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The assessment of nutrition
1939 THE ASSESSMENT OF NUTRITION" By CATH~INE B. CRANE, M.B., B.S., D.P.H.,
Assistant Medical Officer of Health, City of York. There is no known procedure by which the state of nutrition can be accurately assessed. If those of us present were asked to examine the same 50 children independently and classify their nutrition according to the Dunfermline scale set up by McKenzie in 1914, there would be marked differences in our classifications. This scale is the one most generally used for clinical assessment to-day. It is : - A. Excellent nutrition. B. Good. C. Requires supervision. D. Seriously impaired and needs treatment. Dr. W. F. Betenson, County Medical Officer of Health for Breconshire, in his Annual Report for 1985 gives the results of a nutritional survey in which six medical officers working independently assessed the same 100 children by clinical methods. Each medical officer examined all the children with the following results : - (1) All six doctors only agreed unanimously on 19 children. (2) Four doctors agreed with one dissentient on 24 children. (8) Four doctors agreed with two dissentients on 48 children. (4) In no less than 17 instances, the same child was assessed as A by some and C by others, while other children were similarly labelled B and D. The probable explanations of these wide discrepancies are : - (1) The standards of the individual medical officer vary according to the district in which he has been working. Thus one working in a depressed area will tend to have lower standards than the medical officer of a public school. (2) Women observers are harder to satisfy than men. This point was demonstrated by Dr. Betenson's survey. In 1908 Gastpar proposed a classification by which he maintained that he was able to reach a reasonable degree of agreement between different examiners." His classification was : - 1. Good nutrition. 2. Fair. 3. Fair with anaemia. 4. Poor. 5. Poor with antemia. Let us now consider the value of anthropometric standards, that is the assessment of nutrition by comparison of certain measurements with a chosen standard. If we assessed children by this method, we should undoubtedly agree in our findings, but would they be reliable ? In view of the fact that workers are as yet unable to agree on what are normal standards for height, weight and growth, I think that complicated formul~e cannot be used as accurate methods for assessing * Paper read to the Yorkshire Branch, Society of Medical Officers of Health, December 30th, 1938.
PUBLIC HEALTH nutrition. Formuke have been used which include height (standing or sitting), weight, chest measurements, arm measurements, muscle pull, h~emoglobin, thickness of the abdominal fold, etc. None of these have been proved'to be more useful than the Quetelet index of 1886 : " T h e squares of the weights of different ages are as the 5th power of the stature." In 1917, Tuxford proposed different standards for assessing the physical development of boys and girls : Weight in grammes 381--age in months Boys × Height in cms. 54 Weight in grammes 384---age in months Girls - × Height in cms. 48 The Ainerican Child Health Association claim that the arm-chest-hip index of Franzen corresponds more closely with clinical assessments than any other index. In my opinion these indices may be useful for comparing large groups of children, but are useless for the individual. Physiological and chemical tests, such as tests for early vitamin deficiency are now used for clinical medicine, but have scarcely yet come into general use for public health purposes. I thought it might be of interest to consider in detail the report published this year of the recent investigation into the effect of dietary supplements of raw and pasteurised milk on the nutrition of school childrenJ Eight thousand school children were included in the investigation, in Luton, Wolverhampton, Burton-onTrent, Huddersfield and Renfrewshire. Four full-time medical officers, working in pairs, examined these children at three-monthly intervals for a whole school year. After the original assessment of nutrition, the children were divided into four groups and given supplements of grade A or pasteurised milk, the control group being given a biscuit. The interest from the point of view of the present discussion is the details recorded, and means of assessing the nutrition of the children. The four medical officers met in London for a week before the investigation started and were instructed in order that assessments might be as uniform as possible. They also met frequently during the experiment to compare standards. Children were examined stripped to the waist, in a well lighted room and the following points noted : - 1. Clinical Assessment of Nutrition.--Children were assessed as 1, 2, 8 or 4, 1 being the excellent child, 2 good or normal, 3 slightly subnormaland 4 definitely subnormal. 2. Posture.--This was noted as excellent, fair or bad. 3. Expression was recorded as bright and alert, or dull and listless. 4. Complexion was recorded as good, fair or bad. 5. Tonsils were examined and noted whether healthy, diseased or removed. 6. Conjunctivae and Eyelids were recorded as healthy or diseased. 7. Teeth were classified in two groups: less than four carious, four or more carious. 8. Height to the nearest ~ inch. 9. Weight to the nearest ¼ lb. 10. Chest measurement at maximum inspiration and expiration, measured at the nipple line.
