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mslw0227

mslw0227_p22, mslw0227_p23, mslw0227_p24, mslw0227_p25, mslw0227_p26, mslw0227_p27, mslw0227_p28, mslw0227_p29, mslw0227_p30, mslw0227_p31, mslw0227_p32, mslw0227_p33, mslw0227_p34, mslw0227_p35, mslw0227_p36

-15a-, 15a

-13c- Figure 2. -- -Plot of Mean Supplement Intake and Mean Growth Rates in Supine Length from 12-36 Months for Quartiles of Atole (.) and Fresco (x) Villages 19 Males 19 Females Age 12-36 months Age 12-36 months 18 18 Supine length 17 17 x X (cm) - - n = 33,S.E. n = 25, S.E. 16 16 X X 15 15 0 100 200 300 0 100 200 300 kcal/day kcal/day - n = average sample size per point S.E. = average standard error Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227 -14- b. Relationship of maternal and child intake and growth Most mothers breast fed their children well into the second year of life. Since they also participated in the food supplementation program, the question arises as to whether their intake affected the growth of their children through mechanisms such as increased milk yields. However, since mothers and their young children were inseparable, most often attending the supplementation center together, intake of mother and child are consequently highly interrelated as shown in Table 8 for four annual periods: 3-15, 6-18, 9-21, and 12-24 months. Moreover, Table 8 shows that both child and maternal intake are related to residuals in supine length and weight. The slopes for maternal intake were expected to be smaller than for intake of the child at least because one must account for the efficiency of conversion of supplement energy to breast milk energy. In addition, maternal slopes would be smaller to the degree to which the kcal ingested by the mother are utilized for purposes other than for breast milk production. Indeed, the maternal slopes are, relative to those of the child, within reasonable magnitude (Table 8). However, the high interrelationship between maternal and child intake makes it impossible to state whether the association between maternal intake and growth of the child is true or spurious. c Age effects Over the span from birth to 7 years, undoubtedly the first 2 years of life are the most difficult in developing countries. Nutritional needs are still high and often in the transition from breast milk to table food, nutrient intake becomes critically deficient. Further, morbidity rates are generally high. This analysis is consistent with growth data as shown in Figure 3. Here we have drawn the differences between growth rates in a Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227 -14a- Table 8. --Relationship between Supplement Intake of Mother and Child and Growth of the Child Correlation between Period child and Simple slopes Simple slopes for (months) maternal intake Variable for weight* supine length ** .602C Child (3-15) 206 C 3-15 6.47, b n=357 Mother (3-15) 48 2.19 b 6-18 . .493° Child (6-18) 279 4.59 n=398 Mother (6-18) 62 1.46 C C 9-21 .381° Child (9-21) 332. 4.73 b n=430 Mother (9-21) 106 1.82 c 12-24 .285C Child (12-24) 266. 4.43 b n=462 Mother (12-24) 117 2.92a * g per year/100 kcal per day. ** mm per year/100 kcal per day. a ap < .05. b P < . .01. c CP < .001. Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227 -14b- Figure 3. --Differences - in Annual Growth Rates between the Standard and the Lowest Quartile in Fresco Villages 2 Weight 1 kg 0 3- 6- 9- 12- 18- 24- 30- 36- 48- 60- 72- 15 18 21 24 30 36 42 48 60 72 84 Periods (months) 6 Supine length 4 cm 2 0 3- 6- 9- 12- 18- 24- 30- 36- 48- 60- 72- 15 18 21 24 30 36 42 48 60 72 84 Periods (months) Source: ttps://www.industrydocuments.ucsf.edu/docs/mslw0227 -15- - developed nation (Hansman, 1970) and in the group least affected by the supplementation program, the lowest quartile group of the distribution of fresco intake. These differences are a measure of the retardation accrued at each age. Differences are very large at ages 0 to 2 years and surprisingly small thereafter. The differences seen from 4 to 7 years in the case of weight may be due to the preadolescent growth spurt taking place in the standard but not in the local population. We find a tendency for the magnitude of the slopes to be correlated with the differences seen in Figure 3. For weight slopes the correlation is .56 (p > .05, n=11) and for supine length slopes it is .74 (p < .05, n=11). d. Cumulative effects The analyses presented with individual data in prior tables have concentrated on growth rates. In contrast, in Table 9, correlations with size at 3 years are shown for boys and girls of atole and fresco villages. Three-year olds have been selected for analyses because supplement intake is most strongly related to growth rates from birth to about 3 years of age. As before, higher correlations are seen in atole villages. However, the pattern of the relationships is similar for atole and fresco. For instance, the relationships are positive for linear measurements but negative for fatfolds. Further, the sexes are remarkably similar both in terms of correlation sizes and patterns of relationships. Table 10 shows the attained size of 3-year-old children from atole villages for four categories of supplement intake: 0-50, 51-100, 101-200, and more than 200 kcal/day. The estimated energy needs are around 300 kcal/day at least at ages 15 to 36 months where we have measured dietary intakes. Children receiving less than 50 kcal/day would not be receiving Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227 -15a- Table 9. --Correlations between Cumulative Supplementation and Size at Three Years of Age Atole Fresco Males Females Males Females Variable n r n r n r n r b Weight 188 .211 178 .190 201 163a 153 .140 Supine Length 190 .299C 178 . 277 201 126 153 .143 Head circumference 190 147° a 178 154 200 .016 152 .070 Arm circumference 190 - -120 178 -, 091 201 144a 151 117 b Triceps skinfold 190 - .234 178 - 340 201 - 084 153 - 007 Subscapular 190 - 258 C 178 - .149a 201 - 048 153 - 036 285 C b Arm length 141 125 256 151 195a 112 206a Calf circumference 141 162 124 040 151 209b 111 .175 Calf skinfold 141 - 139 125 -. 138 151 - .074 112 .022 Arm muscle area 190 .001 178 104 201 197b 151 .128 b Arm fat area 190 - -.226 178 -.310 C 201 - 017 151 .029 . ap a < . .05 b 5p < . 01 cp<< .001 . Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227 -15b- Table 10. -Cumulative Effect of Caloric Supplementation at Three Years of Age in Atole Villages Males Females Pooled Variable Average Categories* Categories* standard effect Baseline 1 2 3 4 Baseline 1 2 3 4 deviation size *** 1. Weight (kg) 11.89 11.95 12.48 12.71 12.56 11.37 11.61 11.99 12.00 12.61 1.30 .62 2. Supine length (cm) 85.2 84.8 87.5 87.8 88.4 83.4 84.8 85.7 86.5 88.1 3.9 .95 3. Head circumference (cm) 47.5 47.7 48.1 48.1 48.2 46.9 46.9 47.2 47.1 47.6 1.3 .46 4. Arm circumference (cm) 14.9 14.5 14.3 14.4 14.1 14.7 14.4 14.4 14.2 14.4 0.9 -.22 5. Triceps skinfold (mm) 9.5 7.4 7.0 6.7 6.2 9.7 7.8 6.9 6.5 6.6 1.6 -.75 6. Subscapular skin (mm) 5.7 5.6 5.2 5.3 4.6 6.4 5.9 5.6 5.4 5.5 1.1 -.64 7. Arm length (cm) no data 35.4 36.8 36.9 37.3 no data 35.5 35.8 35.9 37.3 2.0 .93 8. Calf circumference (cm) no data 18.4 18.6 18.9 18.8 no data 18.6 18.8 18.6 18.9 1.1 .32 9. Calf skinfold (mm) no data 7.0 7.4 7.1 6.5 no data 7.5 7.2 7.2 7.2 1.1 -.36 10. Arm muscle area (cm2, 11.30 11.90 11.72 11.99 11.72 10.81 11.48 11.92 11.85 12.14 1.6 .15 11. Arm fat area (cm2) 6.37 4.96 4.62 4.46 4.06 6.39 5.17 4.62 4.30 4.47 1.1 -.73 ** Sample size Group 1 31 58 47 59 26 27 66 46 52 14 Group 2 31 26 35 54 26 27 36 30 45 14 * Categories of average daily intake of energy and protein *** from atole. Average effect size = Category kcal / day g/day 1 Where DF and DM represent the mean difference 0 - 50 0 - 3.4 2 51 - 100 3.5 - 6.7 between the highest and the lowest category 3 101 - 200 6.8 - 13.4 (4 minus 1) for males and females respectively 4 > 200 > 13.5 and S is the pooled standard deviation. ** Group 1: variables 1 to 6; variables 10 and 11. Group 2: variables 7, 8, and 9. Source: https://www.industrydocuments.ucst.edu/docs/mslw0227 -16- much to modify growth while children in the top category, more than 200 kcal/day, would be expected to show marked improvements in growth. Baseline data are also included in Table 10 for comparison. This analysis, unfortunately, cannot be carried out for fresco villages. Supine length, arm length, and weight, indicative of linear growth and of the mass of surrounding tissue, have been positively affected, the effect size being equivalent to about one local standard deviation unit. In contrast, the direction of the effects on skinfolds is negative and for triceps and subscapular skinfolds it is equivalent to more than one-half a standard deviation. The comparison of the relative effects on arm areas suggests a reduction in the thickness of the layer of fat. Though slight decreases in arm circumference are observed, these are due to less fat area, muscle area not having changed appreciably. Because the length of the arm has increased, the reduction in arm fat area may not necessarily indicate an absolute decrement in stored fat. Finally, for those variables which have been positively affected, baseline data are slightly smaller than category 1 values. Conversely, for those that have decreased, baseline data are in accordance with the direction of the relationships and therefore a logical reference point for comparison. The supine lengths of children from Denver, Colorado are 96.9 and 95.5 cm, respectively, for boys and girls. 2 These values are not very different from those of other studies in developed countries. The differences between these values and those of children consuming less than 50 kcal/day are 12.0 and 10.7 cm for boys and girls respectively. The effect, or the difference 2 1.7 cm have been added to convert standing to recumbent length. This is the difference found between both techniques (Hansman, 1970) . Source: https://www.industrydocuments.ucst.edu/docs/mslw0227 -17- in height between children consuming more than 200 kcal/day and children consuming less than 50 kcal/day from the supplements, are 3.5 cm for boys and 3.8 cm for girls. In other words, the effect is equivalent to nearly a third of the initial differences between the chronically malnourished Guatemalan population and the standard. Table 11 addresses a number of alternative explanations for the findings presented in Table 10. Accordingly, nutrient intake, socioeconomic and morbidity data are presented per each of the four supplement categories and separately for boys and girls. Table 11 shows first of all, that the physical growth changes observed cannot be ascribed to better home dietary intakes in children receiving more supplementation. In fact, children appear to slightly reduce their home dietary intake as they increase supplement consumption. These reductions are more than compensated by supplement consumption as shown by the greater total nutrient intakes in better supplemented children. Similarly, socioeconomic status (SES), as reflected by the size and quality of the dwelling, and illness prevalence do not provide plausible alternative hypothesis. The data in Table 11 suggest instead that the children who consumed more supplement were of poorer SES and more frequently ill. DISCUSSION If calories are limiting in the diet of the study population, caloric supplementation will, in theory, spare protein from being metabolized as energy (Payne, 1975). This "liberated" protein can therefore serve to sustain growth. The relative limitation of proteins and calories is an important consideration in food supplementation experiments (Martorell et al., Source: https://www.industrydocuments.ucsf.edu/docs/mslw022 -17a- ? of Table 11. .-Nutrient Intake, Socioeconomic Status and Morbidity by Category of Supplement Intake at Three Years of Age* Males Females Pooled Variable Categories standard 1 2 3 4 1 2 3 4 deviation Calories (kcal/day) Supplement 26 74 143 262 24 70 145 254 78 Home diet 813 782 794 770 784 708 734 758 224 Total 839 856 937 1032 808 778 879 1012 Sample size 58 47 59 26 64 46 52 14 Protein (g/day) Supplement 1.8 5.2 10.1 18.5 1.7 4.9 10.2 17.9 5.5 Home diet 21.8 20.6 19.9 19.0 21.5 19.9 19.2 19.6 6.3 Total 23.6 25.8 30.0 37.5 23.2 24.8 29.4 37.5 Sample size 58 47 59 26 64 46 52 14 Socioeconomic status (standardized units) House -.00 -.09 -.06 -.52 .12 .06 - -.06 .06 .88 Sample size 55 46 59 26 61 45 50 14 Morbidity (% days ill) Respiratory 28.4 35.7 36.3 48.7 20.4 29.8 36.7 40.5 24.1 Diarrhea 6.7 8.2 6.7 8.0 4.1 3.7 7.2 7.9 6.5 Anorexia 9.2 16.1 9.8 16.2 6.5 10.6 11.6 14.2 12.8 Sample size 32 41 59 26 39 36 51 14 * Categories as defined in Table 10. Supplement intake is average daily intake from birth to 3 years of age. Home diet is average daily intake as estimated by as many as eight single surveys per child carried out between 1 and 3 years of age. Percent days ill is number of days ill from birth to 3 years of age expressed as a percentage of number of days surveyed from birth to 3 years of age. Source: Ittps://www.industrydocuments.ucsf.edu/docs/mslw0227 -18- 1976b). Thus, in populations in New Guinea, where protein and not calories is the limiting nutrient, caloric supplementation improved growth in weight but not in height (Malcolm, 1970) But in India, where calories and not proteins are limiting as in rural Guatemala, caloric supplementation improved not only growth in weight but in height as well (Gopalan et al., 1973). Dietary data on the four communities studied indicate that calories seem to be more limiting than protein in the diet of the Guatemalan children studied. Comparison of anthropometric data between Guatemalan and United States children also suggest that energy rather than protein is the main nutritional problem (Martorell et al., 1976a) This is inferred from the fact that the relative reduction in arm fat area is greater than in arm muscle area. Also, for the same body weight, Guatemalan children have a similar arm muscle area but a clearly smaller arm fat area than United States children. Moreover, analyses between food supplementation during pregnancy and fetal growth in the same communities under study reveal that calories and not protein are related to birthweight and placental weight (Lechtig et al. , 1975) . These analyses are not complicated by large differences in caloric intake between the atole and the fresco villages, as is the case in the analyses presented for children. Therefore, these sources of evidence present a strong case for expecting an effect of calories rather than proteins on postnatal growth. The findings indicate that the atole supplement clearly affected growth. This is evident in community as well as in individual level analyses. Supine length, arm length, head circumference, and weight were positively affected. Following the scheme presented in Table 1, the pattern of effects would Source: https://www.industrydocuments.ucst.edu/docs/mslw0227 -19- suggest either that the energy given spared dietary protein and/or that the protein provided by the atole affected growth. The unexpected findings with regards to the fat folds might also suggest a protein effect. Suppose that growth is limited by protein and that there are mechanisms whereby the energy which would have been utilized for growth is stored as fat. Then, it might follow that if protein is given, linear growth and hence muscular growth as well would be accelerated, and in the process, the fat stored for growth would be utilized. As suggested in Table 1, choosing between a "protein-sparing or an "additional protein" interpretation becomes feasible upon reviewing analyses of an energy intervention in the same population. However, supplement intake data clearly reveals that the energy intervention, fresco, was not powerful enough, in statistical and biological terms, in the age range when atole intake was most effective, the first 3 years of life. It was found that the relationship between fresco intake and growth rates, though in the expected direction was erratic. In general, the slopes within the fresco villages were larger than those within atole villages suggesting that the relationship between energy supplementation and growth rates may not be linear, the effects being larger at lower levels of intake. Moreover, the pattern of the relationship between fresco intake and the anthropometric battery was similar to that observed in atole villages. The likely explanation therefore, is that the energy provided in the fresco spared dietary protein. The negative effects on fatfolds may be interpreted in a different fashion. In the Guatemalan children studied, the skinfolds diminish with age starting at around 6 months of age. If this drop is dependent on biological rather than on chronological age, what we may be Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227 -20- seeing is that the better supplemented children have smaller skinfolds than the poorly supplemented children because they are biologically older. As shown elsewhere, supplement intake is positively related to skeletal age (IIC) . Therefore, we conclude that in all likelihood, the provision of calories alone leads to sparing of dietary protein in the population studied and in areas with similar dietary patterns. These findings are in accord therefore with those reported for India by Gopalan et al. (1973) who observed improve- ments in growth in height and in weight in children consuming a high-energy cookie supplement. Because the atole and fresco were not isocaloric, however, we are unable to assess whether additional protein is needed once all possible dietary protein is spared. The fact that the best supplemented group did not achieve full growth potential but instead exhibited only 33% improvement at 3 years of age is not unexpected. Even the best supplemented group did not meet energy requirements. Further, morbidity rates remained high in these communities and this limited growth. Our findings were inconclusive with regard to maternal nutrition supplementation during lactation and growth of the breast-fed child. Though we find maternal intake to be positively related to growth of the child, the design does not allow for isolation of the relative contribution of maternal and child intake. The findings presented provide experiences relevant to the design of data collection and the use of anthropometric variables in evaluations of nutritional interventions. There is first the question of what age groups to select for study. We showed that for both supine length and weight Source: https://www.industrydocuments.ucst.edu/docs/mslw0227 -21- ? growth rates, the effect of caloric intake is greatest when C is most deficient. Generalizing from these findings, one would anticipate little or no effect of food supplementation in children already growing adequately or, conversely, that in populations where growth rates are very deficient one should expect notable improvements in growth rates as a result of food supplementation. In other words, the age groups selected should be those in which growth deficiencies are known to occur. The experiences of this study would also indicate that public health workers might be content with just the use of supine length and body weight in nutritional evaluations. Other indicators often proposed, such as arm circumference and triceps and subscapular skinfolds, may not have easy interpretations. In research, however, a wide variety of measures representing linear growth, muscle and fat, as well as mass should be included to explore body composition changes in nutritional interventions. Lastly, the findings of this study have other important public health implications. The problem of growth retardation is a pervasive one among the poor in the developing nations. The corrective measures usually applied in the past have taken the form of expensive highprotein supplementa- tion. If energy is more limiting than protein, as these data suggest, the benefits resulting from these programs may have been achieved at a much cheaper cost through the provision of alternative food sources. Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227 -22- REFERENCES Gopalan C, Swaminathan MC, Jumary KK: Effect of calorie supplementation on growth of undernourished children. Am J Clin Nutr 26:563, 1973. Habicht JP, Martorell R, Yarbrough C, et al: Height and weight standards for preschool children: Are there really ethnic differences in growth potential? Lancet 1:611, 1974. Hansman C: Anthropometry and related data. In, McCammon RW (ed): Human Growth and Development. Springfield, Ill. Charles C. Thomas, 1970, pp. 101-154. Jelliffe DB: The Assessment of the Nutritional Status of the Community. Geneva, World Health Organization, 1966. (Monograph Series No. 53). Lechtig A, Habicht JP, Delgado H. et al: Effect of food supplementation during pregnancy on birth weight. Pediatrics 56:508, 1975. Lechtig A, Yarbrough C, Delgado H, et al: Effect of moderate maternal malnutrition on the placenta. Am J Obstet Gynecol 123:191, 1975. Malcolm LA: Growth and Development in New Guinea - A Study of the Bundi People of the Madang District. Papua, New Guinea, Institute of Human Biology, 1970. (Monograph Series No. 1). Martorell R, Habicht JP, Yarbrough C, et al: The identification and evaluation of measurement variability in the anthropometry of preschool children. Am J Phys Anthropol 43:347, 1975. Martorell R, Yarbrough C, Lechtig A, et al: Upper arm anthropometric indicators of nutritional status. Am J Clin Nutr 29:46, 1976a. Martorell R, Lechtig A, Yarbrough C, et al: Protein-calorie supplementation and postnatal physical growth: A review of findings from developing countries. Arch Latinoam Nutr, XXVI:115, 1976b. Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227

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mslw0227

mslw0227_p22, mslw0227_p23, mslw0227_p24, mslw0227_p25, mslw0227_p26, mslw0227_p27, mslw0227_p28, mslw0227_p29, mslw0227_p30, mslw0227_p31, mslw0227_p32, mslw0227_p33, mslw0227_p34, mslw0227_p35, mslw0227_p36

9

-13c- Figure 2. -- -Plot of Mean Supplement Intake and Mean Growth Rates in Supine Length from 12-36 Months for Quartiles of Atole (.) and Fresco (x) Villages 19 Males 19 Females Age 12-36 months Age 12-36 months 18 18 Supine length 17 17 x X (cm) - - n = 33,S.E. n = 25, S.E. 16 16 X X 15 15 0 100 200 300 0 100 200 300 kcal/day kcal/day - n = average sample size per point S.E. = average standard error Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227 -14- b. Relationship of maternal and child intake and growth Most mothers breast fed their children well into the second year of life. Since they also participated in the food supplementation program, the question arises as to whether their intake affected the growth of their children through mechanisms such as increased milk yields. However, since mothers and their young children were inseparable, most often attending the supplementation center together, intake of mother and child are consequently highly interrelated as shown in Table 8 for four annual periods: 3-15, 6-18, 9-21, and 12-24 months. Moreover, Table 8 shows that both child and maternal intake are related to residuals in supine length and weight. The slopes for maternal intake were expected to be smaller than for intake of the child at least because one must account for the efficiency of conversion of supplement energy to breast milk energy. In addition, maternal slopes would be smaller to the degree to which the kcal ingested by the mother are utilized for purposes other than for breast milk production. Indeed, the maternal slopes are, relative to those of the child, within reasonable magnitude (Table 8). However, the high interrelationship between maternal and child intake makes it impossible to state whether the association between maternal intake and growth of the child is true or spurious. c Age effects Over the span from birth to 7 years, undoubtedly the first 2 years of life are the most difficult in developing countries. Nutritional needs are still high and often in the transition from breast milk to table food, nutrient intake becomes critically deficient. Further, morbidity rates are generally high. This analysis is consistent with growth data as shown in Figure 3. Here we have drawn the differences between growth rates in a Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227 -14a- Table 8. --Relationship between Supplement Intake of Mother and Child and Growth of the Child Correlation between Period child and Simple slopes Simple slopes for (months) maternal intake Variable for weight* supine length ** .602C Child (3-15) 206 C 3-15 6.47, b n=357 Mother (3-15) 48 2.19 b 6-18 . .493° Child (6-18) 279 4.59 n=398 Mother (6-18) 62 1.46 C C 9-21 .381° Child (9-21) 332. 4.73 b n=430 Mother (9-21) 106 1.82 c 12-24 .285C Child (12-24) 266. 4.43 b n=462 Mother (12-24) 117 2.92a * g per year/100 kcal per day. ** mm per year/100 kcal per day. a ap < .05. b P < . .01. c CP < .001. Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227 -14b- Figure 3. --Differences - in Annual Growth Rates between the Standard and the Lowest Quartile in Fresco Villages 2 Weight 1 kg 0 3- 6- 9- 12- 18- 24- 30- 36- 48- 60- 72- 15 18 21 24 30 36 42 48 60 72 84 Periods (months) 6 Supine length 4 cm 2 0 3- 6- 9- 12- 18- 24- 30- 36- 48- 60- 72- 15 18 21 24 30 36 42 48 60 72 84 Periods (months) Source: ttps://www.industrydocuments.ucsf.edu/docs/mslw0227 -15- - developed nation (Hansman, 1970) and in the group least affected by the supplementation program, the lowest quartile group of the distribution of fresco intake. These differences are a measure of the retardation accrued at each age. Differences are very large at ages 0 to 2 years and surprisingly small thereafter. The differences seen from 4 to 7 years in the case of weight may be due to the preadolescent growth spurt taking place in the standard but not in the local population. We find a tendency for the magnitude of the slopes to be correlated with the differences seen in Figure 3. For weight slopes the correlation is .56 (p > .05, n=11) and for supine length slopes it is .74 (p < .05, n=11). d. Cumulative effects The analyses presented with individual data in prior tables have concentrated on growth rates. In contrast, in Table 9, correlations with size at 3 years are shown for boys and girls of atole and fresco villages. Three-year olds have been selected for analyses because supplement intake is most strongly related to growth rates from birth to about 3 years of age. As before, higher correlations are seen in atole villages. However, the pattern of the relationships is similar for atole and fresco. For instance, the relationships are positive for linear measurements but negative for fatfolds. Further, the sexes are remarkably similar both in terms of correlation sizes and patterns of relationships. Table 10 shows the attained size of 3-year-old children from atole villages for four categories of supplement intake: 0-50, 51-100, 101-200, and more than 200 kcal/day. The estimated energy needs are around 300 kcal/day at least at ages 15 to 36 months where we have measured dietary intakes. Children receiving less than 50 kcal/day would not be receiving Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227 -15a- Table 9. --Correlations between Cumulative Supplementation and Size at Three Years of Age Atole Fresco Males Females Males Females Variable n r n r n r n r b Weight 188 .211 178 .190 201 163a 153 .140 Supine Length 190 .299C 178 . 277 201 126 153 .143 Head circumference 190 147° a 178 154 200 .016 152 .070 Arm circumference 190 - -120 178 -, 091 201 144a 151 117 b Triceps skinfold 190 - .234 178 - 340 201 - 084 153 - 007 Subscapular 190 - 258 C 178 - .149a 201 - 048 153 - 036 285 C b Arm length 141 125 256 151 195a 112 206a Calf circumference 141 162 124 040 151 209b 111 .175 Calf skinfold 141 - 139 125 -. 138 151 - .074 112 .022 Arm muscle area 190 .001 178 104 201 197b 151 .128 b Arm fat area 190 - -.226 178 -.310 C 201 - 017 151 .029 . ap a < . .05 b 5p < . 01 cp<< .001 . Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227 -15b- Table 10. -Cumulative Effect of Caloric Supplementation at Three Years of Age in Atole Villages Males Females Pooled Variable Average Categories* Categories* standard effect Baseline 1 2 3 4 Baseline 1 2 3 4 deviation size *** 1. Weight (kg) 11.89 11.95 12.48 12.71 12.56 11.37 11.61 11.99 12.00 12.61 1.30 .62 2. Supine length (cm) 85.2 84.8 87.5 87.8 88.4 83.4 84.8 85.7 86.5 88.1 3.9 .95 3. Head circumference (cm) 47.5 47.7 48.1 48.1 48.2 46.9 46.9 47.2 47.1 47.6 1.3 .46 4. Arm circumference (cm) 14.9 14.5 14.3 14.4 14.1 14.7 14.4 14.4 14.2 14.4 0.9 -.22 5. Triceps skinfold (mm) 9.5 7.4 7.0 6.7 6.2 9.7 7.8 6.9 6.5 6.6 1.6 -.75 6. Subscapular skin (mm) 5.7 5.6 5.2 5.3 4.6 6.4 5.9 5.6 5.4 5.5 1.1 -.64 7. Arm length (cm) no data 35.4 36.8 36.9 37.3 no data 35.5 35.8 35.9 37.3 2.0 .93 8. Calf circumference (cm) no data 18.4 18.6 18.9 18.8 no data 18.6 18.8 18.6 18.9 1.1 .32 9. Calf skinfold (mm) no data 7.0 7.4 7.1 6.5 no data 7.5 7.2 7.2 7.2 1.1 -.36 10. Arm muscle area (cm2, 11.30 11.90 11.72 11.99 11.72 10.81 11.48 11.92 11.85 12.14 1.6 .15 11. Arm fat area (cm2) 6.37 4.96 4.62 4.46 4.06 6.39 5.17 4.62 4.30 4.47 1.1 -.73 ** Sample size Group 1 31 58 47 59 26 27 66 46 52 14 Group 2 31 26 35 54 26 27 36 30 45 14 * Categories of average daily intake of energy and protein *** from atole. Average effect size = Category kcal / day g/day 1 Where DF and DM represent the mean difference 0 - 50 0 - 3.4 2 51 - 100 3.5 - 6.7 between the highest and the lowest category 3 101 - 200 6.8 - 13.4 (4 minus 1) for males and females respectively 4 > 200 > 13.5 and S is the pooled standard deviation. ** Group 1: variables 1 to 6; variables 10 and 11. Group 2: variables 7, 8, and 9. Source: https://www.industrydocuments.ucst.edu/docs/mslw0227 -16- much to modify growth while children in the top category, more than 200 kcal/day, would be expected to show marked improvements in growth. Baseline data are also included in Table 10 for comparison. This analysis, unfortunately, cannot be carried out for fresco villages. Supine length, arm length, and weight, indicative of linear growth and of the mass of surrounding tissue, have been positively affected, the effect size being equivalent to about one local standard deviation unit. In contrast, the direction of the effects on skinfolds is negative and for triceps and subscapular skinfolds it is equivalent to more than one-half a standard deviation. The comparison of the relative effects on arm areas suggests a reduction in the thickness of the layer of fat. Though slight decreases in arm circumference are observed, these are due to less fat area, muscle area not having changed appreciably. Because the length of the arm has increased, the reduction in arm fat area may not necessarily indicate an absolute decrement in stored fat. Finally, for those variables which have been positively affected, baseline data are slightly smaller than category 1 values. Conversely, for those that have decreased, baseline data are in accordance with the direction of the relationships and therefore a logical reference point for comparison. The supine lengths of children from Denver, Colorado are 96.9 and 95.5 cm, respectively, for boys and girls. 2 These values are not very different from those of other studies in developed countries. The differences between these values and those of children consuming less than 50 kcal/day are 12.0 and 10.7 cm for boys and girls respectively. The effect, or the difference 2 1.7 cm have been added to convert standing to recumbent length. This is the difference found between both techniques (Hansman, 1970) . Source: https://www.industrydocuments.ucst.edu/docs/mslw0227 -17- in height between children consuming more than 200 kcal/day and children consuming less than 50 kcal/day from the supplements, are 3.5 cm for boys and 3.8 cm for girls. In other words, the effect is equivalent to nearly a third of the initial differences between the chronically malnourished Guatemalan population and the standard. Table 11 addresses a number of alternative explanations for the findings presented in Table 10. Accordingly, nutrient intake, socioeconomic and morbidity data are presented per each of the four supplement categories and separately for boys and girls. Table 11 shows first of all, that the physical growth changes observed cannot be ascribed to better home dietary intakes in children receiving more supplementation. In fact, children appear to slightly reduce their home dietary intake as they increase supplement consumption. These reductions are more than compensated by supplement consumption as shown by the greater total nutrient intakes in better supplemented children. Similarly, socioeconomic status (SES), as reflected by the size and quality of the dwelling, and illness prevalence do not provide plausible alternative hypothesis. The data in Table 11 suggest instead that the children who consumed more supplement were of poorer SES and more frequently ill. DISCUSSION If calories are limiting in the diet of the study population, caloric supplementation will, in theory, spare protein from being metabolized as energy (Payne, 1975). This "liberated" protein can therefore serve to sustain growth. The relative limitation of proteins and calories is an important consideration in food supplementation experiments (Martorell et al., Source: https://www.industrydocuments.ucsf.edu/docs/mslw022 -17a- ? of Table 11. .-Nutrient Intake, Socioeconomic Status and Morbidity by Category of Supplement Intake at Three Years of Age* Males Females Pooled Variable Categories standard 1 2 3 4 1 2 3 4 deviation Calories (kcal/day) Supplement 26 74 143 262 24 70 145 254 78 Home diet 813 782 794 770 784 708 734 758 224 Total 839 856 937 1032 808 778 879 1012 Sample size 58 47 59 26 64 46 52 14 Protein (g/day) Supplement 1.8 5.2 10.1 18.5 1.7 4.9 10.2 17.9 5.5 Home diet 21.8 20.6 19.9 19.0 21.5 19.9 19.2 19.6 6.3 Total 23.6 25.8 30.0 37.5 23.2 24.8 29.4 37.5 Sample size 58 47 59 26 64 46 52 14 Socioeconomic status (standardized units) House -.00 -.09 -.06 -.52 .12 .06 - -.06 .06 .88 Sample size 55 46 59 26 61 45 50 14 Morbidity (% days ill) Respiratory 28.4 35.7 36.3 48.7 20.4 29.8 36.7 40.5 24.1 Diarrhea 6.7 8.2 6.7 8.0 4.1 3.7 7.2 7.9 6.5 Anorexia 9.2 16.1 9.8 16.2 6.5 10.6 11.6 14.2 12.8 Sample size 32 41 59 26 39 36 51 14 * Categories as defined in Table 10. Supplement intake is average daily intake from birth to 3 years of age. Home diet is average daily intake as estimated by as many as eight single surveys per child carried out between 1 and 3 years of age. Percent days ill is number of days ill from birth to 3 years of age expressed as a percentage of number of days surveyed from birth to 3 years of age. Source: Ittps://www.industrydocuments.ucsf.edu/docs/mslw0227 -18- 1976b). Thus, in populations in New Guinea, where protein and not calories is the limiting nutrient, caloric supplementation improved growth in weight but not in height (Malcolm, 1970) But in India, where calories and not proteins are limiting as in rural Guatemala, caloric supplementation improved not only growth in weight but in height as well (Gopalan et al., 1973). Dietary data on the four communities studied indicate that calories seem to be more limiting than protein in the diet of the Guatemalan children studied. Comparison of anthropometric data between Guatemalan and United States children also suggest that energy rather than protein is the main nutritional problem (Martorell et al., 1976a) This is inferred from the fact that the relative reduction in arm fat area is greater than in arm muscle area. Also, for the same body weight, Guatemalan children have a similar arm muscle area but a clearly smaller arm fat area than United States children. Moreover, analyses between food supplementation during pregnancy and fetal growth in the same communities under study reveal that calories and not protein are related to birthweight and placental weight (Lechtig et al. , 1975) . These analyses are not complicated by large differences in caloric intake between the atole and the fresco villages, as is the case in the analyses presented for children. Therefore, these sources of evidence present a strong case for expecting an effect of calories rather than proteins on postnatal growth. The findings indicate that the atole supplement clearly affected growth. This is evident in community as well as in individual level analyses. Supine length, arm length, head circumference, and weight were positively affected. Following the scheme presented in Table 1, the pattern of effects would Source: https://www.industrydocuments.ucst.edu/docs/mslw0227 -19- suggest either that the energy given spared dietary protein and/or that the protein provided by the atole affected growth. The unexpected findings with regards to the fat folds might also suggest a protein effect. Suppose that growth is limited by protein and that there are mechanisms whereby the energy which would have been utilized for growth is stored as fat. Then, it might follow that if protein is given, linear growth and hence muscular growth as well would be accelerated, and in the process, the fat stored for growth would be utilized. As suggested in Table 1, choosing between a "protein-sparing or an "additional protein" interpretation becomes feasible upon reviewing analyses of an energy intervention in the same population. However, supplement intake data clearly reveals that the energy intervention, fresco, was not powerful enough, in statistical and biological terms, in the age range when atole intake was most effective, the first 3 years of life. It was found that the relationship between fresco intake and growth rates, though in the expected direction was erratic. In general, the slopes within the fresco villages were larger than those within atole villages suggesting that the relationship between energy supplementation and growth rates may not be linear, the effects being larger at lower levels of intake. Moreover, the pattern of the relationship between fresco intake and the anthropometric battery was similar to that observed in atole villages. The likely explanation therefore, is that the energy provided in the fresco spared dietary protein. The negative effects on fatfolds may be interpreted in a different fashion. In the Guatemalan children studied, the skinfolds diminish with age starting at around 6 months of age. If this drop is dependent on biological rather than on chronological age, what we may be Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227 -20- seeing is that the better supplemented children have smaller skinfolds than the poorly supplemented children because they are biologically older. As shown elsewhere, supplement intake is positively related to skeletal age (IIC) . Therefore, we conclude that in all likelihood, the provision of calories alone leads to sparing of dietary protein in the population studied and in areas with similar dietary patterns. These findings are in accord therefore with those reported for India by Gopalan et al. (1973) who observed improve- ments in growth in height and in weight in children consuming a high-energy cookie supplement. Because the atole and fresco were not isocaloric, however, we are unable to assess whether additional protein is needed once all possible dietary protein is spared. The fact that the best supplemented group did not achieve full growth potential but instead exhibited only 33% improvement at 3 years of age is not unexpected. Even the best supplemented group did not meet energy requirements. Further, morbidity rates remained high in these communities and this limited growth. Our findings were inconclusive with regard to maternal nutrition supplementation during lactation and growth of the breast-fed child. Though we find maternal intake to be positively related to growth of the child, the design does not allow for isolation of the relative contribution of maternal and child intake. The findings presented provide experiences relevant to the design of data collection and the use of anthropometric variables in evaluations of nutritional interventions. There is first the question of what age groups to select for study. We showed that for both supine length and weight Source: https://www.industrydocuments.ucst.edu/docs/mslw0227 -21- ? growth rates, the effect of caloric intake is greatest when C is most deficient. Generalizing from these findings, one would anticipate little or no effect of food supplementation in children already growing adequately or, conversely, that in populations where growth rates are very deficient one should expect notable improvements in growth rates as a result of food supplementation. In other words, the age groups selected should be those in which growth deficiencies are known to occur. The experiences of this study would also indicate that public health workers might be content with just the use of supine length and body weight in nutritional evaluations. Other indicators often proposed, such as arm circumference and triceps and subscapular skinfolds, may not have easy interpretations. In research, however, a wide variety of measures representing linear growth, muscle and fat, as well as mass should be included to explore body composition changes in nutritional interventions. Lastly, the findings of this study have other important public health implications. The problem of growth retardation is a pervasive one among the poor in the developing nations. The corrective measures usually applied in the past have taken the form of expensive highprotein supplementa- tion. If energy is more limiting than protein, as these data suggest, the benefits resulting from these programs may have been achieved at a much cheaper cost through the provision of alternative food sources. Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227 -22- REFERENCES Gopalan C, Swaminathan MC, Jumary KK: Effect of calorie supplementation on growth of undernourished children. Am J Clin Nutr 26:563, 1973. Habicht JP, Martorell R, Yarbrough C, et al: Height and weight standards for preschool children: Are there really ethnic differences in growth potential? Lancet 1:611, 1974. Hansman C: Anthropometry and related data. In, McCammon RW (ed): Human Growth and Development. Springfield, Ill. Charles C. Thomas, 1970, pp. 101-154. Jelliffe DB: The Assessment of the Nutritional Status of the Community. Geneva, World Health Organization, 1966. (Monograph Series No. 53). Lechtig A, Habicht JP, Delgado H. et al: Effect of food supplementation during pregnancy on birth weight. Pediatrics 56:508, 1975. Lechtig A, Yarbrough C, Delgado H, et al: Effect of moderate maternal malnutrition on the placenta. Am J Obstet Gynecol 123:191, 1975. Malcolm LA: Growth and Development in New Guinea - A Study of the Bundi People of the Madang District. Papua, New Guinea, Institute of Human Biology, 1970. (Monograph Series No. 1). Martorell R, Habicht JP, Yarbrough C, et al: The identification and evaluation of measurement variability in the anthropometry of preschool children. Am J Phys Anthropol 43:347, 1975. Martorell R, Yarbrough C, Lechtig A, et al: Upper arm anthropometric indicators of nutritional status. Am J Clin Nutr 29:46, 1976a. Martorell R, Lechtig A, Yarbrough C, et al: Protein-calorie supplementation and postnatal physical growth: A review of findings from developing countries. Arch Latinoam Nutr, XXVI:115, 1976b. Source: https://www.industrydocuments.ucsf.edu/docs/mslw0227

The report is prepared by whom?

njyc0227

njyc0227_p0, njyc0227_p1, njyc0227_p2, njyc0227_p3, njyc0227_p4, njyc0227_p5, njyc0227_p6, njyc0227_p7, njyc0227_p8, njyc0227_p9, njyc0227_p10, njyc0227_p11, njyc0227_p12, njyc0227_p13, njyc0227_p14, njyc0227_p15, njyc0227_p16, njyc0227_p17, njyc0227_p18, njyc0227_p19

interdepartmental committee on nutrition for national defense, Interdepartmental committee on nutrition for national defense

