Adequate Diet in Tuberculosis

In a nation made sharply conscious of malnutrition by the figures of the draft for World War II, we are receptive to useful ideas for the improvement of the health of the public. For many years physicians treating tuberculous patients have been working to combat malnutrition, without the reminder of the statistics of draft rejections. During the war, ration boards were empowered to grant extra meat allotments to patients suffering from tuberculosis. It is universally accepted that adequate diet is necessary for the treatment of this disease.

We propose to describe our own experience in the use of diet as a therapeutic agent for treating the tuberculous. Dr. F. M. Pottenger founded the Pottenger Sanatorium for Diseases of the Chest in 1903. Cherishing a firm personal belief that good food formed a sound basis for the treatment of all diseases, he gave primary consideration to the cuisine. His chefs prepared meals as interesting and delectable as those served in a fine hotel. Not only did the patients show an improved state of nutrition, but they anticipated the meals with enjoyment and appeared to adapt themselves contentedly to hospitalization.

With an established policy of good food served attractively, we were ready to make use of the newer knowledge of nutrition as science began to investigate the effects of food on health. Twelve years ago, a special diet was developed for the patients in our institution. The diet was made elective, and about half of our patients chose to receive it. Those who selected their foods without reference to our suggestions, however, were influenced in their choice of foods by the patients on the special diet.

Because of food rationing we have been using a modification of our original diet through World War II. We shall first describe our present menus, and then indicate the changes we shall make when the food market is again normal.

We attempt to provide the vitamin requirements from foods naturally rich in these elements. We alter our food constituents as little as possible by applying low temperatures in cooking. We make extensive use of the hydrophilic colloidal properties of gelatin. We supply an adequate amount of minerals by using relatively crude foodstuffs.

Our breakfast menu is as follows: A cooked whole grain cereal such as rye, oats, barley, wheat or corn, to which is added one-half ounce of raw wheat middlings; one pat of butter; three ounces of 20 per cent raw cream; eight ounces of raw milk; a citrus fruit equivalent to one-half grapefruit or one orange; four prunes; a choice of two eggs and four slices of bacon or a serving of sausage; one slice of whole grain toast; a cup of coffee substitute, and a glass of gelatin drink, containing one-half ounce of gelatin with a suitable flavoring.

Luncheon consists of a meat-stock soup; a meat (when possible, heart, brain, liver, tripe, sweetbreads or kidney); raw liver three times a week; a raw green salad; two cooked vegetables; a dessert such as custard, ice cream, junket or jello, or fruit in season; one slice of whole grain bread with one pat of butter; one glass of gelatin drink; eight ounces of raw milk; one drachm of rice molasses concentrate or one-half ounce of malt extract.

The evening meal follows the luncheon plan except that a roast is usually served in place of other meats. With this amount of food, there is no demand for between-meal feedings.

Whole grains are used in cereals and breads in order to provide adequate minerals. The bread used for all meals except breakfast is made of sprouted wheat and rye and is very rich in the vitamin B complex, inasmuch as it is baked at a temperature of 160°F. The raw wheat middlings are also an excellent source of the vitamin B complex and of vitamin E. The prunes are given for their laxative action.

We serve fertile eggs of hatching quality because of their superiority in estrogenic substances.¹ We use certified raw milk because of the presence in this product of important enzymes necessary in calcium metabolism. Experimentally, we have demonstrated that cooked meat and heat-treated milks, when fed to cats, interfere with proper calcification of the bones, enhance susceptibility to bacterial infection and bring about demineralization.^2,3

Raw liver served in tomato juice is an excellent source of the known necessary minerals and vitamins. We serve other visceral meats whenever possible to provide the patient with an adequate amount of nuclear proteins.

The purpose of the gelatin is to give a hydrophilic colloidal base to the stomach content, reducing the irritation of the gastric mucosa. This is of inestimable value to patients suffering from extensive tuberculous enteritis, most of whom are able to tolerate the diet well, and are apparently aided in the healing of their intestinal lesions.

We find that patients can handle animal fats, particularly the normal fat on meat and butter fats, better than vegetable fats. In salad dressings, we prefer to use olive oil rather than other vegetable oils.

Most patients gain weight on this diet for about three months. However, their tissue tone tends to improve so that they may actually shrink in physical measurements while showing an increased weight. Patients whose disease is extensive and who are almost entirely inactive may develop a good degree of muscle tone in spite of the lack of exercise. The muscular fatigue suffered by tuberculous patients who return to physical activity after long periods in bed is partially avoided by those who have eaten the special diet.

Many patients on this diet correct their bowel habits, even when they have suffered from long standing constipation. In spite of the roughage present, many patients who suffer from tuberculosis of the bowel soon regulate their evacuations and eliminate nocturnal diarrhea. We believe that the special diet improves the nutrition, increasing their resistance to their disease, and cutting down the frequency and severity of gastrointestinal complications.

