|OFFICE OF MEDICAL HISTORY AMEDD REGIMENT AMEDD MUSEUM|
HISTORY OF THE OFFICE OF MEDICAL HISTORY
Malnutrition and Deficiency Diseases
John B. Youmans, M. D.
The record of World War II is notable for the virtual absence of nutritional disease among troops. The Army operated under a high standard of nutritional adequacy in the soldier's diet (as set up by the Food Nutrition Board, National Research Council, together with a set of minimal allowances for short periods for use in emergencies), and an assumption that adequate nutrition is necessary for maximum efficiency and health. Concern was felt with regard to deviations from these standards-during the time the soldier drew upon his body reserves when there was a shortage of food, either because of logistic problems, or personal reactions to the food available as issued, prepared, and served. Under such circumstances frank nutritional disease, except for loss of weight, seldom occurred. This is in great contrast to what might have been expected and would probably have occurred only a few years earlier. The magnificent development and use of new knowledge of all matters concerned with nutrition made possible, and successful, operations of great magnitude, conducted under serious logistic difficulties occasioned by extremes of environment and distance, such as the tropical heat and humidity of the jungles of the South Sea islands and the frigid climate of Iceland. It is safe to say that many operations of World War II would not have been possible or could have been carried out only partially had it not been possible to prevent nutritional disease.
Only under extreme conditions, mostly in prisoners of war subjected to the neglect and cruelties of their captors, and in sporadic instances of individuals conditioned by injury, disease, or some personal peculiarity, did those terrible spectres of other wars-scurvy, dropsy, pellagra, beriberi, and xerophthalmia-return. Such was the achievement of preventive medicine.
To refer, as will be
done below, to the occurrence of an appreciable amount of nutritional deficiency
is not the contradiction that it seems. It is to be explained by the changing
concept of nutritional deficiency states, the recognition of the fact that there
are degrees of deficiency, insufficient to warrant such diagnoses as scurvy,
pellagra, or beriberi which require a considerable period for development even
under controlled conditions. Partial deficiency may exist to an extent
sufficient to prevent the fullest state of health, physical strength, and
fitness, without causing overt or gross disability. Such conditions existed in
the general population before the war and their presence was
reflected in a similar occurrence in the troops under average conditions, although as their service lengthened it was decreased by the highly efficient control of food and nutrition in the Army. It is in this respect that preventive medicine finds its greatest opportunity in the field of nutritional deficiency disease and the opportunity to ensure optimal health and physical fitness as far as nutrition can secure them, by preventing even slight deficiencies.
INCIDENCE AND EPIDEMIOLOGY
It is impossible to state accurately the prevalence of nutritional deficiency in the Army as a whole or in any considerable portion of it. Fully developed clinical forms of the deficiencies such as scurvy and beriberi are reportable in rates, as hospital admissions, per annum, but these give but little indication of the actual prevalence of deficiencies. The prevalence of nutritional deficiencies below the level of the classical expressions of disease is uncertain because individuals with deficiencies of these grades alone are not usually patients, nor are they considered ill; the opportunity and special needs for diagnosis are lacking and the conditions exist unknown and often unsuspected.
Some idea of the prevalence of nutritional deficiency disease can be secured, however, from special research studies and from a search of hospital records. The special research studies were made on groups of presumably healthy troops under field conditions, giving information on the prevalence of the mild or slight forms of the deficiency, and on special groups such as prisoners of war and patients in hospitals with advanced deficiency disease. The latter will give only the incidence of advanced stages as they are recorded in hospital practice under the standard forms of diagnosis.