Republic of Lebanon Nutrition Survey February - April 1961 A Report by the Interdepartmental Committee on Nutrition for National Defense May 1962 Source: https://www.industrydocuments.ucsf.edu/docs/niyco22 OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE WASHINGTON 25, D.C. April 20, 1962 MANPOWER Dear Mr. Prime Minister: It is my pleasure, on behalf of the Interdepartmental Committee on Nutrition for National Defense, to transmit the report of the nutrition survey of the military, civilian and refugee groups in Lebanon which was conducted by a joint Lebanese- United States team, February-April 1961. The preliminary report of the survey was presented to collaborating agencies of the Government of the Republic of Lebanon and the U. S. Mission in Lebanon by the directors of the survey team, Dr. William J. Darby and Dr. William J. McGanity, in November 1961, for review and discussion. This final report has now been prepared and incorporates the excellent suggestions made during these conferences. Our Committee and the U. S. Mission members wish to express, through you, grateful appreciation to the Lebanese Armed Forces, the Ministries of Health, Education, and Agriculture, the staff of the American University of Beirut, the French Faculty, and UNRWA, for their superior cooperation and participation in the survey. Several nutrition problems of major significance were defined. Endemic goiter is a major nutritional deficiency disease. Enrichment of salt with iodate could be accomplished for somewhat less than $30, 000 per year for the entire population. Numerous other nutritional problems have been identified in the various population groups studied, namely, military, civilian and refugees, with corresponding recommendations for health improvement. In Lebanon infants and children are the group most vulnerable to the development of nutritional problems. Although food production in Lebanon is somewhat limited, recommendations have been developed to improve both quantity of food and quality of diet, stressing those foods which Lebanon is capable of producing and are especially important in providing the protective nutrients. The Federal Government can do much toward nutrition improvement in its over-all planning for agriculture, industry, and international trade. Our Committee has been pleased to have the opportunity of collaborating with Lebanon in this study and will welcome requests for further assistance at any time. Respectfully, Frank Burry Frank B. Berry, M.D. His Excellency Deputy Assistant Secretary Rashid Karame (Health and Medical) Prime Minister of Lebanon Beirut, Lebanon Source: https:/lwww.industrydocuments.ucsf.edu/docs/njyc0227 INTERDEPARTMENTAL COMMITTEE ON NUTRITION FOR NATIONAL DEFENSE Department of Defense: Dr. Frank B. Berry, Deputy Assistant Secretary of Defense (Manpower--Health and Medical), Chairman Brig. Gen. Douglas B. Kendrick, Jr., USA, MC Army: Lt. Col. Ralph C. Singer, MC Lt. Col. Jacques L. Sherman, MC Navy: Dr. Howard T. Karsner Rear Admiral Calvin B. Galloway, MC Dr. Robert Van Reen (Alternate) Air Force: Lt. Col. Richard K. Miller, MC Lt. Col. Franklin L. Bowling, MC Department of State: Mr. Walter M. Rudolph Department of Agriculture: Mr. Clarence M. Purves Dr. Hazel K. Stiebeling Department of Health, Education, and Welfare: Dr. Floyd S: Daft, Vice Chairman Agency for International Development: Dr. Eugene P. Campbell Dr. Katharine Holtzclaw Atomic Energy Commission: Dr. James L. Liverman Secretariat Dr. Arnold E. Schaefer, Executive Director Dr. Ernest M. Parrott, Assistant Director for Logistics Dr. Allan L. Forbes, Assistant Director for Medical Programs Dr. Arthur G. Peterson, Agricultural Economist Consultant Panel Dr. William F. Ashe Dr. Karl E. Gardner Dr. William N. Pearson Dr. S. Bayne-Jones Dr. Wendell H. Griffith Lt. Col. Irvin C. Plough, MC Dr. George H. Berryman Dr. David B. Hand Dr. Herbert Pollack Mr. Edwin B. Bridgforth Dr. R. Gaurth Hansen Dr. W. H. Sebrell, Jr. Dr. Gerald F. Combs Dr. D. Mark Hegsted Dr. Fredrick J. Stare 4 Dr. William J. Darby Dr. z. I. Kertesz Dr. Lester J. Teply Dr. Charles S. Davidson Dr. L. A. Maynard Dr. Philip L. White Dr. R. W. Engel Dr. William J. McGanity Dr. John B. Youmans III Source: https://www.industrydocuments.ucsf.edu/docs/njyco227 CONTENTS Section Page List of Tables VI List of Figures IX Team Members XII Acknowledgments XV . . I Mission 1 Interpretative Summary and Recommendations 1 . II Background 11 III Sampling, Methods and Procedures 19 IV The Food Situation in Lebanon and Measures for Its Improvement 27 V Nutritional Status of the Armed Forces 36 VI Nutritional Status of Nonrefugee Civilians 59 VII Nutritional Status of Refugee Civilians 89 VIII Dental Findings 111 IX Special Studies 121 References 135 Appendixes 137 V Source: https://www.industrydocuments.ucsf.edu/docs/njyc0227 LIST OF TABLES LIST OF TABLES (Continued) Table Table Page Page Sampling, Methods and Procedures Nutritional Status of Refugee Civilians (Continued) 30 1 Description of Population Sample, Lebanon 20 Dietary Patterns of Refugee Civilians in Lebanon by Classes of Foods 2 21 Consumed Location of Examinations, Lebanon 90 31 3 Standard Reference Requirements for Energy and Protein Used in Lebanon Contribution of Cereal Products to Energy and Protein Intakes of Refugee Survey 23 Civilians in Lebanon 91 32 4 ICNND Intake Reference Standards for Minerals and Vitamins 23 Protein Intake from Animal and Vegetable Sources by Refugee Civilians 5 Number of Persons Given Dental Examinations, Lebanon 26 in Lebanon 91 33 Biochemical Findings by Sex and Age, Civilian Refugees, Lebanon 93 34 The Food Situation in Lebanon and Measures for Its Improvement Percent Clinical Findings by Sex and Age, Refugee Children Seen at 6 Food Balance Sheet for Lebanon, 1953-55 31 Well-Baby Clinics, Lebanon, 1961 97 35 7 Production, Imports, Exports and Consumption of Agricultural Commodities, Mean Biochemical Levels by Sex and Age, Refugee Children 0-24 Months 1959-60 32 Seen at Well-Baby Clinics, Lebanon, 1961 99 36 8 Effect of Milling on the Thiamine and Riboflavin Content of Flour 34 Percent Clinical Findings by Sex and Age, Civilian Refugees, Lebanon (Abbreviated Examinations) 102 Nutritional Status of the Armed Forces 9 Basic Ration for Armed Forces, Lebanon, 1961 37 Dental Findings 37 10 Nutrient Content of Ration Planned for March 1961, Calculated from 10-Day Mean Numbers of Decayed, Missing and Filled Permanent Teeth Per Person, Lebanon Menus at Four Army Posts, Lebanon 38 111 38 11 Recipe for Bread Made in Army Bakeries, Lebanon 38 Relative DMF Status of Persons of Similar Sect, Civilian Nonrefugees and 12 Nutrient Intake Per Man Per Day, Determined by Recipe and Food Composite Refugees Examined in Lebanon 113 39 Analysis Methods, Military, Lebanon 40 Percentages of Groups Showing Gross Gingivitis, or Further Evidence of 13 Biochemical Findings by Percent "Standard Weight," Military, Lebanon 45 Periodontal Disease, Lebanon 114 40 14 Serum Cholesterol Levels, Military, Lebanon 46 Percentages of Groups With Evidence of Advanced Destructive Periodontal Disease, Lebanon 114 41 Nutritional Status of Nonrefugee Civilians Mean Periodontal Scores Per Person, Lebanon 116 42 15 Composition of Nonrefugee Civilian Families Surveyed in Lebanon 60 Mean Percent Per Person of Teeth Showing Gingival Recession, Lebanon 116 43 16 Daily Energy and Protein Intakes of Nonrefugee Civilians in Lebanon 61 Mean Numbers of Permanent Teeth Missing or Indicated for Extraction in 17 Daily Nutrient Intake of Nonrefugee Civilians in Lebanon 61 the Groups Examined in Lebanon 117 44 18 Dietary Patterns of Nonrefugee Civilians in Lebanon by Classes of Foods Oral Hygiene Status of Groups Examined in Lebanon 117 Consumed 62 Contribution of Cereal Products to Energy and Protein Intakes of Nonrefugee Special Studies 19 45 Civilians in Lebanon 63 Parasites Found in Lebanon 122 Protein Intake from Animal and Vegetable Sources by Nonrefugee Civilians 46 20 Total Serum Protein, Hemoglobin and Percent of "Standard Weight" in 124 in Lebanon 64 Individuals Parasitized With Taenia saginata, Ascaris and E. histolytica Biochemical Findings for Nonrefugee Civilians by Sex and Age, Lebanon 66 Compared With 230 Not Parasitized 21: 123 47 22 Biochemical Findings, Military Personnel Versus Adult Civilians, Lebanon 69 Percent Prevalence of Angular Lesions at Bourj Chemali 124 48 23 Selected Biochemical Findings on Nonrefugee and Refugee Pregnant and Laboratory Findings, Bourj Chemali 125 49 Lactating Women, Lebanon 70 Results of Short Screen Examinations on School Age Children by Geographic 24 Iodine Excretions by Sex and Age, Civilian Nonrefugees and Refugees, Region and Sex, Civilian Nonrefugees and Refugees, Lebanon 132 71 50 Lebanon Percent Prevalence of Clinical Findings, Screen Examinations, School Age 25 Percent Clinical Findings by Sex and Age, Nonrefugee Civilians, Abbreviated Orphans by Location, Lebanon 133 51 Examinations Lebanon 78 Percent Prevalence of Selected Clinical Lesions, Screen Examinations, 26 Percent Clinical Findings by Population Segment, Abbreviated and Detailed School Age Children 6-14 Years, Lebanon 134 Examinations, Lebanon 79 52 Comparison of Clinical Findings, Screen Examinations, Nonrefugees and by . Refugees Versus Orphans by Geographic Region, Lebanon 134 Nutritional Status of Refugee Civilians 27 Composition of Civilian Refugee Families Surveyed in Lebanon 88 Appendix Tables 28 89 I-C-1 Daily Energy and Protein Intakes of Refugee Civilians in Lebanon Biochemical Reproducibility Studies, Lebanon - Blood Determinations I-C-2 145 29 Daily Per Capita Nutrient Intake of Refugee Civilians in Lebanon 90 Biochemical Reproducibility Studies, Lebanon - Urine Determinations 146 VII VI Source: https://www.industrydocuments.ucsf.edu/docs/njyc0227 LIST OF TABLES (Continued) LIST OF FIGURES Table Page Figure Page Appendix Tables (Continued) Background III-A Items and Quantities of Foods on Planned Menus for Armed Forces Messes 1 174 Map of Lebanon 10 During 10-Day Periods, Lebanon, 1961 III-B Nutrient Intake From Foods Served Per Man Per Day in Army Messes, Lebanon, 176 Nutritional Status of the Armed Forces 1961 2 Nutrient Content of Foods Sold at the Canteen, March 10-30, 1961, Tripoli 178 Distribution of Serum Cholesterol Values in the Military, Lebanon 47 III-C 3 Percent of "Standard Weight" by Time in Service, Military, Lebanon 49 III-D Nutrient Content of Foods Sold at the Canteen, March 14-April 14, 1961, 4 178 Weight by Time in Service, Military, Lebanon 49 Sarba 5 180 Age by Time in Service, Military, Lebanon 49 III-E Biochemical Findings by Location, Military, Lebanon 6 Biochemical Findings by Age, Military, Lebanon 184 Skinfold Thickness as Related to Percent "Standard Weight," Military III-F Biochemical Findings by Time in Service, Military, Lebanon 186 Personnel, Lebanon 51 III-G 7 Biochemical Findings by Area of Origin, Military, Lebanon 188 Percent Prevalence of Thyroid Enlargement by Age, Military, Lebanon 53 III-H 8 Average Riboflavin Intakes by Location, Military, Lebanon 54 Percent Clinical Findings by Age, Military, Abbreviated Examinations, is III-I 9 190 Median Riboflavin Excretion Levels by Age, Military, Lebanon 54 Lebanon 10 Percent Prevalence of Cheilosis by Age, Military, Lebanon 54 III-J Percent Clinical Findings by Time in Service, Military, Abbreviated 11 Examinations, Lebanon 191 Percent Prevalence of Angular Lesions by Age, Military, Lebanon 54 12 Average Iron Intakes by Location, Military, Lebanon 55 III-K Percent Clinical Findings by Location, Military, Abbreviated Examinations, 13 192 Mean Hemoglobin Levels by Age, Military, Lebanon 55 Lebanon 14 Percent Distribution of Hemoglobin Levels, Military, Lebanon Percent Clinical Findings by Examiner in Abbreviated Versus Detailed Examina- 55 III-L 15 193 Mean Corpuscular Hemoglobin Concentration by Age, Military, Lebanon 55 tions, Military, Lebanon 16 Average Vitamin A Intakes by Location, Military, Lebanon 56 17 194 Mean Serum Vitamin A Levels by Age, Military, Lebanon 56 IV-A Selected Biochemical Findings on Civilian Population by Location, Lebanon 18 Mean Serum Carotene Levels by Age, Military, Lebanon IV-B Selected Biochemical Findings by Religion, Nonrefugee Versus Refugee 56 19 Civilians, Lebanon 195 Percent Prevalence of Follicular Hyperkeratosis on the Arms by Age, Military, Lebanon IV-C Iodine Excretions by Sex and Location, Nonrefugee Versus Refugee Civilians, 56 20 Lebanon 195 Average Caloric Intakes by Location, Military, Lebanon 57 21 Average Protein Intakes by Location, Military, Lebanon Percent Clinical Findings by Sex and Age, Abbreviated Versus Detailed 57 IV-D 22 Examinations, Nonrefugee Civilians, Lebanon 196 Average Vitamin C Intakes by Location, Military, Lebanon 58 23 Mean Serum Vitamin C Levels by Age, Military, Lebanon Selected Clinical Findings by Age and Examiner, Nonrefugee Civilians 197 58 IV-E IV-F Comparison of Abbreviated Versus Detailed Clinical Findings by Geographic Nutritional Status of Nonrefugee Civilians Region, Nonrefugee and Refugee Civilians Combined, Lebanon 197 24 Growth of Girls 0-6 Years, Lebanon 73 25 Growth of Boys 0-6 Years, Lebanon Biochemical Findings by Region, Refugee Civilians, Lebanon 199 74 V-B 26 Growth of Girls 5-18 Years, Lebanon 75 V-C Percent Clinical Findings by Location, Abbreviated Examinations, Refugee 27 203 Growth of Boys 5-18 Years, Lebanon 76 Civilians, Lebanon 28 Average Caloric Intakes by Location, Nonrefugee Civilians, Lebanon Percent Clinical Findings by Sex, Age and Religion, Abbreviated Examina- 82 V-D 204 29 Average Protein Intakes by Location, Nonrefugee Civilians, Lebanon 82 tions, Refugee Civilians, Lebanon 30 Percent Prevalence of Thyroid Enlargement by Age and Sex, Nonrefugee V-E Percent Clinical Findings by Examiner, Abbreviated and Detailed Examina- 205 Civilians, Lebanon 83 tions, Refugee Civilians, Lebanon 31 Iodine Excretion Levels by Sex and Age, Nonrefugee Civilians, Lebanon 83 32 Average Riboflavin Intakes by Location, Nonrefugee Civilians, Lebanon 84 33 Median Riboflavin Excretion Levels by Sex and Age, Nonrefugee Civilians, Lebanon 84 34 Percent Prevalence of Angular Lesions by Sex and Age, Nonrefugee Civilians, Lebanon 84 35 Percent Prevalence of Cheilosis by Sex and Age, Nonrefugee Civilians, Lebanon 84 36 Average Iron Intakes by Location, Nonrefugee Civilians, Lebanon 85 37 Percent Prevalence, Filiform Papillary Atrophy of the Tongue by Sex and Age, Nonrefugee Civilians, Lebanon 85 VIII IX Source: https://www.industrydocuments.ucsf.edu/docs/njyc0227 LIST OF FIGURES (Continued) LIST OF FIGURES (Continued) Figure Figure Page Page Special Studies Nutritional Status of Nonrefugee Civilians (Continued) 67 38 Mean Hemoglobir Level: by Sex and Age, Nonrefugee Civilians, Lebanon 85 Distribution of Antistreptolysin "0" Titers, Total Group, Lebanon 127 68 Mean Corpuscular Hemoglobin Concentration by Sex and Age, Nonrefugee Distribution of Antistreptolysin "0" Titers by Age Groups, Lebanon 39 128 69 Civilians, Lebanon 85 Distribution of Antistreptolysin "0" Titers by Sex, Lebanon 129 70 40 Average Vitamin A Intakes by Location, Nonrefugee Civilians, Lebanon 86 Distribution of Antistreptolysin "0" Titers Among Refugees, Civilians and the Military, Lebanon 41 Mean Serum Vitamin A Levels by Sex and Age, Nonrefugee Civilians, 130 Lebanon 86 Appendix Figures 42 Mean Serum Carotene Levels by Sex and Age, Nonrefugee Civilians, Lebanon 86 I-C-1 43 Percent Prevalence of Follicular Hyperkeratosis by Sex and Age, Nonrefugee Standard Creatinine Values by 5 Day Periods I-C-2 147 Civilians, Lebanon 86 Laboratory Control - Thiamines, Lebanon I-C-3 149 44 Average Vitamin C Intakes by Location, Nonrefugee Civilians, Lebanon 87 Laboratory Control - N¹-Methylnicotinamides, Lebanon I-C-4 150 45 Mean Serum Vitamin C Levels by Sex and Age, Nonrefugee Civilians, Lebanon 87 A Comparison of the Results of Duplicate Determinations (On Different Days) A . of Urinary Riboflavin I-C-5 151 Nutritional Status of Refugee Civilians Data From Fig. I-C-4 Recalculated to Show the Effect of the Level of Height, Weight and Percent of "Standard Weight" by Sex and Age, Refugee Riboflavin On the Reproducibility of the Determination 46 152 Civilians, Lebanon 101 47 Percent Prevalence of Thyroid Enlargement by Age and Sex, Refugee Civilians, Lebanon 105 48 Iodine Excretion Levels by Sex and Age, Refugee Civilians, Lebanon 105 49 Average Riboflavin Intakes by Location, Refugee Civilians, Lebanon 106 50 Median Riboflavin Excretion Levels by Sex and Age, Refugee Civilians, Lebanon 106 51 Percent Prevalence of Angular Lesions by Sex and Age, Refugee Civilians, Lebanon 106 52 Percent Prevalence of Cheilosis by Sex and Age, Refugee Civilians, Lebanon 106 53 Average Vitamin A Intakes by Location, Refugee Civilians, Lebanon 107 54 Mean Serum Jitamin A Levels by Sex and Age, Refugee Civilians, Lebanon 107 55 Mean Serum Carotene Levels by Sex and Age, Refugee Civilians, Lebanon 107 56 Average Iron Intakes by Location, Refugee Civilians, Lebanon 108 57 Percent Prevalence, Filiform Papillary Atrophy of the Tongue by Sex and Age, Refugee Civilians, Lebanon 108 58 Mean Hemoglobin Levels by Sex and Age, Refugee Civilians, Lebanon 108 59 Mean Corpuscular Hemoglobin Concentration by Sex and Age, Refugee Civilians, Lebanon 108 60 Average Caloric Intakes by Location, Refugee Civilians, Lebanon 109 61 Average Protein Intakes by Location, Refugee Civilians, Lebanon 109 62 Average Vitamin C Intakes by Location, Refugee Civilians, Lebanon 110 63 Mean Serum Vitamin C Levels by Sex and Age, Refugee Civilians, Lebanon 110 Dental Findings 64 Dental Caries in Permanent Teeth, Three Populations in Lebanon Compared With Findings for Baltimore, Maryland 112 65 Chronic Destructive Periodontal Disease in Three Populations in Lebanon, Compared With Findings for White and Negro Populations in Baltimore, Marylan 115 66 Permanent Tooth Mortality in Three Populations in Lebanon 118 XI X Source: https://www.industrydocuments.ucsf.edu/docs/njyc0227 TEAM MEMBERS United States Members (Continued) Dr. Albert L. Russell Dentist United States Members Epidemiology and Biometry Branch Dr. William J. Darby Director and Clinician National Institute of Dental Research Department of Biochemistry Bethesda 14, Maryland Vanderbilt University School of Medicine Mr. Durward R. Thayer Photographer Nashville 5, Tennessee Motion Picture Production Specialist Dr. William J. McGanity Director and Clinician Audiovisual Section Department of Obstetrics and Gynecology Communicable Disease Center University of Texas Medical Branch Atlanta 22, Georgia Galveston, Texas Dr. Rudolph H. Kampmeier Clinician Department of Medicine Vanderbilt University School of Medicine Lebanon Members Nashville 5, Tennessee Major Adib Nasr Military Coordinator Dr. Robert W. Quinn Clinician M.D., Lebanese Army Department of Preventive Medicine and Public Health Lt. Sami B. Abdalla Administrative Assistant Vanderbilt University School of Medicine Lebanese Air Force Nashville 5, Tennessee Lt. Elias Francis Lebanese Air Force Captain William Nunes Clinician U.S. Army Medical Research and Nutrition Laboratory Dr. Edgar Sarrafian Clinician and Biochemist Fitzsimons General Hospital Department of Pediatrics Denver 30, Colorado American University Beirut, Lebanon Dr. William N. Pearson Laboratory Director Department of Biochemistry Dr. Raja Asfour Clinician Vanderbilt University School of Medicine Department of Pediatrics Nashville 5, Tennessee American University Beirut, Lebanon Dr. D. Mark Hegsted Laboratory Director Department of Nutrition Dr. Riad Budeir Clinician Harvard School of Public Health Assistant Field Health Officer, Preventive Medicine Boston 15, Massachusetts United Nations Relief and Works Agency - Lebanon Beirut, Lebanon Mr. Laken G. Warnock Biochemist Department of Biochemistry Dr. Jean Puyet Clinician Vanderbilt University School of Medicine United Nations Relief and Works Agency - Headquarters Nashville 5, Tennessee Beirut, Lebanon Dr. Paul E. Johnson Chief Nutrition Officer Dr. Adonis Asma Clinician Executive Secretary United Nations Relief and Works Agency - Lebanon Food Protection Committee Beirut, Lebanon National Research Council Mrs. Kathryn V. Chaiban Biochemist Washington 25, D.C. American University Dr. LaVell M. Henderson Nutritionist Beirut, Lebanon Department of Biochemistry Miss Zelfa Hamadeh Biochemist Oklahoma State University American University Stillwater, Oklahoma Beirut, Lebanon Dr. David B. Hand Agricultural Specialist Mrs. Ebtihaj Sharif Biochemist Department of Food Science and Technology American University New York State Agricultural Experiment Station Beirut, Lebanon Cornell University Miss Vera Wahbe Biochemist Geneva, New York Department of Pediatrics American University Beirut, Lebanon XII XIII Source: ittps://www.industrydocuments.ucsf.edu/docs/njyco Lebanon Members (Continued) ACKNOWLEDGMENTS Miss Marie Ghazesian Laboratory Assistant American University The Lebanon Nutrition Survey Team wishes to make special recognition of the assist- Beirut, Lebanon ance of the Minister, Director-General and their staffs of the Ministries of Defense, Miss Souad Ajlani Nutritionist Health, Education and Agriculture in carrying out arrangements for the survey conducted Home Economist in Lebanon. Special thanks are also due to Mr. Joseph Donato, Director-General of the Experimental Farm Office of Social Development, to Mr. Abbas Farhat and Miss Marybeth Leininger of the American University of Beirut United Nations Technical Assistance Board, and to Mr. John Davis and Dr. J. S. McKenzie Miss Isabelle Coenegracht Nutritionist Pollack of UNRWA and the members of their staff who served on the survey team. United Nations Relief and Works Agency - Headquarters Beirut, Lebanon In a survey such as this the help and cooperation of many individuals and groups are necessary to its success. We are grateful to the numerous persons who contributed in a Miss Marie Shirfan Nutritionist variety of ways to the work, but space limits the individual recognition of these by name. Ministry of Health The interest and assistance given by each are acknowledged herewith. Beirut, Lebanon Dr. A. H. Gounelle Consulting Member; Nutritional Consultant to the The cordial cooperation and assistance of the people of Lebanon are especially French Faculty acknowledged. It is for them, finally, that the report has been prepared. Centre de Reserches FOC Centrale de Reserches Cliniques et Biologique sur Mr. Magid Arsland, Minister of Defense la Nutrition de 'Homme Dr. Elias Khoury, Minister of Health 4 Av. de *Observatoire Mr. Kamal Jumblatt, Minister of Education and Fine Arts Paris 6, France Mr. Halim Najjar, Director-General, Ministry of Agriculture Miss Marie Therese Rassie Secretary Mr. Edouard Souma, Director of Agricultural Research Institute, Ministry of Agriculture Americar University Mr. Adel Cortas, Head of Agricultural Economics, Ministry of Agriculture Beirut, Lebanon Mr. Jean Baz, Statistician, Ministry of Agriculture Mr. Pakrat S. Bakalian, President of the Council of Administration of the Industrial Mrs. Helga Sarrafian Secretary Society of the Levant American University Dr. Kamal N. Saad, Director, Technical Division, Industry Institute Beirut, Lebanon Dean Robert A. Nichols, School of Agriculture, American University of Beirut Dr. Gordon H. Ward, Head of the Division of Rural Improvement, School of Agriculture, American University of Beirut Cooperating Individuals Mr. Kachadurian, Superintendent, American University of Beirut farm Dr. Zacharia Sabry Dr. John Cummings, Animal Husbandman Department of Food Technology Dr. Kenneth Hanson, Horticulturist American University of Beirut School of Agriculture Dr. Rayno Lamson, Poultry Husbandman Beirut, Lebanon Dr. W. W. Worzella, Agronomist Dr. Cicely D. Williams, Acting Director, School of Public Health, American University Dr. Calvin W. Woodruff of Beirut Department of Pediatrics Dr. J. Harfouche, Department of Pediatrics, American University of Beirut American University of Beirut Professor H. Fillion, Professor of Chemistry, Faculty of Medicine and Pharmacy, Beirut, Lebanon Université St. Joseph Mr. H. Donabedian, Pharmacist; graduate student in chemistry Miss Suad Wakim, Head of the Department of Home Economics and Dietetics, Beirut College for Women Mrs. Jean Sabry, Associate Professor of Foods and Nutrition, Beirut College for Women Major George Malouf, Commandant, 3rd Battalion, Lebanese Army Major Mohammad Halaby, Commandant, 2nd Battalion, Lebanese Army Major Saadalla Najjar, Commandant, 1st Battalion, Lebanese Army Major Said Nasrallah, Commandant, 1st Armored Battalion, Lebanese Army Mrs. Fouad Najjar, Associated Country Women of the World, Beirut Mr. Michael Cortas, Cortas Brothers Canning Company, Beirut Dr. Stanley Flache, Director of Health and WHO Representative, UNRWA Mr. Merriam A. Jones, Agricultural Advisor, U.S. Operations Mission Mr. M. N. Bekhash, Agricultural Assistant, Office of the Agricultural Attaché, U.S. Embassy XIV XV Source: https://www.industrydocuments.ucsf.edu/docs/njyco2 I MISSION At the request of the Government of the Republic of Lebanon, the Interdepartmental Committee on Nutrition for National Defense (ICNND) sponsored a nutrition survey of Lebanon during the period 20 February through 30 April 1961. The survey team was com- posed of Lebanese, American, French, and United Nations Agency personnel who appraised the availability of food, food technology, the dietary pattern, and the physical and bio- chemical status of representative samples of the military, civilian, and refugee segments of the population of the country. The purposes of the survey were to assess the present nutritional position of the country, to train nutritional personnel, to assist in the establishment of a nutrition laboratory, and to provide advice concerning possible improve- ments in the nutritional health of the people of Lebanon. INTERPRETATIVE SUMMARY AND RECOMMENDATIONS The survey was made during the season (February-April) in which fruits and vegetables were becoming available through the country, initially along the sea coast, and subse- quently in the Bekata Valley. Spring blossoms were coming out in the mountain orchards during the final week of the study. For several years preceding the survey unfavorable climatic conditions with severe drought had resulted in increasing reliance upon imported sources of basic food commodities. The survey was conducted by a team of more than 30 nutritional scientists and sup- porting personnel. Operations ranged throughout Lebanon and among all segments of the population. Thirty-four individual locations were visited for study. Approximately 8,600 individuals were examined, including military, civilian, and refugee groups. In this group 3,521 school-age children were examined for evidences of physical signs of deficiencies. Five thousand and ninety-five individuals were given an abbreviated physi- cal examination, with 1,228 of this group receiving in addition a detailed physical exam- ination. Biochemical assessment of several nutrients in blood and urine was completed on 614 of these subjects. One thousand and seventy received careful dental examination and 373 provided specimens for parasitologic studies. Dietary information is based on data obtained from 627 men in the Armed Forces, 129 families from the civilian popula- tion and 51 families from the Palestinian refugees. In addition, direct chemical analy- ses were made of food composites representing 1,234 military rations in four two-day mess surveys. The results indicate that the caloric intake of the average adult Lebanese is adequate. The mean relationship of height and weight to the level of caloric intake and energy expenditure was satisfactory and the average percent of "standard weight" for adults as compared to American or Western European reference standards was within the range of 90-100 percent for all segments. However, in each population group a signifi- cant number of individuals fell into the underweight and obese categories, indicating an excess of caloric intake or a deficit in relation to the level of activity. Overweight was more common and underweight less frequent among the nonrefugees. Growth patterns of boys and girls age 0-14 years were along the lower limits for comparably aged European or American children. The daily caloric intake ranged between 2,800-3,200 Calories in the military, and averaged 2,300 Calories in the civilian population and 2,000 Calories in the refugee group. It is estimated that there was a mean deficit of approximately 300 Calories per day among the refugee group. 1 Source: https://www.industrydocuments.ucst edu/docs/njyc0227 Dietary, biochemical and clinical evidences of widespread deficiency of riboflavin this limited intake of Calories in the latter group, no instances the of gross were encountered. The deficiency exists in all segments of the population and in all wasting, Despite edema, or other evidence of starvation was encountered of the basic except rationing among and supple- younger regions of the country. Whether all the clinical manifestations of cheilosis, angular lesions and nasolabial seborrhea can be attributed to ariboflavinosis needs to be estab- mentary children. feeding This reflects program of the UNRWA over-all and indicates effectiveness that the failure. program provides the important lished by further investigations of these lesions along the lines initiated at the basic intake required to prevent severe nutritional conclusion of the present survey. Investigations should be critically designed and executed in a manner to produce conclusive results. This is easily possible through Clinical evidence of severe protein malnutrition as exemplified by overt kwashiorkor concen- continued use of the laboratory facilities and of the trained personnel who participated or high. On the other hand, prekwashiorkor (growth retardation, dyspigmentation baby clinics edema was not present among the individuals studied. The total plasma protein in the ICNND nutrition survey and by the maximal mobilization of the interest stimulated in the many ministries, several research institutions and the two university medical tration of the hair was and anemia) and marasmus were seen in a number of children in well schools. and at feeding centers. In order to improve riboflavin nutriture in Lebanon it is recommended that (a) em- biochemical and clinical findings all confirm that the Cereal average products intakes of phasis be placed on a general betterment of the usual Lebanese diet through increased Dietary, fat, niacin, ascorbic acid and calcium are adequate. Forces, con- production, availability and use of ciboflavin-containing foodstuffs, and (b) the ribo- carbohydrates, tributed 54, 61 and 64 percent of the total Calories in the diet of the Armed flavin content of processed cereals be increased. This latter measure is feasible where the milling of grains is centralized or where large-scale purchases of flour are made civilians and refugees respectively. under conditions such that specifications for purchase can require improved or enriched Enlargement reflect countrywide nutritional deficiency of iodine. percent all of the thyroid gland (endemic goiter) and low urinary Over excretion 45 levels of all flour. The latter situation obtains in the procurement of flour for the Armed Forces, orphanages and refugees. persons of iodine examined had a goiter. This condition occurred in both sexes, among age groups The intake of thiamine as estimated by calculation from the dietary studies was and in every geographic region. "acceptable." However, chemical analysis revealed a lower content in the prepared diets taken Endemic together magnitude goiter with and the is etiology a findings major of nutritional in this June condition. 1960 deficiency of a It WHO is disease consultant, recommended in Lebanon. gives that matter appropriate clear This evidence in survey, the and biochemical data on urinary excretion likewise revealed a lower than desirable intake of this nutrient. These findings suggest that there may be a significant loss of thiamine during the preparation of foods. Hence, enhancement of the thiamine intake throughout the of measures the to iodate salt (p. 34 be ). taken If, in as keeping the WHO with consultant the discussion advised, of the this cheaper iodide more is country is desirable. Such enhancement can result from improved quality of diet, improved food preparation and enrichment with thiamine of a basic food such as cereals. All of body used of this report it must be established by laboratory surveillance distribution that this and these measures are justified in Lebanon and it is recommended that the previous suggestion in form the process, of iodine is retained in effective amounts throughout iodate the is stable and is of enrichment of flour with riboflavin be accompanied by enrichment with thiamine at levels labile the salt is consumed. Although slightly more expensive recommended for these sufficient to insure an intake of the nutrient equal to the "accepted" dietary standard of a preferable It agent is further recommended that the level of iodization of 1:10,000 This may be to until to employ in iodization of salt. Its use is (similar the ICNND. reasons. that employed in the United States) be the ultimate iodization aim in of the domestic program. and imported salt. at- A considerable proportion of the Lebanese population exhibits moderately low levels of hemoglobin which reflect iron deficiency. This occurs despite a reasonably acceptable The tained initial within level one of or iodization two years after could commencing be somewhat lower (1:20,000) if this be judged de- calculated iron content of the Lebanese dietary. The occurrence of a mild to moderate sirable by the Lebanese authorities degree of anemia among men, women and children in several locations, both in military and civilian groups, suggests that a general increase in available iron intake would be bene- iodate required for iodization would cost $2.50 (U.S.) per ton of salt. against For the an ficial. Accordingly, it is recommended that iron be included among the ingredients for development estimated of endemic per goiter and virtually eradicate iodine deficiency of The $27,500 year, therefore, Lebanon could protect the population all degrees. the enrichment of cereals. Although there is need for further clarification of the eti- ology of this iron-deficiency anemia, sufficient evidence exists to recommend institution control of iodization is simple and inexpensive. The necessary laboratory Ministry of both educational efforts and cereal enrichment. Regulatory for control is available in laboratories of the following groups: French equipment Health, the Industry Institute, American University of Beirut, and the Enrichment of flour with riboflavin, iron and thiamine could be carried out with a University. of One group should be responsible for establishing and monitoring appro- cost of materials estimated not to exceed $0.2565 per ton. For this small expenditure ariboflavinosis occurring in over 15 percent of the population could be eliminated, anemia priate control measures. could be considerably reduced and a safe intake of thiamine assured. Iodization of salt is needed by all groups of the population: military, civilian and Physical lesions suggesting hypovitaminosis A were present in individuals in all groups studied. In the Armed Forces there was additional evidence of inadequate dietary refugees. intake of vitamin A and of low biochemical values. Seasonal variations in the availability Since completion of the initial survey, investigations of iodine deficiency Department and of the of foods rich in vitamin A activity create a shortage at times when green and yellow vege- efficacy of the American University of Beirut. The results of these it is urged that of iodate administration have been initiated by members of the investigations tables are not abundant. Educational and agricultural planning should include attention to improvement of the vitamin A content of the dietary. Pediatrics available within a relatively short time. Accordingly, in order in should planning be for iodization in Lebanon these studies be taken into consideration to guide the level of iodization. 3 2 Source: https://www.industrydocuments.ucsf.edu/docs/njyco227 Dental findings reveal severe periodontal disease associated closely with deposits Regardless of the segment of the population considered, the nature of the nutritional of calculus. Periodontal disease results in a high loss of teeth in excess of that which problems was qualitatively the same. The differences were quantitative, i.e., differences should occur from the relatively low dental caries rate in the country. This periodontal of degree, severity, or prevalence. The following corrective measures are therefore disease could be minimized by good oral hygiene. It is recommended that preventive dental generally needed. hygiene be emphasized in health education throughout the country. (a) Iodization of salt to control iodine deficiency (endemic goiter, cretinism). In some areas the fluoride content in municipal water supplies is low and the higher dental caries rate in those regions can be reduced significantly by fluoridation of the (b) Enrichment of white flour with riboflavin, iron and thiamine to alleviate municipal water supplies. It is recommended that consideration be given to the fluorida- ariboflavinosis and anemia and to improve the thiamine status of the population. tion of water supplies in the larger communities where the municipal water supply is low in this element. (c) Improved feeding of infants and preschool children from the age of 6 months, with especial attention to the needs of the weaning and toddler age groups. Encouragement and support should be given to dental schools to provide more trained personnel and increase the resources in this area for Lebanon and the Middle East. Train- (d) Education at many levels concerning environmental sanitation, personal hygiene, ing provided for these personnel should emphasize the role of preventive dental measures food hygiene and sanitation in order to reduce the food-borne infections and infestations. and should develop adequate and appropriate treatment procedures at a cost level commen- surate with the economic capacity of the country. (e) Education in oral hygiene aimed at reduction of periodontal disease. Evidence obtained concerning the nutriture of infants and younger children revealed (f) Utilization of fluoridation of municipal water supplies in locations where this a frequently encountered pattern of nutritional deterioration from approximately six is indicated in order to minimize dental caries. months of age through five or six years, with a subsequent limitation of average weight of children below standard until early puberty. Clinical and biochemical findings depict (g) Development of an additional dental school with emphasis on adequate and appro- the limitations in this process of several nutrients: energy factors, protein, iron, io- priate preventive and curative dental procedures for the region. dine, ascorbic acid and vitamins A and D. These findings are more striking among the refugee children and most striking among institutionalized infants and children. No doubt (h) Attention to and incorporation of nutritional needs in over-all governmental infections and parasitic infestations contribute to these conditions, but it is obvious planning for agriculture, industry, or international trade. that the diet and nutritional reserves of the child are sufficiently limited that he can- not recover rapidly from the impact of infections and he is therefore more vulnerable than (i) Greater incorporation of nutritional subject matter into the professional train- an adequately nourished child. These influences are reflected in a high infant mortality ing offered in the universities, medical schools and schools of agriculture of the country. rate. (j) Intensified research directed toward the nutritional problems identified by this Iron deficiency anemia is prevalent among infants at approximately one to two years survey. of age and low levels of vitamin A occur in the blood of infants and preschool children. Clinical evidences of mild to moderate rickets were met. These findings support the recom- Effective regulatory procedures and mechanisms should be established by governmental mendation for intensified efforts in education relative to the proper feeding of infants authorities for assuring the quality and safety of foods, including attention to food and the preschool children. additives and residues of agricultural chemicals. This latter is an especially important onsideration due to the importance of proper employment of the chemicals in order to ob- Although Lebanese agriculture at present does not provide sufficient quantities of tain maximum benefit to the consumer and producer and, at the same time, to assure complete food for the population, there is considerable opportunity to bring about a general im- safety of use. Use of agricultural chemicals on export crops (fruits, for example) must provement in the diet by certain agricultural developments. It is recommended that these be such as to assure acceptable quality of product with residues within the limits of include: (a) increased production of poultry flocks and dairy foods, (b) continued bet- tolerances permitted by the importing country. Toward these ends existing legislation terment of food storage and distribution, (c) wider production of vegetables, particularly should be reviewed and effective nethods of controls implemented. of the green and yellow categories, for home use and preservation, and (d) promotion of improved food processing both at the commercial and domestic levels. For economic and agricultural planning there is a need for more reliable, continuing statistics on the available foodstuffs and on food use and consumption. Plans for obtain- Parasitologic studies revealed widespread infestation with a variety of intestinal ing these data at repeated intervals should be made and effected. parasites. These findings indicate a need for improved food hygiene and environmental sanitation. Suggestions concerning improvements in sanitation in military messes are de- In addition to these generalizations, the following points may be made relative to tailed in the body of this report (p. 43). Although not detailed in the report, many the responsibilities of particular agencies or institutions: instances were noted which point to a need for improved understanding of food hygiene and Armed Forces sanitation at household, plant and institutional levels -- such understanding as can be developed through incorporation of relatively simple concepts in primary and secondary school teaching, especially in home economics courses, in adult education at the extension It is recommended that the Armed Forces and public health level, and in "on the job" training of food handlers, cooks and proces- sing personnel. 4 5 Source: https://www.industrydocuments.ucsf.edu/docs/njyc0227 (1) Establish a nutrition service and that one properly trained nutrition officer of the Deficiencies Frequently Manifested be Armed Services. This service would provide and approve menus and make status designated to provide advisory services to the medical and other departments recommendations Age Group Calorie-Proteir Iron Vitamin C Vitamin A Vitamin D for the improvement of nutrition of personnel. It would appraise nutritional and 0-5 mo. - + - - - the military and cooperate with university groups, research institutions others of 6-12 mo. + + + + - among in the study of nutrition problems in the Armed Forces. In addition, the resources of institu- 13-24 mo. + + + + + the service would be accessible to certain agencies responsible for feeding 2-5 years + + ? + + tionalized subjects. - No finding (2) Modify its military ration to provide more riboflavin by + Positive finding (a) Increasing the ration issue to include more riboflavin-rich foods, for example, These changes would increase the riboflavin content of the ration by some ef- mg. at least 3 eggs per man per week and 35 grams of whole milk powder per man 0.23 per It is obvious that nutritional reserves of the child are so limited that he cannot rapidly recover from the impact of infections and infestations and he is more vulnerable than is day. day. Corresponding increases in cheese would also be effective. Other the adequately nourished child. This pattern of malnutrition is more frequent, widespread per fective man modifications per can be used to attain this objective such as incorporating one or and severe among refugee children than among other groups studied, except orphans. The two servings of organ meats per week in the ration. existing UNRWA program of feeding and supplementation would appear to be responsible for the survival of many of the children through the early years of life, and for the absence Specifying and obtaining enriched white flour for military use which calcium. has of even more severe malnutrition, such as frank kwashiorkor. While some modification of been enriched (b) by adding specified quantities of riboflavin, thiamine, iron and this program may be considered, the precarious state of nutriture of the young child is Niacin could be an optional ingredient. such as to caution against any change which would reduce the quality of food available for the child of 6 months to 13 years of age. Reduction in the quality of diet for the age (3) Establish a school for mess personnel for the purpose of instructing cooks and groups from 6 months to 5 years could result in an increased number of marasmic infants sergeants in matters of food preparation, nutrition, food hygiene and should sanitation. accept and of cases of prekwashiorkor, and the appearance of frank kwashiorkor and of more exag- mess would serve to improve all messes within the military. The school gerated growth failure. This trainees from nonmilitary institutions with responsibilities for institutional feeding programs. It would, thereby, favorably influence civilian programs The clinical signs of malnutrition among the refugee population reflect the low intake of many of the same nutrients which are deficient among the nonrefugee civilian (4) Give attention to improvement of military and civilian messes by group and among the military, namely: (1) iodine, (2) iron, (3) riboflavin, and (4) vitamin A. The prevalence of the physical lesions was greater in some instances among (a) Screening all areas of food preparation and excreta disposal. the refugees, but still greater among children in orphanages. Accordingly, similar or identical attacks on these problems may be made wherever they exist. These include iodi- (b) Providing dining halls for those messes where such facilities are not now zation of salt for use throughout Lebanon and adoption of standards for enrichment of white flour with riboflavin (vitamin B2), thiamine (vitamin B1) and iron and use of flour existent. meeting this standard by all agencies (including UNRWA). The greater frequency of both (c) Providing in or near the dining hall washing facilities for mess kits in ariboflavinosis and iron deficiency anemia among the refugee groups than among the non- which these kits can be cleaned and sterilized. refugee civilians argues strongly for adoption of this measure by UNRWA. Other specific measures recommended are the routine administration of iron in pre- UNRWA ventive doses to all infants from 6 months to 1 year of age, and to mothers from the fifth Palestinian refugees included in the population sample were predominantly based ration in- month of pregnancy through the third month of lactation and, until iodization of salt is The living within camps. The appraisal of their nutrient intake is the homes, upon and realized, the prophylactic administration of iodine to all pregnant women. Similarly, recipients formation obtained by dietary interviews, observation of foods available in data and prophylactic administration of potassium iodide tablets to school children would be feasi- knowledge other clinical observations, lead to the conclusion that the refugee has a of the rations issued. These stimates, together with height-weight lower caloric ble and valuable as an interim measure. intake than does the average nonrefugee civilian within the nearby areas (p. 89). Education in health and nutrition should be given greater prominence in the school program of UNRWA. Early introduction of subject matter relative to hygiene, food sanita- deterioration from approximately 6 months of age through 5 or 6 years, with subsequent The nutriture of infants and younger children reveals a pattern of nutritional tion and simple principles of nutrition should occur in courses of instruction. Teaching in home economics with especial reference to foods, nutritional needs and food values, limitation of average weight of children below that of the corresponding nonrefugee reflect age food preparation, hygiene and sanitation, feeding of infants and children, simple prin- until about the age of 13 years. The clinical and biochemical findings vitamins the ciples of nutrition, home food production and preservation should be emphasized in the limitation groups of several nutrients: Calories, protein, iron, iodine, ascorbic follows: acid, upper standards. General health instruction should include consideration of oral hygiene, A and D. These deficiencies evidenced by age group are indicated as the proper care of the teeth, and principles of hygiene and sanitation. It is recognized that the course content of the UNRWA schools is determined by the national program. The survey indicates that similar improvements in teaching should be initiated in the public schools of Lebanon. 7 6 Source: https://www.industrydocuments.ucsf.edu/docs/njyco227 Institution of the above recommendations would alter minimally the present program of UNRWA. The agency has given consideration to possible change of its basic program of resources East available insufficient number of well trained personnel. Because of the excellent A is major the limitation for nutrition development in Lebanon and throughout the Middle supplementation. The findings emphasize the need to continue at least the present level of nutrients available to the vulnerable groups. Any alteration of the program should be and its institutions in Lebanon and its long role of leadership in the region, this toward an effective way of improving the nutritional quality of the diet, especially of is urged that are of first importance as a regional training center. country it nutrition, and by the country itself by the institutions and agencies with exploited to the fullest the present opportunities : for expanded nutrition training be Therefore, the use by recipients of supplements available. Much recent developmental work elsewhere shows that relatively cheap, acceptable infant or supplementary foods can be prepared for many regions (for example, INCAPARINA). Such foods could be used to replace milk if that by international and bilateral agencies concerned with regional responsibility development. for product became more limited in supply, and some of them might have an advantage that their to nutrition In the primary and secondary schools of Lebanon greater prominence should be consumption would more frequently be restricted to the target group. Hence, it may be be teaching. This is discussed subsequently (p.12ff.). Attention given useful for UNRWA to give some attention to such types of products which could be useful nomics cannot in overemphasized, especially to the fuller development of nutrition in to home this eco- need and acceptable within this region, and to make some field acceptability studies in order the schools. to be prepared to meet any emergency which might arise due to decrease in surplus milk produced or other exigency. Consideration of this matter could be facilitated by use of consultants with wide experience with these developments elsewhere (INCAP, India) along with scientists from some institutions of the region (Industry Institute, American Uni- versity of Beirut, Agricultural Research Center, etc.). Educational and Research Institutions The level of cultural development of Lebanon and the position of educational leader- ship which it holds make it and its educational institutions especially important for the Middle East. The heightened interest in nutrition within Lebanon and particularly in its universities augurs well for a fuller role of leadership in this field. Every effort should be made to assure that a broad program of nutrition education is established within the Lebanese universities and colleges. Specialized university training in nutrition should include clinical and medical nutrition, nutrition in public health (especially pediatrics), dietetics, food technology, nutrition training in schools of agriculture and agricultural research stations, and in economics and statistics. Deserving of especial development is the field of home economics with emphasis on foods and nutrition. The research institutes and universities in the country have excellent potential resources to draw upon. These include the resources of the School of Agriculture (espe- cially of the Department of Food Technology) of the American University of Beirut, the Agriculture Institute of the Ministry of Agriculture, the Industry Institute supported jointly by the Lebanese Government and industry, the laboratory facilities of the Ministry of Health, the interest in food analysis and nutrition in the French University and the rapidly developing broad program of nutrition training and research within the American University of Beirut which is being established through a elationship with the Institute of Nutrition Sciences of Columbia University in New York City. The wealth of resources will be exploited in the most efficient manner only if there is joint planning and coordi- nation of activities with assigned responsibilities for certain aspects of development, research training and regulation among the institutions so that appropriate utilization of personnel, facilities and interests occurs. For example, the laboratory of the Ministry of Health has good resources for guiding and monitoring of regulatory laboratory aspects of the control of foods, both imported and domestic, while universities properly can assume leadership in areas of training and research. Such division of functions should be clearly understood and recognized by the several agencies. On the other hand, there are certain basic needs in research which may involve several types of institutions. For example, there is a great need for a comprehensive table of food composition dealing with Lebanese foods, the preparation of which might profitably involve resources of several of the institutions in Lebanon. 8 9 Source: https://www.industrydocuments.ucsf.edu/docs/njyc0227 FIG. 1 II Agrido BACKGROUND LEBANON Lebanon is a young country of ancient origins. The Phoenicians settled around Tyre Tell Hohed) and Sidon in about the 13th century B.C. As a crossroads of east and west it has felt HALBA the impact of many cultures and races. Assyrians, Persians, Greeks and Romans succes- sively ruled the country in the re-Christian era, and were followed by Arabs, Crusaders, Minyo Mamelukes and Turks. Between World Wars I and II Lebanon was under a French mandate. TRIPOLI NORTH Independence was declared in 1941 and full sovereignty granted in 1943. (TRABLOS) Lebanon is a Republic in which a unicameral Chamber of Deputies, elected by the LEBANON people for 4-year terms, elects the President for a 6-year term. The latter appoints Anfe the Prime Minister and heads of Ministries upon approval by the Deputies. The Chamber Chekko/ in THE Ros Boolbek of Deputies has proportional representation by religion as well as by region. Of the g Jdaideh several ministries with responsibility for some aspect of nutrition may be listed the Batrount @CEDARS Ministries of Health, Agriculture, Education and Fine Arts, Defense, Economics, Social Loboueh Affairs and General Planning. BIQA Administratively, the country is divided into four districts, North Lebanon, Mount Lebanon, South Lebanon and the Beka'a. Each district is governed by a Muhafiz appointed Juboit S (Biblos) by the Minister of the Interior. MOUNT EL Bouor Physically this small country of 4,000 square miles encompasses a widely varied BAALBEK topography and climate. East of the narrow, warm Mediterranean coastal plain the Lebanon Jounieh Mountains rise abruptly to peaks that in some places are above 10,000 feet and frequently / LEBANON snow-covered. Beyond the mountains lies the Beka'a Valley which is hot and dry in summer BEIRUT and cold in winter. The eastern border of the country with Syria is the crest of the Jdaideh Anti-Lebanon Mountains. Precipitation is relatively high along the coast and the western Abloh ZAHLE slopes of the Lebanon Mountains, 20-35 inches a year. East of the mountains the rainfall + O PRoyok Choyeifat Bhamdoun Hommang is less. The rainy season is between November and March. Almost no rains fall from May Chtoura Ter bot to September when hot winds blow from the Syrian Desert to the east. Aley Sofor The population of Lebanon is approximately 1,500,000 and the annual rate of growth is about 2.5 percent. Most of the people live in villages of a few hundred families each, Deir EL Kgmar and are often interrelated. About 137,000 Arab refugees live in 16 United Nations Relief BEIT EDDINE and Works Agency (UNRWA) centers throughout the country. Of this number, 83 percent re- o ceive the UNRWA rations and 94 percent are Moslems. Yonto SAIDA Lebanese are predominantly Arab, although the population also includes groups of (SIDON) DAMASCUS Armenians, Syrians, Egyptians, Palestinians and Europeans. Many Lebanese emigrated to the Western hemisphere in the late 19th and early 20th century to escape land pressures, 788 and more people of Lebanese origin now live abroad than in the country. The official SOUTH language is Arabic (Syrian dialect). French is the second language. There are about an E1 Khodr, Hobbouch ATHENS equal number of Moslems and Christians in the country, the Moslems for the most part be- Nobotieh El Tohto, 1146 longing to the Sunni or Shia sects. Most Christians are Maronites, although there are MARJAYOUN NICOSIAT also Greek Catholics and members of the Greek and Armenian Orthodox churches. 244 Kofr Tibnite BEIRUT BAGHDAD t 825 KUWAIT Lebanon is a center of culture for the Near East. Its two outstanding universities LEBANON DAMASCUS 1284 are world-renowned, the American University of Beirut and the Université St. Joseph, fre- SOURO 74 quently known as the French University. The literacy rate in Lebanon is high, estimated (TYRE) at 65 to 80 percent. AMMAI DERUSALEM The economy of the country is based on trade and agriculture. Beirut, the capital Nogouro and chief port, is a leading commercial center for much of the Middle East, with a rapidly 1324 growing population now over half a million. About 5 percent of Lebanon's population might CAIRO DIS TANCES SHOWN IN KILOMETERS 11 USOM/LEBANON ICNND-1960 10 Source: https://www.industrydocuments.ucsf.edu/docs/njyc0227 Nutrition Sciences to establish a center for the study of nutrition at AUB. This will be considered well-to-do, 25 percent middle class and the rest lower income. A survey of Beirut in 1954 indicated that half the families spent more than 50 percent of their greatly aid in meeting many needs for research and training revealed by this report. This rapidly developing resource in Lebanon will be of great aid to the Army Medical income for food. Living costs have risen about 5 percent a year since that time. Govern- Service, the Ministry of Health, of Agriculture, of Education, and to home economists, ment policies in economics are designed to attract foreign capital and promote trade. food technologists and other concerned with nutrition in the country. Such a center Private enterprise is encouraged. These policies have helped maintain a stable economy. might well offer advice in education to the school teachers, dietitians, food economists and other workers in the position to carry educational items related to nutrition to the Agriculture is second only to trade in its contribution to the national income. Ap- public in general. proximately 50 percent of the people are engaged in farming. Due to the mountainous terrain only about 30 percent of the land is suitable for cultivation. Most farms are Within the French Faculty there also is an active interest in food composition and small and owner-operated. Relatively few have more than 25 acres and many are 5 acres dietary studies. The opportunities for collaborative work in nutrition be tween these or less, with scattered plots. Farmers often work part-time in construction or manufac- university faculties and other scientific and nutrition groups in Lebanon are excellent. turing to supplement their incomes. The two principal farming areas are the coastal plain and the Beka'a Valley. The wide range of altitude and climate makes it possible for Training schools for nurses are associated with both these university medical schools, Lebanon to produce a profusion of crops seldom found in one country of such small size. and there are four other nursing training schools in the country. They include citrus fruits, bananas, dates, olives, grapes, figs, apricots, peaches, apples, potatoes and cereals. Stock raising is much less important than crop production The Ministry of Agriculture maintains an Agricultural Research Institute in the Beka'a due to lack of pastures and fodder crops. Goats are the most common livestock. Valley under the direction of Mr. Edouard Souma with projects on such subjects as wheat technology, agricultural engineering and plant and animal breeding. Lebanon has about 2,400 miles of roads, of which 2,200 miles are hard-surfaced. Most are good roads. The chief highways are the coastal road, the Beirut-to-Damascus The School of Agriculture of the American University of Beirut has an experimental road across the mountains, and the road through the Beka'a Valley. Most transportation farm of 250 acres in the Beka'a Valley and a Department of Food Technology at Beirut. is by trucks and buses. The railroads are used mainly to transport freight long distances. The latter department is small and the faculty comprises an assistant professor The two main rivers of the country, the Litani and the Orontes, flow through the Beka'a, and one full-time and one half-time assistant. Research projects are being conducted the former southward and the latter northward. Beirut International Airport, the largest on the calcium and oxalate content of foods and, with financial assistance from the (U.S.) and most modern airport in the region, is served by a number of international airlines. National Institutes of Health, the preparation of food composition tables for Lebanon. A cooperative project on the biological value of proteins is being organized with the lab- The Ministry of Health reported in 1960 that Lebanon had 1,440 physicians, or 1 for oratory of nutrition in the School of Public Health, AUB. every 1,062 of the population. At that time there were 132 hospitals, 608 nurses and hospital attendants, 450 registered pharmacists and 356 midwives. Most of the physicians, The Beirut College for Women has a Department of Home Economics and Dietetics in however, were located in the large population centers. which one course is given on foods and two on nutrition. Home demonstrations are con- ducted by a local, voluntary society, the Home Economics Association. Since 1952 the United States has taken part in a number of programs in Lebanon aimed at improving agricultural practice, water supplies and irrigation, rural electrification, The School of Public Health in the American University of Beirut has an active in- highways and adult education. A few examples of this assistance are the Litani River terest in nutrition, especially of infants and children. A laboratory of nutrition in development project which when completed will provide both electric power and irrigation the Department of Pediatrics of the Medical School of AUB services the work of the School facilities, projects to bring water and electricity to rural villages, and to bring agri- of Public Health, and is closely associated with the Institute of Nutrition Sciences, cultural information to farmers through extension service-type work. The U.S. Operations Columbia University. Through the cooperative work sponsored by AUB and Columbia attention Mission has assisted in the organization of the Lebanese Management Association, and, with will be given to all aspects of nutrition, from growing of food to its ultimate consump- the Government of Lebanon and the Association of Lebanese Industrialists, helped establish tion and effect on health. The program will, therefore, involve the American University's the Industry Institute which serves as a consulting technical assistance to industries in School of Agriculture, School of Public Health, Department of Economics and School of Lebanon and neighboring countries. Medicine. Education The Industry Institute was recently established through joint support of the Govern- ment of Lebanon, the U.S. International Cooperation Administration and industry, as Lebanon's high literacy rate reflects a well functioning school system in primary indicated above, to provide industry with research assistance and scientific counsel. education. Among its institutions of higher learning two are of particular interest inso- The institute is nonprofit but self-supporting through fees charged for research projects. far as the survey is concerned, namely the two universities with medical colleges, the A major emphasis is on market analyses and factory layouts. The institute has excellent American University of Beirut (AUB) and the University of St. Joseph, also known as the facilities with a pilot plant, machine shop and materials testing laboratories. There are French University. Instruction is in the English language in the first of these and in 80 employees. Typical projects related to food processing include studies on the feasi- French in the other. bility of an integrated canning plant, the layout of a food processing pilot plant, the design of a slaughter house, solar salt refining and pilot plant development of instant The medical college of the American University of Beirut is accredited by U.S. accred- cereals and burghul. The institute serves industry in Lebanon and other countries of the itation agencies and has similar standards and programs to those of American medical schools. Near East. A five-year grant has recently (1961) been made to the Columbia University Institute of 13 12 Source: https://www.industrydocuments.ucsf.edu/docs/njyc0227 The Ministry of Health has a Central Public Health Laboratory. The laboratories I. Central Departments of bacteriology and chemistry are of particular interest for the development of food technology. The laboratory analyzes imported foods and alcoholic beverages and conducts II. Regional Departments control analysis on water, milk and other food samples collected by inspectors of the municipal Departments of Health. In spite of the proficiency of the control analyses, The Central Departments are: there is a lack of enforcement of sanitary regulations. This laboratory offers a resource which could be of broad service to the country. A. The Administrative Service, consisting of: Since all these laboratories and their respective agencies are concerned with the 1. The Department of Vital and Health Statistics food industry in Lebanon, there is need for a closer relationship and a considerable de- 2. The Division of International Health Relations gree of cooperation among them. An appropriately planned interinstitutional Council on 3. The Department of Accounting Foods and Nutrition, if organized, could serve as a clearing house to acquaint all agencies with progress that is made in areas of mutual interest. Such a council could call atten- B. The Directorate of Preventive Medicine, which is composed of: tion to projects of special urgency and help to arrange for interagency cooperation. 1. The Preventive Medicine Service, which is divided into three depart- Description of the Military ments: The major strength of the Armed Forces is the Army, with smaller complements in the a. The Department of Communicable Disease Control Air Force and Navy. The Army command is divided into five sectors as follows: (1) Beirut, b. The Department of Tuberculosis Control (2) North Lebanon, (3) South Lebanon, (4) Beka'a and (5) Mount Lebanon. Personnel are c. The Quarantine Department rotated through the several sectors. 2. The Social Health Service, which consists of three departments: Military personnel are recruited by enlistment, one class per year entering the Army about March 1. Recruits from all parts of the country receive their six months of basic a. Department of Maternal and Child Health training in the Army cantonment in Tripoli, following which assignments are made to the b. Department of Nursing and Midwifery several sectors. Medical examination of recruits is carried out at the time of induction c. Department of Health Education and the physical requirements for military service are high. The Army does not have a full-time medical corps although there are several full-time physicians in uniform. Med- 3. The Sanitary Engineering Service, which is responsible for: ical services are also supplied on a contract basis. The Army posts have clinics for sick call with medical corpsmen in attendance, and an infirmary. a. Environmental sanitation b. Insect control There are two military hospitals -- the main one of 150 beds is located in Beirut; C. Industrial health the second hospital of 50 beds is at Ablah. Families of military personnel have access d. Food control to these hospitals only for laboratory studies and consultation. C. The Directorate of Curative Medicine, which is composed of: Food procurement, preparation and conduct of the mess is described elsewhere in this report, but the following is of interest and introduces factors into the survey of the 1. The Department of Hospitals and Clinics military personnel which are difficult or impossible of analysis. Unmarried men eat in 2. The Pharmaceutical Service the messes. Drivers of Army vehicles have a cash allowance and eat wherever convenient and food of their own choice. Married personnel eat all of their meals at home, receiving D. The Directorate of the Central Laboratory a 45 pound allowance monthly for this purpose with a 15 pound cash allowance for the wife and an additional 15 pounds for each child up to age 5. Several officers of the Lebanese The Regional Departments are: Army independently expressed their belief that married men probably did not eat as well as the unmarried ones eating in the regular Army mess. Opinion was stated that the cash A. District Services, consisting of: allowance is often spent on luxury items, entertainment and nonfood items. In the Army mess no consideration is given to food on the basis of religious confession and, except 1. A sanitary engineer at the time of the fast of Ramadan, the military of all faiths eat the same food. 2. A pharmacist 3. A district hospital Public Health (1) 4. Tuberculosis control and maternal and child health 5. Physicians and nurses Modern public health administration and practice were established in the Lebanese 6. A central clinic Government some 12 years ago. The responsibility for public health in Lebanon is that of the Ministry of Public Health. Decentralization of services is the policy of the Min- B. County Health Sections, consisting of: istry. The present Minister of Health is Dr. Elias Khoury. The Ministry of Public Health is composed of: 1. A county hospital in some counties 2. A health unit composed of a physician, a public health nurse, a sanitarian and a driver 14 15 Source: https://www.industrydocuments.ucsf.edu/docs/njyc0227 A health department headed by a Health Officer is in each of the 4 sectors of Lebanon and in Beirut. There are few local health units or departments. It is difficult for UNRWA to obtain accurate census figures, but there were 137,884 registered refugees in Lebanon as of January 1, 1961, of which 59, 656 were in camps and The estimated crude resident birth rate for Lebanon in 1959 was 40 per 1,000. 78,258 were not in camps. Families in camps numbered 13,038, and those not in camps Sixty-four thousand eight hundred ninety-four births occurred in 1959. The birth rate 17,314. Apparently, some of the difficulty in obtaining accurate census figures lies in in the United States for 1959 was 24 per 1,000. During the same year there were 8,468 the reluctance of some refugee families to report deaths because of the possibility of deaths recorded in Lebanon. The tremendous discrepancy between the total number of births and deaths probably indicates that deaths are not being reported adequately. Since the the ter with predominant about 10 of shelter for camps where losing a ration. About 40 percent of the refugees receiving relief live in type an average family of five members is a one-room shel- population of Lebanon shows an annual rate of growth of about 2 percent, this is further square meters of floor area. Obviously there is overcrowding by any evidence that there are inadequacies in reporting of deaths, because the difference be- standard of measurement. Occasionally space permits a small garden where vegetables can tween birth rates and death rates in 1959 would give an annual rate of growth of more be grown, but this is exceptional. Environmental sanitation services are well organized nearly 3.7 percent. The infant mortality rate was estimated by the Minister of Health but are inadequate because of the general environmental characteristics. Disposal of to be about 120 per 1,000 live births. This figure is roughly five times as high as that excreta is mainly through public latrines, but apparently these are shunned by children for the U.S., which was 26 per ,000 in 1960. A study on infant mortality in rural Lebanon and women. The water supply of 10-20 liters per person per day is onsidered safe by reported in 1955 (2) indicated the crude infant mortality rate in Lebanese villages under UNRWA. Garbage and refuse disposal is carried out by the nearby municipalities or by 1,000 in population was 244 per 1, 000 live births in 1953. The male infant mortality rate the Agency in incinerators, but the service is not ideal. Uncollected garbage and num- was estimated at 195 and that for female infants at 315. No data were available with re- erous domestic animals furnish many fly-breeding places and create a serious fly problem during the summer and fall months. gard to the reported causes of death. The Minister of Health stated that heart diseases and cancer were among the leading causes of death, but no figures were available. The basic food ration provided by the Agency supplies about 1,500 Calories which Communicable diseases are reportable. In 1959 tuberculosis ranked first with 564 does not meet minimum requirements and is supplemented by family earnings. However, op- cases, typhoid and paratyphoid fever second with 349 cases, and trachoma third with 182 portunities for employment are scarce. UNRWA recognizes the need and supplies supplemen- cases. The rank order of other communicable diseases was: acute bacillary and acute tary feeding and milk for selected children, and pregnant and nursing women. In some amoebic dysentery, diphtheria, acute poliomyelitis, influenza, favus, epidemic cerebro- camps refugees have sold their daily ration of liquid milk to merchants, but this should spinal meningitis and malaria. No smallpox has been reported since 1957. not lead to condemnation of the total program of provision of supplementary milk. Sanitation in Beirut and in parts of the other larger towns appeared to be good. UNRWA does not provide clothing for refugees, but will pay freight charges on clothing The water supply in Beirut and the larger towns is chlorinated. Raw sewage enters the donated from overseas. Layettes are distributed to pregnant women registered at maternal and child health centers. Mediterranean from Beirut. Plans for a sewage disposal plant for this city are being discussed. In the rural areas and small towns sanitation is quite primitive. Water sup- plies are not chlorinated, poorly constructed, open privies are in general use, and during Hospital services are maintained in each country. Whenever possible, the Agency uses the summer and fall months flies are a serious hazard. Garbage disposal is inadequate the services of existing hospitals in the area, but it does maintain 6 hospitals in areas even where an effort at removal exists. where no other facilities exist. The number of beds available is 2,084, or 2 per 1, 000 population served. Bed occupancy in Lebanon was low in the last quarter of 1960. These observations support the policy of the Ministry of Health of decentralization of services in order better to serve the rural areas where the need is greatest. An active maternal and child health program is operated. Maternal and child health visits to the prenatal clinics in Lebanon averaged 4.2 per pregnant woman during the last The District Health Officers whom we met are very competent men. They are pioneers quarter of 1960. Serologic tests for syphilis were positive in 2.31 percent. Programs of infant and preschool child health and school health are active, but there are difficulties in the field of public health in Lebanon and have a large task to do in education of the people and the medical profession in all phases of public health and preventive medicine. because of understaffing. Immunizations for diphtheria, pertussis, tetanus, typhoid, Progress is being made by the Ministry, and the opportunities for future improvement of paratyphoids A and B and smallpox are given routinely to children below three years of the health of the people in Lebanon are good. age at the infant health centers in organized camps. Immunization against poliomyelitis is not done routinely. At these centers children below two years are given health super- United Nations Relief and Works Agency for vision, and the mothers are given advice regarding breast feeding, weaning, bathing, clothing and prevention of infection. Palestine Refugees in the Near East (UNRWA) (3, 4, 5) The Health Division of UNRWA operates preventive medicine and public health programs An infant mortality survey was conducted in five UNRWA camps in Lebanon in 1959. in each of the countries (Lebanon, Jordan, United Arab Republic, Syria, and Gaza) in which Among a total of 1,381 live births the infant mortality rate was estimated to be around Arab refugees are living. It serves a population of approximately a million. The high 110-120 per 1,000. However, neonatal mortality is thought to be somewhat under-reported quality of personnel in the Health Division and the excellence of services rendered under and is probably slightly higher, around 120-130 per 1,000. The Lebanon Field Office of very difficult conditions are impressive. The program embodies divisions for medical care, UNRWA, under the direction of Dr. Budeir, has conducted an extensive survey of weights of maternal and child health, nutrition, communicable disease control, environmental sanita- infants attending infant health centers (6) and has found (a) refugee babies follow the tion, public health nursing, health education, training programs, medical supplies, statis- same growth pattern as European babies during the first 5 or 6 months of life, (b) during tics and personnel. The Agency operates or subsidizes 89 health centers and 13 mobile the remaining part of the first year, the average weight seems to stay midway between the clinics. Laboratory services are provided in Agency=operated, university, governmental, average line of the curve and the curve representing the lower percentile, (c) considering or private laboratories. 16 17 Source: ttps://www.industrydocuments.ucsf.edu/docs/njyc0227 the lower percentile of the curve as a minimum standard of normal growth, an estimate of III growth failures was found to be: 0-3 months, 7 percent; 3-6 months, 15-20 percent; 6-12 months, 25-30 percent; 12-24 months, 40 percent. SAMPLING, METHODS AND PROCEDURES The latest estimate of the major causes of infant deaths was obtained in a camp in I. General Description of Sample Jordan. They were found to be gastroenteritis and infectious diseases, mainly respira- tory infections. It is not possible to sort out the contribution of malnutrition to these During the survey 8,616 individuals were entered in some aspect of the clinical estimates, but it is probably great. Admissions to the children's department of American nutritional assessment. Of this number 5,095 received an abbreviated physical exami- University Hospital in Beirut for the year 1959 for the age group 0-4 shows 35.4 percent nation and systematically were sampled in the other phases of the survey as follows: of total admissions were due to gastroenteritis, 13.4 percent to respiratory infection, and 12.3 percent to protein deficiency. An infant nutrition survey is presently being con- ducted in Lebanon. It is the belief of UNRWA physicians that the chief infant health Type of Study Armed Forces Civilians Total Percent problems, intestinal and respiratory infections, have nutritional sequelae and all are Nonrefugee mainly preventable. The interest and efforts of the UNRWA staff, especially of the nutri- Refugee Screen1/ tionist, Miss Isabelle Coenegracht, of Drs. McKenzie Pollack, S. Flache, J. Puyet and 346 2,986 199 3,531 Abbreviated R. Budeir, in nutrition is great and they are carrying out most enlightening studies. 1,938 (38.0) 1,871 (36.7) 286 (25.2) 5,095 100.0 Detailed 394 (32.1) 538 (43.8) 296 (24.1) 1,228 100.0 The most prevalent infectious diseases recorded during the year July 1, 1959 - June 30, Dental 520 (29.4) 827 (46.7) 423 (23.9) 1,770 100.0 Biochemical 1960 were conjunctivitis, dysentery, trachoma, mumps, measles, whooping cough and chicken 232 (37.8) 223 (36.2) 161 (26.1) 616 100.0 pox. While the survey team was in Lebanon a group from the Department of Tropical Hygiene Dietary 627 8633/ 3514/ 1,841 of the American University in Beirut discovered a not previously known focus of schistoso- Parasitological 373 miasis among civilians in South Lebanon. 1/ See section IX, Special Studies, for discussion of these examinations. 2/ Numbers in parentheses are percentages. The Agency's tuberculosis control program emphasizes domiciliary treatment, but main- 3/ Represents 129 families. tains a sufficient number of beds to meet the requirements. According to the physician in 4/ Represents 51 families. charge of this program, the prevalence of tuberculosis among refugees is declining. Responsibility for malaria control has been transfered to the National Malaria Eradi- The over-all ratios of abbreviated to detailed, abbreviated to dental and abbreviated cation Programme authorities, but the Agency continues to cooperate within UNRWA camp to biochemical examinations were 4:1, 3:1 and 8:1 respectively. However, minor variations areas. There were 235 cases of malaria reported during the fiscal year 1959-1960. from these proportions occurred within the 3 population segments studied as noted below: In Lebanon the entire sewage and refuse disposal program is becoming more and more difficult to operate safely because of uncontrolled building around the facilities and be- Examination cause of the large number of squatters utilizing them. Abbreviated Detailed Dental Biochemical Insect and rodent control involves antifly insecticidal measures, delousing on a Percent of Sample selected basis, antimosquito measures, and trapping and destroying mice and rats. Armed Forces 100.0 20.3 26.8 12.0 Nonrefugee Civilians 100.0 28.7 44.2 11.7 Public health nursing and health education activities are carried on actively. Refugee Civilians 100.0 23.0 32.9 12.8 Total 100.0 24.1 34.7 12.1 A training program for childbirth attendants is supervised by UNRWA. Nurses are being trained and the costs borne by a voluntary society, "Aid to Palestine Arab Refugees," of ARAMCO (Arabian-American Oil Company) Further description of the abbreviated sample by population segment, age, sex, loca- tion and religion is presented in Table 1. 18 19 Source: https://www.industrydocuments.ucsf.edu/docs/njyc0227 TABLE 1. DESCRIPTION OF POPULATION SAMPLE, LEBANON TABLE 2. LOCATION OF EXAMINATIONS, LEBANON Armed Forces Civilians Military Civilians Nonrefugee Refugee Nonre fugee Refugee Number 1,938 1, 871 1, 286 Tripoli Tripoli Nahr el Bared Percent Distribution Cedars of Lebanon Tukrit Nabatieh Age (years) Saida Jebrail Bourj Chemali 0-4 0.0 6.8 10.7 Marjayoun Nabatieh Gisr el Pasha 5-9 0.0 24.7 42.5 Tyre Marjayoun Dbayeh 10-14 0.0 28.9 27.1 Sarba Aley Baalbek 15-24 65.2 11.8 7.8 Beirut Baaklin Ein el Helweh 25-44 33.8 14.4 10.0 Fayadie Kabieh 45+ 1.0 13.4 1.9 Hammana Hermel Ablah Rachaya Religion Ryak Tamnine Christian 56.3 29.9 23.5 Habbouch Druse 7.5 15.7 0.1 Serine Shia 25.0 34.3 5.2 Beirut Sunni 16.2 18.4 71.2 Kalmoun Sex Beit Edine Male 100.0 44.4 51.2 Female, nonpregnant, nonlactating 0.0 52.5 40.4 Pregnant 0.0 0.8 6.1 II. Dietary Lactating 0.0 2.3 2.3 A. Armed Forces Location of Examination North Lebanon 28.0 22.7 30.2 1. Procedure Mt. Lebanon 8.0 17.1 12.4 Beirut 33.4 9.5 11.2 A substantial segment of the Armed Forces was given clinical and laboratory South Lebanon 20.2 24.2 32.1 examinations and this population was also examined from the standpoint of dietary intake. Beka'a Valley 10.4 26.6 14.2 The dietary team consisted of two American and two Lebanese nutritionists. The latter Geography of Origin served in the civilian aspects of the survey only. One of the American nutritionists con- Coastal 22.2 74.4 fined his activities to the military surveys. In these studies four 2-day surveys of the Mountain --- 51.9 11.5 recipe type were made with food composite samples collected for each period. The military Valley --- 26.0 14.1 messes surveyed were selected from Army units stationed at each of four permanent posts. These units had a total strength of 626 men, so the data represent approximately 3,600 meals. Field operations reached to all perimeters and sectors of Lebanon. Populations were sampled in 34 individual locations (Table 2). 2. Methods a. Food issues. The food procurement officer of each post provided the team with the menu and food issue sheets for selected 10-day periods. These issues are clearly shown on the 10-day menus so that foods planned and issued could be ascertained. The planned menu was adhered to rather closely in all cases. b. Recipe method. The average quantities of each food item ingested dur- ing the survey periods were calculated from head count data and from food weight and waste figures collected in the kitchens during 48-hour periods. The prepared weight and the weight of the food eaten permitted the calculation of the amount of each individual food item consumed by the average soldier. The U.S. Department of Agriculture food tables (7) were used for computing the nutrient content of most of the food items. The FAO Food Com- position Tables (8) were used for certain foods, and for a few foods peculiar to the area the food tables (9, 10) prepared in Lebanon were used. (See also Appendix I-A.) 20 21 Source: ttps://www.industrydocuments.ucsf.edu/docs/njyc0227

