162 PROTEIN
approach would
be to give the safer intradermal prestimulation with B.C.G. and subsequent intralesional P.P.D., since it is known that direct intralesional B.C.G. may be associated with disseminations of B.C.G. It seems that such an approach, which would prime the patient for cross-reaction with P.P.D., and entail only the injection of a non-viable P.P.D. in the lesion, would be safer. Perhaps other alternatives might include priming the patient immunologically with intradermal B.c.G. and subsequently using killed B.C.G. intralesionally. Whittier-Montebello Cancer Research Institute, Montebello, California 90640, U.S.A.
GLENN TISMAN SHOW-JEN GRACE WU GEORGE E. SAFIRE.
THYROTROPHIN-RELEASING HORMONE IN DEPRESSION
SIR,-The initial enthusiastic reports 1-3 of the efficacy of thyrotrophin-releasing hormone (T.R.H.) in the treatment of depression have been followed by a number of controlled trials which failed to confirm the original findings in either neurotic or psychotic depression. 4-8 These negative results caused us to curtail our own investigation which we now report as another negative controlled trial. Ten clinically and biochemically euthyroid patients suffering from severe primary depressive illness with either psychomotor retardation and/or depressive delusions entered the trial. Patients were randomly allocated to treatment with either intravenous saline or T.R.H. 600 g. daily for 4 days. The injections were given in the absence of the psychiatric rater. It was considered unethical to interfere with usual treatment and the consultant in charge decided whether a patient was to receive treatment with antidepressants alone or with electroconvulsive therapy (E.C.T.) in addition. The random allocation to trial treatment was within pairs; each pair was matched for E.C.T. or non-E.c.T. treatment. The E.C.T. pairs had the first two of their treatments of E.C.T. 24 and 96 hours after the first dose of T.R.H. Severity of illness was measured by means of a seven-point global scale and the Hamilton depression scale. Measurements were made at 0, 24, and 120 hours. Three pairs were treated with E.C.T. and antidepressants and two pairs with antidepressants. There was no difference in the initial scores on the global scale and little difference between treatment groups on the initial Hamilton scores. There was no statistically significant difference between T.R.H. and saline groups at 24 or 120 hours on the global scale (P=0-15 and P=0-42 respectively, Whitney Mann u test). Analysis of covariance using the Hamilton scores showed no statistically significant difference in outcome between the saline and T.R.H. treated groups. Our trial joins the growing number of controlled trials which have failed to confirm an antidepressant action for T.R.H. Endocrine Unit, Department of Medicine, Department of Psychological Medicine Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP.
R. HALL P. R. HUNTER.
J. S. PRICE C. Q. MOUNTJOY.
Prange, A. J., Wilson, I. C., Lara, P. P., Alltop, L. B., Breese, G. R. Lancet, 1972, ii, 999. 2. Kastin, A. J., Ehrensing, R. H., Schalch, D. S., Anderson, M. S. ibid. p. 740. 3. Van der Vis Melsen, M. J. E., Weiner, J. D. ibid. p. 1415. 4. Dimitrikoudi, M., Hanson-Norty, E., Jenner, F. A. ibid. 1974, i, 456. 5. Mountjoy, C. Q., Price, J. S., Weller, M., Hunter, P., Hall, R., Dewar, J. H. ibid. p. 958. 6. Ehrensing, R. H., Kastin, A. J., Schalch, D. S., Friesen, H. G., Vargas, J. R., Schally, A. V. Am. J. Psychiat. 1974, 131, 714. 7. Coppen, A., Montgomery, S., Peet, M., Bailey, J., Marks, V., Woods, P. Lancet, 1974, ii, 433. 8. Benkert, O., Martschke, D., Gordon, A. ibid. p. 1146.
