- Email: [email protected]
NUTRITION AND THE UNITED NATIONS AGENCIES
517 the gene, it is unlikely to lead to major changes in the public health least in the short-term future. We now have the knowledge to reduce the incidence of coronary disease as is indeed happening in other countries, and the time has come for the medical profession in this country to tender the appropriate advice in terms which can be readily understood. The prizes are great: thus, for example, many of our hospital beds are filled with geriatric patients, often with chronic cerebrovascular disease, and much of this is preventable. The time, Sir, for debate is passed: we now require action. at
Royal Liverpool Hospital, Prescot Street,
Liverpool L7 8XP
RONALD FINN
would ask in return, what precisely do you expect of the Agencies? Are you proposing that they themselves should carry out research and field studies? In the first place; it is arguable whether large, centrally organised research programmes are likely to be effective (the WHO Special Programme in Tropical Diseases will provide a useful guideline), and whether they are a proper function ofthe UN system. Secondly, progress depends on funds, and these depend on the countries which constitute the governing bodies of the Agencies. As I pointed out in the Boyd Orr lecturetwo years ago, in WHO about 1% and in FAO about 2% of the regular budget is allocated to nutrition. What progress can you expect if the share of nutrition is so small? London School of Hygiene and Tropical Medicine,
London WC1E 7HT
ENERGY REQUIREMENTS AND OBESITY
is not necessarily for UN research and field work. the old and simpler needs: better application of existing knowledge; greater awareness of the importance of nutrition in health and disease;2 and, above all, action not only by UN agencies but also by Governments.-ED.L.
**The appeal
SIR,-I suggest that some of the problems and difficulties that Professor James records in his article (Aug 13, p 386) would become less formidable if we looked more closely at the behaviour of the obese and listened more closely to what they have to say. In particular, we should make ourselves more familiar with the sorts of foods and drinks they take and the circumstances in which they take them. At present, most of the discussion on what the obese eat refers to "food intake" and expresses it usually only in terms of energy-ie, joules or calories-and occasionally also in terms of protein, fat, and carbohydrate. If you talk to an overweight patient, however, you soon discover that, in addition to straightforward meals, he finds he must have a couple of drinks before dinner or a few pints of beer in the pub in the evening; his wife cannot resist having a few biscuits with her tea, and certainly not the chocolates her husband buys for her each weekend. Their children, when they are thirsty, have become accustomed to taking a soft drink from the fridge rather than a glass of water. Certainly these items add to the intake side of the energy intakeoutput equation. But the whisky or beer, or the biscuits and chocolates, or the cola drink, are taken not to satisfy a desire for calories but to satisfy the desire for the effects of alcohol, or the pleasurable tastes of biscuits and chocolates, or the taste (and perhaps the caffeine stimulus) of the cola drink. Ifyou question people who were significantly overweight but who have now become slim and remain slim, you will find that it was largely the highly palatable foods that they used to find irresistible. It was not the meat, eggs, fish, vegetables, or fruit that they took excessively, but the cakes, biscuits, chocolates, sweets, and alcohol. For most of the obese, their condition is the result of seeking the pleasure of taking foods or drinks that are extremely tasty, or relax, or stimulate, when hunger has already been satisfied. People eat for pleasure as well as for hunger. Every lay person knows this; do all research-workers know it, too? .
