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Food and Health: Medical Aspects of the Modern Food Supply CHARLES S. DAVIDSON Associate Professor of Medicine, Harvard Medical School; Associate Director, Second and Fourth Medi- cal Services (Harvard), Boston City Hospital I am honored to be included in this group of experts in the fields of food and nutrition. I'm not entirely sure why I was included. Some years ago, when Alexander Woollcott was asked to speak at the convention of a fraternity of which he was not a member, he likewise confessed, first, that he felt this was an honor, but on second thought, wasn't it a chance for the fra- ternity brothers to laugh a little at what those other fellows, non-members, looked like? I certainly am a non-member, just a physician with a hobby of nutrition. So not being the expert on this panel today, I expect I was put in for comic relief. The science of nutrition as a part of medical practice was already important around the turn of the century, but the science itself was very young, especially as practiced by physicians. Foods were generally "natural," little processed or preserved. There was much discussion in medical circles of acid and alka- line foods, of feeding a cold and starving a fever. Little or nothing was known of vitamins, and the medical understanding of deficiency diseases was just beginning. In fact, in 1912, an expedition to the South Pole was planned without any source of ascorbic acid (vitamin C) in the ration. This is particularly re- markable in that 160 years had elapsed since James Lind, 1753, physician to the Royal Navy, conducted a beautiful piece of 43
clinical investigation which clearly proved the therapeutic bene- fits of lemons in curing, and for that matter, preventing scurvy. In the last 50 or 60 years, however, food science and the science of nutrition have, of course, progressed dramatically. Along with this has gone a great deal of effort on the part of many to acquaint the consumer with various aspects of modern knowledge of nutrition. It is uncommon today to find a woman's magazine without some "authoritative" article on nutrition. Such magazines usually contain advertising, directed to the housewife as well as other members of the family, which conveys con- siderable information, although sometimes it must be confessed misinformation as well. Food faddists and food quacks have capitalized on the new interest in nutrition, and their material likewise finds a ready consumption by housewives and other consumers. This is a sizeable and important problem to grapple with for those concerned with nutrition and for the food industry itself. Important as it is, this is not the major matter I would like to discuss, although we will return to it. Chiefly, I would like to suggest that closer working ties between physicians, the food industry, and nutrition scientists might accomplish a great deal in the field of medical nutrition and so-called special-purpose foods. May I illustrate this by giving two examples: First, foods for sodium-restricted diets. The general use of sodium-restricted diets by physicians has only been spread widely in the last ten years. This is surprising since the effectiveness of restriction in the intake of salt was known to be related to fluid accumulation in heart disease in 1901. In 1922 Allen and his colleagues first advocated salt restriction in the treatment of hypertension. Still little use was made of sodium-restricted diets until Kempner, in 1944, advocated his "rice-fruit diet" and attention became fo- cused upon sodium-restricted diets. The use of sodium-restricted diets in the past ten years has increased immensely so that now, for example, on the medical wards of my own Boston City Hospital it is the most frequent special diet prescribed. Now, it is not easy to develop a severely sodium-restricted diet; much more is necessary than simply eliminating salt at the table and in the cooking of food. Many natural foods contain sodium, especially animal foods, the very foods which are likely 44
to contain the most and highest quality protein and the greatest content of the vitamins of the B complex. Moreover, many foods have sodium added in one form or another during process- ing and packing. For example, peas which are normally quite low in sodium, but otherwise nutritionally valuable, are fre- quently floated off brine during a process which usually con- tributes a considerable amount of sodium to both the tinned and frozen product. Thus, to prepare a diet adequate in calories, protein, vitamins, and other nutrients, and yet restricted to a low figure in sodium, requires a great deal of knowledge on the part of the physician and dietitian, cooperation of manufacturers who produce foods, and finally transmission of all the available in- formation to physicians and dietitians. Believing that communication of this sort of information to physicians, dietitians, food industry, and others was important, the National Research Council's Food and Nutrition Board pre- pared in 1954 a report on this subject which contained a table of the then known sodium content of foods, together with com- mentary on their value and use. During the past years the Council on Foods and Nutrition of the American Medical Asso- ciation has issued statements on the sodium content of