2170
LETTERS
TO
of growing and processing 40.3 times more broccoli than at present. The situation is parallel with other vegetables in the sample diet. The fresh fruits and vegetables in this diet actually represent 4.5 times the amount of all fresh fruits and vegetables now produced. We could increase production but the supply of vegetables is limited by considerations not encountered with livestock and poultry. Because of soil and climate, vegetables for human use can be grown economically only on a relatively small share of the available farmland. Their planting and harvesting requires a great deal of seasonal hand labor. After harvesting, which must be accomplished very quickly and within a very restricted time span, these perishable foods must be used or processed (by canning or freezing) within a few days. However, animal production, because less seasonal, has the important advantage of flexibility. The corn and soybeans grown for animal feed on millions of acres of midwest farmland are easily stored in huge grain elevators without processing and can be used only as needed. Moreover, there is considerable leeway in deciding when animals should be sent to market; beef or pork need never flood the market at any one time. Due to such practical considerations only the livestock, dairy, and poultry industries can supply the nation’s nutritional needs with the efficiency, economy, and abundance we now enjoy. Implementing dietary changes based on the sample diet would require a radical
Midarm Dear
muscle
volume:
THE
EDITOR
redistribution of crops, a vastly expanded supply of seasonal farm labor, and an enormous increase in food processing capacity. Such practical and economic limitations mean that the suggested regimen might be within reach for a few million individuals, but not for the entire population. Three, Dr. Levine and Ms. Parker assume their diet would increase life expectancy in the United States. Although this diet contains twice as much animal protein or 26 as compared to 13 g per capita per day, respectively, it is similar in other respects to the diet of the Chinese whose life expectancy is 10 years less than Americans (N. Eberstadt, Has China Failed, The New York Review 26: 33, 1979). If the majority of Americans followed the diet advocated by Dr. Levine and Ms. Parker, neither the required amount of vegetables or animal food products may be available and they may end up eating even more french fries, potato chips, and other high calorie foods and drinking more soft drinks than they are now eating and drinking. The significant point to my article is that if we minimize the angiotoxic factors unintentionally created by modern food technology we do not need to change our animal protein based diet in order to decrease the incidence of death from heart disease. F. A. Kummerow The Burnsides Research University of Illinois Urbana, Illinois 61801
Laboratory
a suggestion
Sir:
mula: C2 = C1 us, for calculating the underlying muscle circumference (2, 3). The main reason for the trial of this measurement was the obvious visible fact that malnourished children have thin to wasted limbs, due to depletion of both fat (calories) and muscle (protein). The nondominant left arm was used because it is roughly circular, easily held (in a fractious child) and less likely to be affected by edema than the lower limbs. Also, of course, the tape measure is a very cheap and highly portable instrument. Since then this measurement has been -
.
First, we would like to congratulate Dr. Heymsfield and colleagues on their most elegant and useful paper on the radiographic assessment of “protein-calorie undernutrition” (1). The midarm circumference was introduced as a public health index of protein-calorie malnutrition (now generally more commonly referred to as protein-energy malnutrition) in young children in a 1958 national survey in the Republic of Haiti, as was the basic for-
Downloaded from https://academic.oup.com/ajcn/article-abstract/32/11/2170/4691989 by University of Glasgow user on 06 August 2018
LETTERS
TO
widely
used in developing countries. A 23author symposium outlining experience around the world was published in 1969 (4). Numerous “appropriate technology” devices have been suggested for approximate categorization of children in developing countries, including the anthrogauge (5), the Shakir strip (6), the “10-anna” bangle (7), the quipu (8), and the insertion tape (9). As with many apparent “new” ideas, earher, not easily accessible, literature has indicated that others had previously thought along similar lines. For example, in the Indonesian literature, Kierks (10) described the arm circumference/height index in 1956termed by him the “ABC index” because of its simplicity. In the 1920’s, Von Pirquet developed the ingenious, short-lived, composite, and highly complex “Sacratama index” (which attempted to assess sanguinis, crassitudo, turgor and musculus) (11). As a largely unknown forerunner of present approaches, in Vienna, Kornfeld attempted in 1930 to measure fatfolds with the points of a geometric compass, as well as the girth of limbs, both “biceps” and calf, in school children (12). The recent, important greatly increased emphasis on nutritional assessment in hospitalized patients in indusrialized countries has incorporated arm measurements (13, 14), and reference data have been suggested for children and adults (15). Plainly, the arm circumference and the calculation of the underlying muscle circumference are both approximate gauges.
