The Kellogg Report

THE KELLOGG REPORT: The Impact of Nutrition, Environment & Lifestyle on the Health of Americans is an attempt to provide a scientific basis for the incorporation of health promotion, nutrition, addiction and lifestyle factors into the mainstream of medical education, policy, diagnosis and practice. We intend its publication to satisfy the need for a broader paradigm of health policy and practice which will be required if today’s crisis in health care quality and cost is to be met head on, a paradigm that acknowledges the significance of nutrition, environment and lifestyle and incorporates them into established health policy and practice.

About the Authors

Joseph D. Beasley. M.D., has been the director of the Department of Medicine and Nutrition at the Brunswick Hospital Center, Amityville, New York since 1982. He is the Bard Fellow in Medicine and Science and the director of the Institute of Health Policy and Practice of the Bard College Center. A Board Certified physician with training in both clinical and preventive medicine, Dr. Beasley holds the D.T.M. & H. (Lond.) degree from the London School of Hygiene & Tropical Medicine and a Masters Degree in Public Health from Tulane University. He was formerly Chairman of the Department of Applied Health Sciences at the Tulane University Medical Center, Professor of Population Sciences and Chairman of the Department of Demography and Human Ecology at Harvard University, and Dean of the School of Public Health & Tropical Medicine at Tulane University.

Dr. Beasley has served as consultant to such international bodies as the World Bank, the Agency for International Development and the World Health Organization. In the United States, he has been a member of advisory bodies that include the President’s Commission on Population Growth and the American Future, HEW’s National Health Advisory Council, Chairman of the Board of Planned Parenthood-World Population and Chairman of the Board of the Family Health Foundation. He has extensive experience in maternal and child health family planning programs and the development of health care delivery systems in the United States and in developing nations. He writes the monthly column, “Managing the Alcoholic,” for the Medical Tribune and his recent publications include Wrong Diagnosis, Wrong Treatment: The Plight of the Alcoholic in America.

Jerry Swift was born in 1937 and educated in the Northwest. He was a Jesuit from 1955 to 1968 and has Master’s degrees in Philosophy and Theology. In 1968 he was awarded a Management Internship in the Federal Government. He worked as a civil rights mediator in the South and later as a program director for the Rockefeller family in New York. Mr. Swift taught for several years on the secondary and college levels. Since 1981 Mr. Swift has been a Senior Research Associate at the Institute of Health Policy and Practice, working on health and environmental issues.

Nutrition

Nutrition–in its most basic sense–is the complex of processes by which the organism finds, consumes, liberates, absorbs, and utilizes the nutrients it must have to live.

Yet, nutrients are often fragile substances and, though they abound in the world around us, their passage from field and farm to the chemistry of our cells can be risky and fraught with loss. Just as exterior losses are inevitable (and sometimes extensive) up to the moment of eating, so the interior odds of digestion, blocking and binding, absorption, and finally utilization are uncertain at best. Further, just as the body needs nutrients, so nutrients need each other at each step in the body’s process of metabolizing them. The “limiting” nutrient, rather than the body’s need, is all too often the determining factor. There are also considerable variations in how different individuals digest, absorb, and metabolize food.

Given these variables, perhaps the only practicable way we can hope to provide our cells with an ample supply of the nutrients they need is by following four guidelines:

• Build one’s diet around high-nutrient-density foods and whole foods–fresh vegetables and fruits, fish, fowl and meat, eggs and dairy products, whole-grain products, dry beans and nuts, and so on.
• Vary the diet widely from meal to meal and day to day.
• Avoid low-nutrient-density and nutrient-consuming foods, for example, candy and soft drinks, highly sugared baked goods and cereals, white-flour products.
• Avoid highly processed foods, including many “fast” take-out foods. as well as excessive cooking and processing of foods at home.

Is it true–as the Recommended Daily Allowances imply–that people’s nutritional needs are basically the same?

• What group in the U.S. has the highest nutrient needs of all?
• Where or how can I find out my exact nutrient needs?

Discussion:

Because of genetics, the enzyme patterning of each individual is unique. And it is into that enzyme system that nutrients–the missing essentials–must fit, according to that system’s particular needs. Proper nutrition is unique to the individual. When the diet is fully adequate:

• Dietary protein affords the varying combinations of amino acids the organism needs to build its thousands of structural proteins and operating enzymes.
• Carbohydrate and fat meet its operating energy needs.
• Vitamins and certain fats and fatty acids supply the missing coenzymes and other cofactors its unique metabolism requires.
• And minerals provide the essential earth elements it must have to maintain the skeleton, cellular function, and other basic processes.

