Perspectives

Ecological

in Nutrition
Factors
NEVIN

in Nutritional
S. SCRIMSHAW,
PH.D.,

Disease

M.D.*

I M
demic is too ease.
agent

T is

hoped
to

that

Perspectives

in

Nutrition

will
to medical

review

the

literature

selectively,

in-

terpret
stimulation

it moderately
nutritional

and

present

a spectrum

of ideas that will serve problems.

as a continual

research

applied

Downloaded from ajcn.nutrition.org by guest on August 15, 2013

EDICINE

has

always

been

concerned

with aca-

and

environmental

factors

influence

both

the

the

cause

of

disease.

In the cause the agent point

whose

modern

medicine, however, often equated with From

is merely

of a disease of the disof view

two

agent and the nature tween Just disease agent

the host and and outcome and host.

may, in turn, determine of the interaction bethe agent of an infectious to describe its cause, deficiency to explain to iron

an epidemiologic
one of a triad

the
other

as identifying is not sufficient

so

components

are host

factors

and

environmental

factors. Neither the presence of a pathogenic agent nor the deficiency of an essential nutrient alone determines whether or not disease will occur. For example, what is the cause of tuberculosis ? If it were merely infection with the tubercle bacillus, nearly all of us would long since have contracted the clinical disease. Yet we know that with entries without most sick of contracting of us who people tubercle have bacilli clinical have worked into tuberculosis. our extensively repeated lungs experienced

the agent of nutritional of a specific nutrient, the occurrence what extent the cause

disease, the is not sufficient

of the disease. is a dietary

For example, deficiency of microcytic

of hypochromic,

anemia.

The iron intake of a person with such an anemia might be quite adecjuate were it not for the abnormal iron loss resulting from severe hookworm phates sorption
menorrhagia,

disease

or

from

excessive

phos-

in the diet interfering ; or from abnormal

a duodenal ulcer

with iron abblood loss due to

or a hemolytic

disorder,

or even

from

an excessive and of the

loss

of iron

The same exposure, however, in a malnourished or otherwise susceptible person might have resulted in death from acute febrile tuberculosis. Infection disease. fectious agent is obviously Host factors to produce not the synonymous with clinical the disease, with in-

in sweat. Environmental make a given intake

host factors may nutrient wholly

combine

adequate or grossly deficient. In other words, it is the interaction of host, agent and environment which causes the disease. Too often the medical student and young house officer is encouraged then to against medicine
measures

to identify concentrate the agent. has

against

the on

agent

From the Massachusetts Massachusetts.

*Professor Nutrition Presented

Department of Nutrition and Institute of Technology, Contribution No. 549.

of and at Food Nutrition, Science. Man of Medicine, and

Food Science, Cambridge,

of

of disease and peutic action modern

tive

theraBecause effecof

clinical
counter

developed
the agents

Head,

Department

most
well

diseases,
in the

this
hospital.

approach
However,

generally
it may

works
fail

Colloquium College

Environment, New York, New

Albert York,
American

Einstein

miserably
tient returns

in preventing
to the

a relapse
environment

once
from

the
which

pahe
1964

May

27, 1963.
.Tournal of Clinical Nutrition
112

Vol. 14,

February

Ecological
came, disease ally disease and ineffective. as an approach Preoccupation to

Factors
prevention and usuhealth of

in

Nutritional
came to much

Disease
the same conclusions. He

113
also

in a population,

it is irrational of public

emphasized of normally a
contaminated

the importance nonpathogenic

foods fed to

of the organisms
young

high level in grossly

children in

authorities
is

with
likely attack chain

the
to

agent
result the in disease

as

the
control at

cause

of

measures

these The
diarrhea

areas. newly
occurs

which
they link do

are
not in the

uneconomical
of multiple

or ineffective
causation.

because
a vulnerable

recognized
because

syndrome
of of life the

of weanling
synergism of

malnutrition example. As
nent cause in the

and
second

infection.
year

It factors the
are

is most
because and

promivarious

Weanling Gordon a recent

derdeveloped

diarrhea

is a good

has pointed out for the first time in review, in most of the technically unareas of at the the world there is which etiologic this syna

environmental
a peak

and
of both

host

combine
massive

to postduring to for

malnutrition

enteric
weaning this many time

infection
period. the organisms

during
It should children of

weaning
be noted being

and
that exposed

characteristic
diarrheal is an entity. disease epidemiologic

increase
rather

in
time

the
than studies

frequency
an of

of

of weaning

varying

pathogenicity

Microbiological

the
munity.

first

time

and

possess

little

acquired which used

imare by

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drome give exceedingly varied and equivocal results. Depending upon the population studied, only from 20 to 40 per cent of cases can be accounted
las, of is pathogenic