MINOR NUTRITIONAL DEFICIENCY DISEASE
It has been known for
some time that a number of apparently well persons have minor grades of
nutritional deficiencies, sufficient to present recognizable evidence on
physical or laboratory examination. It was this group which was of particular
concern from the point of view of preventive medicine because of the subtle
effect of such disease on efficiency and morale. Also, a potential result could
be a large number of troops who were "under par" and would be quick to
succumb to severe disabling nutritional disease during periods of stress arising
from injury and disease or temporary severe dietary restriction. It was clearly
recognized that under some unavoidable circumstances severe undernutrition might
develop despite all efforts to prevent it. It was known, however, that by proper
care and attention good nutritional state and good reserve could be maintained
in all but rare instances. Such action would lessen and prevent the frequency
and severity of advanced deficiency states when circumstances
tended unavoidably to produce them. Thus injury and disease may produce nutritional disturbances which in turn diminish the resistance to and recovery from illness and injury. Good nutrition prior to injury or illness offers some protection against the effects of such nutritional disease. Similarly, periods of severe restriction of food are less serious if nutrition is good before the starvation begins.
Evidence of the prevalence of those milder forms of deficiency was found in the ration trials at Camp Carson, Colorado, May to August 1944.1 In this experiment, incident to the study of the effect of a variety of special rations, the test subjects were examined for evidence of nutritional deficiency disease by physical and laboratory examinations before the start of the experimental period. These troops consisted of a battalion, approximately 1,000 strong, undergoing rigid advanced infantry training, and may be considered fairly representative of a considerable number of similar troops training at that time in the western part of the Zone of Interior. The prevalence of minor nutritional deficiency, as interpreted from the physical signs, are shown in Table 7.
TABLE 7. MEN IN VARIOUS COMPANIES SHOWING SIGNS OF THE DEFICIENCIES LISTED
Source: Rpt, Armored Med Research Lab, Proj. 30, 22 Nov 44. HD: 430 (Rations).
Data on the prevalence of these deficiencies under other conditions are available from a survey of nutrition of troops in the Pacific area made during April-June 1945.2 Troops examined in this study included selected samples of the garrisons of Hawaii, Guadalcanal, Guam, Iwo Jima; casualties from Okinawa; and combat troops on Luzon and Leyte. The details of the physical examinations were essentially the same as those of the Camp Carson experiment and, in addition, included a record of the dietary. The dietary was more nearly representative of that occurring under a variety of ordinary field conditions in that theater than was the dietary in the Camp Carson study. The
prevalence of the various deficiencies as determined by physical examinations is shown in Table 8.
8. PREVALENCE OF NUTRITIONAL DEFICIENCIES AMONG TROOPS IN THE PACIFIC AS SHOWN
Source: Rpt, Nutrition Div SGO, 22 Aug 45, sub: Nutrition survey in Pacific Theatre of Operations. HD: 720.1.
Certain differences in the various groups comprising the Pacific study are interesting and their significance and possible explanation is discussed in the report. In view of the great environmental and operational differences the groups involved are too small to permit general conclusions as to variations between broad classifications of troops, as between garrison and combat units. The situation is too likely to be modified by a great variety of local circumstances. It is of interest, however, that the combat troops examined were in as good or better nutritional state than the garrison troops (except for body weight) and had the better physical fitness scores.
Evidence of a somewhat different sort is attained from more detailed studies of small numbers, such as those of Rush,3 Beach and Miller,4 and Golden and Schechter.5 However, part of the evidence often interpreted as indicating nutritional deficiency disease was a discrepancy between the intake of various nutrients and the recommended allowances of the Food and Nutrition Board of the National Research Council. It must be remembered that these allowances were liberal and had a large margin of safety. There is also the factor of body store to consider. Nevertheless, there may have been some reduction in tissue stores and, in these cases, actual mild deficiency, particularly of vitamin C.
