Division of Ag f Agricultural Scien c e s UNIVERSITY OF CALIFORNIA /: 1 1ft HP ^ NUTRITIONAL AT US .S.A. Edited by AGNES FAY MORGAN CALIFORNIA AGRICULTURAL EXPERIMENT STATION An Interregional Research Publication BULLETIN 769 AN INTERREGIONAL RESEARCH PUBLICATION The research on which this report is based was partially supported by funds pro- vided under the Research and Marketing Act of 1946. Under the procedure of co- operative publications, this report becomes in effect an identical publication of each of the cooperating agencies and is mailed under the frank and indicia of each of the Expreiment Stations of the states listed below. It is suggested that copies be requested through one source only from supplies available to the Experiment Station Directors of the various states. CONTRIBUTING STATES U. S. Dept. of Agriculture Alabama Louisiana Ohio Alaska Maine Oklahoma Arizona Maryland Oregon Arkansas Massachusetts Pennsylvania California Michigan Rhode Island Colorado Minnesota South Carolina Connecticut Mississippi South Dakota Delaware Missouri Tennessee Florida Montana Texas Georgia Nebraska Utah Hawaii Nevada Vermont Idaho New Hampshire Virginia Illinois New Jersey Washington Indiana New Mexico West Virginia Iowa New York Wisconsin Kansas North Carolina Wyoming Kentucky North Dakota The many papers that make up this report were compiled and edited under the supervision of Dr. Agnes Fay Morgan, Professor of Nutrition, Emeritus, and Bio- chemist, Emeritus, in the California Agricultural Experiment Station, Berkeley. OCTOBER 1959 [2] FOREWORD The value and accomplishments of a voluntary coordinated research program in the field of human nutrition, involving the State Agricultural Experiment Stations of the United States and the Institute of Home Economics of the United States Depart- ment of Agriculture, are well demonstrated in the accompanying bulletin. This research program was stimulated and made possible by the Research and Marketing Act of Congress, later a part of the Amended Hatch Act, which, through financial aid, stimulated the establishment of regional and interregional coordinated and jointly planned research on many problems of importance to agriculture, con- sumers, and the public health. The research on nutritional status is an example of but one of many such endeavors. While the federal regional research funds made available to this program served as the financial skeleton around which the research program was built, the states sup- plemented the federal support with even greater financial assistance from their own funds. In addition, in several states, local and state departments of public health made significant contributions of staff time and facilities. Furthermore, the Institute of Home Economics actively participated in the regional and many state research activi- ties. The objective of the study reported was to obtain factual information of the nutritional level of the nation by means of sampling appreciable numbers of the population of the United States with reference to such variables as age, sex, geo- graphical location, etc. Never before has a program involving such breadth and depth of information been undertaken. This study will serve as a bench mark for the nutri- tional status of our people. It would be well if a similar study were made in another five to ten years to determine if the nutritional status of our people is improving or deteriorating. The nutrition of the people is of utmost importance to our well-being as a nation. Dr. Agnes Fay Morgan of the University of California, Professor of Nutrition and Biochemist in the Agricultural Experiment Station, Emeritus, who was very active in the original research program, was selected by the four regional committees of the United States to analyze and summarize the 178 publications resulting from the work, and to serve as author of the published summary. Paul F. Sharp, Director California Agricultural Experiment Station [3] i CONTENTS Summary PART I How to Get Reliable Food Records 9 Family Food Consumption Records 15 How Much of What Foods Was Eaten? 21 < The Nutrient Value of the Diets 28 How Many Had Less Than the Recommended Allowances of Nutrients? . . 40 The Blood Composition and Its Relation to the Diets 46 i Growth of Children and Adolescents in Relation to Their Diets .... 56 Incidence of Physical Signs Sometimes Associated With Nutritional Deficencies 64 PART II The Role of Lunch, Breakfast, and Between-Meal Snacks in the Nutrition of School Children 71 Overweight and Underweight in Adults 78 Dental Caries 84 Bone Density 88 i Amino Acids and Protein Requirements 92 Vitamin C Needs of Children and Adults 97 The Serum Cholesterol Story 106 Value of Carotene as Pro-Vitamin A Ill Some Studies on Riboflavin 115 Acknowledgments 116 Publications 120 4 Appendix 130 [4] NUTRITIONAL STATUS • • • U.S.A. SUMMARY What is the nutritional status of the U. S. A.? What does nutritional status mean, can it be measured, and is it good? If it is not as good as we would like what should be done to improve it? From 1947 through 1958, over 200 professional nutrition investigators de- voted a good deal of their time to an attempt to answer these questions. The studies were sponsored by the State Agri- cultural Experiment Stations, the Institute of Home Economics of the U. S. Depart- ment of Agriculture, and several of the state departments of public health. About half of the funds expended by the states were appropriated by the Congress as Federal grants to the State Agricultural Experiment Stations; the remainder was supplied by state funds. The U. S. De- partment of Agriculture and the U. S. Public Health Service also supplied con- tributory services. The effort was coopera- tive within and among the four regions of the U. S. A., the Northeast, North Central, South, and West. The answers to the questions were surprisingly alike in all regions and among all ages and economic groups. Nutritional status means state of health of the individual or group as conditioned by choice and amount of foods, or more accurately, nutrients, eaten. Nutrients are the chemical constituents of foods re- quired by the body for normal growth and function. These are the proteins, carbohydrates, fats, vitamins, and min- erals that make up the diet and that are needed every day for our continued well-being. Children from the age of 5 years through age 12, adolescents from 13 to 20, and adults from 20 to past 80 years of age were examined. About 4000 in each of these three age groups were studied in 39 of the 48 states. Usually there were obtained 7-day records of foods eaten as well as physical examina- tions and biochemical analyses of blood and urine samples; sometimes elaborate dental examinations and x-rays of bones and teeth. The results were placed on computer cards and interpreted so as to disclose differences, if any, in persons living in various regions, states and local areas, and in persons of different ages and sex by age and sex groupings. The nutritional status of these citizens of the U. S. A. on the whole was found to be good, probably the best that has ever been reported for any similar pop- ulation groups. The average nutrient intakes by both the boys and girls up to age 12 in all regions was estimated to be adequate, even de luxe, except that the calcium intake of the girls was slightly low. The standards for adequacy were those set up or reaffirmed in 1958 by the National Research Council for rec- ommended daily allowances of nutrients. Food eaten by boys aged 13 to 20 years on the average provided adequate or more than adequate amounts of all nutrients except vitamin C, but the girls in this age range had food adequate or [5} high in only 3 nutrients, vitamin A, ribo- flavin and niacin. The average intakes of the other nutrients by the girls were either seriously low, as for calcium, iron, thiamine and ascorbic acid, or borderline low, as for calories and protein. The diets of the teen-age girls presented the least favorable picture of all those examined. The number of dietaries of adult men studied was relatively small, only 632, but the number of women was adequate, over 3000. The men had adequate or high average intakes of all nutrients except calories and thiamine, which are related to each other in the recommended allow- ances mentioned above. The women had good average intakes of all nutrients ex- cept calories, thiamine, calcium and ribo- flavin. The low calorie intakes cannot be cited as a deficit, since these people were by no means on the average under- weight. The good intake of the vitamins, mineral and proteins in spite of the relatively reduced total calories points to generally wise food choices. The nutrients most often found to be lower than the recommended amounts in the diets of children and adults in all four regions were vitamins A and C, calcium and iron. What to do about it. The implica- tions of these occasional low intakes of certain nutrients are important to Amer- ican agriculture, industry and public health. If it is true that the national eating habits can be criticized because many adolescents and adults have low intakes of ascorbic acid, iron, calcium and vitamin A, what changes in American food choices should be advised? The one major recommendation might be the in- clusion of more fruits and vegetables. The choice should be in favor of dark green and deep yellow vegetables, and tomatoes, berries, citrus fruits and melons. These are the sources of vitamins A and C, iron and some calcium. Milk and cheese contribute much calcium and ribo- flavin and milk fat contributes vitamin A. Milk solids not fat offer a premium value in nutrition if increase in cal- orie intake is undesirable. One excellent method of utilizing this valuable food is in bread. Most white bread in our markets contains less than 4 per cent of nonfat milk solids, in terms of flour , used, and most whole wheat breads con- tain none. If the formula were raised to 12 per cent, an important bonus of more than 35 mg. of calcium and 0.1 mg. of riboflavin per slice would be added to the diets, particularly of teen-agers, who use fairly generous amounts of bread and who especially need both these nutrients. Cottage cheese and low-fat milk sherbets also contribute these milk nutrients with- out much increase in calories, especially from fat. An increase in the use of fruits and . vegetables can apparently produce only favorable results because the calorie load they carry is low compared with their content of valuable nutrients. Even the most calorie sparing diet can be enhanced by their use. Better cooperation among producers, shippers and merchandisers of these foods is urgently required. Fresh, frozen and canned fruits and vegetables all have their place in this program. But dis- crimination in favor of the fresh produce is justified as well as in favor of cer- tain fruits and vegetables. Broccoli, green beans and peas, cauliflower, raw cabbage, + carrots ,tomatoes, turnip greens and all other greens, apricots, peaches, strawber- ries, citrus fruits and yellow melons are among the outstanding candidates for rec- ommendation to the American public, particularly to adolescent girls and older women. Anyone can add these foods to the diet without danger of excess calories and to the betterment of the nutrient balance. Further evidence of low intakes. But good average intakes of any population groups may conceal poor choices by some a individuals. Intake of nutrients in two- thirds or less the recommended amounts [6] was chosen as representing the border- line of inadequate choice of foods. The percentage of people in the 3 age groups who reported intakes below these amounts is a measure of the extent to which the diets were inadequate. Except for vitamin C children under the age of 13 years in 6 states, presented generally few cases of low intakes. Diets of 90 per cent or more of these children provided two-thirds or more of the rec- commended daily allowances of all the nutrients except in New York for iron and niacin, in West Virginia and Iowa calcium, and in Virginia vitamin A. But in all 6 states more than 12 per cent fell short in vitamin C. In the special study of 9- to 11 -year-old-boys and girls in Iowa, Kansas and Ohio, 10 per cent or more of the diets provided less than 2 A of the NRC allowances for calcium and vitamin A as well as vitamin C, especially in the girls' diets. This is not a bad showing, although it indicates areas where improvement is necessary. The intakes of adolescents 13 to 20 years old were more variable and less favorable, especially those of the girls, than were those of either the younger children or the adults. Of the 26 groups of boys and girls studied in as many states those 13 to 16 years old were examined in 8 Western and 3 Northeastern states. Over 90 per cent of the boys had intakes exceeding two-thirds of the recommended allowances for protein, except for the Spanish American group in New Mexico. More than a fifth of this group of boys and also of the Colorado and Maine boys had diets providing less than two thirds the recommended amounts of calcium, a third were equally low in thiamine, nearly a fifth were low also in niacin, and about half were this low in vitamin C. A much greater proportion of girls lacked these food nutrients to this extent. About 20 to 40 per cent of the girls had diets relatively low in protein, vitamin A, ribo- flavin, and niacin. More than 50 per cent had diets relatively low in calcium and ascorbic acid among the girls studied in New Mexico, Colorado and Montana. Relatively few of both boys and girls in Oregon, New York and Maine had low nutrient intakes. Only in calcium, vita- min A and vitamin C were there usually more than 10 per cent of the diets in these three states in the low-intake columns. The young people 16 to 20 years of age in 4 Northeastern, 3 Western states and in Iowa had somewhat better intake records than the younger adolescents. Of the males except in Maine and Colo- rado more than 90 per cent had diets providing more than two-thirds the rec- ommended allowances of protein and niacin. Forty per cent of the diets in Maine, West Virginia and Colorado fell below this level in calcium and about 25 per cent in Idaho and Colorado in vitamin A and thiamine, but in all 8 states 19 to 80 per cent got less than two thirds the recommended amount of vitamin C. The records of the young women were similar, with large num- bers showing relatively low intakes of calcium, iron, vitamin A and vitamin C, especially in Colorado, Idaho and Wash- ington. Riboflavin intake was also low in many of the Maine and Colorado women's diets and calcium in the Iowa diets. Obviously, the same nutrient deficits occur again and again in all parts of the country in vitamin C, calcium, iron and vitamin A. Only among the older women in the North Central region were more than 10 per cent of the adults eating less than two-thirds the recommended amounts of protein. In this group, also, more than 20 per cent showed equally low intakes of thiamine and niacin, more than 30 per cent of riboflavin and vitamin C, more than 40 per cent of vitamin A, and more than 50 per cent of calcium. About 10 per cent of the day's meals of the California and Colorado older women were low in niacin, 10 to 20 [7] per cent in thiamine, iron and riboflavin, 20 to 30 per cent in vitamins A and C, and 30 to 45 per cent in calcium. There were few deficiencies in this sense among the diets of the adult men. More than 90 per cent had more than two-thirds the recommended amounts of all the nutrients except vitamin A, calcium and vitamin C. Of the latter, 20 to 40 per cent of every group had low intakes. The blood analyses and physical signs. The blood analyses in general con- formed with the values expected from the dietary observations. The physical signs often associated with nutritional deficiencies, such as roughness of skin, inflammation and thickening of mucous membrane of the eyes, swollen and red- dened gums, occurred more frequently in the groups with low blood levels of vitamins A and C than in those with satisfactory blood levels. These findings did not, however, always bear out the dietary records of intakes. If facilities were available and one wished to follow one index of nutrition only, analyses for several constituents in the blood may give the best picture of true nutritional status. The hemoglobin content of the blood of nearly all the people examined was fair to excellent and the concentrations of vitamins A and C in the blood serum were generally fair to good. For example, the New York children under 13 years of age showed a high level of serum vitamin C and a low level of incidence of gingivitis and other signs supposed to be associated with low vita- min C intake. The Virginia and Louisi- ana children in the same age range had a high incidence of these signs and a considerably lower, though not poor, level of vitamin C in the blood serum. But the average dietary intakes of vitamin C in the two groups of children were about the same. The reason for this discrepancy probably may be found in the fact that the symptoms and blood values reflect long-range dietary habits, while the 7-day diet records can tell only of present and perhaps temporary conditions of food * intake. Heights and weights of children and adults. The heights and weights of chil- dren and adolescents were measured in several states, particularly in Iowa, Kan- sas, Ohio, New York, Virginia, Louisiana r and several of the Western States. The type of build, growth channels and amount of underweight or overweight for height, age and sex were noted in these groups in most cases, and under- or over- weight for height and sex in most of the adults. * There was more underweight than overweight among the Utah children under 13 years of age and, also, among the Louisiana and Virginia children but the New York children in this group had much more overweight than underweight. 4 The 9- to 11 -year-old Iowa, Kansas and Ohio school children were fairly well balanced between under- and overweight members, about 10 per cent of each. More overweight than underweight was seen in the adolescent girls in nearly every group and more underweight than overweight among the boys. The Spanish „ American and Arizona Indian children had lower average heights and weights than other Western children, except for overweight in the Indian girls. About 50 per cent of the older women in 5 North Central states were overweight when judged in terms of desirable body weight for persons of their height at age 30. About 30 per cent of those weighed were classed as obese, that is, more than 20 per cent overweight for height. Some 30 per cent of the older California and Colorado women were overweight. About * 20 per cent of the California and Colo- rado men over 50 years of age and 40 per cent of the New Jersey men, 20 to 50 years of age were also overweight. Among the California and Colorado adults, about an equal number with those overweight were underweight, but the North Central women and the New Jer- [8] sey men had less than 20 per cent who were underweight for height. The height and weight records of the children corresponded to some extent with the assessment of adequacy of the dietary records and of the blood compo- sition. For instance, the relatively poor diets and low blood levels of vitamins A and C of the Spanish American and Indian children in New Mexico and Ari- zona, the lower levels of hemoglobin, ascorbic acid and carotene of the Kansas children compared with those in Iowa and Ohio, and of rural compared with town Virginia children bear out the poorer showing in height and weight records of these groups of children. Strangely enough, however, overweight in adults can not be identified with high calorie intake, indeed the opposite is sometimes the case. Yet checks by weight, analysis of a good many dietary records appear to affirm the accuracy of these records. Of course, accumulated over- weight is usually the result of long con- tinued overeating, while the diet record covered only one to seven days. The dis- crepancy may, also, reflect variations in activity due in part to the use of modern labor-saving devices, continuation of early food habits into the later ages, problems in estimating nutrient value of the food eaten, and perhaps in actual efficiency of energy transformation. Thus, the low calorie diets may still exceed calorie needs. This may mean that energy re- quirements, especially of older women, need to be studied further. PART I SECTION 1 How to Get Reliable Food Records How good is the American diet? Are Americans well fed? What foods do they eat, how much and how good are the nutritive values of these foods? How do various age groups differ in the quantity and value of the foods they choose? Do the people of the West, South, Northeast, and North Central regions differ in their food patterns? What is good and what needs improvement in these food patterns so far as scientific findings up to now can determine? Do the blood composition, the physical growth of children, the height and weight of adults, the con- dition of skin, eyes, gums, tongue, teeth and bones reflect the good or deficient nutritional quality of the foods usually consumed? How much difference would improvement of these patterns make to the public health? Agriculture and the food industries are concerned with these questions as well as nutritionists, edu- cators and consumers. These are some of the questions which the state experiment stations set out to answer in a 10-year cooperative study of the nutritional status of selected popula- tion groups in all parts of the country. In each of the four regions, coordina- tion of purposes and methods was secured by means of a technical committee con- taining one member from each state and a member from the Human Nutrition Research Branch and the office of Experi- ment Stations, USDA. Aside from these agreements, each state was completely independent as to choice of groups to be studied, size of the sample, and in- terpretation of results. In some of the regions the data were pooled and a regional report was issued. But many other individual studies of local or incidental as well as of funda- mental problems were tackled by the states, and some of these are sketched in later chapters. [9] C^=i c/) X 3 o h- vc Z> H- H (f) o < a: UJ 3 o o L±J o Z or o o DISTRIBUTION OF SUBJECTS OF NUTRITIONAL STUDIES IN 39 STATES Region States Age and Sex Numb e Northeast Connecticut Adult women 91 Maine Children under 13 12 Boys and girls 13-15 208 Boys and girls 16-20 46 Massachusetts Pregnant women 16-35 79 New Jersey Men 20-50 606 New York Children under 13 265 Boys and girls 13-15 222 Boys and girls 16-20 19 Pennsylvania Young adult men 22 Rhode Island Boys and girls 13-15 59 Boys and girls 16-20 237 Vermont Young women 49 West Virginia College students 16-20 181 College students over 20 154 Children under 13 1111 North Central Illinois Women over 30 505 Indiana Women over 30 28 Iowa Women over 30 1116 Children under 13 808 Boys and girls 13-18 380 Kansas Boys and girls 9-11 645 Families 178 Ohio Boys and girls 9-11 710 Families 268 Michigan Women over 30 115 Minnesota Women over 30 120 Missouri Women over 30 15 Nebraska Women over 30 297 South Dakota Women over 30 339 Wisconsin Women over 30 68 South Alabama Adult women 12 Arkansas Families 126 Louisiana Children 8-11 532 Mississippi Families 330 North Carolina Families (statistics) 731 South Carolina Families 297 Tennessee Men and women 19-25 20 Families 122 Texas Adults 9 Virginia Children 8-12 219 Women 20-50 230 Families 252 [11] DISTRIBUTION OF SUBJECTS OF NUTRITIONAL STUDIES IN 39 STATES Region States Age and Sex Number West Arizona Boys and girls 12-16 115 California Men and women over 50 577 Colorado Men and women over 50 175 Boys and girls 13-18 162 Idaho Boys and girls 14-17 274 Montana Boys and girls 13-15 221 Boys and girls 16-20 197 New Mexico Boys and girls 14-17 168 Oregon Boys and girls 14-17 739 Utah Children under 13 141 Boys and girls 13-18 59 Men and women 25-49 41 Washington Boys and girls 14-16 247 Wyoming Women over 60 70 Sampling. A most important point to remember in evaluating the results of these surveys concerns the sampling. Since the results recorded in this bulletin are identified solely by the names of the states in which the data were gathered, it may be misleading to the reader if the type of sampling or selection of subjects is not described. In the extensive North Central study of older women, the sampling was set forth clearly, as noted later. The adoles- cents in the Western states were chosen to represent certain geographical areas, as in Oregon and Washington, or cultures, as in New Mexico and Arizona. The older men and women in California and Colo- rado were chosen from volunteers in se- lected communities, the object of the study being a search for correlations be- tween diet and blood composition and physical condition rather than assessment of a population. In the Northeast, the same objective, that is, discovery of correlations between diet and blood composition and medical findings, was set up, and the sampling of the population was therefore devised not for statistical purposes but for conven- ience of access. Generally, the subiects were those of the designated age and sex i in the communities where the experiment stations are located. Choice of method of obtaining food records. Two of the regions, the North- east and North Central, made a critical examination of the methods to be used in collecting the information on kinds and amounts of food eaten. At least four methods seemed to be available. These were 1) the securing of a detailed history of food intake, likes, and dislikes by inter- view; 2 ) records voluntarily kept by the subjects for one or more days; 3) recall by the subjects of foods eaten one or more days previously; 4) records of weighed food intake kept by the nutri- tionist or by the subject. Everyone agreed that records of weighed food intake were most likety to be reliable, but the likelihood of obtain- ing many of these records was not great. The interview and dietary history might be expected to yield data of value, but it might not represent the actual present- day practices of the subject. If the sub- jects keep records of food eaten or if they recalled the food intake of the day before, how many and which days should be used? Should children's records be kept A by themselves or by their mothers? The margin of error in obtaining a true story * [12] of an individual's food intake by any of these methods and also the error for a group's intake had to be established. How many subjects are required to obtain a given amount of precision? How do sea- son, ethnic origin, and economic level affect the food intakes? Standard measures or servings should be recorded if the foods were not weighed, and accurate esti- mates made of these measures. How ac- curate are the tables of food composition used by the nutritionist to convert food quantities into nutrients (the chemical food constituents needed by the body ) ? The Northeast region undertook to find answers to some of these questions. Their subjects included school children of all ages, college students, pregnant women aged 16 to 35, and male industrial work- ers up to age 50. In the North Central region similar comparisons were made using older women and school children. Numbers of subjects and days. By the use of statistical procedures the Northeast group was able to evolve a chart showing the number of subjects required to obtain a given degree of pre- cision with the 1-day dietary record and the number of days required for a given number of subjects. They found the rec- ords kept by females enough more accu- rate than those kept by males to allow the use of 5 per cent fewer female sub- jects to obtain the same degree of pre- cision in the data. Some of the nutrients, for example, vitamins A and C, were represented so variably in the diets that 10 per cent more records were required to obtain a clear picture of ascorbic acid intake, and vitamin A intake was not reasonably estimated at all by the use of this chart. What days? Most children and college students ate less over the weekends than on the other days of the week. But the records of 150 adults showed little dif- ference between weekends and other days. In the North Central region school chil- dren were found to consume more pro- tein, perhaps as meat, and less calcium, probably in milk, over the weekends than during the school days. How many days? Most of the surveys adopted the 7-day dietary record, but some used the 24-hour record or recall. The dietary interview and history were also obtained in hundreds of cases. A few subjects kept dietary records for 1, 3, 14, and 28 days in order to compare the reliability of these records. The dietary history almost invariably recorded more favorable food intakes, that is, more nearly like the recommended daily allowances, than the actual food diaries kept by the same subjects. On the other hand, the 1-day recall interview and the 7 -day dietary record were fairly well in agreement. It was concluded that the 1-day recall could be used to determine the characteristics of the food use of groups but that a 1 4-day record was needed for a fair estimate of the intake of an individual. The North Central region, studying school children in Iowa, Kansas and Ohio, concluded that no rule of thumb could be adopted but that a preliminary survey is necessary to determine the method of choice in each case. They found 1-day records to yield a greater number of so- called good diets than did the 3 -day diet records and these, in turn, more than the 7 -day records. Effect of season. The North Central studies of school children were carried out in spring and fall. Three-day records kept by 9-, 10- and 11 -year-old children in Ohio and Kansas showed that intake of ascorbic acid (fruits and vegetables) was greater in the spring than in the fall and that of protein (meat, milk, eggs) greater in the fall. However, in two of the studies in the Northeast no significant difference in nutrient intake of children could be ascribed to seasonal influences. What kind of record? Interviews by a skilled nutritionist preceded or followed the record period in most cases. Estimates [13] of size of food portions by weight, by household measure, or by use of models, were taught the subjects, and in some cases the records were checked in this manner also. The estimates of size of servings made by the subjects were checked by weight, and the conclusion reached that estimates on a group basis are not more than 20 per cent wrong, children excepted. College students of home economics, homemakers, male in- dustrial workers, other college students, and junior high school students were accurate in these estimates in the order given. Of course, quantities of some foods, such as bread, rolls, milk, soup, eggs, and suger, were easier to estimate than others. Size of servings. The North Central region recorded the weights of servings of most common foods eaten by 242 women, 30 to 92 years of age, in six states. Some 3170 daily records of weights of foods eaten were examined and fairly consistent averages obtained for size of servings of 15 kinds of meat, 12 vege- tables, 7 kinds of cooked potatoes, 8 fruits, bread, table fat, sugar and cream added to cereals or fruit, and beverage milk. The women over 70 years of age chose smaller portions of nearly all foods than did the younger women, but used some- what more sugar, cream, and butter or margarine. In general, there were no great differences in size of servings among the women living in the six states partici- pating in the study. The authors suggested that the somewhat larger servings of beef and poultry in Nebraska and of fish in Michigan may be connected with the beef, poultry, and fish production in those states. The South Dakota and Iowa wom- en ate the smallest portions of ground beef, and the Michigan and Wisconsin women the largest. The South Dakota women also ate smaller servings of vege- tables, including potatoes, than did the subjects in Iowa, Michigan, Minnesota, and Nebraska. The average serving weights found in this study may be valid only for the women in the age range used. Also, it should be noted that 18 subjects in Michi- gan contributed 40 per cent of the dietary records, since they carried on the experi- ment for 70 days instead of the 4 to 17 r days used by the other state groups. Accuracy of food calculations. To test the reliability of calculated values for the important constituents of foods, the Massachusetts station weighed and ana- lyzed all the food eaten by 21 subjects , for one day and compared the results with the figures obtained by calculation from standard tables of food composition. The figures for protein, calcium, phos- phorus, thiamine (vitamin Bi), and nia- cin were practically the same whether found by analysis or by calculation, but * the fat and ascorbic acid were generally higher and the riboflavin (vitamin B 2 ) lower in the calculated than in the ana- lyzed data. Fat and ascorbic acid are the nutrients most likely to be lost from foods during cooking. This raises the question of the reliability of the standard tables of composition of cooked foods. In any < case the tables used were the same in nearly all the studies. The New Jersey station developed a simplified method of calculating the nu- tritive value of dietaries, which was adopted by the Northeastern cooperators. This involved the direct expression of food composition values as percentages of the recommended dietary allowances (see Section 4). No appreciable loss of accuracy resulted from the use of this time-saving device. The recommended method. The con- clusion was that records of quantities of food eaten by the inidviduals should be procured as accurately as possible and these should then be subjected to calcu- lation from standard tables of composi- tion for raw and cooked foods, to show a the amounts of nutrients, that is, calories, protein, vitamins and minerals, which the C14] individuals obtained. Evaluation of diets by checking against amounts of certain food classes, "the basic four or seven" for example, was rejected as inadequate by itself, since good diet can be achieved in many diverse ways. As will be shown later, no strict uni- formity of dietary recording was achieved in these nation-wide studies. Most of the surveys, however, were made by the 7-day food-diary method, although the North- east study group recommended the one- day recall method as more efficient and equally accurate for determining the food patterns of a group. The choice of day of the week they thought unimportant and for the one-day study they thought the written record or recall equally ac- ceptable. They also found that all trained nutritionists procured diet histories and records of comparable accuracy and cal- culated their nutritive values