The vital statistics of a country, of course the same ones compiled the international health agencies, disease only
most

and

for are

by known
strains of viral with

pathogens.
Escherichia

Shigelcoli have and

do not

reveal

salmonellas
frequency.

found
Most

in this

decreasing of enteric
weanling

order
failed

the true children.

intestinal

basis for diarrheal They indicate

disease is the

in preschool that gastrocause of

studies

common

to show
higher

that
in

the
children

proportion

viruses
diarrhea

death Public
elude

in the health
from

one to authorities
data

four have
that

year age tended

should

group. to constress

than in those without. The characteristic

is
of

these

they

feature
occurs

of
when

the

syndrome
the supply

the the the

construction to prevent rural

of

of latrines infection. Indian highland

Central

and

sanitary village
the and

water of Santa
of Panama

that

the

diarrhea

supplies In the
Maria Nutrition

breast nutritional
supplementary is both

milk is no longer adequate needs of the child and

or grossly substitute in child feeding protein deficient

for when
provided and

Cauqu#{233} in

Guatemala, America

Institute

other

(INCAP) apply for be

tensively

has the

managed public enteric

experimentally health far

carried

to measures more inon a

nutrients
tion. In

and
addition

contaminated
the

by
is

poor
more

sanitalikely

conventional
than could

controlling

infection
be

to

be

playing direct time

come nutritional other The can in the some diarrhea

in

the

dirt

and with

even

to

out

coming in the same

ment cause rates high. diarrhea gens cases have of from

contact his growth

to a virtual deficiency, infectious indicate associated

feces. At and developstandstill and fatality are although pathoof which number also be-

national scale. After been no recognizable

ease village. in children under

three years there still decrease in diarrheal

five years of age in

has disthe

diseases that with a greater to organisms known

The drinking

measures water,

instituted a sanitary

have privy

included for

safe every

data be cases, is

in due

normally
nourished

would
host.

not

be

pathogenic

in

a well

house, the full-time services of a sanitary inspector, and the establishment of a clinic with a nurse and doctor in attendance. These did not reduce morbidity from diarrheal disease when no associated nutritional measures were
taken handling or changes made within in the food home. preparation Spread and of the

Sabin,
February on the

in a paper presented in Geneva last at the United Nations Conference

Application of Science and Technology

for

the

Benefit

of the

Less

Developed

Areas,

diarrheal disease within the family

was shown group, not

to be by contact by water or flies.

114
In a similar village, Santa Catarina,

Scrimshaw
in which

no medical or sanitary changes but in which the children were supplement

protein per

were introduced given a dietary

of good quality there was

toward relatively tant

Malaya, being

disappearance recently in
small but introduced

of beriberi rural areas

mechanical extensively,

a disease. was not an of Thailand

mills, do

Until imporaI1d

problem

containing
day plus other

30

gm.

which a

are more

nutrients,

a decrease in the quency of diarrheal period. fectious

and some ing of cases the

duration, disease that

of a of

severity over the the in the

known lead the to an

and fresame time for an inin ; this

efficient

job

of

polishing

the

rice

than

handmethod a tragic
infantile milk is

It is obvious agent
identification did not causation

search

pounding, which for generations.

increase form. In in beriberi, the

had been the standard The result has been

particularly case the the mothers latter

of diarrhea
really

weanling
pathogen understandsyndrome

child

so deficient inupon

in

thiamine suddenly and

that

many die are

breast-fed within also cities women

in

required volved. The all three One of

way of in disease by

recognition occurrence factors-agent, the clearest

which varies the with

of the of any

multiple disease and

factors depends

infants become matter of hours. Kwashiorkor

ill and marasmus burgeoning because

a inof are

host indications
prevalence time,

environment. of this is the

and nature person. and

creasing in many of the Latin America and Africa

weaning tion because of the of their more children well-to-do and

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earlier, or

either in order

imitato work

place drawn

at industrial to provide substitutes.

Another

or domestic
ignorance

jobs. with
time

Unfortunately,
they fail

The
trated

operation
specific

of

these
examples

factors disease.
WITH

can
from

be

illuseither

poverty,

their
aspect

children
of the

proper
distribution

food
of

nutritional

or infectious
CHANGES

IN DISEASE

TIME

In 1900 in children
City still children from 471) was 1 796

the
4,496 and one per

death one
per in four 100,000

rate year

from

diarrheal in New
1920 45. this 120 In

disease York
it changed in 1920 was For

disease we are
United of about

is periodic accustomed
States two type to three

occurrence. to the
A influenza years

For example, fact that in the

has and a periodicity type B of not

under

of age
it was of 1901 age to

100,000. 1961 years in

only

less

than

four

to about generally

six

years.