The
arm
is not
exactly
circular,
the
underlying tissues include bone, nerves, muscles, fascia, etc., and the triceps’ fold is visibly much larger than the biceps’ fatfold. This has long been appreciated, but has been emphasized
with
scientific
precision
by Dr.
tissue
on
surface
x-rays
and
anatomy.
study
of modern
Thus,
the
EDITOR
2171
midarm muscle volume can easily be calculated by multiplying the midarm muscle area (derived from the nomogram (16) based on arm circumference and triceps fatfold) by one-fifth of the length of the humerus (measured
from
the
acromial
process
to the
ole-
cranon in the standard way) (17). Plainly, the result would only be an approximation, but could give comparable results between individuals and would reflect major muscle mass. Whether this extra measurement is really worthwhile has to be tested. However, it would only need the further use of a tape measure. Specialized studies by Dr. Heymsfield and colleagues would undoubtedly be very helpful here, especially in young children with protein-energy malnutrition. In fact, their use of computerized axial tomography is an excellent instance of a sophisticated study that can assist very greatly in the validation of low cost “appropriate technology” for nutritional assessment, both in developing regions and (especially with everincreasing hospital costs) in industrialized countries as well. Derrick
Head, Family
B. Jel4ffe,
M.D.
Divison of Population, and International Health E. F. Patrice
Lecturer/Associate Division
of Population,
Jelhffe
M.P.H.
Researcher Family
and International Health University of California Los Angeles, California 90024 References
Heyms-
field and colleagues. As these authors reemphasize, muscle is a three dimensional tissue. For this reason, a nomogram for arm muscle area was introduced in 1973 (16), which at least gave a two dimensional measurement. More recently, we have been using the midarm muscle volume, based on the suggestion that the main muscle mass in the upper arm could be postulated as overlying about one-fifth (20%) of the length of the humerus, as judged by examination of soft
THE
cylinder
texts
of
Downloaded from https://academic.oup.com/ajcn/article-abstract/32/11/2170/4691989 by University of Glasgow user on 06 August 2018
1. HEYMSFIELD, S. B., R. P. OLAFSON, M. H. KIJTNER AND D. W. NIxoN. A radiographic method of quantifying protein calorie malnutrition. Am. J. Chin. Nutr. 32: 693, 1979. 2. JELLIFFE, D. B., AND E. F. P. JELLIFFE. The prevalence of protein-calorie malnutrition of early childhood in Haiti. Am. J. Public Health 50: 1355, 1960. 3. JELLIFFE, D. B., AND E. F. P. JELLIFFE. The nutritional status of Haitian children. Acta Trop. 18: 1, 1961. 4. JELLIFFE, E. F. P., AND D. B. JELLIFFE. The arm circumference as a public health index of proteincalorie malnutrition of early childhood. J. Trop. Pediat. 15: 179, 1969. 5. ZERFAS, A. J., I. SCHORR AND C. 0. NEUMANN. Office assessment of nutritional status. Pediat. Chin.
