- Email: [email protected]
The assessment and remedying of inadequate diets in India, as appreciated by Sir Robert McCarrison
NUTRITION/METABOLISM CLASSIC WITH PROSPECTIVE OVERVIEW
Editor: Alexander Walker, DSc
The Assessment and Remedying of Inadequate Diets in India, as Appreciated by Sir Robert McCarrison A. R. P. Walker, DSc From the Human Biochemistry Research Unit, School of Pathology of the University of the Witwatersrand, and the South African Institute for Medical Research, Johannesburg, South Africa INTRODUCTION As background to this “classic” contribution, from information assembled from his detailed obituaries,1,2 Sir Robert McCarrison was born in Ireland in 1878. He graduated with a degree in medicine in Dublin in 1900. He entered the Indian Medical Service in 1902 and soon became known as an able research worker and received the Kaiser-i-Hind gold medal in 1911. At the time of World War I, he worked for 4 y in a hospital in Egypt. He returned to India in 1918. He then began intensive research investigations at the laboratories at the Pasteur Institute, Coonoor, where he remained until 1935. During his early period in India, among other research enquiries, he wrote a series of publications on goiter. Although he did not question the importance of iodine deficiency in causation or the effect of iodine as an antigoitrogenic agent, he insisted that a significant part was played by other factors, including sanitary conditions, goitrogenic substances in certain foods, and the general composition of the diet.3 It was considered that “his work on goiter brought him world-wide recognition.”2 During his postwar service at Coonoor, he carried out a wide variety of investigations and, in his own words, ultimately succeeded in putting nutrition “on the map” in India. Much of his research was simple in conception.4 During his visits to the frontiers of northern India, he was struck by the fine physique and powers of endurance of the local people, and he concluded that these characteristics might be due largely to the type of diet consumed consisting of wholemeal flour, milk products, vegetables, fruits, with a little meat on rare occasions. This belief became the basis of much of his later work. In illuminating experimental studies, concerning the foregoing situation, rats were fed on “good” and “bad” diets resembling those being eaten by various population groups in India. On the good diets they thrived; on the bad, they failed to grow, suffered from a variety of diseases, and died prematurely. From these and other experiments and from his numerous observations in the field, a picture of the problem of nutrition and malnutrition in India emerged, and, in consequence, from his writings and lectures, medical and public-health authorities, administrators, and the educated public, began to realize its importance. It was McCarrison’s epidemiologic and laboratory studies that did much to define the problems.
This article was supported by the South African Institute for Medical Research Foundation, the South African Medical Research Council, and the South African Sugar Association. Correspondence to: A. R. P. Walker, DSc, Human Biochemistry Research Unit, South African Institute for Medical Research, PO Box 1038, Johannesburg, 2000, South Africa. E-mail: [email protected] Nutrition 18:106 –109, 2002 ©Elsevier Science Inc., 2002. Printed in the United States. All rights reserved.
During his career, he published 157 research papers and nine books. Several contributions were published in the British Medical Journal and a very large number in the Indian Journal of Medical Research. Such was the high regard of his contributions that they were summarized in a volume entitled The Work of Sir Robert McCarrison edited by H. M. Sinclair.5 In one of the many tributes to his work, and a point to keep in mind, it was stated that “while many of his conclusions now appear obvious . . . they were far from being obvious forty years ago.”1 McCarrison returned to England, relatively young, at 57 y. He maintained an active interest in health, especially nutritional health, and he gave numerous lectures. His three Cantor Lectures were delivered before the Royal Society of Arts in 1936. They were entitled “Food, Nutrition and Health,” “Relation of Certain Food Essentials to Structure and Functions of the Body,” and “National Health and Nutrition.” These lectures were incorporated into a book, published in London in 1937, entitled Nutrition and National Health.4 The two main health messages, embodied in the lectures, will form the basis of this “classical” contribution. When I visited him in Oxford in 1949, he gave me a signed copy of that book. Interestingly, in the interview, after unhurriedly answering all of the questions raised, he then asked all manner of questions as to the nutrition, health, and ill-health situations in the various sub-Saharan African populations. As a person, McCarrison was credited with being the possessor of a distinguished and commanding presence. He had no slight oratorical gifts. His audiences felt the infection of his own enthusiasm, although the subject might be completely new to them. He brought to his researchers not only a critical mind and a severe self-discipline, but also imagination and a philosophic outlook. His love for India was manifest, and India rewarded him with an affection which was given to few Europeans.1
MCCARRISON’S RESEARCH CONTRIBUTIONS Details will now be given of his two research contributions under consideration: first, his epidemiologic and experimental studies in India, and, second, his suggestions for the improvement of the health and ill-health situation in the United Kingdom.4
Epidemiologic and Experimental Studies in India The following paragraphs are McCarrison’s own words, principally because they communicate a much truer impression of his personality with regard to his research and his appreciation, reasoning, and actions4 than can be communicated in brief summaries. 0899-9007/02/$22.00 PII S0899-9007(01)00736-5
Nutrition Volume 18, Number 1, 2002 The country [India] is made up of many races presenting great diversity in their characteristics, manner of life, customs, religion, food and food habits. The tribes of the Indian Frontier, and of Himalayan regions, the People of the Plains—Sikhs, Rajputs, Mahrattas, Bengalis, Ooriyas, Madrassis, Kanarese and many others— exhibit, in general, the greatest diversity of physique. And as each race is wedded to its own manner of living, to its own national diet, comparison between them is easy. The level of physical efficiency of Indian races is, above all else, a matter of food. No other single factor—race, climate, endemic disease, etc.— has so profound an influence on their physique, and on their capacity to sustain arduous labor and prolonged muscular exertion. The physique of northern races of India is strikingly superior to that of the southern, eastern and western races. This difference depends almost entirely on the gradually diminishing value of the food, from the north to the east, south and west of India, with respect to the amount and quality of its proteins, the quality of the cereal grains forming the staple article of the diet, the quality and quantity of the fats, the mineral and vitamin contents, and the balance of the food as a whole. In addition to these questions there is the further one of quantity. In regard to the latter little need be said . . . In conformity with the constitution of their dietaries, the best are the finest races of India, so far as physique is concerned, and among the finest races of mankind. . . . In general the races of northern India are wheat-eaters, though they make use also of certain other whole cereal grains. Now the biological value of the proteins of whole wheat is relatively high; and the wheat is eaten whole, after being freshly ground into a coarse flour (atta) and