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yljd0227_p17, yljd0227_p18, yljd0227_p19, yljd0227_p20, yljd0227_p21, yljd0227_p22

109170

5 YEAR GRAPH OF ADMISSIONS SELF-CARE SERVICE 2500 2508 2400 2300 2373 2200 2100 2112 2000 1900 1800 1700 1600 1500 1551 1400 1300 1200 1100 1121 1971 1972 1973 1056 1974 1975 *1976 *1976 figure is analyzation based on five months Source: https:llwww.industrydocuments.ucsf.edu/docs/yljd0227 I.G PERCENTAGE GRAPH OF PATIENT DAYS BY YEAR ALL SERVICES 33.00% 32.05% GEN SUBG. 32,95% 32.86% 32.68% 32.57% 32.00% 31.59% 31.00% 30.00% 29.00% 28.59% 28.00% 27.00% 26.66% MEDICINE 26.91% 26.93% 26.00% 25.31% 25.00% 25.06% 10.00% 9.82% PSYCHIATRY10.148 9.55% 9.50% 9.52% 9.22% 9.11% 9.00% 8.50% . 8.00% 7.50% 7.00% 6.74% 6.79% 6.89% 6.64% 6.58% 6.50% 6.49% 6.59% 6.15% GYN 6.38% 5.79% 6.00% 5.84% EYE 5.89% 5.67% 5.68% NEUROLOGY 5. 55% 5.39% 5.50% 5.2118 5.35% 5.14% 5.15% SELF 5.00% 50% ENT 5.08% 5.13% CARE4.74% 4.86% 4.66% 4.80% 4.84% 4.50% 4.00% 3.84% 4.02% 3.96% QB 3.50% 3.47% 3.00% .10% 2.50% 2.00% 2 10% 1.67% 1971 1972 1973 1974 1975 * 1976 *1976 Percentage based on analyzation of first five months. Source: https:/lwww.industrydocuments.ucsf.edu/docs/ylido227 MONTH GRAPH OF PATIENT DAYS FOR 1973 THROUGH 1976 ALL SERVICES 33509 33000 32993 32815 32657 32618 32663 32535 32500 32369 32480 32290 32037 32121 32000 31977 31762 89058 31559 31678 316) 31641 31500 31647 31463 3121,2 33234 31092 31000 3104/2 30829 31027 0773 30751 30688 30500 30596 30451 30000 18867 2992 29781 97 02 29500 29343 29205 29356 29000 28642 28500 28152 28000 Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sep. Oct. Nov. Dec. *1976 totals for Jan. thru May only Source: https://www.industrydocuments.ucsf.edu/docs/ylido227 5 YEAR GRAPH OF TOTAL PATIENT DAYS ALL SERVICES 385000 *384780 380000 378067 375000 370000 370742 371023 365000 360000 355000 353725 350000 345584 345000 340000 1971 1972 1973 1974 1975 *1976 *1976 figure is an analyzation based on 5 month figure of 32064. Source: https://www.industrydocuments.ucsf.edu/docs/yijd0227 110000 110004 5 YEAR GRAPH OF PATIENT DAYS 100000 MEDICINE SERVICE 99933 99000 98000 97000 96000 95201 95687 95000 94000 93000 92918 92000 92138 1971 1972 1973 1974 1975 *1976 *1976 figure is analyzation based on 5 months Source: ittps://www.industrydocuments.ucsf.edu/docs/yijd0227 5 YEAR GRAPH OF PATIENT DAYS GENERAL SURGERY SERVICE (Includes Neuro Surgery) NOTE: NEURO-SURGERY PATIENT DAYS 1975-11, - 964 135000 1976-12,012 (Annualized 5 months) 133224 130000 125328 125000 124249 122173 120000 115000 113353 110000 109170 105000 100000 1971 1972 1973 1974 1975 *1976 *1976 figure is analyzation based on 5 months Source: https:llwww.industrydocuments.ucst.edu/docsyljd022

What is the highest value plotted on the graph?

yljd0227

yljd0227_p17, yljd0227_p18, yljd0227_p19, yljd0227_p20, yljd0227_p21, yljd0227_p22

133224

5 YEAR GRAPH OF ADMISSIONS SELF-CARE SERVICE 2500 2508 2400 2300 2373 2200 2100 2112 2000 1900 1800 1700 1600 1500 1551 1400 1300 1200 1100 1121 1971 1972 1973 1056 1974 1975 *1976 *1976 figure is analyzation based on five months Source: https:llwww.industrydocuments.ucsf.edu/docs/yljd0227 I.G PERCENTAGE GRAPH OF PATIENT DAYS BY YEAR ALL SERVICES 33.00% 32.05% GEN SUBG. 32,95% 32.86% 32.68% 32.57% 32.00% 31.59% 31.00% 30.00% 29.00% 28.59% 28.00% 27.00% 26.66% MEDICINE 26.91% 26.93% 26.00% 25.31% 25.00% 25.06% 10.00% 9.82% PSYCHIATRY10.148 9.55% 9.50% 9.52% 9.22% 9.11% 9.00% 8.50% . 8.00% 7.50% 7.00% 6.74% 6.79% 6.89% 6.64% 6.58% 6.50% 6.49% 6.59% 6.15% GYN 6.38% 5.79% 6.00% 5.84% EYE 5.89% 5.67% 5.68% NEUROLOGY 5. 55% 5.39% 5.50% 5.2118 5.35% 5.14% 5.15% SELF 5.00% 50% ENT 5.08% 5.13% CARE4.74% 4.86% 4.66% 4.80% 4.84% 4.50% 4.00% 3.84% 4.02% 3.96% QB 3.50% 3.47% 3.00% .10% 2.50% 2.00% 2 10% 1.67% 1971 1972 1973 1974 1975 * 1976 *1976 Percentage based on analyzation of first five months. Source: https:/lwww.industrydocuments.ucsf.edu/docs/ylido227 MONTH GRAPH OF PATIENT DAYS FOR 1973 THROUGH 1976 ALL SERVICES 33509 33000 32993 32815 32657 32618 32663 32535 32500 32369 32480 32290 32037 32121 32000 31977 31762 89058 31559 31678 316) 31641 31500 31647 31463 3121,2 33234 31092 31000 3104/2 30829 31027 0773 30751 30688 30500 30596 30451 30000 18867 2992 29781 97 02 29500 29343 29205 29356 29000 28642 28500 28152 28000 Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sep. Oct. Nov. Dec. *1976 totals for Jan. thru May only Source: https://www.industrydocuments.ucsf.edu/docs/ylido227 5 YEAR GRAPH OF TOTAL PATIENT DAYS ALL SERVICES 385000 *384780 380000 378067 375000 370000 370742 371023 365000 360000 355000 353725 350000 345584 345000 340000 1971 1972 1973 1974 1975 *1976 *1976 figure is an analyzation based on 5 month figure of 32064. Source: https://www.industrydocuments.ucsf.edu/docs/yijd0227 110000 110004 5 YEAR GRAPH OF PATIENT DAYS 100000 MEDICINE SERVICE 99933 99000 98000 97000 96000 95201 95687 95000 94000 93000 92918 92000 92138 1971 1972 1973 1974 1975 *1976 *1976 figure is analyzation based on 5 months Source: ittps://www.industrydocuments.ucsf.edu/docs/yijd0227 5 YEAR GRAPH OF PATIENT DAYS GENERAL SURGERY SERVICE (Includes Neuro Surgery) NOTE: NEURO-SURGERY PATIENT DAYS 1975-11, - 964 135000 1976-12,012 (Annualized 5 months) 133224 130000 125328 125000 124249 122173 120000 115000 113353 110000 109170 105000 100000 1971 1972 1973 1974 1975 *1976 *1976 figure is analyzation based on 5 months Source: https:llwww.industrydocuments.ucst.edu/docsyljd022

What is the chart number?

tkyg0227

tkyg0227_p12, tkyg0227_p13, tkyg0227_p14, tkyg0227_p15

17

CHART 21. - PER CAPITA CONSUMPTION OF GRAIN PRODUCTS AND POTATOES (WHITE AND SWEET) - FROM 1879 * (Calories per day) 1,800 1,800 1,600 1,600 1,400 I,400 Grain products 1,200 1,200 1,000 1,000 800 800 600 600 400 400 Total potatoes 200 200 Sweet potatoes White potatoes o 1.1 o 1875 1885 1895 1905 1915 1925 1935 1945 1955 * Data from Part E, Tables VI-A, VIII, IX. Source: https://www.industrydocuments.ucsf.edu/docs/tkyg227 CHART 16. - PER CAPITA CONSUMPTION OF GRAIN PRODUCTS AND SUGAR, FROM 1879* (Calories per day) 1,800 1,800 1,600 1,600 1,400 1,400 Grain products 1,200 1,200 1,000 1,000 800 800 600 600 Sugar 400 400 200 200 o o -8758851895905915925935 1945 1955 * Data from Part E, Tables VI-A, VIII, VIII-A, IX. Source: https://www.industrydocuments.ucsf.edu/docs/tkyg0227 CHART 17. - PER CAPITA CONSUMPTION OF GRAIN PRODUCTS AND VISIBLE FATS, FROM 1879* (Calories per day) 1,800 1,800 1,600 1,600 1,400 I,400 Grain products 1,200 1,200 1,000 1,000 800 800 600 600 Total visible fats 400 Vegetable shortening 400 Lard 200 200 Margarine Butter o o 1875 1885 1895 1905 1915 1925 1935 1945 1955 "Data from Part E, Tables VI-A, VIII, IX. Source: https://www.industrydocuments.ucsf.edu/docs/tkyg0227 CHART 18. - PER CAPITA CONSUMPTION OF GRAIN PRODUCTS AND "MEATS," * FROM 1879 (Calories per day) 1,800 1,800 1,600 1,600 1,400 1,400 Grain products 1,200 1,200 1,000 1,000 800 800 Total "meats" 600 Other "meats" 600 400 400 Pork 200 200 Beef, veal, mutton, lamb o o 1875 1885 1895 1905 1915 1925 1935 1945 1955 * Data from Part E, Tables VI-A, VIII, IX. Source: https://www.industrydocuments.ucsf.edu/docs/tkyg0227

What is the title of the table?

lfdh0227

lfdh0227_p0, lfdh0227_p1, lfdh0227_p2, lfdh0227_p3, lfdh0227_p4, lfdh0227_p5, lfdh0227_p6, lfdh0227_p7, lfdh0227_p8, lfdh0227_p9, lfdh0227_p10

Data on anemia as affected by the milk supplement, Data on Anemia as Affected by the Milk Supplement

of shank File OIR VIIN, seelin SUMMARY REPORT Title: Absorption of Vitamin A from a Fortified Skim Milk Product Principal Investigator: Dr. Nelson Chaves, Director Institute of Nutrition Federal University of Pernambuco Recife, Pe., Brazil Report Prepared By: Dr. George E. Bunce Department of Biochemistry and Nutrition Virginia Polytechnic Institute Blacksburg, Virginia Consultant to OIR/NIH - 2 - Purpose of the Study: A nutrition survey of Northeast Brazil conducted by a joint Brazilian-U.S. team in March-April of 1963 established protein and vitamin A as the nutrients in least supply in this region. These results strengthened the conclusions of previous surveys of more limited scope. The survey report included a number of recommendations, one of which was that the skim milk powders to be distributed in Northeast Brazil should be fortified with 5000 IU of vitamin A per 100 g of powder. It was also suggested that an excellent opportunity existed for the critical evaluation of the effectiveness of this supplement in humans. These data were necessary since such information was not present in the scientific literature in the expert opinion of the U.S. co-directors of the team, Dr. Robert Shank of Washington University, St. Louis, Missouri, and Dr. R. W. Engel, Virginia Polytechnic Institute, Blacksburg, Virginia. Consequently, funds were made available by USAID/Brazil to support research proposals on this problem by Brazilian investigators. This report summarizes the information gathered by Dr. Nelson Chaves' group during the period September 1965 - September 1966. Source: https://www.industrydocuments.ucsf.edu/docs/lfdh227 - 3 - Experimental Design: At the initiation of the project in September 1965, a total of 222 children ranging in ages from 4 to 10 years and equally distributed by age and sex, were chosen for the study. These children were all from families in a specific district of the village of Ribeirão, a small town in the sugar cane growing region of Pernambuco about 50 kilometers from Recife. In an effort to achieve continuity, a socio-economic class above the lowest level of unemployed was chosen. It was felt that this group would be representative of the typical workers and their families in Northeast Brazil but would also be stable and thus available. Each child was given a physical examination in September 1965 and at two month intervals thereafter. A blood sample was collected at each examination and sent to the laboratory for determination of vitamin A, carotene, hemoglobin, serum, total protein and electrophoresis. Three 24-hour recall questionnaire surveys were done on the families in September- November, 1965, December-January 1965-66, and in August-September, 1966. A distribution of skim milk unfortified with vitamin A was made for five days per week from September through December 1965 (blood sampling periods 1 and 2). After collection of the third blood specimen, one-half of the children remaining in the study were given the skim milk product fortified with vitamin A and D, while the remainder were maintained on the unfortified supplement. This schedule was followed through three more blood collection periods (4, 5, and 6) until termination of the study in September 1966. The milk supplement consisted of 200 ml containing 30 g of dried skim milk (11 grams of protein). The fortified product Source: https:/lwww.industrydocuments.ucsf.edu/docs/lfdho227 - 4 - delivered 1500 IU daily of vitamin A and 150 IU of vitamin D. Only 136 of the original 222 children completed the entire study. Results: Below are tables showing mean values and percent distribution per vitamin A, carotene and serum protein over the six two month periods for groups receiving both enriched and non-enriched milk. Mean Serum Carotene Concentrations Period Fortified Milk Non-fortified Milk g% No. Subjects g% No. Subjects I Sept.-Oct. 1965 51 (89) 55 (81) II Nov.-Dec 1965 41 (77) 43* (79) III Jan.-Feb. 1966 48 (72) 46 (70) IV March-April 1966 52 (73) 48 (73) V May-June 1966 43 (66) 46 (70) VI July-Aug. 1966 39 (65) 40* (70) * Sig. different from group 1. P < 0.01. Source: https:/lwww.industrydocuments.ucsf.edu/docs/lfdh0227 - 5 - Mean Serum Vitamin A Concentration Period Fortified Milk Non-fortified Milk g% No. Subjects g% No. Subjects Approx. I' Sept.-Oct. 1965 33 (88) 32 (81) II Nov.-Dec. 1965 28 (77) 27** (79) III Jan.-Feb. 1966 27 : (72) 30 (77) IV March-April 1966 23* (74) 27 *** (73) V May-June 1966 29 (66) 30 (70) VI July-Aug. 1966 33 (65) 39 (71) * I vs. IV Highly sig. difference at PL 0.001. ** I vs. II Significant difference at P 0.02. *** I VS. IV Significant difference at PL 0.01. Distribution in Carotene Values Carotene Hg% Period No. < 20g% 20-39%ug% 40-59g) 50-85ug% > 85ug% No. % No. % No. % No. % No. % I 89 (6) 7 (23) 26 (29) 32 (18) 20 (13) 15 II 77 (7) 9 (30) 39 (21) 27 (15) 20 (4) 5 III 72 (8) 11 (16) 22 (29) 41 (11) 15 (8) 11 IV 73 (4) 5 (21) 29 (27) 37 (15) 21 (6) 8 V 66 (8) 12 (22) 33 (31) 47 (4) 6 (1) 2 VI 65 (10) 15 (23) 35 (22) 34 (7) 11 (3) 5 I 81 (3) 4 (22) 27 (25) 31 (24) 29 (7) 9 II 79 (8) 10 (26) 33 (26) 33 (16) 20 (3) 4 III 77 (6) 8 (22) 29 (30) 39 (11) 14 (8) 10 IV 73 (8) 11 (16) 22 (31) 43 (12) 16 (6) 8 V 70 (4) 6 (24) 34 (34) 49 (6) 8 (2) 3 VI 70 (8) 11 (27) 39 (34) 34 (9) 13 (2) 3 Source:https://www.industrydocuments.ucst.edu/docs/lfdh0227 - 6 - Percent Distribution of Serum Vitamin A Values Non-fortified Milk Period I II III IV V VI No. % No. % No. % No. % No. % No. % Vitamin A conc.g% <10 (0) 0 (1) 1 (1) 1 (1) 1 (0) 0 (0) 0 10-19 (3) 4 (16) 20 (11) 14 (14) 19 (7) 10 (1) 1 20-49 (66) 81 (53) 67 (57) 74 (55) 76 (60) 86 (54) 76 > 50 (12) 15 (9) 12 (8) 11 (3) 4 (3) 4 (16) 23 Fortified Milk 10 (2) 2 (1) 1 (2) 3 (0) 0 (0) 0 (0) 0 10-19 (16) 19 (15) 20 (13) 18 (20) 27 (6) 9 (2) 3 20-49 (60) 68 (54) 70 (53) 74 (52) 70 (55) 83 (54) 83 > 50 (10) 11 (7) 9 (4) 5 (2) 3 (5) 8 (9) 14 Mean Serum Protein Values Fortified Milk No. of Period Total Prot. Alb. al Glob. a2 Glob. BGlob. YGlob. Subjects I 6.7 3.7 0.3 0.7 0.6 1.4 80 II 6.9 3.5 0.3 0.8 0.7 1.6 165 III 6.5 3.2 0.3 0.8 0.7 1.6 61 IV 6.8 3.3 0..3 0.8 0.7 1.8 60 V 6.9 3.4 0.3 0.8 0.8 1.7 55 VI 7.0 3.4 0.4 0.8 0.7 1.8 47 Non-fortified Milk I 6.6 3.73 0.3 0.7 0.6 1.4 81 II 6.9 3.5 0.3 0.8 0.7 1.6 65 III 6.5 3.2 0.3 0.8 0.7 1.6 61 IV 6.7 3.3 0.3 0.8 0.7 1.6 61 V 7.1 3.5 0.3 0.8 0.7 1.7 56 VI 7.0 3.4 0.4 0.8 0.7 1.7 56 Source: https://www.industrydocuments.ucsf.edu/docs/lfdho227 -7- The validity of serum determinations is a crucial point in any study such as this. Quality control by use of a pooled serum is difficult for vitamin A because of a tendency towards false elevations upon frozen storage or loss with storage at temperatures less than freezing. Consequently, as a means of assuring accuracy, random specimens from Ribeirão were sent to the IMIP hospital to be analyzed in its lab for vitamin A. The results, which showed an excellent agreement, are presented below. 188 Vit. A 48% Vit. A Sample Inst. Nutr. IMIP Sample Inst. Nutr. IMIP 71-2 23 17 57-1 12 7 71-3 11 17 63-2 43 38 66-1 22 24 81-1 28 23 75-4 68 59 113-1 20 21 74-4 24 24 51-3 16 17 72-5 35 48 71-3 29 22 57-2 33 36 19-2 24 21 2-4 21 21 31-1 14 15 30-1 17 15 35-4 12 16 19-2 23 23 3-1 19 13 Dietary Survey: The dietary survey data provide support of the studies conducted in the 1963 ICNND survey. (Table page 8). Source: https:llwww.industrydocuments.ucsf.edu/docs/ltdh0227 - 8 - Adequacy of Ribeirão Diets % Consumed of Recommended Intake 100% Nutrient Sept-Nov 65 Dec 65-Jan 66 Aug-Sept 1966 Value 104 families 82 families 69 families Calories 50 53 54 Total protein 74 70 68 Calcium 56 62 64 Iron 105 98 98 Vitamin A 22 40 38 Thiamine 64 64 64 Riboflavin 30 34 34 Niacin 56 56 54 Vitamin C 70 116 116 As in 1963, vitamin A protein, and riboflavin were found to be the most limiting nutrients. Protein intake does not appear to be markedly low when viewed as total intake. Of this total, however, only 16-20 grams was of animal origin and likely to contain a fully satisfactory amino acid pattern. Also, these data were collected on a per capita basis and it is recognized that children, particularly pre-school age children, will not receive a full share. The average vitamin A intake of approximately 1200 IU showed considerable seasonal fluctuation ranging from 700-2000 IU. Not all of the vitamin A intake could be measured, in that children undoubtedly consumed carotene rich fruits away from home. On the other hand, it is obvious that the supply of this vitamin in general barely meets marginal requirements for infants in the most vulnerable group of 6 months to 4 years of age. Source: https://lwww.industrydocuments.ucst.edu/docs/lfdh0227 - 9 - It is clear from these tables that serum vitamin A values show a seasonal fluctuation with the minimum occurring in March, April and May; the time of the original ICNND dietary survey. As has been often observed, there is not a good correlation between serum total carotenoids and serum vitamin A. It is noteworthy that the consumption of vitamin A fortified milk at this level of enrichment and consumption did not prevent a drop in serum vitamin A from the peak of 33 g% to a low of 23 g%. These data do not indicate whether this failure is due to poor absorption or to some other factor. Similarly, serum total protein and albumin were maintained at a level somewhat below the desirable despite the added increment of protein throughout the year. These results cast doubt on the value of such supplements on the overall nutriture of children in a marginal but not severe deficiency state. On the other hand, intake of the milk supplement was irregular. Many children failed to come to the milk distribution center out of simple forgetfulness or disinterest. Others were intentionally kept at home by their mothers during episodes of diarrhea (a frequent problem) in accordance with local customs which advise against milk consumption in this condition. On the average, attendance on a given day during the last six months of the study was about 50%. Fortunately, this problem was anticipated and data were maintained on the actual daily intake of each child for the entire year. These figures are now being tabulated and evaluated by Dr. Chaves' group in order to compare plasma vitamin A levels on the basis of actual consumption. Source: https://www.industrydocuments.ucsf.edu/docs/lfdh227 - 10 - Blood collected from the children was also studied for indications of anemia. Data from microscopic examination as well as determinations of hemoglobin and hematocrit were evaluated as to type of anemia. The results are presented in the table on Page 11. These data have not yet been subjected to statistical analysis but it appears that a substantial number of subjects with normocytic hypochromic anemia were brought to a normal state during the period of protein supplement. These findings are indeed provocative since many persons have suggested that protein insufficiency is a significant cause of anemia in under-developed regions but there are few data in human populations which support this contention. These results certainly deserve further study. Source: https:/llwww.industrydocuments.ucsf.edu/docs/lfdh0227 Data on Anemia as Affected by the Milk Supplement Without Vitamin A Classification 1st Period 2nd Period 3rd Period 4th Period 5th Period 6th Period No. % No. % No. % No. % No. % No. % Normal 20 39 30 59 27 54 26 67 26 49 35 63 Normocytic Anemia 3 6 6 12 8 16 3 8 3 6 2 4 Normochromic Normocytic Anemia 26 51 12 23 15 30 8 20 22 41 16 29 Hypochromic Macrocytic Anemia 0 0 3 6 0 0 0 0 0 0 0 0 Normochromic Microcytic Anemia 2 4 0 0 0 0 2 5 2 4 2 4 Hypochromic Total No. of Cases 51 51 50 39 53 55 With Vitamin A Normal 11 22 24 48 25 47 20 56 30 64 34 61 Normocyt. Normochr. 5 10 12 24 11 21 5 14 4 9 7 12 Normcyt. Hypochrom. 28 56 13 26 17 32 11 30 10 21 13 23 Macrocyt. Normochrom. 0 0 0 0 0 0 0 0 0 0 0 0 Microcyt. Hypochrom. 6 12 1 2 0 0 0 0 3 6 2 4 Total No. 50 50 53 36 47 ; 56 Source: https://www.industrydocuments.ucsf.edu/docs/lfdh227

Mention the heading of the plot?

lglg0227

lglg0227_p34, lglg0227_p35, lglg0227_p36, lglg0227_p37, lglg0227_p38, lglg0227_p39, lglg0227_p40, lglg0227_p41

Freshmen Examination May 1963 Fifteen Subjects, Freshmen Examination May 1963, FRESHMEN EXAMINATION MAY 1963, FRESHMEN EXAMINATION MAY 1963 FIFTEEN SUBJECTS

SLEEP REVERSAL I, JANUARY 1963 FIVE SUBJECTS 120 100 80 60 140 120 100 80 I 2 3 4 5 6 7 8 9 I 2 3 4 5 I II III BASELINE REVERSAL Source: https://www.industrydocuments.ucsf.edu/docs/Iglg0227 SLEEP REVERSAL II, MARCH 1963 FIVE SUBJECTS 70 69 68 86 84 82 80 78 76 74 72 70 68 66 1.2 1.1 1.0 0.9 0.8 0.7 0.6 1.90 1,80 . . 1.70 . T T T 1 T I 2 3 4 5 6 7 8 9 I 2 3 4 5. - - BASELINE I II III REVERSAL Source: https://www.industrydocuments.ucst.edu/docs//glg0227 SLEEP REVERSAL II, MARCH 1963 FIVE SUBJECTS 6.0 DAYTIME 5.0 NIGHT TIME 4.0 14 for 13 12 700 600 21 20 19 18 3.0 2.0 1.0 o -1.0 I 2 3 4 5 6 7 8 9 I 2 3 4 5 - - BASELINE I II III REVERSAL Source: https://www.industrydocuments.ucsf.edu/docs//glg0227 NITROGEN BALANCE POTASSIUM SODIUM g/24 hr (m Eq 24hr) (m Eq. 24 hr) O - 2 3 1 2 3 1 4 5 6 1 R 2 3 D 1 E 5 6 MAY 1861 FRESHMEN EXAMINATION MAY 1963 FIFTEEN SUBJECTS 73 72 . - 71 78 76 74 72 70 1.3 1.2 1.1 1.0 has 0.9 1.80 1.70 1.60 I T T I 2 3 4 5 6 7 I 2 3 4 5 6 7 * one value missing BL R E weighted mean used DAYS Source: https://www.industrydocuments.ucsf.edu/docs/lglg0227 FRESHMEN EXAMINATION MAY 1963 FIFTEEN SUBJECTS 6.0 DAY 5.0 NIGHT 4.0 10.0 . 9.0 8.0 14.0 13.0 . 12.0 700 600 500 .- 20 19 18 I 2 3 4 5 6 I 2 3 4 5 6 BL R E DAYS Source: https://www.industrydocuments.ucst.edu/docs/glg0227 SLEEP REVERSAL II, MARCH 1963 FIVE SUBJECTS 100 80 60 E 40 120 100 E 80 I 2 3 4 5 6 7 8 9 I 2 3 4 5 I II III Source: https://www.industrydocuments.ucsf.edu/docs/Iglg0227 FRESHMEN EXAMINATION MAY 1963 EIGHT SUBJECTS ONLY 70 69 68 80 79 78 - 77 - 76 - M 75 74 73 72 1.2 1.1 1.0 0.9 0.8 1.80 1.70 1.60 1.50 T' I 2 3 4 5 6 7 I 2 3 4 5 6 7 8 9 * one value missing BL R E PE weighted mean used DAYS Source: https://www.industrydocuments.ucsf.edu/docs/Iglg0227

What is mentioned on the x-axis of the plot?

lglg0227

lglg0227_p34, lglg0227_p35, lglg0227_p36, lglg0227_p37, lglg0227_p38, lglg0227_p39, lglg0227_p40, lglg0227_p41

Days, DAYS

SLEEP REVERSAL I, JANUARY 1963 FIVE SUBJECTS 120 100 80 60 140 120 100 80 I 2 3 4 5 6 7 8 9 I 2 3 4 5 I II III BASELINE REVERSAL Source: https://www.industrydocuments.ucsf.edu/docs/Iglg0227 SLEEP REVERSAL II, MARCH 1963 FIVE SUBJECTS 70 69 68 86 84 82 80 78 76 74 72 70 68 66 1.2 1.1 1.0 0.9 0.8 0.7 0.6 1.90 1,80 . . 1.70 . T T T 1 T I 2 3 4 5 6 7 8 9 I 2 3 4 5. - - BASELINE I II III REVERSAL Source: https://www.industrydocuments.ucst.edu/docs//glg0227 SLEEP REVERSAL II, MARCH 1963 FIVE SUBJECTS 6.0 DAYTIME 5.0 NIGHT TIME 4.0 14 for 13 12 700 600 21 20 19 18 3.0 2.0 1.0 o -1.0 I 2 3 4 5 6 7 8 9 I 2 3 4 5 - - BASELINE I II III REVERSAL Source: https://www.industrydocuments.ucsf.edu/docs//glg0227 NITROGEN BALANCE POTASSIUM SODIUM g/24 hr (m Eq 24hr) (m Eq. 24 hr) O - 2 3 1 2 3 1 4 5 6 1 R 2 3 D 1 E 5 6 MAY 1861 FRESHMEN EXAMINATION MAY 1963 FIFTEEN SUBJECTS 73 72 . - 71 78 76 74 72 70 1.3 1.2 1.1 1.0 has 0.9 1.80 1.70 1.60 I T T I 2 3 4 5 6 7 I 2 3 4 5 6 7 * one value missing BL R E weighted mean used DAYS Source: https://www.industrydocuments.ucsf.edu/docs/lglg0227 FRESHMEN EXAMINATION MAY 1963 FIFTEEN SUBJECTS 6.0 DAY 5.0 NIGHT 4.0 10.0 . 9.0 8.0 14.0 13.0 . 12.0 700 600 500 .- 20 19 18 I 2 3 4 5 6 I 2 3 4 5 6 BL R E DAYS Source: https://www.industrydocuments.ucst.edu/docs/glg0227 SLEEP REVERSAL II, MARCH 1963 FIVE SUBJECTS 100 80 60 E 40 120 100 E 80 I 2 3 4 5 6 7 8 9 I 2 3 4 5 I II III Source: https://www.industrydocuments.ucsf.edu/docs/Iglg0227 FRESHMEN EXAMINATION MAY 1963 EIGHT SUBJECTS ONLY 70 69 68 80 79 78 - 77 - 76 - M 75 74 73 72 1.2 1.1 1.0 0.9 0.8 1.80 1.70 1.60 1.50 T' I 2 3 4 5 6 7 I 2 3 4 5 6 7 8 9 * one value missing BL R E PE weighted mean used DAYS Source: https://www.industrydocuments.ucsf.edu/docs/Iglg0227

How many "subjects"are mentioned in the heading?

lglg0227

lglg0227_p34, lglg0227_p35, lglg0227_p36, lglg0227_p37, lglg0227_p38, lglg0227_p39, lglg0227_p40, lglg0227_p41

Fifteen, Fifteen Subjects, FIFTEEN

SLEEP REVERSAL I, JANUARY 1963 FIVE SUBJECTS 120 100 80 60 140 120 100 80 I 2 3 4 5 6 7 8 9 I 2 3 4 5 I II III BASELINE REVERSAL Source: https://www.industrydocuments.ucsf.edu/docs/Iglg0227 SLEEP REVERSAL II, MARCH 1963 FIVE SUBJECTS 70 69 68 86 84 82 80 78 76 74 72 70 68 66 1.2 1.1 1.0 0.9 0.8 0.7 0.6 1.90 1,80 . . 1.70 . T T T 1 T I 2 3 4 5 6 7 8 9 I 2 3 4 5. - - BASELINE I II III REVERSAL Source: https://www.industrydocuments.ucst.edu/docs//glg0227 SLEEP REVERSAL II, MARCH 1963 FIVE SUBJECTS 6.0 DAYTIME 5.0 NIGHT TIME 4.0 14 for 13 12 700 600 21 20 19 18 3.0 2.0 1.0 o -1.0 I 2 3 4 5 6 7 8 9 I 2 3 4 5 - - BASELINE I II III REVERSAL Source: https://www.industrydocuments.ucsf.edu/docs//glg0227 NITROGEN BALANCE POTASSIUM SODIUM g/24 hr (m Eq 24hr) (m Eq. 24 hr) O - 2 3 1 2 3 1 4 5 6 1 R 2 3 D 1 E 5 6 MAY 1861 FRESHMEN EXAMINATION MAY 1963 FIFTEEN SUBJECTS 73 72 . - 71 78 76 74 72 70 1.3 1.2 1.1 1.0 has 0.9 1.80 1.70 1.60 I T T I 2 3 4 5 6 7 I 2 3 4 5 6 7 * one value missing BL R E weighted mean used DAYS Source: https://www.industrydocuments.ucsf.edu/docs/lglg0227 FRESHMEN EXAMINATION MAY 1963 FIFTEEN SUBJECTS 6.0 DAY 5.0 NIGHT 4.0 10.0 . 9.0 8.0 14.0 13.0 . 12.0 700 600 500 .- 20 19 18 I 2 3 4 5 6 I 2 3 4 5 6 BL R E DAYS Source: https://www.industrydocuments.ucst.edu/docs/glg0227 SLEEP REVERSAL II, MARCH 1963 FIVE SUBJECTS 100 80 60 E 40 120 100 E 80 I 2 3 4 5 6 7 8 9 I 2 3 4 5 I II III Source: https://www.industrydocuments.ucsf.edu/docs/Iglg0227 FRESHMEN EXAMINATION MAY 1963 EIGHT SUBJECTS ONLY 70 69 68 80 79 78 - 77 - 76 - M 75 74 73 72 1.2 1.1 1.0 0.9 0.8 1.80 1.70 1.60 1.50 T' I 2 3 4 5 6 7 I 2 3 4 5 6 7 8 9 * one value missing BL R E PE weighted mean used DAYS Source: https://www.industrydocuments.ucsf.edu/docs/Iglg0227