REQUIREMENT
SIR,-Dr Mellanderhas succinctly presented the confused theoretical basis of the protein-supplementation industry. Several points in his letter require comment, since attempts to supplement the protein content of diets, particularly of children, have accounted for many millions of dollars. Although Dr Mellander appears to agree with the levels of protein now recommended,2 he does not accept the implications for the production of supplements. If a diet is too bulky, then protein deficiency could occur secondary to a restricted food intake (i.e., starvation). Has it indeed been shown that the normal cereal and legume based diet onto which most Ethiopian children are weaned is in this way too bulky ? We know of no evidence for this. But were it so, this would not justify the supplement (Faffa) produced by the Ethiopian Nutrition Institute. This3 has a metabolisable energy content of 3-4 kcal. per g., which is similar to that of local cereals. A supplement intended to increase the caloric density of a diet must clearly have a high energy content. That nutritional requirements may be increased by infections is not in dispute. But the implication in Dr Mellander’s letter that the production of infant foods is a good nutritional answer to the effects of poverty is no less wrong for its continuing popularity (though it is increasingly challenged 4.5). He throws off the problems of marketing The Ethiopian Nutrition Institute has made too lightly. every effort to produce Faffa cheaply. Unfortunately, several years of observation of these kinds of marketed product in Ethiopia and elsewhere lead us to concur with Professor McLaren, that their consumption in those sections of the population least able to afford calorie and protein intense foods remains so low as to deny the suitability of this approach to childhood malnutrition. Famine aid to Ethiopia has included a large tonnage of supplementary products. In the context of relief camps, a simple mixture based on dried skimmed milk and local oil and sugar was successfully used for therapeutic feeding,’ and it was perfectly possible otherwise to serve a normal local diet based on cereals and legumes. We saw no need for the relatively expensive addition of supplements. Experience in other famine areas persuades us that whilst protein supplements may sometimes be indicated, their need is far rarer than aid agencies seem to imagine. We submit that the current production of protein supplements is not based on sound nutritional or economic evidence, and we regret that we cannot join with Dr Mellander in giving their continued promotion on any scale " all possible support". JOHN RIVERS London Technical Group, JOHN SEAMAN c/o The Institute of Biology, 41 Queen’s Gate, London SW7. JULIUS HOLT.
SiR,—Comments made by Mr Rivers and his colleagues (Oct. 19, p. 947) on famine relief in Ethiopia, in correspondence initiated by Professor McLaren’s article (July 13, p. 93), cannot go unchallenged. Apart from giving the false impression that the Ethiopian Nutrition Institute (E.N.I.) together with United Nations’ agencies requests large shipments of dry skimmed milk and
1.
Mellander, O. Lancet, 1974, ii, 1508. F.A.O./W.H.O. Expert Committee. Wld Hlth Org. Monogr. Ser. 1973, no. 522. 3. Ågren, G., Gibson, R. Food Composition Table for Use in Ethiopia CNU/ENI/SIDA, Children’s Nutrition Unit Report no. 16, Addis Ababa, 1968. 4. Miller, D. S., Payne, P. R. Nature, 1974, 251, 176. 5. Report of the O.D.A. Advisory Committee on Protein. Ministry of Overseas Development (U.K.), July, 1974. 6. McLaren, D. S. Lancet, 1974, ii, 93. 7. Mason, J. B., Hay, R. W., Lerescne, J., Peel, S., Darley, S. ibid. 1974, i, 332.
1. 2.
approach would
be to give the safer intradermal prestimulation with B.C.G. and subsequent intralesional P.P.D., since it is known that direct intralesional B.C.G. may be associated with disseminations of B.C.G. It seems that such an approach, which would prime the patient for cross-reaction with P.P.D., and entail only the injection of a non-viable P.P.D. in the lesion, would be safer. Perhaps other alternatives might include priming the patient immunologically with intradermal B.c.G. and subsequently using killed B.C.G. intralesionally. Whittier-Montebello Cancer Research Institute, Montebello, California 90640, U.S.A.
GLENN TISMAN SHOW-JEN GRACE WU GEORGE E. SAFIRE.
THYROTROPHIN-RELEASING HORMONE IN DEPRESSION
SIR,-The initial enthusiastic reports 1-3 of the efficacy of thyrotrophin-releasing hormone (T.R.H.) in the treatment of depression have been followed by a number of controlled trials which failed to confirm the original findings in either neurotic or psychotic depression. 4-8 These negative results caused us to curtail our own investigation which we now report as another negative controlled trial. Ten clinically and biochemically euthyroid patients suffering from severe primary depressive illness with either psychomotor retardation and/or depressive delusions entered the trial. Patients were randomly allocated to treatment with either intravenous saline or T.R.H. 600 g. daily for 4 days. The injections were given in the absence of the psychiatric rater. It was considered unethical to interfere with usual treatment and the consultant in charge decided whether a patient was to receive treatment with antidepressants alone or with electroconvulsive therapy (E.C.T.) in addition. The random allocation to trial treatment was within pairs; each pair was matched for E.C.T. or non-E.c.T. treatment. The E.C.T. pairs had the first two of their treatments of E.C.T. 24 and 96 hours after the first dose of T.R.H. Severity of illness was measured by means of a seven-point global scale and the Hamilton depression scale. Measurements were made at 0, 24, and 120 hours. Three pairs were treated with E.C.T. and antidepressants and two pairs with antidepressants. There was no difference in the initial scores on the global scale and little difference between treatment groups on the initial Hamilton scores. There was no statistically significant difference between T.R.H. and saline groups at 24 or 120 hours on the global scale (P=0-15 and P=0-42 respectively, Whitney Mann u test). Analysis of covariance using the Hamilton scores showed no statistically significant difference in outcome between the saline and T.R.H. treated groups. Our trial joins the growing number of controlled trials which have failed to confirm an antidepressant action for T.R.H. Endocrine Unit, Department of Medicine, Department of Psychological Medicine Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP.