made into cakes called chapattis. It thus preserves all the nutrients with which Nature has endowed it, particularly its proteins, its vitamins and its mineral salts. The second most important ingredient of their diet is milk, and the products of milk (clarified butter or ghee, curds, buttermilk); the third is dhal (pulse); the fourth, vegetables and fruit. Some eat meat sparingly, if at all; others, such as the Pathans, use it in considerable quantity. Their food thus contains—when they get the food they want, which they do not always do—all elements and complexes needed for normal nutrition. In contrast, so it is with rice, which is the staple article of diet of about ninety millions of India’s inhabitants. The rice—a relatively poor cereal at best—is subjected to a number of processes before use by the consumer; all of which reduce—some to a dangerous extent parboiled, milled or polished; often all three. It is washed from many of its proteins and mineral salts and of almost all its vitamins. Add to this that the average Bengali or Madrassi uses relatively little milk or milk-products, that by religion he is often a non-meat-eater, that his consumption of protein, whether of vegetable or of animal origin, is, in general, very low, that fresh vegetables and fruit enter into his dietary but sparingly, and we have not far to seek for the poor physique that, in general, characterizes him. . . . In short, it may be said that according as the quality of the diet diminishes with respect to proteins, fats, minerals and vitamins, so do physical efficiency and health; a rule which applies with equal force to the European as to the Indian. Regarding experimental research: So impressed was I by the adequacy of the northern Indian’s diet that during the later years of my experimental work I used it as the diet of my stock rats. These numbered about 1,000. Their food consisted of chapattis lightly smeared with fresh butter, sprouted Bengal gram (pulse), raw, fresh vegetables (cabbage and carrots) ad libitum, milk, the hard crusts of bread (to keep their teeth in order), a small ration of meat
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with bone once a week, and water. They were kept in stock for about two years—a period approximately equal to the first fifty years in the life of a human being—the young being taken as required for the experimental purposes, and the remainder used for breeding. During the five years before my leaving India there was in this stock no case of illness, no death from natural causes, no maternal mortality, no infantile mortality. It is true that the hygienic conditions under which they lived were ideal, they were comfortably bedded in clean straw, that they enjoyed daily exposures to the sun practically the whole year round, and that the care bestowed upon them was great; but the same care was bestowed during these years on several thousand deficiency fed rats, which developed a wide variety of ailments (vide infra) while the well-fed animals enjoyed a remarkable freedom from disease. It is clear, therefore, that it was to their food that this freedom was due. Turning to the application of nutritional and health lessons that were learned in India: If I have convinced you of the fundamental importance of food in relation to public health, it will have become obvious that one of the most urgent problems of our time is how to ensure that each member of the community shall receive a diet that will satisfy his or her physiologic needs. It is clear that to achieve this much-to-be-desired end many barriers— poverty, unemployment, apathy, ignorance, prejudice, habit— must be surmounted, and many interests—agricultural, industrial, and economic—readjusted. To do so is, in the main, a primary function of Government. During the recent election campaign one reads of plans for “the building of an A1 nation”; with the detailing of a commendable measure concerning young and old. McCarrison considered that: All these are well enough—and laudable; they are, indeed, essential parts of a properly organized policy of health. But without measures that will ensure the better feeding of the people they cannot, like a diet inadequate in vitamins though complete in other regards, achieve the end in view—“the building of an A1 nation.” But while the main burden of achieving this end must rest on Government—and a heavy burden it is—there is much that individuals can do for themselves . . . for they can make it their business thoroughly to acquaint themselves with the principles of nutrition, to practice these principles and to inculcate them in others. These principles are not difficult of comprehension, their practice is simple, and the benefits to be derived from their practice are sure. Fifteen years ago, in a book from which I have ventured to quote already, I wrote as follows: “With increasing knowledge of nutritional problems, it has become apparent that our dietetics habits need remodeling, and that education of the people as to what to eat and why they eat it is urgently necessary. It is clear that green vegetables, milk and eggs should form a far higher proportion of the food of the nation than is now customary. . . . Municipalities and other public bodies should concentrate on the provision of an abundance of milk, eggs and vegetables, for there is no measure that could be devised for improving the health and well-being of the people at the present time that surpasses this either in excellence nor in urgency.” Today, fifteen years later, there is little I can add to this exhortation. Indeed, the essence of the “Report on the Physiologic Bases of Nutrition,” by a special committee of the League of Nations . . . emphasizes two needs . . . the need for education in the principles of nutrition and the need for the employment of many of our “unemployed” in the production of more milk, more eggs and more vegetable foods. By naming meat “protective” the impression is created
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that health depends on its inclusion in the diet, which it does not. Far better is it to encourage the use of inexpensive but none the less nutritious foodstuffs (milk, cheese, herrings, whole meal bread, vegetables, etc.), from which satisfying and well balanced meals can readily be made at a relatively low cost. It is here that education is called for— education not only in food values but in the correct and inexpensive selection and combination of foodstuffs. In this matter of education in the principles of nutrition, two of the great professions— the medical and the scholastic—are in a position greatly to aid the endeavors of Government in “the building of an A1 nation.” In regard to my own profession I may repeat what I wrote fifteen years ago—“It is for us to instruct ourselves that we may . . . use our newer knowledge to the end that customs and prejudices may be broken and a more adequate dietary secured for those under our care. . . .” “A special responsibility attaches to our medical schools in this respect. . . . At present, medical students during the early years of their course are given a few lectures and demonstrations dealing with the physiology of nutrition, and perhaps carry out a little laboratory work in this field; the subject is presented as a chapter of physiology, and not as an integral part of preventive medicine. . . .” The authors of the League of Nations Report, from which we here quote, are “far from suggesting that yet another speciality should be added to the already congested medical curriculum.” But surely a subject that is “an integral part of preventive medicine” must in the future be given a place in the medical curriculum commensurate with its importance. In its teaching we must be content with no half-measures. Next the most important direction in which educational effort is required is in the teaching of the elements of nutrition to