There
are
EFFECT OF STANOZOLOL ON ANTITHROMBIN III AND PROTEIN C
SIR,-Plasma concentrations of some coagulation proteins increase in response to anabolic steroids. These proteins include coagulation factors VIII and IX, and it has been suggested that anabolic steroids might be useful in the treatment of haemophilia and Christmas disease. The effect of danazol on plasma proteins has prompted the suggestion that antithrombin III (AT III) deficiency might also be amenable to androgen therapy. 3,4 We have studied the effect of stanozolol on the coagulation and fibrinolytic system in normal subjects and in patients undergoing elective abdominal surgery. The drug was given by mouth, 5 mg twice daily, to eight male and six female healthy volunteers for 6 weeks. AT III levels, measured by both functional and immunological assays, rose significantly in all subjects, from 98±3% pooled normal plasma (functional assay) to 122-t3% after 3 weeks of continuous therapy (p<0-01). No differences were observed in results obtained in males and females. Discontinuation of the drug resulted in a gradual reduction to pretreatment values. Stanozolol also induced a significant increase in protein C antigen activity and in the procoagulant activity of the other vitamin-K-dependent clotting factors II, IX, and X. There were no detectable changes in factor VII levels. For protein C, the mean pretreatment value was 94±4% of normal compared with 146±8% 3 weeks after the start of stanozolol administration
(p<0-01). In
Holly Walk, Hampstead, 16
London NW3
J. C. WATERLOW
JOHN YUDKIN
NUTRITION AND THE UNITED NATIONS AGENCIES
SiR,—Your comment on "anodyne phrases" in response to Mr Lunven’s letter (Aug 13, p 400) seems to me less than fair. I think that FAO and WHO have made a valuable contribution in stimulating and catalysing work on nutrition. For example, I was a member of three successive FAO/WHO committees concerned with requirements for protein and energy. They may not have achieved anything else, but at least they stimulated a great deal of research. In this respect they have had, I believe, more impact than most of the international scientific meetings convened by other bodies, because the UN Agencies provided an input as customers, to use the Rothschild terminology, presenting the scientific community with the challenge of practical problems to be solved. If the reports and the results are inadequate, surely the fault lies with those of us who have been involved as scientists? You ask how much real progress has been made since the 1960s. I
patients undergoing elective gastrointestinal surgery, postoperative protein C levels were significantly higher in those given, preoperatively, a 75 mg intramuscular injection of stanozolol than in a matched group given prophylactic subcutaneous heparin. The effects of stanozolol on AT III and protein C are of potential therapeutic value since both are physiologically important inhibitors of coagulation, and recurrent venous thrombosis has been reported in individuals with a congenital deficiency of either protein. Protein C seems to be especially impoartant, and, when activated, it powerfully inhibits activated clotting factors V and VIII.
Fibrinolytic enhancement by stanozolol is now well recognised seems likely that this mode of action is at least partly responsible for the therapeutic efficacy of the drug in
and it
1. Waterlow
JC. Sixth Boyd Orr memorial lecture: Crisis for nutrition. Proc Nutr Soc
1981; 40: 195-207. 2. Editorial. Clinical nutrition: a new force. Lancet 1983; i: 166. 3. Gralnick HR, Rick ME. Danazol increases factor VIII and factor IX in classic hemophilia and Christmas disease. N Engl J Med 1983; 308: 1393-95. 4. Gelford JA. Exploiting sex for therapeutic purposes. N Engl J Med 1983; 308: 1417-19.
Royal Liverpool Hospital, Prescot Street,
Liverpool L7 8XP
RONALD FINN
would ask in return, what precisely do you expect of the Agencies? Are you proposing that they themselves should carry out research and field studies? In the first place; it is arguable whether large, centrally organised research programmes are likely to be effective (the WHO Special Programme in Tropical Diseases will provide a useful guideline), and whether they are a proper function ofthe UN system. Secondly, progress depends on funds, and these depend on the countries which constitute the governing bodies of the Agencies. As I pointed out in the Boyd Orr lecturetwo years ago, in WHO about 1% and in FAO about 2% of the regular budget is allocated to nutrition. What progress can you expect if the share of nutrition is so small? London School of Hygiene and Tropical Medicine,
London WC1E 7HT
ENERGY REQUIREMENTS AND OBESITY
is not necessarily for UN research and field work. the old and simpler needs: better application of existing knowledge; greater awareness of the importance of nutrition in health and disease;2 and, above all, action not only by UN agencies but also by Governments.-ED.L.
**The appeal
SIR,-I suggest that some of the problems and difficulties that Professor James records in his article (Aug 13, p 386) would become less formidable if we looked more closely at the behaviour of the obese and listened more closely to what they have to say. In particular, we should make ourselves more familiar with the sorts of foods and drinks they take and the circumstances in which they take them. At present, most of the discussion on what the obese eat refers to "food intake" and expresses it usually only in terms of energy-ie, joules or calories-and occasionally also in terms of protein, fat, and carbohydrate. If you talk to an overweight patient, however, you soon discover that, in addition to straightforward meals, he finds he must have a couple of drinks before dinner or a few pints of beer in the pub in the evening; his wife cannot resist having a few biscuits with her tea, and certainly not the chocolates her husband buys for her each weekend. Their children, when they are thirsty, have become accustomed to taking a soft drink from the fridge rather than a glass of water. Certainly these items add to the intake side of the energy intakeoutput equation. But the whisky or beer, or the biscuits and chocolates, or the cola drink, are taken not to satisfy a desire for calories but to satisfy the desire for the effects of alcohol, or the pleasurable tastes of biscuits and chocolates, or the taste (and perhaps the caffeine stimulus) of the cola drink. Ifyou question people who were significantly overweight but who have now become slim and remain slim, you will find that it was largely the highly palatable foods that they used to find irresistible. It was not the meat, eggs, fish, vegetables, or fruit that they took excessively, but the cakes, biscuits, chocolates, sweets, and alcohol. For most of the obese, their condition is the result of seeking the pleasure of taking foods or drinks that are extremely tasty, or relax, or stimulate, when hunger has already been satisfied. People eat for pleasure as well as for hunger. Every lay person knows this; do all research-workers know it, too? .