Epidemics years peak

of and each
when

to

measles occur poliomyelitis

year also in are the often late

every two reaches a

Nutritional Pellagra

and
this

only
dramatic

2.4

in and

1961. host

Obviously, factors
but the

many involved
rates in

enin
New

summec. periodic.

diseases appears

vironmental York worse

areas

are early

decline,

the result
during is

population of the
a long at reached

becomes gradual
winter just a time or before

depleted
dry the when season. new

of niacin of food
The crops to

as a
peak are sun-

City than
today.

as recently in

as the

1900s

were

exhaustion

supplies

technically the same

dystrophy,

underdeveloped reason

For
schaden

somewhat
or starch

mehlnarwas

harvested,

exposure

which

light
contributes

as

result
to the

of

working

in
of

the
the

fields,
skin

exceedingly common of the century and too to much infants, carbohydrate has
is recognized

in Europe at the beginning which came from feeding and

as nothing

exacerbation

too

little Now
more

protein mehinarthan the

lesions. In some

countries

kwashiorkor

has

demon-

disappeared.

schaden

severe protein malnutrition of kwashiorkor. The best example of the virtual disappearance of a nutritional
is pellagra, thousands which of victims

strated a distinct periodicity usually following, by a few weeks, the peak frequency of diarrheal disease which serves as a precipitating factor. Like other infections, diarrheal disease causes a
loss is diet; and of appetite, the metabolic the and there is a tendency toward

disease
in the

from
early in the

the
South

United
1930s and is not

States

claimed
today always

ingestion

of a more

liquid
loss absorption

and

more
of nitrogen

deficient
is increased from

of nitrogen

almost

unheard

of in that
the

region.
trend

sometimes

Unfortunately,

the

gastrointestinal

tract

is decreased.

Pur-

Ecological
gatives worms are which often are direction, administered believed to the close be to get

Factors
rid of the for be-

in

Nutritional being
closer The

Disease lower
to fact the

115 areas
distribution

in
that

equatorial
the

than
of

in those
endemic

responsible

poles.

the tween
hardly

condition.
same

With

all these and

For

factors

operating disease
reasons,

in the

relationship

goiter
stances

is

also and

influenced
diet, hardness

by incidence
factors of

goitrogenic
of water as food argument and social-in less and

subwater

kwashiorkor
surprising.

diarrheal
the other same

is
in-

in the reduced diets, areas only

polution,
being nous goitrous salt

that
by and importation

the
such

is currently
monotononof for the the from iodization

creases
epidemics municable

in the
of

occurrence
measles and

of kwashiorkor
common

follow
com-

diseases.

prophylactic the

strengthens

VARIATION

OF

DISEASE

WITH

PLACE

importance
factors

of all three
-physical,

types

of environmental

biological

The
ascariasis and soil

distribution
is obviously conditions

of
which

hookworm
closely will related support

disease
embryo-

and

to climate

causation Today are

by

of nutritional most of the differentiated

of social, In little is due degree

disease. classic deficiency in place

economic to and understand from of thiamin,

diseases distribution

sharply
the

Downloaded from ajcn.nutrition.org by guest on August 15, 2013

nation of eggs. or nonexistent,

as must in the is beware desert, diseases

Where the soil as in the Arctic,

the propagation impossible. the lives.

is frozen or is dry
of But

hard sand,
these one and

technical this knowing pellagra

development. distribution, that beriberi

order is contributed to a lack

manifestly of judging

macroclimate

forgetting
individual

the

microenvironment

in which in Greenland intestinal

the

to a niacin-tryptophan phthalmia to inadequate

unless we know the

deficiency or xerointakes of vitamin A

environmental and host

actually

A few years ago surveys a high frequency of certain

which and are subtropical considered in to their

showed parasites
tropical and not

factors
tion of

which
these

account
diseases.

for

the

actual

precipita-

be

primarily

distribution

Admittedly, a hospital may administration in cure

this is deceptive.

a clinician be satisfied of a specific clinical

Under

treating a patient in to know only that nutrient syndrome,

the

able
simple. was as if

to survive
The hot in and the

in the
microclimate humid tropics.

Arctic.
and

The
within

answer
the

was
houses

will but
conditions

result even
in

of a given

transmission It is pertinent

occurred that

nineteenth
Eskimo family The wake members classic of the

century
households wholly example

pictures
in of Age, Greenland unclothed. place vast

of

East
show

Coast
all of

which nutritional population, they

When pellagra

deficiencies occur are rarely single.

was common in the

in
southern

the

United
distribution sometimes

States, treatment
thiamin

treatment
precipitated or

with
signs

niacin
of

alone
beriberi.

a nutritional of the world

disease
last Ice

is endemic
and

goiter.
diverse

In Mature,

the
areas

Likewise,
sis clinical with

of beriberi
riboflavin

or ariboflavinoalone fre-

were soil was

left swept

iodine-poor. away and

quently with
resistance from skim children has

resulted
pellagra.