schoolchildren. But to teach the children, the teachers must themselves be taught, and this requires the adequate provision in all training colleges for prospective entrants into the scholastic profession of facilities for the acquisition of a thorough knowledge of the subject. These facilities do not, so far as I can learn, now exist, or if existing they are not adequate. Their provision is an urgent matter. . . . But behind all such effort there is the dark cloud of economic conditions that make it difficult, if not impossible, for large numbers of our people to procure diets that will satisfy their physiologic needs. Happily there are signs that this cloud is lifting, and there is no lack of evidence both of desire and of effort to ensure a better way of life for the less fortunate among us. Until this cloud is dispelled the distribution of relief in kind might well be resorted to. Collective feeding has much to recommend it, both for workers and for unemployed. . . . For my own part, my interests have lain in the direction of learning what I could of the relation of faulty food to nutrition and of both to health and disease; and out of this desire to learn there has come the desire to spread such knowledge of the subject as we already possess.
COMMENT In which respects do McCarrison’s views and writings constitute a classic contribution? How far are they in advance of those of others? Throughout the ages, numerous beliefs have been expressed concerning food practices and the associated health and ill-health. The great Hippocrates wrote “And this I know, moreover, that to the human body it makes a great difference whether the bread be fine or coarse, of wheat with or without the hull.”6 The great Jewish philosopher and physician in the 12th century, Moses Maimonides, wrote extensively on dietary practices; for example, “Bread . . . should not be sifted thoroughly. . . . Meat should be that of hens or roosters . . . boiled or broiled in a pot. . . . As for
Nutrition Volume 18, Number 1, 2002 fruit, one should take before the meal whatever softens the stools, and after the meal those fruits in which there is an astringence like pear, quince and apple.”7 What distinguishes McCarrison’s contribution was his endeavor to explain the reasons for the contrasts evident in the health and ill-health experiences of the numerous diverse populations in India.4,8,9 Apart from his epidemiologic studies, there was his readiness to seek to provide experimental support for his conclusions; hence, his extensive studies on the responses of rats when fed the various diets.4,9 In the latter part of his life, based on the results of his researches in India, there were his forthright recommendations concerning the need for changes in the composition of the diets of Western populations, recommendations that stressed the overriding importance of a high consumption of plant foods, namely unrefined cereals, vegetables, and fruits. As is now well known, his beliefs and teachings have been amply supported by the superior health statistics of certain Mediterranean populations,10 Seventh Day Adventists,11 and vegetarians.12 An important component of his understanding concerned his realization that ill-health cannot be explained solely by the adverse effects of inadequate diets or overeating; the effects of non-dietary factors, lack of good hygiene practices, insufficient exercise, smoking habits, and alcohol consumption also must be considered.4 With regard to his appreciation of the incomplete explanations of health behaviors at that time, doubtless he would have been surprised to know that even today, decades later, in the case of perhaps the most researched of nutritionally related diseases, coronary heart disease, known risk factors still explain only half of the variance in the occurrence of the disease.13 The same lack of knowledge prevails with regard to the risk factors for numerous cancers.14 As a highly practical worker, McCarrison would have been keen to know, ultimately, to what extent his health messages and those of more recent investigators have resulted in health improvements, where such have been feasible. In brief, are the changes that he urged really being attended to, and practiced, with subsequent health improvements? As to the situation in India, whose population has greatly increased and is now approaching a billion, enormous undernutrition and malnutrition still remain, especially among the young. Yet there is some evidence of decreases in the morbidity and mortality rates from communicable diseases and increases in the occurrences of the chronic diseases of lifestyle.15,16 This is especially the case with coronary heart disease; indeed, puzzlingly, Indian immigrants in Britain now have mortality rates from the disease that are higher than those of the white population.17 In India, encouragingly, there is the singular experience of one of the poorest states, Kerala18; how it would have thrilled McCarrison to have known of this commendable situation. For this state, with a population of about 40 million, has a gross national product per capita of only 100th of that of the United Kingdom. Yet, through the adoption of various health measures, total fertility rate has fallen to 1.7. Mean survival times are 79 y for men and 74 for women, with an infant mortality rate of 13 per 1000 live births—vital statistics that are superior to those of many Western populations. With regard to the extent of changes in practices that have occurred in Western populations, the answer is, very little has occurred. Thus, the numerous recent urges to reduce fat intake are almost wholly ignored,19,20 apart from a slight reduction, little more than a tenth, reported in the United States.21 Consumptions of unrefined cereals, vegetables, and fruit have increased, but only very slightly.19 –22 Not least, overeating is now universal in Western populations and those segments of Third World populations who have the means to choose their diets.23,24 Further, many non-dietary risk factors are rising, as in the case of smoking and alcohol consumption among the young.25,26 Not least of health drawbacks, little use is being made of state medical services relating to primary care and ill-health avoidance.27 In brief, “even
Nutrition Volume 18, Number 1, 2002
Assessment and Remedying of Inadequate Diets in India
when people are fully aware of the risks that their indulgences incur, many carry on regardless,”28 for “studies have found little evidence that changes in health related behavior were a response to formal health messages.”29 However, ironically, and this would have surprised a somewhat despondent McCarrison, the present situation is such that, throughout the world, expectations of life span have never been longer30; indeed, the previously very small numbers reaching 100 y are rising considerably,31 due in part to increased medication. So does this imply that health-promotion messages, classic and present, may largely be ignored with impunity? In 1977, a highly challenging and expressive view was put forward that “Nature did not intend us to grow old and ill, we were designed to die young of old age.”32 How whole-heartedly McCarrison would have supported this viewpoint. For the true situation is that practitioners of positive health measures certainly enjoy not only longer life but also longer periods of disease-free years, as exemplified in the cases of the populations already cited.7–9 Currently, in this respect, the results of the US Nurses Study are heartening.33 A study from Norway has reported that the consumption of whole grain is four times higher than in the United States and that there is a lower mortality rate among the high than among low consumers.34 In Sweden, a high fruit intake has been shown to reduce mortality among the middle aged and elderly.35 The list could go on. Why are we so reluctant to learn and to apply?