There
are
EFFECT OF STANOZOLOL ON ANTITHROMBIN III AND PROTEIN C
SIR,-Plasma concentrations of some coagulation proteins increase in response to anabolic steroids. These proteins include coagulation factors VIII and IX, and it has been suggested that anabolic steroids might be useful in the treatment of haemophilia and Christmas disease. The effect of danazol on plasma proteins has prompted the suggestion that antithrombin III (AT III) deficiency might also be amenable to androgen therapy. 3,4 We have studied the effect of stanozolol on the coagulation and fibrinolytic system in normal subjects and in patients undergoing elective abdominal surgery. The drug was given by mouth, 5 mg twice daily, to eight male and six female healthy volunteers for 6 weeks. AT III levels, measured by both functional and immunological assays, rose significantly in all subjects, from 98±3% pooled normal plasma (functional assay) to 122-t3% after 3 weeks of continuous therapy (p<0-01). No differences were observed in results obtained in males and females. Discontinuation of the drug resulted in a gradual reduction to pretreatment values. Stanozolol also induced a significant increase in protein C antigen activity and in the procoagulant activity of the other vitamin-K-dependent clotting factors II, IX, and X. There were no detectable changes in factor VII levels. For protein C, the mean pretreatment value was 94±4% of normal compared with 146±8% 3 weeks after the start of stanozolol administration
(p<0-01). In
Holly Walk, Hampstead, 16
London NW3
J. C. WATERLOW
JOHN YUDKIN
NUTRITION AND THE UNITED NATIONS AGENCIES
SiR,—Your comment on "anodyne phrases" in response to Mr Lunven’s letter (Aug 13, p 400) seems to me less than fair. I think that FAO and WHO have made a valuable contribution in stimulating and catalysing work on nutrition. For example, I was a member of three successive FAO/WHO committees concerned with requirements for protein and energy. They may not have achieved anything else, but at least they stimulated a great deal of research. In this respect they have had, I believe, more impact than most of the international scientific meetings convened by other bodies, because the UN Agencies provided an input as customers, to use the Rothschild terminology, presenting the scientific community with the challenge of practical problems to be solved. If the reports and the results are inadequate, surely the fault lies with those of us who have been involved as scientists? You ask how much real progress has been made since the 1960s. I
patients undergoing elective gastrointestinal surgery, postoperative protein C levels were significantly higher in those given, preoperatively, a 75 mg intramuscular injection of stanozolol than in a matched group given prophylactic subcutaneous heparin. The effects of stanozolol on AT III and protein C are of potential therapeutic value since both are physiologically important inhibitors of coagulation, and recurrent venous thrombosis has been reported in individuals with a congenital deficiency of either protein. Protein C seems to be especially impoartant, and, when activated, it powerfully inhibits activated clotting factors V and VIII.
Fibrinolytic enhancement by stanozolol is now well recognised seems likely that this mode of action is at least partly responsible for the therapeutic efficacy of the drug in
and it
1. Waterlow
JC. Sixth Boyd Orr memorial lecture: Crisis for nutrition. Proc Nutr Soc
1981; 40: 195-207. 2. Editorial. Clinical nutrition: a new force. Lancet 1983; i: 166. 3. Gralnick HR, Rick ME. Danazol increases factor VIII and factor IX in classic hemophilia and Christmas disease. N Engl J Med 1983; 308: 1393-95. 4. Gelford JA. Exploiting sex for therapeutic purposes. N Engl J Med 1983; 308: 1417-19.