similarly. SECTION 2 Family Food Consumption Records The individual dietary records which have hitherto been discussed differ mark- edly from the family food-consumption records which have been used by the U. S. Department of Agriculture for many years. In the latter, an accurate inventory of all food in the house is made at the beginning and at the end of the test period, usually one week, and of all food brought into the kitchen during this period. To get the average consumption of food per person, the quantity of food which disappeared is divided by the household size in equivalent persons. The number of equivalent persons is ob- tained by dividing the number of meals served to all persons in the household by twenty-one. "After the nutritive value of the family food supply is calculated, averages per nutrition unit or adult male equivalent are computed. The number of nutrition units or man-equivalent of the families is ob- tained by estimating how many times the recommended allowance of a given nutrient for a man 25 years of age is needed by all the members of the family. For example, based on the 1958 revision of the National Research Council's rec- ommended dietary allowances, a family having a father and mother, each aged 35 years, 2 sons aged 8 and 12 years, and 2 daughters aged 4 and 14 years, would have 5.5 man-equivalents for protein, riboflavin and ascorbic acid; 4.4 for calories and thiamine; 4.6 for niacin (equivalent); 7.6 for calcium; and 6.7 for iron." A second method used in food-con- sumption surveys is the recall-list method. The investigator obtains from the home- maker a complete report of all the foods used by the family during some immedi- ately previous period, usually one week. A detailed list and careful questioning are required in this process. The listing is much less expensive than the weighed record but may also be less accurate. It is usually possible, however, to obtain bet- ter cooperation from all families drawn in the sample when the recall list schedule is used. The Food Consumption studies in the South in 1947-48 were done by the food record method and were devised not only to learn the kind and nutritive value of foods eaten by families in various farming areas and at various income levels but also to record the cash values and home pro- duction and preservation of these foods. Such studies, either the recall-list or rec- ord type, have been carried out on a large scale by the U. S. Department of Agri- culture for many years with two purposes: 1) To find out the nation's food habits [15] and its probable dietary level, and 2) to determine the market for the farmer's product. The latest of these gigantic ef- forts was made in 1955 and covered the food consumption of over 6,000 families in both cities and rural districts in all four regions of the country. It is inter- esting to make a comparison of some of these findings of food disappearance and man-day apparent consumption of nu- trients with the actual daily intake records of more than 9,000 individuals of nearly all ages studied by the experiment station workers in the cooperative regional nu- tritional status researches here reported. Mississippi and South Carolina workers collaborated with the Bureau of Human Nutrition and Home Economics in a com- parison of the record and list-recall meth- ods of obtaining food consumption data. They worked in two farming areas with negro sharecropper families in Mississippi and with both white and negro families of farm owners and cash renters in South Carolina. Carefully chosen comparable families in each of the states were in- duced to make records of food consump- tion or to answer the recall-list questions on the same subject. There were from 68 to 97 families in each of the groups in the two states, 177 using the lists and 161 the records. In both states, aside from minor differences usually not statistically significant, the two methods of investiga- tion yielded nearly the same results. Ascorbic acid (vitamin C) and vitamin A were the two nutrients which showed the greatest differences in average intakes as recorded by the two methods. This may be due to the same variability of intake seen in the critical Northeastern studies of individual dietary records. However, some bias in the lists was seen, particularly with respect to "prestige" foods such as oranges. By the record, the average consumption in pound of the Mississippi families per household per week of tomatoes and citrus fruit was 1.40, but by the list 3.42. Consumption of other food groups, such as meat, eggs, grain products, other fruits and vege- tables, fats, and milk, differed but little. If the prestige bias of this group is elim- inated, the ascorbic acid and vitamin A intake of the two groups become comparable. The amounts in pounds per week per adult man-equivalent, consumed by the Southern families in the three farming areas were found to be: meat, poultry and fish, 1.5 to 2.1; eggs, 0.4 to 0.6; legumes, 0.34 to 0.64; milk, 5.4 to 12.7; cereal products, 4.4 to 4.8; fats, 1.2 to 1.4; pota- toes, 1.16 to 2.59; vitamin-rich fruits and vegetables, 1.2 to 2.2; other fruits and vegetables, 1.0 to 3.1; sweets and des- serts, 1.10 to 1.68. The quantities used in the various farming areas are shown in figure 1. Compared with the amounts found in a similar study conducted in Kansas and Ohio (fig. 2), the intakes in the Southern states of meat and other protein food, as well as of milk, fruits and vegetables, were low, averaging 30 per cent lower for meat and milk and 60 per cent lower Fig. 1. Consumption of five food groups in pounds per person per week, by low-income families in three areas of the South. [16] for fruits and vegetables. The bread and cereal intake in the South was about 30 per cent higher than in the two North Central states, the fat intake about the same, and sweets and desserts about 20 per cent lower. Of course, the Southern families were living in rural areas and were all in the lowest income groups, but 58 per cent of the Kansas and 30 per cent of the Ohio families were classified as rural. Also, 32 per cent of the Kansas and 15 per cent of the Ohio families had incomes of less than $3,000 per year, but only 4 per cent of Kansas and 1 5 per cent of Ohio families had less than $2,000. On the other hand, all families in the South- ern study lived in rural areas and the average net income was about $1,500 per year. In the South a household averageed six persons, but three-fourths of the Kan- sas and Ohio families had less than six members. It was evident in both studies that quantity of foods and adequacy of diets were lower in rural, low-income, and large families than in the urban, medium- and high-income, and smaller families. No fair comparison therefore can be made between the Southern and North Central family food-consumption studies. Never- theless, the 1955 U. S. Department of Agriculture food-consumption figures for a representative group of families in all four regions, as shown in table 1, indicate somewhat the same but less drastically different patterns of food intake between the South and the other three regions. ,_ MEAT, FISH AND OTHER PROTEIN FOOOS CEREAL PRODUCTS VITAMIN RICH FRUITS AND VEGETABLES Fig. 2. Comparison of consumption records of five food groups in pounds per person per week, by Kansas and Ohio families and by their 9- to 11 -year-old children. Consumption data for Kansas and Ohio families are comparable with those of the 1955 North Central household sur- vey, but the children's records are not compar- able with the latter. The North Central family food-con- sumption study included in the coopera- tive projects was made in Kansas and Ohio in connection with the critical study of the nutritional status of school chil- dren in Kansas, Ohio and Iowa. The recall-list method was used and an effort was made to compare the family con- sumption of foods and nutrients with the TABLE 1. — USDA Food Consumption Survey, 1955. Other Meat, Vitamin- Fruits Poultry, Rich & Vege- Region No. of Fish, Fruits tables Families Eggs, Cereal & Vege- including Legumes Milk Products tables Potatoes 1,262 pounds / person / week Northeast 5.47 9.72 2.21 2.93 7.23 North Central 1,385 5.56 10.23 2.59 2.80 7.72 West 527 5.78 10.43 2.60 2.80 7.70 South 1,381 4.98 8.56 3.69 2.14 6.29 [17] individual 3 -day dietary records of the 9- to 11 -year-old children of these fam- ilies. The family-consumption records in all cases presented a more favorable pic- ture than did the children's records. The reason for this is chiefly that all food, disregarding waste, was included in the family records, whereas in the children's records only the food eaten was reported. As shown in figure 2, the amounts of meat and other protein foods as well as fruits and vegetables consumed per "nu- trition unit" that is, per person, by the families were almost twice those reported in the children's individual records, but the amount of milk taken by the children was slightly higher and that of the cereal products was about the same. This may mean that the children ate less meat, fruit and vegetables and more milk than other members of the family, or it may mean that in the family records the amount of waste or overestimate was greater for meat and similar protein foods and for fruits and vegetables than for the other foods reported. In any case, TABLE 2. — Average Nutrient Intakes of 446 Families in Kansas and Ohio and of 9- to 11 -Year-Old Children of These Families. Method Nutrients Per Day E O) E en E E O) E 1 -a State of 1 <§ 1 c O) E < Study to 1 E 3 £ c °> c *> u c I Ex E G c -Q u o a O o O o O o •t:3 -Q u a. u — > _ i- ac Z < Kansas Family con- sumption 3,974 104 1.14 17 10.15 2.3 2.7 24 1 1 1 Boys 2,220 79 1.08 13 6.69 1.3 2.0 13 70 Girls 2,210 75 1.01 12 7.49 1.3 2.0 13 79 Ohio Family con- sumption 4,017 108 1.10 19 10.33 2.5 2.7 26 133 Boys 2,420 81 1.19 14 7.65 1.8 2.5 16 85 Girls 2,116 72 1.07 13 6.26 1.6 2.0 14 77 Recommended Children Allowances 9-1 1 years 2,250 65 1.1 11 4.00 1.1 1.7 12 65 Families (man- equivalent) 3,200 65 0.8 12 5.00 1.6 1.6 16 Percentage of families and children with le 75 than 2 / 3 alia wance: Kansas. ... Families 1 7 3 3 Boys 14 7 31 10 17 8 10 18 41 Girls 13 8 33 7 13 5 11 14 35 Ohio ... Families 1 1 9 5 1.5 4 Boys 6 3 16 6 18 5 5 6 33 Girls 11 5 25 11 26 7 7 9 31 [18] there appears to be a discrepancy on the optimistic side in the food-consumption studies of families. Another measure of food intake, and a most important one, is the estimate of the nutrients, that is, calories, protein, min- erals, and vitamins, obtained by families or children. As shown in table 2, the aver- age amounts of 9 nutrients consumed per person by the Kansas and Ohio families and by the children of these families are ample in every case except calcium. The amount of calcium is slightly lower than the quantity recommended as a generous allowance by a committee of the National Research Council in 1953, but doubt has frequently been expressed as to the val- idity of this recommended allowance. But averages may be misleading in that some families and children may have had too low, others too high, amounts of nu- trients. If we regard two-thirds or less of the recommended allowances as bor- derline for nutritional safety, the per- centage of families and children whose diets were this low in some or all of the nutrients, is of interest. In both states the proportion of families with borderline intakes of any of the nutrients is very small, to 7 per cent in Kansas and to 9 per cent in Ohio. But the percentage of children in this group is much higher, respectively, 5 to 41 per cent in Kansas and 3 to 33 per cent in Ohio. Of the chil- dren in both states, 32 and 20 per cent had diets low in calcium, 38 and 32 per cent low in ascorbic acid, 15 and 22 per cent low in vitamin A, 4 to 16 per cent low in the other nutrients. Again, it is evident that family consumption rec- ords tend to show larger food quantities and nutrients available to and presumably consumed by family members, especially children, than do the individual records. There is no cause for complacency in these figures. This comparison of the total nutrients reported as available for consumption in the economic sense by the families per man-equivalent with the amounts of these nutrients eaten by the children according to their own individual records is of practical interest. The average amount available for con- sumption per person per day of calories, protein, and the other nurients recorded for the families can be compared with the average intakes of these nutrients re- ported by the children of these families. If the latter are expressed as percentages of the average per-man per-day intakes of the families (fig. 3), it is evident that the children ate only 55 to 70 per cent of the calories, niacin, thiamine, and as- corbic acid; 65 to 75 per cent of protein, iron and vitamin A; and 75 to 108 per cent of the calcium and riboflavin credited per person per day to the families. Because the children had more milk and nearly as much cereal food as the average per person in the families, the discrepancies in riboflavin, calcium, vita- min A, and iron were less than in the other nutrients, that is, protein, thiamine, niacin and ascorbic acid, which were largely supplied by the meat, vegetables _Kpnsas Boys Kansas Girls Ohio Boys | Ohio Girls ASCORBIC NIACIN ACID Fig. 3. Percentage of Kansas and Ohio house- hold food consumption per person of nutrients reported as eaten by children 9 to 1 1 years of age of those families. [19] TABLE 3. — Average Nutrient Intakes Per Person (Man-equivalent) of 730 Low-Income Rural Families in Five Southern States. Description M .2 E o UL «- o d Z M .2 o 5 u E r c '3 *■ o l. a. E O) I O *3 5 u O) E 1 c o k. Ex >- 0) f at c £ o IE i- a> E 1 c > D e: o A £ CO E 1 *G O Z Ascorbic Acid — mg Cotton areas: White 107 .. 201 3,220 2,490 88 63 1.2 0.8 20 16 6.1 3.9 2.3 1.9 2.4 1.6 18 15 76 Negro 51 Tobacco areas: White 157 144 3,100 2,490 90 66 1.1 0.7 18 15 7.3 5.2 2.4 1.9 2.2 1.5 18 15 86 Negro 66 Mountain areas: White 121 3,450 98 1.4 20 5.6 2.3 2.6 16 83 Percentage with less than 2 / 3 recommended: allowances: All white <1 <1 20 <1 13 3 <1 15 All Negro 6 8 37 2 18 21 3 25 and fruits which were eaten in smaller amounts by the children. The remaining large percentage of children who had less than two-thirds of the recommended amount of calcium ( table 2 ) is difficult to explain in view of the fair level of milk intake. Of course, this may indicate merely an uneven distribution of milk drinking, nearly one-third of the children with small intakes, the rest with dispro- portionately large intakes. A similar picture of nutrient values in the diets of the Southern families is shown in table 3. Obviously, the negro families had diets of lower nutritive value than the white and there were more negro families with less than two-thirds the 1953 recommended allowances. The chief deficits in both groups were in calcium, vitamin A, and ascorbic acid. This is the same story told again and again in these dietary records. While there may be some question about the vilidity of the calcium deficits, the vitamin A and ascorbic acid deficits are probably factual and point again to the lack of adequate amounts of vitamin-rich fruits and vegetables, as shown in figure 1. If the calcium deficit is included, milk was the next most im- portant food used in too small amounts by these Southern families. The general conclusion from these fam- ily food-consumption studies is plain. Some families on low-income levels, both white and negro, have diets that are de- ficient in important nutrients because they consume too little milk and vitamin- rich fruits and vegetables. Also, when family food-consumption records are com- pared with the children's individual food diaries, the picture appears less favorable. The children eat less meat, fruits, and vegetables, the same amount of bre?d and cereal foods, but more milk than the average available for consumption per person in the families. The children's diets suggest significant percentages of low intakes of some important nutrients, chiefly ascorbic acid, vitamin A, and cal- cium. Indeed, when the family diet was [20] reckoned to be adequate, only 15 per cent of the children's diets met 100 per cent of the recommended daily allowances of nutrients. Thus, evidence of ample supplies of foods and nutrients available in house- holds is no guarantee of ample intake by all members, particularly the children. SECTION 3 How Much of What Foods Was Eaten? Some of the reports on dietaries gave quantities of certain food groups eaten by children and adults in pounds per week. These calculations of individual intakes which do not include plate or kitchen waste, differ rather strikingly from the "availability" or "disappearance" figures reported in the USDA family or household surveys. Both kitchen and plate waste are included in the latter. On the other hand, the kitchen inventory or re- call-list method used in the surveys may have produced somewhat less variable and more accurate data than the individ- ually kept records, particularly those kept by children. In the household survey over- estimates and underestimates may tend to balance but the individual diet record is more likely to err on the side of omission. Some of the figures quoted in the tables were obtained by recalculation from cal- orie values from the food groups quoted by the original reporters, and these in turn were often calculated from the re- ported number of "servings" of the foods. As noted previously, a good deal of effort was made to ensure agreement on the size of servings and on the nutrient value of the foods included. In some cases rec- ords which were obviously interpreted differently from the majority, although probably valid in themselves, were not included. In the Northeast only seven food groups were presented in this fashion: 1 ) bread and breadstuffs; 2 ) fluid milk; 3) citrus fruits; 4) eggs; 5) meat, poul- try and fish; 6) Irish potatoes; 7) vege- tables and tomatoes. These seven foods contributed about 50 per cent of the total calories consumed by the 778 per- sons who kept the 7-day diet records but between 55 and 70 per cent of the pro- tein, vitamins and minerals. Iowa, Kansas and Ohio children. In the North Central region a pilot study of Iowa, Kansas, and Ohio school children, 9 to 11 years old, yielded esti- mates of the average number of servings per day of six foods taken by 76 children. These foods were 1 ) leafy green and yel- low vegetables; 2 ) vitamin C-rich foods, such as tomatoes and citrus fruits; 3) other fruits and vegetables; 4) milk; 5) protein-rich foods, such as meat, poultry, West Virginia University students check their lunches. [21] fish, eggs, legumes; and 6) cereals. In a later, more comprehensive study of chil- dren in these three states the three-day diet records of more than 1700 children were analyzed. The sample was chosen so as to be statistically representative of the population centers in the three states. Again the average number of servings per day of the six food groups was calculated. Also, the records of a representative group of children in each state who ate the lunch provided by the schools were com- pared with those of a matched group who did not take the officially provided school lunch. The nutrients obtained by the chil- dren were calculated from these records. In figure 4 it is seen that both groups of these children took daily on the average IY2 pints of milk, somewhat less than 5 ounces of meat or other protein food, about eight ounces of breads and cereals, and 10 to 18 ounces of fruits and vege- 6 _>£ CD 0"> if) 0~> ■ Other Fruits and Vegetables Vitamin-Rich Fruits and Vegetables 1 Cereal Products 1 Sweets and Dess. \i Fig. 5. Consumption of six food groups in pounds per week by children 8 to 1 1 years of age in Louisiana, 9 to 1 1 in Iowa, Kansas and Ohio, and 6 to 8, 9 to 12 in Iowa, and 5 to 12 in Utah. Meat, Poultry, Fish, Eggs, Legumes Years 13-15 + 16-20, 13-19 16-20 16-19 14-16 13- 13- 16- 15 20 20 3- 14- 15- 9 16 20 13- 13- 16- 13- 15 20 20 19 14- 15- 16 20 Fig. 6. Consumption of five food groups in pounds per week by adolescents in four Northeastern states, Maine, New York, Rhode Island, and West Virginia; in Iowa; and in three Western states, Montana, Idaho and Utah. [23] TABLE 4. — Consumption of Certain Foods by Adolescents in Three Western and Three Northeastern States.* State Age and Sex •5.2 ± Q> o> U_ J, -=-5 a a! ' o> .E E> 5 "o •- c > o c 5 o aJ v> O) o > o •- II H- O pounds per week ° 5 I- D Oregon 14-16 yrs. 350 boys 2.86 15.5 3.57 1.88 4.54 3.51 9.93 389 girls 2.32 1 1.4 2.26 1.53 5.27 3.63 10.43 Montana 15-20 yrs. 207 boys 4.16 13.7 5.52 2.31 4.09 2.96 9.36 21 1 girls 2.94 9.3 3.62 1.07 3.55 2.47 7.09 Idaho 15-20 yrs. 274 boys and girls 2.52 1 1.7 2.15 1.94 3.46 3.20 8.60 Maine 13-15 yrs. 73 boys 2.62 10.1 2.87 3.02 5.51 8.53 72 girls 2.26 7.8 2.32 2.60 4.50 7.10 New York 13-15 yrs. 1 1 4 boys 3.83 12.1 2.80 4.70 2.96 7.66 145 girls 3.07 1 1.0 2.13 3.32 3.50 6.82 West Virginia 16-20 yrs. 47 boys 4.67 12.4 2.30 2.48 6.95 9.43 98 girls 3.42 7.0 1.67 5.80 7.87 The method of classification of fruits and vegetables differed in the two regions. 50 to past 80 years of age from their 7-day diet records. In addition, similar 7-day records were made for 215 Cali- fornia men past 50 years old. Table 5 indicates the similarity of consumption of nine food groups by these adults. All quantities tend to decrease with increas- ing age, but the North Central and Cali- fornia groups had somewhat different patterns. The California women ate more meat and other protein foods, more milk, more sweets and desserts, less cereal and potatoes, less fat, slightly less fruits and vegetables (fig. 7 ). The California men, as well as the women, increased their milk intake with age but decreased slightly their consumption of the other foods. Data for the 77 New Jersey men are incomplete but indicate that they ate more milk and more cereal foods than did the older California men. Their potato intake was more than twice that of the California men (fig. 8). The California subjects were for the most part city people of comfortable means, but the North Central women were from various types of communities. The Iowa and South Dakota women were chosen so as to represent statistically all the women over 30 years of age in their states. The Illinois women were residents of Urbana and the Michigan white wom- en of the Lansing-East Lansing area, and these samples were so chosen as to be fairly representative of the white women of their age groups. However, the data [24] sa|qoII!W saiun6a-| 'asaaiQ 'S663 HS|j 'Aj4|noj '403^ seiJDtajQ 40 jequinfsj < -a c o s N CO CO CO CO CN CO CO CM O CO 00 CO l\ CO rs K ■6 CO CO CM O co 10 IT) IS CO r\ •— CO CN i— " ^ ^-' CN r^- ^-' --' — '■ CO CN CM O O O CO CO K O CO O O CO N. LO CO in S CM CM CN co CN CN — ■ CN CO CO CO CN O IS O CO 10 O CN r\ CO ** ^r ^r ^t ^r CO LO CN CN 00 K IS O IS 00 K CN CM ^ r- '■ O ^ — OO O CO o CN O O co 00 CO O LO CO LO -0 CO CO O •O 6 d 6 b 6 O 6 6 6 O •0 CN CN ■O CN CN O <> CO ^r CO O CO CN CN CN •— CN ■"" CN r ~ CN CN CN ■"" Is co O O CO CN LO - K CN CO -0 ro CN CN CN CN CO CN CO 0' ^' ^"' 10 IS CO IV IS O CO CN CO LO CN S. CO LO CO CO LO 6 O 6 6 6 C) 6 rs CO -0 CO CN CO CO CO CO LO IS LO LO q ■ ■ r "~ '— "~ "~ "~ CN CN CN ^r t co LO ^3" 10 CN CO CO rs IS IS O CN K + + 7J K K < O O LO -O _|_ 660 LO O IS ^ ■£ *+l UO D C ' s it 0) Z u [25} CD CL 4 (J) =5 O a. Women-. North Central CD California ^ Meat and other Protein Foods Households: North Central Western Milk Vitamin-Rich Fruits and Vegetables M "" 7K-, in *%W All Fruits and Vegetables " h u 6- 4- Potatoes ik Cereal Products I n I Fats iMk Sweets and Desserts n -j M cd cd ai cd rO ^t (o CD Ypnrc III I Teurb 00 o o m <3- m ID CD CD CD to ^- m i I I o o o ro ^- m CD CD CD CD CD ro ^- in 1 1 1 CD + O m O 80 Q_ en I 70 60 50 Mean intakes, A Boys ' o Girls 8 10 12 14 16 18 Years Fig. 14. Average daily protein intake of boys and girls from 4 to 20 years or age. [31] Calories. The figures showing average intake of calories or total food (figs. 12 and 13) indicate that either the calorie allowances for both children and adults are too large or the food records of these subjects con- sistently understate the amounts eaten. However, these separate dietaries for 5664 healthy children and 3670 adults should provide enough data to smooth out any irregularities in the averages. The calorie intakes agree quite satisfactorily with the allowances for children up to 12 years of age, but thereafter the intakes are lower for both boys and girls up to 20 years and men and women to over 70 years of age. Protein. The protein intakes as shown in figures 14 and 15, on the other hand, are de- cidedly greater than the recommended quantity for boys and men at all ages. This is true for girls also up to age 12 or 13, but after that the average daily intake is significantly lower than recommended up to age 20. From 20 to 70 years of age the women's intake of protein was ade- quate, but it dropped significantly after age 70. Such a deficit in teen-age girls is particularly unfortunate. Percentage of calories yielded by the protein of the diet. The percentage of calories yielded by dietary protein is considered by some physiologists and medical advisers to be a better indication of the protein suffi- ciency of the diet than the absolute amount of protein in grams or in grams per pound of body weight. In figure 16 is shown the percentage of calories from protein recommended by the National Re- search Council (1958 version) calculated from the amounts of calories and pro- teins, and the average percentage actually eaten by the children and youths ob- served in these cooperative studies of nutritional status. It is obvious that the dietaries recorded contained more pro- tein in proportion to calories at every age than would be obtained from the amounts in the recommended allowances. The latter show about 11.0 per cent of calories from protein for boys and 12.4 for girls. But the average in the records was 13.2 per cent for boys and 13.0 per cent for girls. This difference is not chiefly due to the lower calorie intakes noted in figure 12 because the deficit in calories below the amounts recommended oc- , curred only after the age of 13, but the percentage of protein calories remained practically unchanged throughout the ob- served age range, from 4 to 20 years. A similar situation is seen in the rec- ords of intakes of adults. In figure 16 it is obvious that the actual percentage of calories from protein is practically con- stant for both men and women at all ages from 20 to past 70, 13.8 per cent for women and 13.6 per cent for men, as compared with rising values of 10.1 to 13.7 per cent rocommended for women and 9 to 12 per cent for men. The cor- responding number of total calories in the recommended allowances falls steadily with age for both men and women, and the actual intakes likewise fall but always on a lower level. As with the children, the constancy of the percentage of calories from protein seems to indicate that the A higher levels found in these dietaries are not merely the result of the lower total calories ingested. Moreover, the constancy of the figures at all ages, 13 to 14 per cent calories from protein for both sexes, suggests either a fixed pattern of dietary choice for the whole country or a re- sponse to some physiological stress, or both these conditions. Some nutritionists have recommended that 15 per cent of the calories be obtained from protein, particularly for adolescents and children. These widespread dietary studies seem to point to voluntary intakes of nearly this composition. [32] ntake Recommended allowances: Male A * Male Female • • Female Fig. 15. Average daily protein intake of men id women from 20 to more than 80 years of age. Recomme ided allowances, _ _■ , • Girls . 1.4 . . A Boys — /f^*- — , Meanmtokes, oGlr | S _^' 1.3 1.2 A- — -• • / Pv I.I 1.0 £ f S s / ^^ * / — S / >l 0.9 1 1 1 10 12 14 Years 16 18 Fig. 17. Average daily calcium intake of boys and girls from 4 to 20 years of age. 40 50 Years Fig. 16. Percentage of calories from protein in the diets of all the subjects. 0.9 £ U 0.8 O O 00 Recommended allowances, A Boys Recommended allowances, . A Boys o Girls 0.7 Mean intakes, 6 0.5 20 30 40 50 60 Years 70 Fig. 18. Average daily calcium intake of men and women from 20 to more than 80 years of age. 6 8 10 12 14 16 18 Years Fig. 19. Average daily iron intake of boys and girls from 4 to 20 years of age. [33] Calcium. The calcium intakes, in figures 17 and 18, show a somewhat similar condition to that of the protein intakes. The boys' average daily calcium intake is at all ages up to 16 years about the same as the recommended amount, but that of the girls is clearly and increasingly low from 11 years of age on. For teen-age girls there is a very wide gap between the recommended allowance and the average intake of calcium. Almost the same con- ditions are true of diets of adult men and women. The women continue to di- minish their calcium intakes into old age. The question may well be raised as to the realtiy of this apparently alarming situation. No objective evidence of un- toward effects from this condition upon health in girls and women was found in these or almost any other inquiries. There is, however, some indirect evidence some- times cited as indicating damage due to low calcium intake. The number of young women who cannot, or at least do not, nurse their babies and the prevalance of dental caries, in boys as well as girls, have sometimes been ascribed to lack of dietary calcium. Proof of an actual rela- tionship has not been seen, however, in either case. It is possible that the estimated allow- ances for calcium are excessive because they are based chiefly on calcium balance or retention studies which are affected strikingly by the level of food calcium to which the subjects are accustomed. Some influential voices have been raised in recent years on this subject. If we dare assume that 5500 presumably healthy fe- males cannot be wrong, the calcium al- lowance may be judged as too high. The dietary averages for girls show a maxi- mum of 1.15 gm at 12 years of age, declining to 0.9 gm at 20 years and 0.5 gm at 70 years and beyond. The corre- sponding values for males are 1.3 gm at 12 years, 1.43 gm at 17 years, and 0.82 gm at 70 and beyond. These high intakes by the boys do not of course prove that their calcium requirements are similar* higher. Iron. The iron requirement has also been th. object of much experimentation and dis- cussion for at least the last 90 years. Fig ures 19 and 20 indicate that the situatio- here is about the same as for calcium. Th r males meet or exceed the recommended amount at all ages, but the food intake of females from 12 years up to 30 shows a wide deficit. From 30 to nearly 60 years of age the requirement is exactly met by the women, but after 60 the deficit is established again. Much the same argu- ments used regarding calcium apply here. Iron absorption by the intestine appears, like that of calcium, to be somewhat self- regulating. Most of these minerals taken in with the food is excreted unabsorbed or is re-excreted into the intestine after absorption. When iron is not needed for blood formation, for example, no matter how much is ingested most or all of it is excreted from the bowel. It has been argued that women have greater blood losses than men in menstrual fluid and in childbearing and should therefore take larger amounts of food iron. But iron conservation appears to be extraordinarily efficient so that the lower intakes by the younger women are compensated by bet- ter absorption or less re-excretion. Hemo- globin, the iron-containing constituent of the blood, is also normally lower in girls and women than in boys and men, and, as well be shown later, this is regardless of iron intake. Vitamin A. The vitamin A in the foods, as men- tioned earlier, is difficult to estimate accurately, partly because the forms in which it appears in animal and vegetable foods are different, and accurate measure- ment of the transformation of the vege- table or carotene forms into true vitamin A in the body is difficult. Some special laboratory studies on this subject are sketched in a later chapter In figures 21 [34] 40 50 Years Fig. 20. Average daily iron intake of men and women from 20 to more than 80 years of age. 10 O o o x »^, v. \ v 0.9 1 1 1 \ 20 30 40 50 60 70 Years Fig. 24. Average daily thiamine intake of men and women from 20 to more than 80 years of age. Fig. 21. Average daily vitamin A intake of boys and girls from 4 to 20 years of age. 2.0 A Men Recommended allowances, • Women \h & E ' o Women "^"- ^*— • cn - 1.4 / y^z cium O O i.o tr* ^^-^ O ^ 0.8 "***$ ' CP 14 Girls Boys -■ Northeast — •• Western A— --A Iowa _ r^-— - ,-A _ /jg&uC-c^^ *S * *-& 13 y 1 1 1 ., _l , , § ' 2 Ik. 10 8 7 9 II 13 15 17 19 Years Fig. 32. Average calcium and iron intakes by children and adolescents in the Northeatsern and Western Regions, and in Iowa. 3418 II 13 15 Years Fig. 31. Average calorie and protein intakes by children and adolescents in the Northeastern and Western Regions, and in Iowa. 100 90 en E 70 "O 60 < o .a o o < 50 100 Girls Boys a ■ Northeast o • Western £t A Iowa A' 90- 80 13 Women Men •- -A Calif, Colo. A New Jersey o N. Central ■ Virginia Recommended! Men ~ Allowance J Women - 20 30 40 50 60 Years 70 80 Fig. 33. Average ascorbic acid intakes by children and adolescents in Northeastern and Western Regions, and in Iowa; and of adults in Northeastern, North Central, and Western Re- gions. [39] intake of thiamine by the North Cen- tral women may be due to their greater use of potatoes and cereal foods. There is little to account for the difference in ascorbic acid intake, however, since the Western women ate slightly less vitamin-rich fruits and vegetables than did those in the North Central states. The wide variation in the occurrence of this vitamin in different foods of vegetable origin may well account for the difference if, as was apparently the case, the Western women chose more of the better endowed vegetables such as broccoli, cress, green peppers, turnip or mustard greens instead of cabbage, cauliflower, tomatoes, peas or green beans. Figure 31 depicts the average intakes of calories and protein by the children and adolescents in the Northeastern and the Western regions and in Iowa. There are obviously few real differences as to protein, but the calorie intakes of the girls show considerable variation. In fig- ure 32 is shown a similar comparison of calcium and iron mean intakes. The iron intakes appear to be fairly similar, but there are differences in the calcium values, particularly in the low intakes of the Iowa boys. The ascorbic acid intakes for both children and adults are shown in figure 33. Low values for the Western boys and girls and relatively high values for Western adults