Malnutrition: Physiological, Clinical and Therapeutic Aspects
The medical aspects of the lack of food were a central part of the technical report on the prevention and treatment of severe malnutrition in times of disaster. Ancel Keys’ report stressed that the proper treatment of patients suffering from starvation had to attempt to achieve the following goals, as far as possible:
- a) Preservation of life.
- b) Prevention of irreversible damage to body and mind.
- c) Establishment of nutritional and general metabolic conditions leading to maximal recovery.
- d) Restoration of morale and promotion of a physiologically healthy state of mind and emotion.
- e) Rebuilding of the wasted tissues of the body to the nearest point to the pre-starvation state.
- f) Total rehabilitation, for the patient to secure his/her place in the community.
Obviously, the practical measures offered to the population had to be adjusted to the available supplies, facilities and personnel, and this could mean serious constraints to the capacity of action. As a consequence, differentiation was made between an ideal treatment and a proper treatment, the latter being understood as “the best which could be provided in a given situation”. Experience gained from the extreme exhaustion provoked by World War II in Greece, the Netherlands, Leningrad, in prisons, and concentration and internment camps, could be applied to future extreme situations caused by wars or natural catastrophes. In fact, Keys tried to follow such experiments in post-war peace times. The Joint FAO/WHO Experts’ Committee looked to give practical advice for the treatment of victims living under starving conditions.
Suffering and death among starving patients and in the general population during famine are not solely the direct result of food shortages and calorie inadequacy. Whenever there is mass starvation there is apt to be a breakdown in sanitary and public health control with the consequent danger of widespread infections and epidemics. Programmes for the prevention or amelioration of the ill effects of famine must, then, give prominence to other public-health measures as well as the basic matter of nutrition... Vaccinations, anticholera inoculations, malaria control, purification of drinking water, and similar measures must be pursued with vigour from the start of any programme for the control and relief of famine.27
Treatment had to be adjusted to the social situation, as well as to each patient. In a catastrophic situation in which large numbers of patients must be treated, complete diagnosis and evaluation for each individual might be impossible, but there could be segregation into groups sharing common nutritional patterns of prescription. To this end, it was useful to classify several varieties of starvation and malnutrition, and to consider several influencing factors too.
The Duration of malnourishment was important for both treatment and prognosis. A certain degree of cachexia could be the result of a few weeks of fasting or of many months of undernourishment. Complete return to health was best when inanition had been short, and therefore the length of the treatment was directly related to the period of malnutrition. Concerning duration, starvation and severe malnutrition was classified as: brief, when it lasted less than one month; moderately prolonged, when it affected the population from one month to one year; and very prolonged and chronic or extremely prolonged, when it starved people for more than one year. A different category, namely lifelong malnutrition, was applied to those suffering since early infancy.
A rough classification of varieties of starvation was proposed by Keys in terms of the most important deficiencies:
- a) Simple starvation and simple undernutrition occurs when the calorie deficiency is of major importance, a condition that could be recognised by the presence of emaciation, bradycardia and other clinical signs derived from the physio-pathological consequence of calorie under-nutrition, such as polyuria, weakness, depression, hypotension, hypothermia. This clinical picture shows the absence of polyneuritis, glossitis, extreme oedema, definite night-blindness and severe gingivitis. “Slight to moderate anaemia and dependent oedema were common; tendon reflexes may be reduced, senses and the intellect were usually unimpaired, but prevailing lethargy and apathy gave the impression of dullness or even stupidity. Major complaints were hunger, weakness, fatigue, dizziness, irritability and cold sensitivity”.
- b) A second variety, which Keys called primary protein deficiency, appeared when the total protein content or quality constituted the most serious defect in the diet. Oedema, liver and kidney disease, and little appetite were common signs of primary protein deficiency.
- c) A third category was primary B-complex deficiency, characterised by cutaneous, mucous-membrane, neurological and sensorial complaints.