PUBLIC
HEALTH
1I. Physical ej~iency was tested by means of the dynamometer described by Hill, Magee and Major in 1987. Each child was given two pulls, and if the difference was greater than 10 lb., a third or even fourth. Children showing tendency to hernia, and those convalescent from certain illnesses were excluded. 12. Romberg test for muscle co-ordination. The children were made to stand with their heels and toes together, and eyes closed for five minutes. Any child who swayed persistently, or changed colour was removed from the test. 18. Teacher's assessment of intellect was recorded as bright, normal or dull. At the first examination any after-effects of preceding illnesses were noted and at subsequent examinations the number of days absent since previous examination, with cause. The recent Bristol investigation 2 into the nutrition of school children shows some interesting points for comparison with the foregoing investigation : - 1. Tonsils were recorded as normal or enlarged, the latter group including removed. 2. Teeth were investigated from the point of view of irregularity. Any overlapping or erupting in an abnormal way or position was noted, and was found to have a definite bearing on nutrition. Rodusch, in his " Diet during childhood," says, " It is believed that the condition of the teeth is the best indication of the state of nutrition." 8. Haemoglobin estimates were made, leading to the following conclusion, " that although there is a tendency for anaemia to be associated with malnutrition, it is neither a common finding, nor can it be reeognised clinically with any reliability." This differs markedly from the findings of the School Medical Officer for Warrington, who states in his annual report for 1985 : - (a) A routine medical inspection group showed only 75 per cent. of children as having a h~emoglobin value above 70 per cent. (b) A group selected because of poverty, who were to be given free milk, showed only 51 per cent. of children having a h~emoglobin value above 70 per cent. Spence of Newcastle in his classic investigation into the health of children of pre-school age*, found 28 per cent. of children of the poorest class to be definitely anmmic, whereas no children of the same age of the welt-to-do class, showed similar anmmia. Sir John Orr 4, considers rickets, bad teeth and anmmia to be three of the characteristic signs of malnutrition in children. Such diverse findings indicate that there is still much need for research into the association between anaemia and malnutrition in children.
4. Incidence of Infectious Diseases.--The Bristol investigations found that the infectious disease rate among well nourished children was higher than among the more poorly nourished groups. This is explained by the exposure of the poorer classes to subclinical attacks, but surely the incidence of complications is the point which needs noting when studying nutrition, rather than the infectious disease rate. Children with rickets show a higher incidence of complications in measles, whooping cough and diphtheria than do children of the same class without rickets3 208
APRIL The Bristol report concludes : " There is no pathognomonic sign of malnutrition, and a well nourished child is superior to a poorly nourished child in almost every respect. He is taller, heavier, looks more robust, stands better, has a more healthy eolour, a better chest expansion, more regular teeth, is less prone to bronchitis, and has suffered less from rickets. His strength is greater and he tends to be more intelligent." How then shall we assess nutrition ? In spite of discrepancies, I still think that the clinical method will ultimately become the most reliable. If our standards can be kept high by repeated reference to children about whom a group have agreed that their nutrition is excellent, discrepancies will vanish. I would conclude. , by quoting the first report of the Ministry of Health s Advisory Committee on Nutrition : " We are unable to recommend any method of assessing the state of nutrition as reliable, and we consider that research should be continued with a view to establishing if possible a reliable test or group of tests."
REFERENCES. 1Interim Report of Milk Nutrition Committee (1938). Part II. 'Roberts, Stone and Bowler (1938). An Investigation into the Nutrition of Children of School Age." The Medical Officer, nSpenee and Charles. (1934). Investigation into the Health and Nutrition of the Children of Newcastle-onTyne between the ages of 1 and 5 years. City and County of Newcastle-upon-Tyne. 4Orr, J. B. (1936). Food, Health and Income. MacmSllan & Co. p. 41. 6NIader and Eckhard. (1934). Arch. Hyg. Bakteriol., 111 i
J
HOSPITAL LmRARIES IN TIME OF WAR.--Following the policy of the Government in taking measures for national defence, the Committee of the British Red Cross Society and Order of St. John Hospital Library have decided that it is advisable to make provisional plans for the continuance of the hospital library service at home and overseas during time of war. This decision has been made in view of the well proved value of books for hospital patients during the last war and since. With regard to the source of the book supply a certain amount of decentralisation from headquarters to county depots would probably be necessary. Those responsible for the administration of local authority hospitals are asked to help in making plans by returning replies to the following questions : - (1) Have you one or more voluntary librarians running your patients' library ? (2) If you are satisfied with their work would you be prepared now to absorb some or all of them as a unit of the hospital, with a view to at least one of them remaining in charge of the library in time of war when presumably the detailed organisation would differ from that of peace time ? (8) If your present head librarian is not working to any system, and has never visited a training centre in London or elsewhere, would he or she be prepared to do so in the near future ? Such a visit would be valuable for present or future work. Replies should be sent to the Organising Secretary, British Red Cross Society and Order of St. John Hospital Library, 48, Queen's Gardens, Lancaster Gate, London, W.2.