Whose picture is shown?

kzhd0227

kzhd0227_p5, kzhd0227_p6, kzhd0227_p7, kzhd0227_p8, kzhd0227_p9, kzhd0227_p10, kzhd0227_p11, kzhd0227_p12

PATIENT E.W., Patient E.W

-5- - - The Experimental Effect of Diet on Co-existing Diseases DRUG-TREATED DISEASES RETURN TO NORMAL CLASSIFICATION AT START OF STUDY WITHOUT DRUGS No. of Subjects No. of Subjects % Angina 3 3 100 Hypertension 8 6 75 Diabetes: ADA Diet-controlled 10 9 90 Oral drugs 1 1 100 Insulin, 80 units 1 2 50 30 units ) 0 Gout 2 2 100 Arthritis 2 2 100 Congestive heart failure 3 2 66 Elevated blood lipids 2 2 100 TABLE 2 Comparison of Artery Stenosis before (1/20/75) and after Study (6/26/75) in L.S. ANGIOGRAPHICALLY AUTOPSY CONFIRMED LOCATION OF STENOSIS DETERMINED % STENOSIS % STENOSIS (1/20/75) (6/26/75) Right common iliac in proximal position 70% 40% Left common iliac at bifurcation 99% 40% Right common femoral at its origin 100% 50% TABLE 3 Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 () Figure 2. Initial baseline angiogram of L.S. This film demonstrates complete occlusion of the right common femoral artery at its origin (arrows). Figure 3. Macroscopic cross section of right common femoral artery stained for elastic tissue. Specimen was taken from a portion of artery which was shown angiographically (see Fig. 2) to be totally occluded. Note that the two branch arteries seen in the left lower quadrant of this cross-section correspond to branch arteries (at the occlusion site) in angio above. Source: ttps://www.industrydocuments.ucsf.edu/docs/kzhd0227 7 Figure 4a. Initial baseline angiogram (January '75) of K.B. Figure 4b. Final angiogram (June '75) of K.B. The numbers in the above line drawings correspond to numbers noted in the text. (1) The origin of the left external iliac indicates an 80% concentric stenosis in the January angiogram becoming a 50% concentric stenosis in the June angiogram; (2) The middle 1/3 of the external iliac is markedly irregular with an 80% concentric stenests in the January angiogram becoming a smooth eccentric 30% stenosis in the June angiogram: (3) The distal 1/3 of the external iliac shows moderately severe irregularities with is eccentric stenosis in the January angiogram becoming a smooth widely patent arterial segment in the June angiogram. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 8 Figure 5a. Dark field high power view of normal non-aggregating red blood cells 6 hours after a low fat meal. 3 Figure 5b. Example of red blood cell aggregation and rouleaux formation 6 hours after a high fat meal. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 () DISCUSSION The reasons for the dramatic results in reversing claudication and other atherosclerotic symptoms on a diet and exercise regimen are elucidated by tissue anoxia studies. Tissue anoxia is present III those consuming the conventional Western diet with its high 40% of total calories in fat Anoxia due to tliet in young undamaged arteries may not cause obvious symptomis, but when there IS some artery stenosis due to plaque formation (and this includes almost everyone over 25 years of age in this country) this results in increases in blood pressure and, in individuals with advanced atherosclerosis, angina and claudication. One of the first to study tissue anoxia produced by a high fat, meal was Swank11 who ted hamsters cream meals and then. through their transparent check pouches. observed the effects on the erythrocytes. As the chylomicrons started to pour in from the cream meal. the erythrocy les began adhering to each other. In 3 to 6 hours after the feeding. the aggregations. now in rouleaux and irregular formations, completely blocked many capillaries. Because of the aggregations. the full surface of the erythrocyte was not available for oxygen transfer and during this condition, the oxygen-carrying capacity of the erythrocyte was directly affected, decreasing the plasma OXY gen level to 68% of starting value. It took 72 hours before the oxygen level reached 95% of the original value. Kuo's study13 with angina patients showed that a cream meal could induce an angina attack by lowering the oxygen-carrying capacity of the blood. After an overnight fast, each subject drank heavy cream, then rested quietly while half-hour blood samples were drawn. In 5 hours. the chylomicron influx had peaked and caused the transparent fasting blood to become 600% more turbid on a plasma lactescence scale. Fourteen angina attacks occurred, simultaneously with ischemic ECGs and abnormal ballistocardiograms. The amazing similarity in the reaction of many individuals to fat was shown in almost identical lactescence curves for 13 of the 14 angina patients. These same patients on another morning drank a fat-free drink with identical calories and bulk. After 5 hours, no increased blood turbidity, no angina and no abnormal ECG tracings were noted. Platelet aggregation occurs under the same conditions that produce erythrocyte aggregation. A U.S. Department of Agriculture study, directed by Iacano13 placed normals on a 25% fat diet instead of their usual 40-45% fat intake. Not only did blood pressure and cholesterol levels drop. but there was a 50% drop in platelet aggregation. When the 40-45% fat diet was resumed. platelet aggregation returned to previous levels. As the aggregations broke up reducing the vessel blockage, the increased vessel area now availat le for blood flow permitted the same volume of blood to flow with lowered pressure. Thus. with reduced fat intake, Iacano achieved universal blood pressure drops even in normal subjects. This effect was confirmed in our study with hypertensives. Relief of coronary and calf angina both occur with increased blood flow and oxygen-carry ing capacity of the blood. In our study, these effects occurred within a few weeks after the diet-exercise regimen was begun and coincided with the rapid drop in blood lipids-an average cholesterol drop of 30% in a few weeks and one triglyceride drop from 360 mg.% to 85 mg.%. Thompson's¹ 6 report of 2 women in their 20's with elevated lipids demonstrates the relationship of blood lipid level to angina by utilizing a more drastic method than dietary reform for alleviating the symptoms. To lower the blood lipids-their cholesterol levels averaged 600 mg." they underwent plasma exchange with cholesterol-free plasma protein fraction. Approximately 50 gms. of cholesterol in the form of low density lipoproteins were removed during the 6 month treatment which involved about 8 exchanges of about 3000 ml. of blood. No other therapy changes were made. Blood lipid levels fell to half their previous value and both women lost their angina. While disappearance of angina can be rapidly achieved within weeks, as was demonstrated in our study, or months, as was accomplished in Thompson's, the ultimate cure depending upon artery plaque reversal, is another matter. In primate studies Armstrong¹ and Wissler¹ have reversed artery stenosis on a low-fat diet. Although our results need confirmation by others, we believe they are the first evidence demonstrating reversal of human atherosclerosis by diet. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 --10- AGE AS A LIMITING FACTOR IN REHABILITATION Our study has indicated the promising rehabilitative potential of a diet and activity regimen tor case of a woman, E.W. She began, almost (1 years ago at age 81. using the same regimen described claudication patients. That age need not be a limiting factor in rehabilitation is demonstrated by the in this paper for the experimental group. Her symptoms. like those of the study patients. included other atherosclerotic manifestations besides claudication. Only 5'3'` tall and weighing 100 lbs 101 the last 40 years, she had developed cardiovascular disease and was treated for angina at age (7 Al age 75 she was hospitalized with a severe heart attack. and at age 81 had claudication, congestive heart failure, hypertension, angina and arthritis. When she began the regimen at age 81. her claudication limited her walking to 100 feet and even then the calf pain was SO disabling she often had to be carried home; and the circulation to her hands was SO impaired she wore gloves in the summertime. Last year, at age 85. and after 4 years on the regimen. she was televised at the Senior Oly 111 Irvine, California, where she won 2 gold medals in the half-mile and mile running events. This youl at age 861/2, she repeated the runs and now has 4 gold medals. Each morning she runs a mile and rides her stationary bicycle 10-15 miles; twice weekly she works out in a gym: and she follows her diet assiduously. Her diastolic pressure is 70 mm. CONCLUSION: This combined low-fat diet and exercise approach has proven to be significantly (PK 0011 more effective in the treatment of severe peripheral atherosclerotic vascular disease than current therapies. It is hoped that the results reported by the use of this regimen will encourage other investigutoto to repeat our studies. Figure 6. Patient E.W. running the mile event at the Senior Olympics in Irvine, California. E.W. was 85 years old when this run was made. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 -- -11- REFERENCES 1. KANNEL, W.B., SKINNER, J.J., JR., SCHWARTZ, M.J., SHURTLEFF. D. Intermittent claudication inci- dence in the Framingham Study. Circulation 41:875, 1970. 2. DELIUS, W., ERIKSON, U. Correlation between angiographic and hemodynamic findings in occlusions of arteries of the extremities. Vascular Surg. 3:201, 1969. 3. SINGER, A., ROB, C. The fate of the claudicator, Brit. Med. J. 2:633, 1960. 4. LIVINGSTONE, P.D., JONES, C. Treatment of intermittent claudication with vitamin E. Lancet 11:602, 1958. 5. HOUSLEY, E., McFADYEN, I.J., Vitamin E. in intermittent claudication. Lancet 1:458, 1974. 6. HAEGER, K. Vitamin E in intermittent claudication. Lancet I:1352, 1974, and Vasa 2:280-287, 1973. 7. LARSEN, O.A., LASSEN, N.A. Effect of daily muscular exercise in patients with intermittent claudication. Scandinavian J. Clin. Lab. Invest. Suppl. 93:168, 1967 and Lancet II:1093, 1966. 8. JOHANSSON, B.W., SIEVERS, J. "Spontaneous course" of intermittent claudication. Scandinavian J. Clin. Lab. Invest. Suppl. 93:156, 1967. 9. ZETTERQUIST, S. The effect of active training on the nutritive blood flow in exercising ischemic legs. Scandinavian J. Clin. Lab. Invest. 25:101, 1970. 10. EBEL, A., KUO, J.C. Tolerance for treadmill walking as an index of intermittent claudication. Arch. Phys. Med. and Rehab. 611-614, Nov., 1967. 11. SWANK, R.A. A biochemical basis of multiple sclerosis. C.C. Thomas Publ., Springfield, III., 1961. 12. KUO, P.T. and JOYNER, C.R., JR. Angina pectoris induced by fat ingestion in patients with coronary heart disease. JAMA 158:1008-13, 1955. 13. IACANO, J.M. Lipid research lab. U.S. Department of Agriculture, Beltsville, Md., 20705. Private communication. 14. ARMSTRONG, M.L. and MEGAN, M.B., ET AL. Plasma and carcass cholesterol in rhesus monkeys after low and intermediate levels of dietary cholesterol Circulation Supp. II, 43: II-III, 1971. Also: ARMSTRONG, M.L. ET AL. Xanthomotosis in rhesus monkeys fed a hypercholesterolemic diet. Arch. of Path. 84:227-37, 1967. 15. WISSLER, R.W. Development of the atherosclerotic plaque. Hosp. practice 8:61-72, 1973. 16. THOMPSON, G.R., LOWENTHAL, R., MYANT, N.B. Plasma exchange in the management of homozygous familial hypercholesterolemia. Lancet I:1208, 1975. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 12 This study was financed in part by the Kirsten Foundation, Manhasset, N.Y., and the Longevity Research Institute, Santa Barbara, Ca. We would like to thank Wallace E. Carroll, M.D., William C. Gnekow, M.D., and Samuel H. Brooks, Ph.D., for their professional assistance in the pathological, radiological, and statistical evaluations made in this study. In addition we would like to give credit to Janie Sternal for her photographic assistance. Finally, we would like to acknowledge the support of the following corporations for their help in providing part of the foods used in the experimental diet: Archon Pure Products Corp.; Celestial Seasonings; Charles Soderstrom Enterprises; Chiquita Brands, Inc.; Erewhon, Inc.; Fisher Mills, Inc.: Hol-Grain Div. of Golden Grain; Hunt-Wesson Foods; and Pure Gold, Inc. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227

what is the number of examined for Kedah?

snyc0227

snyc0227_p257, snyc0227_p258, snyc0227_p259, snyc0227_p260, snyc0227_p261, snyc0227_p262, snyc0227_p263, snyc0227_p264, snyc0227_p265, snyc0227_p266, snyc0227_p267, snyc0227_p268, snyc0227_p269, snyc0227_p270, snyc0227_p271, snyc0227_p272, snyc0227_p273, snyc0227_p274, snyc0227_p275, snyc0227_p276, snyc0227_p277

150

APPENDIX TABLE VI-1. AGE DISTRIBUTION AND TIME IN SERVICE BY LOCATION, MALAYA MILITARY Location Total Number examined 201 150 101 50 85 271 200 210 1,268 Percent Distribution Age (years) 18 -- -- -- -- -- -- 12.5 -- 2.0 19 -- -- -- -- -- 0.7 30.0 0.5 5.0 20-24 29.4 29.3 38.6 4.0 41.2 39.1 57.5 50.5 39.9 25-29 40.8 37.3 35.6 38.0 35.3 32.5 -- 35.2 30.4 30-34 22.9 24.7 17.8 40.0 18.8 22.5 -- 10.0 17.3 35-39 6.5 8.7 7.9 18.0 3.5 4.8 -- 3.8 5.3 40+ 0.5 -- -- -- 1.2 0.4 -- -- 0.2 Time in Service 0-30 days -- -- 8.9 -- -- 1.8 1.0 2.4 1.6 1-4 months -- -- 5.0 4.0 -- 1.1 99.0 12.8 18.5 5-11 months -- 0.7 3.0 4.0 1.2 4.0 6.2 2.4 1-2 years 3.0 4.7 11.9 -- 5.9 2.6 -- 13.8 5.2 3-4 years 15.4 13.3 3.0 -- 16.5 18.1 -- 17.1 12.1 5-7 years 24.4 23.3 20.8 12.0 29.4 23.2 -- 9.5 17.3 8-12 years 38.3 36.0 40.6 46.0 38.8 33.2 - 23.8 29.0 13-20 years 18.4 22.0 6.9 34.0 8.2 15.9 -- 14.3 13.7 21+30 years 0.5 -- -- -- -- -- -- -- 0.1 Source: https://www.industrydocuments.ucsf.edu/docsisnyc0227 APPENDIX TABLE VI-2. LOCATION AND AREA OF ORIGIN OF MALAYAN MILITARY MEN RECEIVING ABBREVIATED EXAMINATIONS Location Total Number examined 201 150 101 50 85 271 200 210 1,268 Area of Origin Percent Distribution Selangor 3.0 2.0 6.9 18.0 11.8 3.7 22.0 7.1 8.2 Kelantan 8.4 9.3 9.9 4.0 7.0 4.8 0.5 3.3 5.5 Pahang 7.5 2.0 4.0 - -- 5.2 1.0 2.8 3.5 Johore 11.4 10.7 5.9 6.0 14.1 19.6 18.0 11.4 13.6 Malacca 37.8 31.3 30.7 40.0 23.5 31.4 39.0 28.6 32.9 Perak 18.4 25.3 24.8 22.0 25.9 18.8 16.5 30.5 22.2 Kedah 5.5 8.7 8.9 8.0 12.9 5.9 1.0 6.2 6.2 Trengganu 1.5 3.3 1.0 -- 1.2 4.4 0.5 -- 1.8 Penang 2.0 6.0 6.9 2.0 1.2 3.3 1.5 3.3 3.2 All others 4.5 1.3 1.0 -- 2.4 3.0 -- 6.7 2.8 Source: https://www.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-3. PERCENT "STANDARD WEIGHT" BY AGE, ABBREVIATED EXAMINATIONS, MALAYA MILITARY Age (years) 18 19 20-24 25-29 30-34 35-39 40+ Total Number examined 25 63 505 385 219 67 3 1,267 Mean 89.0 89.5 90.5 94.5 96.0 98.0 104.0 93.0 S.E.1/ 1.28 0.81 0.34 0.55 0.80 1.71 9.30 0.29 Percent Distribution 70-79 8.0 1.6 4.0 3.6 1.8 6.0 -- 3.6 80-89 40.0 60.3 47.9 38.2 36.1 23.9 -- 42.0 90-99 48.0 33.3 37.4 30.1 33.3 34.3 66.7 34.4 100-109 4.0 3.2 9.1 19.5 15.5 11.9 -- 13.1 110+ -- 1.6 1.6 8.6 13.2 23.9 33.3 6.9 1/ S.E. = standard error. Source: https:/lwww.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-4. SKINFOLD THICKNESS BY AGE, MALAYA MILITARY 20- 25- 30- 35- Age (years) 18 19 24 29 34 39 Total Arm (mm) Number 6 22 97 82 46 13 266 Mean 6.5 8.0 7.6 8.5 7.9 9.5 8.0 Scapula (mm) Number 6 22 97 82 46 13 266 Mean 10.7 9.6 11.2 12.5 14.3 15.4 12.2 263 Source: https:/lwww.industrydocuments.ucsf.edu/docs/snyc0227 TABLE VI-5. ABBREVIATED CLINICAL FINDINGS BY AGE, MALAYA MILITARY 20- 25- 30- 35- Age (years) 18 19 24 29 34 39 40+ Total Number examined 25 63 506 385 219 67 3 1,268 Percent Prevalence Skin, Face and Neck Nasolabial seborrhea 12.0 7.9 14.2 10.1 11.4 6.0 -- 11.7 Lips Angular lesions 4.0 1.6 1.0 0.5 -- -- -- 0.7 Angular scars 8.0 - 1.6 1.8 1.8 7.5 -- 2.0 Cheilosis -- -- 0.2 -- -- -- -- 0.1 Gums Swollen red papillae - Localized 4.0 4.8 4.5 5.2 6.4 10.4 -- 5.4 Diffuse 28.0 14.3 8.1 7.3 12.8 10.4 33.3 9.5 Tongue Filiform papillary atrophy - Slight -- 1.6 1.6 0.2 1.4 1.5 -- 1.1 Moderate -- -- -- -- 0.4 -- -- 0.1 Glossitis -- -- -- -- 0.9 -- -- 0.2 Magenta colored -- -- 0.2 0.5 0.9 1.5 -- 0.5 Glands Thyroid enlarged - Grade I -- 1.6 0.2 0.5 1.4 1.5 -- 0.6 Skin, General Follicular hyperkeratosis - Anywhere -- -- 2.2 0.2 -- -- -- 0.9 Arms -- -- 0.6 -- -- -- -- 0.2 Back -- -- 1.8 0.2 -- -- -- 0.8 Thighs -- -- 0.2 -- -- -- -- 0.1 Lower Extremities Loss of ankle jerk - Unilateral 4.0 -- 0.4 0.8 0.4 1.5 -- 0.6 Bilateral -- 4.8 1.8 1.6 1.4 3.0 -- 1.8 Calf tenderness -- -- -- 0.2 0.4 -- -- 0.2 Source: https://www.industrydocuments.ucst.edu/docsisnyc0227 APPENDIX TABLE VI-6. CLINICAL FINDINGS BY LOCATION, DETAILED EXAMINATIONS, MALAY MILITARY Location Total Number examined 40 30 25 10 18 54 50 42 269 Eyes Thickened opaque bulbar conjunctiva 17.5 4.0 28.0 19.0 11.2 Pingueculae 5.0 100.0 16.0 30.0 66.7 63.0 2.0 32.0 Bitot's spots 5.6 0.4 Conjunctival injection 7.5 5.6 3.7 4.0 3.0 Skin, Face and Neck Nasolabial seborrhea 25.0 3.3 28.0 30.0 22.2 13.0 20.0 38.1 21.6 Other seborrhea 12.0 11.9 4.1 Lips Angular lesions 3.7 0.7 Angular scars 56.7 3.7 2.0 7.4 Gums Marginal redness 57.5 60.0 47.6 27.1 Marginal swelling 65.0 68.0 47.6 29.7 Atrophy of papillae 50.0 4.0 1.8 2.0 9.5 10.0 Recession 52.5 6.7 16.0 20.0 7.4 22.0 26.2 20.4 Swollen red papillae Localized 15.0 23.3 5.6 20.4 8.0 4.8 11.5 Diffuse 36.7 4.0 22.2 5.6 20.0 4.8 11.5 Tongue Filiform papillary atrophy Slight 1.8 4.0 1.1 Fungiform papillary atrophy Slight 4.0 0.4 Moderate 2.0 0.4 Papillary hypertrophy Slight 2.0 0.4 Geographic 3.3 5.6 6.0 2.4 2.2 Furrows 15.0 6.7 4.0 10.0 5.6 10.0 5.9 Fissures 2.5 8.0 1.1 Serrations 2.4 0.4 Red tip and/or lateral margins 3.3 16.7 2.0 1.8 Glands Thyroid enlarged 2.0 0.4 Skin, General Follicular hyperkeratosis Anywhere 12.5 5.6 3.7 2.0 16.7 5.9 Arms, slight 2.4 0.4 265 Source: https:/lwww.industrydocuments.ucsf.edu/docsisnyc0227 APPENDIX TABLE VI-6 (Continued) CLINICAL FINDINGS BY LOCATION, DETAILED EXAMINATIONS, MALAY MILITARY Location Total Number examined 40 30 25 10 18 54 50 42 269 Skin, General (Continued) Back, slight 5.0 5.6 1.8 2.0 9.5 3.3 Moderate/severe 1.8 4.8 1.1 Chest, slight 10.0 2.0 7.1 3.0 Moderate/severe 2.4 0.4 Perifolliculosis 4.0 0.7 Dry skin 28.0 5.2 Acneform eruption 5.6 1.8 6.0 1.8 Lower Extremities Loss of ankle jerk Bilateral 3.3 4.0 11.1 3.7 2.2 Loss of knee jerk Bilateral 2.5 11.1 1.1 266 Source: https:/lwww.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-7. DETAILED CLINICAL FINDINGS BY TIME IN SERVICE, MALAYA MILITARY TTS 27-8 Time in Service Total Number examined 11 57 5 10 30 33 89 34 269 Eyes Percent Prevalence Thickened opaque bulbar conjunctivae -- 24.6 -- -- 10.0 3.0 11.2 5.9 11.2 Pingueculae 27.3 1.8 -- 10.0 26.7 42.4 47.2 50.0 32.0 Bitot's spots -- -- -- -- 3.3 -- -- -- 0.4 Conjunctival injection -- 3.5 -- -- -- -- 4.5 5.9 3.0 Skin, Face and Neck Nasolabial seborrhea 18.2 22.8 20.0 50.0 23.3 18.2 21.3 14.7 21.6 Other seborrhea 18.2 10.5 -- 10.0 6.7 -- -- 4.1 Lips Angular lesions 9.1 -- -- 10.0 -- -- -- -- 0.7 Angular scars 9.1 1.8 -- -- 6.7 6.1 6.7 23.5 7.4 Gums Marginal redness 9.1 54.4 -- 30.0 23.3 18.2 20.2 20.6 27.1 Marginal swelling 9.1 61.4 -- 50.0 26.7 21.2 20.2 17.6 29.7 Atrophy of papillae 1.8 -- 13.3 15.2 13.5 14.7 10.0 -- -- Recession 18.2 19.3 20.0 10.0 13.3 21.2 27.0 14.7 20.4 Swollen red papillae - Localized -- 7.0 20.0 -- 10.0 18.2 12.4 17.6 11.5 Diffuse 18.2 17.5 -- -- 10.0 9.1 7.9 17.6 11.5 Tongue Filiform papillary atrophy 3.5 -- -- -- -- 1.1 -- 1.1 Slight -- Fungiform papillary atrophy -- -- -- -- -- -- 2.9 0.4 Slight -- Moderate 1.8 -- -- -- -- -- -- 0.4 -- 1.8 -- -- -- -- -- -- 0.4 Papillary hypertrophy - Slight -- -- 5.3 -- -- Geographic 6.7 -- -- 2.9 2.2 Furrows -- 8.8 20.0 10.0 3.3 9.1 3.4 5.9 5.9 -- -- -- -- 3.0 1.1 2.9 1.1 Fissures -- -- -- -- -- 1.1 -- 0.4 Serrations -- Red tip and/or lateral margins -- 1.8 3.3 9.1 -- -- 1.8 -- -- Source: https://www.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-7 (Continued) DETAILED CLINICAL FINDINGS BY TIME IN SERVICE, MALAYA MILITARY Time in Service Total Number examined 11 57 5 10 30 33 89 34 269 Glands Percent Prevalence Thyroid enlarged -- 1.8 -- -- - -- 0.4 Skin, General Follicular hyperkeratosis Anywhere 18.2 3.5 -- 10.0 6.7 3.0 7.9 2.9 5.9 Arms -- -- -- - -- 3.0 -- 0.4 Back - Slight 9.1 1.8 -- -- 3.3 3.0 4.5 2.9 3.3 Moderate/Severe -- 1.8 -- 10.0 -- -- 1.1 -- 1.1 Chest - Slight 9.1 1.8 -- -- 6.7 -- 4.5 -- 3.0 Moderate/Severe -- -- -- 10.0 -- -- -- - 0.4 Perifolliculosis -- 3.5 -- -- -- ... -- -- 0.7 Dry skin - 24.6 -- -- -- -- -- -- 5.2 Acneform eruption - 5.3 -- -- 3.3 -- - 2.9 1.8 Lower Extremities Loss of ankle jerk - Bilateral 9.1 -- -- -- 6.7 3.0 1.1 2.9 2.2 Loss of knee jerk - Bilateral -- -- -- -- 3.3 -- 2.2 -- 1.1 Source: https://lwww.industrydocuments.ucsf.edu/docsisnyc0227 APPENDIX TABLE VI-8. BIOCHEMICAL FINDINGS BY LOCATION, MALAYA MILITARY BLOOD Location Total Total Plasma Protein gm/100 ml No. 13 10 25 5 6 19 25 20 123 Mean 7.4 7.2 7.3 7.6 7.3 7.2 6.8 7.7 7.3 S.E.1/ 0.14 0.10 0.09 0.36 0.17 0.07 0.09 0.11 0.05 Percent Distribution 6.00-6.39 -- -- -- -- -- 16.0 -- 3.2 6.40-6.99 15.4 10.0 36.0 20.0 16.7 31.6 56.0 10.0 29.3 >7.00 84.6 90.0 64.0 80.0 83.3 68.4 28.0 90.0 67.5 Albumin/Globulir Ratio No. 13 10 25 5 6 19 25 20 123 Mean 1.22 1.41 1.53 1.42 1.23 1.37 1.26 0.80 1.27 S.E. 0.05 0.10 0.06 0.10 0.07 0.05 0.05 0.04 0.03 Percent Distribution 0.5-0.9 -- -- -- - -- 5.3 -- 80.0 13.3 1.0-1.4 92.3 60.0 36.0 40.0 83.3 68.4 80.0 20.0 57.7 1.5-1.9 7.7 30.0 56.0 60.0 16.7 26.3 20.0 -- 26.0 >2.0 -- 10.0 8.0 -- -- -- -- 2.4 Albumin gm/100 ml No. 13 10 25 5 6 19 25 20 123 Mean 4.0 4.2 4.4 4.5 4.0 4.1 3.8 3.4 4.0 S.E. 0.07 0.08 0.05 0.15 0.08 0.07 0.04 0.11 0.04 Percent Distribution <2.5 -- -- -- -- -- -- 5.0 0.8 2.5-3.4 -- -- -- 5.3 4.0 40.0 8.1 3.5-5.0 100.0 100.0 100.0 100.0 100.0 94.7 96.0 55.0 91.0 >5.0 -- -- -- -- -- -- -- Globulin gm/100 ml No. 13 10 25 5 6 19 25 20 123 Mean 3.4 3.0 3.0 3.2 3.3 3.1 3.1 4.2 3.3 S.E. 0.12 0.14 0.10 0.26 0.17 0.08 0.09 0.13 0.06 Percent Distribution 1.0-1.9 -- -- -- -- -- -- -- -- -- 2.0-2.9 15.4 30.0 56.0 60.0 33.3 42.1 40.0 -- 34.1 3.0-3.5 53.8 50.0 32.0 20.0 50.0 52.6 40.0 10.0 37.4 >3.5 30.8 20.0 12.0 20.0 16.7 5.3 20.0 90.0 28.4 1/ S.E. = standard error. 269 Source: https://www.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-8 (Continued) BIOCHEMICAL FINDINGS BY LOCATION, MALAYA MILITARY BLOOD Location Total Hemoglobin gm/100 ml No. 13 10 25 5 6 21 25 20 125 Mean 16.5 17.6 15.0 16.1 16.1 14.7 15.4 16.3 15.7 S.E. 0.37 0.58 0.37 0.49 0.56 0.32 0.21 0.22 0.14 Percent Distribution <12.0 - -- 4.0 -- -- -- -- -- 0.8 12.0-13.9 7.7 -- 12.0 -- -- 28.6 8.0 -- 9.6 14.0-14.9 -- -- 24.0 20.0 33.3 23.8 20.0 10.0 16.8 >15.0 92.3 100.0 60.0 80.0 66.7 47.6 72.0 90.0 72.8 Hematocrit percent No. 13 10 23 4 6 21 25 20 122 Mean 45.8 48.7 43.5 45.8 44.7 43.1 44.5 46.2 44.9 S.E. 0.84 0.76 0.55 1.11 1.31 0.70 0.57 0.46 0.29 Percent Distribution <36 -- -- -- -- -- -- -- -- 36-41 7.7 -- 26.1 -- 16.7 33.3 20.0 -- 16.4 42-44 23.1 -- 39.1 25.0 50.0 28.6 24.0 15.0 25.4 >45 69.2 100.0 34.8 75.0 33.3 38.1 56.0 85.0 58.2 Mean Corpuscular Hemoglobir Concentration percent No. 13 10 23 4 6 21 25 20 122 Mean 36.0 36.4 34.4 35.2 36.1 34.2 34.7 35.2 35.0 S.E. 0.59 1.16 0.88 0.48 1.33 0.46 0.45 0.38 0.25 Percent Distribution <28.0 -- - 4.3 -- -- -- 4.0 -- 1.6 28.0-29.9 -- -- - -- -- -- -- -- 30.0-31.9 -- -- 8.7 -- 14.3 -- 5.0 4.9 >32.0 100.0 100.0 87.0 100.0 100.0 85.7 96.0 95.0 93.4 Vitamin C mg/100 ml No. 13 10 24 -- 6 19 25 20 117 Mean 0.51 0.36 0.73 -- 0.36 0.44 0.23 0.28 0.42 S.E. 0.07 0.05 0.05 -- 0.06 0.04 0.01 0.02 0.02 Percent Distribution <0.10 -- -- -- -- -- -- -- -- -- 0.10-0.19 15.4 10.0 -- -- 16.7 -- 32.0 15.0 12.8 0.20-0.39 23.1 70.0 4.2 -- 33.3 47.4 68.0 80.0 47.0 >0.40 61.5 20.0 95.8 -- 50.0 52.6 -- 5.0 40.2 270 Source: https://www.industrydocuments.ucsf.edu/docssnyc0227 APPENDIX TABLE VI-8 (Continued) BIOCHEMICAL FINDINGS BY LOCATION, MALAYA MILITARY BLOOD Location Total Vitamin A g/100 ml No. 13 10 24 4 6 18 25 20 120 Mean 48.2 50.5 37.4 59.0 47.7 42.2 49.4 44.8 45.3 S.E. 3.8 3.7 3.0 6.4 4.3 2.1 1.9 3.1 1.2 Percent Distribution <10 - -- 4.2 -- -- -- -- - 0.8 10-19 - -- 12.5 -- -- -- -- -- 2.5 20-49 53.8 50.0 66.7 25.0 50.0 83.3 35.0 70.0 58.3 >50 46.2 50.0 16.7 75.0 50.0 16.7 64.0 30.0 38.3 Carotene g/100 ml No. 13 10 24 5 6 18 25 20 121 Mean 102 95 106 95 118 89 88 95 97 S.E. 8 10 10 15 12 4 3 5 3 Percent Distribution <20 -- -- -- -- - -- -- -- 20-39 -- - -- -- -- -- -- 40-99 46.2 60.0 58.3 40.0 33.3 72.2 76.0 65.0 62.0 >100 53.8 40.0 41.7 60.0 66.7 27.8 24.0 35.0 38.0 Cholesterol mg/100 ml No. 13 10 25 5 6 19 25 18 121 Mean 230 207 179 139 178 148 159 207 180 S.E. 8.8 12.4 6.8 7.5 17.6 6.6 5.3 12.6 4.0 Percent Distribution 70-99 -- -- -- -- -- 5.3 -- -- 0.8 100-149 - -- 20.0 80.0 33.3 42.1 32.0 11.1 24.0 150-199 15.4 50.0 44.0 20.0 33.3 47.4 64.0 27.8 42.1 >200 84.6 50.0 36.0 -- 33.3 5.3 4.0 61.1 33.0 B-Lipoprotein mm No. 13 -- 25 5 6 19 25 20 113 Mean 3.5 -- 3.2 3.3 2.5 3.0 2.5 3.0 3.0 S.E. 0.12 -- 0.13 0.16 0.30 0.14 0.08 0.14 0.06 Lipid Phosphorus mg/100 ml No. 13 10 25 5 6 19 25 18 121 Mean 11.1 11.4 10.6 10.7 10.6 10.1 9.4 9.5 10.2 S.E. 0.54 0.64 0.30 0.20 0.84 0.42 0.27 0.75 0.19 271 Source: https://www.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-8 (Continued) BIOCHEMICAL FINDINGS BY LOCATION, MALAYA MILITARY URINE Location Total Thiamine g/gm creatinine No. 12 10 20 3 5 19 22 15 106 Median 34 27 42 147 41 48 110 44 52 Percent Distribution <27 41.7 50.0 25.0 -- 20.0 21.0 -- 26.7 22.6 27=65 41.7 30.0 65.0 33.3 80.0 52.6 -- 53.3 41.5 66-129 8.3 10.0 -- - 15.8 72.7 13.3 21.7 >130 8.3 10.0 10.0 66.7 -- 10.5 27.3 6.7 14.2 Riboflavin g/gm creatinine No. 12 10 23 4 5 19 25 20 118 Median 26 20 23 12 38 21 94 36 32 Percent Distribution <27 58.3 70.0 56.5 75.0 40.0 57.9 4.0 30.0 42.4 27-79 33.3 30.0 34.8 -- 40.0 42.1 40.0 65.0 40.7 80-269 seca -- 4.3 -- 20.0 56.0 -- 13.6 >270 8.3 -- 4.3 25.0 -- -- - 5.0 3.4 N° -Methylnicotinamide mg/gm creatinine No. 11 10 6 4 5 19 25 15 95 Median 5.6 4.9 3.0 1.7 4. 7 4.0 4.4 4.4 4.2 Percent Distribution <0.5 -- - 16.7 -- -- -- -- -- 1.0 0.5-1.59 -- -- -- 50.0 -- -- 4.0 -- 3.2 1.6-4.29 36.4 40.0 66,7 50.0 40.0 57.9 44.0 46.7 47.4 >4.30 63.6 60.0 16.7 -- 60.0 42.1 52.0 53.3 48.4 272 Source: https://www.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-9. BIOCHEMICAL FINDINGS BY AGE, MALAYA MILITARY Age (years) 18-19 20-24 25-29 30-34 35-39 - Total BLOOD Total Plasma Protein gm/100 ml No. 12 49 36 20 6 123 Mean 6.8 7.2 7.4 7.4 7.5 7.3 S.E.1/ 0.13 0.08 0.08 0.11 0.23 0.05 Percent Distribution 6.00-6.39 16.7 4.1 -- -- -- 3.2 6.40-6.99 41.7 40.8 16.7 20.0 16.7 29.3 >7.00 41.7 55.1 83.3 80.0 83.3 67.5 Albumin/Globulin Ratio No. 12 49 36 20 6 123 Mean 1.22 1.28 1.22 1.37 1.28 1.27 S.E. 0.08 0.04 0.07 0.06 0.07 0.03 Percent Distribution 0.5-0.9 8.3 10.2 25.0 10.0 -- 13.8 1.0-1.4 75.0 63.3 50.0 45.0 66.7 57.7 1.5-1.9 16.7 24.5 19.4 45.0 33.3 26.0 >2.0 -- 2.0 5.6 -- -- 2.4 Albumin gm/100 ml No. 12 49 36 20 6 123 Mean 3.7 4.0 3.9 4.2 4.2 4.0 S.E. 0.05 0.06 0.08 0.08 0.13 0.04 Percent Distribution <2.5 -- 2.0 -- -- -- 0.8 2.5-3.4 8.3 4.1 16.7 5.0 -- 8.1 3.5-5.0 91.7 93.9 83.3 95.0 100.0 91.0 >5.0 -- -- -- -- Globulin gm/100 ml No. 12 49 36 20 6 123 Mean 3.1 3.2 3.4 3.2 3.3 3.3 S.E. 0.14 0.08 0.13 0.12 0.18 0.06 Percent Distribution 1.0-1.9 -- -- -- -- -- -- 2.0-2.9 41.7 32.6 33.3 40.0 16.7 34.1 3.0-3.5 33.3 40.8 33.3 35.0 50.0 37.4 >3.5 25.0 26.5 33.3 25.0 33.3 28.4 1/ S.E. = standard error. - 273 Source. https://www.industrydocuments.ucsf.edu/docsisnyc0227 APPENDIX TABLE VI-9 (Continued) BIOCHEMICAL FINDINGS BY AGE, MALAYA MILITARY Age (years) 18-19 20-24 25-29 30-34 35-39 Total Hemoglobin gm/100 ml No. 12 50 36 21 6 125 Mean 15.3 15.4 16.2 15.8 15.9 15.7 S.E. 0.30 0.22 0.24 0.48 0.76 0.14 Percent Distribution <12.0 -- 2.0 -- -- -- 0.8 12.0-13.9 8.3 8.0 5.6 19.0 16.7 9.6 14.0-14.9 16.7 20.0 11.1 19.0 16.7 16.8 >15.0 75.0 70.0 83.3 61.9 66.7 72.8 Hematocrit percent No. 12 48 36 21 5 122 Mean 44.5 45.0 45.7 43.7 43.6 44.9 S.E. 0.83 0.44 0.50 0.80 1.50 0.29 Percent Distribution <36 -- -- -- -- -- -- 36-41 16.7 16.7 11.1 23.8 20.0 16.4 42-44 33.3 20.8 19.4 38.1 40.0 25.4 >45 50.0 62.5 69.4 38.1 40.0 58.2 Mean Corpuscular Hemoglobin Concentration percent No. 12 48 36 21 5 122 Mean 34.4 34.2 35.5 36.1 35.6 35.0 S.E. 0.59 0.44 0.34 0.77 0.58 0.25 Percent Distribution <28.0 -- 4.2 - - -- 1.6 28.0-29.9 -- -- -- -- -- -- 30.0-31.9 -- 8.3 2.8 4.8 -- 4.9 >32.0 100.0 87.5 97.2 95.2 100.0 93.4 Vitamin C mg/100 ml No. 12 47 34 19 5 117 Mean 0.22 0.44 0.41 0.48 0.62 0.42 S.E. 0.02 0.04 0.04 0.07 0.15 0.02 Percent Distribution <0.10 -- -- -- -- -- -- 0.10-0.19 41.7 6.4 14.7 10.5 -- 12.8 0.20-0.39 58.3 46.8 44.1 47.4 40.0 47.0 >0.40 46.8 41.2 42.1 60.0 40.2 274 Source: https://www.industrydocuments.ucsf.edu/docs/snyco227 APPENDIX TABLE VI-9 (Continued) BIOCHEMICAL FINDINGS BY AGE, MALAYA MILITARY Age (years) 18-19 20-24 25-29 30-34 35-39 Total Vitamin A g/100 ml No. 12 47 35 20 6 120 Mean 49.8 66.6 45.2 42.7 45.5 45.3 S.E. 2.5 1.8 1.9 3.7 9.5 1.2 Percent Distribution <10 -- -- -- -- 16.7 0.8 10-19 -- 2.1 -- 10.0 -- 2.5 20-49 33.3 59.6 71.4 60.0 16.7 58.3 >50 66.7 38.3 29.6 30.0 66.7 38.3 Plasma Carotene g/100 ml No. 12 48 35 20 6 121 Mean 87 98 96 94 127 97 S.E. 4 4 4 6 36 3 Percent Distribution <20 -- -- -- -- -- -- 20-39 -- -- -- -- 40-99 75.0 62.5 57.1 70.0 33.3 62.0 >100 25.0 37.5 42.8 30.0 66.7 38.0 Cholesterol mg/100 ml No. 11 49 35 20 6 121 Mean 156 176 196 175 190 180 S.E. 5.8 5.8 9.1 8.9 15.4 4.0 Percent Distribution 70-99 -- 2.0 -- -- -- 0.8 100-149 36.4 20.4 25.7 25.0 16.7 24.0 150-199 63.6 51.0 20.0 55.0 16.7 42.1 >200 -- 26.5 54.3 20.0 66.7 33.0 B=Lipoprotein¹/ mm No. 12 48 32 16 5 113 Mean 2.6 2.8 3.2 3.2 3.5 3.0 S.E. 0.10 0,08 0.11 0.19 0.22 0.06 Lipid Phosphorus mg/100 ml No. 11 49 35 20 6 121 Mean 10.1 10.1 10.2 10.4 10.9 10.2 S.E. 0.47 0.29 0.41 0.36 0.62 0.19 1/ By precipitin technic. 275 Source: https:/lwww.industrydocuments.ucsf.edu/docsisnyc0227 APPENDIX TABLE VI-9 (Continued) BIOCHEMICAL FINDINGS BY AGE, MALAYA MILITARY Age (years) 18-19 20-24 25-29 30-34 35=39 Total URINE Thiamine g/gm creatinine No. 12 40 30 19 5 106 Median 111 63 32 46 46 52 Percent Distribution <27 -- 15.0 43.3 26.3 -- 22.6 27-65 8.3 37.5 46.7 47.4 100.0 41.5 66-129 58.3 35.0 3.3 5.3 -- 41.5 >130 33.3 12.5 6.7 21.0 -- 14.2 Riboflavin g/gm creatinine No. 12 46 35 20 5 118 Median 77 38 27 34 15 32 Percent Distribution <27 8.3 39.1 48.6 50.0 80.0 42.4 27-79 41.7 37.0 48.6 45.0 -- 40.7 80-269 50.0 19.6 -- 5.0 -- 13.6 >270 -- 4.3 2.8 -- 20.0 3.4 N'-Methylnicotinamide mg/gm creatinine No. 11 37 26 17 4 95 Median 4.8 3.8 4.5 4.9 3.9 4.2 Percent Distribution <0.50 -- -- -- 5.9 -- 1.0 0.50-1.59 -- 5.4 -- 5.9 -- 3.2 1.60-4.29 36.4 56.8 46.2 29.4 75.0 47.4 >4.30 63.6 37.8 53.8 58.8 25.0 48.4 276 Source: https://www.industrydocuments.ucsf.edu/docsisnyc0227 APPENDIX TABLE VI-10. BIOCHEMICAL FINDINGS BY PERCENT OF "STANDARD WEIGHT, " MALAYA MILITARY Percent "Standard Weight" 75-89 90-99 100-109 110+ Total BLOOD Total Plasma Protein gm/100 ml No. 45 44 19 15 123 Mean 7.2 7.1 7.5 7.5 7.3 Percent Distribution 6.00-6.39 4.4 4.5 -- -- 3.2 6.40-6.99 35.6 38.6 15.8 - 29.3 >7.00 60.0 56.8 84.2 100.0 67.5 Albumin/Globulin Ratio No. 45 44 19 15 123 Mean 1.32 1.33 1.16 1.10 1.27 Percent Distribution 0.5=0.9 6.7 4.5 31.6 40.0 13.8 1.0-1.4 64.4 59.1 52.6 40.0 57.7 1.5-1.9 28.9 31.8 10.5 20.0 26.0 >2.0 -- 4.5 5.3 -- 2.4 Albumin gm/100 ml No. 45 44 19 15 123 Mean 4.0 4.0 3.9 3.9 4.0 Percent Distribution <2.5 -- 2.3 - -- 0.8 2.5-3.4 4.4 4.5 15.8 20.0 8.1 3.5-5.0 95.6 93.2 84.2 80.0 91.0 >5.0 -- - -- -- -- Globulin gm/100 ml No. 45 44 19 15 123 Mean 3.2 3.1 3.5 3.6 3.3 Percent Distribution 1.0-1.9 -- -- -- -- -- 2.0-2.9 37.8 43.2 26.3 6.7 34.1 3.0-3.5 40.0 34.1 36.8 40.0 37.4 >3.5 22.2 22.7 36.8 53.3 28.4 Hemoglobin gm/100 ml No. 47 44 19 15 125 Mean 15.2 15.7 16.0 16.6 15.7 Percent Distribution <12.0 -- 2.3 -- -- 0.8 12.0-13.9 17.0 2.3 10.5 6.7 9.6 14.0-14.9 25.5 13.6 10.5 6.7 16.8 >15.0 57.4 81.8 78.9 86.7 72.8 277 Source: hhttps://www.industrydocuments.ucsf.edu/docsisnyc0227 APPENDIX TABLE VI-10 (Continued) BIOCHEMICAL FINDINGS BY PERCENT OF "STANDARD WEIGHT, " MALAYA MILITARY Percent "Standard Weight" 75-89 90-99 100-109 110+ Total BLOOD Hematocrit percent No. 46 42 19 15 122 Mean 43.9 45.2 45.5 45.9 44.9 Percent Distribution <36 - -- - -- - 36-41 28.3 9.5 10.5 6.7 16.4 42-44 28.3 23.8 31.6 13.3 25.4 >45 43.5 66.7 57.9 80.0 58.2 Mean Corpuscular Hemoglobin Concentration, percent No. 46 42 19 15 122 Mean 34.8 34.7 35.2 36.1 35.0 Percent Distribution <28.0 -- 2.4 5.3 - 1.6 28.0-29.9 - -- -- -- -- 30.0-31.9 10.9 2.4 -- -- 4.9 >32.0 89.1 95.2 94.7 100.0 93.4 Vitamin C mg/100 ml No. 41 42 19 15 117 Mean 0.44 0.40 0.47 0.36 0.42 Percent Distribution <0.10 -- -- -- - 0.10-0.19 4.9 16.7 10.5 26.7 12.8 0.20-0.39 48.8 42.8 47.4 53.3 47.0 >0.40 46.3 40.5 42.1 20.0 40.2 Vitamin A g/100 ml No. 45 41 19 15 120 Mean 44.8 45.5 43.0 49.4 45.3 Percent Distribution <10 -- 2.4 -- -- 0.8 10-19 6.7 -- -- -- 2.5 20-49 57.8 53.6 73.7 53.3 58.3 >50 35.6 43.9 26.3 46.7 38.3 Carotene g/100 ml No. 45 42 19 15 121 Mean 95 98 102 94 97 Percent Distribution <20 -- -- -- -- -- 20-39 -- -- -- -- - 40-99 62.2 69.0 47.4 60.0 62.0 >100 37.8 31.0 52.6 40.0 38.0 278 Source: https://www.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-10 (Continued) BIOCHEMICAL FINDINGS BY PERCENT OF 'STANDARD WEIGHT, " MALAYA MILITARY Percent "Standard Weight" 75-89 90-99 100-109 110+ Total BLOOD Cholesterol mg/100 ml No. 45 44 19 13 121 Mean 163 171 203 240 180 Percent Distribution 70-99 2.2 -- -- -- 0.8 100-149 33.3 25.0 15.8 -- 24.0 150-199 46.7 52.3 26.3 15.4 42.1 >200 17.8 22.7 57.9 84.6 33.0 B=Lipoprotein mm No. 43 42 18 10 113 Mean 2.9 2.8 3.2 3.5 3.0 Lipid Phosphorus mg/100 ml No. 45 44 19 13 121 Mean 10.0 9.9 10.6 11.3 10.2 URINE Thiamine g/gm creatinine No. 38 39 16 13 106 Median 70 54 38 39 52 Percent Distribution <27 18.4 17.9 37.5 30.8 22.6 27-65 28.9 46.2 43.8 61.5 41.5 66-129 36.8 15.4 12.5 7.7 21.7 >130 15.8 20.5 6.2 -- 14.2 Riboflavin g/gm creatinine No. 44 40 19 15 118 Median 37 37 20 25 32 Percent Distribution <27 40.9 30.0 57.9 60.0 42.4 27-79 36.4 47.5 36.8 33.3 40.7 80-269 18.2 20.0 -- 6.7 13.6 >270 4.5 2.5 5.3 -- 3.4 N'-Methylnicotinamide mg/gm creatinine No. 35 33 16 11 95 Median 4.1 4.7 4.0 3.9 4.2 Percent Distribution <0.50 -- -- -- 9.1 1.0 0.50-1.59 5.7 3.0 -- -- 3.2 1.60-4.29 48.6 39.4 56.2 54.5 47.4 >4.30 45.7 57.6 43.8 36.4 48.4 279 Source: https:/lwww.industrydocuments.ucst.edu/docsisnyc0227 APPENDIX TABLE VI-11. SUGGESTED GUIDE TO INTERPRETATION OF NUTRIENT INTAKE DATA "Deficient" "Low" "Acceptable' "High" Protein (gm/person/kg) <0.50 0.50-0.99 1.00-1.49 1.50+ Calcium (mg/person/day) <300 300-399 400-799 800+ Iron (mg/person/day) <6.0 6.0-8.9 9.0-11.9 12.0+ Vitamin A (IU/person/day) <2,000 2,000=3,499 3,500-4,999 5,000+ Vitamin C (mg/person/day) <10.0 10.0-29.9 30.0-49.9 50.00 Thiamine (mg/1,000 Calories) <0.20 0.20-0.29 0.30-0.49 0.50+ Riboflavin (mg/person/day) <0.70 0.70-1.19 1.20-1.59 1.60€ Niacin (mg/person/day) <5.0 5.0=9.9 10.0-14.9 15.04 1/ Based primarily on standards for the young adult male; see Manual for Nutrition Surveys, 1st ed., 1957. 280 Source: https://www.industrydocuments.ucsf.edu/docs/snyc0227