certain foods and the use of sodium-restricted diets and, prior to the discontinuance of its acceptance program, provided information to the physician through the Journal of the American Medical Association concerning the actual sodium content of foods as processed and packed by the food industry. In addition, several manufacturers, notably, first, Doctor Bills of the Mead Johnson Company, have produced information about the sodium content of foods. Unfortunately, now that the Council on Foods and Nutrition acceptance program is no longer in force, physicians and others perusing the American Medical Association's columns can no longer learn about the food produced specifically to be low in sodium and for use in sodium-restricted diets and are not, then, informed of the new foods available for this situation or changes in manufacturing which may alter the sodium content of foods. Perhaps you think the physician is now well educated in this realm; such is not the case. Nutrition is not an interesting sub- 45
ject to most physicians until they are driven to learn something about it, and most are unable to keep up with the current litera- ture, particularly when it is not directed to the physician in this field. It is just not possible for the physician to keep up with the finer ramifications of this subject. To fill in this breach many food industries and industry associations have in their advertising described to the physician the sodium content of many foods. In most instances this advertising has been helpful and educa- tional, but sometimes not. The physician is not in a position to know what to believe, or what not to believe, unless it comes from some relatively authoritative source. This story of sodium-restricted diets is one of the better han- dled, I believe. Furthermore, it is not one involving to any great extent major items in the diet and therefore not very large amounts of food. More recently the doctor has become concerned about fats in the diet. This is the second example of the problem I am dis- cussing. Certainly the complications of atherosclerosis are one of the most important medical problems today. Among other things the quantity and quality of fats consumed appear to be related to the cause of atherosclerosis. There is a great deal in the professional medical literature on the subject. There are many conflicting opinions; but most everyone now agrees, that is among the experts, that a person clearly afflicted with this disease should make some marked changes in the fat content of his diet toward the inclusion of more unsaturated fatty acids and less saturated fatty acids. This involves a much larger number of persons and presumably a larger bulk of food than the altera- tions required for the sodium-restricted diets. Thus, this is of great concern to agriculturists and members of the food industry, as well as to physicians and dietitians. Because of this great interest and its obvious importance, both the Food and Nutrition Board and the Council on Foods and Nutrition have publications on this subject, and yet when it comes to the physician and nutritionist working together to make a special diet for the treat- ment of atherosclerosis for a particular patient, many practical facts are lacking and physicians find them hard to obtain ex- 46
cept perhaps from the popular TV screen and certain popular advertising. There are many other examples: foods for aging persons, for infants, and those used in many other diseases. These two ex- amples, however, point out to some degree, I hope, what I consider to be a major problem for the food industry today; that is, the provision of information for the physician on the composition of foods and their utility as special purpose foods and their use for special diets. Such information should be pub- lished promptly and must be up-to-date, easily available, as reliable as possible, and uncolored by the necessity to promote a particular type of food or food product. I believe that this is somewhat akin to the problem in the drug industry which hope- fully will, before long, itself form an organization to pass on to the physician reliable material concerning the indications and the contra-indications for drugs. The food industry might even take the lead, although the problem is even more complicated than that of the pharmaceutical group. My proposal, then, is that those manufacturers producing spe- cial-purpose foods, or believing that their foods may be useful for a special purpose, have a group of scientifically trained impartial personnel which would make the best possible judg- ment of the food, learn as much as possible about its composition, method of preparation where this is germane, indications and contra-indications for its use, and then communicate this infor- mation discreetly but clearly to the physician, nutritionist, and others concerned, for their use. The organization of such a group would be difficult, to say the least, and clear-cut rules would have to be laid down for its operation. Nevertheless, this would seem to me to be a real contribution to medical care. Further- more, and here I return to the physician's customary lack of interest in nutrition, I believe this would stimulate his interest in food and food products as the powerful therapeutic tools they are in medical therapy. 47