2172
LETTERS
TO
Am. 24: 253, 1977. A., AND D. S. MORLEY. Measuring malnutrition. Lancet 1: 758. 1974. 7. LAUGESEN, M. Child’s bangle for nutritional screening. Ind. Pediat. 12: 1261, 1975. 8. JELLIFFE, D. B., AND E. F. P. JELLIFFE. The qulpu in measuring malnutrition. Am. J. Chin. Nutr. 28: 203, 1975. 9. ZERFAS, A. J. The insertion tape: a new circumference tape for nutritional assesssment. Am. J. Chin. Nutr. 28: 782, 1975. 10. KLERKS, J. V. Berita Kementerian Kesehatan Indonesia 5: 21, 1956. Quoted Luyken, R and LuykenKoning, F.W.M. Studies in the physiology of nutrition, IX Somatometrical data. Trop. Geog. Med. 13: 123, 1961. 11. BIGw00D, E. J. Guiding principles for studies of the nutrition of populations. Geneva: League of Nations, III, Health, 1939, p. 177. 12. KORNFELD, W. Uber Durchschnittswerte und Bewertungsgrundlagen einiger Weichteihmasse bei Kin-
THE
North
6.
SHAKIR,
dern
Zinc Dear
verschniedener
Altersstufen.
and inflammatory
Zeitschr.
bowel
EDITOR hehikunde
13.
14.
15.
49: 277, 1930. G. L., B. R. BISTRIAN, B. S. MAINI, H. T. SCHLAUM AND M. F. SMITH. Nutritional and metabolic assessment of the hospitalized patient. J. Parent. Enteral Nutr. 1: 11, 1977. HILL, G. L., R. L. BLACKETF, I. PICKFORD, L. BURKINSHAW, R. A. YOUNG, J. V. WARREN, C. J. SCHORAH AND D. B. MORGAN. Malnutrition in surgical patients: an unrecognized problem. Lancet 1: 689, 1977. FRISHANCHO, A. R. Triceps skmfold and upper arm BLACKBURN,
muscle
size
status.
Am.
norms
for
J. Clin.
the
Nutr.
assessment
27:
1052,
of
nutritional
1974.
16. GURNEY, J. M., AND D. B. JELLIFFE. Arm anthropometry in nutritional assessment. Nomogram for rapid calculation of muscle circumference and crosssectional muscle and fat areas. Am. J. Chin. Nutr. 26: 912, 1973. 17. JELLIFE, D. B. The assessment of the nutritional status of the community. Geneva: WHO Monograph no. 53, 1966.
Kinder-
disease
Sir:
Endogenous zinc is eliminated from the body principally via the intestine, either in intestinal secretions or by desquamation of intestinal mucosal cells containing zinc (1). Zinc supplements have been shown to accelerate the healing of granulating surgical wounds (2) and venous stasis ulcers (3). It would seem appropriate to investigate cases of inflammatory bowel disease for evidence of zinc deficiency in view of the increased mucosal cell turnover that accompanies inflammation. Correction of any deficiency demonstrated might theoretically hasten mucosal healing. Initial evidence of zinc deficiency in inflammatory bowel disease (4) was not confirmed by a British study of plasma zinc levels in ulcerative colitis (5). The assessment of zinc deficiency is difficult as a low plasma zinc may be a nonspecific indicator of disease after many common illnesses such as acute and chronic respiratory infections, malignancy, myocardial infection, uremia, and liver disease (6). Whole body isotope techniques give the most accurate information but are inappropriate for routine use. We have, therefore, used simultaneous fasting total plasma and 24-hr urinary zinc measurements as a relatively noninvasive screening
Downloaded from https://academic.oup.com/ajcn/article-abstract/32/11/2170/4691989 by University of Glasgow user on 06 August 2018
test. Zinc was measured by flame atomic absorption spectrometry. Forty patients with active inflammatory bowel disease were studied in hospital before steroid therapy was started and six patients with inactive ulcerative colitis were studied as out-patients (Table 1). A group of healthy controls of comparable age and sex provided a range of normal results. We found no significant disturbance of zinc levels in patients with active Crohn’s disease (mixed small and large bowel) or inactive ulcerative colitis. However, there was a significant increase in urinary zinc excretion in patients with active ulcerative colitis (P < 0.01). The level of zincuria in these patients was related to the severity of ulcerative colitis (Figure 1) as asTABLE
1
Ulcera Active
No. Plasma zinc’ (umole/hiter) No. 24-Hr urinary (jimole/day) ‘Mean
significant
zinc’
20 14.5 ±6.2 20 16.5 127b
SD. (Student’s
±
P
LETTERS
TO