- d) Other classical deficiency diseases encompassed different categories such as beriberi, scurvy, pellagra and vitamin-A deficiency.
- e) However, mixed deficiencies were common wherever there was malnutrition and, in case of doubt, all severely starved or malnourished patients would be treated as though they had a mixture of nutritional deficiencies.
- f) Finally, nutritional deficiency plus trauma or disease was a typified condition, taking place when malnutrition or starvation was accompanied by serious injuries or complicated by serious disease, the treatment of the nutritional state being essential as part of the global treatment.28
From a purely quantitative perspective, Keys proposed the establishment of several degrees of nutritional deficiency. Based on his clinical experience and the conclusions drawn from his experimental research, this was particularly helpful for large-scale treatment. The categories proposed were:
a) Mild deficiency: characterised by a body weight under 15 per cent, mild primary protein deficiency and a moderate degree of oedema and other signs of vitamin deficiencies: gingivitis, follicular keratitis, glossitis, cheilosis, appetite loss, paresthesia, conjunctivitis, muscular weakness, mild polyneuritis...
- b) Moderate deficiency: implied a loss of weight from 15 to 20 per cent, moderate oedema, alteration of total plasma protein concentration and decrease in haemoglobin below standards.
- c) Severe deficiency: implied more than 20 per cent of weight deficit, oedema, mild anaemia and other clinical signs pointing to a state of semi-starvation. A severe deficiency of proteins and vitamins resulted in pronounced signs of deficiency diseases such as scurvy, beriberi, pellagra, rickets...
- d) Extreme deficiencies: might be diagnosed when the clinical picture indicated imminent danger of death from starvation or malnutrition and major signs and symptoms were present to a very high degree, which used to appear when the body weight was only 60 per cent of the ideal weight.
The typical severely starved person, without other complications, is emaciated, with a pallid, greyish visage and apathetic, depressed expression. Neglect of personal appearance, indifference to the impression of stupidity. Blotchy, pigmentation on the face or elsewhere may be mistaken for simple dirt. This pigmentation sometimes may be ascribed erroneously to pellagra.29
Those and other physical signs were described in Ancel Keys’ report, showing the physical impairment induced by under-nutrition, describing in a detailed way the clinical signs identified by medical examination. A physio-pathological description of functional alterations was also described: muscular weakness, rapid movement impairment, visual and hearing difficulties, changes in respiratory, digestive and circulatory function, heart weakness, oedema in knee joints, and many other signs. The foregoing descriptions apply to uncomplicated starvation and are accompanied by complaints, more or less in proportion to the degree of starvation, of weakness, hunger, fatigue, sensitivity to cold, depression, dizziness on arising, a sense of being old, and polyuria. Substantial deviations from this picture, including other signs or symptoms than those mentioned, indicate other complications -specific nutritional deficiencies, infection, or other concomitant disease. Paresthesias may suggest thiamine and possibly other B-vitamin deficiencies but the possible role of circulatory factors must not be neglected. Great oedema suggests specific protein deficiency, liver disease, heart failure from causes other than simple starvation, or renal disease. Pain referable to the bones with complaints usually centred in the pelvis and the spine indicates the possibility of nutritional osteopathology, which can be checked by x-ray examination. Visual or auditory defects may be ascribed to vitamin deficiencies. Extreme anaemia suggests the presence of blood-destructive infection, specific blood diseases, or iron deficiency; the latter may be indicated by hypochromia. Severe gingivitis, with bleeding, may indicate ascorbic-acid deficiency which should be confirmed by a search for other diagnostic features. There is an increased incidence of hernias and of thrombophlebitis.30
Thanks to his clinical experiments, Keys showed in his report his vast experience in the sequencing and recognition of the clinical signs caused by starvation. In addition, severe starvation could conceal the presence of serious infection, as the normal febrile response to the infection could be diminished or absent, particularly in cold weather. The diagnosis of tuberculosis, for example, could be delayed or missed on this account. The starved person seemed to be relatively unresponsive. Starvation produced changes in muscular and psychological characteristics. Early in the course of starvation there was a loss of muscular endurance with a relatively low loss of fine coordination and muscular strength. The reduction in the ability to make small rapid movements was not marked until the more extreme stages of starvation appeared. A reduction in cardio-circulatory function was large and progressive, but not greatly disproportionate to the basal metabolic demand. Changes in purely respiratory function were not of critical importance in simple starvation, and the same was true for digestive, excretory and renal function. The thermoregulatory function was disturbed in starvation and the limited circulation became increasingly restricted to the more vital organs.