It would manifestly be unfair to use the evidence presented here to establish the prevalence of minor nutritional deficiency disease in the Army as a whole. The sample is too small and not sufficiently representative. Such data, except under conditions of great stability and uniformity, is of little value except for
purposes of a broad comparison, as, for example, of overall prevalence by decades. The figures obtained suffer from all the disadvantages of an average value. The finding of an average value for the hemoglobin of 100 men of 14.5 gm. (within the range of normal) does not reflect sufficiently the seriousness of the fact that an undetermined number may have had hemoglobin concentrations of but 10 grams. A prevalence of minor nutritional disease of only 5 percent in the Army as a whole is of little consolation if a task force of 25,000 fails because minor nutritional deficiencies have rendered 90 percent of the command incapable of putting out their maximum effort. Such an occurrence may be excused if it is clearly recognized at the time and is the result of circumstances beyond control. It is inexcusable if it exists unknown or unsuspected or, if known, without every effort having been made to prevent it. It can always be detected by proper inquiry and, with proper management, can often be predicted and prevented.
Nevertheless, it seems
fair to conclude that except for special instances, probably limited to small
groups, and for short periods, the prevalence of nutritional deficiency disease
in the troops, even in overseas theaters of operations, did not exceed that
presented in Tables 7-9. This may be compared with the prevalence among the
civilian population from which these troops were drawn as shown in the following
tabulation which was calculated for use in connection with the feeding of
civilians in Europe.
9. PREVALENCE OF NUTRITIONAL DEFICIENCIES AMONG TROOPS IN THE PACIFIC AS SHOWN
BY LABORATORY TESTS
Source: Rpt, Nutrition Div SGO, 22 Aug 45, sub: Nutrition survey in Pacific Theatre of Operations. HD: 721.1
Some question may be
raised concerning the validity of the criteria on which these diagnoses were
made. It is recognized that none of the physical signs are pathognomonic in the
degree of deficiency encountered. Some dis-
agreement may be had with the criteria used for interpreting and evaluating the laboratory data. Nevertheless, these criteria have been employed by experienced examiners in a large number of similar studies and have received fairly general acceptance. It should be noted that they at least set rather clearly the minimal amount of nutritional deficiency-more than there may have been if one accepts finer and less clearly established criteria, but there was probably no less.
Mild caloric deficiency, due simply to an insufficiency of food, was fairly common in the Army under combat conditions. This was usually the result of a combination of causes-difficulties of supply, the necessity of using packaged rations calorically inadequate for the energy expended, and decreased consumption of food because of emotional strain, fatigue, and exigencies of the situation. Except among prisoners of war, however, such caloric deficiencies rarely were great enough over long enough periods to cause protein deficiency and physical disability. For example, the nutritional survey of troops in the Pacific theater showed that although troops fresh from combat had some caloric deficiency, as evidenced by loss of weight, their physical fitness was equal to that of troops in the Zone of Interior and in at least one instance, superior.6 Neither were these mild caloric deficiencies often accompanied by vitamin or mineral deficiencies. The reduced caloric intake lessened the need for vitamins and minerals, and the rations, even when only partly consumed, supplied a considerable amount. This circumstance, together with the fact that existing body stores under the system of Army feeding and practice were nearly always high at the outset of a campaign, was sufficient to prevent significant deficiencies except in occasional individuals in whom it could usually be classed as conditioned.
Beriberi (Vitamin B1, Thiamine). Beriberi, as a primary, idiopathic disease in noncaptured American troops was almost nonexistent. For example, in Cutts' report of over 125 cases of beriberi,7 none occurred among American troops. All cases were observed in Chinese troops. Although 5 cases in the entire Army were reported in admissions to hospitals in 1942, most of these must have been "conditioned cases." Occasional reports, mostly rumors, of mild cases of B1 deficiency were received, especially from the China-Burma-India theater, but in most instances the diagnosis was not sufficiently established and the evidence consisted of nonspecific signs and symptoms such as nervousness and fatigability. Such diagnoses were strongly controverted by evidence of a liberal intake of thiamine in the food.
Riboflavin. No outspoken cases of idiopathic riboflavin deficiency disease were reported and the only possible instances of this deficiency were mild cases detected on special surveys and examination,8 in which careful examination and laboratory tests were made. Even some of these may be considered doubtful in view of changing ideas of the specificity of certain signs such as cheilosis and vascularization of the cornea, previously thought to be due to this deficiency; also, because of a lowering of values formerly believed to represent intake requirements.
