AMERICAN JOURNAL OF
Public Editorial Health March 1977 Volume 67, Number 3
EDITOR Alfred Yankauer, MD, MPH EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1977) Chairperson Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) Geroge M. Owen, MD (1979) Doris Roberts, PhD, MPH (1977) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1978) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegrnan, MD, MSOH (1979) Robert J. Weiss, MD (1977) STAFF William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor Janice Coleman Administrative Assistant
CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now William J. Curran, JD, SMHyg Public Health and the Law Jean Conelley Book Section
Established 1911
Nutrition Intervention: Bigger Is Smarter Elsewhere in this issue, Freeman and co-workers' present evidence from a prospective longitudinal study in Guatemala that a 15 per cent increase in energy intake of pregnant or lactating women and of young children exerted favorable effects on growth and cognitive development of the children. This outcome does not appear surprising in view of the usually restricted energy intakes (between 65 and 75 per cent of requirement) of the women and young children in the Guatemalan villages studied. In 1968, the Institute of Nutrition of Central America and Panama (INCAP) initiated an intervention program (preventive and curative medicine and nutrition) for all persons in four small villages in Guatemala. Two types of food supplements were provided: atole (a gruel) andfresco (a cool, refreshing drink). Two villages received the atole (prepared from milk and a vegetable protein mixture yielding 6.1 gm protein and 91 kcal/dl), and two received the fresco (prepared from water, sugar, and flavoring yielding 33 kcalUdl). Although the fresco contained no protein or calcium, it did contain ascorbic acid, thiamin, riboflavin, niacin, vitamin A, iron, and fluoride in amounts similar to those in the atole. These supplements were available for voluntary consumption twice daily. The authors selected three measures-language facility, short-term memory for numbers, and perceptual analysis-from among a battery of some 12 measures of cognitive development employed during the course of the project to use as dependent variables in multiple regression analysis. Three social or environmental measuresquality of house, maternal dress, and task instruction-and two measures of nutritional status-height and head circumference-were selected as independent variables in the statistical analyses. Given the inherent weaknesses of the indicators of nutritional and social status, the authors concluded that there were associations between them and cognitive development in three and four year-old children. That nutritional factors appeared (statistically) to be somewhat more important than the social factors is not unexpected for in the Guatemalan villages the study populations were at substantial nutritional risk. It is important to recognize that the nutritional and social variables examined accounted for relatively small proportions of the total variances in the cognitive measures studied. Some problems arise when the authors examine the impact of the supplements on cognitive development. It was obviously easier to estimate daily acceptance of the supplements than it was to monitor food intake in the home. While differences between "Atole" and "Fresco" children in cumulative intakes of calories from supplements (mothers during pregnancy and lactation and thereafter the children themselves to the time of study of cognition) were substantial, the total energy intakes based on estimates of home diet intakes plus supplements probably only differed by some 10-15 per cent. In this report, the authors have chosen to ignore the estimates of intake from home diets because they ". . are not precise enough. ." It is worth noting that total energy intakes (diet and supplement) were examined in relation to birthweight and to physical growth of three year-old children as reported else.
where.2' 3
AJPH March, 1977, Vol. 67, No. 3
229
EDITORIALS
Between 1969 and 1973, there were some 400 infants born to women who received supplements2 and presumably would have received supplements as toddlers.3 Why are fewer than one-half these youngsters represented among the 573 three-year-olds forming the basis of the current report? The fact that a majority of the children considered in the present report were born to women who had not received supplements during pregnancy or lactation and that nearly one-quarter of the children did not benefit from supplementation ". . . during early life . . ." is reflected in the authors' conclusion that the ". . . nutritional heterogenity . . ." of the groups may account for some of the irregularities of the findings. It is hoped that future analyses will be accomplished with nutritionally homogeneous groups and that head circumference data will be included. In essence, the current report shows that malnourished populations of infants and young children grow bigger when given access to more adequate intakes of calories. Also provided by the current report is additional evidence, which still should be considered preliminary in nature, supporting the
earlier conclusion4 i.e., bigger is smarter, at least among preschool children.
GEORGE M. OWEN, MD REFERENCES 1. Freeman, H. E., Klein, R. E., Kagan, J. and Yarbrough, C. Relations between nutrition and cognition in rural Guatemala. Amer. J. Pub. Health. 67:233-239, 1977. 2. Lechtig, A., Habicht, J. P., Delgado, H., Klein, R. E., Yarbrough, C. and Martorell, R. Effect of food supplementation during pregnancy on birthweight. Pediatrics 56:508-520, 1976. 3. Martorell, R., Lechtig, A., Yarbrough, C., Delgado, H. and Klein, R. E. Relationships between food supplementation, home dietary intake and physical growth. Amer. J. Clin. Nutr. (in press). 4. Klein, R. E., Freeman, H. E., Kagan, J. Yarbrough, C. and Habicht, J. P. Is big smart? The relation of growth to cognition. J. Health and Social Behavior. 13:219-225, 1972.