The most personal of nutrition questions naturally arises.”What are my essential nutrients? Are they much different from people’s? And If so, how can I find out what they are? And if I meet these needs, will that lead to optimal health?”

These natural questions, strangely enough, open up a “Great Divide” in nutrition today.

On one side is most of the American Health establishment, from the National Academy of Sciences (its Food & Nutrition Board), the Food & Drug Administration, and the Department of Agriculture, to the American Medical Association, nearly all doctors, most public-health organizations, university nutrition programs, and virtually all dietitians in the country.

On the other side an array of Nobel laureates, research scientists, individual physicians and psychiatrists (some unorthodox), chiropractors, health-food enthusiasts, vitamin companies, and up to a quarter of American consumers.

What are these two divergent views of nutrition? And how could such a deep difference of opinion occur over something as basic as the essential nutrients?

The second question first. Several factors converged over the last 40 years to create the Nutrition Divide, but perhaps the fundamental one is the scientific lag noted earlier. Actually, there are three lags or gaps involved:

• Medical-school science lagged far behind the evolution of scientific understanding in this century.
• Science’s institutional establishment moves more slowly and cautiously than individual researchers with their insights and breakthroughs.
• And science itself always falls far short of the immediate, practical needs of living people.

The upshot is that many researchers, along with physicians and lay people who take an interest in the subject, see nutrition playing a primary role in human health that the more conservative bodies and those who follow their lead regard as unproven, unwarranted, and possibly dangerous. These institutional voices–the American nutrition establishment–have developed a fairly monolithic position on most aspects of human nutrition: namely, that it’s part of the picture but cannot support the exaggerated expectations many individuals have of it. On the other side, many biochemists, physicians, and others–including Nobel laureates like Linus Pauling and Albert Szent-Gyorgyi and researchers like Roger Williams and Jonas Salk–find nutrients so basic to human metabolism that shortchanging them over time is bound to involve human illness, particularly chronic conditions such as those today’s high technology medicine can’t seem to get a handle on.

As to the differences between these two groups, they emerge clearly on practical questions. There are many, but Table 3-8 summarizes six of the most basic. Each side’s position on these issues flows from a coherent outlook on the human organism and its metabolism, how nutrients fit into the picture, and how much science knows about all this so far. But basically, it is the uniqueness of the organism–how much importance to accord it–that is the crux of the difference, the point of divergence between the two sides. From it, the other disagreements flow.

Nutrition is a Young Science–Still Very Incomplete

• 1593: Richard Hawkins uses citrus juice to alleviate scurvy among sailors; significance forgotten for another century and a half.
• 1753: James Lind reports on shipboard experiments involving 12 men, confirming scurvy as a deficiency disease.
• 1882: Kanehiro Takaki shows that meat and vegetables cure beriberi.
• 1884: Nicholas Lunin proposes that natural foods contain “small quantities of unknown substances essential to life.”
• 1890-1896: Christiaan Eijkman finds that the discarded hulls of refined white rice also contain “an anti-beriberi factor.”
• 1904: M. Mori cures an eye disease with cod liver oil (rich in vitamin A).
• 1906: Sir Frederick Hopkins of Cambridge University publishes a landmark book on “accessory nutrients” as essential, in “trifling amounts,” as protein, fat, and carbohydrate.
• 1911: Casimir Funk presses the search for this “missing factor” in food by reducing 836 lbs. of rice to 170 grams of the magical substance, which he calls “vitamine.”
• 1915: Elmer McCollum lays the groundwork for vitamin research at Johns Hopkins, showing that there must be more than one vitamin and inventing the letter system to name them. He also begins research into the role of the minerals calcium and magnesium.
• 1919: Zinc is shown to have a biological role. By this time the “major minerals” sodium, phosphorus, chlorine, iron, and potassium are also shown to have a biochemical function.
• 1920s: Vitamins A, D, and E are identified and an era of scientific discovery opens. Over the next 15 years one after another of the vitamins are discovered and synthesized, and many of the essential minerals are identified. Some important dates and researchers in this “golden age” of nutrition.
• 1928: Copper and iodine are shown to be essential minerals in the body.
• 1930: Vitamin B2 (riboflavin) is synthesized.
• 1932: Albert Szent-Gyorgyi isolates ascorbic acid, vitamin C, from Hungarian red peppers, for which he is awarded the Nobel prize.
• 1934: Vitamin B6 (pyridoxine) is identified by the Hungarian Paul Gyorgy.
• 1936: Roger Williams’ older brother Robert Williams, working at Bell Labs, first synthesizes B1 (thiamine). Vitamin K was discovered by H. Dam and coworkers in Denmark. Vitamin E is synthesized by Emerson and Evans at the University of California.
• 1936-1940: VItamin B3 (niacin) and another of the B-complex, biotin, are researched and synthesized. Roger Williams identifies and names pantothenic acid (“found everywhere”), vitamin Bs.
• 1941-1945: Folic acid, or folacin, is identified. Its biological functions are exposed by Williams, who names it “folic” because it is found in foliage.
• 1948: The B-complex% is completed with the isolation of B12, which is not synthesized until 1973. Research attention turns to the trace minerals, starting with cobalt.
• 1961-1966: Selenium, zinc, and chromium are accepted as biologically important minerals, but the role of selenium and chromium is unclear for the next 15 years.
• 1968-1973: Five key minerals are discovered in the body (manganese, tin, arsenic molybdenum, fluorine) and join nine others as a group recognized by the World Health Organization as “essential” to life.
• 1974: Silicon, vanadium, and nickel are shown to have a biological role.

