Coping with Nutritional Deficiencies and Malnutrition
A diet mainly composed of bread, potatoes and margarine, and comparatively lacking in eggs, butter, milk and green vegetables was considered incompatible with optimum health at any age, the latter two foodstuffs being identified as protective. Such a diet was deficient in protein of high biological value, in vitamin A and other vitamins and calcium. On the other hand, the falling consumption of milk was considered to be serious deprivation for children. It was seemingly important to realise that the dietary value of animal food bore little relation to their commercial quality and cost, both elements being affected by shortages and inflation. Consequently, various food- deficiency diseases, such as scurvy, beriberi, and hunger oedema, were apt to occur in those people who, while consuming a deficient diet, were forced to make severe physical efforts. The problem deserved to be carefully studied, both from a national and international point of view, involving factors not only of an economic, social, political and agricultural nature, but also of a dietetic and hygienic type.
A general feeling spread among the population about the economic depression that affected the whole world. It not only undermined the social foundations on which the life of nations were based, but also involved serious dangers for people’s physical and mental health and for the survival of millions. The progress made in medicine and hygiene in previous decades was also being threatened. According to the report of the League of Nations’ Health Organisation for the yearly period October 1932 to September 1933, deficient nutrition affected more than 50 million people. Enquiries into the state of nutrition among the unemployed were underway in various countries and, as we know, a conference was convened in Berlin in December 1932. Indeed, in an investigation of the effects of the depression on public health, consideration had to be given to a wide range of aspects, particularly the intensity of the economic crisis, its duration and extent. Working conditions and the cost of living had to be considered, to assess the influence of a plurality of factors on death and morbidity rates. To evaluate the real dimension of the threat, collecting evidence through official statistics was the best way of mapping the situation and planning a solid programme of action.
An important aspect was the efficient organisation of health care in every nation. Several political testimonies in different countries reported that it was not rational, complete or economical, with the cost of medicines representing a very large item in the expenditure incurred by medical care providers. The seriousness of the crisis and its influence on the impairment of economic and social conditions brought to the forefront the idea of compulsory sickness insurance, a possibility that was generally regarded as the most rational method of organising the protection of the working classes against sickness and the risk of malnutrition. In fact, the cost of hospital treatment was one of the most important items of expenditure in some states and therefore governments started to introduce a financial approach to the health care system, considering the idea of exact budgetary calculations, uniform methods and daily costs based on rationalisation. It is worth noting the impairment of the social and health situation of the European population and the growing regulatory intervention of the state as main factors leading to the establishment of national health services in many European countries and not only the pressure of socialist, working class unions and political parties.
A strong link between the experimental science of nutrition, public health, economy and politics was established in the period. Experts in the physiology of nutrition and public health authorities reinforced liaison, as during the inter-war crisis public health work on nutrition was an extremely important part of public health activity. The threat of malnutrition became a serious social and economic issue and, as such, concerned politicians, economists, agriculturists, and social workers as much as it concerned health professionals. Nutrition deficiencies emerged as a new factor for what was perceived as racial degeneration, therefore nutrition, food and diet opened up an avenue to medicalisation and to the spread of medical knowledge as a way to rationalise social relations. Social hygiene was based, in a sense, on a right diet for everyone.
Scientific and medical research showed that the food consumed by the organism was not only important for providing energy. The physical state of the organism largely depended on its nutrition and had a bearing on immunological reactions. From the last decades of the 19th century physiologists such as Claude Bernard had insisted on the importance of nutrition as a fact of organic synthesis, which meant the perpetual creation of what he conceived to be a living organism’s internal environment. Other researchers, such as the American physiologist Walter Cannon, conceptualised this internal balance as homeostasis. At the beginning of the 20th century it was generally believed that the dietary requirements of human beings were satisfied so long as they had enough to eat, and therefore any illness suffered by those who were not hungry would be ascribed to causes other than the diet. Infectious diseases represented the main problem and microbes were held responsible. However, a few decades later, it was accepted that the adequacy of a dietary depended on a number of factors and mere quantitative sufficiency was considered compatible with a whole series of qualitative defects, any one of which might produce the most serious physical consequences. In the late 1920s poverty, children’s infectious diseases and the economic crisis paved the way for a new field of action. Nutrition and infection were the main references.