What is the page number given at the top of the page?

kzhd0227

kzhd0227_p5, kzhd0227_p6, kzhd0227_p7, kzhd0227_p8, kzhd0227_p9, kzhd0227_p10, kzhd0227_p11, kzhd0227_p12

10, -10-

-5- - - The Experimental Effect of Diet on Co-existing Diseases DRUG-TREATED DISEASES RETURN TO NORMAL CLASSIFICATION AT START OF STUDY WITHOUT DRUGS No. of Subjects No. of Subjects % Angina 3 3 100 Hypertension 8 6 75 Diabetes: ADA Diet-controlled 10 9 90 Oral drugs 1 1 100 Insulin, 80 units 1 2 50 30 units ) 0 Gout 2 2 100 Arthritis 2 2 100 Congestive heart failure 3 2 66 Elevated blood lipids 2 2 100 TABLE 2 Comparison of Artery Stenosis before (1/20/75) and after Study (6/26/75) in L.S. ANGIOGRAPHICALLY AUTOPSY CONFIRMED LOCATION OF STENOSIS DETERMINED % STENOSIS % STENOSIS (1/20/75) (6/26/75) Right common iliac in proximal position 70% 40% Left common iliac at bifurcation 99% 40% Right common femoral at its origin 100% 50% TABLE 3 Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 () Figure 2. Initial baseline angiogram of L.S. This film demonstrates complete occlusion of the right common femoral artery at its origin (arrows). Figure 3. Macroscopic cross section of right common femoral artery stained for elastic tissue. Specimen was taken from a portion of artery which was shown angiographically (see Fig. 2) to be totally occluded. Note that the two branch arteries seen in the left lower quadrant of this cross-section correspond to branch arteries (at the occlusion site) in angio above. Source: ttps://www.industrydocuments.ucsf.edu/docs/kzhd0227 7 Figure 4a. Initial baseline angiogram (January '75) of K.B. Figure 4b. Final angiogram (June '75) of K.B. The numbers in the above line drawings correspond to numbers noted in the text. (1) The origin of the left external iliac indicates an 80% concentric stenosis in the January angiogram becoming a 50% concentric stenosis in the June angiogram; (2) The middle 1/3 of the external iliac is markedly irregular with an 80% concentric stenests in the January angiogram becoming a smooth eccentric 30% stenosis in the June angiogram: (3) The distal 1/3 of the external iliac shows moderately severe irregularities with is eccentric stenosis in the January angiogram becoming a smooth widely patent arterial segment in the June angiogram. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 8 Figure 5a. Dark field high power view of normal non-aggregating red blood cells 6 hours after a low fat meal. 3 Figure 5b. Example of red blood cell aggregation and rouleaux formation 6 hours after a high fat meal. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 () DISCUSSION The reasons for the dramatic results in reversing claudication and other atherosclerotic symptoms on a diet and exercise regimen are elucidated by tissue anoxia studies. Tissue anoxia is present III those consuming the conventional Western diet with its high 40% of total calories in fat Anoxia due to tliet in young undamaged arteries may not cause obvious symptomis, but when there IS some artery stenosis due to plaque formation (and this includes almost everyone over 25 years of age in this country) this results in increases in blood pressure and, in individuals with advanced atherosclerosis, angina and claudication. One of the first to study tissue anoxia produced by a high fat, meal was Swank11 who ted hamsters cream meals and then. through their transparent check pouches. observed the effects on the erythrocytes. As the chylomicrons started to pour in from the cream meal. the erythrocy les began adhering to each other. In 3 to 6 hours after the feeding. the aggregations. now in rouleaux and irregular formations, completely blocked many capillaries. Because of the aggregations. the full surface of the erythrocyte was not available for oxygen transfer and during this condition, the oxygen-carrying capacity of the erythrocyte was directly affected, decreasing the plasma OXY gen level to 68% of starting value. It took 72 hours before the oxygen level reached 95% of the original value. Kuo's study13 with angina patients showed that a cream meal could induce an angina attack by lowering the oxygen-carrying capacity of the blood. After an overnight fast, each subject drank heavy cream, then rested quietly while half-hour blood samples were drawn. In 5 hours. the chylomicron influx had peaked and caused the transparent fasting blood to become 600% more turbid on a plasma lactescence scale. Fourteen angina attacks occurred, simultaneously with ischemic ECGs and abnormal ballistocardiograms. The amazing similarity in the reaction of many individuals to fat was shown in almost identical lactescence curves for 13 of the 14 angina patients. These same patients on another morning drank a fat-free drink with identical calories and bulk. After 5 hours, no increased blood turbidity, no angina and no abnormal ECG tracings were noted. Platelet aggregation occurs under the same conditions that produce erythrocyte aggregation. A U.S. Department of Agriculture study, directed by Iacano13 placed normals on a 25% fat diet instead of their usual 40-45% fat intake. Not only did blood pressure and cholesterol levels drop. but there was a 50% drop in platelet aggregation. When the 40-45% fat diet was resumed. platelet aggregation returned to previous levels. As the aggregations broke up reducing the vessel blockage, the increased vessel area now availat le for blood flow permitted the same volume of blood to flow with lowered pressure. Thus. with reduced fat intake, Iacano achieved universal blood pressure drops even in normal subjects. This effect was confirmed in our study with hypertensives. Relief of coronary and calf angina both occur with increased blood flow and oxygen-carry ing capacity of the blood. In our study, these effects occurred within a few weeks after the diet-exercise regimen was begun and coincided with the rapid drop in blood lipids-an average cholesterol drop of 30% in a few weeks and one triglyceride drop from 360 mg.% to 85 mg.%. Thompson's¹ 6 report of 2 women in their 20's with elevated lipids demonstrates the relationship of blood lipid level to angina by utilizing a more drastic method than dietary reform for alleviating the symptoms. To lower the blood lipids-their cholesterol levels averaged 600 mg." they underwent plasma exchange with cholesterol-free plasma protein fraction. Approximately 50 gms. of cholesterol in the form of low density lipoproteins were removed during the 6 month treatment which involved about 8 exchanges of about 3000 ml. of blood. No other therapy changes were made. Blood lipid levels fell to half their previous value and both women lost their angina. While disappearance of angina can be rapidly achieved within weeks, as was demonstrated in our study, or months, as was accomplished in Thompson's, the ultimate cure depending upon artery plaque reversal, is another matter. In primate studies Armstrong¹ and Wissler¹ have reversed artery stenosis on a low-fat diet. Although our results need confirmation by others, we believe they are the first evidence demonstrating reversal of human atherosclerosis by diet. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 --10- AGE AS A LIMITING FACTOR IN REHABILITATION Our study has indicated the promising rehabilitative potential of a diet and activity regimen tor case of a woman, E.W. She began, almost (1 years ago at age 81. using the same regimen described claudication patients. That age need not be a limiting factor in rehabilitation is demonstrated by the in this paper for the experimental group. Her symptoms. like those of the study patients. included other atherosclerotic manifestations besides claudication. Only 5'3'` tall and weighing 100 lbs 101 the last 40 years, she had developed cardiovascular disease and was treated for angina at age (7 Al age 75 she was hospitalized with a severe heart attack. and at age 81 had claudication, congestive heart failure, hypertension, angina and arthritis. When she began the regimen at age 81. her claudication limited her walking to 100 feet and even then the calf pain was SO disabling she often had to be carried home; and the circulation to her hands was SO impaired she wore gloves in the summertime. Last year, at age 85. and after 4 years on the regimen. she was televised at the Senior Oly 111 Irvine, California, where she won 2 gold medals in the half-mile and mile running events. This youl at age 861/2, she repeated the runs and now has 4 gold medals. Each morning she runs a mile and rides her stationary bicycle 10-15 miles; twice weekly she works out in a gym: and she follows her diet assiduously. Her diastolic pressure is 70 mm. CONCLUSION: This combined low-fat diet and exercise approach has proven to be significantly (PK 0011 more effective in the treatment of severe peripheral atherosclerotic vascular disease than current therapies. It is hoped that the results reported by the use of this regimen will encourage other investigutoto to repeat our studies. Figure 6. Patient E.W. running the mile event at the Senior Olympics in Irvine, California. E.W. was 85 years old when this run was made. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 -- -11- REFERENCES 1. KANNEL, W.B., SKINNER, J.J., JR., SCHWARTZ, M.J., SHURTLEFF. D. Intermittent claudication inci- dence in the Framingham Study. Circulation 41:875, 1970. 2. DELIUS, W., ERIKSON, U. Correlation between angiographic and hemodynamic findings in occlusions of arteries of the extremities. Vascular Surg. 3:201, 1969. 3. SINGER, A., ROB, C. The fate of the claudicator, Brit. Med. J. 2:633, 1960. 4. LIVINGSTONE, P.D., JONES, C. Treatment of intermittent claudication with vitamin E. Lancet 11:602, 1958. 5. HOUSLEY, E., McFADYEN, I.J., Vitamin E. in intermittent claudication. Lancet 1:458, 1974. 6. HAEGER, K. Vitamin E in intermittent claudication. Lancet I:1352, 1974, and Vasa 2:280-287, 1973. 7. LARSEN, O.A., LASSEN, N.A. Effect of daily muscular exercise in patients with intermittent claudication. Scandinavian J. Clin. Lab. Invest. Suppl. 93:168, 1967 and Lancet II:1093, 1966. 8. JOHANSSON, B.W., SIEVERS, J. "Spontaneous course" of intermittent claudication. Scandinavian J. Clin. Lab. Invest. Suppl. 93:156, 1967. 9. ZETTERQUIST, S. The effect of active training on the nutritive blood flow in exercising ischemic legs. Scandinavian J. Clin. Lab. Invest. 25:101, 1970. 10. EBEL, A., KUO, J.C. Tolerance for treadmill walking as an index of intermittent claudication. Arch. Phys. Med. and Rehab. 611-614, Nov., 1967. 11. SWANK, R.A. A biochemical basis of multiple sclerosis. C.C. Thomas Publ., Springfield, III., 1961. 12. KUO, P.T. and JOYNER, C.R., JR. Angina pectoris induced by fat ingestion in patients with coronary heart disease. JAMA 158:1008-13, 1955. 13. IACANO, J.M. Lipid research lab. U.S. Department of Agriculture, Beltsville, Md., 20705. Private communication. 14. ARMSTRONG, M.L. and MEGAN, M.B., ET AL. Plasma and carcass cholesterol in rhesus monkeys after low and intermediate levels of dietary cholesterol Circulation Supp. II, 43: II-III, 1971. Also: ARMSTRONG, M.L. ET AL. Xanthomotosis in rhesus monkeys fed a hypercholesterolemic diet. Arch. of Path. 84:227-37, 1967. 15. WISSLER, R.W. Development of the atherosclerotic plaque. Hosp. practice 8:61-72, 1973. 16. THOMPSON, G.R., LOWENTHAL, R., MYANT, N.B. Plasma exchange in the management of homozygous familial hypercholesterolemia. Lancet I:1208, 1975. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 12 This study was financed in part by the Kirsten Foundation, Manhasset, N.Y., and the Longevity Research Institute, Santa Barbara, Ca. We would like to thank Wallace E. Carroll, M.D., William C. Gnekow, M.D., and Samuel H. Brooks, Ph.D., for their professional assistance in the pathological, radiological, and statistical evaluations made in this study. In addition we would like to give credit to Janie Sternal for her photographic assistance. Finally, we would like to acknowledge the support of the following corporations for their help in providing part of the foods used in the experimental diet: Archon Pure Products Corp.; Celestial Seasonings; Charles Soderstrom Enterprises; Chiquita Brands, Inc.; Erewhon, Inc.; Fisher Mills, Inc.: Hol-Grain Div. of Golden Grain; Hunt-Wesson Foods; and Pure Gold, Inc. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227

what is the total number of examined?

snyc0227

snyc0227_p257, snyc0227_p258, snyc0227_p259, snyc0227_p260, snyc0227_p261, snyc0227_p262, snyc0227_p263, snyc0227_p264, snyc0227_p265, snyc0227_p266, snyc0227_p267, snyc0227_p268, snyc0227_p269, snyc0227_p270, snyc0227_p271, snyc0227_p272, snyc0227_p273, snyc0227_p274, snyc0227_p275, snyc0227_p276, snyc0227_p277

1,268

APPENDIX TABLE VI-1. AGE DISTRIBUTION AND TIME IN SERVICE BY LOCATION, MALAYA MILITARY Location Total Number examined 201 150 101 50 85 271 200 210 1,268 Percent Distribution Age (years) 18 -- -- -- -- -- -- 12.5 -- 2.0 19 -- -- -- -- -- 0.7 30.0 0.5 5.0 20-24 29.4 29.3 38.6 4.0 41.2 39.1 57.5 50.5 39.9 25-29 40.8 37.3 35.6 38.0 35.3 32.5 -- 35.2 30.4 30-34 22.9 24.7 17.8 40.0 18.8 22.5 -- 10.0 17.3 35-39 6.5 8.7 7.9 18.0 3.5 4.8 -- 3.8 5.3 40+ 0.5 -- -- -- 1.2 0.4 -- -- 0.2 Time in Service 0-30 days -- -- 8.9 -- -- 1.8 1.0 2.4 1.6 1-4 months -- -- 5.0 4.0 -- 1.1 99.0 12.8 18.5 5-11 months -- 0.7 3.0 4.0 1.2 4.0 6.2 2.4 1-2 years 3.0 4.7 11.9 -- 5.9 2.6 -- 13.8 5.2 3-4 years 15.4 13.3 3.0 -- 16.5 18.1 -- 17.1 12.1 5-7 years 24.4 23.3 20.8 12.0 29.4 23.2 -- 9.5 17.3 8-12 years 38.3 36.0 40.6 46.0 38.8 33.2 - 23.8 29.0 13-20 years 18.4 22.0 6.9 34.0 8.2 15.9 -- 14.3 13.7 21+30 years 0.5 -- -- -- -- -- -- -- 0.1 Source: https://www.industrydocuments.ucsf.edu/docsisnyc0227 APPENDIX TABLE VI-2. LOCATION AND AREA OF ORIGIN OF MALAYAN MILITARY MEN RECEIVING ABBREVIATED EXAMINATIONS Location Total Number examined 201 150 101 50 85 271 200 210 1,268 Area of Origin Percent Distribution Selangor 3.0 2.0 6.9 18.0 11.8 3.7 22.0 7.1 8.2 Kelantan 8.4 9.3 9.9 4.0 7.0 4.8 0.5 3.3 5.5 Pahang 7.5 2.0 4.0 - -- 5.2 1.0 2.8 3.5 Johore 11.4 10.7 5.9 6.0 14.1 19.6 18.0 11.4 13.6 Malacca 37.8 31.3 30.7 40.0 23.5 31.4 39.0 28.6 32.9 Perak 18.4 25.3 24.8 22.0 25.9 18.8 16.5 30.5 22.2 Kedah 5.5 8.7 8.9 8.0 12.9 5.9 1.0 6.2 6.2 Trengganu 1.5 3.3 1.0 -- 1.2 4.4 0.5 -- 1.8 Penang 2.0 6.0 6.9 2.0 1.2 3.3 1.5 3.3 3.2 All others 4.5 1.3 1.0 -- 2.4 3.0 -- 6.7 2.8 Source: https://www.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-3. PERCENT "STANDARD WEIGHT" BY AGE, ABBREVIATED EXAMINATIONS, MALAYA MILITARY Age (years) 18 19 20-24 25-29 30-34 35-39 40+ Total Number examined 25 63 505 385 219 67 3 1,267 Mean 89.0 89.5 90.5 94.5 96.0 98.0 104.0 93.0 S.E.1/ 1.28 0.81 0.34 0.55 0.80 1.71 9.30 0.29 Percent Distribution 70-79 8.0 1.6 4.0 3.6 1.8 6.0 -- 3.6 80-89 40.0 60.3 47.9 38.2 36.1 23.9 -- 42.0 90-99 48.0 33.3 37.4 30.1 33.3 34.3 66.7 34.4 100-109 4.0 3.2 9.1 19.5 15.5 11.9 -- 13.1 110+ -- 1.6 1.6 8.6 13.2 23.9 33.3 6.9 1/ S.E. = standard error. Source: https:/lwww.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-4. SKINFOLD THICKNESS BY AGE, MALAYA MILITARY 20- 25- 30- 35- Age (years) 18 19 24 29 34 39 Total Arm (mm) Number 6 22 97 82 46 13 266 Mean 6.5 8.0 7.6 8.5 7.9 9.5 8.0 Scapula (mm) Number 6 22 97 82 46 13 266 Mean 10.7 9.6 11.2 12.5 14.3 15.4 12.2 263 Source: https:/lwww.industrydocuments.ucsf.edu/docs/snyc0227 TABLE VI-5. ABBREVIATED CLINICAL FINDINGS BY AGE, MALAYA MILITARY 20- 25- 30- 35- Age (years) 18 19 24 29 34 39 40+ Total Number examined 25 63 506 385 219 67 3 1,268 Percent Prevalence Skin, Face and Neck Nasolabial seborrhea 12.0 7.9 14.2 10.1 11.4 6.0 -- 11.7 Lips Angular lesions 4.0 1.6 1.0 0.5 -- -- -- 0.7 Angular scars 8.0 - 1.6 1.8 1.8 7.5 -- 2.0 Cheilosis -- -- 0.2 -- -- -- -- 0.1 Gums Swollen red papillae - Localized 4.0 4.8 4.5 5.2 6.4 10.4 -- 5.4 Diffuse 28.0 14.3 8.1 7.3 12.8 10.4 33.3 9.5 Tongue Filiform papillary atrophy - Slight -- 1.6 1.6 0.2 1.4 1.5 -- 1.1 Moderate -- -- -- -- 0.4 -- -- 0.1 Glossitis -- -- -- -- 0.9 -- -- 0.2 Magenta colored -- -- 0.2 0.5 0.9 1.5 -- 0.5 Glands Thyroid enlarged - Grade I -- 1.6 0.2 0.5 1.4 1.5 -- 0.6 Skin, General Follicular hyperkeratosis - Anywhere -- -- 2.2 0.2 -- -- -- 0.9 Arms -- -- 0.6 -- -- -- -- 0.2 Back -- -- 1.8 0.2 -- -- -- 0.8 Thighs -- -- 0.2 -- -- -- -- 0.1 Lower Extremities Loss of ankle jerk - Unilateral 4.0 -- 0.4 0.8 0.4 1.5 -- 0.6 Bilateral -- 4.8 1.8 1.6 1.4 3.0 -- 1.8 Calf tenderness -- -- -- 0.2 0.4 -- -- 0.2 Source: https://www.industrydocuments.ucst.edu/docsisnyc0227 APPENDIX TABLE VI-6. CLINICAL FINDINGS BY LOCATION, DETAILED EXAMINATIONS, MALAY MILITARY Location Total Number examined 40 30 25 10 18 54 50 42 269 Eyes Thickened opaque bulbar conjunctiva 17.5 4.0 28.0 19.0 11.2 Pingueculae 5.0 100.0 16.0 30.0 66.7 63.0 2.0 32.0 Bitot's spots 5.6 0.4 Conjunctival injection 7.5 5.6 3.7 4.0 3.0 Skin, Face and Neck Nasolabial seborrhea 25.0 3.3 28.0 30.0 22.2 13.0 20.0 38.1 21.6 Other seborrhea 12.0 11.9 4.1 Lips Angular lesions 3.7 0.7 Angular scars 56.7 3.7 2.0 7.4 Gums Marginal redness 57.5 60.0 47.6 27.1 Marginal swelling 65.0 68.0 47.6 29.7 Atrophy of papillae 50.0 4.0 1.8 2.0 9.5 10.0 Recession 52.5 6.7 16.0 20.0 7.4 22.0 26.2 20.4 Swollen red papillae Localized 15.0 23.3 5.6 20.4 8.0 4.8 11.5 Diffuse 36.7 4.0 22.2 5.6 20.0 4.8 11.5 Tongue Filiform papillary atrophy Slight 1.8 4.0 1.1 Fungiform papillary atrophy Slight 4.0 0.4 Moderate 2.0 0.4 Papillary hypertrophy Slight 2.0 0.4 Geographic 3.3 5.6 6.0 2.4 2.2 Furrows 15.0 6.7 4.0 10.0 5.6 10.0 5.9 Fissures 2.5 8.0 1.1 Serrations 2.4 0.4 Red tip and/or lateral margins 3.3 16.7 2.0 1.8 Glands Thyroid enlarged 2.0 0.4 Skin, General Follicular hyperkeratosis Anywhere 12.5 5.6 3.7 2.0 16.7 5.9 Arms, slight 2.4 0.4 265 Source: https:/lwww.industrydocuments.ucsf.edu/docsisnyc0227 APPENDIX TABLE VI-6 (Continued) CLINICAL FINDINGS BY LOCATION, DETAILED EXAMINATIONS, MALAY MILITARY Location Total Number examined 40 30 25 10 18 54 50 42 269 Skin, General (Continued) Back, slight 5.0 5.6 1.8 2.0 9.5 3.3 Moderate/severe 1.8 4.8 1.1 Chest, slight 10.0 2.0 7.1 3.0 Moderate/severe 2.4 0.4 Perifolliculosis 4.0 0.7 Dry skin 28.0 5.2 Acneform eruption 5.6 1.8 6.0 1.8 Lower Extremities Loss of ankle jerk Bilateral 3.3 4.0 11.1 3.7 2.2 Loss of knee jerk Bilateral 2.5 11.1 1.1 266 Source: https:/lwww.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-7. DETAILED CLINICAL FINDINGS BY TIME IN SERVICE, MALAYA MILITARY TTS 27-8 Time in Service Total Number examined 11 57 5 10 30 33 89 34 269 Eyes Percent Prevalence Thickened opaque bulbar conjunctivae -- 24.6 -- -- 10.0 3.0 11.2 5.9 11.2 Pingueculae 27.3 1.8 -- 10.0 26.7 42.4 47.2 50.0 32.0 Bitot's spots -- -- -- -- 3.3 -- -- -- 0.4 Conjunctival injection -- 3.5 -- -- -- -- 4.5 5.9 3.0 Skin, Face and Neck Nasolabial seborrhea 18.2 22.8 20.0 50.0 23.3 18.2 21.3 14.7 21.6 Other seborrhea 18.2 10.5 -- 10.0 6.7 -- -- 4.1 Lips Angular lesions 9.1 -- -- 10.0 -- -- -- -- 0.7 Angular scars 9.1 1.8 -- -- 6.7 6.1 6.7 23.5 7.4 Gums Marginal redness 9.1 54.4 -- 30.0 23.3 18.2 20.2 20.6 27.1 Marginal swelling 9.1 61.4 -- 50.0 26.7 21.2 20.2 17.6 29.7 Atrophy of papillae 1.8 -- 13.3 15.2 13.5 14.7 10.0 -- -- Recession 18.2 19.3 20.0 10.0 13.3 21.2 27.0 14.7 20.4 Swollen red papillae - Localized -- 7.0 20.0 -- 10.0 18.2 12.4 17.6 11.5 Diffuse 18.2 17.5 -- -- 10.0 9.1 7.9 17.6 11.5 Tongue Filiform papillary atrophy 3.5 -- -- -- -- 1.1 -- 1.1 Slight -- Fungiform papillary atrophy -- -- -- -- -- -- 2.9 0.4 Slight -- Moderate 1.8 -- -- -- -- -- -- 0.4 -- 1.8 -- -- -- -- -- -- 0.4 Papillary hypertrophy - Slight -- -- 5.3 -- -- Geographic 6.7 -- -- 2.9 2.2 Furrows -- 8.8 20.0 10.0 3.3 9.1 3.4 5.9 5.9 -- -- -- -- 3.0 1.1 2.9 1.1 Fissures -- -- -- -- -- 1.1 -- 0.4 Serrations -- Red tip and/or lateral margins -- 1.8 3.3 9.1 -- -- 1.8 -- -- Source: https://www.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-7 (Continued) DETAILED CLINICAL FINDINGS BY TIME IN SERVICE, MALAYA MILITARY Time in Service Total Number examined 11 57 5 10 30 33 89 34 269 Glands Percent Prevalence Thyroid enlarged -- 1.8 -- -- - -- 0.4 Skin, General Follicular hyperkeratosis Anywhere 18.2 3.5 -- 10.0 6.7 3.0 7.9 2.9 5.9 Arms -- -- -- - -- 3.0 -- 0.4 Back - Slight 9.1 1.8 -- -- 3.3 3.0 4.5 2.9 3.3 Moderate/Severe -- 1.8 -- 10.0 -- -- 1.1 -- 1.1 Chest - Slight 9.1 1.8 -- -- 6.7 -- 4.5 -- 3.0 Moderate/Severe -- -- -- 10.0 -- -- -- - 0.4 Perifolliculosis -- 3.5 -- -- -- ... -- -- 0.7 Dry skin - 24.6 -- -- -- -- -- -- 5.2 Acneform eruption - 5.3 -- -- 3.3 -- - 2.9 1.8 Lower Extremities Loss of ankle jerk - Bilateral 9.1 -- -- -- 6.7 3.0 1.1 2.9 2.2 Loss of knee jerk - Bilateral -- -- -- -- 3.3 -- 2.2 -- 1.1 Source: https://lwww.industrydocuments.ucsf.edu/docsisnyc0227 APPENDIX TABLE VI-8. BIOCHEMICAL FINDINGS BY LOCATION, MALAYA MILITARY BLOOD Location Total Total Plasma Protein gm/100 ml No. 13 10 25 5 6 19 25 20 123 Mean 7.4 7.2 7.3 7.6 7.3 7.2 6.8 7.7 7.3 S.E.1/ 0.14 0.10 0.09 0.36 0.17 0.07 0.09 0.11 0.05 Percent Distribution 6.00-6.39 -- -- -- -- -- 16.0 -- 3.2 6.40-6.99 15.4 10.0 36.0 20.0 16.7 31.6 56.0 10.0 29.3 >7.00 84.6 90.0 64.0 80.0 83.3 68.4 28.0 90.0 67.5 Albumin/Globulir Ratio No. 13 10 25 5 6 19 25 20 123 Mean 1.22 1.41 1.53 1.42 1.23 1.37 1.26 0.80 1.27 S.E. 0.05 0.10 0.06 0.10 0.07 0.05 0.05 0.04 0.03 Percent Distribution 0.5-0.9 -- -- -- - -- 5.3 -- 80.0 13.3 1.0-1.4 92.3 60.0 36.0 40.0 83.3 68.4 80.0 20.0 57.7 1.5-1.9 7.7 30.0 56.0 60.0 16.7 26.3 20.0 -- 26.0 >2.0 -- 10.0 8.0 -- -- -- -- 2.4 Albumin gm/100 ml No. 13 10 25 5 6 19 25 20 123 Mean 4.0 4.2 4.4 4.5 4.0 4.1 3.8 3.4 4.0 S.E. 0.07 0.08 0.05 0.15 0.08 0.07 0.04 0.11 0.04 Percent Distribution <2.5 -- -- -- -- -- -- 5.0 0.8 2.5-3.4 -- -- -- 5.3 4.0 40.0 8.1 3.5-5.0 100.0 100.0 100.0 100.0 100.0 94.7 96.0 55.0 91.0 >5.0 -- -- -- -- -- -- -- Globulin gm/100 ml No. 13 10 25 5 6 19 25 20 123 Mean 3.4 3.0 3.0 3.2 3.3 3.1 3.1 4.2 3.3 S.E. 0.12 0.14 0.10 0.26 0.17 0.08 0.09 0.13 0.06 Percent Distribution 1.0-1.9 -- -- -- -- -- -- -- -- -- 2.0-2.9 15.4 30.0 56.0 60.0 33.3 42.1 40.0 -- 34.1 3.0-3.5 53.8 50.0 32.0 20.0 50.0 52.6 40.0 10.0 37.4 >3.5 30.8 20.0 12.0 20.0 16.7 5.3 20.0 90.0 28.4 1/ S.E. = standard error. 269 Source: https://www.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-8 (Continued) BIOCHEMICAL FINDINGS BY LOCATION, MALAYA MILITARY BLOOD Location Total Hemoglobin gm/100 ml No. 13 10 25 5 6 21 25 20 125 Mean 16.5 17.6 15.0 16.1 16.1 14.7 15.4 16.3 15.7 S.E. 0.37 0.58 0.37 0.49 0.56 0.32 0.21 0.22 0.14 Percent Distribution <12.0 - -- 4.0 -- -- -- -- -- 0.8 12.0-13.9 7.7 -- 12.0 -- -- 28.6 8.0 -- 9.6 14.0-14.9 -- -- 24.0 20.0 33.3 23.8 20.0 10.0 16.8 >15.0 92.3 100.0 60.0 80.0 66.7 47.6 72.0 90.0 72.8 Hematocrit percent No. 13 10 23 4 6 21 25 20 122 Mean 45.8 48.7 43.5 45.8 44.7 43.1 44.5 46.2 44.9 S.E. 0.84 0.76 0.55 1.11 1.31 0.70 0.57 0.46 0.29 Percent Distribution <36 -- -- -- -- -- -- -- -- 36-41 7.7 -- 26.1 -- 16.7 33.3 20.0 -- 16.4 42-44 23.1 -- 39.1 25.0 50.0 28.6 24.0 15.0 25.4 >45 69.2 100.0 34.8 75.0 33.3 38.1 56.0 85.0 58.2 Mean Corpuscular Hemoglobir Concentration percent No. 13 10 23 4 6 21 25 20 122 Mean 36.0 36.4 34.4 35.2 36.1 34.2 34.7 35.2 35.0 S.E. 0.59 1.16 0.88 0.48 1.33 0.46 0.45 0.38 0.25 Percent Distribution <28.0 -- - 4.3 -- -- -- 4.0 -- 1.6 28.0-29.9 -- -- - -- -- -- -- -- 30.0-31.9 -- -- 8.7 -- 14.3 -- 5.0 4.9 >32.0 100.0 100.0 87.0 100.0 100.0 85.7 96.0 95.0 93.4 Vitamin C mg/100 ml No. 13 10 24 -- 6 19 25 20 117 Mean 0.51 0.36 0.73 -- 0.36 0.44 0.23 0.28 0.42 S.E. 0.07 0.05 0.05 -- 0.06 0.04 0.01 0.02 0.02 Percent Distribution <0.10 -- -- -- -- -- -- -- -- -- 0.10-0.19 15.4 10.0 -- -- 16.7 -- 32.0 15.0 12.8 0.20-0.39 23.1 70.0 4.2 -- 33.3 47.4 68.0 80.0 47.0 >0.40 61.5 20.0 95.8 -- 50.0 52.6 -- 5.0 40.2 270 Source: https://www.industrydocuments.ucsf.edu/docssnyc0227 APPENDIX TABLE VI-8 (Continued) BIOCHEMICAL FINDINGS BY LOCATION, MALAYA MILITARY BLOOD Location Total Vitamin A g/100 ml No. 13 10 24 4 6 18 25 20 120 Mean 48.2 50.5 37.4 59.0 47.7 42.2 49.4 44.8 45.3 S.E. 3.8 3.7 3.0 6.4 4.3 2.1 1.9 3.1 1.2 Percent Distribution <10 - -- 4.2 -- -- -- -- - 0.8 10-19 - -- 12.5 -- -- -- -- -- 2.5 20-49 53.8 50.0 66.7 25.0 50.0 83.3 35.0 70.0 58.3 >50 46.2 50.0 16.7 75.0 50.0 16.7 64.0 30.0 38.3 Carotene g/100 ml No. 13 10 24 5 6 18 25 20 121 Mean 102 95 106 95 118 89 88 95 97 S.E. 8 10 10 15 12 4 3 5 3 Percent Distribution <20 -- -- -- -- - -- -- -- 20-39 -- - -- -- -- -- -- 40-99 46.2 60.0 58.3 40.0 33.3 72.2 76.0 65.0 62.0 >100 53.8 40.0 41.7 60.0 66.7 27.8 24.0 35.0 38.0 Cholesterol mg/100 ml No. 13 10 25 5 6 19 25 18 121 Mean 230 207 179 139 178 148 159 207 180 S.E. 8.8 12.4 6.8 7.5 17.6 6.6 5.3 12.6 4.0 Percent Distribution 70-99 -- -- -- -- -- 5.3 -- -- 0.8 100-149 - -- 20.0 80.0 33.3 42.1 32.0 11.1 24.0 150-199 15.4 50.0 44.0 20.0 33.3 47.4 64.0 27.8 42.1 >200 84.6 50.0 36.0 -- 33.3 5.3 4.0 61.1 33.0 B-Lipoprotein mm No. 13 -- 25 5 6 19 25 20 113 Mean 3.5 -- 3.2 3.3 2.5 3.0 2.5 3.0 3.0 S.E. 0.12 -- 0.13 0.16 0.30 0.14 0.08 0.14 0.06 Lipid Phosphorus mg/100 ml No. 13 10 25 5 6 19 25 18 121 Mean 11.1 11.4 10.6 10.7 10.6 10.1 9.4 9.5 10.2 S.E. 0.54 0.64 0.30 0.20 0.84 0.42 0.27 0.75 0.19 271 Source: https://www.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-8 (Continued) BIOCHEMICAL FINDINGS BY LOCATION, MALAYA MILITARY URINE Location Total Thiamine g/gm creatinine No. 12 10 20 3 5 19 22 15 106 Median 34 27 42 147 41 48 110 44 52 Percent Distribution <27 41.7 50.0 25.0 -- 20.0 21.0 -- 26.7 22.6 27=65 41.7 30.0 65.0 33.3 80.0 52.6 -- 53.3 41.5 66-129 8.3 10.0 -- - 15.8 72.7 13.3 21.7 >130 8.3 10.0 10.0 66.7 -- 10.5 27.3 6.7 14.2 Riboflavin g/gm creatinine No. 12 10 23 4 5 19 25 20 118 Median 26 20 23 12 38 21 94 36 32 Percent Distribution <27 58.3 70.0 56.5 75.0 40.0 57.9 4.0 30.0 42.4 27-79 33.3 30.0 34.8 -- 40.0 42.1 40.0 65.0 40.7 80-269 seca -- 4.3 -- 20.0 56.0 -- 13.6 >270 8.3 -- 4.3 25.0 -- -- - 5.0 3.4 N° -Methylnicotinamide mg/gm creatinine No. 11 10 6 4 5 19 25 15 95 Median 5.6 4.9 3.0 1.7 4. 7 4.0 4.4 4.4 4.2 Percent Distribution <0.5 -- - 16.7 -- -- -- -- -- 1.0 0.5-1.59 -- -- -- 50.0 -- -- 4.0 -- 3.2 1.6-4.29 36.4 40.0 66,7 50.0 40.0 57.9 44.0 46.7 47.4 >4.30 63.6 60.0 16.7 -- 60.0 42.1 52.0 53.3 48.4 272 Source: https://www.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-9. BIOCHEMICAL FINDINGS BY AGE, MALAYA MILITARY Age (years) 18-19 20-24 25-29 30-34 35-39 - Total BLOOD Total Plasma Protein gm/100 ml No. 12 49 36 20 6 123 Mean 6.8 7.2 7.4 7.4 7.5 7.3 S.E.1/ 0.13 0.08 0.08 0.11 0.23 0.05 Percent Distribution 6.00-6.39 16.7 4.1 -- -- -- 3.2 6.40-6.99 41.7 40.8 16.7 20.0 16.7 29.3 >7.00 41.7 55.1 83.3 80.0 83.3 67.5 Albumin/Globulin Ratio No. 12 49 36 20 6 123 Mean 1.22 1.28 1.22 1.37 1.28 1.27 S.E. 0.08 0.04 0.07 0.06 0.07 0.03 Percent Distribution 0.5-0.9 8.3 10.2 25.0 10.0 -- 13.8 1.0-1.4 75.0 63.3 50.0 45.0 66.7 57.7 1.5-1.9 16.7 24.5 19.4 45.0 33.3 26.0 >2.0 -- 2.0 5.6 -- -- 2.4 Albumin gm/100 ml No. 12 49 36 20 6 123 Mean 3.7 4.0 3.9 4.2 4.2 4.0 S.E. 0.05 0.06 0.08 0.08 0.13 0.04 Percent Distribution <2.5 -- 2.0 -- -- -- 0.8 2.5-3.4 8.3 4.1 16.7 5.0 -- 8.1 3.5-5.0 91.7 93.9 83.3 95.0 100.0 91.0 >5.0 -- -- -- -- Globulin gm/100 ml No. 12 49 36 20 6 123 Mean 3.1 3.2 3.4 3.2 3.3 3.3 S.E. 0.14 0.08 0.13 0.12 0.18 0.06 Percent Distribution 1.0-1.9 -- -- -- -- -- -- 2.0-2.9 41.7 32.6 33.3 40.0 16.7 34.1 3.0-3.5 33.3 40.8 33.3 35.0 50.0 37.4 >3.5 25.0 26.5 33.3 25.0 33.3 28.4 1/ S.E. = standard error. - 273 Source. https://www.industrydocuments.ucsf.edu/docsisnyc0227 APPENDIX TABLE VI-9 (Continued) BIOCHEMICAL FINDINGS BY AGE, MALAYA MILITARY Age (years) 18-19 20-24 25-29 30-34 35-39 Total Hemoglobin gm/100 ml No. 12 50 36 21 6 125 Mean 15.3 15.4 16.2 15.8 15.9 15.7 S.E. 0.30 0.22 0.24 0.48 0.76 0.14 Percent Distribution <12.0 -- 2.0 -- -- -- 0.8 12.0-13.9 8.3 8.0 5.6 19.0 16.7 9.6 14.0-14.9 16.7 20.0 11.1 19.0 16.7 16.8 >15.0 75.0 70.0 83.3 61.9 66.7 72.8 Hematocrit percent No. 12 48 36 21 5 122 Mean 44.5 45.0 45.7 43.7 43.6 44.9 S.E. 0.83 0.44 0.50 0.80 1.50 0.29 Percent Distribution <36 -- -- -- -- -- -- 36-41 16.7 16.7 11.1 23.8 20.0 16.4 42-44 33.3 20.8 19.4 38.1 40.0 25.4 >45 50.0 62.5 69.4 38.1 40.0 58.2 Mean Corpuscular Hemoglobin Concentration percent No. 12 48 36 21 5 122 Mean 34.4 34.2 35.5 36.1 35.6 35.0 S.E. 0.59 0.44 0.34 0.77 0.58 0.25 Percent Distribution <28.0 -- 4.2 - - -- 1.6 28.0-29.9 -- -- -- -- -- -- 30.0-31.9 -- 8.3 2.8 4.8 -- 4.9 >32.0 100.0 87.5 97.2 95.2 100.0 93.4 Vitamin C mg/100 ml No. 12 47 34 19 5 117 Mean 0.22 0.44 0.41 0.48 0.62 0.42 S.E. 0.02 0.04 0.04 0.07 0.15 0.02 Percent Distribution <0.10 -- -- -- -- -- -- 0.10-0.19 41.7 6.4 14.7 10.5 -- 12.8 0.20-0.39 58.3 46.8 44.1 47.4 40.0 47.0 >0.40 46.8 41.2 42.1 60.0 40.2 274 Source: https://www.industrydocuments.ucsf.edu/docs/snyco227 APPENDIX TABLE VI-9 (Continued) BIOCHEMICAL FINDINGS BY AGE, MALAYA MILITARY Age (years) 18-19 20-24 25-29 30-34 35-39 Total Vitamin A g/100 ml No. 12 47 35 20 6 120 Mean 49.8 66.6 45.2 42.7 45.5 45.3 S.E. 2.5 1.8 1.9 3.7 9.5 1.2 Percent Distribution <10 -- -- -- -- 16.7 0.8 10-19 -- 2.1 -- 10.0 -- 2.5 20-49 33.3 59.6 71.4 60.0 16.7 58.3 >50 66.7 38.3 29.6 30.0 66.7 38.3 Plasma Carotene g/100 ml No. 12 48 35 20 6 121 Mean 87 98 96 94 127 97 S.E. 4 4 4 6 36 3 Percent Distribution <20 -- -- -- -- -- -- 20-39 -- -- -- -- 40-99 75.0 62.5 57.1 70.0 33.3 62.0 >100 25.0 37.5 42.8 30.0 66.7 38.0 Cholesterol mg/100 ml No. 11 49 35 20 6 121 Mean 156 176 196 175 190 180 S.E. 5.8 5.8 9.1 8.9 15.4 4.0 Percent Distribution 70-99 -- 2.0 -- -- -- 0.8 100-149 36.4 20.4 25.7 25.0 16.7 24.0 150-199 63.6 51.0 20.0 55.0 16.7 42.1 >200 -- 26.5 54.3 20.0 66.7 33.0 B=Lipoprotein¹/ mm No. 12 48 32 16 5 113 Mean 2.6 2.8 3.2 3.2 3.5 3.0 S.E. 0.10 0,08 0.11 0.19 0.22 0.06 Lipid Phosphorus mg/100 ml No. 11 49 35 20 6 121 Mean 10.1 10.1 10.2 10.4 10.9 10.2 S.E. 0.47 0.29 0.41 0.36 0.62 0.19 1/ By precipitin technic. 275 Source: https:/lwww.industrydocuments.ucsf.edu/docsisnyc0227 APPENDIX TABLE VI-9 (Continued) BIOCHEMICAL FINDINGS BY AGE, MALAYA MILITARY Age (years) 18-19 20-24 25-29 30-34 35=39 Total URINE Thiamine g/gm creatinine No. 12 40 30 19 5 106 Median 111 63 32 46 46 52 Percent Distribution <27 -- 15.0 43.3 26.3 -- 22.6 27-65 8.3 37.5 46.7 47.4 100.0 41.5 66-129 58.3 35.0 3.3 5.3 -- 41.5 >130 33.3 12.5 6.7 21.0 -- 14.2 Riboflavin g/gm creatinine No. 12 46 35 20 5 118 Median 77 38 27 34 15 32 Percent Distribution <27 8.3 39.1 48.6 50.0 80.0 42.4 27-79 41.7 37.0 48.6 45.0 -- 40.7 80-269 50.0 19.6 -- 5.0 -- 13.6 >270 -- 4.3 2.8 -- 20.0 3.4 N'-Methylnicotinamide mg/gm creatinine No. 11 37 26 17 4 95 Median 4.8 3.8 4.5 4.9 3.9 4.2 Percent Distribution <0.50 -- -- -- 5.9 -- 1.0 0.50-1.59 -- 5.4 -- 5.9 -- 3.2 1.60-4.29 36.4 56.8 46.2 29.4 75.0 47.4 >4.30 63.6 37.8 53.8 58.8 25.0 48.4 276 Source: https://www.industrydocuments.ucsf.edu/docsisnyc0227 APPENDIX TABLE VI-10. BIOCHEMICAL FINDINGS BY PERCENT OF "STANDARD WEIGHT, " MALAYA MILITARY Percent "Standard Weight" 75-89 90-99 100-109 110+ Total BLOOD Total Plasma Protein gm/100 ml No. 45 44 19 15 123 Mean 7.2 7.1 7.5 7.5 7.3 Percent Distribution 6.00-6.39 4.4 4.5 -- -- 3.2 6.40-6.99 35.6 38.6 15.8 - 29.3 >7.00 60.0 56.8 84.2 100.0 67.5 Albumin/Globulin Ratio No. 45 44 19 15 123 Mean 1.32 1.33 1.16 1.10 1.27 Percent Distribution 0.5=0.9 6.7 4.5 31.6 40.0 13.8 1.0-1.4 64.4 59.1 52.6 40.0 57.7 1.5-1.9 28.9 31.8 10.5 20.0 26.0 >2.0 -- 4.5 5.3 -- 2.4 Albumin gm/100 ml No. 45 44 19 15 123 Mean 4.0 4.0 3.9 3.9 4.0 Percent Distribution <2.5 -- 2.3 - -- 0.8 2.5-3.4 4.4 4.5 15.8 20.0 8.1 3.5-5.0 95.6 93.2 84.2 80.0 91.0 >5.0 -- - -- -- -- Globulin gm/100 ml No. 45 44 19 15 123 Mean 3.2 3.1 3.5 3.6 3.3 Percent Distribution 1.0-1.9 -- -- -- -- -- 2.0-2.9 37.8 43.2 26.3 6.7 34.1 3.0-3.5 40.0 34.1 36.8 40.0 37.4 >3.5 22.2 22.7 36.8 53.3 28.4 Hemoglobin gm/100 ml No. 47 44 19 15 125 Mean 15.2 15.7 16.0 16.6 15.7 Percent Distribution <12.0 -- 2.3 -- -- 0.8 12.0-13.9 17.0 2.3 10.5 6.7 9.6 14.0-14.9 25.5 13.6 10.5 6.7 16.8 >15.0 57.4 81.8 78.9 86.7 72.8 277 Source: hhttps://www.industrydocuments.ucsf.edu/docsisnyc0227 APPENDIX TABLE VI-10 (Continued) BIOCHEMICAL FINDINGS BY PERCENT OF "STANDARD WEIGHT, " MALAYA MILITARY Percent "Standard Weight" 75-89 90-99 100-109 110+ Total BLOOD Hematocrit percent No. 46 42 19 15 122 Mean 43.9 45.2 45.5 45.9 44.9 Percent Distribution <36 - -- - -- - 36-41 28.3 9.5 10.5 6.7 16.4 42-44 28.3 23.8 31.6 13.3 25.4 >45 43.5 66.7 57.9 80.0 58.2 Mean Corpuscular Hemoglobin Concentration, percent No. 46 42 19 15 122 Mean 34.8 34.7 35.2 36.1 35.0 Percent Distribution <28.0 -- 2.4 5.3 - 1.6 28.0-29.9 - -- -- -- -- 30.0-31.9 10.9 2.4 -- -- 4.9 >32.0 89.1 95.2 94.7 100.0 93.4 Vitamin C mg/100 ml No. 41 42 19 15 117 Mean 0.44 0.40 0.47 0.36 0.42 Percent Distribution <0.10 -- -- -- - 0.10-0.19 4.9 16.7 10.5 26.7 12.8 0.20-0.39 48.8 42.8 47.4 53.3 47.0 >0.40 46.3 40.5 42.1 20.0 40.2 Vitamin A g/100 ml No. 45 41 19 15 120 Mean 44.8 45.5 43.0 49.4 45.3 Percent Distribution <10 -- 2.4 -- -- 0.8 10-19 6.7 -- -- -- 2.5 20-49 57.8 53.6 73.7 53.3 58.3 >50 35.6 43.9 26.3 46.7 38.3 Carotene g/100 ml No. 45 42 19 15 121 Mean 95 98 102 94 97 Percent Distribution <20 -- -- -- -- -- 20-39 -- -- -- -- - 40-99 62.2 69.0 47.4 60.0 62.0 >100 37.8 31.0 52.6 40.0 38.0 278 Source: https://www.industrydocuments.ucsf.edu/docs/snyc0227 APPENDIX TABLE VI-10 (Continued) BIOCHEMICAL FINDINGS BY PERCENT OF 'STANDARD WEIGHT, " MALAYA MILITARY Percent "Standard Weight" 75-89 90-99 100-109 110+ Total BLOOD Cholesterol mg/100 ml No. 45 44 19 13 121 Mean 163 171 203 240 180 Percent Distribution 70-99 2.2 -- -- -- 0.8 100-149 33.3 25.0 15.8 -- 24.0 150-199 46.7 52.3 26.3 15.4 42.1 >200 17.8 22.7 57.9 84.6 33.0 B=Lipoprotein mm No. 43 42 18 10 113 Mean 2.9 2.8 3.2 3.5 3.0 Lipid Phosphorus mg/100 ml No. 45 44 19 13 121 Mean 10.0 9.9 10.6 11.3 10.2 URINE Thiamine g/gm creatinine No. 38 39 16 13 106 Median 70 54 38 39 52 Percent Distribution <27 18.4 17.9 37.5 30.8 22.6 27-65 28.9 46.2 43.8 61.5 41.5 66-129 36.8 15.4 12.5 7.7 21.7 >130 15.8 20.5 6.2 -- 14.2 Riboflavin g/gm creatinine No. 44 40 19 15 118 Median 37 37 20 25 32 Percent Distribution <27 40.9 30.0 57.9 60.0 42.4 27-79 36.4 47.5 36.8 33.3 40.7 80-269 18.2 20.0 -- 6.7 13.6 >270 4.5 2.5 5.3 -- 3.4 N'-Methylnicotinamide mg/gm creatinine No. 35 33 16 11 95 Median 4.1 4.7 4.0 3.9 4.2 Percent Distribution <0.50 -- -- -- 9.1 1.0 0.50-1.59 5.7 3.0 -- -- 3.2 1.60-4.29 48.6 39.4 56.2 54.5 47.4 >4.30 45.7 57.6 43.8 36.4 48.4 279 Source: https:/lwww.industrydocuments.ucst.edu/docsisnyc0227 APPENDIX TABLE VI-11. SUGGESTED GUIDE TO INTERPRETATION OF NUTRIENT INTAKE DATA "Deficient" "Low" "Acceptable' "High" Protein (gm/person/kg) <0.50 0.50-0.99 1.00-1.49 1.50+ Calcium (mg/person/day) <300 300-399 400-799 800+ Iron (mg/person/day) <6.0 6.0-8.9 9.0-11.9 12.0+ Vitamin A (IU/person/day) <2,000 2,000=3,499 3,500-4,999 5,000+ Vitamin C (mg/person/day) <10.0 10.0-29.9 30.0-49.9 50.00 Thiamine (mg/1,000 Calories) <0.20 0.20-0.29 0.30-0.49 0.50+ Riboflavin (mg/person/day) <0.70 0.70-1.19 1.20-1.59 1.60€ Niacin (mg/person/day) <5.0 5.0=9.9 10.0-14.9 15.04 1/ Based primarily on standards for the young adult male; see Manual for Nutrition Surveys, 1st ed., 1957. 280 Source: https://www.industrydocuments.ucsf.edu/docs/snyc0227

what is the number of births mentioned?