“Inborn differences with detrimental effects of varying magnitude affect all individuals…A map advance in improving health cancome for providing the best nutrition possible on an individual basis.” The Panel concluded that reliance on the RDAs has been “inadequate in providing optimal nutrition for individuals.”

The use of standard numerical “allowances” for selected nutrients–reduced to a simply balanced diet–as the official American position on nutrition will gradually give way to a more enlightened approach. Improved diagnostic tools will permit fine-tuning the nutrient intake of individuals through diet and supplementation to restore health or improve resistance and performance. Obstacles to progress on this fundamental human quest include:

1. The nutrition establishment bias for objective, standard, discrete, defensible minimum.
2. The intrinsic difficulty of assessing the individual’s actual nutrient needs.
3. The scarcity of resources being devoted to this goal.

A fourth difficulty may be the lack of qualified people to apply new nutritional understanding. In the words of the President’s Panel (1976:174):

“It appears that a new type of nutrition specialist will be required for bringing this type of health care to the individual. Whether the training of such practitioners will come from specialization subsequent to medical school training or from a new type of professional training is not yet apparent.”

• Illness is usually the result of something that happens to us: a fall, a germ, a burn. Can we also become sick because of something that doesn’t happen?
• In 1969 it was reported that a prosperous middle-aged American banker had developed scurvy. The man lived alone (his wife had died the year before) and his diet consisted almost entirely of meat, milk, bread, coffee, and alcoholic drinks (Sandstead et al. 1969).
• What if the banker had sipped a little orange juice every morning–not enough to meet all his vitamin C needs, but just enough that it prevented the overt medical signs of scurvy? With no obviously swollen gums, loose teeth, joint pains, or skin hemorrhages, he probably wouldn’t have gone to the doctor or the doctor mightn’t have recognized what was wrong. The banker would’ve felt lousy all the time, tired, discouraged, and–attributing it to his wife’s death–figured nothing much could be done; life had just ceased to have any pleasure

Discussion:

Nutrients are essential for life and health.The lack of nutrients leads to systemic illness and specific diseases.

• Starvation: in the complete absence of water and food, death occurs within five days. Marginal intake staves off death, but not for long.
• Kwashiorkor (in Ghanese “the forgotten one”): severe protein malnutrition of young children after they have been displaced from the breast by a newborn; causes developmental abnormalities and often death.
• Marasmus (or Failure to Thrive): profound lack of protein and calories from birth, arresting the child’s development and often leading to death.
• Classic Deficiency Diseases: identified syndromes associated with a particular limiting nutrient; for example: night-blindness (vitamin A), beriberi (B1), pellagra (B3), pernicious anemia (B12), scurvy (C), rickets (D), goiter (iodine). (Table 3-11)
• Contemporary Deficiency Diseases: also associated with a limiting nutrient, but quite common in the U.S. today; for example, osteoporosis (calcium) and anemia (iron).