On the other hand, experimental and clinical research had proved that an insufficient diet leads to serious diseases like rickets, scurvy, beriberi, pellagra, dental caries, certain types of anaemia and neuropathy. It also opens the gate to infectious diseases, including tuberculosis, the so-called white pest. But the diet was not only a factor in the prevention and treatment of certain diseases; it was also related to physical development and, in that respect, public health not only aimed to prevent populations from disease, but also to create a maximum level of wellbeing, with nutrition becoming a central subject.
Under those circumstances, the hygienic control of foodstuffs became a key issue. Public health authorities were concerned about the protection of the public against dangerous contaminated foodstuffs and fraudulent practices in connection with the sale of food and the feeding of population groups in schools, factories, prisons, asylums, naval and military establishments and also in any commercial transaction. In war times, governments had to feed large armies whose physique and morale had to be maintained at all costs, and at the same time responsibility for providing food for the civilian population had to be assumed, a hard challenge to be successfully faced in times of shortage.
As a consequence of the economic crisis, unemployment and poverty had imposed on governments enormous responsibilities in the sphere of public assistance, one of the most urgent being the combat against defective diseases and malnutrition. The emergency situations produced by the war, post-war period and the depression had helped to make clear the importance of public health nutrition work in normal times. In many European countries, concerned governments controlled food availability and the nutritional conditions of the population. State central administrations extended their programmes of action under the influence of public measures and regulations, so that nutrition was paid increasing attention in the field of public health. Governmental involvement was
easy to understand in a context of emergency, but it was becoming even more systematic for public health and economic reasons. In the 1930s vast numbers of human beings were malnourished or undernourished and, indeed, famine itself had not yet disappeared, remaining a threat. But the situation would only worsen as a consequence of the war, first in Spain and then in most European regions, becoming a sort of social epidemic.
Although the effects of the crisis had not yet been reflected in vital and epidemiological statistics, several indications of increased morbidity among the unemployed and their families suggested a deterioration of their state of nutrition, especially among the social groups badly hit by the crisis. The situation was growing worse, and the resources of the unemployed and assisted persons were so scant in certain regions that they no longer sufficed to procure an adequate diet. A clinical typology of undernourished states and a precise definition of malnutrition were necessary.
The Health Committee of the League of Nations decided to establish contact between the experts responsible for the enquiries at the time, proceeding to reach an agreement on how the state of nutrition could be determined by means of a clinical examination of a standard type to be decided upon. A conference was convened for this purpose in Berlin in December 1932, chaired by Professor E. Gorter, the director of the Children’s Clinic of Leyden University (Netherlands). Two possible methods of action were discussed at the conference. One was to study the nature and quantity of foodstuffs consumed by the individuals under examination, discussing records of diet and consumption, and making a decision about whether their diet was adequate or not. The second option was based on clinical examination with a view to determining physical condition by direct exploration. Under such critical circumstances, the second method was regarded as the most reliable to obtain a picture of the situation. Obviously, these medical examinations had to be applied to a sufficiently large number of people from the various classes of the unemployed and needy groups, comparing data with groups of persons belonging to the same class, whose incomes and living conditions had been unaffected by the crisis
If the number of unemployed individuals was considerable, other tests - anaemia, fatigability, the pulse rate, signs of avitaminoses (xerophtalmia, rickets, oedema) - could also be conducted to a lesser extent. For the organisation of the enquiries, the agencies conducting them were official public health and social hygiene services comprised of doctors, visiting nurses and social workers with the necessary expertise and personal skills to ensure the best results.
Driven by the need to determine nutritional deficiencies according to scientific patterns, a general programme of research into biological measurements and tests for the definition of states of malnutrition was published by H. Laugier in 1936. Notwithstanding the hard methodological difficulties, some interesting points were emphasised in this report in order to make the practical screening of malnutrition possible. If accurate information was available concerning the weight of the person examined before the period of malnutrition, the ratio between the weight at the moment of checking and the previous weight constituted the basic criterion. In the absence of such data, some alternative measures could orient the diagnosis, such as Bouchard’s index for adults and Pirquet’s index for children. The amount of subcutaneous adipose tissue was also to be ascertained, but always taking into account that some obese individuals do not lose weight even if they eat very little and, conversely, there are thin people who do not put on weight despite their copious food intake.
Research in connection with the physiological effects of fasting might have shown regularities determined by urine analysis, a very valuable way of establishing malnutrition indices. Unfortunately, there was a lack of such investigations and, besides, they had never been applied to determine the state of malnutrition. Some clinical signs could point to deficient nutrition, such as the loss of muscular energy and the capacity for sustained effort - reduced in a state of malnutrition - but they were mainly studied in connection with unusual movements.