We have used this diet in the treatment of patients suffering from asthma and allergies, with good results. We have had the experience of seeing positive tuberculin reactions in many children become negative after a period of time on this diet.⁴ We feel that the improved dietary has contributed in large measure to this loss of tuberculin sensitivity.

Analysis of our diet, in daily amounts, is as follows⁵:

 

Protein aFat  aCarbohydrates  Calories Calcium Phosphorus Iron  Iodine Vitamin A  Thiamin  Riboflavin  Nicotinic acid  Ascorbic acid  Vitamin D

231 g. 187 g. 310 g. 3,840 1,697 mg. 3,007 mg. 29 mg. 107 mmg. 19,337 I.U. 4,168 mmg. 5,086 mmg. 48 mg. 120 mg. 107 I.U.

 

A group of dentists in California, who are alert to the part that nutrition plays in dental health, recently convened for a Seminarb at Palm Springs, California. It is of interest to note that their food recommendations closely resemble those which we use at the Sanatorium. This group has worked out a dietary which they advise for maintaining a healthy condition of the teeth and gums. It consists of the following elements, in the daily amounts listed⁶:

 

Protein Fat  Carbohydrates  Calories Calcium Phosphorus Iron  Iodine Vitamin A  Thiamin  Riboflavin  Nicotinic acid  Ascorbic acid  Vitamin D

211 g. 115 g. 201 g. 2,600 2,342 mg. 3,060 mg. 27 mg. 225 mmg. 18,480 I.U. 1,560 mmg. 4,335 mmg  53 mg. 177 mg. 168 I.U.

 

Three items which were part of our original diet have been curtailed by World War II. It is our intention to resume their use as soon as materials are again available. First, we used raw bone meal with our breakfast cereal. We have found that the femur of the steer, ground at low temperatures, provides an excellent source of calcium. It is easily chewed into a gelatinous mass and is more readily assimilable than heat-treated bone meal and other forms of calcium. Second, we used the sprouted Chinese mung-bean in our green salad once a day. These sprouts are rich in vitamins B1 and C, and contain a small amount of vitamin A as well as diastase, prochlorophyll, minerals and hydrolyzed vegetable protein. Third, we used visceral meats as one-third of the daily meat ration, instead of their occasional use as at this time.

We believe that it is possible to use this dietary in public institutions where the food costs must be closely budgeted. By substituting the less expensive cuts of meats, including visceral meats, by using sprouted seeds of some type as part of a green salad, by using whole grain cereal ground in the hospital kitchen as well as whole grain bread-stuffs, and by cutting down refined carbohydrates, it is possible to adapt this high protein, high fat, low carbohydrate diet for use in public institutions.

It is our conclusion that the logical basis on which to estimate the cost of food for tuberculous patients is the cost per patient per period of arrestment rather than the cost per patient per day. If a highly vital diet of slightly greater cost will restore a patient to health in a shorter time than a cheap diet of poor nourishing quality, the end-result is a saving of time and a saving of the tax-payer’s money.

We serve our employees a high protein diet without the adjuncts of rice molasses concentrate, malt extract or gelatin. The fact that we have had no known tuberculous infections attributable to employment among our employees in forty-two years is suggestive of the protective value of the food eaten.

One of the foremost names in nutritional research is Sir Robert McCarrison. Following World War I, he performed experiments on rats, monkeys and pigeons by feeding them the diets of the various peoples of India. Ill health was imposed upon these animals comparable to that suffered by the people consuming the inadequate diet.⁷ We have performed similar experiments on cats in our own laboratory with like results.⁸

One of the outstanding experiments with human beings is the Papworth Settlement in England.⁹ Here tuberculous patients carry on supervised work. Two rules are rigidly enforced: first, that all patients must expectorate into sputum pocket flasks, thus eliminating the possibility of mass doses of infection; second, that all patients must consume an adequate diet. Sir Pendrill Varrier-Jones, in a report in 1936, reported that none of the children born of parents in this settlement showed active infection. He concludes that “the child’s resistance to disease is maintained by (a) adequate nutrition and (b) the absence of mass doses of infection.”

Wrench9 sums up the influence of circumstances which predispose human beings to infection as follows: “Living in dark, close alleys and tenements means also faulty food. The impure air of slums means one food, namely, oxygen, being defective, but it means also that people who breathe it have not the money for foods that cannot, like oxygen, be got for nothing. Alcohol in excess destroys the appetite. So do the poisons of such diseases as diabetes and kidney disease. So does confinement in prisons, workhouses, and workshops. None of the people debilitated by such places or such diseases eats heartily of good food. As to catarrh of the respiratory passages, that in itself was produced by McCarrison and also by Mellanby by faulty food. The barrier breaks down before the catarrhal microbes. A mass attack of tubercle bacilli may do the rest.”