in the

development likely
the child

of signs to limit
suffering giving in vitamin

of the
a A of

iodine-rich by new crystalline

only As ment the air going Today goiter sea about the great of the into on areas currents,

replaced

Treatment

of xerophthalmia of

soil created by rock, the iodine

one-tenth glaciers soil the a for began air some in which can process the be the by receded,

the grinding up of content of which was

average iodine which of mature iodine replenishfrom liberated soil.

only
protein milk contributed

vitamin
and

A is still
growth

deficiency. supplement alone are diets to

Conversely, also low

to protein-deficient precipitation

whose

by oxidation
10,000 to incidence reciprocally

and
has 20,000

carried
now of years. endemic

by
been

widespread

xerophthalmia.
VARIATION OF DISEASE WITH PERSON

is intense

correlated

In of
per

1817
cent

the
whereas

case Virginia,
in

fatality ranged
1962 there

from
were

scarlet from

fever 12

with iodine

the

length

of

the the

postglacial prevalence

period usually

in Richmond,

10 to
essentially

replenishment,

116 no year able, Mexico

189 Measles

Scrimshaw
deaths for the was is times from which 90 higher a nearly this disease. rate higher that than highly all children and In figures from and in the communicable children early in 1960, were measles Guatemala States. disease in life. use viruUnited the last availin

needs
preschool

are

relatively
child, as

greatest
well as

in the
during the

infant
pubertal

and and

comparable times

mortality

growth lactation.
milk must

spurt

and

during nutrients
by the

pregnancy contained
mother in addition

All the
be ingested

in breast the lack of

to

her

usual

requirements.

Even

affecting

Death
well of

from
nourished

measles

is exceedingly
,

rare
without and the

among
the

even

teeth at a very young and old age may be of nutritional Both environmental and
involved tribution in of the many highly nutritional

frequently also at significance. host factors are

age disThe disorders.

sulfonamides

antibiotics,

characteristic

lence three
and The greatly during school infectious

of the countries.
Mexico malnutrition

measles
are simply

virus Young
which growth period reduces

does children
more

not

differ

in the
hosts. for their and to

in Guatemala
susceptible

age
been

specificity
described.

of weanling
Infantile

diarrhea
beriberi

has

already
in

occurs

is responsible and between their

breast-fed age because thiamin

deficient

infants this
mother

at at

two birth

to the

three meager
exhausted

months stores born

if

of of

retarded the age, critical also diseases.

development weaning resistance

is when
become

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present

in a child

of a
the

Earlier
to in has struck fatality food cal from villages. care Santa which been

in this
Catarina, the improved two this in village, children

discussion,
a rural of of has receiving though rendered remained the feeding

reference
village the dietary measles not the no and high program additional the been preschool

was

made
child

in Guatemala supplements. have additional medimortality was intronow a single

mothers milk is deficiency anemia proper supplementary after iron

is most needed most

deficient in in a child feeding of age, since

during because bone

thiamin. Iron not receiving usually begins innate

the vitamin

nutrition by daily epidemics there

six last

months longer
frequently

stores Rickets
period D Even

of
of is

than
growth for

those
seen

of thiamin.

Although

active primarily

enlargement.

regularly has measles Since

even been has

in marked whether
factors

vitamin classic
as protein

D deficiency rickets
deficiency may in the demands

it is doubtful when
the a major of of pregnancy

can

develop
prevent he women

such
growth host child-

in surrounding

of the
factor bearing

child.
pregnancies in age. malnutrition When

duced,
also had

the

children less
of episodes

shorter,

in Santa Catarina severe and somewhat

diarrhea than villages
DISEASE

have less
or

Frequent

frequent than still

HOST

before

occur
FACTORS

in surrounding
IN NUTRITIONAL

and
own partum

lactation
tissues diet

are
is not

not

met

by

diet,
to

the
If

mothers
the postrepletion,

become

depleted. sufficient

allow

I will
and ble and cannot for

now
the

return
variation Although

to the
factors of disease I

triad
which

of host,
are with to the time,

agent
place

the

mother

becomes

progressively

more

poorly

environmental person. interpret

responsiemphasize

wish

nourished. This also reflects on the early health of successive offspring. In a study in rural India a direct correlation
has been found between the number of preof

environmental either tional factors

The stood

factors

in this

presentation,
effects

we in nutrithe host

adequately

environmental or agent factors disease without recognizing with

effects in terms

vious pregnancies and In some parts of India incidence had ship repeated to iron of osteomalacia

survival of the infant.4 there is also an increased in women who have relationin nearly

which
of age of

they
and the

interact.
sex are best underchanges physiological

pregnancies. A similar deficiency anemia is seen areas.