Niacin. A few cases of pellagra in otherwise well individuals occurred from time to time in all theaters of operations. For the most part, these were caused by a deficient intake of proper food due to habit, food dislikes and prejudices, irregularities of eating related to duty assignments, and similar causes, such as could be ascertained by questioning the patients. These cases exhibited no differences from those observed in civilian practice.
Vitamin C. A number of reports of scurvy and vitamin C deficiency as well as special studies of vitamin C nutrition were made.9 Some reason for concern and a suspicion of the existence of this deficiency were justified because in certain of the rations, particularly in the C, K, and ten-in-one, the source of most of the vitamin C was the synthetic fruit juice powders, which, on the whole, were not well consumed by the soldiers. It was often forgotten, however, that the standard of daily requirements for this nutrient was set at a very high level, 75 mg. per day, an amount three times as great as that actually needed to protect against a state of true physiologic deficiency. It is, therefore, not surprising that in many instances, reported cases and outbreaks of scurvy and vitamin C deficiency could not be substantiated when subjected to careful analysis. There was also some tendency on the part of medical officers to attach too much significance to such signs and symptoms as gingivitis and bleeding gums, which, while suggestive, are not very specific or reliable, especially in mild or early deficiencies.
Vitamin A. Vitamin A deficiency, too, was very seldom seen, though it was often suspected, or diagnosed when it was not present. Considerable anxiety was expressed concerning it, especially in relation to visual acuity in dim light or the dark (night blindness), particularly in the Air Forces. Again, it was forgotten that it takes months, probably over a year, to deplete a normal adult's stores of vitamin A and that the diet of all troops before being subjected to any dietary shortages was high in vitamin A. It was also commonly forgotten, or not known, that much of the vitamin A is ingested in the form of carotene, obtained from such foods as green and yellow vegetables and that vitamin A is quite stable. It is not necessary to have all or even most of the
vitamin A as such, as in animal foods. Finally, it is probable that the standard of requirements, 5,000 international units daily, which was in general well supplied and consumed even under conditions of difficult supply and feeding, was so high as to provide a large margin of safety.
It is not surprising then that there was little or no primary vitamin A deficiency of a significant grade in American troops. This does not exclude the probability, however, of a slight dietary deficiency for long periods prior to Army service, and the existence of a chronic low-grade deficiency yet insufficient to produce such classical disease as xerophthalmia. Some evidence of such a mild deficiency could be found in any body of troops if one was willing to take as evidence the presence of mild perifollicular hyperkeratosis of either the dry, horny, or the acneform type, which though not highly specific is suggestive. Such evidence can be found in any group of the population in this country.
Vitamin D and Calcium Deficiency. Much concern also was expressed concerning vitamin D and calcium deficiency. Such deficiency was not infrequently reported in Essential Technical Medical Data (ETMD) reports. For the most part these reports came from the more distant or remote overseas theaters, especially the China-Burma-India, the Pacific, and some of the Arctic stations. This concern and such diagnoses were based largely on two circumstances: the lack of milk and the presence of subjective symptoms, the latter usually highly unreliable and susceptible of numerous other explanations. In the Arctic, lack of sunshine was sometimes considered a factor. Again, the rations, even under restricted conditions, usually provided calcium in amounts equal or close to standard requirements which are probably very liberal. There were shortages as the result of difficulties in supply and failure of mess personnel to incorporate the milk and milk products in the prepared foods. So far as it is known, no instances of idiopathic calcium or vitamin D deficiency, established by blood calcium studies, demonstration of significant demineralization of bone, or the occurrence of tetany were observed. It should be remembered that the normal adult possesses a large reserve store of calcium in his skeleton and deficiency must be severe and long continued to produce an actual pathologic state of calcium deficiency in otherwise normal persons. Vitamin D requirements are, of course, very small in adults and deficiency of this vitamin is uncommon.