characterize this figure. SECTION 5 How Many Had Less Than the Recommended Allowances of the Nutrients? The average amounts of the nutrients taken by the many subjects of these dietary studies seem on the whole to be fairly satisfactory. But there were, of course, many persons with intakes which were well below these averages. The per- centages of children, adolescents, and adults who had less than two-thirds of the recommended amounts were reported in several of the regions. Perhaps these fig- ures indicate better than the averages the true story of good or poor food habits. Children under 13 years of age. The percentages of 1710 children 5 to 12 years of age who ate less than two-thirds of the recommended amounts for their age of eight nutrients are shown in figure 34. In all these comparisons the 1953 version of the Recommended Allow- ances was used. The columns in figure 34 represent states in all four regions. The number of children with diets deficient in protein is obviously small. More were deficient in calcium, 7 to 20 per cent in all regions and 3 to 13 per cent in iron, most in New York and Virginia. Vitamin A-low diets were few except in Virginia and Louisiana and thiamine- and ribo- flavin-low diets were also few, less than 8 per cent in all states. Niacin was moderately low in New York, West Vir- ginia, and Virginia diets, but ascorbic acid was present in less than two-thirds the recommended amount in 12 to 42 per cent of diets in all regions, Utah, Virginia, West Virginia, and Louisiana most markedly. These figures seem to indicate that a considerable number of children under 12 were eating too little citrus fruits, berries, tomatoes, melons, raw cabbage, and other vitamin C-rich fruits and vegetables. In the two Southern states the intake of vitamin A-rich fruits and vegetables, such as peaches, apricots, greens, and carrots, was also low. The high percentage of low niacin and iron intakes in New York may point to low meat intake and the moderate amount of calcium-low diets in all regions to some- what low milk intakes. [40] In a few cases there are food-intake records to confirm these surmises. Utah children ate about 2.5 pounds per week of vitamin-rich fruits and vegetables com- pared with 4.5 pounds eaten by Iowa children. The ascorbic acid-low intakes in figure 34 reflect this. The Louisiana report on the number of servings of various foods eaten by 1222 children under 12 shows somewhat low average intakes of citrus fruits, green and yellow vegetables, butter and margarine, and eggs. All of these foods contribute vitamin A and the vegetables and eggs also contribute iron, both of which appear low in the Louisi- ana diets. The Virginia children were 175 white children, both town and rural, aged 8 to 11 years. Of these children the percentage receiving less than two-thirds the recommended allowances of ribo- flavin, ascorbic acid, protein, and vitamin A was greater than was found in any of the other five states which reported studies of children under 13 years of age. As will be seen later, the weights and physical condition of the children re- flected these relatively low intakes. Studies of large groups of boys and girls 9 to 11 years of age in Iowa, Kan- sas, and Ohio showed that the propor- tions of those who received less than two-thirds of the allowances varied among these states. In figure 35 it is shown that generally there were more deficits among the Kansas than the Iowa or Ohio chil- dren. This is true of iron and thiamine for the boys, riboflavin, niacin, ascorbic acid, protein, and calcium for both boys and girls. The Iowa and Ohio children had approximately the same percentage of deficit in all the nutrients except vita- min A and ascorbic acid, of which more Ohio children had low intakes. The Kan- sas children, especialy the boys, ate less milk, fruits and vegetables, and fats than the Iowa and Ohio children. However, it is not always easy to assess the cause of the low nutrient intakes from the food pattern. The vitamin and mineral con- BOYS GIRLS Fig. 34. Percentage of children under 13 years of age from six states who ate less than two-thirds the recommended allowance of men- tioned nutrients. Fig. 35. Percentage of children 9 to 1 1 years of age in Iowa, Kansas, and Ohio who ate less than two-thirds the recommended allowance of mentioned nutrients. [41] tents of the various fruits and vegetables vary over such a wide range that generous intakes of these foods in one case may make poor nutrient provision, and in an- other, adequate or rich provision. Lettuce, celery, onions, radishes, apples, pears, even bananas and pineapple, carry relatively small amounts of both vitamins A (caro- tene) and C, as compared with tomatoes, peaches, apricots, yellow melons, straw- berries, citrus fruits, carrots, spinach and most other greens. Cabbage and potatoes are notable chiefly because they are often used in generous amounts and significant contributions of ascorbic acid therefore obtained from them. As will be shown later, these lower nutrient intakes by the Kansas children were associated with lower blood hemo- globin, serum ascorbic acid, and serum carotene but not lower serum vitamin A than were seen in the Ohio and Iowa children. These blood values are corre- lated with the lower protein and ascorbic acid intakes of Kansas boys and girls, low iron in the boys but relatively normal vitamin A intakes. On the other hand, the Ohio children shown to have low vitamin A intakes had also the lowest level of blood vitamin A. The adolescents. In two Northeastern and six Western states many more adolescents (13 to 16 years old) than younger children reported less than two-thirds of the recommended allowance of one or more nutrients. In practically all cases the girls had far more dietary deficiencies than the boys. This was especially marked in calcium, iron, thiamine, riboflavin, and vitamin A. In a comparison of New York and Maine with Idaho, Montana, and Washington groups the percentage of boys with low intake records was about the same in both re- gions, but for girls the percentage was GIRLS BOYS GIRLS Per Cent 60 40 20 i — | — r 1 N Mex Sp Amer NMex Anglo Oregon Colorado Idaho Montana Washington New York Maine Fig. 36. Percentage of boys and girls 13 to 16 years of age in six Western and two North- eastern states who ate less than two-thirds the recommended amounts of mentioned nutrients. Fig. 37. Percentage of boys and girls 13 to 16 years of age in six Western and two North- eastern states who ate less than two-thirds the recommended amounts of mentioned nutrients. [42] smaller in the Northeast, (figs. 36 and 37.) Among the Oregon children 14 to 16 years old, few had less than two-thirds the recommended amounts of protein, vitamin A, thiamine, riboflavin, or niacin, but 20 to 30 per cent had less than that amount of ascorbic acid and iron, and 8 to 26 per cent were equally low in cal- cium. In all cases except that of ascorbic acid there were more girls than boys in the deficit column. More Spanish-American New Mexico children had low intakes of every nutrient than did the Anglo-New Mexico or Ore- gon subjects of the same age range. Nearly half the Spanish-American girls had low intakes of most of the nutrients, and nearly half the boys had low intakes of vitamin A, ascorbic acid, thiamin, and niacin. Sixty-five to 75 per cent of the diets of both boys and girls were low in calcium. The Anglo-New Mexico children had less deficits in every case than the Spanish Americans but, except for pro- tein and niacin in the case of the boys, more than the Oregon children. As will be seen later, these differences in intakes were accompanied by differences in growth rate, in physical signs of possible deficiency, and in blood composition. In figure 38 are shown the correspond- GIRLS Per Cent 50 40 30 20 "i — r Per Cent 20 30 40 50 ■ W/////M f— ~ ~~~] Aqes 15-18 Ages 12-14 WWM//////f/^ \ , 1 , I E ^ Ml Fig. 38. Percentage of Iowa children 12 to 1 8 years of age who ate less than two-thirds the recommended amounts of mentioned nutri- ents. ing percentages of Iowa children 12 to 18 years old whose intakes of the eight nutrients were less than two-thirds the amounts recommended. These deficits are not large except for calcium, iron, and ascorbic acid. Again, more girls than boys had low intakes, and there were more in the 15- to 18-year than in the 12- to 14-year groups. Young people of college age, 16 to 20 years, in Rhode Island, West Virginia, and Idaho also often had low nutrient intakes (fig. 39). The boys had no iron deficit, but many of the girls had low iron intakes. The other deficiencies were generally similar and not excessive except for ascorbic acid and calcium. A start- lingly large proportion of the young women in Rhode Island had diets defi- cient in thiamine. The girls' diets showed more deficits in iron and riboflavin than did those of the boys, but in all other nutrients the deficits were equally fre- quent in the diets of both girls and boys. MEN Per Cent 50 40 30 20 10 WOMEN Per Cent 10 20 30 40 50 n ^ 1 Elllllllllllllllllllll ^ Rho Wes Idoh Je Isle Virg nd ma ASCORBIC ACID Fig. 39. Percentage of men and women 16 to 20 years of age in Rhode Island, West Virginia, and Idaho who ate less than two-thirds the recommended amounts of mentioned nutrients. [43] It seems that the girls past 16 years of age improved their eating habits slightly, but an equal number of boys retrogressed from the good status achieved up to age 16. Adults. As shown in figure 40, many women from 30 years to past 80 took less than the recommended amounts of the nu- trients. Of the women in six North Cen- tral states, nearly three-fourths had less than two-thirds the recommended amount of calcium, about half were similarly low in vitamin A, 20 to 30 per cent also were low in niacin, and 30 to 40 per cent in ascorbic acid and riboflavin. In nearly all cases the percentage of defi- ciency increased with age. Women past 50 years of age were also studied in California and Colorado and were found to have somewhat similar but less severe ML. RIBOFLAVIN ASCORBIC ACID rr JLU 1 m I B M&X 1 1 m f m *. III i Fig. 40. Percentage of women 20 to 50 years of age in Virginia, 30 to past 80 years of age in six North Central states, and 50 to past 80 in two Western states who ate less than two- thirds the recommended amounts of mentioned nutrients. deficits. No consistent age change was observed in the intakes of the Western women. A group of women industrial workers in Virginia, 20 to 50 years old, was also included in this comparison. The percentage of the Virginia women in the deficiency column was much lower than those of the older North Central and Western women except for iron, vitamin A, and ascorbic acid. The number of women past 70 with low protein, iron, vitamin A, and ascorbic acid intakes is especially worthy of note. In figure 41 are shown the correspond- ing data for New Jersey men 20 to 50 years old, a few Utah men 25 to 49, and California and Colorado men past 50 years old. In nearly all cases the Colorado men had more deficits than the California men of similar age. This was especially striking in calcium, vitamin A, and ascor- bic acid. The protein, iron, and niacin intakes were generally fair in all cases. The New Jersey and Utah men had RIBOFLAVIN" Fig. 41. Percentage of men 20 to 50 years of age in New Jersey, and 50 to past 80 in California and Colorado who ate less than two- thirds the recommended amounts of mentioned nutrients. [44] smaller percentages of deficit than the older groups in California and Colorado except for calcium and ascorbic acid. The men's records compare favorably with those of the women of similar ages ex- cept for ascorbic acid in which 20 to 40 per cent of both sexes were deficient. The Utah Study. An interesting comparison was made in Ogden, Utah, between the nutritional sta- tus of 131 children who had recovered from rheumatic fever and that of 131 carefully chosen similar children who had not had rheumatic fever. Some of the control children were brothers and sisters of those who had a history of rheumatic fever, and 41 parents, 20 men and 21 women, 25 to 49 years old, were also included in the group examined. Ascorbic acid, calcium, and iron were the nutrients most frequently low in the children's diets, and ascorbic acid was most often low for both boys and girls. The older girls, 13 to 17 years old, fre- quently lacked enough iron and calcium. This was ascribed to their low intakes of milk and eggs. The younger children, under 10 had more relatively good diets (fig. 42), those 10 to 12 years old had diets of intermediate value and the oldest group, 13 to 19 years old had the poorest intakes. The girls in the control group ate more calories, protein, fat, iron, thiamine, and niacin than those who had had rheu- matic fever, and these control girls like- wise had better hemoglobin and red blood cell counts than the rheumatic fever group. Intake of other nutrients and the levels of other blood constituents, except for sedimentation rates, were not signifi- cantly different in the two groups. A statistical calculation of the influence of sex, age, nutrient intake, and rheu- matic fever history revealed that age had the greatest influence on hemoglobin, red blood cell count, serum ascorbic acid, and serum carotene, but sex influenced serum WA Boys in rheumatic fever group LI1111U Girls in rheumatic fever group | | Boys in non-rheumatic group k\YJ Sir's in non-rheumatic group CALCIUM ASCORBIC ACID X3 20% 20 40% 20 40 60% 5 to 9 years 10 to 12 years 13 to 19 years Fig. 42. Percentage of children in Utah study who ate less than two-thirds the recommended amounts of mentioned nutrients. cholesterol and blood riboflavin, and rheu- matic fever influenced the sedimentation rate. The sedimentation rate was higher in the girls who had had rheumatic fever than in the controls. All the children had equally poor teeth. The 14- to 1 6-year-olds, for example, had an average of 11.5 decayed, missing, or filled teeth, exclusive of X-ray findings. Slightly more of the children in the rheumatic fever group were underweight and classified as showing borderline or poor physique and growth. More of the boys with good physique and growth met the daily allowances for all nutrients ex- cept ascorbic acid than did those with poor growth. This distinction was not seen in the girls. It is imposible to judge from these findings how much bearing, if any, diet habits may have had upon the incidence of the fever. Changes in diet undoubtedly occurred when the children were taken to the clinic, and some of these changes may have persisted. Changes in physical activity no doubt accompanied the con- valescence from the disease. But some, although slight, effects upon blood com- position and physique remained in the group which had had rheumatic fever. [45] SECTION 6 The Blood Composition and Its Relation to the Diets The blood composition is known to reflect the nutriture of the body, especially in the amount of hemoglobin, number of red cells, and concentration of ascorbic acid, vitamin A, and carotene. The amount of circulating alkaline phospha- tase, an enzyme, is thought to be indica- tive of bone metabolism. Blood riboflavin may show the adequacy of intake of that vitamin, and serum cholesterol levels may have some diagnostic value, especially as to atherosclerotic danger. In most of the regional studies, only hemoglobin, serum ascorbic acid, vitamin A, and carotene were determined. The chief interest in making these analyses was the detection of variations from the currently accepted norms and correlation with the known Top left and right: North Central Region youngsters have blood samples taken for hemoglobin measurements. Lower left and right: Taking blood samples and getting vitamin A readings in the Northeastern Region. [46] dietary intakes of the corresponding nutrients. In the Northeast, hemoglobin, ascorbic acid, vitamin A, and carotene were deter- mined on most of the subjects studied. A few drops of blood taken from the fingertip were sufficient for these tests, since approved microchemical methods were available. Referee blood samples were prepared and six of the Northeast- ern stations collaborated on a test of the accuracy and reproducibility of the meth- ods. They concluded that day-to-day and hour-to-hour variability in the blood com- position of the subjects was as great as the laboratory-to-laboratory variability and that neither the instruments nor the length of storage of the samples had a significant effect upon the results. Thus, in the Northeast at least, the blood values obtained at the six cooperating stations, Maine, Massachusetts, New York, New Jersey, Rhode Island and West Virginia, are comparable. The age range in New York was from 4 to 20 years, but the number of subjects in the l6-to-20-year group was too small for reliability. In Maine the subjects were adolescents 13 to 15 years and college students 16 to 20; in Rhode Island the same age groups and a smaller group of women over 20 years of age; in West Virginia large groups of college students 16 to 20 years old and of both men and women over 20 years. Men 20 to 50 years old in New Jersey and pregnant women in Massachusetts were the other subjects. In the North Central region much the same techniques as those adopted in the Northeast were used for both sampling and analysis. The subjects were chiefly school children, 9 to 11 years old, exam- ined in Iowa, Kansas, and Ohio in con- nection with a study of the adequacy of the school lunches served in those states. In addition, a large sample of Iowa chil- dren 6 to 18 years of age was studied, including finger blood analysis as well as elaborate physical measurements and dietary records. In Virginia and Louisiana 8- to 11 -year- old children were examined as to blood composition and heights and weights re- corded. Women 20 to 50 years old in Virginia were also subjects of this type of study. Blood samples were also ana- lyzed in eight Western states. The subjects were adolescents 13 to 17 years old in seven Western states; in California and Colorado men and women over 50 years of age were studied, and in Utah children and adolescents from 5 to 19 and adults 25 to 49 years old. Hemoglobin. Up to the age of 12 there appeared to be no significant differences between the New York boys and girls in regard to hemoglobin content of the blood. A slow rise in the level is evident in both sexes up to that age, but thereafter the level for the boys continued to rise and that for the girls slowly declined (fig. 43). The groups 13 to 15 and 16 to 20 years old in Maine, Rhode Island, and West Virginia also showed higher values for the boys in all cases with increases in the levels in the older group, but no such increase occurred in the girls (fig. 44). By the usual standard of comparison ( less than 11.0 to 13.0 gram-per cent hemo- globin according to age and sex) more of the Maine and Rhode Island subjects, especially the girls, were close to anemia than were the New York or West Vir- ginia subjects. Statistical study of the blood values for about 1500 subjects in the Northeast revealed several valid correlations with related dietary constituents. Hemoglobin was found to be corelated significantly with both dietary protein and dietary iron in five of the six cooperating states. The sixth state, New Jersey, examined only male industrial workers 20 to 50 years of age. Here there appeared to be a negative correlation with iron, none with protein. However, the iron and dietary intakes of these men as well as their hemoglobin levels, mean level 15.3 per [47] cent, were all high, and the correlation may therefore not represent a true nutri- tional relationship. In Virginia, town and rural whites and negroes were examined, and in Louisiana white children from five parishes, two in cities and three in farming areas. All were 8 to 11 years old. The sample was HEMOGLOBIN Fig. 43. Hemoglobin and ascorbic acid levels of blood of New York children. HEMOGLOBIN ASCORBIC ACID I3-I5yrs 16 Ml Maine II I Rhode Island M I West Virginia #/ r ■I ? 2 ° E ^n I3-I5yrs l6-20yrs I3-I5yrs I6"20yrs Fig. 44. Hemoglobin, ascorbic acid, vitamin A, and carotene levels of blood of Maine, Rhode Island, and West Virginia adolescents. chosen to represent these areas statis- tically. The Virginia town subjects, both white and negro, had higher hemoglobin values than their rural counterparts in both the 8- to 9- and 10- to 11-year-old groups. The Louisiana children had values similar to those of the Virginia town chil- dren and the New York children of the same ages (fig. 45). Only 4 per cent of the Louisiana children were classified as in poor condition so far as hemoglobin goes, as compared with 15 per cent of the Virginia children. In Virginia a posi- tive correlation was found between diet- ary protein and hemoglobin levels but no such relationship between dietary iron and hemoglobin. In Louisiana a highly significant positive correlation was de- tected between dietary iron and hemo- globin levels but no significant correlation with dietary protein. The Louisiana chil- dren had diets considerably richer in pro- tein than did the Virginia children and ASCORBIC ACID White Negro White * ^' ~'~"~ \ \ \ NEW YORK Boys s \ > \ ... — ~ — <> - Girls IOWA ^^> \ V N X ^^ - o- WESTERN REGION " ^K, Nj -< - 1 1 1 1 ! 1 1 1 1 I 1 1 10 12 14 Age in Yeors Fig. 55. Alkaline phosphatase concentration in blood of New York, Iowa, and Western chil- dren. 13 to 15. These years represent the peak of pubertal growth in the two sexes. The Iowa children showed the same peak ages (fig. 55) followed by gradual lowering to 2.5 and 1.5 by age 18. The latter are the usual adult levels, reached earlier by girls than by boys. It is interesting that between ages 7 and 8 and 12 to 13, when the Iowa girls showed a conspicuous slow- ing of growth in both heights and weights, the alkaline phosphatase levels dropped precipitously. The same is true of the boys; at ages 9 to 10 when the slowest rate of growth occurred there was the same drop in alkaline phospha- tase. Rapid growth in girls at age 10 to 12 and in boys at 13 to 15 was accom- panied by sharp rises in serum alkaline phosphatase. Quite similar results were noted in the West (fig. 55). The girls at age 11 and the boys at age 14 showed maximal values as well as maximal growth rate. Rapid lowering to the adult level at age 18 occurred in girls but not in boys. In Montana an inverse relationship was [55] TOTAL SERUM CHOLESTEROL Males — Femoles 280 _ 260 o 240 £ 220 E200 180 160 5-9 10-12 13-15 16-19 50"59 60"69 70+ 25-49 Age in Years Fig. 56. Total serum cholesterol levels of chil- dren and adults in seven Western states. shown between phosphatase levels and height within sex groups; the taller sub- jects generally had the lower phosphatase levels. There was also a trend toward higher phosphatase levels in the subjects with the lower calcium intakes. This is a valuable clue which should be followed up because easily determined indications of good or poor calcium nutriture are not at present available. Blood serum cholesterol. Only in the West was blood serum cho- lesterol determined in nearly all subjects (fig. 56). At all ages the females had higher levels than the males except for the small groups of men and women in Utah between the ages of 25 and 49. In Utah a small group of subjects aged 5 to 12 years was also studied. The large number of adolescents from 13 to 20 years old studied in Idaho, Montana, Washington, Colorado, and New Mexico establishes fairly well norms of 167 mg- per cent for girls and 156 for boys at about age 14, and 172 and 163 mg-per cent at about age 18. The older women from age 50 on had much higher values, 260 at 55 to a peak of 273 at 65 and down to 262 at 70 and over. The men of those ages showed a steady decline from 245 at 55 years to 232 at age 70 and over. These studies were among the first to establish the relative cholesterol levels in older men and women and revealed the need for separate norms for men and women of this blood constituent. The Cal- ifornia study of the older group of men and women showed a positive correlation of blood cholesterol with both fat and cholesterol in the diet. Much interest has been shown in recent years in the con- centration of circulating cholesterol, since there are suggestions that this may be an index of arteriosclerosis. The establish- ment of a normal range for age is there- fore an important problem not yet fully solved. In a later chapter the experiments in this field carried on in the Northeast, North Central, and Western regions are reviewed. SECTION 7 Growth of Children and Adolescents in Relation to Their Diets It is well established that the growth of children may be affected by diet as well as by hereditary factors, hormones, illness, and other factors of environment. In some of these regional studies meas- urements were made of height, weight, build, developmental schedule, and other characteristics of the children whose diets were recorded. In Iowa an elaborate set of measure- ments of about 1200 boys and girls 6 to 18 years of age was obtained in 61 schools. Less detailed but similar observa- tions were made in Louisiana and Vir- ginia on children 8 to 11 years old; in the joint study of school children 9 to 11 years old in Iowa, Kansas, and Ohio; and on smaller groups of children under [56] Of these 10-year-old Iowa girls, all but the one in the center were in the A4 channel of body build. The one in the center was in the A3 or medium channel. These are 13-year-old Iowa girls. The one in the center was in the A3 or medium channel; the others are in the A4 or stocky channel of body build. [57] 13 years of age in Utah and New York. Adolescents were studied in New Mexico, Washington, Idaho, Montana, New York, Maine, Rhode Island, and West Virginia. In all these studies an attempt was made to relate the diets of the children to their physical growth and development. The Iowa children. The average heights and weights of Iowa school children 6 to 18 years old are shown in figure 57. As it happened, earlier studies done in Iowa City to obtain standards regarding the growth of chil- dren and in Des Moines to standardize clothing sizes, provided excellent confirma- tion of the validity of these measurements and of the comparatively stable growth rates of Iowa children. A tendency toward an increase in weight in proportion to height showed itself, however, especially in teen-age girls. Between 10 and 13 years of age the girls' growth in both height and weight exceeded that of the boys. After age 14 this tendency was reversed. The height - weight - age - sex measure- ments of these children were compared with the so-called standards set up by Baldwin and Wood in 1923 from exami- nation of some 129,000 children of school age (5 to 19 years) from 12 schools in the Northeastern and North Central re- gions. Other so-called norms for school- HEIGHTS age children, the Jackson-Kelly charts based on height and weight measurements of 24,500 Iowa children, were published in 1943 and the similar Stuart and Mere- dith tables, also based on studies of Iowa City children, were published in 1946. Another standard of both growth and development is the Wetzel Grid, a chart set up in 1941 for measuring the progress of individual boys and girls over a period of years. These body build or physique classifications are based on mathematical formulae set up to interpret these data in terms of growth. The relationship of weight to height 4etermines the physique channel of the child and this is further adjusted to age to indicate the channel of development or "auxodrome" in which the child is placed. The physique chan- nels are Obese, Stocky, Medium, Thin, and Very Thin. The develovmental auxo- dromes indicate the probable type of growth, that is, Good, Doubtful, or Poor, by comparison with the records of 7000 normal children previously examined. Thus a child might have height and weight indicating stocky or medium phy- sique but in comparison with the de- velopmental standards, good, doubtful or poor development for age. In figure 58 it can be seen that at all ages more Iowa girls than boys were of obese and stocky physique and that usu- ally fewer girls were medium or thin. The tendency toward stockiness increased in Wk Very heavy and obese □ Medium M Stocky QH Thin Years-. 6 Boys Girls +_ 60 c 6 8 10 12 14 16 18 G 8 10 12 14 16 18 Age in Years Fig. 57. Mean heights and weights of Iowa children 6 to 1 8 years of age. Fig. 58. Percentage of Iowa children with various body builds. [58] the girls from the younger to the older groups but was relatively constant in the boys. In figure 59 the schedule of develop- ment of the children in the pilot study is also shown, indicating that 65 to 75 per cent had both good physique and good growth. About 7 per cent of the boys and 11 per cent of the girls were obese; less than 5 per cent of the children had good physique but slow growth except for the 16- to 18-year-old group of whom 13 per cent had slow growth. At all ages more boys than girls had thin build but good growth. Only 5 to 7 per cent had thin build and poor growth; however, 12 per cent of the 9- to 12 -year-old girls fell into this category. The Iowa, Kansas, and Ohio children, 9 to 11 years old. The comparison of Iowa, Kansas, and Ohio school children 9 to 11 years old is of interest also in reference to these measurements. In a preliminary survey of children 6 to 18 years old in one school in each of the three states, 62 to 64 per cent of all the boys were classified as of medium body build, while the Wet- zel norm was 70 per cent. In Iowa 72 per cent of the girls were of medium Years 6-8 □ 9-12 ■ 13-15 Hi Obese Boys Girls Boys Good Physique Good Growth Gii build, in Kansas 55 per cent, and in Ohio only 43 per cent, against a standard of 57 per cent. There were no obese boys in Ohio and less than 5 per cent in Iowa and Kansas. However, in all three states there was an excess of obese girls, 11 to 12 per cent as against the norm of 8 per cent. There were more stocky Iowa Fig. 59. Schedule of development of Iowa children. A well fed, healthy, Iowa girl. [59] Obese Boys Girls Wetzel Standard n Oh ipp Kansa s Bg Iowa if" Medium Boys Girls Fig. 60. Percentage of Iowa, Kansas, and Ohio children 9 to 1 1 years of age with various body builds, compared with the Wetzel standard of occurrence of these builds. boys and Ohio girls than the Wetzel standard called for, more thin boys at every age in all three states and fewer thin girls except for Ohio, more very thin boys in Kansas and Ohio, and fewer very thin girls in Iowa and Kansas than the so-called standard. The Ohio girls and the Iowa boys showed the greatest variation from the standards (fig. 60). The rate of development pictured in figure 61 shows again that nearly 50 per Development: Good Questionable Medium to Stocky Build: Medium to Stocky r ffii Thin to Very Thin Thin to Very Thin M M ^lowa gj Kansas djohio Fig. 61. Schedule of development of Iowa, Kansas, and Ohio children 9 to 1 1 years of age. cent of the children in all three states were of medium to stocky build with good rate of development; 15 to 18 per cent of the Kansas and Ohio children, but only 5 per cent of the Iowa children, were of this build but questionable devel- opment. Many more Iowa children, how- ever, were thin to very thin and showed questionable development, but relatively few of this body build showed poor devel- opment. In general, it was concluded that the growth of the majority of the 397 boys and girls was satisfactory, although more of the boys were thin or very thin and more of the girls obese than in the standard Wetzel distribution. Weight-height-age-sex comparison with the Baldwin-Wood standards, children under 13 years. The under- or overweight attained by children was frequently compared with so-called standards or norms obtained by statistical treatment of measurements of large numbers of children. The Baldwin- Wood survey was most often used for these comparisons. In the Virginia study (fig. 62 ) of white and negro town and rural children 8 to 11 years old, the following percentages were determined: those more than 10 per cent underweight for height and age, those within 10 per cent of normal, and those more than 10 per cent overweight. The same comparison was made for the 487 white children of the same age in Louisiana. The white children in the two states had almost the same distribution, 23 per cent under- and 14 per cent over- weight. Of the negro children 40 per cent were underweight and 12 per cent overweight. By this criterion the Iowa, Kansas, and Ohio children of nearly the same ages (9 to 11 years) had about the same dis- tribution of under- and overweight as the Southern white children. In Iowa there were fewer in both the under- and overweight class, however, than in the other states (fig. 62). [60] Utah boys and girls 5 to 12 years old may be compared with New York chil- dren of the same age group. The New York boys and girls obviously had fewer underweight and more overweight mem- bers than the Utah group. The Northeastern measurements: adolescents. Similar comparisons of children of high school and college age were made in Maine, New York, Rhode Island, and West Virginia (fig. 63). In Maine the boys and girls 13 to 15 years old had a normal distribution of under- and over- weight with more of each among the girls, but 54 and 60 per cent in the nor- mal category. In West Virginia nearly 30 per cent of the boys and nearly 60 per cent of the girls were underweight. This latter is an extraordinary figure for girls of this age. In the Northeastern region New York had the fewest boys who were underweight and the most who were overweight. The New York and Rhode Island girls were of like distribu- 80 60 5 20 80 I I + 10 % of normal More than 10 % underweight More than 10 % overweight Boys and Girls Years 5-12 Utah Boys and Girls 4-12 New York M 60 20 Boys and Girls, 8-12 Years V ^ Q Lou.siana ^(g a Ohio Kansas Iowa Fig. 62. Percentage of children under 13 years of age in seven states who were signifi- cantly underweight or overweight for their age, height, and sex. tion with about one-third more than 10 per cent overweight. In the smaller groups of college age, 16 to 20 years, in Maine underweight was more common than overweight, in Rhode Island these were well balanced, but in West Virginia the number of girls who were under- weight and of boys who were overweight was unusual. The Western measurements: adolescents. Adolescents in large numbers were studied in New Mexico, Montana, Idaho, and Washington and a special group of Papago Indian children in Arizona. In figure 64 the average heights and weights of these groups are illustrated along with those of the Iowa children of the same ages. The New Mexico children were of two types, the Spanish Americans, de- scendants of original settlers, largely Span- ish in origin, and the so-called Anglos, mostly of