kycg0227

kycg0227_p2, kycg0227_p3, kycg0227_p4, kycg0227_p5

25,000-50,000 births, 25,000-50,000

Review of Galactosemia and the "Galactose=Free Diet" Galactosemia is an inherited disorder character= ized by an inability to convert galactose to glucose in the normal manner. This results in an abnormal accumulation of the metabolites of galactose in cells of the body. This, in turn, causes damage to various tissues. The inactivity of the specific enzyme, l-phosphogalactose-uridyl transferase (P=gal-transferase), is known to be the cause of this defect in metabolisme Jaundice is the first symptom of the disease. Later others such as a poor appetite, vomiting, increased susceptibility to infection and poor weight gain appear. If the infant survives, cata racts develop and physical and mental growth are retarded. An early diagnosis is made by: 1) the severity of the symptoms; 2) the genetic pattern; and 3) the presence of proteinuria and galacto- suria. If milk is removed from the diet, most of the physical manifestations of the disease will regress with the possible exception of the cata- racts and the brain damage. If the diet regimen is instituted within the first few weeks of life, there is an excellent chance that all the symptoms, including mental retardation, can be preventedo Galactosemia is transmitted by an autosomal gene. Both parents are hsterozygotes for the defective gene and contribute equally to the devel- opment of the disorder in affected childrono Galactosemia can be expected to occur in one of four births in such families in a normal distri- butiono The incidence of galactosemia in the popula- tion is not known. It is estimated to occur once in -3- Source: ttps://www.industrydocuments.ucsf.edu/docs/kycg0227 COMPARISON OF THREE CUPS OF VITAMIN D MILK AND NUTRAMIGEN IN MEETING THE NRC RECOMMENDED DIETARY ALLOWANCES FOR A 1-3 YEAR OLD CHILD 25,000-50,000 births. However, in view of the fact that a significant percentage of the affected chil- Milk dren die in the first few months of life, the actual incidence of the gene in the general population may Nutramigen be higher than originally estimated. 146 135 Treatment is directed toward rigid exclusion of galactose from the diet. Since galactose is a como 100 ponent of lactose, a milk sugar, this means that all types of milk and all milk products must be omitted from the diet as well as bread, cereals, puddings, cookies and other food items containing milk in any form. 80 Galactose is also a part of some complex carbo- hydrates, such as stachyose, found in some vegetables. Any known food containing stachyose, or other forms of carbohydrate with galactose a,s a component, should be eliminated from the diet until it is determined with certainty whether these foods yield galactose during 60 metabolism. As new knowledge becomes available in the field of carbohydrate metabolism, it is possible that changes will be made in the galactose=free diet. Milk Substitute 40 To substitute for milk in the child*s diet, Nutramigen, a protein hydrolysate, manufactured by Mead Johnson & Company, or a meat-base formula may be given. Nutramigen has been the most preferred product and is widely used. 20 Nutramigen looks like any other milk formula when it is liquified. The nutritive value is the same or greater than cow's milk with the exception of lactose. See chart. o A NUTRIENTS -4- -5- Source: https://www.industrydocuments.ucsf.edu/docs/kycg0227 The manufacturer of Nutramigen is experimenting with it in liquid form but until it is perfected, If an evaluation of the galactose content and the powder must be mixed with water. Parents have the nutritive value of the individual child's diet found the easiest method of preparing the formula is is indicated, the mother, or the child when older, to make a paste of the powder and a small amount of may be asked to keep a diet record periodically. water before adding the total amount of water. A blender or osterizer works well. Labels The Nutramigen has been well accepted by these As explained in the Parents' Guide, most food children. Parents may find it offensive in odor and products are required by law to carry an accurate taste as they unconsciously compare it to milk and label of ingredients. In lifornia, the only find it so different. foods not required to show this information and which might contain milk are chocolate and certain Parents frequently do not understand that Nutra= breads=wwite, enriched, raisin, milk, whole wheat migen, like regular milk, contains nutrients necessary and graham. Parents should be encouraged to check for growth. There is a tendency for these parents to with the individual baking companies and the local out down or eliminate the Nutramige when the child bakery as to the ingredients used in these breads. becomes a pre=schooler or goes to school. If less All other breads and bread products, including rye, than three cups of Nutramigen are consumed (as a bev- specialty breads, English muffins and bagels, must erage or in food) each day, it is necessary to supo: be labeled, in California, with the specified in- plement the diet with calcium and vitamin Do It is gredients. difficult to provide these nutrients in the recom- mended amounts if milk, or a milk substitute, is Parents should be instructed in reading labels excluded from the diet. to look not only for milk, butter, cream or cheese, but also for other forms of milk which contain Planning the Diet lactose as nonfat dry milk solids, whey and curds. Lactate, lactic acid, lactalbumin and calcium com- For the baby, the diet is planned as for other pounds do not contain lactose. babies with the Nutramigen substituted for breast or cow's milko Most of the "baby foods" such as cereals, Lactose may be used in drugs without having vegetables, fruits and meat are milk=free. Most of to be identified on the label. It is found mostly the "baby dinners" and the soups and puddings for in tablets as a "filler" or as a sweetening agent. infants contain milk in some formo (Gerber's Baby The content of medications and toiletries should Food Company has a table of their products with the be checked with the individual drug company. ingredients listed for each itemo The Family and the Diet As the child grows and eats table foods, a rell-balanced family diet, listed in the Parents The entire family must have a realistic under- Guide, will insure that he has the nutrients needed standing of galactosemia and the value of the die t for growth and development. This diet includes in order for the regimen to be successful. meats, eggs, vegetables, fruits, cereals, and bread, in addition to the Nutramigen. The professional person will find that these parents have anxieties beyond those most parents -6- -7 - - Source: https:/lwww.industrydocuments.ucsf.edu/docs/kycg0227 experience when raising children. The fear of mental retardation, the grave responsibility of teaching their child to follow the diet when away from home and the feeling of guilt for not giving the child their own favorite foods are examples of some of ACKNOWLEDGMENTS their worries. The mother will also encounter additional work We wish to express our gratitude to Richard involved with shopping and preparing the diet. She Koch, M.D , and his multidisciplinary team at the must study carefully each label of food purchased. Child Development Clinic; George N. Donnell, M.D., She may have to search for markets selling milk-free Head of Metabolic and Renal Research; and to margarines and contact baking companies for infor- William Bergren, Ph.D., Head of the Biochemistry mation on ingredients used in their products. ( You Research Division of the Los Angeles Childrens may be able to supply her with brand names (for Hospital, for their interest, encouragement and specific food items) and the names of stores in her assistance in developing this booklet. neighborhood where these products are sold.) We are also indebted to Edward S. Rorem, Ph.D., The professional person will find it a rewarding of the Western Regional Research Laboratory of the experience to counsel these parents whether it be at U.S. Department of Agriculture, for his generosity the doctor's office, a clinic, in the child's home in sharing with us his knowledge of carbohydrates. or in a planned meeting for parents If the child is retarded, the Children's Bureau publication, The We are also grateful to many professional Mentally Retarded Child in the Home may be of help. persons and to parents of children with galacto- semia for their contributions of time, effort and The Parents' Guide is available in separate encouragement. form for distribution to parents. Bureau of Public Health Nutrition California State Department of Public Health -8- Source: https://wwww.industrydocuments.ucsf.edu/docs/kycg0227

what is rigidly excluded from diet?

kycg0227

kycg0227_p2, kycg0227_p3, kycg0227_p4, kycg0227_p5

galactose

Review of Galactosemia and the "Galactose=Free Diet" Galactosemia is an inherited disorder character= ized by an inability to convert galactose to glucose in the normal manner. This results in an abnormal accumulation of the metabolites of galactose in cells of the body. This, in turn, causes damage to various tissues. The inactivity of the specific enzyme, l-phosphogalactose-uridyl transferase (P=gal-transferase), is known to be the cause of this defect in metabolisme Jaundice is the first symptom of the disease. Later others such as a poor appetite, vomiting, increased susceptibility to infection and poor weight gain appear. If the infant survives, cata racts develop and physical and mental growth are retarded. An early diagnosis is made by: 1) the severity of the symptoms; 2) the genetic pattern; and 3) the presence of proteinuria and galacto- suria. If milk is removed from the diet, most of the physical manifestations of the disease will regress with the possible exception of the cata- racts and the brain damage. If the diet regimen is instituted within the first few weeks of life, there is an excellent chance that all the symptoms, including mental retardation, can be preventedo Galactosemia is transmitted by an autosomal gene. Both parents are hsterozygotes for the defective gene and contribute equally to the devel- opment of the disorder in affected childrono Galactosemia can be expected to occur in one of four births in such families in a normal distri- butiono The incidence of galactosemia in the popula- tion is not known. It is estimated to occur once in -3- Source: ttps://www.industrydocuments.ucsf.edu/docs/kycg0227 COMPARISON OF THREE CUPS OF VITAMIN D MILK AND NUTRAMIGEN IN MEETING THE NRC RECOMMENDED DIETARY ALLOWANCES FOR A 1-3 YEAR OLD CHILD 25,000-50,000 births. However, in view of the fact that a significant percentage of the affected chil- Milk dren die in the first few months of life, the actual incidence of the gene in the general population may Nutramigen be higher than originally estimated. 146 135 Treatment is directed toward rigid exclusion of galactose from the diet. Since galactose is a como 100 ponent of lactose, a milk sugar, this means that all types of milk and all milk products must be omitted from the diet as well as bread, cereals, puddings, cookies and other food items containing milk in any form. 80 Galactose is also a part of some complex carbo- hydrates, such as stachyose, found in some vegetables. Any known food containing stachyose, or other forms of carbohydrate with galactose a,s a component, should be eliminated from the diet until it is determined with certainty whether these foods yield galactose during 60 metabolism. As new knowledge becomes available in the field of carbohydrate metabolism, it is possible that changes will be made in the galactose=free diet. Milk Substitute 40 To substitute for milk in the child*s diet, Nutramigen, a protein hydrolysate, manufactured by Mead Johnson & Company, or a meat-base formula may be given. Nutramigen has been the most preferred product and is widely used. 20 Nutramigen looks like any other milk formula when it is liquified. The nutritive value is the same or greater than cow's milk with the exception of lactose. See chart. o A NUTRIENTS -4- -5- Source: https://www.industrydocuments.ucsf.edu/docs/kycg0227 The manufacturer of Nutramigen is experimenting with it in liquid form but until it is perfected, If an evaluation of the galactose content and the powder must be mixed with water. Parents have the nutritive value of the individual child's diet found the easiest method of preparing the formula is is indicated, the mother, or the child when older, to make a paste of the powder and a small amount of may be asked to keep a diet record periodically. water before adding the total amount of water. A blender or osterizer works well. Labels The Nutramigen has been well accepted by these As explained in the Parents' Guide, most food children. Parents may find it offensive in odor and products are required by law to carry an accurate taste as they unconsciously compare it to milk and label of ingredients. In lifornia, the only find it so different. foods not required to show this information and which might contain milk are chocolate and certain Parents frequently do not understand that Nutra= breads=wwite, enriched, raisin, milk, whole wheat migen, like regular milk, contains nutrients necessary and graham. Parents should be encouraged to check for growth. There is a tendency for these parents to with the individual baking companies and the local out down or eliminate the Nutramige when the child bakery as to the ingredients used in these breads. becomes a pre=schooler or goes to school. If less All other breads and bread products, including rye, than three cups of Nutramigen are consumed (as a bev- specialty breads, English muffins and bagels, must erage or in food) each day, it is necessary to supo: be labeled, in California, with the specified in- plement the diet with calcium and vitamin Do It is gredients. difficult to provide these nutrients in the recom- mended amounts if milk, or a milk substitute, is Parents should be instructed in reading labels excluded from the diet. to look not only for milk, butter, cream or cheese, but also for other forms of milk which contain Planning the Diet lactose as nonfat dry milk solids, whey and curds. Lactate, lactic acid, lactalbumin and calcium com- For the baby, the diet is planned as for other pounds do not contain lactose. babies with the Nutramigen substituted for breast or cow's milko Most of the "baby foods" such as cereals, Lactose may be used in drugs without having vegetables, fruits and meat are milk=free. Most of to be identified on the label. It is found mostly the "baby dinners" and the soups and puddings for in tablets as a "filler" or as a sweetening agent. infants contain milk in some formo (Gerber's Baby The content of medications and toiletries should Food Company has a table of their products with the be checked with the individual drug company. ingredients listed for each itemo The Family and the Diet As the child grows and eats table foods, a rell-balanced family diet, listed in the Parents The entire family must have a realistic under- Guide, will insure that he has the nutrients needed standing of galactosemia and the value of the die t for growth and development. This diet includes in order for the regimen to be successful. meats, eggs, vegetables, fruits, cereals, and bread, in addition to the Nutramigen. The professional person will find that these parents have anxieties beyond those most parents -6- -7 - - Source: https:/lwww.industrydocuments.ucsf.edu/docs/kycg0227 experience when raising children. The fear of mental retardation, the grave responsibility of teaching their child to follow the diet when away from home and the feeling of guilt for not giving the child their own favorite foods are examples of some of ACKNOWLEDGMENTS their worries. The mother will also encounter additional work We wish to express our gratitude to Richard involved with shopping and preparing the diet. She Koch, M.D , and his multidisciplinary team at the must study carefully each label of food purchased. Child Development Clinic; George N. Donnell, M.D., She may have to search for markets selling milk-free Head of Metabolic and Renal Research; and to margarines and contact baking companies for infor- William Bergren, Ph.D., Head of the Biochemistry mation on ingredients used in their products. ( You Research Division of the Los Angeles Childrens may be able to supply her with brand names (for Hospital, for their interest, encouragement and specific food items) and the names of stores in her assistance in developing this booklet. neighborhood where these products are sold.) We are also indebted to Edward S. Rorem, Ph.D., The professional person will find it a rewarding of the Western Regional Research Laboratory of the experience to counsel these parents whether it be at U.S. Department of Agriculture, for his generosity the doctor's office, a clinic, in the child's home in sharing with us his knowledge of carbohydrates. or in a planned meeting for parents If the child is retarded, the Children's Bureau publication, The We are also grateful to many professional Mentally Retarded Child in the Home may be of help. persons and to parents of children with galacto- semia for their contributions of time, effort and The Parents' Guide is available in separate encouragement. form for distribution to parents. Bureau of Public Health Nutrition California State Department of Public Health -8- Source: https://wwww.industrydocuments.ucsf.edu/docs/kycg0227

what is the common component of lactose?

kycg0227

kycg0227_p2, kycg0227_p3, kycg0227_p4, kycg0227_p5

galactose

Review of Galactosemia and the "Galactose=Free Diet" Galactosemia is an inherited disorder character= ized by an inability to convert galactose to glucose in the normal manner. This results in an abnormal accumulation of the metabolites of galactose in cells of the body. This, in turn, causes damage to various tissues. The inactivity of the specific enzyme, l-phosphogalactose-uridyl transferase (P=gal-transferase), is known to be the cause of this defect in metabolisme Jaundice is the first symptom of the disease. Later others such as a poor appetite, vomiting, increased susceptibility to infection and poor weight gain appear. If the infant survives, cata racts develop and physical and mental growth are retarded. An early diagnosis is made by: 1) the severity of the symptoms; 2) the genetic pattern; and 3) the presence of proteinuria and galacto- suria. If milk is removed from the diet, most of the physical manifestations of the disease will regress with the possible exception of the cata- racts and the brain damage. If the diet regimen is instituted within the first few weeks of life, there is an excellent chance that all the symptoms, including mental retardation, can be preventedo Galactosemia is transmitted by an autosomal gene. Both parents are hsterozygotes for the defective gene and contribute equally to the devel- opment of the disorder in affected childrono Galactosemia can be expected to occur in one of four births in such families in a normal distri- butiono The incidence of galactosemia in the popula- tion is not known. It is estimated to occur once in -3- Source: ttps://www.industrydocuments.ucsf.edu/docs/kycg0227 COMPARISON OF THREE CUPS OF VITAMIN D MILK AND NUTRAMIGEN IN MEETING THE NRC RECOMMENDED DIETARY ALLOWANCES FOR A 1-3 YEAR OLD CHILD 25,000-50,000 births. However, in view of the fact that a significant percentage of the affected chil- Milk dren die in the first few months of life, the actual incidence of the gene in the general population may Nutramigen be higher than originally estimated. 146 135 Treatment is directed toward rigid exclusion of galactose from the diet. Since galactose is a como 100 ponent of lactose, a milk sugar, this means that all types of milk and all milk products must be omitted from the diet as well as bread, cereals, puddings, cookies and other food items containing milk in any form. 80 Galactose is also a part of some complex carbo- hydrates, such as stachyose, found in some vegetables. Any known food containing stachyose, or other forms of carbohydrate with galactose a,s a component, should be eliminated from the diet until it is determined with certainty whether these foods yield galactose during 60 metabolism. As new knowledge becomes available in the field of carbohydrate metabolism, it is possible that changes will be made in the galactose=free diet. Milk Substitute 40 To substitute for milk in the child*s diet, Nutramigen, a protein hydrolysate, manufactured by Mead Johnson & Company, or a meat-base formula may be given. Nutramigen has been the most preferred product and is widely used. 20 Nutramigen looks like any other milk formula when it is liquified. The nutritive value is the same or greater than cow's milk with the exception of lactose. See chart. o A NUTRIENTS -4- -5- Source: https://www.industrydocuments.ucsf.edu/docs/kycg0227 The manufacturer of Nutramigen is experimenting with it in liquid form but until it is perfected, If an evaluation of the galactose content and the powder must be mixed with water. Parents have the nutritive value of the individual child's diet found the easiest method of preparing the formula is is indicated, the mother, or the child when older, to make a paste of the powder and a small amount of may be asked to keep a diet record periodically. water before adding the total amount of water. A blender or osterizer works well. Labels The Nutramigen has been well accepted by these As explained in the Parents' Guide, most food children. Parents may find it offensive in odor and products are required by law to carry an accurate taste as they unconsciously compare it to milk and label of ingredients. In lifornia, the only find it so different. foods not required to show this information and which might contain milk are chocolate and certain Parents frequently do not understand that Nutra= breads=wwite, enriched, raisin, milk, whole wheat migen, like regular milk, contains nutrients necessary and graham. Parents should be encouraged to check for growth. There is a tendency for these parents to with the individual baking companies and the local out down or eliminate the Nutramige when the child bakery as to the ingredients used in these breads. becomes a pre=schooler or goes to school. If less All other breads and bread products, including rye, than three cups of Nutramigen are consumed (as a bev- specialty breads, English muffins and bagels, must erage or in food) each day, it is necessary to supo: be labeled, in California, with the specified in- plement the diet with calcium and vitamin Do It is gredients. difficult to provide these nutrients in the recom- mended amounts if milk, or a milk substitute, is Parents should be instructed in reading labels excluded from the diet. to look not only for milk, butter, cream or cheese, but also for other forms of milk which contain Planning the Diet lactose as nonfat dry milk solids, whey and curds. Lactate, lactic acid, lactalbumin and calcium com- For the baby, the diet is planned as for other pounds do not contain lactose. babies with the Nutramigen substituted for breast or cow's milko Most of the "baby foods" such as cereals, Lactose may be used in drugs without having vegetables, fruits and meat are milk=free. Most of to be identified on the label. It is found mostly the "baby dinners" and the soups and puddings for in tablets as a "filler" or as a sweetening agent. infants contain milk in some formo (Gerber's Baby The content of medications and toiletries should Food Company has a table of their products with the be checked with the individual drug company. ingredients listed for each itemo The Family and the Diet As the child grows and eats table foods, a rell-balanced family diet, listed in the Parents The entire family must have a realistic under- Guide, will insure that he has the nutrients needed standing of galactosemia and the value of the die t for growth and development. This diet includes in order for the regimen to be successful. meats, eggs, vegetables, fruits, cereals, and bread, in addition to the Nutramigen. The professional person will find that these parents have anxieties beyond those most parents -6- -7 - - Source: https:/lwww.industrydocuments.ucsf.edu/docs/kycg0227 experience when raising children. The fear of mental retardation, the grave responsibility of teaching their child to follow the diet when away from home and the feeling of guilt for not giving the child their own favorite foods are examples of some of ACKNOWLEDGMENTS their worries. The mother will also encounter additional work We wish to express our gratitude to Richard involved with shopping and preparing the diet. She Koch, M.D , and his multidisciplinary team at the must study carefully each label of food purchased. Child Development Clinic; George N. Donnell, M.D., She may have to search for markets selling milk-free Head of Metabolic and Renal Research; and to margarines and contact baking companies for infor- William Bergren, Ph.D., Head of the Biochemistry mation on ingredients used in their products. ( You Research Division of the Los Angeles Childrens may be able to supply her with brand names (for Hospital, for their interest, encouragement and specific food items) and the names of stores in her assistance in developing this booklet. neighborhood where these products are sold.) We are also indebted to Edward S. Rorem, Ph.D., The professional person will find it a rewarding of the Western Regional Research Laboratory of the experience to counsel these parents whether it be at U.S. Department of Agriculture, for his generosity the doctor's office, a clinic, in the child's home in sharing with us his knowledge of carbohydrates. or in a planned meeting for parents If the child is retarded, the Children's Bureau publication, The We are also grateful to many professional Mentally Retarded Child in the Home may be of help. persons and to parents of children with galacto- semia for their contributions of time, effort and The Parents' Guide is available in separate encouragement. form for distribution to parents. Bureau of Public Health Nutrition California State Department of Public Health -8- Source: https://wwww.industrydocuments.ucsf.edu/docs/kycg0227

Nutramigen is manufactured by which company?

kycg0227

kycg0227_p2, kycg0227_p3, kycg0227_p4, kycg0227_p5

Mead Johnson & Company, mead johnson & company

Review of Galactosemia and the "Galactose=Free Diet" Galactosemia is an inherited disorder character= ized by an inability to convert galactose to glucose in the normal manner. This results in an abnormal accumulation of the metabolites of galactose in cells of the body. This, in turn, causes damage to various tissues. The inactivity of the specific enzyme, l-phosphogalactose-uridyl transferase (P=gal-transferase), is known to be the cause of this defect in metabolisme Jaundice is the first symptom of the disease. Later others such as a poor appetite, vomiting, increased susceptibility to infection and poor weight gain appear. If the infant survives, cata racts develop and physical and mental growth are retarded. An early diagnosis is made by: 1) the severity of the symptoms; 2) the genetic pattern; and 3) the presence of proteinuria and galacto- suria. If milk is removed from the diet, most of the physical manifestations of the disease will regress with the possible exception of the cata- racts and the brain damage. If the diet regimen is instituted within the first few weeks of life, there is an excellent chance that all the symptoms, including mental retardation, can be preventedo Galactosemia is transmitted by an autosomal gene. Both parents are hsterozygotes for the defective gene and contribute equally to the devel- opment of the disorder in affected childrono Galactosemia can be expected to occur in one of four births in such families in a normal distri- butiono The incidence of galactosemia in the popula- tion is not known. It is estimated to occur once in -3- Source: ttps://www.industrydocuments.ucsf.edu/docs/kycg0227 COMPARISON OF THREE CUPS OF VITAMIN D MILK AND NUTRAMIGEN IN MEETING THE NRC RECOMMENDED DIETARY ALLOWANCES FOR A 1-3 YEAR OLD CHILD 25,000-50,000 births. However, in view of the fact that a significant percentage of the affected chil- Milk dren die in the first few months of life, the actual incidence of the gene in the general population may Nutramigen be higher than originally estimated. 146 135 Treatment is directed toward rigid exclusion of galactose from the diet. Since galactose is a como 100 ponent of lactose, a milk sugar, this means that all types of milk and all milk products must be omitted from the diet as well as bread, cereals, puddings, cookies and other food items containing milk in any form. 80 Galactose is also a part of some complex carbo- hydrates, such as stachyose, found in some vegetables. Any known food containing stachyose, or other forms of carbohydrate with galactose a,s a component, should be eliminated from the diet until it is determined with certainty whether these foods yield galactose during 60 metabolism. As new knowledge becomes available in the field of carbohydrate metabolism, it is possible that changes will be made in the galactose=free diet. Milk Substitute 40 To substitute for milk in the child*s diet, Nutramigen, a protein hydrolysate, manufactured by Mead Johnson & Company, or a meat-base formula may be given. Nutramigen has been the most preferred product and is widely used. 20 Nutramigen looks like any other milk formula when it is liquified. The nutritive value is the same or greater than cow's milk with the exception of lactose. See chart. o A NUTRIENTS -4- -5- Source: https://www.industrydocuments.ucsf.edu/docs/kycg0227 The manufacturer of Nutramigen is experimenting with it in liquid form but until it is perfected, If an evaluation of the galactose content and the powder must be mixed with water. Parents have the nutritive value of the individual child's diet found the easiest method of preparing the formula is is indicated, the mother, or the child when older, to make a paste of the powder and a small amount of may be asked to keep a diet record periodically. water before adding the total amount of water. A blender or osterizer works well. Labels The Nutramigen has been well accepted by these As explained in the Parents' Guide, most food children. Parents may find it offensive in odor and products are required by law to carry an accurate taste as they unconsciously compare it to milk and label of ingredients. In lifornia, the only find it so different. foods not required to show this information and which might contain milk are chocolate and certain Parents frequently do not understand that Nutra= breads=wwite, enriched, raisin, milk, whole wheat migen, like regular milk, contains nutrients necessary and graham. Parents should be encouraged to check for growth. There is a tendency for these parents to with the individual baking companies and the local out down or eliminate the Nutramige when the child bakery as to the ingredients used in these breads. becomes a pre=schooler or goes to school. If less All other breads and bread products, including rye, than three cups of Nutramigen are consumed (as a bev- specialty breads, English muffins and bagels, must erage or in food) each day, it is necessary to supo: be labeled, in California, with the specified in- plement the diet with calcium and vitamin Do It is gredients. difficult to provide these nutrients in the recom- mended amounts if milk, or a milk substitute, is Parents should be instructed in reading labels excluded from the diet. to look not only for milk, butter, cream or cheese, but also for other forms of milk which contain Planning the Diet lactose as nonfat dry milk solids, whey and curds. Lactate, lactic acid, lactalbumin and calcium com- For the baby, the diet is planned as for other pounds do not contain lactose. babies with the Nutramigen substituted for breast or cow's milko Most of the "baby foods" such as cereals, Lactose may be used in drugs without having vegetables, fruits and meat are milk=free. Most of to be identified on the label. It is found mostly the "baby dinners" and the soups and puddings for in tablets as a "filler" or as a sweetening agent. infants contain milk in some formo (Gerber's Baby The content of medications and toiletries should Food Company has a table of their products with the be checked with the individual drug company. ingredients listed for each itemo The Family and the Diet As the child grows and eats table foods, a rell-balanced family diet, listed in the Parents The entire family must have a realistic under- Guide, will insure that he has the nutrients needed standing of galactosemia and the value of the die t for growth and development. This diet includes in order for the regimen to be successful. meats, eggs, vegetables, fruits, cereals, and bread, in addition to the Nutramigen. The professional person will find that these parents have anxieties beyond those most parents -6- -7 - - Source: https:/lwww.industrydocuments.ucsf.edu/docs/kycg0227 experience when raising children. The fear of mental retardation, the grave responsibility of teaching their child to follow the diet when away from home and the feeling of guilt for not giving the child their own favorite foods are examples of some of ACKNOWLEDGMENTS their worries. The mother will also encounter additional work We wish to express our gratitude to Richard involved with shopping and preparing the diet. She Koch, M.D , and his multidisciplinary team at the must study carefully each label of food purchased. Child Development Clinic; George N. Donnell, M.D., She may have to search for markets selling milk-free Head of Metabolic and Renal Research; and to margarines and contact baking companies for infor- William Bergren, Ph.D., Head of the Biochemistry mation on ingredients used in their products. ( You Research Division of the Los Angeles Childrens may be able to supply her with brand names (for Hospital, for their interest, encouragement and specific food items) and the names of stores in her assistance in developing this booklet. neighborhood where these products are sold.) We are also indebted to Edward S. Rorem, Ph.D., The professional person will find it a rewarding of the Western Regional Research Laboratory of the experience to counsel these parents whether it be at U.S. Department of Agriculture, for his generosity the doctor's office, a clinic, in the child's home in sharing with us his knowledge of carbohydrates. or in a planned meeting for parents If the child is retarded, the Children's Bureau publication, The We are also grateful to many professional Mentally Retarded Child in the Home may be of help. persons and to parents of children with galacto- semia for their contributions of time, effort and The Parents' Guide is available in separate encouragement. form for distribution to parents. Bureau of Public Health Nutrition California State Department of Public Health -8- Source: https://wwww.industrydocuments.ucsf.edu/docs/kycg0227

what looks like any other milk formula when liquified?

kycg0227

kycg0227_p2, kycg0227_p3, kycg0227_p4, kycg0227_p5

nutramigen, Nutramigen

Review of Galactosemia and the "Galactose=Free Diet" Galactosemia is an inherited disorder character= ized by an inability to convert galactose to glucose in the normal manner. This results in an abnormal accumulation of the metabolites of galactose in cells of the body. This, in turn, causes damage to various tissues. The inactivity of the specific enzyme, l-phosphogalactose-uridyl transferase (P=gal-transferase), is known to be the cause of this defect in metabolisme Jaundice is the first symptom of the disease. Later others such as a poor appetite, vomiting, increased susceptibility to infection and poor weight gain appear. If the infant survives, cata racts develop and physical and mental growth are retarded. An early diagnosis is made by: 1) the severity of the symptoms; 2) the genetic pattern; and 3) the presence of proteinuria and galacto- suria. If milk is removed from the diet, most of the physical manifestations of the disease will regress with the possible exception of the cata- racts and the brain damage. If the diet regimen is instituted within the first few weeks of life, there is an excellent chance that all the symptoms, including mental retardation, can be preventedo Galactosemia is transmitted by an autosomal gene. Both parents are hsterozygotes for the defective gene and contribute equally to the devel- opment of the disorder in affected childrono Galactosemia can be expected to occur in one of four births in such families in a normal distri- butiono The incidence of galactosemia in the popula- tion is not known. It is estimated to occur once in -3- Source: ttps://www.industrydocuments.ucsf.edu/docs/kycg0227 COMPARISON OF THREE CUPS OF VITAMIN D MILK AND NUTRAMIGEN IN MEETING THE NRC RECOMMENDED DIETARY ALLOWANCES FOR A 1-3 YEAR OLD CHILD 25,000-50,000 births. However, in view of the fact that a significant percentage of the affected chil- Milk dren die in the first few months of life, the actual incidence of the gene in the general population may Nutramigen be higher than originally estimated. 146 135 Treatment is directed toward rigid exclusion of galactose from the diet. Since galactose is a como 100 ponent of lactose, a milk sugar, this means that all types of milk and all milk products must be omitted from the diet as well as bread, cereals, puddings, cookies and other food items containing milk in any form. 80 Galactose is also a part of some complex carbo- hydrates, such as stachyose, found in some vegetables. Any known food containing stachyose, or other forms of carbohydrate with galactose a,s a component, should be eliminated from the diet until it is determined with certainty whether these foods yield galactose during 60 metabolism. As new knowledge becomes available in the field of carbohydrate metabolism, it is possible that changes will be made in the galactose=free diet. Milk Substitute 40 To substitute for milk in the child*s diet, Nutramigen, a protein hydrolysate, manufactured by Mead Johnson & Company, or a meat-base formula may be given. Nutramigen has been the most preferred product and is widely used. 20 Nutramigen looks like any other milk formula when it is liquified. The nutritive value is the same or greater than cow's milk with the exception of lactose. See chart. o A NUTRIENTS -4- -5- Source: https://www.industrydocuments.ucsf.edu/docs/kycg0227 The manufacturer of Nutramigen is experimenting with it in liquid form but until it is perfected, If an evaluation of the galactose content and the powder must be mixed with water. Parents have the nutritive value of the individual child's diet found the easiest method of preparing the formula is is indicated, the mother, or the child when older, to make a paste of the powder and a small amount of may be asked to keep a diet record periodically. water before adding the total amount of water. A blender or osterizer works well. Labels The Nutramigen has been well accepted by these As explained in the Parents' Guide, most food children. Parents may find it offensive in odor and products are required by law to carry an accurate taste as they unconsciously compare it to milk and label of ingredients. In lifornia, the only find it so different. foods not required to show this information and which might contain milk are chocolate and certain Parents frequently do not understand that Nutra= breads=wwite, enriched, raisin, milk, whole wheat migen, like regular milk, contains nutrients necessary and graham. Parents should be encouraged to check for growth. There is a tendency for these parents to with the individual baking companies and the local out down or eliminate the Nutramige when the child bakery as to the ingredients used in these breads. becomes a pre=schooler or goes to school. If less All other breads and bread products, including rye, than three cups of Nutramigen are consumed (as a bev- specialty breads, English muffins and bagels, must erage or in food) each day, it is necessary to supo: be labeled, in California, with the specified in- plement the diet with calcium and vitamin Do It is gredients. difficult to provide these nutrients in the recom- mended amounts if milk, or a milk substitute, is Parents should be instructed in reading labels excluded from the diet. to look not only for milk, butter, cream or cheese, but also for other forms of milk which contain Planning the Diet lactose as nonfat dry milk solids, whey and curds. Lactate, lactic acid, lactalbumin and calcium com- For the baby, the diet is planned as for other pounds do not contain lactose. babies with the Nutramigen substituted for breast or cow's milko Most of the "baby foods" such as cereals, Lactose may be used in drugs without having vegetables, fruits and meat are milk=free. Most of to be identified on the label. It is found mostly the "baby dinners" and the soups and puddings for in tablets as a "filler" or as a sweetening agent. infants contain milk in some formo (Gerber's Baby The content of medications and toiletries should Food Company has a table of their products with the be checked with the individual drug company. ingredients listed for each itemo The Family and the Diet As the child grows and eats table foods, a rell-balanced family diet, listed in the Parents The entire family must have a realistic under- Guide, will insure that he has the nutrients needed standing of galactosemia and the value of the die t for growth and development. This diet includes in order for the regimen to be successful. meats, eggs, vegetables, fruits, cereals, and bread, in addition to the Nutramigen. The professional person will find that these parents have anxieties beyond those most parents -6- -7 - - Source: https:/lwww.industrydocuments.ucsf.edu/docs/kycg0227 experience when raising children. The fear of mental retardation, the grave responsibility of teaching their child to follow the diet when away from home and the feeling of guilt for not giving the child their own favorite foods are examples of some of ACKNOWLEDGMENTS their worries. The mother will also encounter additional work We wish to express our gratitude to Richard involved with shopping and preparing the diet. She Koch, M.D , and his multidisciplinary team at the must study carefully each label of food purchased. Child Development Clinic; George N. Donnell, M.D., She may have to search for markets selling milk-free Head of Metabolic and Renal Research; and to margarines and contact baking companies for infor- William Bergren, Ph.D., Head of the Biochemistry mation on ingredients used in their products. ( You Research Division of the Los Angeles Childrens may be able to supply her with brand names (for Hospital, for their interest, encouragement and specific food items) and the names of stores in her assistance in developing this booklet. neighborhood where these products are sold.) We are also indebted to Edward S. Rorem, Ph.D., The professional person will find it a rewarding of the Western Regional Research Laboratory of the experience to counsel these parents whether it be at U.S. Department of Agriculture, for his generosity the doctor's office, a clinic, in the child's home in sharing with us his knowledge of carbohydrates. or in a planned meeting for parents If the child is retarded, the Children's Bureau publication, The We are also grateful to many professional Mentally Retarded Child in the Home may be of help. persons and to parents of children with galacto- semia for their contributions of time, effort and The Parents' Guide is available in separate encouragement. form for distribution to parents. Bureau of Public Health Nutrition California State Department of Public Health -8- Source: https://wwww.industrydocuments.ucsf.edu/docs/kycg0227

what does the x-axis represent?

kycg0227

kycg0227_p2, kycg0227_p3, kycg0227_p4, kycg0227_p5

Nutrients, nutrients

Review of Galactosemia and the "Galactose=Free Diet" Galactosemia is an inherited disorder character= ized by an inability to convert galactose to glucose in the normal manner. This results in an abnormal accumulation of the metabolites of galactose in cells of the body. This, in turn, causes damage to various tissues. The inactivity of the specific enzyme, l-phosphogalactose-uridyl transferase (P=gal-transferase), is known to be the cause of this defect in metabolisme Jaundice is the first symptom of the disease. Later others such as a poor appetite, vomiting, increased susceptibility to infection and poor weight gain appear. If the infant survives, cata racts develop and physical and mental growth are retarded. An early diagnosis is made by: 1) the severity of the symptoms; 2) the genetic pattern; and 3) the presence of proteinuria and galacto- suria. If milk is removed from the diet, most of the physical manifestations of the disease will regress with the possible exception of the cata- racts and the brain damage. If the diet regimen is instituted within the first few weeks of life, there is an excellent chance that all the symptoms, including mental retardation, can be preventedo Galactosemia is transmitted by an autosomal gene. Both parents are hsterozygotes for the defective gene and contribute equally to the devel- opment of the disorder in affected childrono Galactosemia can be expected to occur in one of four births in such families in a normal distri- butiono The incidence of galactosemia in the popula- tion is not known. It is estimated to occur once in -3- Source: ttps://www.industrydocuments.ucsf.edu/docs/kycg0227 COMPARISON OF THREE CUPS OF VITAMIN D MILK AND NUTRAMIGEN IN MEETING THE NRC RECOMMENDED DIETARY ALLOWANCES FOR A 1-3 YEAR OLD CHILD 25,000-50,000 births. However, in view of the fact that a significant percentage of the affected chil- Milk dren die in the first few months of life, the actual incidence of the gene in the general population may Nutramigen be higher than originally estimated. 146 135 Treatment is directed toward rigid exclusion of galactose from the diet. Since galactose is a como 100 ponent of lactose, a milk sugar, this means that all types of milk and all milk products must be omitted from the diet as well as bread, cereals, puddings, cookies and other food items containing milk in any form. 80 Galactose is also a part of some complex carbo- hydrates, such as stachyose, found in some vegetables. Any known food containing stachyose, or other forms of carbohydrate with galactose a,s a component, should be eliminated from the diet until it is determined with certainty whether these foods yield galactose during 60 metabolism. As new knowledge becomes available in the field of carbohydrate metabolism, it is possible that changes will be made in the galactose=free diet. Milk Substitute 40 To substitute for milk in the child*s diet, Nutramigen, a protein hydrolysate, manufactured by Mead Johnson & Company, or a meat-base formula may be given. Nutramigen has been the most preferred product and is widely used. 20 Nutramigen looks like any other milk formula when it is liquified. The nutritive value is the same or greater than cow's milk with the exception of lactose. See chart. o A NUTRIENTS -4- -5- Source: https://www.industrydocuments.ucsf.edu/docs/kycg0227 The manufacturer of Nutramigen is experimenting with it in liquid form but until it is perfected, If an evaluation of the galactose content and the powder must be mixed with water. Parents have the nutritive value of the individual child's diet found the easiest method of preparing the formula is is indicated, the mother, or the child when older, to make a paste of the powder and a small amount of may be asked to keep a diet record periodically. water before adding the total amount of water. A blender or osterizer works well. Labels The Nutramigen has been well accepted by these As explained in the Parents' Guide, most food children. Parents may find it offensive in odor and products are required by law to carry an accurate taste as they unconsciously compare it to milk and label of ingredients. In lifornia, the only find it so different. foods not required to show this information and which might contain milk are chocolate and certain Parents frequently do not understand that Nutra= breads=wwite, enriched, raisin, milk, whole wheat migen, like regular milk, contains nutrients necessary and graham. Parents should be encouraged to check for growth. There is a tendency for these parents to with the individual baking companies and the local out down or eliminate the Nutramige when the child bakery as to the ingredients used in these breads. becomes a pre=schooler or goes to school. If less All other breads and bread products, including rye, than three cups of Nutramigen are consumed (as a bev- specialty breads, English muffins and bagels, must erage or in food) each day, it is necessary to supo: be labeled, in California, with the specified in- plement the diet with calcium and vitamin Do It is gredients. difficult to provide these nutrients in the recom- mended amounts if milk, or a milk substitute, is Parents should be instructed in reading labels excluded from the diet. to look not only for milk, butter, cream or cheese, but also for other forms of milk which contain Planning the Diet lactose as nonfat dry milk solids, whey and curds. Lactate, lactic acid, lactalbumin and calcium com- For the baby, the diet is planned as for other pounds do not contain lactose. babies with the Nutramigen substituted for breast or cow's milko Most of the "baby foods" such as cereals, Lactose may be used in drugs without having vegetables, fruits and meat are milk=free. Most of to be identified on the label. It is found mostly the "baby dinners" and the soups and puddings for in tablets as a "filler" or as a sweetening agent. infants contain milk in some formo (Gerber's Baby The content of medications and toiletries should Food Company has a table of their products with the be checked with the individual drug company. ingredients listed for each itemo The Family and the Diet As the child grows and eats table foods, a rell-balanced family diet, listed in the Parents The entire family must have a realistic under- Guide, will insure that he has the nutrients needed standing of galactosemia and the value of the die t for growth and development. This diet includes in order for the regimen to be successful. meats, eggs, vegetables, fruits, cereals, and bread, in addition to the Nutramigen. The professional person will find that these parents have anxieties beyond those most parents -6- -7 - - Source: https:/lwww.industrydocuments.ucsf.edu/docs/kycg0227 experience when raising children. The fear of mental retardation, the grave responsibility of teaching their child to follow the diet when away from home and the feeling of guilt for not giving the child their own favorite foods are examples of some of ACKNOWLEDGMENTS their worries. The mother will also encounter additional work We wish to express our gratitude to Richard involved with shopping and preparing the diet. She Koch, M.D , and his multidisciplinary team at the must study carefully each label of food purchased. Child Development Clinic; George N. Donnell, M.D., She may have to search for markets selling milk-free Head of Metabolic and Renal Research; and to margarines and contact baking companies for infor- William Bergren, Ph.D., Head of the Biochemistry mation on ingredients used in their products. ( You Research Division of the Los Angeles Childrens may be able to supply her with brand names (for Hospital, for their interest, encouragement and specific food items) and the names of stores in her assistance in developing this booklet. neighborhood where these products are sold.) We are also indebted to Edward S. Rorem, Ph.D., The professional person will find it a rewarding of the Western Regional Research Laboratory of the experience to counsel these parents whether it be at U.S. Department of Agriculture, for his generosity the doctor's office, a clinic, in the child's home in sharing with us his knowledge of carbohydrates. or in a planned meeting for parents If the child is retarded, the Children's Bureau publication, The We are also grateful to many professional Mentally Retarded Child in the Home may be of help. persons and to parents of children with galacto- semia for their contributions of time, effort and The Parents' Guide is available in separate encouragement. form for distribution to parents. Bureau of Public Health Nutrition California State Department of Public Health -8- Source: https://wwww.industrydocuments.ucsf.edu/docs/kycg0227

what does the y-axis represent?

kycg0227

kycg0227_p2, kycg0227_p3, kycg0227_p4, kycg0227_p5

percentage of NRC allowances, Percentage of NRC allowances

Review of Galactosemia and the "Galactose=Free Diet" Galactosemia is an inherited disorder character= ized by an inability to convert galactose to glucose in the normal manner. This results in an abnormal accumulation of the metabolites of galactose in cells of the body. This, in turn, causes damage to various tissues. The inactivity of the specific enzyme, l-phosphogalactose-uridyl transferase (P=gal-transferase), is known to be the cause of this defect in metabolisme Jaundice is the first symptom of the disease. Later others such as a poor appetite, vomiting, increased susceptibility to infection and poor weight gain appear. If the infant survives, cata racts develop and physical and mental growth are retarded. An early diagnosis is made by: 1) the severity of the symptoms; 2) the genetic pattern; and 3) the presence of proteinuria and galacto- suria. If milk is removed from the diet, most of the physical manifestations of the disease will regress with the possible exception of the cata- racts and the brain damage. If the diet regimen is instituted within the first few weeks of life, there is an excellent chance that all the symptoms, including mental retardation, can be preventedo Galactosemia is transmitted by an autosomal gene. Both parents are hsterozygotes for the defective gene and contribute equally to the devel- opment of the disorder in affected childrono Galactosemia can be expected to occur in one of four births in such families in a normal distri- butiono The incidence of galactosemia in the popula- tion is not known. It is estimated to occur once in -3- Source: ttps://www.industrydocuments.ucsf.edu/docs/kycg0227 COMPARISON OF THREE CUPS OF VITAMIN D MILK AND NUTRAMIGEN IN MEETING THE NRC RECOMMENDED DIETARY ALLOWANCES FOR A 1-3 YEAR OLD CHILD 25,000-50,000 births. However, in view of the fact that a significant percentage of the affected chil- Milk dren die in the first few months of life, the actual incidence of the gene in the general population may Nutramigen be higher than originally estimated. 146 135 Treatment is directed toward rigid exclusion of galactose from the diet. Since galactose is a como 100 ponent of lactose, a milk sugar, this means that all types of milk and all milk products must be omitted from the diet as well as bread, cereals, puddings, cookies and other food items containing milk in any form. 80 Galactose is also a part of some complex carbo- hydrates, such as stachyose, found in some vegetables. Any known food containing stachyose, or other forms of carbohydrate with galactose a,s a component, should be eliminated from the diet until it is determined with certainty whether these foods yield galactose during 60 metabolism. As new knowledge becomes available in the field of carbohydrate metabolism, it is possible that changes will be made in the galactose=free diet. Milk Substitute 40 To substitute for milk in the child*s diet, Nutramigen, a protein hydrolysate, manufactured by Mead Johnson & Company, or a meat-base formula may be given. Nutramigen has been the most preferred product and is widely used. 20 Nutramigen looks like any other milk formula when it is liquified. The nutritive value is the same or greater than cow's milk with the exception of lactose. See chart. o A NUTRIENTS -4- -5- Source: https://www.industrydocuments.ucsf.edu/docs/kycg0227 The manufacturer of Nutramigen is experimenting with it in liquid form but until it is perfected, If an evaluation of the galactose content and the powder must be mixed with water. Parents have the nutritive value of the individual child's diet found the easiest method of preparing the formula is is indicated, the mother, or the child when older, to make a paste of the powder and a small amount of may be asked to keep a diet record periodically. water before adding the total amount of water. A blender or osterizer works well. Labels The Nutramigen has been well accepted by these As explained in the Parents' Guide, most food children. Parents may find it offensive in odor and products are required by law to carry an accurate taste as they unconsciously compare it to milk and label of ingredients. In lifornia, the only find it so different. foods not required to show this information and which might contain milk are chocolate and certain Parents frequently do not understand that Nutra= breads=wwite, enriched, raisin, milk, whole wheat migen, like regular milk, contains nutrients necessary and graham. Parents should be encouraged to check for growth. There is a tendency for these parents to with the individual baking companies and the local out down or eliminate the Nutramige when the child bakery as to the ingredients used in these breads. becomes a pre=schooler or goes to school. If less All other breads and bread products, including rye, than three cups of Nutramigen are consumed (as a bev- specialty breads, English muffins and bagels, must erage or in food) each day, it is necessary to supo: be labeled, in California, with the specified in- plement the diet with calcium and vitamin Do It is gredients. difficult to provide these nutrients in the recom- mended amounts if milk, or a milk substitute, is Parents should be instructed in reading labels excluded from the diet. to look not only for milk, butter, cream or cheese, but also for other forms of milk which contain Planning the Diet lactose as nonfat dry milk solids, whey and curds. Lactate, lactic acid, lactalbumin and calcium com- For the baby, the diet is planned as for other pounds do not contain lactose. babies with the Nutramigen substituted for breast or cow's milko Most of the "baby foods" such as cereals, Lactose may be used in drugs without having vegetables, fruits and meat are milk=free. Most of to be identified on the label. It is found mostly the "baby dinners" and the soups and puddings for in tablets as a "filler" or as a sweetening agent. infants contain milk in some formo (Gerber's Baby The content of medications and toiletries should Food Company has a table of their products with the be checked with the individual drug company. ingredients listed for each itemo The Family and the Diet As the child grows and eats table foods, a rell-balanced family diet, listed in the Parents The entire family must have a realistic under- Guide, will insure that he has the nutrients needed standing of galactosemia and the value of the die t for growth and development. This diet includes in order for the regimen to be successful. meats, eggs, vegetables, fruits, cereals, and bread, in addition to the Nutramigen. The professional person will find that these parents have anxieties beyond those most parents -6- -7 - - Source: https:/lwww.industrydocuments.ucsf.edu/docs/kycg0227 experience when raising children. The fear of mental retardation, the grave responsibility of teaching their child to follow the diet when away from home and the feeling of guilt for not giving the child their own favorite foods are examples of some of ACKNOWLEDGMENTS their worries. The mother will also encounter additional work We wish to express our gratitude to Richard involved with shopping and preparing the diet. She Koch, M.D , and his multidisciplinary team at the must study carefully each label of food purchased. Child Development Clinic; George N. Donnell, M.D., She may have to search for markets selling milk-free Head of Metabolic and Renal Research; and to margarines and contact baking companies for infor- William Bergren, Ph.D., Head of the Biochemistry mation on ingredients used in their products. ( You Research Division of the Los Angeles Childrens may be able to supply her with brand names (for Hospital, for their interest, encouragement and specific food items) and the names of stores in her assistance in developing this booklet. neighborhood where these products are sold.) We are also indebted to Edward S. Rorem, Ph.D., The professional person will find it a rewarding of the Western Regional Research Laboratory of the experience to counsel these parents whether it be at U.S. Department of Agriculture, for his generosity the doctor's office, a clinic, in the child's home in sharing with us his knowledge of carbohydrates. or in a planned meeting for parents If the child is retarded, the Children's Bureau publication, The We are also grateful to many professional Mentally Retarded Child in the Home may be of help. persons and to parents of children with galacto- semia for their contributions of time, effort and The Parents' Guide is available in separate encouragement. form for distribution to parents. Bureau of Public Health Nutrition California State Department of Public Health -8- Source: https://wwww.industrydocuments.ucsf.edu/docs/kycg0227

which has more calcium milk or nutramigen?