STATES

all lesser

developed

with
the the of

which
faster higher body the the

they
rate

are

associated.
and requirements means that

In

general,
PATHOLOGIC unit

of growth This

development, per

nutritional

In ample,

a person

whose

food can

supply occur as

is apparently a result of

weight.

nutrient

malnutrition

Ecological noninfectious Some of these, pathologic such as states congenital in

Factors the host.

in

Nutritional

Disease

117

to cines

say

nothing which alter

of the

administration

of medimotility and an inantecan be

the In synergism which the It disease

metabolic

gastrointestinal

disorders, origin ; ponent,

beyond

are others such

the

of immediate environmental with an environmental cornas cancer and heart disease, are
of this discussion. Infectious

not

scope

flora. It is not surprising, fectious episode is an cedent to kwashiorkor.

thought of symptoms weanling of is malnutrition of the however, doubtful, of as of diarrhea and a frequent and malnutrition there malnutrition

therefore, that almost invariable Kwashiorkor

result infection is infection whether also in predominate. either of in predominate. a which

diseases, clearly which

status.

however, are host factors which have their origin in the environment and have a profound effect on nutritional
The in effect technically on nutrition is particularly areas underdeveloped

synergism

important in which in poorly

Large

a high nourished.
increases

incidence which
in

of infections are
the

occurs relatively
output of

symptoms

infection

populations

already
urinary fever, viral

would
the

be of public
presence of both

health
factors.

importance closely In are

without

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nitrogen
diseases and acute

have
such

been
as

demonstrated
typhoid tuberculosis,

in bacterial
pneumonia diseases

the

Avitaminosis stress of A

A is also infection. levels

associated with most infections considerably states, jaundice

may appear and other

febrile

vitamin duced eluding has

chronic the

blood

reinand
in

such as measles and chickenpox, protozoan diseases such as malaria. For

been

and studies,

systemic it
balance

and in certain pneumonia,

nephritis, the Moreover,

pathological obstructive
vitamin giardiasis

example,
impossible

in
to

metabolic
maintain

nitrogen

in patients fever
increased

with febrile
protein

such

acute

diseases despite
In that the over

as typhoid greatly
only 4 gm. such

intestinal absorption
1892 of Spicer

parasites of
in

may
England

impair As
reported

intestinal early
that

and of

tuberculosis
intake.63

vitamin developed

as
xero-

study
and

a rickettsial
found

disease body balance infections studies weight

in man, was

Harrell required the febrile nitroshown of

also nitrogen. with the

phthalmia

frequently

in

children

co-workers14

protein to maintain
period of

per

kg.

of

with meningitis, infantile diarrhea, chronic tuberculosis, measles, whooping cough and severe chickenpox. Measles and other infections are recognized to be a major factor in the occurrence of xerophthalmia and keratomalacia children result,
Africa As to

nitrogen
Rocky

during
spotted

Mountain

fever.

Not gen that against

the increase This is

only losses,

do severe but INCAP

increase have

in Indonesia, become and more

and thiamin of war

where

large

numbers

of

infections smallpox
new the also live-virus

resulting and

from vaccination administration

measles excretion vaccine of

partially sporadically
Asia. deficiency,

or totally blind as a in Latin America,

the observations of

Southeast

urinary true no for febrile

immunization

many
prisoner

qualified

observers
camps in

interned
World

in Japanese
War
II

17-D
duces

strain
almost

of yellow longer some

the

fever any

vaccine doubt nitrogen decrease that

which
reaction.

pro-

leave

or systemic

There tions urine,

absorption

is no and be that
from

all infecloss
tract.

no doubt clinical
chronically

that dysentery beriberi in

deficient

will persons bugs

precipitate whose have been

acute, diet is listed beriberi thiamin decreased as

cause

some

increased

in the protein
It

in thiamin.2#{176}

Pneumonia,

of them
gastrointestinal

malaria

and

even

bed

would these for all,

nutritional infections

a mistake, effects most,

status. are accompanied

however, of of
As

to assume infection their influence

mentioned, a tendency

that account on
to

factors capable in persons in

21

of precipitating a borderline of infection increased with clinical

to the

acute state of with scurvy paper by

frequency

metabolic or even

The blood vitamin tablished.

1917

association levels and An

called

already by

urinary

excretion is well Hess22

with

of esin

C and

reduce stitute

the watery

intake gruels

of

solid of lower

food

and

to

sub-

interesting

protein

content,

attention

118 which low they otitis, tion and an urine

reaction. precipitate

Scrimshaw florid income scurvy families developed in New a febrile or nephritis. has
in

in children York illness Even been have primary City

from after such as vaccinato

sometimes eliminated protein intakes, but is drastically stances because dietary therapy.

experimentally more often protein

by

high intake

had contracted pneumonia against recent increased at the the

scurvy

reduced under these circumof poor appetite and poor

smallpox INCAP excretion height studies

reported
children,23

malnourished

demonstrated acid in the

tion

INFLUENCE

OF

ENVIRONMENT

of ascorbic of the

Medical veying
of the

schools to their
significance

have students of disease.