All the experimental evidence seemed to prove that an undernourished person reacted to renourishment rapidly and positively.
Further experiments developed in internment camps and other nutritional experiments on humans confirmed this idea. Weight and the basal metabolism increase, the pulse quickens and the blood pressure rises as motor capacities improve. Moreover, a series of additional tests could be made on a comparative basis before and after this period of feeding. A test consisted of meals rich in proteins. It had been noticed that undernourished persons retained nitrogen, as this element was not found in their urine in sufficient quantities. A glycosemia rate was also considered to be helpful. The general aim was to translate into laboratory indices the biological negative effects of a deficient diet.
The biological supervision of food, especially of its vitamin content, was to become one of the experimental possibilities to modify and improve nutritional qualities through an artificial vitaminisation of foodstuffs. The first technical challenge to solve was the preservation of vitamins, because industrial processes were not free of risks. Some evidence showed that the permanent and excessive ingestion of artificially vitaminised foods had drawbacks over time, and accidents were reported in France, Italy and England. Randoin argued for the strict suppression of advertisements exaggerating the positive effects of vitamins, the expression of vitamin contents in food in international units and the establishment of effective controls over artificial vitaminisation by means of international regulations. Rather than an advantage, some industrial techniques affecting food had become a supplementary risk.
Surveys showed that in the 1930s the problem of nutrition varied widely from one part of the world to another. In some countries, an adequate diet was still probably within the reach of the majority of the population, while in others practically everyone lived just a little above a bare subsistence level. In some countries, food prices were relatively low, but in others they were high in relation to incomes. National surveys were recommended, since local differences implied that nutrition policies varied in different areas, their goal being to ensure that all sections of the population had an adequate diet: sufficient energybearing and protective foods for optimum health.
Nevertheless, experts reported that food habits were gradually changing in the right direction, and “those communities, on the whole, are now consuming, in addition to the indispensable foods of high energy value, more milk and dairy products, more fruit and more vegetables than a generation ago”. Improvement was said to come from the understanding of dietary needs, but the movement towards better nutrition had not gone far enough. Once again, popular culture and tradition clashed with scientific knowledge and, from the nutritionists’ point of view, poverty and ignorance were considered to be main obstacles to progress, while the disparity between prices and incomes was a factor that increased difficulties. Indeed, nutrition policy was required to achieve two goals: the consumption of those products recommended as essential by experimental science, but also an improved supply, which required agriculture and commerce to adapt to new demands and cultural patterns derived from scientific knowledge.
Admitting that hunger was a national problem in most countries was the starting point for any solution in nutritional policies. More than ever, politicians became aware of the necessity of bringing together scientists, public health experts, economists, agricultural experts, consumers’ representatives, teachers and administrators in some kind of national nutrition committees that recognised the importance of integrating agricultural, educational, health and economic policies. European governments afforded direct relief, especially to the unemployed, and the extension of such social interventions was considered extremely important in order to improve the population’s health status, bearing in mind that the problem of malnutrition was urgent. Many governments adopted measures of direct assistance to supplement the diets of the more exposed, especially to prevent malnutrition in childhood by way of giving milk to infants, children, adolescents and expectant and nursing mothers.
From the perspective of social assistance, school meals were to play an important role in a context of dietary policies based on public and private provision of food needs. The crisis forced modern states to become directly committed to intervening in private habits, but also in public and private institutions, shaping a network of community nutrition: school canteens, hospital meals, charitable and benevolent institutions, relief centres, the army and navy, prisons and other state services and institutions. Public and private authorities assumed responsibilities for the provision of meals, trying to ensure that all nutrient constituents as defined by experimental science were provided.
In all Western countries, the average diet of the population had become increasingly diversified from the beginning of the 20th century. There had been a tendency for the consumption of dairy produce, eggs, fruit and vegetables to increase; and the great staples, such as cereals and potatoes, had come to constitute a smaller proportion of human foodstuffs. The fact that a larger amount of the total calorie requirements were derived from the highly protective foods represented a great nutritional advance and provided evidence that there was a natural tendency on the part of consumers to become more aware of the importance of rational nutrition as far as economic circumstances permitted. An exception usually mentioned was the increasing consumption of sugar in certain countries.