Assistant Medical Officer of Health, City of York. There is no known procedure by which the state of nutrition can be accurately assessed. If those of us present were asked to examine the same 50 children independently and classify their nutrition according to the Dunfermline scale set up by McKenzie in 1914, there would be marked differences in our classifications. This scale is the one most generally used for clinical assessment to-day. It is : - A. Excellent nutrition. B. Good. C. Requires supervision. D. Seriously impaired and needs treatment. Dr. W. F. Betenson, County Medical Officer of Health for Breconshire, in his Annual Report for 1985 gives the results of a nutritional survey in which six medical officers working independently assessed the same 100 children by clinical methods. Each medical officer examined all the children with the following results : - (1) All six doctors only agreed unanimously on 19 children. (2) Four doctors agreed with one dissentient on 24 children. (8) Four doctors agreed with two dissentients on 48 children. (4) In no less than 17 instances, the same child was assessed as A by some and C by others, while other children were similarly labelled B and D. The probable explanations of these wide discrepancies are : - (1) The standards of the individual medical officer vary according to the district in which he has been working. Thus one working in a depressed area will tend to have lower standards than the medical officer of a public school. (2) Women observers are harder to satisfy than men. This point was demonstrated by Dr. Betenson's survey. In 1908 Gastpar proposed a classification by which he maintained that he was able to reach a reasonable degree of agreement between different examiners." His classification was : - 1. Good nutrition. 2. Fair. 3. Fair with anaemia. 4. Poor. 5. Poor with antemia. Let us now consider the value of anthropometric standards, that is the assessment of nutrition by comparison of certain measurements with a chosen standard. If we assessed children by this method, we should undoubtedly agree in our findings, but would they be reliable ? In view of the fact that workers are as yet unable to agree on what are normal standards for height, weight and growth, I think that complicated formul~e cannot be used as accurate methods for assessing * Paper read to the Yorkshire Branch, Society of Medical Officers of Health, December 30th, 1938.
PUBLIC HEALTH nutrition. Formuke have been used which include height (standing or sitting), weight, chest measurements, arm measurements, muscle pull, h~emoglobin, thickness of the abdominal fold, etc. None of these have been proved'to be more useful than the Quetelet index of 1886 : " T h e squares of the weights of different ages are as the 5th power of the stature." In 1917, Tuxford proposed different standards for assessing the physical development of boys and girls : Weight in grammes 381--age in months Boys × Height in cms. 54 Weight in grammes 384---age in months Girls - × Height in cms. 48 The Ainerican Child Health Association claim that the arm-chest-hip index of Franzen corresponds more closely with clinical assessments than any other index. In my opinion these indices may be useful for comparing large groups of children, but are useless for the individual. Physiological and chemical tests, such as tests for early vitamin deficiency are now used for clinical medicine, but have scarcely yet come into general use for public health purposes. I thought it might be of interest to consider in detail the report published this year of the recent investigation into the effect of dietary supplements of raw and pasteurised milk on the nutrition of school childrenJ Eight thousand school children were included in the investigation, in Luton, Wolverhampton, Burton-onTrent, Huddersfield and Renfrewshire. Four full-time medical officers, working in pairs, examined these children at three-monthly intervals for a whole school year. After the original assessment of nutrition, the children were divided into four groups and given supplements of grade A or pasteurised milk, the control group being given a biscuit. The interest from the point of view of the present discussion is the details recorded, and means of assessing the nutrition of the children. The four medical officers met in London for a week before the investigation started and were instructed in order that assessments might be as uniform as possible. They also met frequently during the experiment to compare standards. Children were examined stripped to the waist, in a well lighted room and the following points noted : - 1. Clinical Assessment of Nutrition.--Children were assessed as 1, 2, 8 or 4, 1 being the excellent child, 2 good or normal, 3 slightly subnormaland 4 definitely subnormal. 2. Posture.--This was noted as excellent, fair or bad. 3. Expression was recorded as bright and alert, or dull and listless. 4. Complexion was recorded as good, fair or bad. 5. Tonsils were examined and noted whether healthy, diseased or removed. 6. Conjunctivae and Eyelids were recorded as healthy or diseased. 7. Teeth were classified in two groups: less than four carious, four or more carious. 8. Height to the nearest ~ inch. 9. Weight to the nearest ¼ lb. 10. Chest measurement at maximum inspiration and expiration, measured at the nipple line.