We live in a sea of microorganisms, many of which are potentially harmful. They do not normally infect us because the body’s immune system and other defense mechanisms hold them at bay. But when resistance is low–usually because inadequate nutrition isn’t supplying the organism’s many defense needs–any sudden or prolonged stress (overwork, tension, a chill, emotional shock, an accident, etc.) overwhelms the body’s weakened defenses and illness ensues. This is what Claude Bernard meant by the milieu interieur and what Pasteur–the discoverer of germs–was referring to when he exclaimed on his deathbed, “Bernard is right; the pathogenesis nothing, the terrain is everything” (White 1978:4).

The converse is also true. Acute or chronic infection, accidents, trauma, fear, and other stressors greatly increase the body’s need for protein and other nutrients (Scrimshaw & Young 1976:59). Studies by the Food & Nutrition Board have shown that protein loss during a fever or infection is substantial and takes about four times as long as the period of infection to return to normal (Scrimshaw 1977). Parasite infections typically deplete vitamin B12, further compromising the nutritional state of the patient. On a broad scale this complication is seen in developing countries, where respiratory and intestinal infections lead to acute “nutritional disease” (Scrimshaw & Young 1976). The term “malnutrition-infection complex” best describes this cycle of disease (Katz 1982). Only a sustained, highly nutritious diet can break the cycle.

Indeed, the crucial role of nutrition in health is most evident in the Third World, where other medical measures often are lacking. The World Health Organization has stated: “For the time being, an adequate diet is the most effective “vaccine” against most of the diarrhoeal, respiratory, and other common infections” (Dixon 1978:71).

The details of the interaction between nutrition and resistance are far from understood. In a comprehensive review, Dreizen (1979) links malnutrition to a weakening of several specific immune responses (Table 3-11). A potentially momentous study (Beach et al, 1982) found that pregnant mice fed a diet only moderately deficient in zinc produced offspring with depressed immune function through six months of age. (As we shall see in 3K, significant numbers of U.S. women of child-bearing age appear to be deficient in zinc.) Further, although given a completely normal diet including adequate zinc, these offspring produced similarly immune-depressed offspring–through three generations. The authors conclude that such inherited deficiencies can only be overcome by extraordinary supplementation.

Perhaps the clearest concrete example of the effects of nutritional inadequacy can be found in the elderly: One of the most basic reasons they catch pneumonia or break bones at far higher rates than others (and than they themselves did when younger) is that their resistance and resilience have long been undermined by inadequate nutrition. As we grow older we need fewer and fewer calories but just as many or more nutrients each day. Thus, we all require an increasingly nutrient-dense diet as the years pass, a need that is scarcely recognized and rarely met in contemporary America.

A similar effect among younger groups–the middle-aged and even adolescents (Brody 1984)–is obesity, which appears in many cases to be the result of a prolonged calorie-excessive, nutrient-deficient diet in genetically predisposed individuals.

The earlier the nutrient inadequacy, the more profound the impairment. Malnutrition in children, especially insufficient protein, causes neurological dysfunctions that many experts fear are irreversible. Severe low birthweight associated with malnutrition in mothers is now established as a major cause of brain damage. In all, “seventy-five percent of the mental retardation in this country is estimated to occur in areas of urban and rural poverty” (Drew 1970: 6). Even lesser malnutrition has neurological effects. Broad behavioral changes”are likely to be among the consequences of marginal vitamin deficiency” (Brio 1979:272).

Thus, any significant deviation from the proper intake and utilization of nutrients is considered a form of malnutrition. These deviations are divided into four categories:

1. Critical: extreme malnutrition with threat of death. Common examples are protein deficiency in children (kwashiorkor), abnormal heart beating (arrhythmia) due to lack of zinc or essential fatty acids, and heat prostration due to lack of water.
2. Clinical: deficiency extreme enough to cause symptoms observable in a routine medical examination. Some of the classic deficiency diseases, such as beriberi, are again turning up in countries with a heavy reliance on rice as a dietary staple.
3. Subclinical: an insufficiency of one or more nutrients that results in long-term deterioration, not immediately observable in a doctor’s examination. A good example is the recently documented association between periodontal disease and a deficiency of vitamin C without any symptoms of scurvy.
4. Marginal: an imbalance of nutrients leading to a lack of well being or behavioral changes that may not be observable except in controlled conditions. Included here are such generalized complaints as tiredness, anxiety, and depression. (Hoffmann-La Roche 1982: 10, Harrison’s 1983:435, Ensminger et al. 1983:526)