of growing and processing 40.3 times more broccoli than at present. The situation is parallel with other vegetables in the sample diet. The fresh fruits and vegetables in this diet actually represent 4.5 times the amount of all fresh fruits and vegetables now produced. We could increase production but the supply of vegetables is limited by considerations not encountered with livestock and poultry. Because of soil and climate, vegetables for human use can be grown economically only on a relatively small share of the available farmland. Their planting and harvesting requires a great deal of seasonal hand labor. After harvesting, which must be accomplished very quickly and within a very restricted time span, these perishable foods must be used or processed (by canning or freezing) within a few days. However, animal production, because less seasonal, has the important advantage of flexibility. The corn and soybeans grown for animal feed on millions of acres of midwest farmland are easily stored in huge grain elevators without processing and can be used only as needed. Moreover, there is considerable leeway in deciding when animals should be sent to market; beef or pork need never flood the market at any one time. Due to such practical considerations only the livestock, dairy, and poultry industries can supply the nation’s nutritional needs with the efficiency, economy, and abundance we now enjoy. Implementing dietary changes based on the sample diet would require a radical
Midarm Dear
muscle
volume:
THE
EDITOR
redistribution of crops, a vastly expanded supply of seasonal farm labor, and an enormous increase in food processing capacity. Such practical and economic limitations mean that the suggested regimen might be within reach for a few million individuals, but not for the entire population. Three, Dr. Levine and Ms. Parker assume their diet would increase life expectancy in the United States. Although this diet contains twice as much animal protein or 26 as compared to 13 g per capita per day, respectively, it is similar in other respects to the diet of the Chinese whose life expectancy is 10 years less than Americans (N. Eberstadt, Has China Failed, The New York Review 26: 33, 1979). If the majority of Americans followed the diet advocated by Dr. Levine and Ms. Parker, neither the required amount of vegetables or animal food products may be available and they may end up eating even more french fries, potato chips, and other high calorie foods and drinking more soft drinks than they are now eating and drinking. The significant point to my article is that if we minimize the angiotoxic factors unintentionally created by modern food technology we do not need to change our animal protein based diet in order to decrease the incidence of death from heart disease. F. A. Kummerow The Burnsides Research University of Illinois Urbana, Illinois 61801
Laboratory
a suggestion
Sir:
mula: C2 = C1 us, for calculating the underlying muscle circumference (2, 3). The main reason for the trial of this measurement was the obvious visible fact that malnourished children have thin to wasted limbs, due to depletion of both fat (calories) and muscle (protein). The nondominant left arm was used because it is roughly circular, easily held (in a fractious child) and less likely to be affected by edema than the lower limbs. Also, of course, the tape measure is a very cheap and highly portable instrument. Since then this measurement has been -
.
First, we would like to congratulate Dr. Heymsfield and colleagues on their most elegant and useful paper on the radiographic assessment of “protein-calorie undernutrition” (1). The midarm circumference was introduced as a public health index of protein-calorie malnutrition (now generally more commonly referred to as protein-energy malnutrition) in young children in a 1958 national survey in the Republic of Haiti, as was the basic for-
Downloaded from https://academic.oup.com/ajcn/article-abstract/32/11/2170/4691989 by University of Glasgow user on 06 August 2018
LETTERS
TO
widely
used in developing countries. A 23author symposium outlining experience around the world was published in 1969 (4). Numerous “appropriate technology” devices have been suggested for approximate categorization of children in developing countries, including the anthrogauge (5), the Shakir strip (6), the “10-anna” bangle (7), the quipu (8), and the insertion tape (9). As with many apparent “new” ideas, earher, not easily accessible, literature has indicated that others had previously thought along similar lines. For example, in the Indonesian literature, Kierks (10) described the arm circumference/height index in 1956termed by him the “ABC index” because of its simplicity. In the 1920’s, Von Pirquet developed the ingenious, short-lived, composite, and highly complex “Sacratama index” (which attempted to assess sanguinis, crassitudo, turgor and musculus) (11). As a largely unknown forerunner of present approaches, in Vienna, Kornfeld attempted in 1930 to measure fatfolds with the points of a geometric compass, as well as the girth of limbs, both “biceps” and calf, in school children (12). The recent, important greatly increased emphasis on nutritional assessment in hospitalized patients in indusrialized countries has incorporated arm measurements (13, 14), and reference data have been suggested for children and adults (15). Plainly, the arm circumference and the calculation of the underlying muscle circumference are both approximate gauges.
