difficulties were related more to matters of immediate concern to the Quartermaster than to the Medical Corps.
Sanitary reports from the Pacific area contained references to calcium deficiency in certain troops, diagnosis of that condition having been based on the doubtful criterion of poor (carious) dentition, and on slow clotting time. Dietary intake low in ascorbic acid, thiamine, and riboflavin was described. There were descriptions of lack of desirable fresh meat, eggs, fruits, and vegetables, and of problems related to supply, transportation, preparation, and palatability of food as well as its nutritional adequacy. However, observations on clinical evidence of malnutrition-with the exception of those noted above-and of weight loss were strikingly absent.
At least one example of the reaction of those concerned with effecting action on the basis of these reports should be described because it is indicative of the different perspective of persons not then subjected to the conditions under which these reports were made and thus able to comment upon them from a dispassionate point of view. Such an example included acceptance of the factual basis of complaints that certain processed and fresh foods received from Allied Nations did not meet our best standards.43 However, it was pointed out that the reports came from troops who had been overseas for some 2 years, that their morale was lowered, and that their neuropsychiatric case rate was rising. It was advised that efforts be made to improve the quality and acceptability of food in the Pacific area.
Numerous surveys were made of the nutritional adequacy of food issued and consumed and of the nutritional status of troops in the Pacific area. Those available for perusal point to the same dietary and potentially nutritional deficiencies already described: calcium, thiamine, riboflavin, ascorbic acid, and total calories. For example, a quantitative study of diet provided and consumed on a small tropical island in a forward area in the tropics showed the primary deficiencies to be in calcium, and the vitamins listed above.44 A careful
study of Eighth United States Army messes for a period of 20 days, 20 February through 15 March 1945 showed less than desirable amounts of calcium, thiamine, and riboflavin.45 One such study reported the finding of nutritional inadequacy in ascorbic acid, a conclusion based on the determination of the plasma levels of that vitamin.46
Major Problems in Nutrition Overseas
To attempt to generalize the problems of overseas theaters in nutrition is to invoke a storm of criticism by those intimate with individual situations. However, certain of these problems were apparent at one time or another in all areas outside the United States. They evolved from difficulties in supply and in meeting demand. Problems in logistics derived from the tactical situation were not uncommon. Accordingly, rations designed for use over short periods of time were actually consumed over very long periods. Their caloric constitution was not always suited to the needs of troops under such circumstances; their limited number of food items provided a very monotonous diet when unrelieved for many days or weeks; and the food habits of troops so fed varied markedly. Caloric inadequacy due to the constitution of the rations and to their rejection by the individual soldier resulted in weight loss. Difficulties met in the provision of fresh foods including meats, fruits, and vegetables, and in the handling of food products, including their storage and preparation, not infrequently resulted in diets inadequate in calcium and the water-soluble vitamins.
Certain special problems in nutrition were more or less common to all theaters. These included temporary or permanent need for nutritional officers or dietitians. The feeding of Air Force personnel on lengthy missions was rarely solved to the satisfaction of the personnel. Provision of special diets in hospitals often constituted a problem, in spite of the fact that it was general practice to give hospitals priority in respect to food. The feeding of Allied troops and civilians, and of prisoners of war raised many questions. Although these problems were considerable and their solution difficult of accomplishment, and although the feeding of troops overseas undoubtedly left something to be desired, the remarkably little evidence of deficiency states reported attests to the fact that on the whole the nutritional status of the Army overseas spoke well for the technical and professional skill of those concerned with its feeding during World War II.