Iron. Iron deficiency anemia is likewise very unusual in the normal adult male and in the nonchildbearing female because of the extreme conservation of iron by the body. Such iron deficiency anemia as might occur would most likely have existed before entry into the service and would have constituted a probable cause for rejection.
Recent studies, however, particularly
those on "folic" acid, have shown that an anemia of the macrocytic
type might occur with a restriction of foods
generally considered to furnish much of the B complex vitamins. The presence of troops in areas where tropical anemia (probably a macrocytic type) existed suggested such a possibility. Reports of anemia among Army nurses in the Pacific area led to the inclusion of an inquiry into this disease in a general survey of nutrition during March-May 1945 in the Pacific theater. However, a significant degree of anemia was found to be relatively uncommon, and its dependence on dietary factors was not established.
As has been indicated, frank nutritional disease was extremely rare among the troops. It must be realized that these cases include only those of primary nutritional disease admitted with the diagnosis. Undoubtedly, additional cases of severe nutritional deficiency occurred as complications of other injury and disease and, even though recognized, failed to be included in the diagnosis because of the tendency to omit the diagnosis of complications. This is particularly true of the less well-known and established deficiencies such as the protein, iron, and riboflavin deficiencies. Even sodium chloride deficiency is apt to be omitted. Therefore, even the hospital records will fail to give all of such cases.
Prisoners of War
The greatest incidence of evident nutritional deficiency disease occurred in recovered Allied prisoners of war and in civilians of liberated and conquered countries. In the Asiatic and Pacific theaters the number of instances of these diseases was much greater than in Europe. No reliable data are available as to the actual prevalence because of lack of records. The best sources of information in this field are the reports of the examination of prisoners of war made during the period of incarceration and following their release and return to this country.10
These cases of deficiency diseases, while conforming in general to the pattern traditionally established, revealed certain characteristics of unusual interest, particularly in the cases of starvation edema and in cases of thiamine deficiency. In these subjects, both those in Europe and in the Pacific, loss of body tissues (emaciation) caused by inadequate caloric intakes was the most pronounced and most frequent deficiency state accompanying this starvation. There was, in many cases, an edema characteristic of starvation or famine edema. Such edema has ordinarily been considered in recent years to be a manifestation of protein deficiency dependent for its immediate production on hypoproteinemia. Studies in many of these subjects revealed normal serum protein concentrations. Furthermore, many of the subjects with extreme de-
grees of emaciation failed to present edema. These discrepancies were also observed in experimental studies of nutritional deficiencies to be described below.
In April and May 1945 a considerable number of Japanese prisoners of war suffering from nutritional deficiency disease were seen by the writer in Leyte. Among some 20 or 30 such patients the principal disease seemed to be starvation and protein deficiency. Though many had been diagnosed as beriberi, the persistence of the tendon reflexes, the absence of significant sensory changes, and atrophy and muscle weakness, indicated that the edema present was more probably a result of caloric and protein deficiency.
In attempting to discover the explanation for these observations, in apparent variance to previous concepts, the following facts must be kept in mind. In many instances the observations consisted of a single determination of the serum protein concentration which was interpreted in its relation to edema without consideration of such factors as salt and water intake, diarrhea, dehydration, physical activity, and other factors known to affect the relationship between serum protein concentration levels and the occurrence of edema. Nevertheless, as will be discussed below, the observations were made so frequently and under so many independent circumstances that they strongly suggest another important factor in the production of edema in these persons.
With the severe emaciation (caloric and protein deficiency) there were seen a percentage of other nutritional deficiency diseases as shown above. These were for the most part beriberi and pellagra.
There was, however, a great difference in the two major theaters, European and Pacific, in this respect. The vitamin deficiencies in florid form appear to have been uncommon in the European theater but were fairly frequent in the Pacific. How much this was concerned with the factor of length of incarceration is not clear. There appears to be no data available indicating the relation between the occurrence of these other diseases and the period of captivity. It might be suspected, however, that such a relationship was at least a partial explanation for the difference in the two theaters. In general, the feeding of prisoners of the Germans was more nearly adequate until the last few weeks before release. In general, the prisoners in the Pacific were badly fed during the entire period.