R. HALL P. R. HUNTER.
J. S. PRICE C. Q. MOUNTJOY.
Prange, A. J., Wilson, I. C., Lara, P. P., Alltop, L. B., Breese, G. R. Lancet, 1972, ii, 999. 2. Kastin, A. J., Ehrensing, R. H., Schalch, D. S., Anderson, M. S. ibid. p. 740. 3. Van der Vis Melsen, M. J. E., Weiner, J. D. ibid. p. 1415. 4. Dimitrikoudi, M., Hanson-Norty, E., Jenner, F. A. ibid. 1974, i, 456. 5. Mountjoy, C. Q., Price, J. S., Weller, M., Hunter, P., Hall, R., Dewar, J. H. ibid. p. 958. 6. Ehrensing, R. H., Kastin, A. J., Schalch, D. S., Friesen, H. G., Vargas, J. R., Schally, A. V. Am. J. Psychiat. 1974, 131, 714. 7. Coppen, A., Montgomery, S., Peet, M., Bailey, J., Marks, V., Woods, P. Lancet, 1974, ii, 433. 8. Benkert, O., Martschke, D., Gordon, A. ibid. p. 1146.
REQUIREMENT
SIR,-Dr Mellanderhas succinctly presented the confused theoretical basis of the protein-supplementation industry. Several points in his letter require comment, since attempts to supplement the protein content of diets, particularly of children, have accounted for many millions of dollars. Although Dr Mellander appears to agree with the levels of protein now recommended,2 he does not accept the implications for the production of supplements. If a diet is too bulky, then protein deficiency could occur secondary to a restricted food intake (i.e., starvation). Has it indeed been shown that the normal cereal and legume based diet onto which most Ethiopian children are weaned is in this way too bulky ? We know of no evidence for this. But were it so, this would not justify the supplement (Faffa) produced by the Ethiopian Nutrition Institute. This3 has a metabolisable energy content of 3-4 kcal. per g., which is similar to that of local cereals. A supplement intended to increase the caloric density of a diet must clearly have a high energy content. That nutritional requirements may be increased by infections is not in dispute. But the implication in Dr Mellander’s letter that the production of infant foods is a good nutritional answer to the effects of poverty is no less wrong for its continuing popularity (though it is increasingly challenged 4.5). He throws off the problems of marketing The Ethiopian Nutrition Institute has made too lightly. every effort to produce Faffa cheaply. Unfortunately, several years of observation of these kinds of marketed product in Ethiopia and elsewhere lead us to concur with Professor McLaren, that their consumption in those sections of the population least able to afford calorie and protein intense foods remains so low as to deny the suitability of this approach to childhood malnutrition. Famine aid to Ethiopia has included a large tonnage of supplementary products. In the context of relief camps, a simple mixture based on dried skimmed milk and local oil and sugar was successfully used for therapeutic feeding,’ and it was perfectly possible otherwise to serve a normal local diet based on cereals and legumes. We saw no need for the relatively expensive addition of supplements. Experience in other famine areas persuades us that whilst protein supplements may sometimes be indicated, their need is far rarer than aid agencies seem to imagine. We submit that the current production of protein supplements is not based on sound nutritional or economic evidence, and we regret that we cannot join with Dr Mellander in giving their continued promotion on any scale " all possible support". JOHN RIVERS London Technical Group, JOHN SEAMAN c/o The Institute of Biology, 41 Queen’s Gate, London SW7. JULIUS HOLT.
SiR,—Comments made by Mr Rivers and his colleagues (Oct. 19, p. 947) on famine relief in Ethiopia, in correspondence initiated by Professor McLaren’s article (July 13, p. 93), cannot go unchallenged. Apart from giving the false impression that the Ethiopian Nutrition Institute (E.N.I.) together with United Nations’ agencies requests large shipments of dry skimmed milk and
1.
Mellander, O. Lancet, 1974, ii, 1508. F.A.O./W.H.O. Expert Committee. Wld Hlth Org. Monogr. Ser. 1973, no. 522. 3. Ågren, G., Gibson, R. Food Composition Table for Use in Ethiopia CNU/ENI/SIDA, Children’s Nutrition Unit Report no. 16, Addis Ababa, 1968. 4. Miller, D. S., Payne, P. R. Nature, 1974, 251, 176. 5. Report of the O.D.A. Advisory Committee on Protein. Ministry of Overseas Development (U.K.), July, 1974. 6. McLaren, D. S. Lancet, 1974, ii, 93. 7. Mason, J. B., Hay, R. W., Lerescne, J., Peel, S., Darley, S. ibid. 1974, i, 332.
1. 2.