northern European descent. These two groups proved to be diverse in diet habits, body measurements, and blood composition. The mean heights and weights of the Spanish-American and the c 10 CD I I + 10 % of normal 13-18 Boys 13-15 Years West Virginia New York More than 10 % underweight More than 10 % overweight Boys 16-20 Yeors Rhode West ^ me Island Virginia 13-18 Girls 13-15 Years Virginia New Rhode York Island Girls 16-20 Years Rhode West Island Virginia Fig. 63. Percentage of adolescents 13 to 20 years of age in four Northeastern states who were significantly under- or overweight. [61] Many of the young subjects were most cooperative. On the left a nutritionist weighs and measures a school child; on the right a New York subject is being tested. Arizona Indian boys were significantly less than those of the other boys, and this was also true of the heights of the girls. The Arizona Indian girls, strangely enough, had much the greatest average body weight of any of the Western group. The Spanish-American New Mexico girls were, on the other hand, lighter in weight than any of the others. A significant cor- relation was found in the New Mexico study between the protein of the diet and the heights of the children. This was true of both sexes and both cultures. The average heights of 14- to 16-year-old Spanish-American and Anglo boys were 64.3 and 68.7 inches, of the girls 61.4 and 64.0 inches. The protein intakes of these two groups of boys were 77 and 101 gms. per day, of the girls 68 and 73. Weights and body build of Western adolescents. Comparisons of the percentage of over- and underweight adolescents 14 to 16 years old were also made in five states in the West (fig. 65 ) . More than 70 per cent of the New Mexico Anglo girls fell in the normal column with equal numbers under and overweight. The Washington, Idaho, Montana, and Colorado girls were much alike in that more than 50 per cent were in the normal weight range with somewhat more overweight than under- weight. The Spanish-American girls in New Mexico were conspicuously under- weight, 38 per cent, with 48 per cent in the normal column and 14 per cent over- weight. The Spanish-American boys were even more underweight, 45 per cent, with [62] I ]NM-SpAmer g| Montana H Idaho NM- Anglo Hlowa H Washington ■ Arizona 5-16 12-16 Fig. 64. Mean heights and weights of boys and girls 12 to 16 years of age in six states. only 12 per cent overweight. More New Mexico Anglo and Colorado boys were also underweight, 31 and 38 per cent, than overweight, 12 and 14 per cent. The other Western boys had fairly bal- anced numbers of under- and overweight. New Mexico, Washington, and Idaho adolescents were classified as to physique channel, using the Wetzel Grid charts. There were no obese boys among the Spanish-American New Mexico subjects; only 4 per cent were stocky and 54 per cent thin or very thin. Among the Anglo New Mexico boys, 14 per cent were obese or stocky and 28 per cent thin or very thin. The division among the Washington boys was about the same as of the Anglos, but Idaho boys had 24 per cent obese or stocky and only 18 per cent thin or very thin. Whether racial stock, diet, cli- mate, or other environmental factors govern these differences remains to be determined ( fig. 66 ) . Under- and overweight of adults. The North Central study of women over 30 years old and that made in Cali- ^ 20 E^More thon 10 % underweight □ ± 10% of normal M More thon 10% overweight New Mexico Spanish Anglo American Girls l4-!6 Years Wosh " Idaho Montana Colorado ington 1 70 Boys 14-16 Years New Mexico .. , „„ Wash- . Spanish Anglo Montana ington American Idaho Colorado r Fig. 65. Percentage of boys and girls 14 to 16 years of age in five Western states who were significantly under- or overweight for height, age, and sex. fornia and Colorado on men and women over 50 yielded some figures on amount of under- and overweight in adults. The New Jersey study of 600 male industrial workers also included weight records. Stocky Boys Girls Fig. 66. Percentage of adolescents of various body builds in three Western states. [63} 40 □ ± 10 % of normal M More than 10 % underweight tS 10 to 20 % overweight Ml More than 20 % overweight South Dakota Women Illinois Iowa Michigan White Negro Women California, California, New Colorado Jersey Fig. 67. Percentage of under- and overweight among adult men in three states, and adult women in seven states. The North Central women, in South Dakota, Iowa, Illinois, and Michigan, showed relatively high percentages of overweight, the greatest, 47 per cent more than 20 per cent overweight occurring among the Michigan negro women. There were 23 to 25 per cent in this classifica- tion in the other North Central groups. Only 14 per cent of the Minnesota women, who were on the average older than the other North Central women, had this amount of overweight, as did only 12 per cent of the older women in the West (fig. 67). About 45 per cent of all the North Central women were more than 10 per cent overweight, com- pared with only 12 per cent who were underweight. The degree of overweight noted in the women in South Dakota and Iowa is significant because the sample chosen was fully representative of all the women in this age group in these two states. Also the incidence of overweight in the women studied in Illinois and Michigan is probably significant for these specific groups of urban women. Only 6 per cent of the negro women and 11 to 17 per cent of the others in the North Central states were under- weight. The California and Colorado women had a relatively high degree of underweight, 28 per cent. These western women were older on the whole than those in the North Central study since they were all over 50 years of age, instead of over 30 years as in the North Central states. The New Jersey men 20 to 50 years old had less underweight and more over- weight than the older California and Colorado men. Only 8 per cent of the latter were excessively overweight but 20 per cent of the former were. This is not unexpected because of the tendency for men to decrease in weight with advanc- ing decades. SECTION 8 Incidence of Physical Signs Sometimes Associated With Nutritional Deficiencies A long and varied set of physical signs discernible by an experienced medical examiner has been listed as possibly re- lated to nutritional failures of one kind or another. Many of these signs are inter- pretable in acutely varying ways, depend- ing upon the experience and judgment of the examiner. In several of the coop- erative studies, especially in the North- east and the West, an attempt was made to conform to one list of such signs, each carefully described. Nevertheless, varia- bility in the reports of the examiners was obvious and disturbing. The same exam- [64] iner operated in California and Oregon, another in Colorado, New Mexico, and Arizona, two others in Montana, two in Idaho, and two in Washington. In the Northeast a competent physician con- ducted the examinations in each state and these examiners had the assistance of a special advisory committee of five experienced physicians. A group of three experienced physicians conducted the ex- amination of the Louisiana preadolescent children and one well-qualified physician made all the observations in the similar Virginia study. In spite of the general consensus that the symptoms defined and described vaguely as of nutritional origin are usu- ally nonspecific and may be caused by several impinging deficiencies, by injury, disease, or other unrelated factors, the physical examination is considered to be worth while in assessing nutritional status. In any case, in these three regions the examinations were made and recorded. The tissues studied are all external. Usually noted are condition of skin, par- ticularly of the face; the eyes, especially the conjunctiva; the lips and mouth, tongue, gums; enlargement of thyroid; and sometimes the state of bones and teeth. The main signs noted were dryness or scaliness of the skin, overgrowth or roughening of the follicles, folliculosis. waxy deposits around the nose and lips, acne, crusted eyelids, thickening and in- flammation of the conjunctiva (mem- brane covering eyeball and inner eyelids ) , swelling of the thyroid, inflammation and creases at the angles of the mouth, inflam- mation or reddening of the gums, and Assuring, roughening, or reddening of the tongue. In most cases if any sign was found, the degree of severity was also noted. These photos from the Northeastern Region show typical examinations of (top) mouth tis- sues, (center) skin and arms, and (bottom) eyes of children used in the tests. [65] Drying Follicle changes Waxy skin plugs TONGUE Changes in tongue West Virginia Crusted Eyeball Eyeball Eyelid eyelids membranes memb memb inflamed thickened thickened Fig. 68. Incidence of physical signs sometimes associated with nutritional deficiency in children under 13 years of age in Louisiana, Virginia, West Virginia, New York, and Maine. SKIN 50 r- 40 - £20-^ -1 o -s k I 1 1 1 v/;/;//;/;;;/;;//;//;;;///;/A 1 Drying and hardening 50 13-15 Years ~I3"I6 Years 16 -20 Years 40 % 30 - a 20 10 IU Follicle changes Waxy skin plugs Acne M F NY, Maine, R.I. Ariz , Utah, Col., Idaho, Mont, Wash., N M, Ore Me,N Y.RI.W.Va. EYES H Crusted eyelids MILi Eyeball Eyelid Fig. 69. Incidence of physical signs sometimes associated with nutritional deficiency in adoles- cents 13 to 20 years of age in four Northeastern and eight Western states. Of the Southern children 8 to 1 1 years old (fig. 68), 12 to 21 per cent had scaly or roughened skin and naso-labial seb- orrhea ( waxy deposit on skin of nose and lips), 30 per cent had roughening or creasing of the skin at the mouth corners and red or cracked lips (cheilosis), and 12 per cent inflammation, atrophy, re- cession, or swelling of the gums (gingi- vitis). More than 30 per cent also showed some changes in the tongue, and 11 and 15 per cent had inflamed or thickened conjunctiva. Very few New York and Maine children under 13 years of age showed any of these signs, but in West Virginia miners' families 28 per cent had cheilosis, 25 per cent had gingivitis, and 8 per cent had inflamed conjunctiva. Possibly because of difference in age the Southern children showed very little thy- roid enlargement, compared with 10 to 12 per cent among the Northeastern groups. Rather large numbers of boys and girls 13 to 15 and 16 to 20 years old were examined in the Northeast and in the West (figs. 69 and 70). In both regions more boys than girls had acne, 35 to 40 per cent as against 30 and 32 per cent, and more girls than boys showed skin Years M 13- 13- 16" - 15 H Hny, Me., R.I - 16 ||_ Ariz., Col, Ul -20 Hi Me, N Y,RI, , Utah , Idaho, Mont , Wash , N M , Ore. WVa hOtT) Jl Enlarged n t Eh l l K t Lips dry and Gums inflamed Changes in reddened, sore shrivelled or papillae mouth corners retracted LjU Fig. 70. Incidence of physical signs sometimes associated with nutritional deficiency in adoles- cents 13 to 20 years of age in four Northeastern states and eight Western states. 1661 scaling, dryness, and follicle changes. The Western children had significantly less tongue, gum, and mouth changes than those in the Northeast. The same was true of inflammation and thickening of the conjunctiva. The older group, 16 to 20 years, in the Northeast, generally showed a decrease in incidence of these signs, some of which are possibly due to hor- monal pubertal changes. The male industrial workers in New Jersey and the men and women over 50 years of age in California and Colorado were also examined for these signs of possible deficiences (fig. 71). The older men and women in California had more drying and hardening of the skin than either the Colorado older people or the young and middleaged New Jersey men. Gingivitis occurred oftener in the men than the women and more in the older than the younger men. Changes in the tongue also were more frequent in the Drying and Waxy skin plugs Lips dry and Gums inflamed reddened, sore mouth corners or shrivelled 60 c 40 o S. 20 100 80 E 60 o I 40 20 Age(Yrs) MF 20+ m New Jersey 50+ m California 49+ || Colorado _ 20+ |L W. Virginia THYROID n n TONGUE _ Enlarged Changes in papillae Eyelid mem- Eyelid mem- Eyeball mem- branes branes branes inflamed thickened inflamed Eyeball mem- branes thickened Fig. 71. Incidence of physical signs sometimes associated with nutritional deficiency in adults 20 to past 80 years of age in New Jersey, Cali- fornia, Colorado and West Virginia. older group as were those in the con- junctiva. Ten to 15 per cent of the younger men in New Jersey had skin dryness, cracking skin at the angles of the mouth, tongue and conjuctival changes, but more than 20 per cent showed gum inflammation, atrophy, or retraction. The younger West Virginia subjects, college students over 20 years old, had few of these signs except for gingivitis in the men and thyroid enlarge- ment in the women. Obviously, some at least of the superficial changes which have been ascribed to nutritional deficiencies, notably of vitamins A and C and ribo- flavin, are also characteristic of aging. It is difficult, therefore, to decide whether such changes are eventually inevitable or whether they may result from long- continued but slight dietary deficiencies. Eye and skin signs vs. vitamin A and riboflavin nutriture. The children under 13 years of age in Louisiana and Virginia had a greater incidence of both skin and eye signs than those in West Virginia and New York. The mean vitamin A in the diets was al- most the same in all these groups, as was alto the mean dietary riboflavin. However, in comparison with New York and West Virginia, more than twice as many Louisi- ana and Virginia children received less than two-thirds of the recommended al- lowance of both vitamin A and riboflavin. The average blood vitamin A and caro- tene levels of the Southern children were also lower than those of the New York group (fig. 72). In the adolescent groups, 13 to 15 years of age, the children in New York, Maine, and Rhode Island had twice as many showing skin signs and four times as many with eye signs as in the Western group of the same age. But the mean intakes of both vitamin A and ribo- flavin in the Northeast were equal to or larger than those in the West. Likewise, the percentage of boys and girls with less than two-thirds the recommended [67] amounts of these two vitamins was about the same in the two regions. However, the mean blood vitamin A and carotene levels were both significantly higher in the Western than the Northeastern sub- jects. The older Northeastern subjects 16 to 20 years old had fewer cases of skin and eye signs than the adolescent, 13 to 15 years, Northeastern children, yet their intakes of vitamin A and riboflavin were less on the whole and a greater percentage had excessively low intakes. Again, how- ever, their mean blood vitamin A and carotene levels were definitely higher than those of the adolescents. Clearly the blood levels are a better index of vitamin A and riboflavin nutriture than 7-day diet- ary records, no matter how carefully supervised, or else these eye and skin changes are unrelated to current vitamin Per Cent 50 40 30 20 10 i | 1 Boys ond t-v.:-:-:-:.:-:-:-:-:-:-x- r~ Less than 13 Years 13-15 Boys Girls T Boys Girls ims 16-20 Boys Girls INCIC AND ENCE OF SKIN SIG EYE >JS ( Boys and Girls Less than 13 Years SERUM CAROTENE meg Per Cent 40 80 120 160 , I I I 1, . . 1 Louisiana r^ W :v-— .^ av,rg,n,a New York Fig. 72. Incidence in New York and two Southern states of eye and skin changes some- times associated with vitamin A and riboflavin deficiencies, in children under 13 years of age, and in Northeastern and Western adolescents compared with their serum vitamin A and caro- tene levels. intake, although perhaps influenced by long-time dietary habits (fig. 72). The older men and women in Cali- fornia exhibited a higher percentage of eye and skin signs than did the Colorado old people or the middle-aged men in New Jersey. But their mean intakes of vitamin A and riboflavin were highest, and the percentage having less than two- thirds the recommended allowance of vitamin A and riboflavin was lower ex- cept for vitamin A in the New Jersey group. Their blood vitamin A, but not carotene values were higher than those of the New Jersey men. Obviously in older people long-time food habits may show more correlation of eye and skin symptoms with nutrient intakes, especi- ally of vitamin A, than current dietary habits, or else other factors than those in food influences the health of these tissues increasingly with advancing age. Mouth signs vs. ascorbic acid and riboflavin nutriture. The mouth and tongue signs such as cheilosis (redening and angling of the lips) and gingivitis (gum changes) have long been thought to be associated with ascorbic acid or riboflavin intakes or metabolism. The young children in Vir- ginia and Louisiana showed much greater incidence of these changes than did the New York children of about the same ages. The mean intakes of both ascorbic acid and riboflavin were however about the same. But the percentage of children at the lower end of the intake range was usually twice as great in the South as in New York. Also, the mean ascorbic acid level in the blood of the New York children was nearly twice that of the Southern children (fig. 73). The Northeastern and Western adoles- cents 13 to 16 years old may again be compared. Mouth and tongue signs were recorded two or three times as often in the Northeast as in the West, but the mean ascorbic acid and riboflavin intakes were on the whole greater in the Northeastern [68] group. The percentages of boys and girls having less than two-thirds the recom- mended amounts of the vitamins were greater in the West than in the Northeast. Nevertheless, the serum ascorbic acid lev- els in the West were definitely higher than in the Northeast. Perhaps blood will tell when records do not, or perhaps the mouth signs are irrelevant to ascorbic acid and riboflavin status. Again, the older Northeastern subjects 16 to 20 years old showed fewer mouth signs than the corresponding adolescents. Again, their intakes of the vitamins were less and the percentage of cases at the lower end of the intake range was greater, but their blood levels were somewhat higher than those of the younger group. It is interesting to note also that the girls at all ages had higher blood ascorbic acid INCIDENCE OF MOUTH SIGNS Per Cent 50 40 30 20 10 I 1 1 1 P SERUM ASCORBIC ACID mg Per Cent Boys and Girls Less than 13 Years 13-15 Boys Girls Boys Girls w///y///yA Louisiana ft Virginia Fig. 73. Incidence of changes in mouth, gums, and tongue sometimes associated with ascorbic acid deficiency in New York and Southern chil- dren under 13 years of age and in Northeastern and Western adolescents compared with their serum ascorbic acid levels. Vermont children undergoing physical examinations. [69] levels than the boys and also lower in- cidence of mouth signs of possible insufficiency. About the same story repeated itself for the California, Colorado, and New Jersey subjects. There were more mouth signs of so-called deficiency in the Cali- fornia older men and women than in Colorado, and both of these had more than middle-aged New Jersey men, yet the ascorbic acid and riboflavin intakes of the California subjects were greater than the others and the percentage of Cali- fornia people with intakes lower than two-thirds the recommended allowance was lower than in New Jersey or Colo- rado. However, the serum ascorbic acid level was higher in the California than the New Jersey men and still higher in the California women. If the gum re- cession and retraction cases noted by the California and Colorado examiners but not by the Northeastern examiners are excluded from the count, the incidence of mouth signs is considerably greater in the New Jersey men than in the older California and Colorado men and women. The blood ascorbic acid levels are in the opposite order, California women and men having the higher levels, the New Jersey men the lowest. It seems on the whole that these physi- cal changs in skin, eyelids, conjunctiva, lips, gums, and tongue have limited sig- nificance as indications of the nutritional deficiencies which have been found to produce such changes under experimental conditions. Long-continued and severe de- ficiencies do produce these signs, but many other factors may also be con- cerned. For instance, of the 23 signs searched for in all the Northeastern sub- jects, the greatest incidence, 23 per cent, was found among the pregnant women in Massachusetts, the next, 18 per cent, among the Maine school children and col- lege students. The Rhode Island school children had 11 per cent and all others much less. The pregnant condition in the first group, climate and diet in the second and third may be in part accountable for these differences. The greatest average in- cidence, 11 per cent, occurred in the 13- to 15 -year-old children, the least in the children under 13. Incidence among girls on the whole was 10 per cent, among the men and boys 8 per cent. This is weighted by the group of pregnant women studied in Massachusetts. The review of these population groups in the light of their dietary records, their blood composition, and the appearance of physical signs appears to support the view that the physical signs are only faintly related to the current nutrient intakes but fairly plausibly connected with the blood levels of certain vitamins, notably ascorbic acid, vitamin A, and carotene. 70} PART II SOME SPECIAL STUDIES The data presented in Part I were collected in all four regions on segments of the population by methods which were comparable enough to permit their com- mon interpretation. In addition to gath- ering these data, however, many of the experiment stations undertook special studies of urgent or fundamental prob- lems concerned with nutritional status. Some of these started with obvious public health problems connected with nutrition, and some with questions of theory, cause and effect, and mechanism of action of the nutrients. Five examples of each class are briefly described in the pages which follow. In Class I are 1 ) the effect of nutritive quality of school lunches and of break- fasts and snacks on the nutritional status of children; 2 ) the amount and effect of under- and overweight in adults; 3) the relation of diet to nutritional status in pregnancy; 4) the extent, causes, and prevention of dental caries in school chil- dren and adolescents; 5) the density of bone of children and adults in relation to diet, age and sex. In Class II are 6) some studies of the need of men and women for certain essen- tial amino acids and the utilization of food sources of these amino acids; 7) studies of vitamin C utilization in men, women, and children, with reference to effects of diet, age, and sex; 8) the effect of age and sex on the level of cholesterol in the blood and its relationship to diet, altitude, and other conditions; 9) con- ditions which affect the value of carotene of vegetables and fruits as a source of vitamin A in the body; 10) levels of blood riboflavin and their relationship to diet. THE ROLE OF LUNCH, BREAKFAST, AND BETWEEN-MEAL SNACKS IN THE NUTRITION OF SCHOOL CHILDREN The provision of a partly Government- subsidized lunch in many public schools has long been considered a major step toward the improvement of the nutri- tional status of the children. Definite ob- jective proof of such improvement has not been readily obtainable, partly because of the variation in the home diets of the children and partly because of variation in the nutritive value of the school lunches provided. Iowa -Kansas -Ohio. In both the Northeastern and the North Central regions an attack was made on this problem. The most elaborate and long-continued study was that carried out in Iowa, Kansas, and Ohio between 1947 and 1957. Many of the findings of this triple endeavor have been quoted in the preceding pages on nutrient intakes, blood composition, and body measure- ments. Among other things, it was shown quite clearly that neither advantage nor disadvantage in the blood components measured resulted from the participation of 9- to 11 -year-old children in the lunch programs of their schools (fig. 48). The average intake of calcium in some of the age groups was below the recom- mended allowance. Eighteen to 40 per cent of both boys and girls had less than two-thirds the recommended allowance of ascorbic acid, 12 to 33 per cent had sim- [71] ilarly low intakes of calcium, and 10 to 25 per cent had low intakes of vitamin A. Only a small number of the children had diets which met the recommended allowance for all nutrients. The dietary intakes of these children on the whole cannot be classed as adequate. Since the levels of ascorbic acid, caro- tene and hemoglobin in the blood of some of the children were low and the prev- alence of dental caries was high, the nutritional status, also on the whole, can- not be called satisfactory. The Papago Indian study. In the Arizona study of 115 Indian children attending a public and a private school, clear differences in status, par- ticularly as to vitamins A and C, were seen between the children who were given an ample, well-chosen lunch at the public school and those who had a much smaller, less adequate lunch at the pri- vate school. Since the home diets were 1.0- "0.8- o 0.6|- < .y 0.4 -Q O o CO 0.2 100- 1 80 60 40 20 30 u E < .£ 2C E o ^ 10 U Good lunch F] Poor lunch CO c (75 •^lOOr- ^8C 60 5 40 o u O 20 1.8 n n >N 1.5 c \? <1) Q (1) 0.9 r o CD 0.6 03 c c u. ■a 111 Fig. 74. Blood vitamin A, carotene, vitamin C, and the occurrence of physical signs of poor vitamin status in Indian boys and girls attending a private school with poor lunch, and public school with good lunch; and the bone densities of two groups of girls. marginal in value, the differences brought about by the lunches were readily ob- served. There were no perceptible dif- ferences between the two groups in height, weight, hemoglobin, red blood cell or white blood cell count, or blood serum riboflavin, protein, glucose, or cho- lesterol. The blood serum vitamin C, vitamin A, and carotene values were lower among those having the poorer lunch, and the bone density of these girls was less than that of the girls with the ample lunch (fig. 74). The Northeast. In Bangor, Maine, 450 junior high school children were examined for physi- cal signs possibly associated with nutri- tional deficits. Underweight, acne, red- dened peeling lips (cheilosis), and gingi- vitis (inflamed gums) were more com- mon among the boys than the girls, and overweight and rough dry skin (follicu- losis) were more often found among the girls. Conjunctivitis, inflammation of the eyelids (blepharitis), and changes in the papillae of the tongue occurred about equally in the two sexes. More than a third of the children showed one or more of these defects. Blood tests for vitamin C, vitamin A, carotene, and hemoglobin confirmed these findings. More than half of the girls and two-thirds of the boys were ranked only fair or poor in blood vitamin C, 80 per cent of both sexes was fair or poor in blood carotene, 39 per cent of the boys and 44 per cent of the girls were fair or poor in blood serum vitamin A. About a third were ranked fair but only four children were poor in hemoglobin levels. All others ranked excellent or good. A 4-day record of the diet of the chil- dren revealed that more than half the boys and nearly 40 per cent of the girls had poor intakes of the vitamin-rich vege- tables and fruits, 17 per cent of both were fair or poor in protein food intakes, but only 4 to 5 per cent of these were poor. Twenty-one to 28 per cent were [72] poor in milk intake. Much sweet food, low in vitamins and proteins, made up the calorie quota. The blood values and physical signs reflected faithfully these dietary defects. The type of lunch eaten by the children was then observed. These were 1) the school lunch as served; 2) the school lunch altered by omissions or additions; 3) a box lunch from home; 4) lunch at a neighborhood store; 5) lunch at home. There were 17 to 32 children in each of these lunch groups. The nutritive values of the various lunches were judged ac- cording to their provision of at least one- third of the recommended daily allow- ances of nine nutrients. The school lunches as served were found to be generally deficient except for milk content and low in calories, iron, niacin, and ascorbic acid for the girls, and in thiamine also for the boys. For example, the boys often took extra serv- ings when they were available. They also often added high-calorie foods, such as candy, potato chips, ice cream, and cookies. The girls sometimes omitted all or part of the milk. The box lunch brought from home was still more deficient. On the average, it contained less than a third of the recom- mended amounts of all nutrients except protein, calcium, thiamine, and riboflavin for the boys, and thiamine, riboflavin, and niacin for the girls. Iron, vitamin A, and ascorbic acid were most notably missing. For neither group did the home diets provide in the other two meals enough nutrients to make up these deficits. The lunches bought in a neighborhood store were deficient in all nutrients and usually contained only 10 to 20 per cent of the recommended amounts of all the nutrients. The home diets of this group of children were the poorest of all groups studied. The greatest percentage of children who received in their three meals at least 80 per cent of the recommended allow- ance of nutrients occurred in the group who ate the hot school lunch; those who ate at home or brought a box lunch were intermediate, and those who bought a store lunch fared the worst. More than half the girls had diets deficient in vita- min C, and this was true of the boys also except for the box-lunch group and the group who ate a modified hot lunch. There followed a recommended revi- sion of the hot school lunch so that with appropriate additions and exchanges the lunch furnished a third of the day's allow- ance of nutrients. The chief additions were of raw and canned spinach, toma- toes, and citrus fruit. Larger portions were served to supply the missing cal- ories, and extra bread, butter, peanut butter, and jam were given the boys especially. These revised lunches met the Type A requirements of the federal school lunch program and provided between 40 and 60 per cent of the daily allowances for vitamin C, niacin, thiamine, and iron and over 100 per cent of the daily allow- ance for vitamin A. These nutrients had been found to be those most likely to be low in the home meals of the children. A supplementary study of the breakfast habits of 57 Maine teen-agers was carried on in three communities. The breakfasts, especially those of the girls, were apt to be low in calories, protein, iron, vitamin A, and niacin. Milk, bread, cereals, and citrus fruit or juices made up most of these breakfasts. About 40 per cent of the children had less than 15 per cent of the recommended daily allowance of vitamin C in their breakfasts, and the daily intakes as a whole were deficient in vitamin C, calcium, iron, and calories. The inadequate breakfasts tended to re- sult in deficiencies in nutrient intake for the whole day. The school lunches and breakfasts of the Maine junior high school students on the whole were low in calories, iron, niacin, and vitamin C. Meat, eggs, citrus fruit, tomatoes, and whole grain or enriched bread and cereals supply these nutrients. [73] Maine junior high school students in line for the school lunch. Here Rhode Island high school girls select a school lunch. [74] Breakfast and between-meal foods of 316 adolescent boys and girls in Maine, New York, and Rhode Island were exam- ined for nutrient value. Seven-day dietary records were studied. Breakfasts contrib- uted only one-fifth of the recommended daily allowances of nutrients in all three groups. Fifty per cent or more of the chil- dren consumed one-fourth or less of their daily intakes of calories and protein at breakfast. The boys as a rule ate more satisfactory breakfasts than the girls, and the children who always ate breakfast more nearly met the recommended allow- ances than those who missed breakfast once a week or more. Between-meal snacks contributed 10 per cent or less of the daily nutrient intakes of the junior high school Maine and New York children but such snacks were more important to the Rhode Island high school children since they contained substantial contributions to the intakes of calories, protein, calcium, and phosphorus. Costs and adequacy of lunches in an Iowa school. A pilot study of the nutrient values, waste, and costs of the lunches served in an Iowa rural school revealed some discrepancies in service to the 200 chil- dren in the various grades. The lunches eaten by children in grades 1 to 3, 4 to 6, and 7 to 12, inclusive, were studied separately. About half the lunches served to the children in grades 1 to 3 met the criterion of adequacy, that is, contained one-third of the recommended daily al- lowances of nutrients for that age range, one-tenth met this criterion for grades 4 to 6, and none for grades 7 to 12. This was because the youngest children were served first and were allowed to de- termine the size and number of portions served. By the time the older children were served, shortages usually appeared in the more popular items. A boy in the lowa-Kansas-Ohio school lunch study is given a hand grip test. The greatest deficit in the lunches as served was in vitamin A, the least in vitamin C. A survey of 25 schools. In another survey, 25 public schools were chosen for study in Iowa as repre- senting statistically the 622 schools of that state. Significant differences in labor time, in kitchen and serving area, and in A doctor examines the eyes and eyelids (con- junctiva) of an Arizona Indian girl. {75} costs were found among the three groups of schools, elementary, high, and 12 -grade schools. The daily average number of paid-for lunches served during the year was 19.7. Six per cent of type A lunches were served free to pupils, and the aver- age price charged to the other pupils was 22.6 cents. About 34 per cent of all pupils participated in the school lunch. The range was from 10 per cent in a large city school to 96 per cent in two small 12 -grade schools. Plate waste averaged 0.9 ounce, with more return of salads, vegetables, and main dishes, 8 to 12 per cent, than of milk or desserts, usually 2 to 4 per cent. The fruit juices were completely con- sumed. On the one day of observation, in none of the schools did the standard portions of food supply the one-third of the recommended daily allowances of nine nutrients which Type A lunches should supply. Food energy (calories) and iron were the nutrients most often inadequate. Per hour of labor time, preparing, serving, and cleaning, 7.9 revenue lunches were served and 7.2 lunches per