From a purely medical perspective, the psychological influence of severe malnutrition and starvation was conditioned by the somatic impairment that especially affected the person’s emotional balance. But the more severe the picture, the more consistent the psychological deterioration pattern, which ended in delirium prior to the comatose state. The most outstanding emotional characteristic was depression and apathy, which took the patient to a state of mindlessness, irritability, weakness and fatigability, all this resulting in very slow movements and quietness. Social kindness and politeness disappeared and moral patterns were altered. Mutual self-help became difficult to maintain without strong leadership from non-starving persons. Neurotic tendencies were exacerbated, but, according to Keys’ report, few of them turned into psychosis or psychotic behaviour, suicide being uncommon. The basic intellective abilities were not deeply altered, except for the most extreme starvation cases. But intellective activity was reduced as a result of physical deterioration. When feeding was resumed, the return of strength made up for the accumulated damage and irritation. At this stage, doctors noticed that the patient was far more troublesome than before starving. When severe deficiencies of vitamin B complex occurred, the psychological picture became altered, producing violent personality changes, which explains why pellagra was also associated to dementia.
The extremely starved person was incapable of any useful work and of taking care of themselves. In less extreme states, starved people could work in line with their limitations, “but constant stimulation and supervision may be necessary”. The moderately starved person showed little endurance for heavy manual work, but was still able to do jobs that required little muscular effort or prolonged standing. Obviously, under famine conditions, mortality rates would frequently rise due to several causes leading to direct starvation deaths and fatalities by infection or other causes. However, general mortality did not necessarily rise in times of famine, as it reduced the prevalence of certain diseases. Diabetes mellitus, for instance, was notably reduced; coronary diseases and hypertension also tended to decrease and available data suggested that no rise and possibly a slight fall in deaths from neoplastic diseases took place. On the contrary, under famine conditions, a marked increase in the number of deaths attributed to respiratory and gastro-intestinal diseases, senile decay and violence was observed, with tuberculosis being a major threat. A general pattern of behaviour was recommended from a medical point of view:
Where there is a mass-starvation problem a single agency or organisation
should be in charge of the treatment of starved persons in the area involved and the effective direction must be given to experts in medical nutrition. This agency must have responsibility and authority over the selection of patients and hospitals or treatment centres, over the recruitment, assignment and direction of professional, nursing, and other personnel, over the requisitioning and allocation of supplies and equipment, and over the general policies and methods of treatment. In a city where several hospitals, hotels and other structures or areas are designated as starvation-treatment centres, a single body, agency or board must have authority over all these facilities. Such centralisation of power was essential both for efficiency and to prevent large discrepancies in the aid given to patients in equal need. All food gifts and food distribution by welfare agencies must be rigorously controlled for the protection of the patients themselves, who may be seriously harmed by over-zealous feeding.