The
arm
is not
exactly
circular,
the
underlying tissues include bone, nerves, muscles, fascia, etc., and the triceps’ fold is visibly much larger than the biceps’ fatfold. This has long been appreciated, but has been emphasized
with
scientific
precision
by Dr.
tissue
on
surface
x-rays
and
anatomy.
study
of modern
Thus,
the
EDITOR
2171
midarm muscle volume can easily be calculated by multiplying the midarm muscle area (derived from the nomogram (16) based on arm circumference and triceps fatfold) by one-fifth of the length of the humerus (measured
from
the
acromial
process
to the
ole-
cranon in the standard way) (17). Plainly, the result would only be an approximation, but could give comparable results between individuals and would reflect major muscle mass. Whether this extra measurement is really worthwhile has to be tested. However, it would only need the further use of a tape measure. Specialized studies by Dr. Heymsfield and colleagues would undoubtedly be very helpful here, especially in young children with protein-energy malnutrition. In fact, their use of computerized axial tomography is an excellent instance of a sophisticated study that can assist very greatly in the validation of low cost “appropriate technology” for nutritional assessment, both in developing regions and (especially with everincreasing hospital costs) in industrialized countries as well. Derrick
Head, Family
B. Jel4ffe,
M.D.
Divison of Population, and International Health E. F. Patrice
Lecturer/Associate Division
of Population,
Jelhffe
M.P.H.
Researcher Family
and International Health University of California Los Angeles, California 90024 References
Heyms-
field and colleagues. As these authors reemphasize, muscle is a three dimensional tissue. For this reason, a nomogram for arm muscle area was introduced in 1973 (16), which at least gave a two dimensional measurement. More recently, we have been using the midarm muscle volume, based on the suggestion that the main muscle mass in the upper arm could be postulated as overlying about one-fifth (20%) of the length of the humerus, as judged by examination of soft
THE
cylinder
texts
of
Downloaded from https://academic.oup.com/ajcn/article-abstract/32/11/2170/4691989 by University of Glasgow user on 06 August 2018
1. HEYMSFIELD, S. B., R. P. OLAFSON, M. H. KIJTNER AND D. W. NIxoN. A radiographic method of quantifying protein calorie malnutrition. Am. J. Chin. Nutr. 32: 693, 1979. 2. JELLIFFE, D. B., AND E. F. P. JELLIFFE. The prevalence of protein-calorie malnutrition of early childhood in Haiti. Am. J. Public Health 50: 1355, 1960. 3. JELLIFFE, D. B., AND E. F. P. JELLIFFE. The nutritional status of Haitian children. Acta Trop. 18: 1, 1961. 4. JELLIFFE, E. F. P., AND D. B. JELLIFFE. The arm circumference as a public health index of proteincalorie malnutrition of early childhood. J. Trop. Pediat. 15: 179, 1969. 5. ZERFAS, A. J., I. SCHORR AND C. 0. NEUMANN. Office assessment of nutritional status. Pediat. Chin.