kycg0227

kycg0227_p2, kycg0227_p3, kycg0227_p4, kycg0227_p5

milk, Milk

Review of Galactosemia and the "Galactose=Free Diet" Galactosemia is an inherited disorder character= ized by an inability to convert galactose to glucose in the normal manner. This results in an abnormal accumulation of the metabolites of galactose in cells of the body. This, in turn, causes damage to various tissues. The inactivity of the specific enzyme, l-phosphogalactose-uridyl transferase (P=gal-transferase), is known to be the cause of this defect in metabolisme Jaundice is the first symptom of the disease. Later others such as a poor appetite, vomiting, increased susceptibility to infection and poor weight gain appear. If the infant survives, cata racts develop and physical and mental growth are retarded. An early diagnosis is made by: 1) the severity of the symptoms; 2) the genetic pattern; and 3) the presence of proteinuria and galacto- suria. If milk is removed from the diet, most of the physical manifestations of the disease will regress with the possible exception of the cata- racts and the brain damage. If the diet regimen is instituted within the first few weeks of life, there is an excellent chance that all the symptoms, including mental retardation, can be preventedo Galactosemia is transmitted by an autosomal gene. Both parents are hsterozygotes for the defective gene and contribute equally to the devel- opment of the disorder in affected childrono Galactosemia can be expected to occur in one of four births in such families in a normal distri- butiono The incidence of galactosemia in the popula- tion is not known. It is estimated to occur once in -3- Source: ttps://www.industrydocuments.ucsf.edu/docs/kycg0227 COMPARISON OF THREE CUPS OF VITAMIN D MILK AND NUTRAMIGEN IN MEETING THE NRC RECOMMENDED DIETARY ALLOWANCES FOR A 1-3 YEAR OLD CHILD 25,000-50,000 births. However, in view of the fact that a significant percentage of the affected chil- Milk dren die in the first few months of life, the actual incidence of the gene in the general population may Nutramigen be higher than originally estimated. 146 135 Treatment is directed toward rigid exclusion of galactose from the diet. Since galactose is a como 100 ponent of lactose, a milk sugar, this means that all types of milk and all milk products must be omitted from the diet as well as bread, cereals, puddings, cookies and other food items containing milk in any form. 80 Galactose is also a part of some complex carbo- hydrates, such as stachyose, found in some vegetables. Any known food containing stachyose, or other forms of carbohydrate with galactose a,s a component, should be eliminated from the diet until it is determined with certainty whether these foods yield galactose during 60 metabolism. As new knowledge becomes available in the field of carbohydrate metabolism, it is possible that changes will be made in the galactose=free diet. Milk Substitute 40 To substitute for milk in the child*s diet, Nutramigen, a protein hydrolysate, manufactured by Mead Johnson & Company, or a meat-base formula may be given. Nutramigen has been the most preferred product and is widely used. 20 Nutramigen looks like any other milk formula when it is liquified. The nutritive value is the same or greater than cow's milk with the exception of lactose. See chart. o A NUTRIENTS -4- -5- Source: https://www.industrydocuments.ucsf.edu/docs/kycg0227 The manufacturer of Nutramigen is experimenting with it in liquid form but until it is perfected, If an evaluation of the galactose content and the powder must be mixed with water. Parents have the nutritive value of the individual child's diet found the easiest method of preparing the formula is is indicated, the mother, or the child when older, to make a paste of the powder and a small amount of may be asked to keep a diet record periodically. water before adding the total amount of water. A blender or osterizer works well. Labels The Nutramigen has been well accepted by these As explained in the Parents' Guide, most food children. Parents may find it offensive in odor and products are required by law to carry an accurate taste as they unconsciously compare it to milk and label of ingredients. In lifornia, the only find it so different. foods not required to show this information and which might contain milk are chocolate and certain Parents frequently do not understand that Nutra= breads=wwite, enriched, raisin, milk, whole wheat migen, like regular milk, contains nutrients necessary and graham. Parents should be encouraged to check for growth. There is a tendency for these parents to with the individual baking companies and the local out down or eliminate the Nutramige when the child bakery as to the ingredients used in these breads. becomes a pre=schooler or goes to school. If less All other breads and bread products, including rye, than three cups of Nutramigen are consumed (as a bev- specialty breads, English muffins and bagels, must erage or in food) each day, it is necessary to supo: be labeled, in California, with the specified in- plement the diet with calcium and vitamin Do It is gredients. difficult to provide these nutrients in the recom- mended amounts if milk, or a milk substitute, is Parents should be instructed in reading labels excluded from the diet. to look not only for milk, butter, cream or cheese, but also for other forms of milk which contain Planning the Diet lactose as nonfat dry milk solids, whey and curds. Lactate, lactic acid, lactalbumin and calcium com- For the baby, the diet is planned as for other pounds do not contain lactose. babies with the Nutramigen substituted for breast or cow's milko Most of the "baby foods" such as cereals, Lactose may be used in drugs without having vegetables, fruits and meat are milk=free. Most of to be identified on the label. It is found mostly the "baby dinners" and the soups and puddings for in tablets as a "filler" or as a sweetening agent. infants contain milk in some formo (Gerber's Baby The content of medications and toiletries should Food Company has a table of their products with the be checked with the individual drug company. ingredients listed for each itemo The Family and the Diet As the child grows and eats table foods, a rell-balanced family diet, listed in the Parents The entire family must have a realistic under- Guide, will insure that he has the nutrients needed standing of galactosemia and the value of the die t for growth and development. This diet includes in order for the regimen to be successful. meats, eggs, vegetables, fruits, cereals, and bread, in addition to the Nutramigen. The professional person will find that these parents have anxieties beyond those most parents -6- -7 - - Source: https:/lwww.industrydocuments.ucsf.edu/docs/kycg0227 experience when raising children. The fear of mental retardation, the grave responsibility of teaching their child to follow the diet when away from home and the feeling of guilt for not giving the child their own favorite foods are examples of some of ACKNOWLEDGMENTS their worries. The mother will also encounter additional work We wish to express our gratitude to Richard involved with shopping and preparing the diet. She Koch, M.D , and his multidisciplinary team at the must study carefully each label of food purchased. Child Development Clinic; George N. Donnell, M.D., She may have to search for markets selling milk-free Head of Metabolic and Renal Research; and to margarines and contact baking companies for infor- William Bergren, Ph.D., Head of the Biochemistry mation on ingredients used in their products. ( You Research Division of the Los Angeles Childrens may be able to supply her with brand names (for Hospital, for their interest, encouragement and specific food items) and the names of stores in her assistance in developing this booklet. neighborhood where these products are sold.) We are also indebted to Edward S. Rorem, Ph.D., The professional person will find it a rewarding of the Western Regional Research Laboratory of the experience to counsel these parents whether it be at U.S. Department of Agriculture, for his generosity the doctor's office, a clinic, in the child's home in sharing with us his knowledge of carbohydrates. or in a planned meeting for parents If the child is retarded, the Children's Bureau publication, The We are also grateful to many professional Mentally Retarded Child in the Home may be of help. persons and to parents of children with galacto- semia for their contributions of time, effort and The Parents' Guide is available in separate encouragement. form for distribution to parents. Bureau of Public Health Nutrition California State Department of Public Health -8- Source: https://wwww.industrydocuments.ucsf.edu/docs/kycg0227

What is the title?

lycg0227

lycg0227_p0, lycg0227_p1, lycg0227_p2, lycg0227_p3, lycg0227_p4, lycg0227_p5, lycg0227_p6, lycg0227_p7, lycg0227_p8, lycg0227_p9, lycg0227_p10, lycg0227_p11, lycg0227_p12, lycg0227_p13

THE LOW PHENYLALANINE DIET, FOR PROFESSIONAL USE, the low phenylalanine diet

for professional use The Low Phenylalanine Diet STATE OF CALIFORNIA DEPARTMENT OF PUBLIC HEALTH 2151 Berkeley Way Berkeley 4, California THE LOW PHENYLALANINE DIET This concise description of the practical aspects of the low phenyl- alanine diet for phenylketonuria is intended for physicians, nurses, dieti- tians, nutritionists, social workers, and others who may give guidance to parents of children with phenylketonuria. Assistance in preparing this booklet for professional use and the included material for parents' use was obtained from many professional persons and parents who Prepared by have had practical experience with the low phenylalanine diet. THE BUREAU OF PUBLIC HEALTH NUTRITION OF THE CALIFORNIA The material for distribution to parents is intended to supplement the STATE DEPARTMENT OF PUBLIC HEALTH individual child's diet and instructions from his physician. An entire copy (except for cover) of A Diet Guide for Parents of Children with Phenylketonuria is included in the Appendix for the purpose of infor- mation. It contains a simple definition of phenylketonuria, an explana- tion of the diet, practical suggestions for preparing the synthetic food product, a daily meal guide (to be filled out by the child's physician), Active cooperation was given by: low phenylalanine exchange lists, and recipes. THE CHILD DEVELOPMENT CLINIC OF THE LOS ANGELES CHILDRENS HOSPITAL Review of the Low Phenylalanine Diet and The low phenylalanine diet is prescribed for the control of phenyl- ketonuria (PKU), a metabolic disorder in which the amino acid, THE DEPARTMENT OF PEDIATRICS OF THE phenylalanine, is not properly utilized by the body. Usually associated UNIVERSITY OF SOUTHERN CALIFORNIA SCHOOL OF MEDICINE with uncontrolled phenylketonuria are severe mental retardation, hyper- active behavior and frequently convulsive disorders and eczema. Assistance in preparation was given by: Phenylalanine is found in large amounts in all protein-rich foods and THE BUREAU OF MATERNAL AND CHILD HEALTH in lesser amounts in cereals, vegetables and other foods. It is an essential THE BUREAU OF CRIPPLED CHILDREN SERVICES amino acid which means that some is needed by the body. The child's THE BUREAU OF HEALTH EDUCATION physician will determine the amount of phenylalanine the child needs CALIFORNIA STATE DEPARTMENT OF PUBLIC HEALTH for growth without the danger of toxicity. This amount may vary from 10 to 20 milligrams per pound of body weight per day depending upon the individual child and his age. The diet may be prescribed in milligrams of phenylalanine or grams of protein as most proteins con- tain about five percent phenylalanine. A diet program with the desired amount of phenylalanine is then tailored to the child's need so that the serum phenylalanine content will vary between 2 and 6 milligrams per 100 parts. The diet must include a synthetic food as it is impossible to obtain enough protein for growth from natural foods without also getting a toxic amount of phenylalanine. 1 Source: ittps://www.industrydocuments.ucst.edu/docs/lycg022 A casein hydrolysate formula* called Lofenalac, manufactured by FOOD VALUES OF LOW PHENYLALANINE EXCHANGES Mead Johnson Company, looks like a milk formula when liquefied and (See parents' guide in the Appendix, p. 7, for the complete exchange lists) is used widely. See graph below for nutrient comparison. Note that Phenyl- Carbo- ascorbic acid is completely missing in Lofenalac. alanine Protein Fat bydrate List Exchange * mg. gm. gm. gm. Calories I. Lofenalac 30 6.0 7.0 22.0 175 II. Vegetables 15 0.3 1.0 5 -- COMPARISON OF THREE CUPS OF VITAMIN D MILK AND LOFENALAC IN III. Fruits 15 0.2 20.0 80 ---- MEETING THE NRC DIETARY ALLOWANCES FOR A CHILD FROM IV. Breads 30 0.5 5.0 20 --- ONE TO THREE YEARS OLD V. Fats 5 0.1 5.0 45 ---- VI. Desserts 30 2.0 varies varies varies 138 VII. Free Foods 0 0 varies varies varies VIII. Foods not allowed --- --- --- 102 Milk * The Lofenalac exchange is four tablespoons of the dry Lofenalac or reconstituted in one cup 100 (8 oz.) of water. The size servings of other exchanges will vary slightly according to the Lofenlac The fat, carbohydrate and calories are approximate averages for vegetables, fruits, bread. phenylalanine content of the individual food. Desserts and free foods will vary according to the recipe and food. The Meal Guide 75 In addition to the Exchange Lists, the child's physician will provide the parents with a Meal Guide (see Appendix p. 6). This will indicate the number of servings that the child should have of each exchange, such as for breakfast, 1 exchange of fruit, 2 exchanges of bread, 1 ex- 50 change of fat. By this method, the child will have the prescribed amount of phenyl- alanine and the mother will be spared the tedious task of counting the 25 milligrams of phenylalanine. Recipes The recipes in A Diet Guide for Parents of Children With Phenyl- 0 Calories Protein Calcium Iron Vitamin Thiamine Ribo- Ascorbic Vitamin ketonuria (see Appendix p. 11) have been tested and are popular with A flavin Acid D the children. Some contain very little phenylalanine and can help satisfy NUTRIENTS the children. Other recipes have extra amounts of Lofenalac to compen- sate for the Lofenalac that the child may not want to drink. Exchange Lists The Child and the Diet To simplify the low phenylalanine diet for families and professional Mealtimes should be a pleasant experience for children and their persons, exchange lists have been perfected. The lists are similar to the diabetic exchange lists in that foods of similar phenylalanine content parents even though the child's food may be different from that of the rest of the family. If this diet is started early, the baby readily adapts are listed together and can be exchanged one for another within a list to the low phenylalanine formula along with the low-protein fruits, to give variety to the diet. The phenylalanine content of the foods is based on 5 percent of the protein content as listed in the Bowes and vegetables, and cereals. As these children grow, they usually continue Church Food Values of Portions Commonly Used. to enjoy the diet. Pre-schoolers may prefer the Lofenalac more con- centrated, or with a flavoring or mixed as a paste with fruits or vege- The eight exchange lists are: Lofenalac; vegetables; fruits; breads; fats; tables. desserts; free foods (low in phenylalanine); and the foods to avoid If the diet is initiated when the child is older, it may take longer (high in phenylalanine). for the child to accept it. The child will gradually learn to like the * The first low phenylalanine product on the market was Ketonil manufactured by Merck, Sharpe low phenylalanine products if the parents are patient and do not force and Dohme Company. It needs to be mixed with oil or other fat, sugar and water and is brown in color. This low phenylalanine acid casein hydrolysate has supplementary amino the child to accept the diet. The child may prefer the Lofenalac bev- acids, choline and minerals added. erage with one of the flavorings suggested in the parents' guide. It may 2 3 Source: https://www.industrydocuments.ucsf.edu/docs/lycg0227 be necessary to experiment with the flavorings. For example, one child liked the Lofenalac with a little coffee flavoring. APPENDIX If the child is retarded, helpful suggestions about approaches to feed- ing are listed in the Children's Bureau booklet, The Mentally Retarded Child at Home. The Family and the Diet The entire family should have a realiste understanding of phenylketo- nuria and the value of the diet in order for the regimen to be suc- cessful. Some members of a family may feel sorry for the child because they compare the Lofenalac with milk and find it different and offen- sive. Others may feel guilty over not sharing their favorite foods with the child. Mothers may feel more secure about the diet if assistance is given in planning the first week's menus. The menu planning with the mother should take into consideration her household routine, the child's usual PKU feeding pattern, and the other children's meals. Most mothers find it helpful to record what the child eats. This record also helps the doctor in determining the actual phenylalanine and nutritive value of the child's diet. The family may be over-protective of the child, and delay weaning or self-feeding. The parents should be encouraged to look for and accept the child's readiness for either. Parents should expect appetite changes, food "jags," and hunger strikes as they would with any child. The importance of the father's role should be stressed even though he may not actually prepare the food or feed the child. His supportive A Diet Guide for attitude toward the mother and influence on other members of the family may determine the success of the dietary treatment. Some families are able to adjust to the diet regimen easily; others need more guidance and reassurance. Public health nurses may give Parents of Children additional support and dietary instruction during home visits. Some families may benefit by individual casework service or planned group meetings with other parents of children with phenylketonuria. The professional person will find that working with these families with Phenylketonuria will be a rewarding experience, whether it be in the hospital, the doctor's office, the clinic, or the child's home. The professional person who wants to know more about the diet (fen°.il-ke"-to-nu're-ah) - and other aspects of the disease may secure a recently annotated Bibli- ography on Phenylketomuria from the Children's Bureau, U.S. Depart- ment of Health, Education, and Welfare, Washington, D.C. It is recom- State of California mended for all professional persons working with families of children with phenylketonuria. Department of Public Health For the purpose of information, content of the pamphlet for parents 2151 Berkeley Way of children with PKU, developed by the California State Department Berkeley 4, California of Public Health, is reproduced in the following pages. 5 4 2-44348 Source: https://www.industrydocuments.ucsf.edu/docs/lycgo227 in most well-child conferences in California, for it is so important to find this condition early. If the diaper test indicates that the acid is present, a test will be made to find the amount of phenylalanine in the blood and to prove or disprove the diagnosis. WHAT IS PHENYLKETONURIA? Symptoms Phenylketonuria (fen"-il-ke"-to-nu'-re-ah) called PKU for short, is an A child with PKU whose condition has not been found soon enough inherited condition some children have that makes it impossible for to have the advantage of the low phenylalanine diet may have severe their bodies to properly use phenylalanine (fe-nil-al'-ah-nin), an amino mental retardation, sometimes eczema, excessive uncontrolled body acid found in some foods. If this condition is not treated, the brain movements, and convulsions. Many of these children are irritable and does not develop normally. seem to be unhappy. It is easier to understand phenylketonuria if you can think of it in When one of these children is found and placed on the proper diet, first terms of food. Foods such as meat, fish, milk, eggs, cheese, dried beans his behavior and itching or eczema, if present, usually show the and peas, and most breads and cereals have proteins which are neces- signs of improvement. When an infant or young child with PKU is sary for growth and development. When a person eats such foods as already retarded at the time the diet is started, some improvement in meat, milk and fish, the proteins are broken down into amino acids mentality (I.Q.) may be expected, but usually there remains some which the body uses with the help of body chemicals called enzymes. amount of permanent retardation. This is why it is so important that low In phenylketonuria, a particular liver enzyme is lacking. As a result, phenylketonuria be discovered early and the child kept on the to the amino acid phenylalanine is not all used by the body and collects phenylalanine diet. It still is not known how long the child needs in large amounts in the blood, preventing the brain from developing remain on the diet. There is some evidence that the diet may not have normally and causing other harm to the body. to be continued after the brain is fully developed. Treatment of this condition was discovered very recently. Medical scientists are now trying to control the condition through a diet low Management in phenylalanine. If the diet is started early enough, the child's brain development will be normal in most cases. But even at a later age, a two or three months or whenever his doctor feels that it is important. the Every child with PKU under treatment should have blood tests every low phenylalanine diet often results in noticeable improvement, es- From these tests, his doctor knows how much phenylalanine is in pecially in behavior. child's blood. Some phenylalanine is necessary for a child to grow normally as the body cannot manufacture it. Inheritance From the blood tests, the doctor will decide how much phenylalanine Phenylketonuria is found in about one out of every 25,000 births. can It is inherited, although it is not a strong enough trait to be inherited plan suitable for the age of the child will be planned developed phenylalanine, with the for parents. chidren diet be allowed in the diet. With this amount of a unless both the mother and father carry this tendency. Even then, not Two low phenylalanine products have been and all the children of these parents will have phenylketonuria. Usually with PKU to substitute for protein foods such as milk, meat, eggs, similar only one out of four children of such parents will have this condition, fish. These products are low in phenylalanine but are otherwise and but this is not always true, When one child with phenylketonuria is to milk in food value. One is Ketonil, made by the Merkk, Sharpe found in a family, all children should be checked, especially infants. Dohme and When the child with PKU becomes an adult and if he or she marries and has children, the chances are small that the children will have PKU. Johnson Drug widely Company. Company; the other is Lofenalac, made expensive limited. by Ketonil the because Mead Lofenalac looks more like milk than is more used at present. The products are This is due to the slight chance of marrying another adult with PKU the manufacturing process is complex and their use is or a carrier of the tendency. have very little phenylalanine such as fruits and most vegetables, must Diets using these low phenylalanine products, along with foods that Diagnosis be carefully planned for each child with PKU. With proper dietary and The diagnosis is usually simple. The urine of a child with PKU, who management, the child should gain weight, or lose if overweight, will is not on a diet, will contain phenylpyruvic acid which comes from the excess phenylalanine in the blood. A simple chemical test of urine grow have many understanding people to help them-doctors, dietitians, nurses normally. The parents are responsible for the diet, but they or a wet diaper with 10 percent ferric chloride will show that it is and other professional people. present. This test is now being done regularly by some physicians and The following pages will give further details on managing the diet. 7 6 Source: https://www.industrydocuments.ucsf.edu/docs/lycgo227 she and her husband realized what was wrong. As she told us later, they changed their attitude to thinking only "that this wonderful diet will make it possible for our child to live a happy life". Most of the children on Lofenalac have liked it if they were started THE LOW PHENYLALANINE DIET on it while they were very young. The older children who have been Your doctor has given you a diet program for your child with eating other food may not like it at first, but in time will like it. phenylketonuria. The diet may seem confusing to you. If it does, you Mothers have added flavors to it such as sugar, chocolate, honey, are not alone. Many families have had this feeling when they received almond extract, maple syrup, fruit juices, and fruits (especially pine- the diet or when they first started to prepare it at home, but soon they apple). Strained vegetables mixed with the formula make a cream soup became familiar with it. that many older children like. A few drops of food coloring help Families in the past did not have the opportunity you have to help sometimes. their children with phenylketonuria. The condition was unknown until When your child with PKU is a baby, the Lofenalac formula given a few years ago. Now a family who has a child with PKU can follow to him will look like any baby formula, and the amounts and kinds of a diet, low in the amino acid phenylalanine, and help their child. What strained fruits and vegetables will be about the same as for any baby. a small price to pay for the rewards it brings! It is when the child is older that the diet is plainly different from that of other children. He will not be eating eggs, meat and other foods The Diet Plan high in phenylalanine, but will still need Lofenalac to provide most of Your doctor has determined the number of milligrams of phenylala- his needs for growth. To add variety, you many find the special recipes nine your child should have in his diet each day and has planned with in this booklet helpful. you a Meal Guide, usually of six feedings. The Meal Guide will change as your child grows older. Weaning Along with the Meal Guide, you have been given food lists. These You may need to give your child with PKU extra attention when are called Exchange Lists because foods of the same sort and about the you think that he is ready to drink from a cup. This takes patience same amount of phenylalanine are grouped together. For variety, you especially if the child is clumsy or shows no interest in drinking from can exchange or substitute the foods within a group. Many of these a cup or glass. Some mothers use a training cup that has a lid and a foods are those you can serve the entire family. spout. Others find the child will drink from a cup if he is given a There are eight exchange lists: Lofenalac (the low phenylalanine small pitcher with a little Lofenalac in it and is encouraged to pour it food) vegetables; fruit; breads; fats; desserts; "free foods"; and "foods into a small cup himself. to avoid." While you are weaning your child, he may not want to take all of In a short time, you will find it easy to plan with the exchange list. the prescribed Lofenalac in liquid form, so you may have to use more For example, if your child's meal guide calls for one serving of a vege- of it in puddings, cereals, fruits and soups. table exchange, you can choose one of twelve or more. Each vegetable will have listed the size serving. If you wanted strained carrots, it would Self-Feeding be three tablespoons. If you chose strained beets, it would be two table- Your child, of course, must learn to feed himself. Watch for signs of spoons. Each serving would contain the same amount of phenylalanine. his wanting to feed himself and encourage him to do it. At first, if he seems slow, it may be harder and more awkward for him than for Lofenalac other children, but he will learn in time. A difficulty that you may have is that the milk substitute formula If he has never put things in his mouth, you can dip his fingers into your child must have will look like milk, but to you it will not taste or the strained fruits and put them in his mouth to give him the idea. You smell like milk. It may even seem distasteful to you, but it is very im- can then teach him to pick up bits of fruit or vegetable or dry cereal portant that you do not show this feeling to your child, either by word to put in his mouth. or action, for he may refuse the formula just because he senses that you You can show him how to pick up a spoon and then guide it to his do not like it. mouth. Some mothers find this works best if you stand behind him to One mother using Lofenalac disliked the smell so much that she, do it. Foods like pudding or thick cereal are best to begin with because without thinking of the effect on her child, would "make a face" when they stay better on the spoon. she gave it to him. Because of this, he refused it for several days, until 8 9 Source: https://www.industrydocuments.ucsf.edu/docs/lycg0227 Changes in Appetite As your child grows, his appetite will change from time to time. Some days he will eat more than others. He does not have to eat the exact amounts shown on his meal plan every day. If you are concerned about his appetite, talk it over with your doctor. LOW PHENYLALANINE MEAL GUIDE Parents' Anxieties for It is natural for all parents to have worries when raising a child. You Date may have more concern with your child on a PKU diet, just as other Age Milligrams of phenylalanine per pound parents have with children on strict diets. Some of your worry may come from well-meaning relatives and neighbors who may not under- Weight Milligrams of phenylalanine for the day stand the child's condition and who think it is cruel to deprive the child of foods they happen to like. Mix Lofenalac to ounces of water. Some parents, knowing how important it is that their child does not BREAKFAST Milligrams of get too much phenylalanine, have a fear that the child will accidently Phenylalanine eat a forbidden food. They may not realize that if a child has never Give ounces of the Lofenalac mixture tasted a food, he probably will not want it. Choose Exchanges from List 3 (Fruits) Some parents foresee that they may become discouraged with the Choose Exchanges from List 4 (Breads & Cereals) diet and feel sorry for themselves. Choose Exchanges from List 5 (Fats) Some mothers are concerned that they will give too much attention MIDMORNING to their child with PKU and neglect the rest of their family. These are but examples of fears that you may never experience. If Choose Exchanges from List you do have worries about the child and the diet, it will help to dis- DINNER cuss them with the doctor or other professional person working with Give ounces of the Lofenalac mixture him such as the nurse, the nutritionist, or the social worker. Choose In time, your child's diet, which he must have, will soon become Exchanges from List 2 (Vegetables) Choose Exchanges from List 3 (Fruits) routine to you and to your child. The main job, of course, is the Choose Exchanges from List 4 (Breads & Cereals) mother's, but the father's help and support are just as important in Choose Exchanges from List 5 (Fats) getting the cooperation of the entire family in the dietary treatment of Choose Exchanges from List 6 (Desserts) your child with phenylketonuria. The following pages contain the meal guide, the exchange lists, and MIDAFTERNOON recipes for the low phenylalanine diet. At first, the diet may be difficult Choose Exchanges from List to follow, but it will get easier as you learn from experience. SUPPER Give ounces of the Lofenalac mixture Choose Exchanges from List 2 (Vegetables) Choose Exchanges from List 3 (Fruits) Choose Exchanges from List 4 (Breads & Cereals) Choose Exchanges from List 5 (Fats) Choose Exchanges from List 6 (Desserts) BEDTIME Choose Exchanges from List TOTAL You can vary your child's meal by choosing different food listed in each of the six exchange lists. 10 11 Source: https://www.industrydocuments.ucsf.edu/docs/lycg0227 EXCHANGE LISTS FOR LOW PHENYLALANINE DIET Cabbage, raw, shredded 4 Tbsp. (Adapted from Exchange Lists of the Dietary Service and Department of Pedi- Carrots, raw 1/4 Large atrics, College of Medical Evangelists, and reproduced with permission from the canned 4 Tbsp. American Dietetic Association.) Cauliflower 2 Tbsp. Celery, raw 2 Stalks DEFINITIONS Corn c. Cup. One standard household measuring cup. Dry foods are 1 Tbsp. Cucumber, raw 1/3 Med. measured as one level measuring cup. One cup contains one- Lettuce, head 2 Leaves half pint or 8 fluid ounces. Mushrooms, cooked 2 Tbsp. Tbsp. Tablespoon. One standard household measuring tablespoon. Okra, pod, cooked 1 Pod Dry foods are measured as one level measuring tablespoon. 16 Onion, mature 1/3 Med. level tablespoons equal one cup. Two tablespoons equal one green 2 Med. ounce. Parsley 2 Sprigs Tsp. Teaspoon. One standard household measuring teaspoon. Dry Potato, Irish 1 Tbsp. foods are measured as one level teaspoon. Three teaspoons Pumpkin, cooked 2 Tbsp. equal one tablespoon. Radish, small, raw 3 Small Spinach, creamed, canned only * 2 Tbsp. LIST 1. LOFENALAC * Squash, winter, cooked 2 Tbsp. Each serving, or Exchange, contains 30 milligrams of Phenylalanine summer, cooked 4 Tbsp. Lofenalac, dry 4 Tbsp. Tomato, raw 1/4 Small Lofenalac, reconstituted canned 2 Tbsp. 1 cup powder to 1 quart water 1 c. fluid juice 2 Tbsp. or 16 packed, level measures of powder to one quart Turnip 4 Tbsp. water 1 c. fluid Yam and sweet potato, cooked 1 Tbsp. Directions for Mixing Lofenalac LIST 3. FRUITS Make a paste of the Lofenalac with a small amount of boiling water before adding the total water Each serving or Exchange contains 15 milligrams of Phenylalanine or Sprinkle the Lofenalac on top of the water and beat with an Baby and Junior Fruits eggbeater Apricot-applesauce, strained and junior 10 Tbsp. or Mix in a blender or Osterizer Banana 7 Tbsp. Orange juice 3 Tbsp. LIST 2. VEGETABLES Peaches, strained 5 Tbsp. Each serving, or Exchange, contains 15 milligrams of Phenylalanine junior 7 Tbsp. Baby and Junior Vegetables Pears, strained and junior 10 Tbsp. Beans, green, strained & junior 2 Tbsp. Pear-pineapple, strained and junior 7 Tbsp. Beets, strained 2 Tbsp. Plums with tapioca, strained 5 Tbsp. Carrots, strained & junior 3 Tbsp. junior 7 Tbsp. Spinach, creamed, strained & junior 2 Tbsp. Prunes, strained 3 Tbsp. Squash, winter, strained 3 Tbsp. Table Fruits junior 6 Tbsp. Apple, raw 1 Small Tomato juice 2 Tbsp. Apricot, canned 2 Halves Yam or sweet potato, strained 2 Tbsp. juice 1/4 c. Avocado Table Vegetables 2 Tbsp. Banana Asparagus 2 Stalks 4 Tbsp. Dates, dried 2 Beans, green, cooked 3 Tbsp. Cantaloupe 1/8 Melon Beets, cooked 3 Tbsp. * Do not use home-cooked spinach. * Mead Johnson Company 12 13 Source: https://www.industrydocuments.ucsf.edu/docs/lycg022 Fruit cocktail, canned 2 Tbsp. LIST 5. FATS Grapefruit, sections or juice 1/3 c. Each serving or Exchange contains 5 milligrams of Phenylalanine Guava, raw 1/3 Med. Butter 1 Tsp. Orange, sections or juice 3 Tbsp. Cream, heavy 1 Tsp. Grape juice 1/3 c. Margarine 1 Tbsp. Lemon or lime juice 3 Tbsp. Mayonnaise 1¹/² Tbsp. frozen concentrate, mixed 1/2 c. Olives, ripe 1 Large Mango 1/2 Small Oil 1 Tsp. Papaya juice 1/2 c. Papaya, cubed LIST 6. DESSERTS 1/4 c. Peaches, raw 2/3 Med. Each serving or Exchange contains 30 milligrams of Phenylalanine canned in syrup 1¹/² Halves Cake * 1/6 of cake Pear, raw Cookies-Rice Flour * 2 1/3 c. canned in syrup 3 Halves Corn Starch 2 Pineapple, raw 1/3 c. Cookies, Arrowroot 1¹/2 canned in syrup 1¹/² sm.sl. Ice Cream-Chocolate 1/3 c. juice 1/2 c. Pineapple 1/3 c. Strawberry * Plums, canned in syrup 1 Med. 1/3 c. Popsicle with fruit juice 1 Vanilla * 1/3 c. Prunes, cooked 2 Med. Puddings * 1/2 c. juice 1/3 c. Sauce, Hershey 2 Tbsp. Raisins 1 Tbsp. Wafers, Sugar, Nabisco 6 Strawberries 3 Large LIST 7. FREE FOODS Tangerine 2/2 Small Each serving or Exchange contains little or no Phenylalanine. Watermelon 2/3 c. May be used as desired. LIST 4. BREAD, CEREALS Apple juice If more than a cup, Honey count as a fruit Each serving or Exchange contains 30 milligrams of Phenylalanine Applesauce Jams, Jellies, Marmalades exchange. Jel-Quick (artificial gelatin) Baby Foods Candy Molasses Barley cereal, Gerber's, dry 2 Tbsp. butterscotch Pepper Cereal food, Gerber's, dry 2 Tbsp. cream mints 3 Tbsp. fondant Popsicle (with fruit flavoring only) Mixed cereal, Pablum, dry Salt Oatmeal, Gerber's, strained 3 Tbsp. gum drops Pablum, dry 3 Tbsp. hard Sauces * Table Foods jelly beans lemon Biscuits * lollipops white 1 Small Cornstarch Sugar, brown or white Cornflakes 1/3 c. Guava butter Syrups, corn, maple Cornpone 1 Small Guavas Tapioca Crackers, Barnum animal 6 Saltines 3 LIST 8. FOODS TO AVOID Cream of Wheat, cooked 3 Tbsp. Each serving is very bigh in Phenylalanine. May not be used Hominy grits, cooked 5 Tbsp. except with physician's permission. Rice Flakes, Quaker 1/3 c. Breads Legumes (dried peas, beans and seeds) Rice Krispies, Kelloggs 1/3 c. Cheese, all kinds Nuts Rice, Puffed, Quaker 1/2 c. Eggs Nut butters Sugar Crisps 1/4 c. Flour, all kinds Milk (55 milligrams phenylalanine Wheat, Puffed, Quaker 1/3 C. Meat, poultry, fish per ounce) * Low phenylalanine recipes. * Low phenylalanine recipes. 14 15 Source: https://www.industrydocuments.ucsf.edu/docs/lycg0221 ICE CREAM (Strawberry) Ingredients Amount Mixing Instructions Water 1/4 C. Mix together and cook in top of Sugar 6 tbsp. double boiler until thickened. Cornstarch 3 tbsp. Place in refrigerator to cool. RECIPES Lemon juice 1 tbsp. Beat cream with hand or rotary Cream, 30-40% 1 c. beater until it stands in peaks (Reproduced with permission of the Dietary Department and Department of Strawberries, fresh 1/2 c. sliced but isn't buttery. Fold in fresh Pediatrics of The College of Medical Evangelists of Los Angeles and the American sliced strawberries and starch Dietetic Association.) mixture. If cornstarch mixture is too thick, thin with whipped ICE CREAM (Chocolate) cream or decrease cornstarch to Ingredients Amount Mixing Instructions 2 tbsp. Place in freezer unit and Water 1/4 c. freeze. Heat together in double boiler Cornstarch 3 tbsp. the water and the chocolate until Makes 3 cups. Sweetened chocolate 1 square chocolate is melted. Add corn- Nutrients per 1/3 cup serving: Cream, 30-40% 1 c. starch and cook until thickened. Pro. 0.6 gm., Fat 6.4 gm., CHO 13.0 gm., Phenylalanine 30 mg. Sugar 6 tbsp. Place in refrigerator to cool. Vanilla 1 tsp. Beat cream with hand or electric Vanilla Ice Cream: Follow above directions substituting 1 tbsp. vanilla beater until it stands in peaks for fresh sliced strawberries. but is not buttery. Add sugar Nutrients per 1/3 cup serving: and vanilla. Then fold in choco- Pro. 0.6 gm., Fat 6.4 gm., CHO 12.0 gm., Phenylalanine 28 mg. late mixture and combine thor- oughly. If chocolate mixture is too thick, thin with some of the whipped cream or decrease corn- BLANC MANGE starch to 2 tbsp. Place in freezer unit to freeze. Ingredients Amount Mixing Instructions Makes 3 cups. Sugar 1/2 c. Mix sugar, cornstarch, and salt Nutrients per 1/3 cup serving: Cornstarch 5 tbsp. in top of double boiler. Mix Protein 0.6 gm., Fat 7.2 gm., CHO 13.0 gm., Phenylalanine 31 mg. Salt 1/4 tsp. Lofenalac with boiling water. Lofenalac (dry) 2 c. Gradually add to cornstarch Boiling water 4 c. mixture mixing until smooth. Vanilla 2 tsp. Place over boiling water and cook, stirring constantly until ICE CREAM (Pineapple) mixture thickens. Cover and Ingredients Amount Mixing Instructions continue cooking 10 minutes longer. Remove from heat. Add Pineapple juice 1/4 c. Mix together and cook in top of vanilla and cool. Cornstarch 3 tbsp. double boiler until thickened. Makes 8 servings. Lemon juice 1 tbsp. Place in refrigerator to cool. May be served with karo, jelly, honey or jam. Sugar 4 tbsp. Beat cream with hand or electric Nutrients per serving: Approximate 1/2 cup. Cream, 30-40% 1 c. beater until it stands in peaks Pro. 6.0 gm., Fat 5.1 gm., CHO 33.2 gm., Phenylalanine 30 mg. Pineapple, crushed 1/2 c. but is not buttery. Fold in crushed pineapple and the above mixture. If cornstarch mixture is too thick, thin with some of whipped cream or decrease corn- starch to 2 tbsp. Place in freezer unit and freeze. Makes 3 cups. Nutrients per 1/3 cup serving: Protein 0.6 gm., Fat 6.4 gm., CHO 13.0 gm., Phenylalanine 32 mg. 17 16 Source: ttps://www.industrydocuments.ucsf.edu/docs/lycg0227 LEMON PUDDING PINEAPPLE PUDDING Ingredients Amount Mixing Instructions Ingredients Amount Mixing Instructions Lofenalac (dry) 9 tbsp. Mix Lofenalac and boiling water Lofenalac (dry) 8 tbsp. Boiling water 11/4 c. together with rotary beater until Mix together Lofenalac and Boiling water 11/2 c. boiling water until well blended. Sugar 1/2 c. well blended. Combine sugar, Pineapple juice 4 tbsp. Cornstarch cornstarch, and salt, and mix Add pineapple juice. Combine 2 tbsp. Sugar 1/2 c. Salt I/8 tsp. with liquid Lofenalac. Cook in sugar, cornstarch, and salt, then Cornstarch double boiler until thickened. 2 tbsp. mix with Lofenalac-pineapple Oil 1 tbsp. Salt Add oil, lemon rind, and juice. 1/8 tsp. juice. Cook in double boiler until Grated lemon rind 1 tsp. Oil 1 tbsp. thickened. Add oil, vanilla, and Lemon juice 3 tbsp. Stir until well blended. Vanilla 1 tsp. crushed pineapple. Stir until Remove from heat and cool. Makes three 1/2 cup servings. Crushed pineapple 1/4 c. well blended. Nutrients per serving (approximately 1/2 cup): Pro. 4.5 gm., Fat 9.9 gm., CHO 55.2 gm., Phenylalanine 28.0 mg. Makes three 1/2 cup servings. Nutrients per serving (approximately 1/2 cup): Pro. 4.1 gm., Fat 9.8 gm., CHO 58.5 gm., Phenylalanine 28.5 mg. CHOCOLATE PUDDING Ingredients Amount Mixing Instructions Lofenalac (dry) 9 tbsp. Mix Lofenalac and boiling water Boiling water 1¹/2 c. together with 'rotary beater until VANILLA PUDDING AND BANANA PUDDING Chocolate, unsweetened 1/2 ounce well blended. Place in double Sugar 1/2 c. boiler. Add unsweetened choco- Ingredients Amount Mixing Instructions Cornstarch 2 tbsp. late to liquid Lofenalac. Heat Lofenalac (dry) 11 tbsp. Mix Lofenalac and boiling water Salt 1/8 tsp. until chocolate melts. Combine Boiling water 11/2 c. together with rotary beater until Oil 1 tbsp. sugar, cornstarch, and salt, then Sugar 1/2 c. well blended. Combine sugar, Vanilla 1 tsp. mix with Lofenalac-chocolate Cornstarch 2 tbsp. cornstarch, and salt, then mix mixture and cook until thick- Salt I/8 tsp. with Lofenalac. Cook in double ened. Add oil and vanilla and Oil 1 tbsp. boiler until thickened. Add oil, stir until well blended. Vanilla 2 tsp. vanilla, and lemon juice. Stir Makes three 1/2 cup servings. Lemon juice 1 tsp. until well blended. Nutrients per serving (approximately 1/2 cup): Pro. 4.5 gm., Fat 10.9 gm., CHO 54.8 gm., Phenylalanine 29.6. mg. Remove from heat and cool. Makes three I/2 cup servings BANANA PUDDING: Follow above recipe substituting 1 tsp. banana TAPIOCA PUDDING flavor and 2 tbsp. mashed banana for the vanilla. Ingredients Amount Mixing Instructions Nutrients per serving (approximately 1/2 cup): Vanilla Banana Stir water slowly into tapioca. Protein Boiling water 1 c. 5.2 gm. 5.7 gm. Add sugar, salt, and Lofenalac. Fat Quick-cooking tapioca 2 1/2 tbsp. 10.8 gm. 10.8 gm. Mix until thoroughly blended. CHO 57.8 gm. 58.4 gm. Sugar 1/4 c. Salt 1/8 tsp. Cook over boiling water 12 Phenylalanine 29.0 mg. 31.0 mg. Lofenalac (dry) 6 tbsp. minutes or until clear, stirring Vanilla 1/2 tsp. frequently. Cool. Add vanilla. Chill. Makes 2 servings. COMMERCIAL PUDDING MIXES PEACH: Before chilling, stir in 2 1/2 tbsp. junior peaches. PINEAPPLE: Before chilling, stir in 1/4 cup drained crushed pineapple. Various pudding mixes on the market which require cooking may be used by substituting double strength (8 tbsp. to 1 cup water) Lofenalac Nutrients per serving: Approximately 1/2 cup Vanilla Peach Pineapple in place of the milk ordinarily used. A 1/2 cup serving gives 30 mg. of Protein 4.5 gm. 4.5 gm. phenylalanine. These mixes should not contain gelatin, flour, milk or 4.5 gm. Fat 5.1 gm. 5.1 gm. 5.1 gm. eggs. CHO 52.4 gm. 61.9 gm. 61.9 gm. Phenylalanine 29.2 mg. 32.7 mg. 34.2 mg. 18 19 Source: https://wwww.industrydocuments.ucsf.edu/docs/lycg0227 PLAIN CAKE LEMON SAUCE * Ingredients Amount Mixing Instructions Ingredients Amount Mixing Instructions Fat (oil or margarine) 4 tbsp. Sift dry ingredients together. Sugar 1/2 cup Cream fat, add sugar, mix well. Sugar 1/2 c. Mix together sugar, cornstarch, Cornstarch Lofenalac, liquid 1/2 cup plus 1 Add liquid, dry ingredients and 11/2 tbsp. salt and dry Lofenalac. Salt tbsp. vanilla. Bake in greased pan 1/4 tsp. Gradually add water to above Cake flower 1 cup (9" X 9" X 2") or muffin pans at Lofenalac (dry) 5 tbsp. ingredients. Cook over medium Baking powder 3 tsp. 375° for 25-30 minutes. Boiling water 11/2 c. heat, stirring constantly until Oil Salt 1/4 tsp. 2 tbsp. sauce thickens and comes to Vanilla 1/2 tsp. Lemon juice 3 tbsp. boil. Boil 2 minutes. Remove Grated lemon rind Can be used as birthday cake. 1 cup cake or 1/6 of cake gives 30 mg. 2 tsp. from heat and add oil, lemon juice, and rind. phenylalanine. Makes about 2 cups. Use as topping for puddings. RICE FLOUR COOKIES * Nutrients per serving (2 tbsp.) Pro. 0.5 gm., Fat 2.3 gm., CHO 8.7 gm., Phenylalanine 3.1 mg. Ingredients Amount Mixing Instructions Cornstarch 1/2 c. Sift together cornstarch, sugar, Confectioner's sugar 1/2 C. flour and salt. Blend room Rice flour, white 1 c. temperature butter (or oil) into Salt 1/4 tsp. dry ingredients with fork until WHITE SAUCE * Butter or oil 1 c. a soft ball is formed. Shape into Ingredients Amount Vanilla 1/4 tsp. small balls with hands. Place on Mixing Instructions Oil ungreased baking sheet about 3 tbsp. Place oil in saucepan. Add corn- 11/2 inches apart. Flatten cookies Cornstarch 2 tbsp. starch and salt and blend well. with fork. Bake in 300° F. oven Salt 1 tsp. Mix together Lofenalac and for 20-25 minutes. Lofenalac (dry) 1/2 c. water using rotary beater to Makes about 2 dozen small cookies. Warm water 2 c. blend well. Add to oil-corn- starch-salt mixture and cook Nutrients per cookie: until thickened. Pro. 0.3 gm., Fat 5.0 gm., CHO 7.0 gm., Phenylalanine 14.7 mg. (If oil is used, phenylalanine content is slightly decreased.) Makes about 2 cups white sauce. Two tbsp. chopped parsley may be CORNSTARCH COOKIES * added for variety. White sauce is useful in preparation of a variety of creamed vegetables, etc. Ingredients Amount Mixing Instructions Nutrients per serving (2 tbsp.): Cornstarch 1 c. unsifted Sift together cornstarch, salt, Pro. 0.7 gm., Fat 3.5 gm., CHO 3.6 gm., Phenylalanine 4 mg. Baking powder 1 tsp. and baking powder. Salt 1/4 tsp. Mix oil (or room temperature Oil or butter 1/3 c. butter), sugar, syrup, egg, and Sugar 1/2 c. vanilla in bowl. Beat with hand Corn syrup 2 tbsp. beater until thoroughly blended. CORN PONE Egg 1 unbeaten Add sifted dry ingredients and Ingredients Amount Mixing Instructions Vanilla 2 tsp. mix well. Cover baking sheet with brown paper. Do not Corn meal, yellow Sift cornmeal and salt together. enriched grease. Drop batter by tea- 1/4 c. Add boiling water to make a Salt spoonfuls 3 inches apart on 1/3 tsp. firm mixture. Shape into 5 thin paper. Bake in 350° F. oven 12 Boiling water 1/2 c. cakes, place in pan well greased with oil and bake in 400° F. minutes. oven 15-20 minutes. Cool slightly before removing from baking sheet. Makes 18 cookies. Makes 5 small cakes. NOTE: 1 tsp. cinnamon or nutmeg makes a pleasing variation. Nutrients per serving (per 1 small cake): Nutrients per cookie: Pro. 0.6 gm., Fat 0.1 gm., CHO 5.7 gm., Phenylalanine 29 mg. Pro. 0.3 gm., Fat 4.3 gm., CHO 13.4 gm., Phenylalanine 17.9 mg. (If butter is used, phenylalanine content is slightly increased.) * Recipes adapted from Allergy Recipes, American Dietetic Association, 1957. * Recipes adapted from Allergy Recipes, American Dietetic Association, 1957. 20 21 Source: https://www.industrydocuments.ucst.edu/docs/lycg0227 TNS 6-1 Published by the STATE OF CALIFORNIA DEPARTMENT OF PUBLIC HEALTH BUREAU OF HEALTH EDUCATION 2151 BERKELEY WAY BERKELEY 4, CALIFORNIA Source: industry is

in Figure 6. "PATIENT E.W" is "running the mile event" at which competition?