Experimental studies as
well as clinical observations suggest that the characteristics of deficiency
disease resulting from relatively acute and chronic deficiency states vary
considerably. This difference may be illustrated by some unusual features of the
cases of thiamine deficiency from the Pacific. Among these, there occurred an
unusual and unexpected number with evidence of
involvement of the second (optic) and eighth (acoustic) cranial nerves.12 Involvement of the optic nerve in thiamine deficiency had only rarely been observed and reported previously. The writer has seen two cases, apparently of this kind, with atrophy of the nerve head and at certain stages an optic neuritis characterizing the findings. While some doubt has existed as to the etiology, and a suspicion of a toxic optic neuritis from methanol poisoning existed in some, this does not seem to be an entirely adequate explanation. There is, furthermore, the theoretical possibility that a primary thiamine deficiency may have predisposed and conditioned to an effect of methanol which would otherwise not have occurred. The cases in civilian life observed by the writer occurred in chronic alcoholics. So far the condition has remained stationary in most of these subjects with little or no evidence of improvement in function and no change in the morphologic appearance. Unfortunately, a variety of treatment and modification of the nutritional condition before studies were begun to determine the nutritional status and possible etiology made later studies essentially valueless.
Much the same situation occurred in those subjects with involvement of the eighth nerve. Deafness, partial or nearly complete, of a "nerve" type, with little tendency to improve was the principal finding.
Other findings of unusual interest in recovered prisoners from the Pacific suffering from nutritional deficiencies (thiamine) was a loss of libido, testicular atrophy, loss of hair (body hair in particular), and certain manifestations of feminization, particularly enlargement of the breast. These changes are of particular interest in view of recent work suggesting a relation between the sex hormones, liver function, and the B complex group of vitamins. Similar observations were made in the experimental studies already mentioned.
Although much of the research in nutrition dealt with such aspects of preventive medicine as the requirements of the various nutrients, considerable new knowledge of actual nutritional disease was added by studies conducted by the Office of The Surgeon General or under its auspices.
Of these the most extensive was that conducted at the University of Minnesota by Keys and his associates,13 supported in part by the Office of The Surgeon General. These studies consisted in the controlled production of starvation (caloric deficiency) in a group of young men. By careful adjust-
ment, the caloric intake was maintained at a level sufficiently less than a planned energy output to cause a steady, progressive loss of weight. The energy output was maintained at a moderately high level (3,100 calories). Protein intake was minimum (40 gm.), but animal protein was very low, possibly inadequate in amino acids. Other nutrients, vitamins, and minerals were at levels judged to be minimally adequate. After an initial period of adjustment the subjects were maintained on this regime for some 3 to 4 months. By this time all had been reduced to a severe stage of starvation, and restoration was accomplished by successive increments of food in a manner designed to simulate relief dietaries.
The results of these experiments, in addition to providing much new data on the physiology of such starvation, are of particular interest in comparison with the starvation observed in Allied and enemy prisoners of war, civilian inmates of prison and detention camps, and the general civilian populations. As in most of these latter examples, the outstanding deficiency disease was starvation (loss of weight) and loss of muscle tissue, presumably reflecting at least a relative protein deficiency. Evidence of other deficiencies were uncommon and minor in degree. Among the outstanding changes in both groups were the pigmentation, the loss of body hair, edema, bradycardia, hypotension, and muscular weakness, particularly that related to sustained or rapidly repeated acts. Changes in the emotions and psyche with a trend to the so-called psychoneuroses were observed. Rehabilitation was slower than might have been expected if all effects are included, and the most rapid and desirable rate of recovery required large feedings. There was some tendency to overweight with recovery. These studies have added much to the knowledge of the effects of starvation.