11. Snowdon DA. Animal product consumption and mortality because of all causes combined, coronary heart disease, stroke, diabetes and cancer in Seventh Day Adventists. Am J Clin Nutr 1988;48:739 12. Segasothy M, Phillips PA. Vegetarian diet: panacea for modern lifestyle diseases? QJM 1999;92:531 13. Leeder S, Gliksman M. Prospects for preventing heart disease. BMJ 1990;301: 1004 14. Marshall E. Search for a killer: focus shifts from fat to hormones. Science 1993;259:619 15. Nath I. India. Challenges of transition. Lancet 1998;351:1265 16. Krishnaswami K. Nutritional disorders— old and changing. Lancet 1998;351: 1268 17. Bhopal R, Unwin N, White M, et al. Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi and European origin populations: cross sectional study. BMJ 1999;319:215 18. Thankappan KR, Valiathan MS. Health at low cost—the Kerala model. Lancet 1998;351:1274 19. Ministry of Agriculture, Fisheries, and Food. National food survey, 1996. Annual report on food expenditure, consumption and nutrient intakes. London: Her Majesty’s Stationery Office, 1996 20. Beer-Borst S, Hercberg S, Morabia A, et al. Dietary patterns in six European populations: results from EURALIM, a collaborative European data harmonization and information campaign. Eur J Clin Nutr 2000;54:253 21. Popkin BM, Siega Riz AM, Haines PS. A comparison of dietary trends among racial and socioeconomic groups in the United States. N Engl J Med 1996;335: 716 22. Larsson I, Lissner L, Wilhelmsen L. The ’Green Keyhole’ revisited: nutritional knowledge may influence food selection. Eur J Clin Nutr 1999;53:776 23. Walker ARP. Epidemiology and health implications of obesity, with special reference to African populations. Ecol Food Nutr 1998;37:21 24. Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: prevalence and trends, 1960 –1994. Int J Obes Relat Metab Disord 1998;22:39 25. Tobacco use among middle and high school students—United States, 1999. MMWR 2000;49:453 26. McGregor A. Young Swiss drinkers. Lancet 1995;345:1566 27. Reynolds T. Putting prevention into practice—the communities’ role. Ann Intern Med 1999;130:336 28. The Lancet. Hard sell for health. Lancet 1998;352:687 29. Austoker J, Sanders D, Fowler G. Smoking and cancer: smoking cessation. BMJ 1994;308:1478 30. Greencross S, Murphy E, Quam L, Rochon P, Smith R. Aging: a subject that must be at the top of the world agendas. BMJ 1997;315:1029 31. The Lancet. So professor, how will we die? Lancet 1999;353:421 32. Wynder EL, Kristein MM. Suppose we died young, late in life. . . ? JAMA 1977;238:1507 33. Hu FB, Stampfer MJ, Manson JE, et al. Trends in the incidence of coronary heart disease and changes in diet and lifestyle in women. N Engl J Med 2000;343:530 34. Jacobs DR, Meyer HE, Solvoll K. Reduced mortality among whole grain bread eaters in men and women in the Norwegian County Study. Eur J Clin Nutr 2001;55:137 35. Strandhagen E, Hansson P-O, Bosaeus I, Isaksson B, Eriksson H. High fruit intake may reduce mortality among middle-aged and elderly men. The study of men born in 1913. Eur J Clin Nutr 2000;54:337
ACKNOWLEDGMENTS The author thanks Mrs. F. Adam and Mrs. B. F. Walker for typing assistance and library work.