great

difficulty

in conappreciafactors

vaccination infections occurrence

direct. The

an adequate
of environmental

Of fluence
anemia,

several iron
blood

ways
loss is

in which and
the

inof co-

in the

causation

The

specific

agent

metabolism carried

the
most

of a disease

is usually

identified

by the

physician

modern
workers24

studies

out

by

Roche

and

tagged
worm

25 in Venezuela using Crand hemoglobin have shown that each causes a daily loss of approximately

Fehook0.03
million

with the help of the laboratory, available to him for interview the environment from which
may be largely unknown.

and the host is and study, but the patient comes

Downloaded from ajcn.nutrition.org by guest on August 15, 2013

An

oral

description

of the from

environmental physician a socioeconomic Yet and occurrence

environment.

factors attending frequently group

may a patient with

mean who which key

little comes he to
personal

to is the

ml. eggs

of

blood

or

2.74 Of

ml. persons

of in

blood

per

excreted.

a hyperendemic

area
and more

10 to 20 per
for a single

cent
human

will with
uncommon.

have
host

an egg excretion 100 worms,

have If the 500 diets or of to

unfamiliar. nature
patients

the disease
Without

equivalent
worms

to infection
is not

at least

of the environment,

lies key

in the may

knowledge not be
knowledge

of the available
of an

this
is not

persons with severe hookworm low in iron, typical iron deficiency certainly be observed. Another example
Diphyllobolhrium

infection are will almost interesting fish tapeworm, can produce of its special

to

the

physician. firsthand
are particularly

Adequate
usually

environment

obtained, ence.
Environmental

however,

without
factors

experisig-

is

the anemia

effect
latum,

of

the which because

macrocytic

in man

nificant Moreover, mon in

in the

causation

of nutritional diseases are underdeveloped

diseases. most cornareas in are

be

avidity for vitamin B12.267 Chronic infection may decrease iron-binding capacity, reduce iron retention and shorten life span of erythrocytes. bone marrow in persons
may be unable to increase

nutritional technically the environmental to

By

the

which most clear and well.

physicians.

circumstances and not western-trained

it should

At the same time, the with chronic infections

red cell production

obscure that the

western
environment

term

includes

only

physical as the least

sufficiently The
trauma

to is the
fractures, also result

compensate so-called
in strongly accidental

for anemia

these
and

factors.
surgical nitrogen

result
Burns,

of infection.

biological In the

factors, case of factors

but social factors nutritional disease, may act in at

environmental

negative

balance
stresses,

for
like

prolonged
that of

periods
infection,

of time.
result in

These
an in-

three different ways : (1) by affecting the availability of nutrients, (2) by affecting nutritional requirements of the host, and (3) by affecting The the intake of nutrients. factors influencing the environmental

creased mobilizes tively and

adrenal nitrogen

glucocorticoid from muscle

secretion and use by Part other

which relathe liver of this

dispensible tissues for other essential organs.

mobilized nitrogen Direct necrosis at contributes burns

gen

spills over into the urine. the site of the lesions also protein large.
can

availability of nutrients are obviously of major significance, but almost entirely beyond the control of the physician. Included among the environmental bility of nutrients soil and tural climate production, factors affecting the availaare physical factors such as which directly biological influence factors agriculwhich

to the be very
of

loss The
be

and

in the negative

case nitro-

of
and

may
balance

trauma

minimized

Ecological influence the types of plants and animals

Factors which

in

Nutritional

Disease

119

the land can latter exert

of tion services stability good ; availability and ;

support, their

and effect
practice of

social factors. The through knowledge

and and its applicaextension economic or disturbance

there three was

are reports of studies in rats in which times as much thaimin per gram of food required to prevent increased pyruvate in the
it A can be

agricultural credit freedoni ;

excretion
minosis

urine
has induced

at
been

35#{176}c. compared
reported more that rapidly

with
avitain rats

agricultural political civil tenure ; ; and

13#{176}c. Also,

from and

war;
land food food

governmental
distribution storage distribution. and

regulations
processing

and
facilities

policies;
for of

adequacy

in a hot environment.2 The effect of low environmental temperatures is greatly reduced by protective clothing heated buildings. On the other hand,
necessity of may under performing significantly work in increase heavy, clothing caloric

and the
re-

clumsy

The
tors, ments

second
those of the

category
influencing host, are

of environmental
the most nutrient likely to be

facrequireunder-

quirements.
doors

Thus,
conditions

persons
of

working
extreme

out
cold

of
re-

stood
biological are At is an quantities perspiration
losses

by
all

the
and

physician.
social aspects

Again,
of the temperatures

physical,
environment there significant through chloride or muscle higher

quire

more

calories

and

hence

more

thiamin become urinary In addi-

as

Downloaded from ajcn.nutrition.org by guest on August 15, 2013

involved. high increased of

.