minute were served per serving line at peak load. Kitchen space per daily number of revenue lunches averaged 2.3 square feet (range, 0.6-8.5). This met the recom- mended 1.5 square feet in 19 schools. The recommended 9 square feet of dining room space per seat was met in only nine schools. More than half the schools had good refrigerators and ranges, fewer than half had good dish-washing facilities. These differences in equipment were reflected in labor time and menus. The total income in all schools aver- aged 27 cents per lunch (range, 16 to 47 cents). The chief source of income was the sale of lunches at average price of 21 cents (range, 9 to 36 cents). Federal reimbursement averaged 4 cents, sale of milk and other extra food items 2 cents, and all other sources 1 cent. But the total average cost of the lunches was 26 cents, divided as follows: food, 15 cents, labor 8 cents, other costs 3 cents. Thus income and costs were fairly balanced. Distribution of food eaten among meals by Iowa children. The Iowa group also studied the dis- tribution of nutrients between meals and snacks of school children. Breakfasts con- tributed only 15 to 20 per cent of the total calories for the day, lunches 32 to 34 per cent, dinners 33 to 35 per cent, and snacks 13 to 17 per cent. The older girls tended to have fewer calories at breakfast and obtained more through snacks. The breakfasts were generally low in vitamin A and niacin, the dinners in calcium and ascorbic acid. Most of the breakfasts provided 10 per cent or more of the day's protein. These calorie-low, protein-low breakfasts of so many chil- dren were considered a definite nutritional problem requiring further study. For cer- tain age groups the between-meal snacks which provided as many calories as the breakfasts were also high in carbohydrate and low in all other nutrients except as- corbic acid. The diets of the 1188 children, from 6 to 18 years of age, were classified as to their nutrient values in terms of the recommended allowances. In Class I all nutrients were provided in amounts of 100 per cent or more of the recommended allowances; in Class II, some were less than 100 per cent but none was present in less than 67 per cent; and in Class III, at least one nutrient was present in less than 67 per cent of the recommended allowance. The differences among the diets of classes I and III could not be ascribed to any one of these meals, but rather to low-calorie meals, generally poor in nutrients. Another analysis of the foods eaten by these 1188 Iowa children showed that one-half to two-thirds of the breakfasts were predominantly poor by the criteria used. Too little milk, fruit, meat, and eggs were used. Since bread and break- [76] fast cereals and their accompaniments often made up the breakfasts, the nutrient intakes depended on the choice of these cereal foods. The use of milk by the rural children was notably poor, as was also that of milk and eggs by nearly all the older girls. The boys ate more as they grew older, but the quality of the diets was not improved. In general, poor break- fasts were associated with poor total diets. The school lunch program in Ohio. A survey of school lunch service made in Ohio in 1948 covered 288 of the 1400 school lunch programs of that state. Of these, 216 were federally supported, that is, they received financial aid from the U. S. Department of Agriculture through the Ohio State Department of Education. It was found that 45 to 50 per cent of the children ate a hot lunch when it was offered at school. Most of the schools offered a planned plate lunch, including milk, at a cost of 23 cents in the federally aided schools and 27 cents in the non- federal programs. Over one-third of the schools served only whole milk but 62 per cent served both whole and chocolate milk. The lunch habits of 3813 high school students were noted. About 3 per cent ate no lunch, 32 per cent ate the school lunch at an average cost of 26 cents, 12 per cent a restaurant lunch costing 45 cents, 4 per cent a drug store lunch costing 39 cents, 35 per cent went home, and 15 per cent brought a box lunch from home. The children who ate no lunch spent 16 cents for between-meal snacks. More than 40 per cent of all the children bought snacks, but 75 per cent of those who ate in restaurant or drug store spent money for snacks. A later study in 1954-55 concerned the amount of plate waste in the school lunches. Plate waste of about 200 children in grades 1 to 8, served a Type A lunch, was weighed for a total of 28 days in three periods in October, November and April-May. The mean percentage of waste for these three periods was 7.0, 6.4 and 5.8 per cent. Waste of milk was much less than of other foods, varying from none in the 4th grade children to 4.6 per cent during one period in the 8th grade. Total plate waste was always high- est in grade 1, least in grades 4, 6, and 7. The amount of waste tended to decrease from the first to the last part of the school year. Meat loaf, baked ham, and barbecued beef sandwiches were returned more often than ground bologna, chicken, or wiener sandwiches. The next year a new study was made to discover the relative amounts of waste in different kinds of vegetables, fruits, des- serts, and protein-rich foods. The highest percentage of plate waste, no matter how calculated, occurred in vegetables and the lowest in desserts. Peas, sweet potatoes, and gelatin- vegetable salads were rejected most often, with about 20 per cent left to the plate. Waste of frozen vegetables was about 16 per cent, of canned vege- tables 11 per cent, of raw vegetables 14 per cent. Wieners, hamburger patties, and ground bologna were quite completely consumed, but 7.4 per cent of other high- protein foods, such as fish, eggs, and pork, and 15.8 per cent of mixed chicken and rice, chicken pie or loaf, and tuna salad were rejected. About 9 per cent of the fruit and 10 per cent of fruit desserts were returned. Children in grades 1 and 2 returned more food than any of the other groups. They accounted for 61 per cent of the total dessert waste and about 40 per cent of all the other waste. First, 2nd, and 6th graders were responsible for more than half the total plate waste. Methods of decreasing waste through choice of food, method of preparation, and size of serving were developed. [77] OVERWEIGHT AND UNDERWEIGHT IN ADULTS Obesity often has been said to be the outstanding nutritional disease in the United States. Numerous surveys, chiefly by insurance statisticians, have revealed that 25 to 30 per cent of the adult popu- lation is 10 per cent or more overweight and that mortality from heart disease is 40 per cent higher among moderately overweight and 65 per cent higher among markedly overweight persons than among those in the standard weight range. Over- weight has also been associated with the development of high blood pressure, and the combination of overweight and high blood pressure may be accompanied by the early appearance of various types of £3 More than 10% underweight |r| 10 to 20 % Overweight □ + 10 % Normal. Rv3 More than 20 % Overweight. u-^J Minnesota CD Q -20 r n r P FH Fig. 75. Percentage of over- and underweight in North Central women. o 16 2 60-62.5 inches Height: 63-65.5 inches 66-68.5 inches 30 40 50 60 lo 1o to to 70+ 39 49 59 69 30 40 50 60 lo to to to 70+ 39 49 59 69 Years of Age 30 40 50 60 to to to to 70+ 39 49 59 69 Fig. 76. Amount of overweight of Iowa women 30 to past 80 years of age, of three height ranges. heart disease. Interestingly enough, this association of obesity with arteriosclerotic and other heart disease is far less obvious in women than in men. The incidence and degree of obesity among women over 30 years old in the North Central region was observed in connection with the dietary studies on these women. Fifteen to 20 per cent were moderately overweight, that is, 10 to 20 per cent over the desirable weight for height, and 20 to 30 per cent in addition were excessively overweight, that is, more than 20 per cent over the so-called stand- ard weight. The exception was in Minne- sota, where only 14 per cent were excessively overweight (fig. 75). Standard weight is here defined as the normal or desirable weight for height at age 25 (fig. 76). Overweight was most prevalent in the 50- to 59-year-old women and least prevalent in those past 70. Ailments and overweight. The gen- eral health of the overweight women ap- peared to be less good than that of those who were normal or underweight for height. This was shown by the number of complaints or ailments reported by the women themselves. Such troubles as short- ness of breath, pain and swelling in joints, high blood pressure, constipation, ulcers, indigestion, fatigability and headaches were reported, as well as serious symp- toms such as gall bladder attacks, "stroke," "heart trouble." If a woman reported that she had sought medical attention for an ailment, double value was assigned to that ailment in the tabulation. Among women of desirable weight, the number of ailments increased from 2.0 per person in the 30-to 39-year age group to 3.6 in those past 70. The women who were more than 20 per cent above desirable weight reported more symptoms at earlier ages than did those of normal weight. Even though these are subjective ratings, their suggestions of a relationship be- [78] tween overweight and gradations in vi- tality and well-being are of interest, (fig. 77). Of a group of 54 white and 36 negro women between 40 and 90 years of age studied in 1948 and again in 1955 in Michigan, about 40 per cent of the white and 60 per cent of the negro women were classified as overweight. Low intake of calories and poor-quality diets were com- mon among the overweight subjects. Ail- ments such as unexplained tiredness, pains in the joints and shortness of breath were reported by more than 40 per cent, and these ailments were more numerous among the women with low intakes of nutrients, particularly vitamin A and as- corbic acid. Mortality rates for the six years between the examinations of these women were higher for the negro women than for the white women, and in both groups they were higher for those who reported intakes of less than 40 per cent of recommended quantities of one or more nutrients than among those with larger intakes of nutrients. Overweight and food intake. A per- sistent and unexpected inverse relation- ship between obesity and calorie intake was noted by the North Central workers. In figure 78, the average calorie intake of the women of four weight groups studied in five states is presented. In each state sample, the women who were more than 20 per cent overweight reported the day's Age Years Ailments per Person Normal Weight Over Weight 30-39 40-49 50-59 60-69 70 Plus All Ages 2.0 2. 1 2.2 3.2 3.6 2.5 1.9 3.2 3.3 3.4 3.3 3. 1 Fig. 77. The number of ailments reported by normal and overweight Iowa women of various ages. [79] CD _0 1400 D o 1200 Q More than 10 % underweight El 10 to 20 % Overweight I I ± |0 % Normal. f|| More thon 20 % Overweight T I I Mich Illinois (White) 1 1 Fig. 78. Average daily calorie intake by North Central women who were of normal weight, or under- or overweight. dietaries with the lowest mean energy value, the underweight and normal weight women generally the highest mean energy values. This was only partly explained by the attempt at reducing which some of the women reported. In one group of women, those who were trying to lose weight consumed foods yielding 1200 calories per day, those who were not at- tempting to reduce, 1700 calories. More- over, the nutritional inadequacy of these reducing diets was striking. The accuracy of comparable reports of food intake was checked at the Iowa sta- tion by comparison of the one-day recall calculated records of another group of women with those of weighed food in- takes for seven days and with actual calorie determination by heat of combus- tion measurements of two days' intake. These three types of daily calorie-intake records yielded respectively the mean figures, 1735, 1715, and 1711. The uni- formity of the reports of calories con- sumed throughout the region also lends credence to the comparisons. The average calorie intake of 339 South Dakota wom- en was 1705, of 1072 Iowa women 1735, of 457 Illinois women 1780, of 97 white Michigan women 1664, 104 negro Michi- Overweights n Every Ten Girls Young Women Middle Aged Women Old Women Fig. 79. The increasing amount of overweight with age among Iowa girls and women. [80] gan women 1071 and of 120 Minnesota women 1780. The explanation for the low energy intakes of the overweight women offered by the researchers is that the physical activity of homemakers in town and coun- try must have greatly decreased in the 50 years since the early estimates of women's calorie needs were made, when 2100 to 2300 calories was deemed necessary. The steady increase in overweight up to age 60 (fig. 79) shown by these women may be due to the accumulated excess of cal- orie intake over energy output due to custom and extension of early appetite. The decreases in average weight after age 70 may well result from the longer life span of the less overweight population, or it may represent a true physiological change in body weight in response to changes in endocrine function. In any case, food intake of these overweight women was surprisingly low and in many cases poorly chosen. The poor nutritional quality of these low-calorie diets may have produced actual loss of protoplasmic tissue without decreasing the fat deposits. Experiments with animals have indicated this possibility. The California and Colorado women and men over 50 years of age had less overweight members than these North Central women; 28 per cent of the wom- en and 24 per cent of the men were 10 per cent or more overweight. Only 12 and 8 per cent respectively were excess- ively overweight, that is, 20 per cent or more overweight for height. Of the still older group of Wyoming women, all over 60 years of age, 56 per cent were over- weight. This is somewhat greater than the amount of overweight, 39 to 47 per cent, found in the North Central women. Of the 600 New Jersey men, 20 to 50 years old, 19 per cent were more than 10 per cent overweight and 20 per cent were more than 20 per cent overweight. The difference from the California and Colorado figures may be ascribed to the younger average age of the New Jersey men. The California and Colorado men and women also had significantly more underweight members than the North Central women or the New Jersey men. Summary. It is obvious that over- weight is of frequent occurrence among adults, especially women, but that the amount varies widely. One quarter to one half of all the women examined in widely separated parts of the country were 10 per cent or more overweight, and more than half of these in turn were more than 20 per cent overweight. The sam- pling of men was smaller but the over- weight found was about the same, 24 per cent in California and Colorado and 39 per cent in New Jersey, with about half of these excessively overweight. The daily calorie intake of the women was found to be about 1700 on the aver- age, considerably less than the 1800 to 2200 calories of the recommended allow- ances. The conclusion of the North Cen- tral group of researchers was that the energy requirements of modern women must be less than those estimated by the early workers in this field. NUTRITION IN PREGNANCY As part of the Northeastern nutritional status research the Massachusetts station chose to study the nutrition of pregnant women. They examined the diets, blood, and urine composition of 79 women dur- ing early and late pregnancy and in the fourth month post-partum, that is, after the infant was born. About 70 per cent of the women took a mineral-vitamin supplement containing calcium, phos- [81] phorus, iron, thiamine, riboflavin, and vitamin D. The hemoglobin levels of about half the group were in the lower normal range, and the mean levels during preg- nancy were lower than after delivery. The women who took no iron supplement had protein intakes of only 54 gm daily and had lower hemoglobin than the others. In late pregnancy correlations between diet- ary iron and protein and hemoglobin levels were established. Blood vitamin A and carotene levels were also in the lower range for 25 to 33 per cent, but there was an increase in the carotene levels in the ninth month of pregnancy. Ascorbic acid intake, serum level, and urinary output were significantly corre- lated. About one-third of the women had blood levels below the normal range. This is about the proportion of such levels found in other segments of the North- eastern populations sampled. The urinary excretion of ascorbic acid was decreased post-partum, probably due to decrease in intake. The excretion of thiamine in the urine was related to the intake. Between 10 and 20 per cent of the women excreted thia- mine in amounts which indicated an in- adequate intake. Riboflavin excretion was also related to intake, but none of the women excreted amounts indicating an inadequate supply of the vitamin. No relationship was found between birth weights and lengths of the infants and adequacy of the mothers' nutrient in- takes, including protein intake. These results and the dietary studies point to protein, calcium, iron, ascorbic acid, and vitamin A as the nutrients present at critical levels in the diets. Calcium intake was the lowest of all nutrients in comparison with the recom- mended allowance. Sixty-three per cent of the women had less than two-thirds the recommended amount, and even with the mineral-vitamin supplement the aver- age intake was less than three-fourths the recommended amount, which is 1.5 gm daily for the last three months of preg- nancy. Forty per cent of the women had less than two-thirds the recommended allowance of riboflavin and iron, and 30 per cent of protein, thiamine, and ascorbic acid. The supplement made up the deficit, on the average, for iron, riboflavin, and thiamine, but the protein and ascorbic acid deficits remained unalleviated. Amount of money spent for food and total income appeared to have little rela- tionship to the adequacy of the diets. Socio-economic factors, chiefly educa- tional, perhaps, were of more importance. The diets chosen by the women post- partum were closer to adequacy, especially in milk and citrus fruit, than were those used during pregnancy. Apparently the instruction in nutrition accompanying the study had some effect. Special attention was given to the relationship of tryptophan, one of the essential amino acids, with the utilization of niacin, one of the B vitamins, which is interrelated with tryptophan. There had been some evidence that this interrela- tionship was different in pregnancy from that of the normal nonpregnant state. The urinary output of the end products of niacin and tryptophan metabolism was found in these women to be considerably greater in pregnancy, especially late preg- nancy, than in the late post-delivery pe- riod. The output of these end products often exceeded the equivalent of the total intake of niacin, both that in the diet as such and that which was thought to be obtainable from the tryptophan of the dietary protein. To test this further, 500 mg doses of tryptophan were given to 12 pregnant women for 14 days. All end products of niacin and tryptophan were excreted in increased amounts except that of "free" typtophan, which decreased. When this supplement was given post-partum there was a similar but much smaller increase. [82] These observations appear to indicate that the conversion of tryptophan to nia- cin, is more efficient in the pregnant than in the nonpregnant woman. This may represent a protective mechanism. The urinary excretion of tryptophan and of seven other essential amino acids by 13 pregnant women was investigated next at this station. All the amino acids were excreted in greater amounts during pregnancy than post-partum. Threonine and tryptophan excretion was doubled or trebled in early and late pregnancy com- pared with the nonpregnant state, and that of the other amino acids increased from 3 to 118 per cent. The amount of excretion was not generally related to protein intake, weight, or age. These observations are of special interest be- cause they were the first in which amino acid excretion was measured in the same women in the pregnant and nonpregnant states. Obviously the utilization of thre- onine and tryptophan is different and less economical in the pregnant than in the nonpregnant women. The provision of adequate amounts of these amino acids through the use of enough good protein foods, such as eggs, meat and milk, in the diet is indicated. Although complications of pregnancy occurred in all the groups, the percentage of women who had such symptoms as nausea, anemia, edema, and other compli- cations was less in the group whose diets supplied at least two-thirds of the rec- ommended allowances of all nutrients, 32 per cent of the group, than in those who had less than this amount of at least one nutrient, 47 per cent of the group (fig. 80). The Wisconsin study. A study of intake and output of vita- min B6 was made at the Wisconsin station on six nonpragnant and four preg- nant young adult women. The diets were self-chosen and were weighed and ana- lyzed during a 5 -day period in each of the last three months of pregnancy and CD 0- 20 r J ^ Group I Q Group II Preg nanc y JZl Fig. 80. Group I: women whose diets con- tained at least two-thirds the recommended al- lowances of all nutrients (41 women). Group II: women whose diets had less than two-thirds the recommended allowance of at least one nutrient (36 women). after the birth of the infant. The non- pregnant women were similarly studied during a total of 15 five-day periods. The intakes averaged 0.86 mg vitamin B 6 per day for the nonpregnant, 1.39 mg for the pregnant, and 1.06 mg for the post- partum cases. The output of vitamin B 6 and its end product in the excreta in all cases was two to four times the intake and was not essentially different in the pregnant and nonpregnant subjects. The authors interpreted these and other ex- periments to mean that vitamin B 6 is synthesized in the body, and that this synthesis acounts for the difficulty experi- enced in producing a deficiency of this vitamin in adult human subjects. The nonpregnant women showed a marked nitrogen loss in 9 of the 15 periods, something which the authors believe could have been avoided if the vitamin B 6 intakes had been more generous. A later improvement in the method of determining the amount of 4-pyridoxic acid, the chief end product of vitamin B, 5 , proved, however, that other fluorescent compounds in the urine accounted for 40 to 70 per cent of the substances previously assessed as resulting from vitamin B^ metabolism. Actually, the output after known intakes of the vitamin in natural diets was about 40 per cent of the intake. [83] The error involved in using the older methods in this attempt at a balance of intake and urinary output of the chief end product of vitamin B 6 was greater the lower the vitamin B6 in the diet. Much more work is needed on the in- takes, outputs, utilization, and functions of this vitamin, B 6 , or as it is sometimes called, pyridoxine. The diets reported as satisfactory in these cooperative studies were not analyzed for probable B6 con- tent, nor has any daily allowance been recommended for it. Until the dietary studies include values for vitamin B 6 , and probably also pantothenic acid, our confidence in them canot be complete. DENTAL CARIES Five of the Western stations made a well-planned cooperative attack on the prevalence and causes of dental caries in high school children. Only native-born- and-reared boys and girls were studied, and biochemical, physical and dietary studies accompanied the dental examina- tions. The dental caries experience of freshmen entering the five state colleges or universities was first determined as a basis for choice of areas for the survey. Boys and girls 14, 15, and 16 years old, born and reared in eleven areas, were chosen. These areas were Coeur d'Alene, Boise, and Nampa in Idaho; Bozeman and Great Falls in Montana; in Oregon, two coast counties, two in the Willamette Valley and two in central Oregon; Ogden in Utah; and a coast and a central county in Washington. Altogether, 2068 children were studied. A travelling laboratory trailer was used in the Oregon study with a team of nutri- tionists, biochemists, a doctor, dentist and X-ray technician. The methods of exami- nation used throughout the region were largely established and confirmed by this group. Bite-wing radiographs of the teeth, one on each side, were taken to supple- ment the usual dental examination. These X-rays greatly increased the accuracy of the examinations and revealed 29 per cent more cavities than the usual methods. The results were expressed as DMF, number of decayed, missing, or filled teeth per person. The regional field study continued for five years. Effects of geographical and climatic factors. The effects of the widely varying geo- graphic and climatic conditions were as- sessed. Altitudes varied from sea level in Oregon and Washington to over 4000 ft. in Utah, Central Oregon, and Montana; mean annual relative humidity varied from 45 to 80 per cent; mean pre- cipitation from 7.2 inches in Yakima County, Washington, to 70 inches in the Oregon coast counties. In the eight areas with low fluoride in the water the num- ber of DMF teeth appeared to be in- creased with higher latitude, decreased with higher elevations, and in some cases decreased with greater amounts of sun- shine. In this discussion low fluoride includes those areas with fluoride con- centrations of 0.0 to 0.3 ppm. Little relationship could be found between number of DMF teeth and amount of precipitation, relative humidity, and tem- perature range. Complications due to increased radiation at the seacoast and in high altitudes, and the varying amounts of clothing worn by the children in the areas of different sunshine, temperature, and precipitation made the interpretation of the climatic and geographical factors difficult. Effect of diet. The effect of diet upon caries was con- sidered in these five states. More than 60 per cent of the 739 Oregon children had diets which met the recommended [84} allowances for all nutrients except as- corbic acid and iron. In the other four states a much higher percentage of boys than girls had diets that were relatively satisfactory in comparison with the rec- ommended allowances, but over a third of all boys and girls had low ascorbic acid intakes. Only a tenth or less of the boys had low intakes of any other nu- trient, but half the girls had low intakes of iron and one-fifth to one-third also had low intakes of all the other nutrients studied except protein and niacin. There was not much variation of diet among the areas. The amounts of candy, carbonated beverages, and total carbohydrates were the same in all areas. On the whole no clear effect of diet upon the DMF rate could be seen. Effect of fluorides in the water supply. The fluoride in the water supplies of the 11 areas varied from to 1.5 ppm. Concentrations of 0.1, 0.2, or 0.3 ppm did not reduce the incidence of caries when compared with the effect of fluo- ride-free water, but 0.5 ppm produced a definite decrease, 39 per cent in the Boise, Idaho, and Gervais, Oregon, groups as shown in figure 81. In Great Falls, Mon- tana, where the water contained 1.0 ppm fluoride the caries incidence was further reduced by 55 per cent, and in Nampa, Idaho, with 1.5 ppm in the water, the reduction was 61 per cent. All these chil- dren had lived in the same areas and had consumed the water since birth. In the areas with 1.0 and 1.5 ppm fluoride in the water 13 per cent of the children were caries-free. In the areas with low-fluoride water less than 1 per cent were caries- free. However, the actual percentages of children with decayed, missing, or filled teeth in the areas with 1.0 and 1.5 ppm fluoride were not significantly dif- ferent. Probably optimum protection was afforded by 1.0 ppm. This significant and striking relation- ship between the fluoride of the water and the incidence of dental caries is sim- ilar to findings in other studies in this country and abroad. The benefits to the children of these moderate concentrations In Oregon, a dentist examines a child's teeth and (right) a nutritionist gets a dietary record from a boy in the dental caries study. [85] 0.0-0.3 0.5 1.0 1.5 Fluoride Concentration (ppm) Fig. 81. Mean number (without radiographs) of decayed, missing, and filled teeth for chil- dren classified according to the concentration of fluoride in the municipal water supplies. of fluoride in the water supply are striking, (fig. 81). Effects of hardness of the water supplies. An inverse relationship between hard- ness of the water and dental caries ex- perience has been suggested. This may be due to the calcium carbonate of the hard waters or to the presence of some other component, not fluoride, with a caries- resistant influence. To investigate this possibility the West- ern group studied the total hardness of the waters used in the low-fluoride areas. There appeared to be a moderate de- crease in caries incidence in the children who received water of increasing hard- ness, from extremely soft with 13.9 DFM teeth, to soft with 12.6, moderately soft with 13.5, hard with 12.9, and very hard with 11.5. In the fluoride areas this effect of hardness was not apparent, since the fluo- ride factor overwhelmed any differences which might have been attributable to hardness. Incidence of dental caries in these states. The amount of dental caries in the adolescents living in the 11 areas studied was high when compared to most epi- demiological studies of the same age groups. In the low-fluoride areas the boys at 14, 15 and 16 years of age had DMF values of 10.6, 12.6, and 13.9 and the girls 12.0, 13.8 and 14.3. These values were distributed among decayed, missing, and filled teeth, as shown in figure 82. The girls generally had more filled and miss- ing teeth, indicating more dental care. By age 16 the girls had lost an average of 1.6 and the boys 0.9 teeth. The sex differ- ence in caries experience was probably not due altogether to the earlier age of eruption of the teeth in the girls. In the fluoride areas the 16-year-old boys and girls had lost only 0.3 and 0.4 teeth respectively. Need for dental care was obvious in 95 per cent of the children in the low-fluoride and 77 per cent in the fluoride areas ( fig. 82 ) . The investigators closed their report of this monumental study with the statement that the incidence of caries in the chil- dren who had lived all their lives in the low-fluoride areas exceeded that of chil- dren studied in most other surveys and that further studies are needed to discover causes for the high accumulated caries attack rates of children living in Idaho, Montana, Oregon, Utah, and Washington. Dental caries in other regions. The only other records of dental caries incidence included in these cooperative researches were those made in the Iowa- Kansas-Ohio study of 9- to 11 -year-old school children, in a Rhode Island experi- ment with dietary supplements for 17 children and adolescents, and, inciden- tally, in a few other surveys. Among 219 children in an Iowa school only 4 per cent were found to have teeth and gums in a healthy condition. Ninety per cent had one or more cavities and 43 per cent moderately diseased [86} gums. Of 190 children in a Kansas school, 15 per cent had no cavities, 73 per cent had from 1 to 9 cavities, 12 per cent more than 10 cavities, and 5 per cent had diseased gums. In the Ohio school, 3 of the 53 children examined had no carious surfaces, half had 6 or more, and 14 had 10 or more. The incidence of these defects in the three schools is not directly comparable because different methods of measure- ment were used, DMF in Iowa, open cavities in Kansas, and carious surfaces in Ohio. When allowances are made for these differences, the caries rates in the three schools are seen to be quite similar. Caries was considered the chief physical defect in the children. In the extensive Louisiana nutritional status study on 8- to 11 -year-old children, 56 per cent were found to have one or more carious teeth, 46 per cent had one or more filled teeth, and 36 per cent had one or more missing teeth. However, these figures include both deciduous and permanent teeth and the former may have accounted for most of the missing teeth. In the similar study in Virginia over 50 per cent of both white and negro children had carious teeth, 49 per cent of the white and 12 per cent of the negro chil- dren had filled teeth, and 47 per cent of the whole group had missing teeth. In the Rhode Island study, 17 children of school age were examined as to blood composition, dietary intake, body meas- urements, skin and tongue signs of possi- ble deficiency, and especially condition of the gums and teeth. A team of two den- tists made all the mouth examinations. The examination was repeated at 6-month intervals for two and one-half years. After the first 18 months the children were divided into two groups, to one of which a tablet of 100 mg ascorbic acid was given daily and to the other a placebo, that is, a harmless dummy capsule. After 6 and 12 months the examinations were repeated. Boys 14 Girls 2 Boys * Girls RsS D wm DMF £SSSN^££5S ■HBHUHM :■:-:•:•:■:■:•:•:•:■:* O I 2 3 4 5 6 7 8 9 10 II 12 13 14 15 Mean Number M, D, F, and DMF Teeth Fig. 82. Mean number (without radiographs) of decayed teeth (D), of missing teeth (M), of filled teeth (F), and of decayed, missing, and filled teeth (DMF) for children in areas with 0.0 to 0.3 ppm fluoride in the municipal water sup- plies, classified by age and sex. Redness, swelling, thickening, bleeding, and retraction of the gums occurred in about half the subjects and were not perceptibly affected by the supplements. The average number of decayed, missing, and filled teeth was 2.5 at the beginning and 3-3 after two years and showed no relationship to the ascorbic acid supplementation. The nutrient intake of almost all the subjects was inadequate in some respects, especially in calcium, iron, thiamine, nia- cin, and ascorbic acid. In the group re- ceiving the placebo none had sufficient ascorbic acid. Their blood serum reflected this in that the ascorbic acid level was significantly lower throughout the sup- plementary period than that of the group which received the ascorbic acid tablet. The other blood values were not affected by the supplement nor were there initial differences between the groups. However, before the supplementation began, all these children had been found for 18 months to maintain good or excellent [87] levels of serum ascorbic acid, from 0.98 to 1.58 milligram-per cent. Perhaps this good ascorbic acid status to begin with may account for the lack of effect of the supplement on the condition of gums and teeth. The New Mexico study of high school children in Las Vegas revealed that the rate of dental caries was unusually low. The mean DMF of the Spanish-American group was 1.9, of the Anglos 4.7. The water supply contained only a trace of fluoride. The greater consumption of soft drinks and candy by the Anglos may ac- count for their higher DMF rate. A state- wide follow-up on this study may provide an explanation. The Arizona study of Papago Indian children also revealed some differences in occurrence of gingivitis between the children attending an Indian Service school which provided a good lunch and those attending a private school which provided a smaller, less adequate lunch. Only 16 per cent of the former group had unhealthy gums, 81 per cent of the latter. The mean blood ascorbic acid levels of the two groups were 0.87 and 0.99 mg- per cent for boys and girls respectively at the Indian Service school, and 0.39 and 0.59 mg-per cent at the private school. The following generalizations might be ventured as a summary of these re- searches: 1) The fluoride content of the water supply from 0.5 to 1.5 ppm has a striking protective action against caries for children who receive such water all their lives. 