Address reprint requests to Dr. George M. Owen, Associate Professor of Pediatrics, University of New Mexico, 2701 Frontier, N.W., UNM Surge Building, Albuquerque, NM 87106.
Quality Assurance through Computer Surveillance and Feedback The development of a computer-based medical record system has been a tantalizing objective for a number of years. The illegibility, disorganization, and frequent unavailability of the manual record has been contrasted with the benefits that could potentially accrue from a computer-based information system. In this issue McDonald and his colleagues describe an exciting experiment using a computerbased medical record to improve medical care by reminding the physician of appropriate rules that should be considered in specific circumstances in the care of a particular patient. ' There may be differences of opinion about the merits of the information system, the methods of data collection, and the display process. For example, McDonald uses input documents that can be directly input into the computer using an optical character reader. He claims that the error rate is within reasonable limits, and in spite of the requirement to enter text separately, that a system using machine readable forms is more efficient than a system using paper forms and later transcription. It would be useful to have independent confirmation of these claims and experimentation documenting whether or not practicing physicians are willing and able to record data accurately and completely using this data capture strategy. Certainly the cost of personnel time for the transcription of medical information from paper forms is an important additional element in the cost of such a system. I challenge McDonald's arguments supporting a dual record system (a typical hand-written medical record coupled with an abbreviated computer record system). Maintaining dual record systems is overly time-consuming for the 230
physician and usually results in one or both systems being incomplete. Furthermore, as long as there is a parallel manual system, the potential benefits of a totally computer-based system cannot be fully achieved. The marginal cost of expanding the computer record to include all medical information seems relatively small compared to the additional advantages that would result from having all medical data available on the computer for primary care and for programs of quality assurance. The claim that paper records are inexpensive is misleading if measured only in terms of the cost of paper. The costs of assembling, pasting, sorting, filing and retrieving manual medical records are orders of magnitude more than the price of a sheet of paper. In addition, the cost of maintaining a manual medical record room is primarily a labor cost and therefore seems certain to increase. In contrast, the,cost of computer technology has decreased about 15 per cent per year in the past decade, and this downward trend seems likely to continue for the next decade. I also challenge McDonald's minimization of the importance of rapid accessibility to medical information in ambulatory practice. A significant portion of ambulatory care consists of non-scheduled visits, visits to the emergency department or telephone "encounters". When a manual medical record is used, medical decisions are often made without adequate information about the patient's active problems, current therapy, allergies, immunization status, or laboratory test results. A computer-based system can provide ready accessibility to this medical information. McDonald's position appears to be shifting in this regard, since he plans to install AJPH March, 1977, Vol. 67, No. 3
Public Editorial Health March 1977 Volume 67, Number 3
EDITOR Alfred Yankauer, MD, MPH EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1977) Chairperson Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) Geroge M. Owen, MD (1979) Doris Roberts, PhD, MPH (1977) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1978) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegrnan, MD, MSOH (1979) Robert J. Weiss, MD (1977) STAFF William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor Janice Coleman Administrative Assistant
CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now William J. Curran, JD, SMHyg Public Health and the Law Jean Conelley Book Section
Established 1911
Nutrition Intervention: Bigger Is Smarter Elsewhere in this issue, Freeman and co-workers' present evidence from a prospective longitudinal study in Guatemala that a 15 per cent increase in energy intake of pregnant or lactating women and of young children exerted favorable effects on growth and cognitive development of the children. This outcome does not appear surprising in view of the usually restricted energy intakes (between 65 and 75 per cent of requirement) of the women and young children in the Guatemalan villages studied. In 1968, the Institute of Nutrition of Central America and Panama (INCAP) initiated an intervention program (preventive and curative medicine and nutrition) for all persons in four small villages in Guatemala. Two types of food supplements were provided: atole (a gruel) andfresco (a cool, refreshing drink). Two villages received the atole (prepared from milk and a vegetable protein mixture yielding 6.1 gm protein and 91 kcal/dl), and two received the fresco (prepared from water, sugar, and flavoring yielding 33 kcalUdl). Although the fresco contained no protein or calcium, it did contain ascorbic acid, thiamin, riboflavin, niacin, vitamin A, iron, and fluoride in amounts similar to those in the atole. These supplements were available for voluntary consumption twice daily. The authors selected three measures-language facility, short-term memory for numbers, and perceptual analysis-from among a battery of some 12 measures of cognitive development employed during the course of the project to use as dependent variables in multiple regression analysis. Three social or environmental measuresquality of house, maternal dress, and task instruction-and two measures of nutritional status-height and head circumference-were selected as independent variables in the statistical analyses. Given the inherent weaknesses of the indicators of nutritional and social status, the authors concluded that there were associations between them and cognitive development in three and four year-old children. That nutritional factors appeared (statistically) to be somewhat more important than the social factors is not unexpected for in the Guatemalan villages the study populations were at substantial nutritional risk. It is important to recognize that the nutritional and social variables examined accounted for relatively small proportions of the total variances in the cognitive measures studied. Some problems arise when the authors examine the impact of the supplements on cognitive development. It was obviously easier to estimate daily acceptance of the supplements than it was to monitor food intake in the home. While differences between "Atole" and "Fresco" children in cumulative intakes of calories from supplements (mothers during pregnancy and lactation and thereafter the children themselves to the time of study of cognition) were substantial, the total energy intakes based on estimates of home diet intakes plus supplements probably only differed by some 10-15 per cent. In this report, the authors have chosen to ignore the estimates of intake from home diets because they ". . are not precise enough. ." It is worth noting that total energy intakes (diet and supplement) were examined in relation to birthweight and to physical growth of three year-old children as reported else.