PUBLIC
HEALTH
1I. Physical ej~iency was tested by means of the dynamometer described by Hill, Magee and Major in 1987. Each child was given two pulls, and if the difference was greater than 10 lb., a third or even fourth. Children showing tendency to hernia, and those convalescent from certain illnesses were excluded. 12. Romberg test for muscle co-ordination. The children were made to stand with their heels and toes together, and eyes closed for five minutes. Any child who swayed persistently, or changed colour was removed from the test. 18. Teacher's assessment of intellect was recorded as bright, normal or dull. At the first examination any after-effects of preceding illnesses were noted and at subsequent examinations the number of days absent since previous examination, with cause. The recent Bristol investigation 2 into the nutrition of school children shows some interesting points for comparison with the foregoing investigation : - 1. Tonsils were recorded as normal or enlarged, the latter group including removed. 2. Teeth were investigated from the point of view of irregularity. Any overlapping or erupting in an abnormal way or position was noted, and was found to have a definite bearing on nutrition. Rodusch, in his " Diet during childhood," says, " It is believed that the condition of the teeth is the best indication of the state of nutrition." 8. Haemoglobin estimates were made, leading to the following conclusion, " that although there is a tendency for anaemia to be associated with malnutrition, it is neither a common finding, nor can it be reeognised clinically with any reliability." This differs markedly from the findings of the School Medical Officer for Warrington, who states in his annual report for 1985 : - (a) A routine medical inspection group showed only 75 per cent. of children as having a h~emoglobin value above 70 per cent. (b) A group selected because of poverty, who were to be given free milk, showed only 51 per cent. of children having a h~emoglobin value above 70 per cent. Spence of Newcastle in his classic investigation into the health of children of pre-school age*, found 28 per cent. of children of the poorest class to be definitely anmmic, whereas no children of the same age of the welt-to-do class, showed similar anmmia. Sir John Orr 4, considers rickets, bad teeth and anmmia to be three of the characteristic signs of malnutrition in children. Such diverse findings indicate that there is still much need for research into the association between anaemia and malnutrition in children.
4. Incidence of Infectious Diseases.--The Bristol investigations found that the infectious disease rate among well nourished children was higher than among the more poorly nourished groups. This is explained by the exposure of the poorer classes to subclinical attacks, but surely the incidence of complications is the point which needs noting when studying nutrition, rather than the infectious disease rate. Children with rickets show a higher incidence of complications in measles, whooping cough and diphtheria than do children of the same class without rickets3 208
APRIL The Bristol report concludes : " There is no pathognomonic sign of malnutrition, and a well nourished child is superior to a poorly nourished child in almost every respect. He is taller, heavier, looks more robust, stands better, has a more healthy eolour, a better chest expansion, more regular teeth, is less prone to bronchitis, and has suffered less from rickets. His strength is greater and he tends to be more intelligent." How then shall we assess nutrition ? In spite of discrepancies, I still think that the clinical method will ultimately become the most reliable. If our standards can be kept high by repeated reference to children about whom a group have agreed that their nutrition is excellent, discrepancies will vanish. I would conclude. , by quoting the first report of the Ministry of Health s Advisory Committee on Nutrition : " We are unable to recommend any method of assessing the state of nutrition as reliable, and we consider that research should be continued with a view to establishing if possible a reliable test or group of tests."
REFERENCES. 1Interim Report of Milk Nutrition Committee (1938). Part II. 'Roberts, Stone and Bowler (1938). An Investigation into the Nutrition of Children of School Age." The Medical Officer, nSpenee and Charles. (1934). Investigation into the Health and Nutrition of the Children of Newcastle-onTyne between the ages of 1 and 5 years. City and County of Newcastle-upon-Tyne. 4Orr, J. B. (1936). Food, Health and Income. MacmSllan & Co. p. 41. 6NIader and Eckhard. (1934). Arch. Hyg. Bakteriol., 111 i
J
HOSPITAL LmRARIES IN TIME OF WAR.--Following the policy of the Government in taking measures for national defence, the Committee of the British Red Cross Society and Order of St. John Hospital Library have decided that it is advisable to make provisional plans for the continuance of the hospital library service at home and overseas during time of war. This decision has been made in view of the well proved value of books for hospital patients during the last war and since. With regard to the source of the book supply a certain amount of decentralisation from headquarters to county depots would probably be necessary. Those responsible for the administration of local authority hospitals are asked to help in making plans by returning replies to the following questions : - (1) Have you one or more voluntary librarians running your patients' library ? (2) If you are satisfied with their work would you be prepared now to absorb some or all of them as a unit of the hospital, with a view to at least one of them remaining in charge of the library in time of war when presumably the detailed organisation would differ from that of peace time ? (8) If your present head librarian is not working to any system, and has never visited a training centre in London or elsewhere, would he or she be prepared to do so in the near future ? Such a visit would be valuable for present or future work. Replies should be sent to the Organising Secretary, British Red Cross Society and Order of St. John Hospital Library, 48, Queen's Gardens, Lancaster Gate, London, W.2.