2) Freedom from caries is not achieved except by a small percentage of children, average 13 per cent, even with the optimum fluoride content in the water. 3 ) Direct effect of any nutrients is not apparent. 4) Hardness of the water or some element, not fluorine, exerts a small but perceptible reduction in the incidence of caries. 5 ) Caries is the most prevalent physical defect in American school children, increasing regularly from the youngest age through adolescence. 6) Ascorbic acid intake affects crucially the condition of the gums of children who are on the borderline of adequacy but cannot produce measurable improve- ment in groups already in good vitamin C status. BONE DENSITY A reliable method of assaying the cal- cium status of the individual has long been sought. Since most of the calcium of the body is present in the bones, some measure of bone density might serve this purpose. A method of tracing the depth of X-ray shadows was developed at the Pennsylvania station in the hope of assessing the amount of calcification of the bones of living subjects. Bone density was evaluated by this microphotometric scanning procedure on the assumption that the density of the shadow is related in a known manner to density of mineral deposit in the bone and that through the use of a tiny ladder of ivory or alloy, photographed on the same film with the bone, corrections can be applied for any errors in exposure and development technique. Some difficulties arose in that the soft tissue surrounding the bone also has den- sity and this appears to be highly variable. When two X-rays of the heel or hand were taken at different angles, the den- sity of the soft tissue could be calculated separately from that of the bone. When only one film was used, as sometimes oc- cured, only the combined density was measured. However, a correction factor [88] ^END 1 ^CENTER I^END Standard film location for phalanx 5-2 bone density determinations. was developed for tentative calculation of bone density only for these cases. Another correction factor was also de- veloped so that the readings against the ivory ladder used in the early surveys cauld be evaluated in terms of the metal ladder used in the later years of the Western study. The two photos indicate the position of foot and hand and the standard film locations for the bone density determina- tions. Note the shadow of the ladder stardard. The Western region included this X-ray procedure in all its nutritional status studies. Radiographs of heel and little finger, along with the ivory or alloy ladder, were taken and sent to the Pennsylvania station for tracing. Nearly 2,000 subjects of both sexes, ranging in age from 5 to past 80 years of age, were examined. In figure 83, the average density of the os calcis, the heel bone, for males and females of this age range is shown, as well as similar curves for the density of the ends and centers of the little finger bones, phalanx 5-2. These densities were corrected for soft tissue. It seemed clear that there was little change in the density of the heel bone with age and that there was some differ- [89] Standard film location for os calcis bone density determinations. — 1.8- / C a; a 0.3 m -o o o 0.2 O.i 0.0 CD 6 ( 8 9 10 II 12 13 14 15 16 17 l£ Age in years Fig. 86. Changes in mean intakes and mean serum concentrations of vitamin C with age for Iowa children sampled from 44 schools in 1949-1951, and for whom both serum values and dietary rec- ords were available. [98] mean blood ascorbic acid level of all the boys and girls was 0.7 mg-per cent, compared with 0.9 for the 128 Iowa chil- dren of this age group. The mean intake was 74 mg per day, compared with 77 mg for the Iowa children. The difference in current intake seems insufficient to account for the differences in blood levels. However, the usual significant correlation was found by the Louisiana workers be- tween intake and blood levels. Linear cor- relation ceased at intakes above 110 mg and serum levels of 1.1 mg-per cent, doubtless because saturation was reached. The condition of the gums of these children was recorded by a highly com- petent medical observer. Such changes as marginal redness, bleeding, swelling, atrophy of papillae, and recession were graded as 0, 1, 2, according to occurrence and severity, and compared with the blood levels of ascorbic acid. The num- ber and severity of gum changes were found to be correlated with the blood levels. On the whole, the ascorbic acid status of these children was only border- line, since half the blood values were 0.6 mg-per cent or less and more than 40 per cent of the daily intakes were less than 60 mg. Some of the children were examined in the spring and some in the autumn and winter. The blood levels observed in the fall were higher than in the spring, ob- viously because of intake of more fresh fruits and vegetables during the sum- mer. Citrus fruit, strawberries, and raw tomatoes contributed 54 per cent of the ascorbic acid of the diets; other fruits, raw, cooked, and canned, 7 per cent; potatoes 9 per cent; all other vegetables 20 per cent, and milk about 1 1 per cent. The potatoes and milk, though insignifi- cant usually as sources of vitamin C, were used in large enough quantities by these children, nearly 5 quarts of milk and 4 or 5 servings of potatoes per week, to make their contribution important. The Washington adolescents. The Washington station studied 248 boys and girls, 15 and 16 years old. Rather elaborate slit-lamp or biomicro- scopic examinations of skin of the upper arm and of the gums were checked by colored photographs of these tissues, by dietary records, and by serum ascorbic acid determination. The intakes on the whole were moderate to low, 82 mg per day for the boys and 69 for the girls. As might be expected, the serum values were only fair, 0.67 mg-per cent for the boys and 0.79 for the girls. The difference between the levels for the boys and girls was significant. These blood values, how- ever, compare favorably with those of the Iowa adolescents of the same age group, 0.54 mg-per cent for boys and 0.57 for girls. The intakes of the Iowa children were higher, 92 and 80 mg for boys and girls, respectively. As was true of the Iowa girls over 15 years of age, the Wash- ington girls had higher blood levels with lower intakes than might have been expected. The gum changes indicated a moderate amount of deficiency, generally more marked in the boys than in the girls, and more chronic than acute. Significant correlations between vitamin C intake, blood level, and gum changes were not established in this study, possibly because the gum changes represented long-stand- ing conditions whereas the blood levels and intakes reflected only recent and cur- rent customs. The use of the Kodachrome slides to confirm and preserve the observations on the gums appeared well justified. Similar conclusions were reached in the North- eastern region in the evaluation of photo- graphic evidence. Women in a Connecticut institution. Three different groups of women 27 to 74 years old were the subjects in a study of the response of serum ascorbic acid level to gradually increasing levels of [99] intake of the vitamin. On an intake of 45 mg ascorbic acid per day the blood levels fell in two months from 0.97 mg- per cent to 0.42, and in five months to 0.13. After one month on a 25 mg supple- ment, then one month on a 50 mg daily suplement of the pure vitamin, the serum level rose to 1.49 mg-per cent. On 100 mg daily no further rise occurred, possibly because the tissues were already saturated with the vitamin. This was in- dicated by the failure of urinary ascorbic acid excretion to rise above the usual 5 mg per day until after the month on 100 mg supplement, when the excretion was 30 mg. Urinary excretion during an 8- hour night was taken to be an indicator of surplus intake of the vitamin. A second experiment with 19 women showed quite similar results. After seven weeks on a dietary intake of 33 mg without supplement, the blood levels fell to 0.47 mg-per cent, increased to 0.74 after five weeks on an added supplement of 25 mg, to 1.47 after five weeks on 50-mg suplement, and to 1.69 following five weeks on a 100-mg supplement, making a total daily intake of 133 mg. The ascorbic acid of the white blood cells, which is thought to represent the satura- tion of the tissues as the serum ascorbic acid represents the current intake and utilization, fluctuated much less, from about 30 to 20 mg-per cent on the low intake, then up to 27 and 35 mg-per cent on the larger supplements. On 133-mg daily intake on the average no further increase occurred (fig. 87). It was con- cluded that over a period of several months the ascorbic acid of the white blood cells and of the serum varied in nearly the same order and so the serum value might be a fair indication of that of the white blood cells and the tissues. A third study concerned the effect of age on the utilization of ascorbic acid by women. Fifteen women, average age 31 years, had 0.33 mg-per cent in the serum after seven weeks on 32 mg daily intake of ascorbic acid and this rose to 1.76 mg-per cent when the intake was gradu- ally raised to 107 mg. The concentration 20i Fig. 87. Average values for ascorbic acid in blood serum and in white blood cells for 19 women receiving an average dietary intake of 33 mg ascorbic acid per day, with the following ascorbic acid supplementation: 25 mg from Jan. 22 to Feb. 26; 50 mg from Feb. 26 to Apr. 2; 100 mg from Apr. 2 to May 7. [100] of ascorbic acid in the white blood cells at the same time rose from 26 to 35 mg-per cent, the maximum at 57 mg intake. In 13 older women, average age 64 years, the serum ascorbic acid rose from 0.24 to 1.42 mg-per cent during the 10-week period, and the white blood cell level from 22 to 35 mg-per cent. The latter maximum value was not reached until the intake was 72 mg per day, as compared with 57 mg for the younger women. Correlation between serum and white blood cell ascorbic acid levels was significant only in the younger women on intakes of 32 and 47 mg ascorbic acid per day. Young men and women at the New York Agricultural Experiment station. At the New York station young men and women were the subjects, and the object was again to determine the effect of intake of vitamin C on the levels in blood serum and white blood cells. After 31 days on a diet containing only 7 mg ascorbic acid per day, the serum level fell to 0.3 mg-per cent, and the white blood cells to 13 mg-per cent, after 78 days to 0.2 and 11.5 mg-per cent. When the serum values were less than 0.4 mg-per cent only one white cell value was greater than 14 mg-per cent. With serum values over 0.4 mg-per cent, the white cells all had more than 14 mg-per cent. This would indicate that serum of 0.4 mg- per cent or less would indicate a past history of poor ascorbic acid status and an inadequate present intake. Values this low had been found in 18 to 44 per cent of boys 13 to 20 years old and 5 to 27 per cent of girls of the same age range in the Northeast nutritional status surveys. Another study by these same methods involved 13 subjects, 10 men and 3 women. After a very low intake period of 78 days, each subject took in succession 20, 30 or 40 mg of ascorbic acid daily. After 7 to 11 days on 40 mg the serum and white blood cell levels of the vitamin were significantly higher than on 30 mg intake for 11 to 14 days. Even on 20 mg those with very low previous levels showed a rise in white blood cell values. This seemed to show that the ascorbic acid status of the subject previous to the supplementation may affect the rate of response — the greater the depletion, the better the response. The Vermont study. An interesting study of the effect of daily supplementation of the diet with 400 mg ascorbic acid on the condition of the gums of 49 young student nurses was carried on for three years. Colored photographs of the gums were taken in the spring and fall from the fall of 1952 to the spring of 1955. Three blood sam- ples were analyzed for serum and white cell ascorbic acid, and 17-day diet records were secured each fall and spring. After the 1952 examination, the group was divided into test and control groups, the former receiving thereafter 400 mg as- corbic acid daily and the latter imitation tablets or placebos containing no ascorbic acid. Pitting, color, bleeding, retraction, thick- ening, blunting, recession, and swelling of the gums were systematically evalu- ated from color transparenices, and any changes in two and one-half years evalu- ated. These signs were not changed by the ascorbic acid supplementation. There was no consistent difference in the sever- ity of these signs, as noted at the end of the study, between the test and control groups. There was an immediate signifi- cant increase, however, in the concentra- tion of ascorbic acid in both serum and white blood cells. The Texas study. At the Texas station, eight women and one man were the subjects for a pro- longed study of the utilization of ascorbic acid. Five of the women were between 61 and 71 years of age, and three of the [101] women and the man were between 26 and 38 years of age. A simple mixed diet adequate in all nutrients except for ascorbic acid was used in the five periods of 14 to 19 days each. The amount of ascorbic acid given daily in raw cabbage or as the synthetic vitamin was propor- tional to the body weight of the subjects, from 1.5 to 2.5 mg per kilogram per day, and the criterion of utilization was the level of ascorbic acid in the blood plasma. An effect of season on the utiliza- tion of the vitamin was noted, in that on the same intake the blood ascorbic acid levels in most of the subjects were sig- nificantly higher in the winter than in the summer. Higher environmental tem- peratures appeared to increase the need for this vitamin. For most of the subjects, the ascorbic acid of raw cabage was as fully used as was that of the pure synthetic substance. When the group was given 1.5 and 2.5 mg per kg per day doses of the vitamin, the plasma ascorbic acid levels were always higher on the higher dosage. This confirms the findings of the Connecticut studies previously mentioned. In the Texas study, no clear difference in utilization of ascorbic acid could be ascribed to age, chiefly perhaps because of the variability of response by the subjects. A carefully '0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 0.5 1.0 1.5 2.0 2.5 3.0 3.5 ". ' . *-' ! MICHIGAN • •"" •Recall dietaries (serum) ■■ Weighed food intakes (plasma) 3.0 3.5 4.0 4.5 . 0.5 1.0 1.5 2.0 2.5 3.0 3.5 SO. DAKOTA 3.0 3.5 4.0 4.5 0.5 1.0 1.5 2.0 2.5 3.0 3.5 24 22 20 18 1.6 1.4 1.2 1.0 08 06 04 0.2 0.0 2 4 2.2 2.0 1.8 1.6 1.4 +H.2 1.0 08 0.6 04 0.2 00 O _: P ° fc 2 o , c o l» £ o > °- E fc 3 O b c/> Intake of Vitamin C in mg./kg. body weight/day Fig. 88. Scattergrams of the vitamin C concentration in the blood of women in five locations in the North Central Region, plotted against intakes in mg per kg body weight per day. The lines rep- resent the averages. Note good correlation in all cases. [102] controlled investigation of the age factor in the use of this vitamin by both older men and women is obviously needed. The North Central studies of women. The five North Central stations used only women, 20 to 80 years of age. There were 596 women altogether, 68 of them studied in two periods. Seven-day records of self-selected diets were kept, blood samples were analyzed, and in 135 of the subjects urinary excretion of vitamin C was determined. The mean blood levels for the five states, Iowa, South Dakota, Michigan, Illinois, and Nebraska, varied from 0.76 to 1.20 mg-per cent in the various age decades, and the intakes from 60 to 104 mg per day. There was a direct relationship between intakes and blood levels but this was curvilinear rather than linear (fig. 88) . Urinary excre- tions of vitamin C studied at the Iowa, Michigan, and South Dakota stations, whether before or after a dose of 400 mg of the vitamin had been given, showed a good deal of variation. When the daily intake exceeded 1.1 mg per kg body weight, the basal excretion was in nearly linear relationship to the intake. Beyond a usual intake of 1.25 mg per kg intake, the slope of the excretion of the extra 400 mg dose was less steep than at lower intakes (fig. 89). On less than 1.1 mg per kg per day intake, the blood levels were likely to be less than 0.8 mg-per cent, the basal urinary excre- tions less than 15 mg, and the extra dose or test-load excretions less than 115 mg. Intakes greater than 1.1 mg per kg per day resulted in higher values in these three parameters. When the Iowa subjects were classified into groups having more or less than 1.1 mg per kg intake per day, 71 per cent were found in two groups, those who had urine and blood figures above the expected figures and those with values below the expected figures. Of the remaining 29 per cent, one-half could not be so classified because of the blood 5 1.0 1.5 2.0 2.5 3 3 5 4.0 Intoke of Vitomin C in mg./kg body wt./day Fig. 89. Urinary excretion of vitamin C during 24 hours after a dose of 400 mg ascrobic acid was given, plotted against the average daily intake of vitamin C by these women. Note fair correlation. value only. The South Dakota and Michi- gan subjects were less easily classifiable, possibly due to the greater average age, or the smaller number of subjects. The conclusion was reached that age did not influence either the intake or the blood level of these women. The Iowa women were in ascorbic acid equilibrium with blood levels above 0.8 mg-per cent when the intake equalled or exceeded 1.1 mg per kg per day. This was accepted as a desirable minimum intake, 64 mg for the woman of average weight, 58 kg, comparable with the 70 mg of the 1958 recommended allowance. The California study of older men and women. The last ascorbic acid study to be re- ported here was that done in California with 569 men and women over 50 years old. The self -selected diets of the 525 men and women living in their homes contained adequate mean amounts of as- corbic acid, 99 mg daily for the men and 86 for the women. In terms of body weight these values were 1.4 and 1.3 mg per kg and were not significantly differ- ent. There were 44 men over 60 years of age living in the County Home also included in this study. Their institution diet contained 40 mg per day, or 0.62 mg per kg body weight. [ 103 } Fig. 90. Mean blood serum vitamin C of Cali- fornia men and women, plotted against age. Note peaks at 62 years in both men and women, and extremely low values for men in the county home. The limits of statistical variation are shown in the barred areas. 70 80 50 60 Age in Years Fig. 91. The mean daily intake of vitamin C of California men and women 50 to past 80 years of age. Note peak in both men and women at 62 years of age and very low intakes of men at the county home. The limits of standard error are indicated by the light lines. S 60 0.9 Serum Ascorbic Acid All Fig. 92. Variation of blood serum vitamin C with economic status. c/) CD O O 50 40- 30 c CD <■> 20 10 Q Edentulous H No gingivitis ( Gingivitis n n <0.5 0.5-1.1 >l.l All Serum Ascorbic Acid mg. % Fig. 93. Increase in percentage of edentulous (toothless) persons, and in gingivitis (inflamed gums), with decrease in level of blood serum vitamin C. [104] The blood levels of the men and women living at home were on the aver- age 0.83 and 1.07 mg-per cent respec- tively, but that of the men in the County Home was only 0.27. The men at every age had lower blood levels than the women, even with equal or larger intakes. About a third of the men and a tenth of the women had blood levels of less that 0.4 mg-per cent, the "poor" rating. As shown in figure 90, a peak occurred in both sexes at about age 62; likewise, a peak of intake, followed by a dip, oc- curred at this age (fig. 91). The men in the County Home had extremely low intakes and blood levels at all ages. Whether intake or serum ascorbic acid levels were used as point of reference, the close correlation of one with the other was evident for both men and women. The possible effect of adrenal and sex hormones on ascorbic acid nutriture was suggested by these results. The peak of serum ascorbic acid at about age 62 in both men and women may result from abrupt postmenopausal decrease in sex hormone production. Since ascorbic acid is in some undefined way related to pro- duction of these and the adrenal hor- mones, more of the vitamin may be re- leased in the blood stream when hor- mone production is decreased. The same suggestion was made to explain the sus- tained high blood cholesterol levels of women past the menopause. The general conclusion reached was that men over 50 may have a definitely higher ascorbic acid requirement than women. An interesting relationship between eco- nomic level and blood ascorbic acid was noted (fig. 92). The men in the County Home, those on public assistance rolls, the large majority (70%) in the middle- income bracket, and the small number in the top-income group had levels of blood ascorbic acid increasing in that order. This difference was ascribed to education and food habits rather than to sheer buying power. About 39 per cent of all these people were edentulous, that is, had no teeth, 17 per cent had marked or moderate gin- givitis, and 43 per cent had relatively healthy mouths. More of the edentulous and those with gingivitis had low serum ascorbic acid levels than did those with teeth and no gingivitis (fig. 93). This accords with the general findings (fig. 73) that serum ascorbic acid has an in- verse relationship to prevalence of gum and mouth signs of possible deficiency. There emerges from these cooperative researches some indication of the greater need for vitamin C of males than females, at least after age 12. Both tissue content, as shown by the ascorbic acid level of the white blood cells, and circulating blood concentration reflect the intake of this vitamin, the tissues indicating the past history and the blood serum the recent custom. Changes during adolescence and menopause appear to exert stresses which affect the utilization of this vitamin and may increase the need for it in the diet. About a third of the men and boys and a somewhat smaller proportion of women and girls had blood levels indicating an unsatisfactory status as to ascorbic acid. [105] THE SERUM CHOLESTEROL STORY A great deal of interest has arisen in recent years in regard to the levels at which cholesterol and other lipids circu- late in the blood. This is because of the suspicion that arteriosclerosis and heart damage may be associated with high lev- els of these substances, especially choles- terol, in the blood. The effect of fat in the diet has been studied in numerous efforts to determine why blood cholesterol is so much higher in Americans and North Europeans than in some other peoples, for example, Japanese, Italians, and Spanish. Likewise, incidence of deaths from arteriosclerotic disease is much greater among North Europeans and Americans than among the other peoples named. However, methods of diagnosis of this disease are undoubtedly different in the United States from those in some of these other countries. The outstanding difference in the diets of all these peoples is in the quantity and quality of the fat. Americans obtain a high proportion of their calories from fat, 40 to 45 per cent, but Japanese, Ital- ian, and Spanish laborers get only 20 per cent of their calories from fat and this is of vegetable origin. Present evidence in- dicates that fat in the diet is the single factor which most directly affects the serum cholesterol level. Fats and oils of vegetable origin, containing a high pro- portion of unsaturated fatty acids and especially of the highly unsaturated es- sential faty acids, tend to lower rather than to raise the serum cholesterol. Fats of animal origin, especially milk fat, have the opposite effect. Csn we then control incidence of coro- nary occlusion and similar serious circu- latory diseases by controlling our fat intake? Is the dietary fat effect the same in men and in women? Coronary acci- dents are far more frequent in middle- aged men than in women, but with advancing age the sex difference tends to disappear. Does the level of cholesterol in the blood also follow this pattern, high in middle-aged men but not in women, equalized in the older age groups? Three of the regional groups undertook studies of serum cholesterol in older women and one also studied older men in the hope of adding a few facts to the mounting pile of evidence on this problem. Women in a Connecticut institution. Twenty-nine women 28 to 77 years old, living in an institution, were studied for serum cholesterol while living on the regular institution diet exclusive of all high-vitamin-C foods. This was low in ascorbic acid content but was supple- mented after seven weeks by increasing dosages of ascorbic acid, from 15 to 75 mg per day, each dose maintained for a two-week period. The mean serum choles- terol of the 15 young women (28 to 34 years old, agerage 31) was 172 mg-per cent, of the 14 older women (56 to 77 years, average 64) was 230. The diet was the same in both groups. Both the fat and cholesterol intakes averaged the same in the two groups. In both groups 34 per cent of the total calories was ob- tained from fat. As the serum ascorbic acid of both groups rose with the increas- ing supplements of ascorbic acid, no change occurred in the serum cholesterol of the young women, but a significant rise occurred in the older women. Such a rise in serum cholesterol has been ob- served when there is a rise in serum ascorbic acid. But in the young women this extra cholesterol may be utilized in the production of female sex hormone, which is chemically closely related to cholesterol. If the sex hormone is no longer elaborated in the older women, the extra cholesterol might be circulated in the blood. This had been suggested by the California investigations. C106] In any case, the investigators concluded that the difference in blood cholesterol between the two groups of women seemed to be due to age, with diet playing no part. However, the cholesterol levels found were low compared with all others reported for similar groups of women. Low cholesterol levels are characteristic of institutionalized people, both men and women. Iowa, Nebraska and Illinois women. In the North Central region three studies on this subject were carried out. The Iowa and Nebraska stations combined a report on 54 women in Iowa and 130 in Nebraska, 18 to 92 years of age. There were from 18 to 51 women in each dec- ade from 20 to 80 years. In figure 94 is shown the mean serum cholesterol value for these women. A steady rise was seen from age 20 to the seventh decade, aver- age age 63.4 years, followed by a fall in the eighth decade. Basal metabolism, blood pressure, and weight were only slightly associated with this rise, which was ascribed to age. The diets used were typical of North Central custom, contain- ing rather high contents of both protein and fat. The intake of both of these con- stituents of the diet declined with advanc- ing age, but the average body weight increased up to average age 63. However, statistical calculations revealed no signifi- cant correlation of the serum cholesterol with any factor except age. A very large number of cholesterol determinations on the blood of mid-Western men, who un- doubtedly consumed diets quite similar to those of the women in this study, had shown a similar rise with age but with the peak about 10 years earlier, at 55 years. The fat in the diet of these men had been rather convincingly shown to be positively correlated with their serum cholesterol levels. The cholesterol values for these Iowa and Nebraska women were lower at all ages than those found in the lowo a Nebrasko •— • 1 Connecticut O— 02 Colorodo ■—■3 Cohfornio o — a 4 Illinois A— *5 Wyoming o — 06 Iowa 4-47 Fig. 94. Mean serum cholesterol of men and women from 20 to past 80 years of age in three regions. Note peak in the mid-sixties for all the women except the Colorado group, with peak in the seventies. No peak in the records of the men. other cooperative researches and, indeed, lower than any reported for women living at home. The Illinois station studied serum cholesterol in 113 women from 26 to 92 years of age. Only nine were more than 70 years old. Again, a steady rise in cho- lesterol with advancing age was found (fig. 94) to a maximum of 302 mg-per cent at 65.8 years of age. Practically the same level, however, was observed at 54.2 years. The group beyond 70 years, mean age 77.2, showed an abrupt decline to 249 mg-per cent. All these levels are much higher than those found by the Iowa and Nebraska workers, although the diets, age, and other characteristics of the subjects were similar. No correlation was found between serum cholesterol levels and blood pressure, percentage of calories from fat or protein in the diets (39 and 16 per cent, respectively), or energy value of the diet. Positive correlations were found between serum cholesterol and body weight as well as age. Body weight expressed as pounds per inch increased from 2.02 at age 37 to 2.56 at age 57, then slowly declined. Most of the rise in cholesterol, however, was ascribed to age only. However, the number of subjects in the various age groups was rather [107] small for the establishment of valid correlations. Another report came from Iowa on a study of 58 women 30 to 90 years old. The main question raised was as to the rate and completeness of absorption of fat by the older women, but cholesterol levels were also measured. The minute particles of fat, chylomicrons, which enter the blood stream during absorption of a meal of fat, reached a peak of concentra- tion in the blood of older women later than in young adult women. The usual peak time is 2 to 4 hours after a fat meal, with return to resting value at a fairly rapid rate. In the older women the peak was reached after 4 to 6 hours, in the younger women after 1 to 3 hours. With every additional decade the peak was de- layed about 1 hour. Also, the longer it took for the peak to be reached, the greater was the count of chylomicrons in Women 65 75 Age in Years 85 Fig. 95. Changes with age in serum choles- terol levels of California men and women living in their own homes, and men in the county home. The area of standard error is marked. the blood. Thus it appears that with ad- vancing age the pattern of fat absorption is changed and fat utilization delayed. If the presence of a high concentration of fat in the blood for long periods is harmful, as some medical investigators have claimed, then high fat diets may not be safe for old people. The serum choleseterol of these women rose from the younger to the older age groups in much the same fashion seen by the Illinois investigators (fig. 94). The highest cholesterol concentration again was found in the seventh decade, at 60 to 69 years of age, with a sharp drop thereafter. However, no significant rela- tionship was found between chylomicron count and serum cholesterol, indicating that serum cholesterol level may not be dependent upon the pattern of fat absorption. The California study of women and men. The California station studied the serum cholesterol in 577 men and women past 50 years of age and on diets of known composition. The women at every age had higher serum cholesterol than the men, even on diets of like composition. The serum level was found to be sig- nificantly related to both the fat and the cholesterol of the diet, but the sex dif- ference held even when these compo- nents were present in larger amounts in the diets eaten by the men (fig. 95). The levels attained by the women at various ages were somewhat lower than those re- ported by Iowa and Illinois but higher than those found in the Iowa-Nebraska study. Again the average peak value oc- curred in the age period 60 to 69 years, but the figures changed very little in the 20 years from 50 to 70 The fat content of the diets of these California women was lower, 36 per cent of calories, than that of the North Central women, 42-44 per cent of calories. The contrast with the values for men of the same ages was striking. The highest value for the men was found in the 50- to [108] 59-year-old group, followed by a smooth decrease in every decade thereafter. The men in the County Home. A spe- cial group of 50 men who lived in the County Home presented an interesting contrast. Their blood cholesterol levels were strikingly lower at every age than those of the men living in their own homes. Their diets were much lower in both fat and cholesterol as well as in vitamin A, caro- tene, and ascorbic acid, than the diets of men living at home. This is another ex- ample of the occurrence of low choles- terol values in persons living in institu- tions. Oddly enough, the mortality rate from arteriosclerotic causes of these Coun- ty Home men in the eight years follow- ing the study was nearly three times that of the men living at home, and the mor- tality rate of the women all living in their own homes was only about half that of the men living in their own homes. These mortality figures are strangely con- tradictory of the assumed relationship between blood cholesterol levels and arteriosclerotic disease. However, the three groups are not comparable because sex is obviously a controlling factor in establishing the serum cholesterol level; the dietary regimes of the people in the County Home and of those living in their own homes were radically different, and other traumatic influences may well have been operative in the County Home group. This study was one of the first to establish the need