Arrangements for starved patients were to be made by fully acknowledging the special situation of the patients, who were weak, fatigued and frequently troubled with polyuria and diarrhoea. Famine victims were almost universally careless and untidy, which often made sanitation hard to maintain. Under those difficult circumstances, the major risks were tuberculosis, typhus and all forms of sewage and food- borne infections. Experienced doctors and nurses were considered to be essential for efficient health care. Ancel Keys’ technical report made reference to the most convenient technical facilities and equipment for the exploration of patients: X-ray, fluoroscopic units, blood analysis and other instruments. However, food was the essential problem:
The number of patients to be treated and the efficacy of their treatment are strictly dependent upon the food and feeding supplies of the centre for the treatment of starvation. Though some semi-starved adults may demand, and may eat when offered, as much as 5,000 or 6,000 calories a day, calculations as to the real needs for starved patients under treatment can be made at a far more modest level. For a mixed population of ambulatory patients of both sexes and all ages, none of whom is doing heavy work, a supply level of 3,500 cal. should be ample, unless there is excessive waste, and 3,000 cal. should suffice to allow fairly rapid rehabilitation if the distribution is properly adjusted to the size, age, sex, and activity of the patients. These figures cover estimated waste not exceeding 10% and are proposed for a temperate climate and people of the size of ordinary north Europeans.
The actual food items to be supplied had to be selected by taking account of the nutritional characteristics of the diet, acceptability by the patient, cooking and feeding facilities at hand and foods available. The general character of the diet had to be aimed at a high-protein and low- residue level, and be as high in vitamins and minerals as possible. The treatment schedule proposed was as follows: firstly, the patient had to be classified according to the degree of medical urgency; then supportive treatment would be initiated for critical cases; and a diagnosis would then be made. To start with, moderation was the rule and any patients looking moribund would be treated as a medical emergency. In any case, Keys’ report recommended that the first feeding underestimated rather than overestimated the capacity of the patient to assimilate food. Patients who were ambulatory and not very emaciated could be put directly on any available diet that was readily digestible and nutritious, but in no case was it recommended to exceed 2,000 cal. on the first day or to exceed 3,000 cal. in any day of the first week. The best guide to the feeding programme for the first few days was considered to be the estimate of the dietary intake of the preceding few days. If this was considered to be of the order of 1,000 to 1,500 cal. it was safe to increase this by 50 per cent. If the patient was extremely cachectic, even this modest amount had to be provided in five or more daily feedings of highly digestive foods, chiefly liquid.
The whole feeding programme should be devised to increase the nutrient intake as rapidly as is consistent with safety and comfort to reach the maximal rate at which the body can really utilize the food. Surpassing this rate means at best either gastro-intestinal problems or excessive fat deposition or both. Unlimited crowding of either calories or proteins in the diet into the body does not mean necessarily any gain in tissues rebuilt or strength restored. The dietary supply should be reduced with the appearance of any sign of indigestion, cardio-circulatory embarrassment, or appetite
After the first few days of dietary treatment many immediate dangers and problems would be overcome, but the succeeding few weeks also brought difficulties. The feeding programme for the first few weeks continued to be conservative. For a severely starved man whose normal body-weight was 65 kg, and who was ambulatory but not labouring or continuously active, an average intake of 3,000 cal. daily for the first month was considered ample and anything over 3,500 cal. Excessive. These amounts were lower for women and older men. When possible, it was considered desirable to divide the daily diet into more than three meals. After one or two weeks, it was time to institute a cautious programme of mild exercise for all patients for whom it would seem appropriate.
But feeding was not deemed to be enough to restore strength and wasted muscles could not be rebuilt without exercise. After a month the most severely starved patients would still be extremely weak, definitely anaemic and in no condition to do without external care. The less severely starved patients could be ready to care for themselves on an outpatient basis, but would still receive dietary and medical guidance and be protected from heavy work or exposure to inclement weather. As a matter of fact, Keys argued that starved patients would not be fully recovered for many months to come. “If the normal body weight of an adult is regained in less than five or six months the body composition will be excessively high in fat and in no case can one expect complete restoration of proper body composition and function in less than this time or indeed short of eight or ten months. During all this time a relatively high intake of proteins, vitamins, and minerals is advisable”.
From a community perspective, the provision of relief could be organised as follows:
- 1. A public health office to direct all operations and keep records.