where.2' 3
AJPH March, 1977, Vol. 67, No. 3
229
EDITORIALS
Between 1969 and 1973, there were some 400 infants born to women who received supplements2 and presumably would have received supplements as toddlers.3 Why are fewer than one-half these youngsters represented among the 573 three-year-olds forming the basis of the current report? The fact that a majority of the children considered in the present report were born to women who had not received supplements during pregnancy or lactation and that nearly one-quarter of the children did not benefit from supplementation ". . . during early life . . ." is reflected in the authors' conclusion that the ". . . nutritional heterogenity . . ." of the groups may account for some of the irregularities of the findings. It is hoped that future analyses will be accomplished with nutritionally homogeneous groups and that head circumference data will be included. In essence, the current report shows that malnourished populations of infants and young children grow bigger when given access to more adequate intakes of calories. Also provided by the current report is additional evidence, which still should be considered preliminary in nature, supporting the
earlier conclusion4 i.e., bigger is smarter, at least among preschool children.
GEORGE M. OWEN, MD REFERENCES 1. Freeman, H. E., Klein, R. E., Kagan, J. and Yarbrough, C. Relations between nutrition and cognition in rural Guatemala. Amer. J. Pub. Health. 67:233-239, 1977. 2. Lechtig, A., Habicht, J. P., Delgado, H., Klein, R. E., Yarbrough, C. and Martorell, R. Effect of food supplementation during pregnancy on birthweight. Pediatrics 56:508-520, 1976. 3. Martorell, R., Lechtig, A., Yarbrough, C., Delgado, H. and Klein, R. E. Relationships between food supplementation, home dietary intake and physical growth. Amer. J. Clin. Nutr. (in press). 4. Klein, R. E., Freeman, H. E., Kagan, J. Yarbrough, C. and Habicht, J. P. Is big smart? The relation of growth to cognition. J. Health and Social Behavior. 13:219-225, 1972.
Address reprint requests to Dr. George M. Owen, Associate Professor of Pediatrics, University of New Mexico, 2701 Frontier, N.W., UNM Surge Building, Albuquerque, NM 87106.
Quality Assurance through Computer Surveillance and Feedback The development of a computer-based medical record system has been a tantalizing objective for a number of years. The illegibility, disorganization, and frequent unavailability of the manual record has been contrasted with the benefits that could potentially accrue from a computer-based information system. In this issue McDonald and his colleagues describe an exciting experiment using a computerbased medical record to improve medical care by reminding the physician of appropriate rules that should be considered in specific circumstances in the care of a particular patient. ' There may be differences of opinion about the merits of the information system, the methods of data collection, and the display process. For example, McDonald uses input documents that can be directly input into the computer using an optical character reader. He claims that the error rate is within reasonable limits, and in spite of the requirement to enter text separately, that a system using machine readable forms is more efficient than a system using paper forms and later transcription. It would be useful to have independent confirmation of these claims and experimentation documenting whether or not practicing physicians are willing and able to record data accurately and completely using this data capture strategy. Certainly the cost of personnel time for the transcription of medical information from paper forms is an important additional element in the cost of such a system. I challenge McDonald's arguments supporting a dual record system (a typical hand-written medical record coupled with an abbreviated computer record system). Maintaining dual record systems is overly time-consuming for the 230
physician and usually results in one or both systems being incomplete. Furthermore, as long as there is a parallel manual system, the potential benefits of a totally computer-based system cannot be fully achieved. The marginal cost of expanding the computer record to include all medical information seems relatively small compared to the additional advantages that would result from having all medical data available on the computer for primary care and for programs of quality assurance. The claim that paper records are inexpensive is misleading if measured only in terms of the cost of paper. The costs of assembling, pasting, sorting, filing and retrieving manual medical records are orders of magnitude more than the price of a sheet of paper. In addition, the cost of maintaining a manual medical record room is primarily a labor cost and therefore seems certain to increase. In contrast, the,cost of computer technology has decreased about 15 per cent per year in the past decade, and this downward trend seems likely to continue for the next decade. I also challenge McDonald's minimization of the importance of rapid accessibility to medical information in ambulatory practice. A significant portion of ambulatory care consists of non-scheduled visits, visits to the emergency department or telephone "encounters". When a manual medical record is used, medical decisions are often made without adequate information about the patient's active problems, current therapy, allergies, immunization status, or laboratory test results. A computer-based system can provide ready accessibility to this medical information. McDonald's position appears to be shifting in this regard, since he plans to install AJPH March, 1977, Vol. 67, No. 3