The most notable trends, apart from the remarkable increase in sugar consumption, were the continuous rise in the consumption of milk, butter and eggs, the steady fall in bread consumption and the post-war decline in the consumption of potatoes. It seemed clear, from the examples given, that the average diet of the urban working classes in Western countries tended to include larger amounts of protective foods. Instead of the general improvements and changes in feeding habits, the diet of a substantial portion of the population remained deficient in essential nutritive elements, giving way to an unquestionable problem of malnutrition, even in countries with the highest standards of living.
The changing content of the diet of Western countries was not an accident; it corresponded to a genuine change both in physiological requirements and in the possibility to satisfy them. Most of the experts believed that the principal factors were the reduction in the expenditure of muscular energy caused by unemployment and increased mechanisation in industry and agriculture. There was also the reduction in the hours of work on the one hand and the rising number of those engaged in commerce, trade, clerical work, administration and other quasi-sedentary occupations on the other. By far, labourers doing heavy manual work spent more energy than machine operators or office workers. Ever a smaller fraction of the population was engaged in the primary industries such as agriculture and forestry, and a constantly increasing proportion was involved in manufacturing, trade, transportation, clerical and professional occupations. Economic facts were also to be kept in mind: the foodstuffs that had tended to feature in the diet were usually more expensive than those they had displaced, and the so-called modern diet became dearer than the diet of previous decades, which had uneven effects upon everyday life in times of crisis.
The effects of deficient nutrition caused by poverty and exclusion was not immediate; it took some time to reach a clinical level, becoming apparent after a long interval. “A child whose diet contains too high a proportion of cheap carbohydrates may retain a normal weight for a fairly long time, even though a state of anaemia and debility has already set in. The actual duration of the inadequate nutrition is a very important factor”. However, it was widely recognised that even among the very poor, the diet could be influenced by factors other than income, such as maternal efficiency and cultural habits. Nutritional experts suspected some prevalence of hidden undernourishment in all social levels. After the 1930s crisis and World War II relief was necessary as a social tool, but also education in marketing, values, cooking and methods of food preservation. Housewife efficiency was deemed to be a keystone of the problem of nutrition during the economic crisis and it mostly depended upon educating mothers. All instruments had to be put into action to reach this target: campaigns, films, lectures and radio. Mothers became a key player in the process of civilisation. Changing dietary habits was a part of it.
An international food policy, as called for by the international committees, also required the international unification of the technical analysis and control of food quality of foodstuffs, setting up standards of reference and specifications for grading foods of all kinds according to quality. Bearing in mind that each country had previously developed its own regulations and institutions for the control and expertise, coordination of the nutrition work carried out by different authorities was recommended. Based on the collection of records about consumption by families of different occupational groups with different income levels, international comparative records were to become essential in verifying to what extent national dietaries fell short of the new standards. Scientific standards aimed to become references of authority in the process of disciplining both the economy and dietary habits.
During the Depression years it was thought that general incomes would rise sooner or later and therefore special actions had to be taken to improve the nutrition of particular community groups.
A meeting on the Nutritional state of children was held in December 1936 following the initiative of the League of Nations Experts’
Committee on Nutrition. In their final report, the experts recommended an assessment of the state of nutrition of large numbers of children, and to further develop somatometric, clinical and physiological tests, designed to detect the first signs of malnutrition at the earliest possible moment. Nutritive food requirements in the first year of life were also discussed, paying special attention to breastfeeding and milk supplies as a means to avoid problems in the child’s organic development and nutritional deficiencies. In the last meeting, held in November 1937, the technical commission on nutrition endeavoured to show, in the light of recent research, why milk was a foodstuff of such paramount importance, especially during growth in childhood. It also emphasised the need to eliminate the dangers of milk as a vehicle for bacterial infection.
Between June 1938 and April 1939 the work of the Health Organisation Technical Commission on Nutrition concentrated on two main lines. It changed the geographical perspective, previously focused on Western countries and, in pursuance of a recommendation adopted by the General Advisory Health Council in 1937, it was to undertake the study of nutrition in Asia and tropical countries in general. In addition, the Commission was to deal with qualitative and quantitative surveys designed to bring any nutritional deficiencies to light.