REFERENCES 1. Obituary. Sir Robert McCarrison. BMJ 1960;i:1663, 1743, 1818 2. Obituary. Robert McCarrison. Lancet 1960;i:1198 3. McCarrison R, Madhava KB. The life line of the thyroid gland. A contribution to the study of goiter. Indian Med Res Mem 1932;23:378 4. McCarrison R. Nutrition and national health. The Cantor Lectures. London: Faber and Faber, 1936 5. Sinclair HM. The work of Sir Robert McCarrison. London: Faber and Faber, 1953 6. Adams F. The genuine works of Hippocrates. Baltimore: Williams & Wilkins, 1939 7. Leibowitz JP, Marcus S. Moses Maimodies on the causes of symptoms. Los Angeles: University of California Press, 1974 8. McCarrison R. A lecture on some surgical aspects of faulty nutrition. BMJ 1931;i:966 9. McCarrison R. Problems of nutrition in India. Nutr Abstr Rev 1932;2:1 10. Trichopoulou A, Vasilopoulou E. Mediterranean diet and longevity. Br J Nutr 2000;84(suppl):205
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Editor: Alexander Walker, DSc
The Assessment and Remedying of Inadequate Diets in India, as Appreciated by Sir Robert McCarrison A. R. P. Walker, DSc From the Human Biochemistry Research Unit, School of Pathology of the University of the Witwatersrand, and the South African Institute for Medical Research, Johannesburg, South Africa INTRODUCTION As background to this “classic” contribution, from information assembled from his detailed obituaries,1,2 Sir Robert McCarrison was born in Ireland in 1878. He graduated with a degree in medicine in Dublin in 1900. He entered the Indian Medical Service in 1902 and soon became known as an able research worker and received the Kaiser-i-Hind gold medal in 1911. At the time of World War I, he worked for 4 y in a hospital in Egypt. He returned to India in 1918. He then began intensive research investigations at the laboratories at the Pasteur Institute, Coonoor, where he remained until 1935. During his early period in India, among other research enquiries, he wrote a series of publications on goiter. Although he did not question the importance of iodine deficiency in causation or the effect of iodine as an antigoitrogenic agent, he insisted that a significant part was played by other factors, including sanitary conditions, goitrogenic substances in certain foods, and the general composition of the diet.3 It was considered that “his work on goiter brought him world-wide recognition.”2 During his postwar service at Coonoor, he carried out a wide variety of investigations and, in his own words, ultimately succeeded in putting nutrition “on the map” in India. Much of his research was simple in conception.4 During his visits to the frontiers of northern India, he was struck by the fine physique and powers of endurance of the local people, and he concluded that these characteristics might be due largely to the type of diet consumed consisting of wholemeal flour, milk products, vegetables, fruits, with a little meat on rare occasions. This belief became the basis of much of his later work. In illuminating experimental studies, concerning the foregoing situation, rats were fed on “good” and “bad” diets resembling those being eaten by various population groups in India. On the good diets they thrived; on the bad, they failed to grow, suffered from a variety of diseases, and died prematurely. From these and other experiments and from his numerous observations in the field, a picture of the problem of nutrition and malnutrition in India emerged, and, in consequence, from his writings and lectures, medical and public-health authorities, administrators, and the educated public, began to realize its importance. It was McCarrison’s epidemiologic and laboratory studies that did much to define the problems.
This article was supported by the South African Institute for Medical Research Foundation, the South African Medical Research Council, and the South African Sugar Association. Correspondence to: A. R. P. Walker, DSc, Human Biochemistry Research Unit, South African Institute for Medical Research, PO Box 1038, Johannesburg, 2000, South Africa. E-mail: [email protected] Nutrition 18:106 –109, 2002 ©Elsevier Science Inc., 2002. Printed in the United States. All rights reserved.
During his career, he published 157 research papers and nine books. Several contributions were published in the British Medical Journal and a very large number in the Indian Journal of Medical Research. Such was the high regard of his contributions that they were summarized in a volume entitled The Work of Sir Robert McCarrison edited by H. M. Sinclair.5 In one of the many tributes to his work, and a point to keep in mind, it was stated that “while many of his conclusions now appear obvious . . . they were far from being obvious forty years ago.”1 McCarrison returned to England, relatively young, at 57 y. He maintained an active interest in health, especially nutritional health, and he gave numerous lectures. His three Cantor Lectures were delivered before the Royal Society of Arts in 1936. They were entitled “Food, Nutrition and Health,” “Relation of Certain Food Essentials to Structure and Functions of the Body,” and “National Health and Nutrition.” These lectures were incorporated into a book, published in London in 1937, entitled Nutrition and National Health.4 The two main health messages, embodied in the lectures, will form the basis of this “classical” contribution. When I visited him in Oxford in 1949, he gave me a signed copy of that book. Interestingly, in the interview, after unhurriedly answering all of the questions raised, he then asked all manner of questions as to the nutrition, health, and ill-health situations in the various sub-Saharan African populations. As a person, McCarrison was credited with being the possessor of a distinguished and commanding presence. He had no slight oratorical gifts. His audiences felt the infection of his own enthusiasm, although the subject might be completely new to them. He brought to his researchers not only a critical mind and a severe self-discipline, but also imagination and a philosophic outlook. His love for India was manifest, and India rewarded him with an affection which was given to few Europeans.1
MCCARRISON’S RESEARCH CONTRIBUTIONS Details will now be given of his two research contributions under consideration: first, his epidemiologic and experimental studies in India, and, second, his suggestions for the improvement of the health and ill-health situation in the United Kingdom.4
Epidemiologic and Experimental Studies in India The following paragraphs are McCarrison’s own words, principally because they communicate a much truer impression of his personality with regard to his research and his appreciation, reasoning, and actions4 than can be communicated in brief summaries. 0899-9007/02/$22.00 PII S0899-9007(01)00736-5
Nutrition Volume 18, Number 1, 2002 The country [India] is made up of many races presenting great diversity in their characteristics, manner of life, customs, religion, food and food habits. The tribes of the Indian Frontier, and of Himalayan regions, the People of the Plains—Sikhs, Rajputs, Mahrattas, Bengalis, Ooriyas, Madrassis, Kanarese and many others— exhibit, in general, the greatest diversity of physique. And as each race is wedded to its own manner of living, to its own national diet, comparison between them is easy. The level of physical efficiency of Indian races is, above all else, a matter of food. No other single factor—race, climate, endemic disease, etc.