SUMMARY

It is a universally accepted fact that adequate diet is necessary for the treatment of tuberculosis. Our experience at the Pottenger Sanatorium has borne out the value of the high protein, high fat, low carbohydrate diet, rich in natural vitamins, in the treatment of active tuberculosis.

Twelve years ago we adopted an elective diet which we have made available to all our patients wishing to elect it since that time. There have been as few substitutions as possible throughout the war years. We provide a daily intake of approximately 225 g. of protein, 250 g. of fat and 235 g. of carbohydrate. We attempt to supply the vitamin and mineral requirements from foods naturally rich in these elements. We alter our food constituents as little as possible by applying low temperatures in cooking, and we make extensive use of the hydrophilic colloidal properties of gelatin.

We have found that this vital diet apparently increases the resistance of the tuberculous individual to his disease, and improves muscle tone, often in spite of lack of exercise. We have subsequently used this same type of diet in the treatment of a group of allergic children, with good results.

It is our conclusion that the logical basis on which to estimate the cost of food for tuberculous patients is the cost per patient per period of arrestment, rather than the cost per patient per day. If a highly vital diet of slightly greater cost will restore a patient to health in a shorter time than a cheap diet of poor nourishing quality, the end-result will be a saving of time and a saving of the tax-payer’s money.

We believe that a highly vital diet can build the resistance of an individual to his disease, and help him to maintain his health so as to continue as a useful member of society.

SUMARIO

Es un hecho aceptado universalmente que para el tratamiento de la tuberculosis se necesita una alimentación adecuada. Nuestras observaciones en el Sanatorio Pottenger comprueban el valor de una dieta alta en proteína y grasa, escasa en hidratos de carbono, y rica en las vitaminas naturales, para el tratamiento de la tuberculosis activa.

Hace 12 años adoptamos una dieta que desde entonces hemos puesto a la disposición de los enfermos que deseaban seguirla. Durante los años de la guerra hemos hecho en ella el menor número de cambios posible. La ingestión diaria es aproximadamente de 225 gm. de proteína, 250 gm. de grasa y 235 gm. de hidratos de carbono, tratándose de llenar los requisitos de vitaminas y sales minerales por medio de alimentos naturalmente ricos en dichos elementos. Los componentes alimenticios son alterados lo menos posible, aplicando temperaturas bajas para la cocción, y utilizando en gran escala las propiedades hidrófilas coloidales de la gelatina.

Hemos observado que esta dieta vital aumenta aparentemente la resistencia del tuberculoso a la enfermedad, y mejora la tonicidad muscular, a menudo a pesar de la falta de ejercicio. Hemos utilizado después la misma clase de dieta en un grupo de niños alérgicos, con buenos resultados.

Nuestras conclusiones son que la base lógica para calcular el costo del alimento de los tuberculosos es el costo por enfermo por periodo de estacionamiento, más bien que el costo diario por enfermo. Si una dieta muy vital que cuesta un poco más restablece la salud en menos tiempo que una alimentación barata más poco nutritiva, al final de cuentas economizará dinero y ahorrará los fondos de los contribuyentes.

A nuestro parecer, una alimentación muy vital reforzará la resistencia del individuo a la enfermedad, y lo ayudará a mantener su salud, continuando así como miembro útil de la sociedad.

 

^aThese figures were compiled on a specially equipped I.B.M. Machine by Michael Walsh, M.Sc ., San Diego, California. The figures are based on the usual portions and ingredients; allowance must be made for the fact that we do not trim the fat from our meat servings, and our custards and other dishes containing carbohydrates are made with a minimum amount of sugar and additional eggs and milk.

^bThe Second Annual Seminar of Dental Medicine, sponsored by the Southern California State Dental Association and the Oregon State Dental Association at the Desert Inn, Palm Springs, California, October 7 to 12, 1945.

References Cited:

1. RIBOULLEAR, J.: Compt. rend. Soc. de biol., 1938, 129, 914. 
2. POTTENGER, F. M., JR., AND SIMONSEN, D. G.: J. Lab. & Clin. Med., 1939, 25, 238. 
3. POTTENGER, F. M., JR.: The effect of heat processing of food on the dento-facial structures of experimental animals, to appear in Am. J. Orthodontics.
4. POTTENGER, F. M., JR., AND POTTENGER, F. M.: Am. Rev. Tuberc., 1943, 47, 11. 
5. Analysis by Michael J. Walsh, M.Sc., F.I.C., A.I.Ch.E., San Diego, California. 
6. Analysis by Michael J. Walsh (5). 
7. MCCARRISON, ROBERT: Studies in Deficiency Disease, Oxford Medical Publications, 1921. 
8. POTTENGER, F. M., JR., AND SIMONSEN, D. G.: Tr. Am. Therap. Soc., 1940, 39, 21. 
9. WRENCH, G. T.: The Wheel of Health, C. W. Daniel Co., Ltd., 1938.