- 2. An emergency hospital, which could serve as a central storehouse of medical supplies and special foods.
- 3. A nutritional and medical survey team.
- 4. A chief sanitary officer and assistants.
- 5. A community kitchen that has medical supervision.
- 6. An isolation hospital for communicable diseases.
- 7. An outpatient clinic.
- 8. A special clinic for pregnant women, nursing mothers and infants.
- 9. A transport section to move patients, supplies and facilities.
A specific section was to be devoted to parenteral therapy, commonly used in modern hospitals, including intravenous infusions and transfusions. In 1951 the nutrition experts considered these new technologies very useful in the treatment of severely starved persons, where the primary needs were to give the tissues an ample supply of nutrients and to support circulation. But in any other cases “parenteral feeding is an expedient to be resorted to only when other methods of feeding are clearly inadequate or inapplicable. Intravenous infusions always entail some risk and this is much increased when applied under conditions other than those of a good modern hospital. Specific recommendations about the content of intravenous alimentation were detailed in the report.
A section of the clinical report was devoted to the special problems of infants and children, and considered the nutritional requirements for growth and the formation of milk by the nursing woman. The protein requirement for growth was high and, in a situation of shortage, dietary proteins tend to be used for energy purposes only. This leads to a serious protein deficiency in diets poor in calories, even when the protein intake is reasonably high. Moreover, for new tissue to be formed, the incorporation of appropriate vitamins and minerals is necessary, so the amounts of these nutrients must be directly related to the rate of growth. Body size, muscle condition and organic impairment must be explored. The experts believed that infants and young children were best taken care of by their mothers or relatives, wherever possible. In large camps and hospitals, efforts were made to provide separate quarters for family groups or for women with young children. Emergency feeding stations for infants and young children, and pregnant and nursing women, were considered of great value for providing direct nutritional aid to those vulnerable members of the community. Such stations would provide medical help, health education and instruction in the feeding of infants. For school-age children, school canteens were most convenient. Visiting nurses and social workers could be assigned to assessing social conditions that influence malnutrition. Special management for diarrhoeal disease was also included.
After the clinical approach to starvation by Ancel Keys, the last part of the technical report published by the Joint Committee was devoted to the organisation of general relief activities in relation to nutrition when famine conditions prevailed. In the immediate post-war period a lot of experience of organised relief feeding was gained, with some evident examples mentioned: the United Nations Relief and Rehabilitation Administration (UNRRA); UNICEF; the International Red Cross; the League of Red Cross Societies; and the Society of Friends. When the emergency was formidable and needs were great, national action alone was insufficient and relief was regarded on large-scale and food shortages as an international responsibility. The agencies concerned with relief had to be ready to move in supplies and personnel at the right moment.
Distribution centres, mobile canteens, field kitchens, etc. must be set up without delay in the affected area. Equipment that will provide some means of cooking within the homes may be necessary. It is important to consider also supply of water and fuel needed for cooking. In arranging the provision of food the local dietary habits and patterns of the people to be relieved should be taken into account, as far as this is possible.3
The first task was to make surveys of small samples of the population to discover the level of feeding during the famine period and the current state of nutrition. This was intended to show to what extent people were suffering from specific food-deficiency states, as well as from generalised deficient nutrition. Also, it would indicate both the level of relief required and the need for foods rich in particular nutrients to overcome specific food deficiencies. Under the living circumstances of Western Europe, where famine conditions were not superimposed on chronic deficient nutrition, relief could be needed by three broad categories: a) the normal underfed population; b) ambulant close to starvation cases, affected by 25 per cent body-weight loss; and c) acute starvation cases provoking cachexia, oedema and other clinical signs. To deal with this situation three types of feeding teams were considered necessary: medical selection teams, distribution teams and clinical teams. The types of personnel required were physicians, nurses, nutritionists, distribution officers, cooks and kitchen staff.