— has so profound an influence on their physique, and on their capacity to sustain arduous labor and prolonged muscular exertion. The physique of northern races of India is strikingly superior to that of the southern, eastern and western races. This difference depends almost entirely on the gradually diminishing value of the food, from the north to the east, south and west of India, with respect to the amount and quality of its proteins, the quality of the cereal grains forming the staple article of the diet, the quality and quantity of the fats, the mineral and vitamin contents, and the balance of the food as a whole. In addition to these questions there is the further one of quantity. In regard to the latter little need be said . . . In conformity with the constitution of their dietaries, the best are the finest races of India, so far as physique is concerned, and among the finest races of mankind. . . . In general the races of northern India are wheat-eaters, though they make use also of certain other whole cereal grains. Now the biological value of the proteins of whole wheat is relatively high; and the wheat is eaten whole, after being freshly ground into a coarse flour (atta) and made into cakes called chapattis. It thus preserves all the nutrients with which Nature has endowed it, particularly its proteins, its vitamins and its mineral salts. The second most important ingredient of their diet is milk, and the products of milk (clarified butter or ghee, curds, buttermilk); the third is dhal (pulse); the fourth, vegetables and fruit. Some eat meat sparingly, if at all; others, such as the Pathans, use it in considerable quantity. Their food thus contains—when they get the food they want, which they do not always do—all elements and complexes needed for normal nutrition. In contrast, so it is with rice, which is the staple article of diet of about ninety millions of India’s inhabitants. The rice—a relatively poor cereal at best—is subjected to a number of processes before use by the consumer; all of which reduce—some to a dangerous extent parboiled, milled or polished; often all three. It is washed from many of its proteins and mineral salts and of almost all its vitamins. Add to this that the average Bengali or Madrassi uses relatively little milk or milk-products, that by religion he is often a non-meat-eater, that his consumption of protein, whether of vegetable or of animal origin, is, in general, very low, that fresh vegetables and fruit enter into his dietary but sparingly, and we have not far to seek for the poor physique that, in general, characterizes him. . . . In short, it may be said that according as the quality of the diet diminishes with respect to proteins, fats, minerals and vitamins, so do physical efficiency and health; a rule which applies with equal force to the European as to the Indian. Regarding experimental research: So impressed was I by the adequacy of the northern Indian’s diet that during the later years of my experimental work I used it as the diet of my stock rats. These numbered about 1,000. Their food consisted of chapattis lightly smeared with fresh butter, sprouted Bengal gram (pulse), raw, fresh vegetables (cabbage and carrots) ad libitum, milk, the hard crusts of bread (to keep their teeth in order), a small ration of meat
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with bone once a week, and water. They were kept in stock for about two years—a period approximately equal to the first fifty years in the life of a human being—the young being taken as required for the experimental purposes, and the remainder used for breeding. During the five years before my leaving India there was in this stock no case of illness, no death from natural causes, no maternal mortality, no infantile mortality. It is true that the hygienic conditions under which they lived were ideal, they were comfortably bedded in clean straw, that they enjoyed daily exposures to the sun practically the whole year round, and that the care bestowed upon them was great; but the same care was bestowed during these years on several thousand deficiency fed rats, which developed a wide variety of ailments (vide infra) while the well-fed animals enjoyed a remarkable freedom from disease. It is clear, therefore, that it was to their food that this freedom was due. Turning to the application of nutritional and health lessons that were learned in India: If I have convinced you of the fundamental importance of food in relation to public health, it will have become obvious that one of the most urgent problems of our time is how to ensure that each member of the community shall receive a diet that will satisfy his or her physiologic needs. It is clear that to achieve this much-to-be-desired end many barriers— poverty, unemployment, apathy, ignorance, prejudice, habit— must be surmounted, and many interests—agricultural, industrial, and economic—readjusted. To do so is, in the main, a primary function of Government. During the recent election campaign one reads of plans for “the building of an A1 nation”; with the detailing of a commendable measure concerning young and old. McCarrison considered that: All these are well enough—and laudable; they are, indeed, essential parts of a properly organized policy of health. But without measures that will ensure the better feeding of the people they cannot, like a diet inadequate in vitamins though complete in other regards, achieve the end in view—“the building of an A1 nation.” But while the main burden of achieving this end must rest on Government—and a heavy burden it is—there is much that individuals can do for themselves . . . for they can make it their business thoroughly to acquaint themselves with the principles of nutrition, to practice these principles and to inculcate them in others. These principles are not difficult of comprehension, their practice is simple, and the benefits to be derived from their practice are sure. Fifteen years ago, in a book from which I have ventured to quote already, I wrote as follows: “With increasing knowledge of nutritional problems, it has become apparent that our dietetics habits need remodeling, and that education of the people as to what to eat and why they eat it is urgently necessary. It is clear that green vegetables, milk and eggs should form a far higher proportion of the food of the nation than is now customary. . . . Municipalities and other public bodies should concentrate on the provision of an abundance of milk, eggs and vegetables, for there is no measure that could be devised for improving the health and well-being of the people at the present time that surpasses this either in excellence nor in urgency.” Today, fifteen years later, there is little I can add to this exhortation. Indeed, the essence of the “Report on the Physiologic Bases of Nutrition,” by a special committee of the League of Nations . . . emphasizes two needs . . . the need for education in the principles of nutrition and the need for the employment of many of our “unemployed” in the production of more milk, more eggs and more vegetable foods. By naming meat “protective” the impression is created
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that health depends on its inclusion in the diet, which it does not. Far better is it to encourage the use of inexpensive but none the less nutritious foodstuffs (milk, cheese, herrings, whole meal bread, vegetables, etc.), from which satisfying and well balanced meals can readily be made at a relatively low cost. It is here that education is called for— education not only in food values but in the correct and inexpensive selection and combination of foodstuffs. In this matter of education in the principles of nutrition, two of the great professions— the medical and the scholastic—are in a position greatly to aid the endeavors of Government in “the building of an A1 nation.” In regard to my own profession I may repeat what I wrote fifteen years ago—“It is for us to instruct ourselves that we may . . . use our newer knowledge to the end that customs and prejudices may be broken and a more adequate dietary secured for those under our care. . . .” “A special responsibility attaches to our medical schools in this respect. . . . At present, medical students during the early years of their course are given a few lectures and demonstrations dealing with the physiology of nutrition, and perhaps carry out a little laboratory work in this field; the subject is presented as a chapter of physiology, and not as an integral part of preventive medicine. . . .” The authors of the League of Nations Report, from which we here quote, are “far from suggesting that yet another speciality should be added to the already congested medical curriculum.” But surely a subject that is “an integral part of preventive