environmental loss of essential Excessive must develop. be The

well. As environmental temperatures colder, there is also an increase in the excretion of N-methylnicotinarnide. tion, wearing sary sweat
sweating

water sodi

and nutrients am

water

requirements
of heavy

may
muscular

be

increased
activity

by
while

performance

clothing and which It

may

which subsequently is
occur

is heavier leads that

either

than

necesexcessive
or low

in

sweat will

replaced relatively

to excessive
high

cramps

loss.

paradoxical
at

incidence
tropics
I1UIY

of

iron

deficiency

anemia

in

the

in
and

sweat.
potassium

in part be due to excessive Copper, manganese,

are in sweat, hour also and present from in at 5 to

iron losses phosphorus

least 15 trace mg. of

environmental Sunshine adverse tures. On are derived sufficient vitamin was the the
As

temperatures. and humidity of high also play a role in the environmental beneficial of the the of reduced in which sunlight exposure until
nu-

effects

temperaeffects skin to of there and of

quantities calcium ler

may

the sweat blood

circumstances. appears plasma

be lost, depending Iodine concentration with likely

development lost in sweat

upon in that in to be a
of is

the other hand, from exposure to prevent In areas shortage further

sunshine D deficiency. wintertime clothing

occurrence

to vary directly ; thus it is not

factor in of nitrogen the

significant

protective

endemic The

amount

skin to sunlight, advent of vitamin

to the biological

rickets was common D concentrates.

factors influencing

sufficient to influence nitrogen balance experiments and may be one of a number of factors contributing
malnutrition

trient infection ments,

requirements in the of the is host particularly discussed. of social

of the increase

host,

the which nutrient

occurrence through requireand factors has incited.

to the
or

high not be
loss. per

prevalence
in tropical

of protein
areas.

of pathogens

environment, important or cultural

can nutritional with

kwashiorkor

Conditions
significant temperature of 75 irig.
in

need
nitrogen
of

extreme
At

to
an in

produce
ambient

of 90#{176}F. in New nitrogen moderately

Orleans,
hour young

an output
sweat was men.3#{176}

already been Examples

fluencing Persons anemia host who because

requirements acquire of infection

also fish

be

observed

active

macrocytic tapeworm

Under such total amino loss decreases Water-soluble in general, cance in

conditions acids would with lower vitamin they are practical

from 2.2 to 2.6 gm. of be lost. However this dietary protein intakes. losses also occur but, to be of signifiNevertheless,

would not be in this predicament for their custom of consuming deficiency anemia would in not areas everyone wore shoes worm is endemic.

if it were not raw fish. Iron be as common in which hookif

too small nutrition.

120 Dietary habits which of foods containing goitrogens example occurrence

protect

Scrimshaw result in the significant iodine falls

from

tion of

consumpquantities category whose

to keep

government

policies

may

be

powerful

factors

in either

increasing availability extent

or reducing of food that it leads

the

prevalence

increase which
them

requirements. into this children

sun

Another is the
parents

of malnutrition. Improved only to the

is significant to increased factors which are often the results and

of rickets turning West darker.

in
the

their common

skin

from among

This

is not

unin

food consumption. influence food decisive ones. from dietary

The cultural consumption I\Ialnutrition habits based

Indian

Negroes

Panama and the Canal Zone and has recently been described also in the Dominican Republic. The physical, biological and cultural factors affecting can also in either to tend zones. the consumption of food by be readily identified. Food hot tropical or cold arctic be different Altitude per from those in se has little direct the host patterns climates temperate effect but

very often on ignorance

food prejudice. view many beliefs even when there in the culture. difficult because knowledge where placing deepseated Sometimes basis. For developed potential food

From a nutritional point of regarding food are irrational is a rationalization for them Nutrition education is so it involves not only but have supplying also disthere is none, beliefs. prejudices

Downloaded from ajcn.nutrition.org by guest on August 15, 2013

does influence the type of food immediately available. As to biological influences, it has already been emphasized that the effect of infectious diseases in decreasing appetite and influencing the more important direct
By

a rational

example, in some technically underareas cows milk is considered a cause of diarrhea in young children.

character of the diet to nutritional states group food relatively of

is probably than to its of environis cost of

This belief arises from the poor quality of milk available in many technically underdeveloped areas lack stances stituted especially with due to adulteration, of refrigeration. reluctance dried when milk its to use contamination Under such accept is likely even understandable to coincide of
now

metabolic effects. far the most significant factors influencing The

and circumrecon-

mental the in

consumption high

socioeconomic.