for separate norms for blood cholesterol values of men and women. Wyoming women and high altitude. At the Wyoming station 70 women over 60 years of age were studied. Their serum cholesterol levels were uniformly higher than those of the California women and were of the same order as those of the Iowa and Illinois groups. The diets of the Wyoming and California women con- tained the same amount of fat, but the Wyoming women had considerably more of the fat from animal sources. But the Wyoming study showed no correlation between fat intake and serum cholesterol even though a positive correlation was found between the serum cholesterol and the cholesterol of the diet. The Wyoming subjects, living at an altitude of 7200 ft., had significantly higher hemoglobin levels and a greater volume of red blood cells than did the California group who lived at sea level. They also had a good deal more overweight, 56 per cent, as compared with 24 per cent among the California women. No correlation was found, however, between overweight and blood cholesterol in either the California or Wyoming women. But such a corre- lation appeared when the fat and choles- terol of the diets of the California men were compared with amounts of under- weight and overweight (fig. 96). The Wyoming study was interpreted to mean that the high altitude affected blood cholesterol as well as hemoglobin. This is a new concept based on the notion that the increase in red cell count caused by altitude may be accompanied by an 120 100 *_ 80 o □ Men M Women n 1000 o 800 a> | 600 o 6 400 en ^ 200 + , Overweight — ,Underweight >20 IOto20 IO-tolO+ IOto20 — 4- Per oent >20 Fig. 96. Fat and cholesterol intakes of Cali- fornia men and women in relation to under- and overweight. Note that amounts of dietary fat and cholesterol increase with overweight in men, but not in women. [109} increase in the residue of broken-down "ghost" cells which contribute cholesterol to the blood. This effect of altitude was not seen when the blood values of the Colorado men and women living at 8,000 to 11,00 ft. altitude were compared with those of the same age in California. The Colorado diets were much lower in fat and cholesterol than those of the Cali- fornia subjects. The Western adolescents and alti- tude. A review of the blood cholesterol levels of the adolescents examined in seven Western states might shed some light on this problem. Arizona and Idaho, at roughly 2400 ft. altitude, reported serum cholesterol for boys and girls 12 to 16 and 15 to 16 years of age, respec- tively, as 135 and 166 mg-per cent for boys, 145 and 175 mg-per cent for girls (table 6). But the groups are not com- parable, the Arizona subjects being Pa- pago Indian children living on a rela- tively marginal diet; the Idaho children were by most standards well fed and well grown. The Montana and Utah adoles- cents at 4000 ft. altitude differed also, with the Montana boys and girls having the low mean blood cholesterol values of 133 and 144, the same as the Arizona group, and the Utah subjects 156 and 167, al- most the same as the Idaho group. Clearly altitude cannot be the dominant influence. Another comparison is seen in New Mexico at an altitude of 6400 ft. Here the two groups, one Spanish Ameri- TABLE 6. — Altitude Effect on Hemoglobin and Serum Cholesterol of Western Adolescents. Station h U •4- ~ a u E^ Arizona 2400 Idaho 2400 Montana 4200 Utah 4300 New Mexico 6400 Spanish Americans Anglos Colorado 6000 to 1 1,000 Washington Sea Level to 1 1,000 12-16 Boys Girls 15-16 Boys Girls 14-16 Boys Girls 13-19 Boys Girls 14-16 Boys Girls Boys Girls Boys Girls 15-16 Boys Girls 48 46 124 154 1 10 1 12 54 70 48 58 28 36 74 74 124 124 13.7 12.5 15.4 13.9 15.2 14.0 14.0 13.3 14.1 13.5 15.2 13.8 14.8 14.3 14.8 13.5 135 145 166 175 133 144 156 167 152 164 173 187 170 177 165 178 [HO] can and one Anglo, living side by side, reported quite different diets, had differ- ent rates of growth and different blood composition generaly. The Spanish-Amer- ican boys and girls had serum cholesterol levels like those of children in Utah and Arizona, 152 and 164 mg-per cent. The Anglos' average levels were 173 and 187, the highest levels reported in any of the Western studies of adolescents. Perhaps the New Mexico high altitude had some effect in raising the cholesterol level of the Spanish Americans above that of the Arizona Indians and of the Anglos above those of the similarly fed and smilarly developed children in Utah and Idaho. The low values of the Montana subjects are puzzling. Colorado boys and girls at 8000 to 11,000 ft. altitude had cholesterol levels almost identical with the Idaho, New Mexican Anglos, and Washington sub- jects of the same age range, 14 to 16 years. Here again no consistent altitude effect can be discerned. Hemoglobin and cholesterol levels compared. The hemoglobin levels in the blood follow the expected trend and are roughly paralleled by the cholesterol lev- els, again with the exception of the Mon- tana values. The Arizona children had lower hemoglobin than any of the others, likewise the lowest cholesterol. The Utah, New Mexico Spanish-American, Colo- rado, and Washington children had the next higher hemoglobin and cholesterol values, the Spanish American equalling the Utah group in spite of relatively poorer diets, perhaps because of the influ- ence of the higher altitude. The Idaho and New Mexico Anglo groups had the high- est levels of hemoglobin and cholesterol, which were about the same even though the Idaho intake of nutrients generally exceeded that of the Anglos. Perhaps alti- tude was the assisting factor in the latter case. The Montana children had the ex- pected high hemoglobin levels even though the serum cholesterols were low. VALUE OF CAROTENE AS PRO-VITAMIN A The conditions which affect the trans- formation of carotene, the deep-orange pigment found in many fruits and vege- tables, into vitamin A in the body are not clearly known, even though experiments on the subject have been carried on since 1930. This is an important problem because in many diets, especially of vegetarians, most of the vitamin A is provided as carotene. Indeed, it was as- sumed in the estimation of the need for vitamin A that in the American diet about two-thirds is supplied in the form of carotene. One of the offshoots of the nutritional status project in the West was a study of this question. The Arizona station ex- amined the effect of nonfat milk on the utilization of carotene by rats and found that in the presence of the milk a me- dium sized daily dose of pure carotene, 60 micrograms (1,000 micrograms = 1 milligram; 1,000 mg = 1 gm), labora- tory rats were able to store more vitamin A in the liver than when the carotene was given without milk. When vitamin A itself was given instead of carotene, no difference in liver vitamin A storage due to the presence of the nonfat milk could be detected. Alpha-tocopherol, vitamin E, was tried similarly at the California station. It had been reported elsewhere that small amounts of alpha-tocopherol given daily significantly increased the amount of vita- min A which rats could store in their livers and kidneys when carotene was fed. The California study included feeding 0.5 cm] and 1.0 mg vitamin E daily along with large and small daily doses of pure caro- tene or pure vitamin A. A favorable effect of the vitamin E was found within certain narrow limits of carotene feeding, 1,200 to 2,400 micrograms total in two weeks, but not when the amounts given were above or below these crucial levels. The total amount of carotene which was trans- formed into vitamin A and stored never much exceeded the daily dose of carotene. On the other hand, quantitative cumula- tive storage of vitamin A was found when vitamin A itself was fed in doses above 75 micrograms daily, either with or with- out vitamin E. Apparently the growing rat uses up 75 micrograms vitamin A daily and stores the rest without reference to vitamin E, but even large daily doses of carotene are wasted with or without vitamin E. This is partly due to losses from the digestive tract. A further study was made of the rate and site of carotene transformation to vitamin A. Vitamin A was found in the intestinal wall two hours after carotene was given either in water dispersion or in oil, and after three hours this vitamin A had disappeared from the intestinal wall and appeared in the liver, the site of permanent storage. On the whole, the role of vitamin E in making carotene a more effective source of vitamin A was not supported by these experiments, but the vast difference in availability between vitamin A from animal food sources and the carotene of vegetable foods was emphasized. Another condition which has been sug- gested as important in the utilization of carotene is that of hypothyroidism or hyperthyroidism. At the California sta- tion, experiments on both rats and dogs were devised to test this. These animals can be made deficient in thyroid function by administration of certain drugs, for example, thiouracil. The thyroids enlarge, change in cellular character, and produce little of the important thyroid hormone, thyroxin. Such rats were found to store more vitamin A in the livers than did normal control rats when small carotene doses were given. But when the dose of carotene was much increased, the differ- ence disappeared. When normal and hypothyroid rats were depleted of vitamin A, the hypothyroid animals had more liver vitamin A left than the normals, thus indicating slower utilization of stored vitamin A in the former. This could be attributable to reduced body weight gains, since normal animals lim- ited in their food consumption likewise retained more vitamin A stores during the period of depletion. When carotene in oil was fed, it disappeared from the intestines of the partly starved, normal and hypothyroid rats at the same rate. Thus, absorption from the intestine, transformation, and utilization of caro- tene appeared to be the same in normal and hypothyroid animals, but slower growth and lighter weight caused by the thyroid condition reduced the utilization of the vitamin A formed and allowed more storage from the same intake of carotene. Mature young dogs similarly treated were studied chiefly as to changes in the blood. A single dose of carotene pro- duced a peak in the blood level of vita- min A in 8 to 11 hours in both normal and hypothyroid dogs. But in contrast to the findings in the rats, hypothyroidism alone caused a rise in the level of the serum lipids, especially carotene, vitamin A, and cholesterol. Both groups of dogs had considerable deposits of carotene in the liver as well as vitamin A, and about equal amounts of carotene and vitamin A in the adrenal glands. Two stock dogs fed large amounts of vitamin A had much larger stores of vitamin A in the liver and kidneys and much higher levels in the circulating blood than the caro- tene-fed experimental dogs, but their adrenals contained no carotene and only the same amount of vitamin A as the [112] adrenals of the experimental animals. Thus there appeared to be a fixed control of the vitamin A of the adrenals only. Again, it was concluded that absorption and utilization of carotene in hypothy- roid dogs was not affected by the thyroid but that the lipid levels of the blood, including cholesterol as well as vitamin A and carotene, were raised by this con- dition. This had been noted in humans for cholesterol but not previously for vitamin A and carotene. The Montana station used yeast or synthetic sources of the B vitamins in testing the effect of large amounts of ascorbic acid on the utilization of caro- tene with rats. A sex difference was seen in the response. On 25 mg-per cent ascorbic acid daily, female rats stored more vitamin A from a given dose of carotene than did those without the as- corbic acid, but the male rats stored less. When the ascorbic acid dose was doubled, the effect disappeared. When the carotene dose was increased 3- or 4-fold, the effect on liver vitamin A storage also disappeared. Ascorbic acid, like vitamin E, is an antioxidant, and it is not surprising that the effects of large and small amounts vary radically. This has been noted earlier by the Cali- fornia workers for the vitamin E effects on carotene utilization. At all levels of ascorbic acid the amount of carotene retained as liver and kidney vitamin A in both male and fe- male animals was greater when synthetic B vitamins were fed than when yeast was used as their source. This curious dis- crepancy was investigated in a new series of experiments in the hope of discovering what constituent was responsible for the difference. Vitamin Bi 2 was present in the synthetic vitamin mixture but pre- sumably not in the yeasts. Rats fed the same amount of carotene without vita- min Bi 2 were given four different yeasts as source of the B vitamins, and on three of these yeasts they stored more vitamin A than on the fourth. The vita- min A storage of the rats on these three yeasts was the same as that of the group which received the synthetic vitamin B mixture without vitamin B12. When Bi 2 was added to two of the yeast diets, carotene utilization was increased, but it was not when B12 was added to the synthetic vitamin mixture All this seemed to indicate the presence of some factor other than vitamin Bi 2 in one of the yeasts and in the synthetic mixture, which affected the utilization of carotene. They next tried choline, a vitamin-like substance present in foods and in body tissues, chiefly combined with fats as phospholipids or in acetylcholine, an important compound indispensable for muscle function. When choline was added to the yeast diet, the rats stored more liver vitamin A from carotene than they did without the choline. The same was true when vitamin B12 was fed. But on the synthetic vitamin-mix diet, choline and vitamin B i2 brought about no such improvement. The reason for this has still to be found, but it seems clear that there is something in yeast which stimulates carotene utilization when choline or vita- min Bi 2 is fed, but which is not effective alone. This might be concerned with the use of methionine, an important sulfur- containing amino acid, because this amino acid, as well as choline and vitamin Bi 2 , is active in methylation, transfer of the methyl group, CH 3 , to other physiological compounds such as creatine, cystine, or niacin. The Montana workers also noted the effects of choline and vitamin Bi 2 on serum and liver cholesterol values. Ade- quate or nearly adequate amounts of cho- line were found to lower liver cholesterol and slightly increase serum cholesterol. When vitamin Bi 2 was fed, varying re- sults were found. Generally there was no effect on liver cholesterol, but when it was fed along with yeast, there was an [113] increase in blood serum cholesterol. More study of the problem is indicated. There were three studies of carotene utilization on human subjects, namely, on preadolescent girls in Louisiana, adolescent boys and girls in Washington, and men and women over 50 years of age in Cali- fornia. Six girls, 8 to 9 or 11 years of age, were kept under close observation on their self-selected usual diets for six weeks and on a controlled diet for six weeks. The diets contained adequate amounts of all nutriets except vitamin A and carotene during the basal periods, and during the experimental periods 3.6 mg carotene was supplied each child daily in the form of the carotene of sweet potatoes. All fecal carotene was measured as an index of the intestinal absorption of the sweet potato carotene. In the five younger girls, the absorption was 22 to 29 per cent and in the 11 -year-old girl, 39 per cent, overall average, 28 per cent. Meanwhile, the blood serum levels for carotene were raised when the sweet po- tatoes were fed, although the rise was not statistically significant. The vitamin A levels of the blood were higher during the controlled diet periods, especially in the first three weeks on the basal diet, after which the addition of sweet potatoes or of nonfat milk had no effect on serum levels of either carotene or vitamin A. Some other factor in the controlled diet, perhaps protein, must have effected the rise in the vitamin A blood level pre- ceding the addition of the sweet potatoes. The effect was possibly not changed by that addition. Here is another puzzle awaiting investigation. The Washington station studied 248 15 and 16-year-old native-born-and-reared boys and girls in two geographical areas of that state. The 7-day diet records, blood serum levels of carotene and vita- min A, biomicroscopic study of skin and conjunctiva of the eyes, reinforced by examination of Kodachrome photographs, were used to determine the vitamin A status. There was no real difference due to age or to geographical location in the vitamin A and carotene intakes, but the boys always had greater intakes than the girls. Similarly, there were no signifi- cent differences due to age, area, or sex in the levels of blood vitamin A or carotene. Intakes were classified as excel- lent, but blood levels and physical signs were only fair to good. Significant cor- relations were found for vitamin A intake with serum carotene and serum ascorbic acid, and for carotene intake also with these two blood levels, and between the serum levels of vitamin A, carotene and ascorbic acid. The subclinical changes in skin and eye membranes did not correlate with serum levels or dietary intakes of these vitamins. The carotene levels in the blood. 106 to 117 mcg-per cent, were lower than were reported for many other adolescent groups, but vitamin A levels were somewhat higher, 44 to 46 mcg-per cent. This would indicate lower immedi- ate intakes of carotene with high vitamin A intakes, or else good intakes of caro- tene and vitamin A in the past, with temporarily low values at the time of the study. Blood carotene levels and dietary carotene contents, it will be remembered, do not always indicate the fixed vitamin A status which is the result of the total dietary history. In the Washington study, the immediate intake was high in vita- min A when compared with carotene, but physical signs and blood values indi- cated probably lower intakes in the past. The study of 514 older people in Cali- fornia showed only small declines with age in blood levels of carotene and vita- min A, no sex differences, and generally good status. The intakes of vitamin A and carotene were calculated separately, and carotene was found to average less than a third of the combined intake in- stead of the two-thirds usually estimated. The total intakes in International Units were high, 8 to 10 thousand daily. Posi- tive correlations between vitamin A [114} intake and serum vitamin A, and between carotene intake and carotene levels, were found. Thickening of the eye membranes and drying or keratinization of the skin were often found, but these changes were no more marked in those with poor than in those with good intakes and blood levels of vitamin A. Apparently advanc- ing age had more influence on these changes than the vitamin A status. SOME STUDIES ON RIBOFLAVIN Blood riboflavin. Both free and total blood serum ribo- flavin were determined in several of the Western states (fig. 97). The values for the latter were found to be variable and much higher in the older than the younger subjects. The difference between free and total riboflavin is taken as a measure of the riboflavin combined with another compound to form an active com- ponent of one or more enzyme systems. Unlike the free and total serum choles- terol, the free and total riboflavin levels varied independently. Riboflavin is one of the B vitamins essential to the opera- tion of many of the enzyme systems which control metabolism, and adequate intake is certainly important. In the Idaho study of adolescents, no correlation could be found between se- rum-free or total riboflavin and ribo- flavin in the diet. This may be due to the liberal riboflavin content of the diets, since only 10 per cent of the boys and 15 per cent of the girls had less than two-thirds the recommended allowance of riboflavin. In Montana, some correla- tion between total blood riboflavin and dietary intake was found, but, again, con- vincingly only when the subjects with low intakes were included. The relation- ship did not hold for free riboflavin. In Oregon, seven adult women, 24 to 44 years old, were subjects for a study of riboflavin metabolism on controlled diets containing 1.2 mg riboflavin. The daily fasting values averaged 3.21 mcg-per cent total blood serum riboflavin, and 1.41 free riboflavin, in over 200 analyses. The urinary excretions ranged from 27 to 40 per cent of the riboflavin intake. When a dose of riboflavin was given, the blood riboflavin rose to a peak in half an hour and declined to fasting value again after five hours. The peak in uri- nary riboflavin occurred one hour after the test dose, and by the fifth hour was back to the one-hour excretion level. Two of the seven subjects were not in equi- librium on the 1.2 mg riboflavin daily and probably needed more than this amount in their diets. The New York group maintained three women and nine men for 42 days on 50 to 66 per cent of the recommended allowance for riboflavin, then for 32 days on 35 to 40 per cent of this allowance. The diet contained an adequate amount of protein. The average total riboflavin of red blood cells and blood serum was found to be 22.4 and 3.85 mcg-per cent, respectively, in the beginning, and only 14.6 and 2.63 at the end of the study. Nitrogen retention was determined in all Fig. 97. Total serum riboflavin levels of chil- dren and adults in six Western states. [115] cases, too, but no relationship between this and the blood levels was found. On the whole, riboflavin excretion and nitro- gen retention were inversely related. This experiment was a clear demonstration that blood levels soon reflect inadequacy of riboflavin in the diet. Riboflavin excretion and retention. In Tennessee, in connection with a 3 -year study of calcium, phosphorus, and nitrogen balances on 17 college women 19 to 25 years old, riboflavin intakes and excretions were measured on restricted, supplemented, and natural food diets. The restricted diets contained no milk, eggs, or wheat, the suplemented diet had dical- cium phosphate and riboflavin added, and the natural diets had eggs, milk and wheat added. The study was prompted by inter- est in the widely used nonallergic diets. Riboflavin balance was maintained on the 1.0 to 1.3 mg riboflavin provided by the restricted diet, but was promptly in- creased when either pure riboflavin or riboflavin in eggs, milk, or wheat was added to the diet. The increase was always greater when the natural foods were added, and the subjects obviously utilized riboflavin in amounts well above the 1.4 to 1.9 mg of the recommended daily allowances. ACKNOWLEDGMENTS The Research and Marketing Act of 1946 provided funds for the Agricultural Experiment Stations not only for research in agriculture and marketing but for nu- trition research as well. One section of the Act reserved a specific portion of the funds for the support of cooperative re- search between or among two or more State Experiment Stations. These regional funds were administered by a Committee of Nine acting for the Experiment Sta- tions through their regional groups, Northeast, North Central, South, and West. Each of the regions established at once a series of cooperative researches, each implemented by the appointment of a Tachnical Committee containing one or more representatives from each cooperat- ing state and usually a representative of the corresponding section of the U. S. Department of Agriculture and of the Office of Experiment Stations. Each such committee had an administrative adviser, usually an Experiment Station director. In 1947 a good many of these coopera- tive research projects were set in motion. One project, that on Nutritional Status, was inaugurated in all four regions at the same time. In the South the first phase of this study was a food consumption survey, but in 1950 this region also adopted Nutritional Status as title of the project. These projects had formal num- bers and titles and each of them was implemented by a corresponding contrib- uting project set up by each of the coop- erating states and by the Federal agencies. The titles and lists of cooperating states follow. Northeast Region. Project NE 4, 1947-1952. Cooperative nutritional status studies in the Northeast region. Maine, ^ Massachusetts, New Jersey, New York, Rhode Island, West Virginia. The ob- jective was the correlation of dietary < surveys, biochemical studies, and medical examinations. Subcommittees on dietary methods, bio- •* chemical methods, and medical examina- tions tested and agreed upon suitable pro- cedures which were then followed by all cooperating groups. Statistical meth- ods of evaluating the results were also [116] ■■"■ z/' ■■ . - Interior and exterior views of a mobile laboratory used in Colorado during the studies reported in this bulletin. £117] established for the region. The popula- tion groups studied were: Maine, junior high school students; Massachusetts, preg- nant (pre- and postpartum) women; New Jersey, male industrial workers; New York, preadolescent and adolescent boys and grils; Rhode Island, high school and college students; West Virginia, col- lege students, families, and preadolescent children. When these studies were terminated in 1952, the new title and number NE 16 were adopted, emphasizing the effect of nutrient intake (the food supply) upon the nutritional status of human subjects, and six more stations joined in the project. More than 3700 persons were studied. Project NE 16, 1952-1956. Relation- ship of nutrient intake to nutritional staus in human subjects. The cooperating sta- tions were, Connecticut (Storrs), Dela- ware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York (Cornell), Pennsylvania, Rhode Island, Vermont, West Virginia, Bureau of Hu- man Nutrition and Home Economics (USDA). North Central Region. Project NC 5, 1947-1957. Nutritional status and dietary needs of population groups in the North Central region. Subproject 1. The nutri- tional status and dietary needs of older people. This was started in 1947 by Iowa, Michigan, Minnesota, Nebraska, South Dakota, Bureau of Human Nutrition and Home Economics, and Office of Experi- mental Stations (USDA). In 1949 Illi- nois, Indiana, Missouri, and Wisconsin joined the group, and these nine stations continued the study until 1959. Subproj- ect 2. Nutritional status of school children as influenced by the school lunch. This was begun in 1947 by Ohio, Kansas, Iowa, Bureau of Human Nutrition and Home Economics (USDA). Subproject 3. Protein and amino acid requirements in human metabolism. 1948-1952. Indiana, Michigan, Wisconsin. After 1952, Sub- project 3 was incorporated in Subproject 1 and the project retitled "Nutritional status and dietary requirements of older women." Energy and protein or amino acid needs of older women were the chief subjects investigated. Subproject 2 was retitled "Nutritional status of school children." More than 5100 subjects participated in these surveys. Southern Region. Project S 4. Family food consumption in the Southern region in certain types of farming areas. 1947- 1951. Arkansas, Mississippi, South Caro- lina, Tennessee, Virginia, North Carolina, Bureau of Human Nutrition and Home A nutritionist records the amounts and kinds of foods eaten by one Iowa woman and (right) nutri- ents in the dietary records are calculated by workers in the Northeastern Region. [118} Economics, U. S. Department of Agricul- ture. Project S 15. Assessment of nutri- tional status of humans. 1950-1956. Sub- project 1. Nutritional requirements and utilization of selected nutrients. Alabama, Louisians, Mississippi, Kentucky, Tennes- see, Texas, BHNHE, USDA. Subproject 2. Evaluation of means of assessing nutri- tional status. Georgia, Louisiana, Virginia. Preadolescent children, 6-9 and 8-11 years old, were the subjects of the first studies of status and later of controlled metabolic measurements. Nearly 900 persons were included in the studies. Western Region. Project W 4. Sub- project 1. Nutritional status and dietary needs of population groups in selected areas of the West. 1947-1958. Arizona, California, Colorado, Idaho, Montana, New Mexico, Oregon, Utah, Washington. The cooperative funds were allotted whol- ly or largely in the West to one, two, or three states each year, so that in the 10 years each state had the major sum twice. This made for a greater concentration of effort and production during the crucial field surveys. A trailer laboratory and truck were loaned the region by the U. S. Public Health Service and this unit was sent first to Oregon, in 1947-48, then to California, in 1948-49, and to Colorado, Arizona, and New Mexico in 1949-50. After July, 1950, the trailer was returned to Wash- ington, D. C, and local laboratory space was provided in Idaho and Utah, 1950-51, and in Washington and Montana, 1951- 52. The trailer laboratory was especially useful in the remote areas in Arizona and in California and Colorado where space was at a premium during the year of this study. The X-ray and dental equip- ment was kept in the trailer and con- veniently transferred from place to place over mountains and bridges during the first three years of the project. Pho- tographs of the interior and exterior of the mobile laboratory are shown on page 117. Several members of the team of nutri- tionists, biochemists, and other technicians went with the trailer during the first few years of the study. Except for California, all of the states chose to study children of high school or college age. California and Colorado examined men and women from 50 to 89 years old and Utah and Arizona groups of children 6 to 19 years old. The Arizona children were Papago In- dians attending two schools. The Utah children were either former rheumatic fever patients and their parents or a matched group, none of whom had had this disease. More than 3100 men, women, and children were examined in this region. The extent and possible nutritional origins of dental caries formed one of the main lines of inquiry in Oregon, Utah, Washington, Idaho, and Montana. Regional and state publications. In the Northeast, a series of 7 regional bulle- tins incorporated all phases of the nutri- tional survey findings in a uniform and correlated manner. In addition, in that region 8 papers concerned with methods in both field and laboratory were pub- lished by two or more cooperating sta- tions, and 30 independent papers were issued by 8 states. In the North Central region, 7 regional bulletins incorporating the work of two or more states, 8 cooperative journal papers and 34 individual station papers from 8 states reported the primary data. In the South, 3 regional bulletins pre- senting the food consumption studies were issued by six states and the Bureau of Human Nutrition and Home Econom- ics, and 17 papers by six stations on the nutritional status data. In the West, five regional bulletins or papers and 55 papers from nine states were published. The total list contains 38 regional or joint bulletins or papers, and 140 inde- pendent station reports most of which have been published in scientific journals. [119] Nine of the reports used in compiling this Williams of New York ( Cornell ) , and bulletin were in manuscript form but had Clara A. Storvick of Oregon, either been accepted or approved for Assistance was rendered by the provi- publication. The total number of pub- sion of additional data, photographs, and lications reviewed was 178. constructive suggestions by Hazel K. All data mentioned and summaries pre- Stiebeling and Ruth M. Leverton, Insti- sented as tables or graphs in this review tute of Home Economics, and Lura M. are taken from these bulletins and papers. Odland, State Experiment Stations Divi- The compiled tables of data published sion, U. S. D. A., M. J. Babcock of New in the four regions are available to those Jersey, Mary M. Clayton of Maine, Walter professionally interested on application Lewis of West Virginia, Susan B. Merrow to the University of California Library, of Vermont, Catherine J. Personius of Berkeley, California. The full bibliog- New York (Cornell), Ruth Tucker of raphy is printed as an appendix to this Rhode Island, Ercel Eppright, Charlotte Bulletin. Roderuck, and Elisabeth Willis of Iowa, The Interregional Committee who Lida Burrill of South Dakota, Janice M. sponsored this publication and who ap- Smith of Illinois, Dorothy S. Moschette proved it on authorization by the four of Louisiana, Willamay T. Dean of Vir- regional Technical Committees on Nutri- ginia, Elizabeth Dyar of Colorado, Mar- tional Status was made up of Pearl P. garet M. Hard of Washington, Edith M. Swanson of Iowa (Chairman), Florence Lantz of New Mexico, Ethelwyn B. L. MacLeod of Tennessee, Harold H. Wilcox of Utah. PUBLICATIONS NE 4 and NE 16: Cooperative Nutritional Status Studies in the Northeast Region A. Regional Bulletins Our Code No.* NE 12 I. Techniques — Northeast Regional Publication No. 5. Cornell University Agr. Exp. Sta. Memoir 307, Ithaca, N. Y. Mar. 1951. NE 13 II. Physical Findings. Babcock, M. J., Bryan, A. Hughes, M. D., Clayton, Mary M., Faster, Walter D., Lawless, J. J., Tucker, Ruth, Wertz, Anne W., and Young, Charlotte M. Northeast Regional Publ. No. 8. N. J. Agr. Exp. Sta. Bull. 763, New Brunswick, N. J. June 1952. NE 11 III. Dietary Methodology Studies. Young, Charlotte M., Chalmers, Faith W., Church, Helen N., Clayton, Mary M., Gates, Lorraine O., Hagan, Gladys C, Steele, Betty F., Tucker, Ruth E., Wertz, Anne W., and Foster, Walter D. With technical assistance of: Brine, Constance, Brown, Phyllis T., Fogler, Elaine, Franklin, Ruth E., Goff, Ruth, Higg'ns, Prudence S., Smudski, Vivian L., Turner, Dorothy U. and West, Rae. N. E. Regional Publ. No. 10. U. of Agr. Exp. Sta. Bull. 469, Amherst, Mass. Aug. 1952. NE 14 IV. Dietary Findings. Tucker, Ruth E., Chalmers, Faith W., Church, Helen N., Clayton, Mary M., Foster, Walter D., Gates, Lorraine O., Hagan, Gladys C.