medicine” must in the future be given a place in the medical curriculum commensurate with its importance. In its teaching we must be content with no half-measures. Next the most important direction in which educational effort is required is in the teaching of the elements of nutrition to schoolchildren. But to teach the children, the teachers must themselves be taught, and this requires the adequate provision in all training colleges for prospective entrants into the scholastic profession of facilities for the acquisition of a thorough knowledge of the subject. These facilities do not, so far as I can learn, now exist, or if existing they are not adequate. Their provision is an urgent matter. . . . But behind all such effort there is the dark cloud of economic conditions that make it difficult, if not impossible, for large numbers of our people to procure diets that will satisfy their physiologic needs. Happily there are signs that this cloud is lifting, and there is no lack of evidence both of desire and of effort to ensure a better way of life for the less fortunate among us. Until this cloud is dispelled the distribution of relief in kind might well be resorted to. Collective feeding has much to recommend it, both for workers and for unemployed. . . . For my own part, my interests have lain in the direction of learning what I could of the relation of faulty food to nutrition and of both to health and disease; and out of this desire to learn there has come the desire to spread such knowledge of the subject as we already possess.
COMMENT In which respects do McCarrison’s views and writings constitute a classic contribution? How far are they in advance of those of others? Throughout the ages, numerous beliefs have been expressed concerning food practices and the associated health and ill-health. The great Hippocrates wrote “And this I know, moreover, that to the human body it makes a great difference whether the bread be fine or coarse, of wheat with or without the hull.”6 The great Jewish philosopher and physician in the 12th century, Moses Maimonides, wrote extensively on dietary practices; for example, “Bread . . . should not be sifted thoroughly. . . . Meat should be that of hens or roosters . . . boiled or broiled in a pot. . . . As for
Nutrition Volume 18, Number 1, 2002 fruit, one should take before the meal whatever softens the stools, and after the meal those fruits in which there is an astringence like pear, quince and apple.”7 What distinguishes McCarrison’s contribution was his endeavor to explain the reasons for the contrasts evident in the health and ill-health experiences of the numerous diverse populations in India.4,8,9 Apart from his epidemiologic studies, there was his readiness to seek to provide experimental support for his conclusions; hence, his extensive studies on the responses of rats when fed the various diets.4,9 In the latter part of his life, based on the results of his researches in India, there were his forthright recommendations concerning the need for changes in the composition of the diets of Western populations, recommendations that stressed the overriding importance of a high consumption of plant foods, namely unrefined cereals, vegetables, and fruits. As is now well known, his beliefs and teachings have been amply supported by the superior health statistics of certain Mediterranean populations,10 Seventh Day Adventists,11 and vegetarians.12 An important component of his understanding concerned his realization that ill-health cannot be explained solely by the adverse effects of inadequate diets or overeating; the effects of non-dietary factors, lack of good hygiene practices, insufficient exercise, smoking habits, and alcohol consumption also must be considered.4 With regard to his appreciation of the incomplete explanations of health behaviors at that time, doubtless he would have been surprised to know that even today, decades later, in the case of perhaps the most researched of nutritionally related diseases, coronary heart disease, known risk factors still explain only half of the variance in the occurrence of the disease.13 The same lack of knowledge prevails with regard to the risk factors for numerous cancers.14 As a highly practical worker, McCarrison would have been keen to know, ultimately, to what extent his health messages and those of more recent investigators have resulted in health improvements, where such have been feasible. In brief, are the changes that he urged really being attended to, and practiced, with subsequent health improvements? As to the situation in India, whose population has greatly increased and is now approaching a billion, enormous undernutrition and malnutrition still remain, especially among the young. Yet there is some evidence of decreases in the morbidity and mortality rates from communicable diseases and increases in the occurrences of the chronic diseases of lifestyle.15,16 This is especially the case with coronary heart disease; indeed, puzzlingly, Indian immigrants in Britain now have mortality rates from the disease that are higher than those of the white population.17 In India, encouragingly, there is the singular experience of one of the poorest states, Kerala18; how it would have thrilled McCarrison to have known of this commendable situation. For this state, with a population of about 40 million, has a gross national product per capita of only 100th of that of the United Kingdom. Yet, through the adoption of various health measures, total fertility rate has fallen to 1.7. Mean survival times are 79 y for men and 74 for women, with an infant mortality rate of 13 per 1000 live births—vital statistics that are superior to those of many Western populations. With regard to the extent of changes in practices that have occurred in Western populations, the answer is, very little has occurred. Thus, the numerous recent urges to reduce fat intake are almost wholly ignored,19,20 apart from a slight reduction, little more than a tenth, reported in the United States.21 Consumptions of unrefined cereals, vegetables, and fruit have increased, but only very slightly.19 –22 Not least, overeating is now universal in Western populations and those segments of Third World populations who have the means to choose their diets.23,24 Further, many non-dietary risk factors are rising, as in the case of smoking and alcohol consumption among the young.25,26 Not least of health drawbacks, little use is being made of state medical services relating to primary care and ill-health avoidance.27 In brief, “even
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when people are fully aware of the risks that their indulgences incur, many carry on regardless,”28 for “studies have found little evidence that changes in health related behavior were a response to formal health messages.”29 However, ironically, and this would have surprised a somewhat despondent McCarrison, the present situation is such that, throughout the world, expectations of life span have never been longer30; indeed, the previously very small numbers reaching 100 y are rising considerably,31 due in part to increased medication. So does this imply that health-promotion messages, classic and present, may largely be ignored with impunity? In 1977, a highly challenging and expressive view was put forward that “Nature did not intend us to grow old and ill, we were designed to die young of old age.”32 How whole-heartedly McCarrison would have supported this viewpoint. For the true situation is that practitioners of positive health measures certainly enjoy not only longer life but also longer periods of disease-free years, as exemplified in the cases of the populations already cited.7–9 Currently, in this respect, the results of the US Nurses Study are heartening.33 A study from Norway has reported that the consumption of whole grain is four times higher than in the United States and that there is a lower mortality rate among the high than among low consumers.34 In Sweden, a high fruit intake has been shown to reduce mortality among the middle aged and elderly.35 The list could go on. Why are we so reluctant to learn and to apply?