becomes

so-called protective the appearance

foods is a major factor malnutrition in any States such costs are to malnutrition in on limited incomes. the price free temporary areas there nutritional of suitable within distribution measure, solution. related to their

population particularly retired

; in the United conducive persons living

episodes of infectious origin. The original basis not hard to understand. pork which is insufficiently source pork that of sometimes tapeworm, of beef, can fatal
Tinea

diarrhea for avoiding

We know

other pork is
that

cooked trichinosis
solim,

is a potential and which, hydatid of the unlike disease

In technically underdeveloped is little hope of improving status of the people unless the food economic of food may can somehow reach. be Although brought

give

rise

to

through autoinfection with fertile ova. In the United States, food faddism is a coinmon called sources imbalanced sumption balanced the diets cause of malnutrition. At best the sohealth foods are needlessly expensive of nutrients and at worst nutritionally and irrational. Excessive con-

be an effective

it is not acceptable as a permanent Economic factors are closely

political ones. For example, subsidies and price controls may make it easier for people to buy food ment food ; duties and special taxes may raise costs. Legislation of cereals and other requiring the enrichstaple foods can insure

essential nutrients even when changes in food habits are difficult to achieve. Systems of food rationing or food disposal plans imposed
by governments represent a direct attempt to

of some of them to the exclusion of a diet may be dangerous. Although consumed by the lacto-ovo vegetarians are usually excellent, eventually the strict vegetarians are likely to have a megaloblastic deficiency. reducing nutritional physicians anemia due to vitamin B12 Diet fads, especially some of the diets, are likely to lead to serious deficiency. are guilty Unfortunately, of recommending even or

influence Depending

an

individuals upon their

food consumption. wisdom and objectives,

Ecological approving tionally

Outright

Factors are nutrilikely

in

Nutritional lower
part of

Disease socioeconomic
countries family income the

121 groups
the by

reducing unsound.
food Although usual of a result, quackery

diets

which
is particularly

in
the

technically
of on father

underdeveloped

expenditure

to
are takes

victimize
the

elderly

persons
nutritional quackery,

living
food

on
deficiencies faddism

fixed
or

cheap his
more

liquor family.
nourishing

leaves Alcoholic
foods

insufficient beverages
in his

money also
own diet.

to

feed

incomes.

displace factors in-

ignorance toxicity A and United

occasionally
nutrient.

result
A number

in

excessive
of cases

inof

It

should

be clear

that

the

social

from excessively vitamin D have States. As in

large been other

doses of vitamin reported in the aspects of therathe dangerous of a good thing Cases
fiom in excessive Rica who reCosta

fluencing food habits and food consumption are equalled in significance only by the primary availability underdeveloped anthropological,
trative and of

of

food. countries religious,

In

the alike
all intake

developed
,

and adminis-

educational,
influence of the the mdi-

peutics (and misconception the better

carotenernia consumption carotenemia

of human society), that the more is

have of has

economic,

political the

factors nutrient

hard
been carrots, been

to

eliminate.
reported and

of

adequacy

vidual

subject.

Downloaded from ajcn.nutrition.org by guest on August 15, 2013

seen

in

a child

CONCLUSION

ceived In
tendency

excessive technically
of

quantities of African underdeveloped

mothers to withhold

palm areas
solid

oil. the
food

The causes of the diseases of man can understood only in terms of his relationship his
disease

be to

environment.
is the relative

The the
which

agent
lack of

of
an

nutritional
essential

from the children at the onset of diarrhea to substitute watery gruels and starchy tions
tributing

and solucon-

nutrient,
host factors

but nutrient host.

etiology
determine

of the will which be

disease
whether

includes
or not a

is, as already
to the high

noted,
incidence

a major

factor

of kwashiorkor.

given and
to

intake factors

adequate, both

and agent and three the re-

Unfortunately, and followed

cians and, that for

by Of
the

this practice otherwise

this reason, be

is often encouraged well trained physiis doubly hard

environmental The social influence

quirements

affect

combat.
intent

course,
child

it is not
maintained

the

physicians
on a watery

environment as well as the

of the

includes biological physical factors. All of nutrients,

for specific host

availability

inadequate common perpetuate

passed.

diet for many weeks, but this result, since protein malnutrition the diarrhea after the infection
Physicians in this country who

is a can has

nutrients,

and ing study

host,

the the

consumption cause of in human

and

of nutrients. nutritional the

Determindisease is interaction

a of

recom-

ecology-of
environment.
ACKNOWLEDGMENT

mend withholding solid episodes are fortunate are well episodes

years increases that

food during in that their start been

of with recovery

diarrheal patients that the for fifty

and fat even

agent

nourished are short.

the quantitatively

at the It has

and known
intake

This

paper

is the

outcome

of innumerable

discussions

with
represents experience to

Dr.

John
the

E. the

Gordon

absorption

nitrogen

application

though
Clinically adequate his food stools

it is less
a feeding is increased.

efficient
even

in diarrheal
is better the though

disease.
with of volume

with the understanding

of Harvard University of much of his philosophy epidemiology of infectious

of nutritional
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