2172
LETTERS
TO
Am. 24: 253, 1977. A., AND D. S. MORLEY. Measuring malnutrition. Lancet 1: 758. 1974. 7. LAUGESEN, M. Child’s bangle for nutritional screening. Ind. Pediat. 12: 1261, 1975. 8. JELLIFFE, D. B., AND E. F. P. JELLIFFE. The qulpu in measuring malnutrition. Am. J. Chin. Nutr. 28: 203, 1975. 9. ZERFAS, A. J. The insertion tape: a new circumference tape for nutritional assesssment. Am. J. Chin. Nutr. 28: 782, 1975. 10. KLERKS, J. V. Berita Kementerian Kesehatan Indonesia 5: 21, 1956. Quoted Luyken, R and LuykenKoning, F.W.M. Studies in the physiology of nutrition, IX Somatometrical data. Trop. Geog. Med. 13: 123, 1961. 11. BIGw00D, E. J. Guiding principles for studies of the nutrition of populations. Geneva: League of Nations, III, Health, 1939, p. 177. 12. KORNFELD, W. Uber Durchschnittswerte und Bewertungsgrundlagen einiger Weichteihmasse bei Kin-
THE
North
6.
SHAKIR,
dern
Zinc Dear
verschniedener
Altersstufen.
and inflammatory
Zeitschr.
bowel
EDITOR hehikunde
13.
14.
15.
49: 277, 1930. G. L., B. R. BISTRIAN, B. S. MAINI, H. T. SCHLAUM AND M. F. SMITH. Nutritional and metabolic assessment of the hospitalized patient. J. Parent. Enteral Nutr. 1: 11, 1977. HILL, G. L., R. L. BLACKETF, I. PICKFORD, L. BURKINSHAW, R. A. YOUNG, J. V. WARREN, C. J. SCHORAH AND D. B. MORGAN. Malnutrition in surgical patients: an unrecognized problem. Lancet 1: 689, 1977. FRISHANCHO, A. R. Triceps skmfold and upper arm BLACKBURN,
muscle
size
status.
Am.
norms
for
J. Clin.
the
Nutr.
assessment
27:
1052,
of
nutritional
1974.
16. GURNEY, J. M., AND D. B. JELLIFFE. Arm anthropometry in nutritional assessment. Nomogram for rapid calculation of muscle circumference and crosssectional muscle and fat areas. Am. J. Chin. Nutr. 26: 912, 1973. 17. JELLIFE, D. B. The assessment of the nutritional status of the community. Geneva: WHO Monograph no. 53, 1966.
Kinder-
disease
Sir:
Endogenous zinc is eliminated from the body principally via the intestine, either in intestinal secretions or by desquamation of intestinal mucosal cells containing zinc (1). Zinc supplements have been shown to accelerate the healing of granulating surgical wounds (2) and venous stasis ulcers (3). It would seem appropriate to investigate cases of inflammatory bowel disease for evidence of zinc deficiency in view of the increased mucosal cell turnover that accompanies inflammation. Correction of any deficiency demonstrated might theoretically hasten mucosal healing. Initial evidence of zinc deficiency in inflammatory bowel disease (4) was not confirmed by a British study of plasma zinc levels in ulcerative colitis (5). The assessment of zinc deficiency is difficult as a low plasma zinc may be a nonspecific indicator of disease after many common illnesses such as acute and chronic respiratory infections, malignancy, myocardial infection, uremia, and liver disease (6). Whole body isotope techniques give the most accurate information but are inappropriate for routine use. We have, therefore, used simultaneous fasting total plasma and 24-hr urinary zinc measurements as a relatively noninvasive screening
Downloaded from https://academic.oup.com/ajcn/article-abstract/32/11/2170/4691989 by University of Glasgow user on 06 August 2018
test. Zinc was measured by flame atomic absorption spectrometry. Forty patients with active inflammatory bowel disease were studied in hospital before steroid therapy was started and six patients with inactive ulcerative colitis were studied as out-patients (Table 1). A group of healthy controls of comparable age and sex provided a range of normal results. We found no significant disturbance of zinc levels in patients with active Crohn’s disease (mixed small and large bowel) or inactive ulcerative colitis. However, there was a significant increase in urinary zinc excretion in patients with active ulcerative colitis (P < 0.01). The level of zincuria in these patients was related to the severity of ulcerative colitis (Figure 1) as asTABLE
1
Ulcera Active
No. Plasma zinc’ (umole/hiter) No. 24-Hr urinary (jimole/day) ‘Mean
significant
zinc’
20 14.5 ±6.2 20 16.5 127b
SD. (Student’s
±
P