11. Snowdon DA. Animal product consumption and mortality because of all causes combined, coronary heart disease, stroke, diabetes and cancer in Seventh Day Adventists. Am J Clin Nutr 1988;48:739 12. Segasothy M, Phillips PA. Vegetarian diet: panacea for modern lifestyle diseases? QJM 1999;92:531 13. Leeder S, Gliksman M. Prospects for preventing heart disease. BMJ 1990;301: 1004 14. Marshall E. Search for a killer: focus shifts from fat to hormones. Science 1993;259:619 15. Nath I. India. Challenges of transition. Lancet 1998;351:1265 16. Krishnaswami K. Nutritional disorders— old and changing. Lancet 1998;351: 1268 17. Bhopal R, Unwin N, White M, et al. Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi and European origin populations: cross sectional study. BMJ 1999;319:215 18. Thankappan KR, Valiathan MS. Health at low cost—the Kerala model. Lancet 1998;351:1274 19. Ministry of Agriculture, Fisheries, and Food. National food survey, 1996. Annual report on food expenditure, consumption and nutrient intakes. London: Her Majesty’s Stationery Office, 1996 20. Beer-Borst S, Hercberg S, Morabia A, et al. Dietary patterns in six European populations: results from EURALIM, a collaborative European data harmonization and information campaign. Eur J Clin Nutr 2000;54:253 21. Popkin BM, Siega Riz AM, Haines PS. A comparison of dietary trends among racial and socioeconomic groups in the United States. N Engl J Med 1996;335: 716 22. Larsson I, Lissner L, Wilhelmsen L. The ’Green Keyhole’ revisited: nutritional knowledge may influence food selection. Eur J Clin Nutr 1999;53:776 23. Walker ARP. Epidemiology and health implications of obesity, with special reference to African populations. Ecol Food Nutr 1998;37:21 24. Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: prevalence and trends, 1960 –1994. Int J Obes Relat Metab Disord 1998;22:39 25. Tobacco use among middle and high school students—United States, 1999. MMWR 2000;49:453 26. McGregor A. Young Swiss drinkers. Lancet 1995;345:1566 27. Reynolds T. Putting prevention into practice—the communities’ role. Ann Intern Med 1999;130:336 28. The Lancet. Hard sell for health. Lancet 1998;352:687 29. Austoker J, Sanders D, Fowler G. Smoking and cancer: smoking cessation. BMJ 1994;308:1478 30. Greencross S, Murphy E, Quam L, Rochon P, Smith R. Aging: a subject that must be at the top of the world agendas. BMJ 1997;315:1029 31. The Lancet. So professor, how will we die? Lancet 1999;353:421 32. Wynder EL, Kristein MM. Suppose we died young, late in life. . . ? JAMA 1977;238:1507 33. Hu FB, Stampfer MJ, Manson JE, et al. Trends in the incidence of coronary heart disease and changes in diet and lifestyle in women. N Engl J Med 2000;343:530 34. Jacobs DR, Meyer HE, Solvoll K. Reduced mortality among whole grain bread eaters in men and women in the Norwegian County Study. Eur J Clin Nutr 2001;55:137 35. Strandhagen E, Hansson P-O, Bosaeus I, Isaksson B, Eriksson H. High fruit intake may reduce mortality among middle-aged and elderly men. The study of men born in 1913. Eur J Clin Nutr 2000;54:337
ACKNOWLEDGMENTS The author thanks Mrs. F. Adam and Mrs. B. F. Walker for typing assistance and library work.
REFERENCES 1. Obituary. Sir Robert McCarrison. BMJ 1960;i:1663, 1743, 1818 2. Obituary. Robert McCarrison. Lancet 1960;i:1198 3. McCarrison R, Madhava KB. The life line of the thyroid gland. A contribution to the study of goiter. Indian Med Res Mem 1932;23:378 4. McCarrison R. Nutrition and national health. The Cantor Lectures. London: Faber and Faber, 1936 5. Sinclair HM. The work of Sir Robert McCarrison. London: Faber and Faber, 1953 6. Adams F. The genuine works of Hippocrates. Baltimore: Williams & Wilkins, 1939 7. Leibowitz JP, Marcus S. Moses Maimodies on the causes of symptoms. Los Angeles: University of California Press, 1974 8. McCarrison R. A lecture on some surgical aspects of faulty nutrition. BMJ 1931;i:966 9. McCarrison R. Problems of nutrition in India. Nutr Abstr Rev 1932;2:1 10. Trichopoulou A, Vasilopoulou E. Mediterranean diet and longevity. Br J Nutr 2000;84(suppl):205
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