With particular regard to the Far East and tropical countries, the Committee considered that fuller information was required on dietary habits, the incidence of diseases connected with dietary deficiencies and the nutritional value of local foods. As a starting point, it reached some general conclusions on national programmes and urged certain adjustments in the sphere of agriculture to increase the production of protective foods. However, more complete dietary surveys were to be made to find food supplies in the rural and urban areas of several countries using statistics on production and consumption as a main tool.
Three types of enquiries into the state of nutrition of populations were suggested. Large-scale demographic investigations were proposed, consisting of a record of the age, sex, physical appearance, height and weight of each subject. They represented a sort of individual chart containing general anthropometric features. A second level of research included more detailed investigations that covered a limited number of individuals. Among other data suggested were: core features of children’s diet; an exhaustive medical examination of individuals; the economic and social position of the family; as well as somatometric records, photographs and tests to detect pre-deficiency conditions. The third level consisted of surveying bio-topological investigations regarding morphological characteristics and biological functions, as well as psychological examination of the population.
During its August session, the attention of the Special Committee was drawn to the fact that, even in Europe, disturbing conditions existed in which the problem was no longer to lay down the bases for a satisfactory diet, but rather to prevent the population from the risk of dying from starvation. This was, more particularly, the position of Spain in 1938, affected by two years of war. To cope with it, the Society of Friends sought guidance in the preparation of an emergency diet for the refugees. The Committee suggested that a diet of this character should be mainly composed of whole wheat, brewer’s dried yeast, cod liver oil and various salts. This emergency diet was designed to include vitamins and essential inorganic constituents. At the same time, the Committee pointed out that such a diet was, at most, adequate to sustain life and to prevent the appearance, during a limited period, of the more serious effects of malnutrition. But it was not to be interpreted as a permanent dietary pattern. It could only be looked upon as an emergency diet, to be supplemented at the earliest possible moment by fresh foods. The risk of undernourishment and chronic malnutrition was a real threat and the situation would deteriorate in several European regions in the following years as a consequence of the war.
-  Ibidem, p. 456.
-  Ibidem, p. 473.
-  “Report of the Health Organisation for the Period October 1932 to September 1933.IV. Economic Depression and Public Health”, League of Nations Quarterly Bulletinof the Health Organisation, Vol. 2, 1933, pp. 529-535.
-  Guillem-Llobat, Perdiguero, 2006, pp. 33-40.
-  Burnet, Aykroyd, 1935, pp. 323-474.
-  “The most Suitable Methods of Detecting Malnutrition Due to the EconomicDepression, The. Conference held at Berlin from December 5th to 7th, 1932”, Leagueof Nations Quarterly Bulletin of the Health Organisation, Vol. 1, 1933, pp. 116-129.
-  The Conference was attended by representatives from Austria (E. Nobel), Belgium(D.L.J. Gilbert), United Kingdom (Janet M. Campbell and A.F. Hurst), Denmark(Th. Madsen), France (J. Parisot), Germany (C. Hamel, E. Atzler, G. von Bergmann,W. Bansi, O. Martineck, p. Stefani and H. Zondeck), Italy (C. Gini) and USA(K.D. Blackfan and J.R. Murlin) and several members of the German Reichstag.
-  “The most Suitable Methods”, 1933, p. 119.
-  Laugier, H., “General Programme of Research into Biological Measurements andTests for the Definition of States of Malnutrition”, League of Nations QuarterlyBulletin of the Health Organisation, Vol. 5, No. 3, 1936, pp. 505-530.
-  Nutrition in internment camps and nutritional experiments on the pathological effectsof malnutrition in humans will be discussed in a further chapter.
-  Randoin, L., “On the necessity for a biological supervision of food (with SpecialReference to its Vitamin Content)”, League of Nations Quarterly Bulletin of theHealth Organisation, Vol. 5, No. 3, 1936, pp. 493-504.
-  Final report, 1937, p 32.
-  Ibidem.
-  Ibidem, p 36-38.
-  Burnet, Aykroyd, 1935, p. 384.
-  Guillem-Llobat, X., El control de la qualitat dels aliments. El cas Valencia en elcontext international (1878-1936), Valencia, PUV, 2007.
-  “Report on the physiological bases”, 1936, pp. 97-98.
-  “Report on the work of the Health Organisation between June 1937 and May 1938,and on its 1938 Programme. 4. Nutrition”, League of Nations Bulletin of the HealthOrganisation, Vol. 7, 1938, p. 646.
-  Ibidem, pp. 27-32.
-  Ibidem, p. 29.
-  Ibidem, p. 32.