[ Steele, Betty F., Wertz, Anne W., Young, Charlotte M. N. E. Regional Publ. No. 11. R. I. Agr. Exp. Sta. Bull. 319, Contribution 802, Kingston, R. I. June 1952. *The code numbers are used in the compiled tables of data, not printed in this bulletin, but available on microfilm (see page 130). [120] Our Code No. NE 15 V. Blood Findings. Clayton, Mary M., Babcock, M. J., Foster, W. D., Stregevsky, S., Tucker, Ruth E., Wertz, Anne W. and Williams, H. H. N. E. Regional Publ. No. 14. U. of Maine Agr. Exp. Sta. Bull. 516, Orono, Maine. May 1953. NE 16 VI. Correlations. Babcock, M. J., Clayton, Mary M., Foster, Walter D., Lojkin, Mary E., Tucker, Ruth E., VanLandingham, H., and Young, Charlotte M. N. E. Regional Publ. No. 13. W. Va. U. Agr. Exp. Sta. Bull. 361T, Morgantown, W. Va. June 1953. NE 1 VII. Contribution of Seven Food Groups to the Diet. Steele, Betty F., Chalmers, Faith W., Church, Helen N., Clayton, Mary M., Gates, Lorraine O., Murphy, Gladys C, Tucker, Ruth E., Wertz, Anne W., Young, Charlotte M. and Foster, Walter D. Assisted by Brine, Constance R., Brown, Phyll's T., Cornell, Marian Brooks and Randall, Shirley Wing N. E. Reg'l. Publ. No. 17. Cornell U. Agr. Exp. Sta. Memoir 333, Ithaca, N. Y. July 1954. B. Regional Papers NE 53 A comparison of dietary study methods. I. Dietary history vs. seven-day record. Young, C. M., Chalmers, F. W., Church, H. N., Clayton, M. M., Tucker, R. E., Wertz, A. W. and Foster, W. D. J. Am. Dietet. A. 28:124-128, 1952. NE 53A A comparison of dietary study methods. II. Dietary h'story vs. seven-day record vs. 24-hour recall. Young, C. M., Hagan, G. C, Tucker, R. E., and Foster, W. D. J. Am. Dietet. A. 28:218-221, 1952. NE 54 The dietary record — how many and which days? Chalmers, F. W., Clayton, M. M., Gates, L. O., Tucker, R. E., Wertz, A. W., Young, C. M. and Foster, W. D. J. Am. Dietet. A. 28:711-717, 1952. NE 17 Role of breakfast and of between-meal foods in adolecents' nutrient intake. Steele, B. F., Clayton, M. M., and Tucker, R. E. J. Am. Dietet. A. 28:1054, 1952. NE 42 A referee blood experiment involving the use of microchemical methods. Clayton, M. M., Babcock, M. J., Foster, W. D., Stregevsky, S., Tucker, R. E., Wertz, A. W. and Williams, H. H. J. Nutr. 52:383-393, 1954. NE 55 Subjects' esrmation of food intake and calculated nutritive value of the diet. Young, C. M., Chalmers, F. W., Church, H. N., Clayton, M. M., Murphy, G. C. and Tucker, R. E. J. Am. Detet. A. 29:1216-1220, 1953. NE 56 Can different interviewers obtain comparable dietary survey data? Church, H. N., Young, C. M., Clayton, M. M. and Foster, W. D. J. Am. Dietet. A. 30:777-779, 1954. NE 47 Examiners' ratings of color transparencies of clinical signs associated with vitamin deficienc'es. Merrow, S. B., Clayton, M. M., Newhall, C. A. and Foster, W. D. Am. J. Clin. Nutr. 5:56-61, 1957. C. Station Papers Connecticut, Storrs Station NE 44 Ascorbic acid utilization by women. Response of serum level and night urinary excretion to increasing levels of intake. Potgieter, M., Morse, E. H. and Walker, G. R. J. Nutr. 55:217-224, 1955. NE 43A A study of the eating habits and the nutritional adequacy of the diets of thirty-three women in a State training school for mental defectives. Potgieter, M., Morse, E. H. and Walker, G. R. Am. J. Mental Def. 60:335-339, 1955. NE 43 Ascorbic acid utilization by women. Response of blood serum and white blood cells to increasing levels of intake in two groups of women of different age levels. Morse, E. H., Potgieter, M. and Walker, G. R. J. Nutr. 60:291-298, 1956. NE 46 Ascorbic acid utilization by women. Response of blood serum and white blood cells to increasing levels of intake in two groups of women of different age levels. Morse, E. H., Potgieter, M. and Walker, G. R. J. Nutr. 60:229-236, 1956. NE 18 Serum cholesterol levels of young and of elderly women consuming an institution diet. Walker, G. R., Morse, E. H. and Potgieter, M. J. Nutr. 60:517-525, 1956. NE 57 Published vs. analyzed values for ascorbic acid. Morse, E. H., Potgieter, M. and Walker, G. R. J. Am. Dietet. A. 34:265-266, 1958. NE 62 Ascorbic acid and cholesterol studies on women in an institution for the handicapped. Potgieter, M., Morse, E. H., Walker, G. R. and Dayton, N. A. Am. J. Mental Def. 63:325-329. 1958. [121] Our Code No. Maine NE 9 Remodeling the school lunch for the teen-ager. Clayton, Mary M. and Ullman, Doro- thy E. Maine Agr. Exp. Sta. Bull. 475. Aug. 1949. NE 8 Breakfasts of Maine teen-agers. Clayton, Mary M. Maine Agr. Exp. Sta. Bull. 495 Nov. 1951. NE 10 Food habits of Maine school children. Clayton, Mary M. Abstract of a talk presented before Am. School Food Service Assoc, meeting in N. Y. Nov. 1951. Am. J. Pub. Health 426 (No. 8), 967-968. 1952. Massachusetts NE 31 Metabolism of nicotinic acid in pregnancy. Lojkin, M. E., Wertz, A. W. and Dietz, C. G. J. Nutr. 46:335-352, 1952. NE 3 Diets of pregnant women: influence of socio-economics factors. Murphy, G. H. and Wertz, A. W. J. Am. Dietet. A. 30:34-38, 1954. NE 52 Amino acid content of foods. Wertz, A. W., Ruttenberg, P. K., French, G. P., Mur- phy, B. H. and Guild, L. P. J. Am. Dietet. A. 32:926-928, 1956. NE 41 Nutrition in pregnancy: dietary and biochemical data. Wertz, A. W., Holden, E. M., Murphy, G. C, Lojkin, M. E., Van Horn, P. S., Guild, L. P. and Dietz, C. E. Univ. of Mass. Agr. Exp. Sta. Bull. 487. 1956. NE 59 Tryptophan-niacin relationships in pregnancy. Wertz, A. W., Lojkin, M. E., Bon- chard, B. S. and Derby, M. B. J. Nutr. 64:339-353, 1958. NE 60 Urinary excretion of amino acids by the same women during and after pregnancy. Wertz, A. W., Derby, M. E., Ruttenberg, P. K. and French, G. F. (mss.) 1958. New Jersey NE 34 Simplification of the "long method" for calculating the nutritional value of diets. Babcock, M. J. New Jersey Agr. Exp. Sta. Bull. 751. Rutgers Univ., New Bruns- wick, N. J. June 1950. NE 7 Nutritional status of industrial workers. I. Dietary, blood and physical findings. Bab- cock, M. J., Church, Helen N. and Gates, Lorraine O. Milbank Memorial Fund Quarterly 32:323-342, 1954. NE 7a Nutritional status of industrial workers. II. Effects of education, age, income and ethnic groups. Babcock, M. J., Church, Helen N. and Gates, Lorraine O. Milbank Me- morial Fund Quarterly 33:137-151, 1955. NE 33 Methods for measuring fingernail growth rates in nutritional studies. Babcock, M. J. J. Nutr. 55:323-326, 1955. New York NE 30 Fall and spring diets of school children in New York State in terms of NRC recom- mended daily allowances. Young, C. M., Smudski, V. L. and Steele, B. F. J. Am. Dietet. A. 27:289-292, 1951. NE 29 The use of checked seven-day records in a dietary survey. Steele, B. F., Franklin, R. E., Smudski, V. L. and Young, C. M. J. Am. Dietet. A. 27:957-959, 1951. NE 49 Nitrogen retention and riboflavin metabolism in human subjects fed low intakes of the vitamin. Lutz, R. M., Derby, M. B., Einset, B. M., Pierce, Z. H. and Williams, H. H. (Abstract) Fed. Proc. 15:561. 1956. NE 26 Ascorbic acid nutriture in the human. II. Content of ascorbic acid in the white cells and sera of subjects receiving controlled low intakes of the vitamin. Steele, B. F., Liner, R. L., Pierce, Z. H. and Williams, H. H. J. Nutr. 57:361-368, 1955. NE 27 Ascorbic acid nutriture in the human. I. Tyrosine metabolism and blood levels of ascorbic acid during ascorbic acid depletion and repletion. Steele, B. F., Hsu, C, Pierce, Z. H. and Williams, H. H. J. Nutr. 48:49-59, 1952. NE 28 Weekly variation in nutritive intake of young adults. Young, C. M., Franklin, R. E., Foster, W. D. and Steele, B. F. J. Am. Dietet. A. 29:459-464, 1953. Pennsylvania NE 45 The relative dynamic effects of high versus low protein diets' of equicaloric content. Swift, R. W., Barron, G. P., Jr., Fisher, K. H., Magruder, N. D., Black, Alex, Bratzler, J. W., French, C. E, Hartsook, E. W., Hershberger, T. V., Keck, E. and Stil es, F. P. Penn. Agr. Exp. Sta. Bull. 618. March 1957. 61 The effect of high versus low protein equicaloric diets on the heat production of human subjects. Swift, R. W., Barron, G. P., Fisher, K. H., French, C. E., Hart- sook, E. W., Hershberger, T. V., Keck, E., Long, T. A. and Magruder, N. D. J. Nutr. 65:89-102. 1958. [122] Our Code No. Rhode Island NE 21 Nutrition studies in Rhode Island. Tucker, R. E. and Brown, P. T., R. I. Agr. Exp. Sta. Bull. 327. Apr. 1955. NE 58 Diet and dental health. Tucker, R. E. and Brown, P. T., R. I. Agr. Exp. Sta. Bull. 340. June 1957. Vermont NE 63 Relationship between the diet and clinical time schedules of a group of student nurses. Merrow, S. B. and Labecki, G. Mss. approved for publication. 1958. NE 64 The response of gum tissue to ascorbic acid supplementation. Pierce, H. B., Newhall, C. A., Merrow, S. B., Lamden, M. P., Schweiker, C. and Laughlin, A. Mss. ap- proved for publication. 1958. West Virginia NE 2 Nutritional survey of West Virginia University students. Chalmers, F. W., Lawless, J. J. and Stregevsky, S. W. Va. Univ. Agr. Exp. Sta. Bull. 352. June 1952. NE 40 Nutritional status studies in Monongalia County, West Virginia. Chalmers, F. W., Chapman, L. L., Lawless, J. J., Lewis, W. R., Stregevsky, S., Voth, O. L. and Van Landingham, A. H. W. Va. Agr. Exp. Sta. Bull. 375T. 1955. NC 5: Nutritional Status and Dietary Needs of Population Groups in the North Central Region A. Regional Bulletins NC 2 Weights of foods eaten per meal by 242 women 30 to 92 years of age. Beegle, R. M., Roberts, P. H., Howard, N., Stiles, J. S., Pesek, I. C, Britton, M. H., Biester, A., Hutchinson, M. B., McCormick, P. L., Leverton, R. M., Chaloupka, M., Burrill, L., Alsup, B., Reynolds, M. S., Lutz, R. and Jolinette, E. Michigan Agr. Exp. Sta. Tech. Bull. 244. 32 pp. 1954. NC 40 Nutrition of 9, 10 and 11-year-old public school children in Iowa, Kansas and Ohio. I. Dietary findings. Eppright, E. S., Jebe, E., Sidwell, V. D., Marlatt, A. L. and others, Patton, M. B. and others. Iowa Agr. Exp. Sta. Research Bull. 434 and NC Reg. Publ. 59. Ames, 1955. NC 20 Quantity, nutritive content and cash value of food used by 178 families in Kansas and 268 families in Ohio. Marlatt, A. L. et al, and Patton, M. B. et al. Ohio Agr. Exp. Sta. Bull. 804, North Central Regional Publ. No. 79. 1958. NC 72 Nutritional status of 9, 10 and 11 -year-old public school children in Iowa, Kansas and Ohio. II. Blood findings. Patton, M. B., Marlatt, A. L. and Eppright, E. S. Ohio Agr. Exp. Sta. Research Bull. 794 and NC Reg. Publ. 72. 1957. NC 59 Nutrition of children in three selected schools in Iowa, Kansas and Ohio: A pilot study. Marlatt, A. L., Eppright, E. S., Patton, M. B. and Hathaway, M. L. Kansas Agr. Exp. Station Tech. Bull. 81 and NC Reg. Publ. 70. 1956. NC 74 Methods used for human metabolic studies in the North Central region. Leichsenring, J. M., Biester, A., Roberts, H., Swanson, P. P., Brewer, W., Gram, M. R., and Burrill, L. M. Minn. Agr. Exp. Sta. Tech. Bull. 225 and NC Reg. Publ. 80. 1958. NC 17 Food intakes of 2189 adult women in five North Central states. Swanson, P. P., Willis, E., Burrill, L., Biester, A., Jebe, E., Ohlson, M. A. and Smith, J. Accepted for publication as NC Reg. Publ. 83. 1959. B. Regional Papers NC 12 Intakes and retentions of nitrogen, calcium and phosphorus by 136 women between 30 and 85 years of age. Ohlson, M. A., Brewer, W. D., Jackson, L., Swanson, P. P., Roberts, P. H., Mangel, M., Leverton, R. M., Chaloupka, M., Gram, M. R., Reynolds, M. S. and Lutz, R. Fed. Proc. 11:775-783. 1952. NC 18 Blood values of women: cholesterol. Swanson, P. P., Leverton, R., Gram, M. R., Rob- erts, H. and Pesek, I. J. Gerontology 10:41-47. 1955. NC 29 Working together for a better understanding of the nutrition of school children. Patton, M. B., Eppright, E. S., Marlatt, A. L. and Hathaway, M. L. J. Home Eco- nomics 45:161-164. 1953. [123] Our Code No. NC 31 Dietary study methods. V. Some problems in collecting dietary information about groups of children. Eppright, E. S., Patton, M. B., Marlatt, A. L. and Hathaway, M. L. J. Am. Detet. A. 28:43-48. 1952. NC 13 Essential amino acids in self-selected diets of older women. Mertz, E. T., Baxter, E. J., Jackson, L. E., Roderuck, C. E. and Weis, A. J. Nutr. 46:313-322. 1952. NC 1 Anthropometry and nutritional status of adult women. Ohlson, M. A., Biester, A., Brewer, W. D., Hawthorne, B. E. and Hutchinson, M. B. Human Biology 28: 189-202. 1956. NC 73 Source of calories in the recorded self-chosen diets of women. Leverton, R. L., Ellison, J., Childs, M. T., Carver, A. F. and Twardock, D. J. Home Econ. 51:33-38. 1959. NC 76 Estimated dietary intake, urinary excretion, blood vitamin C in women of different ages. Roderuck, C, Burrill, L., Campbell, L. J., Brakke, B. E., Childs, M. T., Leverton, L., Chalupka, M., Jebe, E. H. and Swanson, P. P. J. Nutr. 66:15-28. 1958. C. Station Papers Illinois NC 7 The relation of serum cholesterol to the physical measurements and diet of women. Butler, L. C, Childs, M. T. and Forsythe, A. J. J. Nutr. 59:469-478. 1956. Indiana NC 60 Amino acid requirements of men and women. I. Lysine. Clark, H. E., Mertz, E. T., Kwong, E. H, Howe, J. M. and De Long, D. C. J. Nutr. 62:71-82. 1957. Iowa NC 16 The relation of age to fat absorption in adult women together with observations on concentration of serum cholesterol. Garcia, P., Roderuck, C. and Swanson, P. J. Nutr. 55:601-609. 1955. NC 14 Food intake and body weight of older women. Weight control — a collection of papers presented at the weight control colloquium held at Iowa State College, January 1955. Swanson, P., Roberts, H., Willis, E., Pesek, I. and Mairs, P. Iowa State College Press, pp. 80-96. 1955. NC 22 Nutritional adequacy, cost and acceptability of lunches in an Iowa school lunch pro- gram. Augustine, G., McKinley, M., Laughlin, S. L., James, E. L. and Eppright, E. J. Am. Dietet. A. 26:654-662. 1950. NC 34 Relaton of price to food selection. Nelson, P. E. J. Am. Dietet. A. 26:769-770. 1950. NC 28 Food habits of Iowa children — breakfast. Sidwell, V. D. and Eppright, E. S. J. Home Econ. 45:401-405. 1953. NC 8 Nutritive value of the diets of Iowa school children. Eppright, E. S., Sidwell, V. D., and Swanson, P. P. J. Nutr. 54:371-388. 1954. NC 9 Relationship of estimated nutrient intake of Iowa school children to physical and biochemical measurements. Eppright, E. S., Roderuck, C, Sidwell, V. D. and Swanson, P. P. J. Nutr. 54:557-570. 1954. NC 82 Management aspects of school lunch programs in Iowa. Donaldson, B. and Augustine, G. Iowa Agr. Exp. Sta. Research Bull. 448. 1957. NC 10 Physical measurements of Iowa school children. Eppright, E. S. and Sidwell, V. D. J. Nutr. 54:543-556. 1954. NC 37 Distribution of nutrients among meals and snacks of Iowa school children. Eppright, E. S. and Swanson, P. P. J. Am. Dietet. A. 31:256-260. 1955. NC 27 Distribution of calories in diets of Iowa school children. Eppright, E. S. and Swan- son, P. P. J. Am. Dietet. A. 31:144-148. 1955. NC 5 Serum vietamin C of Iowa school children and its relationship to diet and age. Rod- eruck, C, Pudelkewicz, C, Jebe, E. H. and Eppright, E. S. J. Nutr. 59:309-318 1956. NC 41 Diet and nutritional status of Iowa school children. Eppright, E. S. and Roderuck, C. Am. J. Pub. Health 45:464-471. 1955. NC 15 Food intake and body s*ze of Iowa children. Weight control — a collection of papers presented at the weight control colloquium held at Iowa State College, January 1955. Eppright, E. S., Sidwell, V. and Jebe, E. Iowa State College Press, pp 119- 131. 1955. NC 19 Very heavy and obese school children in Iowa. Eppright, E. S., Coons, I. and Jebe E. J. Home Econ. 48:168-172. 1956. [124] Our Code No. Michigan NC 58 Food selection and well-being of aging women. Kelley, L., Ohlson, M. A. and Harper, L. J. J. Am. Dietet. A. 33:466-470. 1957. NC 11 Nutrition and dietary habits of aging women. Ohlson, M. A., Jackson, L., Boek, J., Cederquist, D. C, Brewer, W. D., Brown, E. G. with technical assistance of Traver, J., Lott, M. M., Mayhew, M., Dunsing, D. and Tobey, H. Am. J. Pub. Health 40:1101-1108. 1950. Nebraska NC 26 Serum iron and hemoglobin values of 275 healthy women. Chaloupka, M., Leverton, R. M. and Diedrichsen, E. Proc. Soc. Exp. Biol, and Med. 77:677-680. 1951. NC 62 Availability to man of amino acids from foods. I. General methods. Linkswiler, H., Geschwender, D., Ellison, J. I., Fox, H. M. J. Nutr. 65:441-454. 1958. NC 63 Availability to man of amino acids from foods. II. Valine from corn. Linkswiler, H., Fox, H. M., Geschwender, D. and Fry, P. E. J. Nutr. 65:455-468. 1958. NC 73A Blood values of women 30 to 90 years of age in five North Central states. Leverton, R. M. (unpubl.) Ohio NC 24 Lunch programs in Ohio public schools. Sando, L. G. and Patton, M. B. J. Am. Dietet. A. 27:285-288. 1951. NC 77 Plate waste in a school lunch. I. Overall waste. Carver, A. F. and Patton, M. B. J. Am. Dietet. Assoc. 45:615-618. 1958. NC 77a Plate waste in a school lunch. II. Sources of waste. Patton, M. B., Carver, A. F. and Hunt, F. E. J. Am. Dietet. Assoc. 34:733-737. 1958. NC 77b Plate waste in a school lunch. III. A vegetable acceptance study. Hunt, F. E., Patton, M. B. and Carver, A. F. J. Am. Dietet. Assoc. 34:810-813. 1958. South Dakota NC 8a Food habits of South Dakota women. Burrill, L. M. and Alsup, B. S.D. Agr. Exp. Sta. Bull. 451. 1955. Wisconsin NC 6 Studies on amino acids in self-selected diets. Futrell, M. F., Lutz, R. M., Reynolds, M. S. and Baumann, C A. J. Nutr. 46:299-311. 1952. NC 35 Nitrogen balances and amino acid content of self-selected diets of women. Reynolds, M. S., Futrell, M. F. and Baumann, C. A. J. Am. Dietet. A. 29:359-364. 1953. NC 61 Nitrogen balances of women maintained on various levels of methionine and cystine. Reynolds, M. S., Steel, D. M., Jones, E. M. and Baumann, C. A. J. Nutr. 64:99- 111. 1958. NC 4 Nitrogen balances of women maintained on various levels of lysine. Jones, E. M., Baumann, C. A. and Reynolds, M. S. J. Nutr. 60:549-562. 1956. NC 80 Intake and elimination of vitamin Be and metabolites by women. I. Nonpregnant women. Marquez, L. R. and Reynolds, M. S. J. Am. Dietet. A. 31:1116-1118. 1955. NC 81 Intake and elimination of vitamin Be and metabolites by women. II. Pregnant women. Turner, E. R. and Reynolds, M. S. J. Am. Dietet. A. 31:1119-1120. 1955. S 4 and S 15: Food Consumption and Nutritional Status Studies in the Southern Region A. Regional Bulletins S 7 Family food consumption in three types of farming areas in the South. I. An analysis of 1947 food data. Dickins, D., Gillaspie, B., Moser, A. M., Staab, J., Dean, W. T., Phipard, E. F. and Anderson, R. L. Southern Coop. Series Bull. 7. 1950. S 1 Family food consumption in three types of farming areas in the South. II. An analysis of weekly food records, late winter and early spring, 1948. Dickins, D., Gillaspie, B., Moser, A. M., Staab, J., Dean, W. T., Phipard, E. F. and Anderson, R. L. Southern Coop. Series Bull. 20. 1951. S 19 Collection methods in dietary surveys. A comparison of the food list and record in two farming areas in the South. Murray, J., Blake, E. C, Dickins, D. and Moser, A. M. Southern Coop. Series Bull. 23. 1952. [125} B. Station Papers Our Code No. Alabama S 12 The urinary excretion of tryptophan by human subjects on controlled diets varying in levels and sources of protein. Frazier, E. I. J. Nutrition, 53:115-127. 1954. Arkansas S 19 & S 7 See regional bulletins. Louisiana S 6 The hemoglobin concentrations, erythrocyte counts and hematocrits of selected Louisiana elementary school children. McBee, M., Moschette, D. S. and Tucker, C. J. Nutr. 42:539-556. 1950. S 5 Ascorbic acid nutrition in children. Dallyn, M. H. and Moschette, D. S. J. Am. Dietet. A., 28:718-722. 1952. S 13 Metabolic studies with pre-adolescent girls. I. Utilization of carotene. Moschette, D. S. J. Am. Dietet. A., 31:37-44. 1955. S 14 Metabolic studies with pre-adolescent girls. II. Energy absorption. Patrick, R. M., Rich- ardson, P. S. and Moschette, D. S. J. Am. Dietet. A., 31:138-143. 1955. S 14A Metabolic studies with pre-ado'escent girls. III. Nitrogen retention. Patrick, R. M., Beamer, K. C. and Moschette, D. S. J. Am. Detet. Assoc. 31:1010-1015. 1955. S 14B Metabolic studies with pre-adolescent girls. IV. Utilization of calcium. Glidden, M. A., Morrison, R. I. and Moschette, D. S. J. Am. Dietet. A., 32:29-35. 1956. S 3 Nutritional status of pre-adolescent boys and girls in selected areas of Louisiana. Mos- chette, D. S., Causey, K., Cheely, E., Dallyn, M., McBryde, L. and Patrick, R. Louisiana Agr. Exp. Sta. Tech. Bull. 465. 1952. S 4 Nutritional status of pre-adolescent children in a French community of Louisiana. Mos- chette, D. S., McBryde, L. C, Pudelkewicz, D. and Tucker, C. J. Home Econ., 44:344-350. 1952. S 20 Food habits of Louisiana boys and girls. Morrison, R. and McBryde, L. Louisiana Agr. Exp. Sta. Bull. 510. 1957. Mississippi S 19 See regional bulletins. S 7 See regional bulletins. North Carolina S 19 See regional bulletins. S 7 See regional bulletins. South Carolina S 19 See regional bulletins. S 7 See regional bulletins. Tennessee S 8 Utilization of calcium, phosphorus, riboflavin and nitrogen on restricted and supple- mented diets. Schofield, F. A., Williams, D. E., Morrell, E., McDonald, B. B., Brown, E. and MacLeod, F. L. J. Nutr. 59:561-577. 1956. S 18 Influence of mineral intake on bone density in humans and in rats. Williams, D. E., McDonald, B. B., Morrell, E., Schofield, F. A. and MacLeod, F. L. J. Nutr. 61- 489-505. 1957. S 19 & S 7 See regional bulletins. Texas S 22 Human utilization of ascorbic acid. Whitacre, J., McLaughlin, L., Futrell, M. F. and Grimes, E. T. J. Am. Dietet. A. 35:139-145. 1959. S 21 Calories and essential ammo acids in an experimental diet. Futrell, M. F., Weddle, E., Grimes, E. T. and Whitacre, J. J. Am. Dietetic A. 34:1208-1213. 1958. S 23 Human utilization of ascorbic acid: a review of publications. Whitacre J J Home Econ. 45:235. 1953. Virginia S 16 Nutritional status of women industrial workers in Virginia. Dean W T T Am Dietet A., 32:24-28. 1956. S 2 Nutritional status of pre-adolescent boys and girls in the Blacksburg School District Dean, W. T., Davis, B. C. and McConnell, S. L. Va. Agr. Exp Sta Tech Bull 122. 1954. S 1 9 See regional bulletins. S 7 See regional bulletins. [126] W 4: Cooperative Nutritional Status Studies in the Western Region A. Regional Bulletins Our Code No. W 7 Cooperative nutritional status studies in the Western region. I. Nutrient intake. Wilcox, E. B., Gillum, H. L. and Hard, M. M. Utah Agr. Exp. Sta. Bull. 383. Western Regional Research Publication. 1956. W 99 Variat'on in dental caries experience among children in five Western states. Tank, G., Warnick, K., Esselbaugh, N. C. and Storvick, C. A. Ore. Agr. Exp. Sta. Tech. Bui. 45, Western Regional Publication. 1959. W 98 Cooperative nutritional status studies in the Western region. II. Bone density. Odland, L. M., Warwick, K. P. and Esselbaugh, N. C. Montana Agr. Exp. Sta. Bull. 534. 1958. W 97 Biochemical and physical findings in the Western region. Dyar, E., Gillum, H. L., Kemmerer, A. R. and Lantz, E. M., to be published. B. Regional Papers Our Code No. W 58 Micro determination of cholesterol by use of 0.04 ml of blood serum. Galloway, L. S., Nielsen, P. W., Wilcox, E. B. and Lantz, E. M. Clinical Chemistry 3:226-232. 1957. C. Station Papers Our Code No. Arizona W 1 The nutritional status of Papago Indian children. Vavich, M. G., Kemmerer, A. R. and Hirsch, J. J. Nutr. 54:121-132. 1954. W 2 Effect of non-fat milk on the utilization of carotene and vitamin A. Vavich, M. G., Stull, J. W., Raica, N. and Kemmerer, A. R. Archives Biochem. Biophys. 55:310- 314. 1955. California W 6 Nutritional status of the aging. I. Hemoglobin levels, packed cell volumes and sedi- mentation rates of 577 normal men and women over 50 years of age. Gillum, H. L. and Morgan, A. F. J. Nutr. 55:265-288. 1955. II. Blood glucose levels. Gillum, H. L., Morgan, A. F. and Williams, R. I. J. Nutr. 55:289-303. 1955. III. Serum ascorbic acid and intake. Morgan, A. F., Gillum, H. L. and Williams, R. I. J. Nutr. 55:431-448. 1955. IV. Serum cholesterol and diet. Gillum, H. L., Morgan, A. F. and Jerome, D. W. J. Nutr. 55:449-468. 1955. V. Vitanr'n A and carotene. Gillum, H. L., Morgan, A. F. and Sailer, F. J. Nutr. 55:655-670. 1955. VI. Serum protein, blood non-protein, nitrogen, uric acid and creatinine. Morgan, A. F., Murai, M. and Gillum, H. L. J. Nutr. 55:671-685. 1955. W 10 Nutritional status of the aging. Chope, H. D. and Breslow, L. Amer. J. Pub. Health 46:61-67. 1956. W 11 Relation of nutrition to health in aging persons. A four-year follow-up of a study in San Mateo County. Chope, H. D. California Medicine 81 :335-338. 1954. W 12 The nutritional status of the aging. Chope, H. D. and Dray, S. Public health aspects. California Medicine 74:105-107. 1951. W 13 The San Mateo study of the nutritional status of the aging. Morgan, A. F. California's Health 13:65-70. 1955. W 36 The influence of alpha-tocopherol upon the utilization of carotene and vitamin A. Hebert, J. W. and Morgan, A. F. J. Nutr. 50:175-189. 1953. W 37 The effect of hypothyroidism on the metabolism of carotene in dogs. Arnrich, L. T. Nutr. 65:35-49. 1955. W 38 The utilization of carotene by hypothyroid rats. Arnrich, L. and Morgan, A. F. J. Nutr 54:107-119. 1954. Idaho W 30 Nutritional status of school children 15 and 16 years of age in three Idaho com- munities. Warnick, K. P., Bring, S. V. and Woods, E. U. of Idaho Agr. Exp Sta Research Bull. 33. 1956. [127] Our Code No. W 32 Dental caries prevalence in children 15 and 16 years of age in three Idaho communities. Porter, K. O. and Woods, E. J. Dental Research 33:542-551. 1954. W 33 Nutritional status of school children 15 and 16 years of age in three Idaho communi- ties; blood biochemical tests. Bring, S. V., Warnick, K. P. and Woods, E. J. Nutr. 57:29-45. 1955. 1 W 34 Nutritional status of adolescent Idaho children. I. Evaluation of seven-day dietary rec- ords. Warnick, K. P., Bring, S. V. and Woods, E. J. Am. Dietet. A. 31:486-490. 1955. W 33 A Nutritional status of adolescent Idaho children. II. Food habits. Warnick, K. P., Bring, S. V. and Woods, E. J. Am. Dietet. A. 31:1143-1146. 1955. Montana W 40 Dietary studies of Montana fifteen-year-olds and of Montana college freshmen. Odland, L. M., Page, L. and Guild, L. P. Montana State College Agr. Exp. Sta. Tech. Bull. 518. 1956. W 41 The influence of ascorbic acid and the source of the B-vitamins on the utilization of carotene. Mayfield, H. L. and Roehm, R. R. J. Nutr. 58:203-217. 1956. W 42 Carotene utilization as influenced by the addition of vitamin Bi 2 to diets containing yeast or a synthetic vitamin mixture. Mayfield, H. L. and Roehm, R. R. J. Nutr. 58:483-493. 1956. W 43 Dental studies of Montana college freshmen and of Montana adolescents. Odland, < L. M., Page, L. and Mayfield, H. L. Montana State College Agr. Exp. Sta. Tech. Bull. 506. 1955. W 44 Nutrient intakes and food habits of Montana students. Odland, L. M., Page, L. and Guild, L. P. J. Amer. Dietet. A. 31:1134-1142. 1955. W 45 Dental caries experience of Montana students. Odland, L. M., Page, L. and Dohrman, S. T. J. Am. Dietet. A. 31:1218-1222. 1955. W 46 Clinical and biochemical studies of Montana adolescents. Odland, L. M. and Ostle, R. J. J. Am. Dietet. A. 32:823-828. 1956. W 47 Serum alkaline phosphatase relationships in nutritional status evaluation of adolescents. Odland, L. M. and Ostle, R. J. Fed. Proc. 13. (Abstract) 1954. W 61 Nutritional status of Montana fifteen-year-olds and of Montana college freshmen. Guild, L. P. and Odland, L. M. Montana Agr. Exp. Sta. Tech. Bull. 536. 1958. W 66 Carotene utilization and cholesterol metabolism as influenced by added choline and vitamin Bi 2 to diets containing yeast or a synthetic vitamin mixture. Mayfield, H. L. and Roehm, R. R. J. Nutr. 64:571-586. 1959. W 68 Bone density studies of normal human subjects. Odland, L. M. Proc. 4th Int'l Congress Nutr. 1:266 (Abstract) July 1957. ' 4 New Mexico W 5A-B Nutrition of New Mexican Spanish- American and "Anglo" adolescents. I. Food habits and intakes of essential nutrients. II. Blood findings, height and weight data and physical condition. Lantz, E. M. and Wood, P. J. Am. Dietet. A. 34 138-1 53 1958. W 71 The nutritional condition of New Mexican children. Lantz, E. M. and Wood, P. J Am Dietet. Assoc. 34:1199-1207. 1958. * Oregon W 14 Nutritional status of selected population groups in Oregon. I. Food habits of native born and reared school children in two regions. Storvick, C. A., Schaad, B., Coffey, R. E. and Deardorff, M. B. Milbank Memorial Fund Quarterly 29:165-183. 1951. W 15 Nutritional status of selected population groups in Oregon. II. Biochemical tests of the blood of native born and reared school children in two regions. Storvick C. A., Hathaway, M. L. and Nitchals, R. M. Milbank Memorial Fund Quarterly ■+ 29:255-272. 1951. W 17 Dental caries experience among selected population groups in the State of Oregon. Hadjimarkos, D. M., Storvick, C. A. and Sullivan, J. H. Oregon State College Agr. Exp. Sta. Tech. Bull. 19. 1950. [128] Our Code No. W 23 Geographic variations of dental caries in Oregon. I. Dental status of native born and reared school children in two reg ; ons. Hadjimarkos, D. M. and Storvick, C. A. J. Dental Research 28:415-423. 1949. W 24 Geographic variations of dental caries in Oregon. II. Dental caries among institution- alized children and the possible influence of certain ecological factors on its incidence. Hadjimarkos, D. M. and Storvick, C. A. J. Dental Research 28:594- 599. 1949. W 25 Geographic variations of dental caries in Oregon. III. A consideration of the influence of some environmental factors on the caries experience of native born and reared school children in two regions. Hadjimarkos, D. M., Storvick, C. A. and Sullivan, J. H. Oral Surgery, Oral Medicine and Oral Pathology 3:481-491. 1950. W 20 Geographic variations of dental caries in Oregon. IV. Observations on first molars. Hadjimarkos, D. M. and Storvick, C. A. Amer. J. Pub. Health 40: No. 12. 1950. W 48 Riboflavin metabolism of women on controlled diets. Wu, M., Warren, E. and Stor- vick, C. A. J. Nutr. 51:231-240. 1953. W 79 Micro determination of glutamic-oxalacetic transaminase in blood serum. Hermann, F., Brookes, M. H. and Storvick, C. A. (In Press) 1958. W 53 Statistical interpretation of salivary analyses on 555 school children in two geographic areas in Oregon. Sullivan, J. H. and Storvick, C. A. J. Dental Research 29:173- 176. 1950. Utah W 26 Dental caries experience of some freshman college students in Utah. Dental caries experience of a group of school children at Ogden, Utah, with and without rheumatic fever. Wilcox, E. B., Greenwood, D. L. and Galloway, L. S. J. Dental Research 31:844-848, 849-853. 1952. W 29 Children with and without rheumatic fever. I. Nutrient intake, physique and growth. II. Food habits. III. Blood serum vitamins and phosphatase data. IV. Hemoglobin, packed red cells, red and white cell count, sedimentation rate, blood glucose, serum iron and copper. Wilcox, E. B. and Galloway, L. S. J. Amer. Dietet. A. 30:345-350; 453-459; 1231-1238, 1954. 31:45-51, 1955. Washington W 8 Nutritional status of selected adolescent children. I. Description of subjects and dietary findings. Hard, M. M. and Esselbaugh, N. C. Am. J. Clin. Nut. 4:261-268. 1956. W 9 Dental caries experience among Washington born and reared freshman students at the State College of Washington in 1950. Jacobson, F. L., Esselbaugh, N. C. and Hard, M. M. J. Dental Research 35:132-136. 1956. W 60 Nutritional status of selected adolescent children. II. Vitamin A nutrition assessed by dietary intake, serum levels, biomicroscopic and gross observations. Donald, E. A., Esselbaugh, N. C. and Hard, M. M. Am. J. Clin. Nutr. 6:126-135. 1958. W 59 Nutritional status of selected adolescent children. III. Ascorbic acid nutriture assessed by serum level and subclinical symptoms in relation to daily intake. Hard, M. M., Esselbaugh, N. C. and Donald, E. A. Am. J. Clin. Nutr. 6:401-408. 1958. W 81 Food patterns of Washington adolescent children. Hard, M. M. and Esselbaugh, N. C. Mss. approved for publ. 1959. Wyoming W 72 Effect of altitude and diet on hematopoiesis and serum cholesterol. Payne, I. R. J. Nutr. 64:433-446. 1958. [129] APPENDIX The following are titles only of tables compiled during the research reported in this bulletin. The tables themselves have been recorded on microfilm and are available as follows: Positive film strips for use in a microfilm reader are on deposit in the Agricultural Reference Service, University of California Library, Berkeley, and in the Library of the U. S. Department of Agriculture, in Washington, D. C. These are identified in the card catalog as follows: Morgan, agnes fay, Editor Nutritional Status, U.S.A. Bulletin 769, California Agricultural Exp. Sta. October, 1959. Microfilm supplement, appendix tables. Copies of the entire microfilm supplement may be purchased from Library Photo- graphic Service, University of California, Berkeley. The price for the entire strip is $1.25. Checks or money orders should be made payable to The Regents of the Uni- versity of California, and sent with orders to the Library Photographic Service. Specify L.P.S. Misc. Microfilm No. 34. Copies of individual tables within the microfilm strip, enlarged to approximately 8V^" x 11", may be obtained from the Library Photograph Service. The cost is $1.50 postpaid for one to four prints; 35$ postpaid for each additional print. Specify Misc. Microfilm No. 34 and give numbers of section and tables desired. TABLES OF DATA Section of Bulletin Table 1. Average amounts of foods consumed by children, in pounds per week. Table 2. Average amounts of foods consumed by adults, in pounds per week. Table 3. Fat intakes of children and adults in 6 North Central, 7 Western and one Southern state. Table 4. Summary of average amounts of food consumed by children, in pounds per week. Table 1. Mean daily calorie, protein, calcium, iron and vitamin intakes of children and adolescents. Table 2. Mean daily calorie, protein, calcium, iron and vitamin intakes of adults. [130} Section of Bulletin Table 3. Table Mean nutrient intakes of children and adolescents compared with (1958) recommended allowances. Mean nutrient intakes of adults compared with (1958; recom- mended allowances. Table 1. Table 2. Table 3. Table 1. Table 2. Table 3. Table 4. Table 5. Table 1. Table 2. Table 3. Percentage of children and adolescents receiving less than two- thirds the recommended allowances of nutrients. Percentage of adults receiving less than two-thirds the recom- mended allowances of nutrients. Summary of percentages of children and adolescents receiving less than two-thirds of the recommended allowances of nutrients. Blood composition, Northeastern region, children and adults. Blood composition, Virginia and Louisiana children. Blood composition, Iowa, Kansas and Ohio children, 9 to 1 1 years old. Blood composition, Iowa children. Blood composition, Western region, children and adults. Heights and weights of children in all regions. Some average body measurements and percentage of children in Wetzel grid physique channels. Underweight and overweight in adults. Table Table Table Table Table Table 4. Incidence of physical signs possibly associated with nutritional deficiencies. Summary of physical signs possibly associated with nutritional deficiencies. Skin and eye symptoms in children and adolescents and their possible association with vitamin A or riboflavin deficiencies. Skin and eye symptoms in adults and their possible association with vitamin A or riboflavin deficiencies. Mouth, tongue and gum symptoms in children and adolescents and their possible association with ascorbic acid deficiencies. Mouth, tongue and gum symptoms in adults and their possible association with ascorbic acid deficiency. l6w-10, , 59(H.N.Press)\VP