kzhd0227

kzhd0227_p5, kzhd0227_p6, kzhd0227_p7, kzhd0227_p8, kzhd0227_p9, kzhd0227_p10, kzhd0227_p11, kzhd0227_p12

SENIOR OLYMPICS, Senior Olympics

-5- - - The Experimental Effect of Diet on Co-existing Diseases DRUG-TREATED DISEASES RETURN TO NORMAL CLASSIFICATION AT START OF STUDY WITHOUT DRUGS No. of Subjects No. of Subjects % Angina 3 3 100 Hypertension 8 6 75 Diabetes: ADA Diet-controlled 10 9 90 Oral drugs 1 1 100 Insulin, 80 units 1 2 50 30 units ) 0 Gout 2 2 100 Arthritis 2 2 100 Congestive heart failure 3 2 66 Elevated blood lipids 2 2 100 TABLE 2 Comparison of Artery Stenosis before (1/20/75) and after Study (6/26/75) in L.S. ANGIOGRAPHICALLY AUTOPSY CONFIRMED LOCATION OF STENOSIS DETERMINED % STENOSIS % STENOSIS (1/20/75) (6/26/75) Right common iliac in proximal position 70% 40% Left common iliac at bifurcation 99% 40% Right common femoral at its origin 100% 50% TABLE 3 Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 () Figure 2. Initial baseline angiogram of L.S. This film demonstrates complete occlusion of the right common femoral artery at its origin (arrows). Figure 3. Macroscopic cross section of right common femoral artery stained for elastic tissue. Specimen was taken from a portion of artery which was shown angiographically (see Fig. 2) to be totally occluded. Note that the two branch arteries seen in the left lower quadrant of this cross-section correspond to branch arteries (at the occlusion site) in angio above. Source: ttps://www.industrydocuments.ucsf.edu/docs/kzhd0227 7 Figure 4a. Initial baseline angiogram (January '75) of K.B. Figure 4b. Final angiogram (June '75) of K.B. The numbers in the above line drawings correspond to numbers noted in the text. (1) The origin of the left external iliac indicates an 80% concentric stenosis in the January angiogram becoming a 50% concentric stenosis in the June angiogram; (2) The middle 1/3 of the external iliac is markedly irregular with an 80% concentric stenests in the January angiogram becoming a smooth eccentric 30% stenosis in the June angiogram: (3) The distal 1/3 of the external iliac shows moderately severe irregularities with is eccentric stenosis in the January angiogram becoming a smooth widely patent arterial segment in the June angiogram. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 8 Figure 5a. Dark field high power view of normal non-aggregating red blood cells 6 hours after a low fat meal. 3 Figure 5b. Example of red blood cell aggregation and rouleaux formation 6 hours after a high fat meal. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 () DISCUSSION The reasons for the dramatic results in reversing claudication and other atherosclerotic symptoms on a diet and exercise regimen are elucidated by tissue anoxia studies. Tissue anoxia is present III those consuming the conventional Western diet with its high 40% of total calories in fat Anoxia due to tliet in young undamaged arteries may not cause obvious symptomis, but when there IS some artery stenosis due to plaque formation (and this includes almost everyone over 25 years of age in this country) this results in increases in blood pressure and, in individuals with advanced atherosclerosis, angina and claudication. One of the first to study tissue anoxia produced by a high fat, meal was Swank11 who ted hamsters cream meals and then. through their transparent check pouches. observed the effects on the erythrocytes. As the chylomicrons started to pour in from the cream meal. the erythrocy les began adhering to each other. In 3 to 6 hours after the feeding. the aggregations. now in rouleaux and irregular formations, completely blocked many capillaries. Because of the aggregations. the full surface of the erythrocyte was not available for oxygen transfer and during this condition, the oxygen-carrying capacity of the erythrocyte was directly affected, decreasing the plasma OXY gen level to 68% of starting value. It took 72 hours before the oxygen level reached 95% of the original value. Kuo's study13 with angina patients showed that a cream meal could induce an angina attack by lowering the oxygen-carrying capacity of the blood. After an overnight fast, each subject drank heavy cream, then rested quietly while half-hour blood samples were drawn. In 5 hours. the chylomicron influx had peaked and caused the transparent fasting blood to become 600% more turbid on a plasma lactescence scale. Fourteen angina attacks occurred, simultaneously with ischemic ECGs and abnormal ballistocardiograms. The amazing similarity in the reaction of many individuals to fat was shown in almost identical lactescence curves for 13 of the 14 angina patients. These same patients on another morning drank a fat-free drink with identical calories and bulk. After 5 hours, no increased blood turbidity, no angina and no abnormal ECG tracings were noted. Platelet aggregation occurs under the same conditions that produce erythrocyte aggregation. A U.S. Department of Agriculture study, directed by Iacano13 placed normals on a 25% fat diet instead of their usual 40-45% fat intake. Not only did blood pressure and cholesterol levels drop. but there was a 50% drop in platelet aggregation. When the 40-45% fat diet was resumed. platelet aggregation returned to previous levels. As the aggregations broke up reducing the vessel blockage, the increased vessel area now availat le for blood flow permitted the same volume of blood to flow with lowered pressure. Thus. with reduced fat intake, Iacano achieved universal blood pressure drops even in normal subjects. This effect was confirmed in our study with hypertensives. Relief of coronary and calf angina both occur with increased blood flow and oxygen-carry ing capacity of the blood. In our study, these effects occurred within a few weeks after the diet-exercise regimen was begun and coincided with the rapid drop in blood lipids-an average cholesterol drop of 30% in a few weeks and one triglyceride drop from 360 mg.% to 85 mg.%. Thompson's¹ 6 report of 2 women in their 20's with elevated lipids demonstrates the relationship of blood lipid level to angina by utilizing a more drastic method than dietary reform for alleviating the symptoms. To lower the blood lipids-their cholesterol levels averaged 600 mg." they underwent plasma exchange with cholesterol-free plasma protein fraction. Approximately 50 gms. of cholesterol in the form of low density lipoproteins were removed during the 6 month treatment which involved about 8 exchanges of about 3000 ml. of blood. No other therapy changes were made. Blood lipid levels fell to half their previous value and both women lost their angina. While disappearance of angina can be rapidly achieved within weeks, as was demonstrated in our study, or months, as was accomplished in Thompson's, the ultimate cure depending upon artery plaque reversal, is another matter. In primate studies Armstrong¹ and Wissler¹ have reversed artery stenosis on a low-fat diet. Although our results need confirmation by others, we believe they are the first evidence demonstrating reversal of human atherosclerosis by diet. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 --10- AGE AS A LIMITING FACTOR IN REHABILITATION Our study has indicated the promising rehabilitative potential of a diet and activity regimen tor case of a woman, E.W. She began, almost (1 years ago at age 81. using the same regimen described claudication patients. That age need not be a limiting factor in rehabilitation is demonstrated by the in this paper for the experimental group. Her symptoms. like those of the study patients. included other atherosclerotic manifestations besides claudication. Only 5'3'` tall and weighing 100 lbs 101 the last 40 years, she had developed cardiovascular disease and was treated for angina at age (7 Al age 75 she was hospitalized with a severe heart attack. and at age 81 had claudication, congestive heart failure, hypertension, angina and arthritis. When she began the regimen at age 81. her claudication limited her walking to 100 feet and even then the calf pain was SO disabling she often had to be carried home; and the circulation to her hands was SO impaired she wore gloves in the summertime. Last year, at age 85. and after 4 years on the regimen. she was televised at the Senior Oly 111 Irvine, California, where she won 2 gold medals in the half-mile and mile running events. This youl at age 861/2, she repeated the runs and now has 4 gold medals. Each morning she runs a mile and rides her stationary bicycle 10-15 miles; twice weekly she works out in a gym: and she follows her diet assiduously. Her diastolic pressure is 70 mm. CONCLUSION: This combined low-fat diet and exercise approach has proven to be significantly (PK 0011 more effective in the treatment of severe peripheral atherosclerotic vascular disease than current therapies. It is hoped that the results reported by the use of this regimen will encourage other investigutoto to repeat our studies. Figure 6. Patient E.W. running the mile event at the Senior Olympics in Irvine, California. E.W. was 85 years old when this run was made. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 -- -11- REFERENCES 1. KANNEL, W.B., SKINNER, J.J., JR., SCHWARTZ, M.J., SHURTLEFF. D. Intermittent claudication inci- dence in the Framingham Study. Circulation 41:875, 1970. 2. DELIUS, W., ERIKSON, U. Correlation between angiographic and hemodynamic findings in occlusions of arteries of the extremities. Vascular Surg. 3:201, 1969. 3. SINGER, A., ROB, C. The fate of the claudicator, Brit. Med. J. 2:633, 1960. 4. LIVINGSTONE, P.D., JONES, C. Treatment of intermittent claudication with vitamin E. Lancet 11:602, 1958. 5. HOUSLEY, E., McFADYEN, I.J., Vitamin E. in intermittent claudication. Lancet 1:458, 1974. 6. HAEGER, K. Vitamin E in intermittent claudication. Lancet I:1352, 1974, and Vasa 2:280-287, 1973. 7. LARSEN, O.A., LASSEN, N.A. Effect of daily muscular exercise in patients with intermittent claudication. Scandinavian J. Clin. Lab. Invest. Suppl. 93:168, 1967 and Lancet II:1093, 1966. 8. JOHANSSON, B.W., SIEVERS, J. "Spontaneous course" of intermittent claudication. Scandinavian J. Clin. Lab. Invest. Suppl. 93:156, 1967. 9. ZETTERQUIST, S. The effect of active training on the nutritive blood flow in exercising ischemic legs. Scandinavian J. Clin. Lab. Invest. 25:101, 1970. 10. EBEL, A., KUO, J.C. Tolerance for treadmill walking as an index of intermittent claudication. Arch. Phys. Med. and Rehab. 611-614, Nov., 1967. 11. SWANK, R.A. A biochemical basis of multiple sclerosis. C.C. Thomas Publ., Springfield, III., 1961. 12. KUO, P.T. and JOYNER, C.R., JR. Angina pectoris induced by fat ingestion in patients with coronary heart disease. JAMA 158:1008-13, 1955. 13. IACANO, J.M. Lipid research lab. U.S. Department of Agriculture, Beltsville, Md., 20705. Private communication. 14. ARMSTRONG, M.L. and MEGAN, M.B., ET AL. Plasma and carcass cholesterol in rhesus monkeys after low and intermediate levels of dietary cholesterol Circulation Supp. II, 43: II-III, 1971. Also: ARMSTRONG, M.L. ET AL. Xanthomotosis in rhesus monkeys fed a hypercholesterolemic diet. Arch. of Path. 84:227-37, 1967. 15. WISSLER, R.W. Development of the atherosclerotic plaque. Hosp. practice 8:61-72, 1973. 16. THOMPSON, G.R., LOWENTHAL, R., MYANT, N.B. Plasma exchange in the management of homozygous familial hypercholesterolemia. Lancet I:1208, 1975. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 12 This study was financed in part by the Kirsten Foundation, Manhasset, N.Y., and the Longevity Research Institute, Santa Barbara, Ca. We would like to thank Wallace E. Carroll, M.D., William C. Gnekow, M.D., and Samuel H. Brooks, Ph.D., for their professional assistance in the pathological, radiological, and statistical evaluations made in this study. In addition we would like to give credit to Janie Sternal for her photographic assistance. Finally, we would like to acknowledge the support of the following corporations for their help in providing part of the foods used in the experimental diet: Archon Pure Products Corp.; Celestial Seasonings; Charles Soderstrom Enterprises; Chiquita Brands, Inc.; Erewhon, Inc.; Fisher Mills, Inc.: Hol-Grain Div. of Golden Grain; Hunt-Wesson Foods; and Pure Gold, Inc. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227

what is the department name mentioned?

lycg0227

lycg0227_p0, lycg0227_p1, lycg0227_p2, lycg0227_p3, lycg0227_p4, lycg0227_p5, lycg0227_p6, lycg0227_p7, lycg0227_p8, lycg0227_p9, lycg0227_p10, lycg0227_p11, lycg0227_p12, lycg0227_p13

DEPARTMENT OF PUBLIC HEALTH

for professional use The Low Phenylalanine Diet STATE OF CALIFORNIA DEPARTMENT OF PUBLIC HEALTH 2151 Berkeley Way Berkeley 4, California THE LOW PHENYLALANINE DIET This concise description of the practical aspects of the low phenyl- alanine diet for phenylketonuria is intended for physicians, nurses, dieti- tians, nutritionists, social workers, and others who may give guidance to parents of children with phenylketonuria. Assistance in preparing this booklet for professional use and the included material for parents' use was obtained from many professional persons and parents who Prepared by have had practical experience with the low phenylalanine diet. THE BUREAU OF PUBLIC HEALTH NUTRITION OF THE CALIFORNIA The material for distribution to parents is intended to supplement the STATE DEPARTMENT OF PUBLIC HEALTH individual child's diet and instructions from his physician. An entire copy (except for cover) of A Diet Guide for Parents of Children with Phenylketonuria is included in the Appendix for the purpose of infor- mation. It contains a simple definition of phenylketonuria, an explana- tion of the diet, practical suggestions for preparing the synthetic food product, a daily meal guide (to be filled out by the child's physician), Active cooperation was given by: low phenylalanine exchange lists, and recipes. THE CHILD DEVELOPMENT CLINIC OF THE LOS ANGELES CHILDRENS HOSPITAL Review of the Low Phenylalanine Diet and The low phenylalanine diet is prescribed for the control of phenyl- ketonuria (PKU), a metabolic disorder in which the amino acid, THE DEPARTMENT OF PEDIATRICS OF THE phenylalanine, is not properly utilized by the body. Usually associated UNIVERSITY OF SOUTHERN CALIFORNIA SCHOOL OF MEDICINE with uncontrolled phenylketonuria are severe mental retardation, hyper- active behavior and frequently convulsive disorders and eczema. Assistance in preparation was given by: Phenylalanine is found in large amounts in all protein-rich foods and THE BUREAU OF MATERNAL AND CHILD HEALTH in lesser amounts in cereals, vegetables and other foods. It is an essential THE BUREAU OF CRIPPLED CHILDREN SERVICES amino acid which means that some is needed by the body. The child's THE BUREAU OF HEALTH EDUCATION physician will determine the amount of phenylalanine the child needs CALIFORNIA STATE DEPARTMENT OF PUBLIC HEALTH for growth without the danger of toxicity. This amount may vary from 10 to 20 milligrams per pound of body weight per day depending upon the individual child and his age. The diet may be prescribed in milligrams of phenylalanine or grams of protein as most proteins con- tain about five percent phenylalanine. A diet program with the desired amount of phenylalanine is then tailored to the child's need so that the serum phenylalanine content will vary between 2 and 6 milligrams per 100 parts. The diet must include a synthetic food as it is impossible to obtain enough protein for growth from natural foods without also getting a toxic amount of phenylalanine. 1 Source: ittps://www.industrydocuments.ucst.edu/docs/lycg022 A casein hydrolysate formula* called Lofenalac, manufactured by FOOD VALUES OF LOW PHENYLALANINE EXCHANGES Mead Johnson Company, looks like a milk formula when liquefied and (See parents' guide in the Appendix, p. 7, for the complete exchange lists) is used widely. See graph below for nutrient comparison. Note that Phenyl- Carbo- ascorbic acid is completely missing in Lofenalac. alanine Protein Fat bydrate List Exchange * mg. gm. gm. gm. Calories I. Lofenalac 30 6.0 7.0 22.0 175 II. Vegetables 15 0.3 1.0 5 -- COMPARISON OF THREE CUPS OF VITAMIN D MILK AND LOFENALAC IN III. Fruits 15 0.2 20.0 80 ---- MEETING THE NRC DIETARY ALLOWANCES FOR A CHILD FROM IV. Breads 30 0.5 5.0 20 --- ONE TO THREE YEARS OLD V. Fats 5 0.1 5.0 45 ---- VI. Desserts 30 2.0 varies varies varies 138 VII. Free Foods 0 0 varies varies varies VIII. Foods not allowed --- --- --- 102 Milk * The Lofenalac exchange is four tablespoons of the dry Lofenalac or reconstituted in one cup 100 (8 oz.) of water. The size servings of other exchanges will vary slightly according to the Lofenlac The fat, carbohydrate and calories are approximate averages for vegetables, fruits, bread. phenylalanine content of the individual food. Desserts and free foods will vary according to the recipe and food. The Meal Guide 75 In addition to the Exchange Lists, the child's physician will provide the parents with a Meal Guide (see Appendix p. 6). This will indicate the number of servings that the child should have of each exchange, such as for breakfast, 1 exchange of fruit, 2 exchanges of bread, 1 ex- 50 change of fat. By this method, the child will have the prescribed amount of phenyl- alanine and the mother will be spared the tedious task of counting the 25 milligrams of phenylalanine. Recipes The recipes in A Diet Guide for Parents of Children With Phenyl- 0 Calories Protein Calcium Iron Vitamin Thiamine Ribo- Ascorbic Vitamin ketonuria (see Appendix p. 11) have been tested and are popular with A flavin Acid D the children. Some contain very little phenylalanine and can help satisfy NUTRIENTS the children. Other recipes have extra amounts of Lofenalac to compen- sate for the Lofenalac that the child may not want to drink. Exchange Lists The Child and the Diet To simplify the low phenylalanine diet for families and professional Mealtimes should be a pleasant experience for children and their persons, exchange lists have been perfected. The lists are similar to the diabetic exchange lists in that foods of similar phenylalanine content parents even though the child's food may be different from that of the rest of the family. If this diet is started early, the baby readily adapts are listed together and can be exchanged one for another within a list to the low phenylalanine formula along with the low-protein fruits, to give variety to the diet. The phenylalanine content of the foods is based on 5 percent of the protein content as listed in the Bowes and vegetables, and cereals. As these children grow, they usually continue Church Food Values of Portions Commonly Used. to enjoy the diet. Pre-schoolers may prefer the Lofenalac more con- centrated, or with a flavoring or mixed as a paste with fruits or vege- The eight exchange lists are: Lofenalac; vegetables; fruits; breads; fats; tables. desserts; free foods (low in phenylalanine); and the foods to avoid If the diet is initiated when the child is older, it may take longer (high in phenylalanine). for the child to accept it. The child will gradually learn to like the * The first low phenylalanine product on the market was Ketonil manufactured by Merck, Sharpe low phenylalanine products if the parents are patient and do not force and Dohme Company. It needs to be mixed with oil or other fat, sugar and water and is brown in color. This low phenylalanine acid casein hydrolysate has supplementary amino the child to accept the diet. The child may prefer the Lofenalac bev- acids, choline and minerals added. erage with one of the flavorings suggested in the parents' guide. It may 2 3 Source: https://www.industrydocuments.ucsf.edu/docs/lycg0227 be necessary to experiment with the flavorings. For example, one child liked the Lofenalac with a little coffee flavoring. APPENDIX If the child is retarded, helpful suggestions about approaches to feed- ing are listed in the Children's Bureau booklet, The Mentally Retarded Child at Home. The Family and the Diet The entire family should have a realiste understanding of phenylketo- nuria and the value of the diet in order for the regimen to be suc- cessful. Some members of a family may feel sorry for the child because they compare the Lofenalac with milk and find it different and offen- sive. Others may feel guilty over not sharing their favorite foods with the child. Mothers may feel more secure about the diet if assistance is given in planning the first week's menus. The menu planning with the mother should take into consideration her household routine, the child's usual PKU feeding pattern, and the other children's meals. Most mothers find it helpful to record what the child eats. This record also helps the doctor in determining the actual phenylalanine and nutritive value of the child's diet. The family may be over-protective of the child, and delay weaning or self-feeding. The parents should be encouraged to look for and accept the child's readiness for either. Parents should expect appetite changes, food "jags," and hunger strikes as they would with any child. The importance of the father's role should be stressed even though he may not actually prepare the food or feed the child. His supportive A Diet Guide for attitude toward the mother and influence on other members of the family may determine the success of the dietary treatment. Some families are able to adjust to the diet regimen easily; others need more guidance and reassurance. Public health nurses may give Parents of Children additional support and dietary instruction during home visits. Some families may benefit by individual casework service or planned group meetings with other parents of children with phenylketonuria. The professional person will find that working with these families with Phenylketonuria will be a rewarding experience, whether it be in the hospital, the doctor's office, the clinic, or the child's home. The professional person who wants to know more about the diet (fen°.il-ke"-to-nu're-ah) - and other aspects of the disease may secure a recently annotated Bibli- ography on Phenylketomuria from the Children's Bureau, U.S. Depart- ment of Health, Education, and Welfare, Washington, D.C. It is recom- State of California mended for all professional persons working with families of children with phenylketonuria. Department of Public Health For the purpose of information, content of the pamphlet for parents 2151 Berkeley Way of children with PKU, developed by the California State Department Berkeley 4, California of Public Health, is reproduced in the following pages. 5 4 2-44348 Source: https://www.industrydocuments.ucsf.edu/docs/lycgo227 in most well-child conferences in California, for it is so important to find this condition early. If the diaper test indicates that the acid is present, a test will be made to find the amount of phenylalanine in the blood and to prove or disprove the diagnosis. WHAT IS PHENYLKETONURIA? Symptoms Phenylketonuria (fen"-il-ke"-to-nu'-re-ah) called PKU for short, is an A child with PKU whose condition has not been found soon enough inherited condition some children have that makes it impossible for to have the advantage of the low phenylalanine diet may have severe their bodies to properly use phenylalanine (fe-nil-al'-ah-nin), an amino mental retardation, sometimes eczema, excessive uncontrolled body acid found in some foods. If this condition is not treated, the brain movements, and convulsions. Many of these children are irritable and does not develop normally. seem to be unhappy. It is easier to understand phenylketonuria if you can think of it in When one of these children is found and placed on the proper diet, first terms of food. Foods such as meat, fish, milk, eggs, cheese, dried beans his behavior and itching or eczema, if present, usually show the and peas, and most breads and cereals have proteins which are neces- signs of improvement. When an infant or young child with PKU is sary for growth and development. When a person eats such foods as already retarded at the time the diet is started, some improvement in meat, milk and fish, the proteins are broken down into amino acids mentality (I.Q.) may be expected, but usually there remains some which the body uses with the help of body chemicals called enzymes. amount of permanent retardation. This is why it is so important that low In phenylketonuria, a particular liver enzyme is lacking. As a result, phenylketonuria be discovered early and the child kept on the to the amino acid phenylalanine is not all used by the body and collects phenylalanine diet. It still is not known how long the child needs in large amounts in the blood, preventing the brain from developing remain on the diet. There is some evidence that the diet may not have normally and causing other harm to the body. to be continued after the brain is fully developed. Treatment of this condition was discovered very recently. Medical scientists are now trying to control the condition through a diet low Management in phenylalanine. If the diet is started early enough, the child's brain development will be normal in most cases. But even at a later age, a two or three months or whenever his doctor feels that it is important. the Every child with PKU under treatment should have blood tests every low phenylalanine diet often results in noticeable improvement, es- From these tests, his doctor knows how much phenylalanine is in pecially in behavior. child's blood. Some phenylalanine is necessary for a child to grow normally as the body cannot manufacture it. Inheritance From the blood tests, the doctor will decide how much phenylalanine Phenylketonuria is found in about one out of every 25,000 births. can It is inherited, although it is not a strong enough trait to be inherited plan suitable for the age of the child will be planned developed phenylalanine, with the for parents. chidren diet be allowed in the diet. With this amount of a unless both the mother and father carry this tendency. Even then, not Two low phenylalanine products have been and all the children of these parents will have phenylketonuria. Usually with PKU to substitute for protein foods such as milk, meat, eggs, similar only one out of four children of such parents will have this condition, fish. These products are low in phenylalanine but are otherwise and but this is not always true, When one child with phenylketonuria is to milk in food value. One is Ketonil, made by the Merkk, Sharpe found in a family, all children should be checked, especially infants. Dohme and When the child with PKU becomes an adult and if he or she marries and has children, the chances are small that the children will have PKU. Johnson Drug widely Company. Company; the other is Lofenalac, made expensive limited. by Ketonil the because Mead Lofenalac looks more like milk than is more used at present. The products are This is due to the slight chance of marrying another adult with PKU the manufacturing process is complex and their use is or a carrier of the tendency. have very little phenylalanine such as fruits and most vegetables, must Diets using these low phenylalanine products, along with foods that Diagnosis be carefully planned for each child with PKU. With proper dietary and The diagnosis is usually simple. The urine of a child with PKU, who management, the child should gain weight, or lose if overweight, will is not on a diet, will contain phenylpyruvic acid which comes from the excess phenylalanine in the blood. A simple chemical test of urine grow have many understanding people to help them-doctors, dietitians, nurses normally. The parents are responsible for the diet, but they or a wet diaper with 10 percent ferric chloride will show that it is and other professional people. present. This test is now being done regularly by some physicians and The following pages will give further details on managing the diet. 7 6 Source: https://www.industrydocuments.ucsf.edu/docs/lycgo227 she and her husband realized what was wrong. As she told us later, they changed their attitude to thinking only "that this wonderful diet will make it possible for our child to live a happy life". Most of the children on Lofenalac have liked it if they were started THE LOW PHENYLALANINE DIET on it while they were very young. The older children who have been Your doctor has given you a diet program for your child with eating other food may not like it at first, but in time will like it. phenylketonuria. The diet may seem confusing to you. If it does, you Mothers have added flavors to it such as sugar, chocolate, honey, are not alone. Many families have had this feeling when they received almond extract, maple syrup, fruit juices, and fruits (especially pine- the diet or when they first started to prepare it at home, but soon they apple). Strained vegetables mixed with the formula make a cream soup became familiar with it. that many older children like. A few drops of food coloring help Families in the past did not have the opportunity you have to help sometimes. their children with phenylketonuria. The condition was unknown until When your child with PKU is a baby, the Lofenalac formula given a few years ago. Now a family who has a child with PKU can follow to him will look like any baby formula, and the amounts and kinds of a diet, low in the amino acid phenylalanine, and help their child. What strained fruits and vegetables will be about the same as for any baby. a small price to pay for the rewards it brings! It is when the child is older that the diet is plainly different from that of other children. He will not be eating eggs, meat and other foods The Diet Plan high in phenylalanine, but will still need Lofenalac to provide most of Your doctor has determined the number of milligrams of phenylala- his needs for growth. To add variety, you many find the special recipes nine your child should have in his diet each day and has planned with in this booklet helpful. you a Meal Guide, usually of six feedings. The Meal Guide will change as your child grows older. Weaning Along with the Meal Guide, you have been given food lists. These You may need to give your child with PKU extra attention when are called Exchange Lists because foods of the same sort and about the you think that he is ready to drink from a cup. This takes patience same amount of phenylalanine are grouped together. For variety, you especially if the child is clumsy or shows no interest in drinking from can exchange or substitute the foods within a group. Many of these a cup or glass. Some mothers use a training cup that has a lid and a foods are those you can serve the entire family. spout. Others find the child will drink from a cup if he is given a There are eight exchange lists: Lofenalac (the low phenylalanine small pitcher with a little Lofenalac in it and is encouraged to pour it food) vegetables; fruit; breads; fats; desserts; "free foods"; and "foods into a small cup himself. to avoid." While you are weaning your child, he may not want to take all of In a short time, you will find it easy to plan with the exchange list. the prescribed Lofenalac in liquid form, so you may have to use more For example, if your child's meal guide calls for one serving of a vege- of it in puddings, cereals, fruits and soups. table exchange, you can choose one of twelve or more. Each vegetable will have listed the size serving. If you wanted strained carrots, it would Self-Feeding be three tablespoons. If you chose strained beets, it would be two table- Your child, of course, must learn to feed himself. Watch for signs of spoons. Each serving would contain the same amount of phenylalanine. his wanting to feed himself and encourage him to do it. At first, if he seems slow, it may be harder and more awkward for him than for Lofenalac other children, but he will learn in time. A difficulty that you may have is that the milk substitute formula If he has never put things in his mouth, you can dip his fingers into your child must have will look like milk, but to you it will not taste or the strained fruits and put them in his mouth to give him the idea. You smell like milk. It may even seem distasteful to you, but it is very im- can then teach him to pick up bits of fruit or vegetable or dry cereal portant that you do not show this feeling to your child, either by word to put in his mouth. or action, for he may refuse the formula just because he senses that you You can show him how to pick up a spoon and then guide it to his do not like it. mouth. Some mothers find this works best if you stand behind him to One mother using Lofenalac disliked the smell so much that she, do it. Foods like pudding or thick cereal are best to begin with because without thinking of the effect on her child, would "make a face" when they stay better on the spoon. she gave it to him. Because of this, he refused it for several days, until 8 9 Source: https://www.industrydocuments.ucsf.edu/docs/lycg0227 Changes in Appetite As your child grows, his appetite will change from time to time. Some days he will eat more than others. He does not have to eat the exact amounts shown on his meal plan every day. If you are concerned about his appetite, talk it over with your doctor. LOW PHENYLALANINE MEAL GUIDE Parents' Anxieties for It is natural for all parents to have worries when raising a child. You Date may have more concern with your child on a PKU diet, just as other Age Milligrams of phenylalanine per pound parents have with children on strict diets. Some of your worry may come from well-meaning relatives and neighbors who may not under- Weight Milligrams of phenylalanine for the day stand the child's condition and who think it is cruel to deprive the child of foods they happen to like. Mix Lofenalac to ounces of water. Some parents, knowing how important it is that their child does not BREAKFAST Milligrams of get too much phenylalanine, have a fear that the child will accidently Phenylalanine eat a forbidden food. They may not realize that if a child has never Give ounces of the Lofenalac mixture tasted a food, he probably will not want it. Choose Exchanges from List 3 (Fruits) Some parents foresee that they may become discouraged with the Choose Exchanges from List 4 (Breads & Cereals) diet and feel sorry for themselves. Choose Exchanges from List 5 (Fats) Some mothers are concerned that they will give too much attention MIDMORNING to their child with PKU and neglect the rest of their family. These are but examples of fears that you may never experience. If Choose Exchanges from List you do have worries about the child and the diet, it will help to dis- DINNER cuss them with the doctor or other professional person working with Give ounces of the Lofenalac mixture him such as the nurse, the nutritionist, or the social worker. Choose In time, your child's diet, which he must have, will soon become Exchanges from List 2 (Vegetables) Choose Exchanges from List 3 (Fruits) routine to you and to your child. The main job, of course, is the Choose Exchanges from List 4 (Breads & Cereals) mother's, but the father's help and support are just as important in Choose Exchanges from List 5 (Fats) getting the cooperation of the entire family in the dietary treatment of Choose Exchanges from List 6 (Desserts) your child with phenylketonuria. The following pages contain the meal guide, the exchange lists, and MIDAFTERNOON recipes for the low phenylalanine diet. At first, the diet may be difficult Choose Exchanges from List to follow, but it will get easier as you learn from experience. SUPPER Give ounces of the Lofenalac mixture Choose Exchanges from List 2 (Vegetables) Choose Exchanges from List 3 (Fruits) Choose Exchanges from List 4 (Breads & Cereals) Choose Exchanges from List 5 (Fats) Choose Exchanges from List 6 (Desserts) BEDTIME Choose Exchanges from List TOTAL You can vary your child's meal by choosing different food listed in each of the six exchange lists. 10 11 Source: https://www.industrydocuments.ucsf.edu/docs/lycg0227 EXCHANGE LISTS FOR LOW PHENYLALANINE DIET Cabbage, raw, shredded 4 Tbsp. (Adapted from Exchange Lists of the Dietary Service and Department of Pedi- Carrots, raw 1/4 Large atrics, College of Medical Evangelists, and reproduced with permission from the canned 4 Tbsp. American Dietetic Association.) Cauliflower 2 Tbsp. Celery, raw 2 Stalks DEFINITIONS Corn c. Cup. One standard household measuring cup. Dry foods are 1 Tbsp. Cucumber, raw 1/3 Med. measured as one level measuring cup. One cup contains one- Lettuce, head 2 Leaves half pint or 8 fluid ounces. Mushrooms, cooked 2 Tbsp. Tbsp. Tablespoon. One standard household measuring tablespoon. Okra, pod, cooked 1 Pod Dry foods are measured as one level measuring tablespoon. 16 Onion, mature 1/3 Med. level tablespoons equal one cup. Two tablespoons equal one green 2 Med. ounce. Parsley 2 Sprigs Tsp. Teaspoon. One standard household measuring teaspoon. Dry Potato, Irish 1 Tbsp. foods are measured as one level teaspoon. Three teaspoons Pumpkin, cooked 2 Tbsp. equal one tablespoon. Radish, small, raw 3 Small Spinach, creamed, canned only * 2 Tbsp. LIST 1. LOFENALAC * Squash, winter, cooked 2 Tbsp. Each serving, or Exchange, contains 30 milligrams of Phenylalanine summer, cooked 4 Tbsp. Lofenalac, dry 4 Tbsp. Tomato, raw 1/4 Small Lofenalac, reconstituted canned 2 Tbsp. 1 cup powder to 1 quart water 1 c. fluid juice 2 Tbsp. or 16 packed, level measures of powder to one quart Turnip 4 Tbsp. water 1 c. fluid Yam and sweet potato, cooked 1 Tbsp. Directions for Mixing Lofenalac LIST 3. FRUITS Make a paste of the Lofenalac with a small amount of boiling water before adding the total water Each serving or Exchange contains 15 milligrams of Phenylalanine or Sprinkle the Lofenalac on top of the water and beat with an Baby and Junior Fruits eggbeater Apricot-applesauce, strained and junior 10 Tbsp. or Mix in a blender or Osterizer Banana 7 Tbsp. Orange juice 3 Tbsp. LIST 2. VEGETABLES Peaches, strained 5 Tbsp. Each serving, or Exchange, contains 15 milligrams of Phenylalanine junior 7 Tbsp. Baby and Junior Vegetables Pears, strained and junior 10 Tbsp. Beans, green, strained & junior 2 Tbsp. Pear-pineapple, strained and junior 7 Tbsp. Beets, strained 2 Tbsp. Plums with tapioca, strained 5 Tbsp. Carrots, strained & junior 3 Tbsp. junior 7 Tbsp. Spinach, creamed, strained & junior 2 Tbsp. Prunes, strained 3 Tbsp. Squash, winter, strained 3 Tbsp. Table Fruits junior 6 Tbsp. Apple, raw 1 Small Tomato juice 2 Tbsp. Apricot, canned 2 Halves Yam or sweet potato, strained 2 Tbsp. juice 1/4 c. Avocado Table Vegetables 2 Tbsp. Banana Asparagus 2 Stalks 4 Tbsp. Dates, dried 2 Beans, green, cooked 3 Tbsp. Cantaloupe 1/8 Melon Beets, cooked 3 Tbsp. * Do not use home-cooked spinach. * Mead Johnson Company 12 13 Source: https://www.industrydocuments.ucsf.edu/docs/lycg022 Fruit cocktail, canned 2 Tbsp. LIST 5. FATS Grapefruit, sections or juice 1/3 c. Each serving or Exchange contains 5 milligrams of Phenylalanine Guava, raw 1/3 Med. Butter 1 Tsp. Orange, sections or juice 3 Tbsp. Cream, heavy 1 Tsp. Grape juice 1/3 c. Margarine 1 Tbsp. Lemon or lime juice 3 Tbsp. Mayonnaise 1¹/² Tbsp. frozen concentrate, mixed 1/2 c. Olives, ripe 1 Large Mango 1/2 Small Oil 1 Tsp. Papaya juice 1/2 c. Papaya, cubed LIST 6. DESSERTS 1/4 c. Peaches, raw 2/3 Med. Each serving or Exchange contains 30 milligrams of Phenylalanine canned in syrup 1¹/² Halves Cake * 1/6 of cake Pear, raw Cookies-Rice Flour * 2 1/3 c. canned in syrup 3 Halves Corn Starch 2 Pineapple, raw 1/3 c. Cookies, Arrowroot 1¹/2 canned in syrup 1¹/² sm.sl. Ice Cream-Chocolate 1/3 c. juice 1/2 c. Pineapple 1/3 c. Strawberry * Plums, canned in syrup 1 Med. 1/3 c. Popsicle with fruit juice 1 Vanilla * 1/3 c. Prunes, cooked 2 Med. Puddings * 1/2 c. juice 1/3 c. Sauce, Hershey 2 Tbsp. Raisins 1 Tbsp. Wafers, Sugar, Nabisco 6 Strawberries 3 Large LIST 7. FREE FOODS Tangerine 2/2 Small Each serving or Exchange contains little or no Phenylalanine. Watermelon 2/3 c. May be used as desired. LIST 4. BREAD, CEREALS Apple juice If more than a cup, Honey count as a fruit Each serving or Exchange contains 30 milligrams of Phenylalanine Applesauce Jams, Jellies, Marmalades exchange. Jel-Quick (artificial gelatin) Baby Foods Candy Molasses Barley cereal, Gerber's, dry 2 Tbsp. butterscotch Pepper Cereal food, Gerber's, dry 2 Tbsp. cream mints 3 Tbsp. fondant Popsicle (with fruit flavoring only) Mixed cereal, Pablum, dry Salt Oatmeal, Gerber's, strained 3 Tbsp. gum drops Pablum, dry 3 Tbsp. hard Sauces * Table Foods jelly beans lemon Biscuits * lollipops white 1 Small Cornstarch Sugar, brown or white Cornflakes 1/3 c. Guava butter Syrups, corn, maple Cornpone 1 Small Guavas Tapioca Crackers, Barnum animal 6 Saltines 3 LIST 8. FOODS TO AVOID Cream of Wheat, cooked 3 Tbsp. Each serving is very bigh in Phenylalanine. May not be used Hominy grits, cooked 5 Tbsp. except with physician's permission. Rice Flakes, Quaker 1/3 c. Breads Legumes (dried peas, beans and seeds) Rice Krispies, Kelloggs 1/3 c. Cheese, all kinds Nuts Rice, Puffed, Quaker 1/2 c. Eggs Nut butters Sugar Crisps 1/4 c. Flour, all kinds Milk (55 milligrams phenylalanine Wheat, Puffed, Quaker 1/3 C. Meat, poultry, fish per ounce) * Low phenylalanine recipes. * Low phenylalanine recipes. 14 15 Source: https://www.industrydocuments.ucsf.edu/docs/lycg0221 ICE CREAM (Strawberry) Ingredients Amount Mixing Instructions Water 1/4 C. Mix together and cook in top of Sugar 6 tbsp. double boiler until thickened. Cornstarch 3 tbsp. Place in refrigerator to cool. RECIPES Lemon juice 1 tbsp. Beat cream with hand or rotary Cream, 30-40% 1 c. beater until it stands in peaks (Reproduced with permission of the Dietary Department and Department of Strawberries, fresh 1/2 c. sliced but isn't buttery. Fold in fresh Pediatrics of The College of Medical Evangelists of Los Angeles and the American sliced strawberries and starch Dietetic Association.) mixture. If cornstarch mixture is too thick, thin with whipped ICE CREAM (Chocolate) cream or decrease cornstarch to Ingredients Amount Mixing Instructions 2 tbsp. Place in freezer unit and Water 1/4 c. freeze. Heat together in double boiler Cornstarch 3 tbsp. the water and the chocolate until Makes 3 cups. Sweetened chocolate 1 square chocolate is melted. Add corn- Nutrients per 1/3 cup serving: Cream, 30-40% 1 c. starch and cook until thickened. Pro. 0.6 gm., Fat 6.4 gm., CHO 13.0 gm., Phenylalanine 30 mg. Sugar 6 tbsp. Place in refrigerator to cool. Vanilla 1 tsp. Beat cream with hand or electric Vanilla Ice Cream: Follow above directions substituting 1 tbsp. vanilla beater until it stands in peaks for fresh sliced strawberries. but is not buttery. Add sugar Nutrients per 1/3 cup serving: and vanilla. Then fold in choco- Pro. 0.6 gm., Fat 6.4 gm., CHO 12.0 gm., Phenylalanine 28 mg. late mixture and combine thor- oughly. If chocolate mixture is too thick, thin with some of the whipped cream or decrease corn- BLANC MANGE starch to 2 tbsp. Place in freezer unit to freeze. Ingredients Amount Mixing Instructions Makes 3 cups. Sugar 1/2 c. Mix sugar, cornstarch, and salt Nutrients per 1/3 cup serving: Cornstarch 5 tbsp. in top of double boiler. Mix Protein 0.6 gm., Fat 7.2 gm., CHO 13.0 gm., Phenylalanine 31 mg. Salt 1/4 tsp. Lofenalac with boiling water. Lofenalac (dry) 2 c. Gradually add to cornstarch Boiling water 4 c. mixture mixing until smooth. Vanilla 2 tsp. Place over boiling water and cook, stirring constantly until ICE CREAM (Pineapple) mixture thickens. Cover and Ingredients Amount Mixing Instructions continue cooking 10 minutes longer. Remove from heat. Add Pineapple juice 1/4 c. Mix together and cook in top of vanilla and cool. Cornstarch 3 tbsp. double boiler until thickened. Makes 8 servings. Lemon juice 1 tbsp. Place in refrigerator to cool. May be served with karo, jelly, honey or jam. Sugar 4 tbsp. Beat cream with hand or electric Nutrients per serving: Approximate 1/2 cup. Cream, 30-40% 1 c. beater until it stands in peaks Pro. 6.0 gm., Fat 5.1 gm., CHO 33.2 gm., Phenylalanine 30 mg. Pineapple, crushed 1/2 c. but is not buttery. Fold in crushed pineapple and the above mixture. If cornstarch mixture is too thick, thin with some of whipped cream or decrease corn- starch to 2 tbsp. Place in freezer unit and freeze. Makes 3 cups. Nutrients per 1/3 cup serving: Protein 0.6 gm., Fat 6.4 gm., CHO 13.0 gm., Phenylalanine 32 mg. 17 16 Source: ttps://www.industrydocuments.ucsf.edu/docs/lycg0227 LEMON PUDDING PINEAPPLE PUDDING Ingredients Amount Mixing Instructions Ingredients Amount Mixing Instructions Lofenalac (dry) 9 tbsp. Mix Lofenalac and boiling water Lofenalac (dry) 8 tbsp. Boiling water 11/4 c. together with rotary beater until Mix together Lofenalac and Boiling water 11/2 c. boiling water until well blended. Sugar 1/2 c. well blended. Combine sugar, Pineapple juice 4 tbsp. Cornstarch cornstarch, and salt, and mix Add pineapple juice. Combine 2 tbsp. Sugar 1/2 c. Salt I/8 tsp. with liquid Lofenalac. Cook in sugar, cornstarch, and salt, then Cornstarch double boiler until thickened. 2 tbsp. mix with Lofenalac-pineapple Oil 1 tbsp. Salt Add oil, lemon rind, and juice. 1/8 tsp. juice. Cook in double boiler until Grated lemon rind 1 tsp. Oil 1 tbsp. thickened. Add oil, vanilla, and Lemon juice 3 tbsp. Stir until well blended. Vanilla 1 tsp. crushed pineapple. Stir until Remove from heat and cool. Makes three 1/2 cup servings. Crushed pineapple 1/4 c. well blended. Nutrients per serving (approximately 1/2 cup): Pro. 4.5 gm., Fat 9.9 gm., CHO 55.2 gm., Phenylalanine 28.0 mg. Makes three 1/2 cup servings. Nutrients per serving (approximately 1/2 cup): Pro. 4.1 gm., Fat 9.8 gm., CHO 58.5 gm., Phenylalanine 28.5 mg. CHOCOLATE PUDDING Ingredients Amount Mixing Instructions Lofenalac (dry) 9 tbsp. Mix Lofenalac and boiling water Boiling water 1¹/2 c. together with 'rotary beater until VANILLA PUDDING AND BANANA PUDDING Chocolate, unsweetened 1/2 ounce well blended. Place in double Sugar 1/2 c. boiler. Add unsweetened choco- Ingredients Amount Mixing Instructions Cornstarch 2 tbsp. late to liquid Lofenalac. Heat Lofenalac (dry) 11 tbsp. Mix Lofenalac and boiling water Salt 1/8 tsp. until chocolate melts. Combine Boiling water 11/2 c. together with rotary beater until Oil 1 tbsp. sugar, cornstarch, and salt, then Sugar 1/2 c. well blended. Combine sugar, Vanilla 1 tsp. mix with Lofenalac-chocolate Cornstarch 2 tbsp. cornstarch, and salt, then mix mixture and cook until thick- Salt I/8 tsp. with Lofenalac. Cook in double ened. Add oil and vanilla and Oil 1 tbsp. boiler until thickened. Add oil, stir until well blended. Vanilla 2 tsp. vanilla, and lemon juice. Stir Makes three 1/2 cup servings. Lemon juice 1 tsp. until well blended. Nutrients per serving (approximately 1/2 cup): Pro. 4.5 gm., Fat 10.9 gm., CHO 54.8 gm., Phenylalanine 29.6. mg. Remove from heat and cool. Makes three I/2 cup servings BANANA PUDDING: Follow above recipe substituting 1 tsp. banana TAPIOCA PUDDING flavor and 2 tbsp. mashed banana for the vanilla. Ingredients Amount Mixing Instructions Nutrients per serving (approximately 1/2 cup): Vanilla Banana Stir water slowly into tapioca. Protein Boiling water 1 c. 5.2 gm. 5.7 gm. Add sugar, salt, and Lofenalac. Fat Quick-cooking tapioca 2 1/2 tbsp. 10.8 gm. 10.8 gm. Mix until thoroughly blended. CHO 57.8 gm. 58.4 gm. Sugar 1/4 c. Salt 1/8 tsp. Cook over boiling water 12 Phenylalanine 29.0 mg. 31.0 mg. Lofenalac (dry) 6 tbsp. minutes or until clear, stirring Vanilla 1/2 tsp. frequently. Cool. Add vanilla. Chill. Makes 2 servings. COMMERCIAL PUDDING MIXES PEACH: Before chilling, stir in 2 1/2 tbsp. junior peaches. PINEAPPLE: Before chilling, stir in 1/4 cup drained crushed pineapple. Various pudding mixes on the market which require cooking may be used by substituting double strength (8 tbsp. to 1 cup water) Lofenalac Nutrients per serving: Approximately 1/2 cup Vanilla Peach Pineapple in place of the milk ordinarily used. A 1/2 cup serving gives 30 mg. of Protein 4.5 gm. 4.5 gm. phenylalanine. These mixes should not contain gelatin, flour, milk or 4.5 gm. Fat 5.1 gm. 5.1 gm. 5.1 gm. eggs. CHO 52.4 gm. 61.9 gm. 61.9 gm. Phenylalanine 29.2 mg. 32.7 mg. 34.2 mg. 18 19 Source: https://wwww.industrydocuments.ucsf.edu/docs/lycg0227 PLAIN CAKE LEMON SAUCE * Ingredients Amount Mixing Instructions Ingredients Amount Mixing Instructions Fat (oil or margarine) 4 tbsp. Sift dry ingredients together. Sugar 1/2 cup Cream fat, add sugar, mix well. Sugar 1/2 c. Mix together sugar, cornstarch, Cornstarch Lofenalac, liquid 1/2 cup plus 1 Add liquid, dry ingredients and 11/2 tbsp. salt and dry Lofenalac. Salt tbsp. vanilla. Bake in greased pan 1/4 tsp. Gradually add water to above Cake flower 1 cup (9" X 9" X 2") or muffin pans at Lofenalac (dry) 5 tbsp. ingredients. Cook over medium Baking powder 3 tsp. 375° for 25-30 minutes. Boiling water 11/2 c. heat, stirring constantly until Oil Salt 1/4 tsp. 2 tbsp. sauce thickens and comes to Vanilla 1/2 tsp. Lemon juice 3 tbsp. boil. Boil 2 minutes. Remove Grated lemon rind Can be used as birthday cake. 1 cup cake or 1/6 of cake gives 30 mg. 2 tsp. from heat and add oil, lemon juice, and rind. phenylalanine. Makes about 2 cups. Use as topping for puddings. RICE FLOUR COOKIES * Nutrients per serving (2 tbsp.) Pro. 0.5 gm., Fat 2.3 gm., CHO 8.7 gm., Phenylalanine 3.1 mg. Ingredients Amount Mixing Instructions Cornstarch 1/2 c. Sift together cornstarch, sugar, Confectioner's sugar 1/2 C. flour and salt. Blend room Rice flour, white 1 c. temperature butter (or oil) into Salt 1/4 tsp. dry ingredients with fork until WHITE SAUCE * Butter or oil 1 c. a soft ball is formed. Shape into Ingredients Amount Vanilla 1/4 tsp. small balls with hands. Place on Mixing Instructions Oil ungreased baking sheet about 3 tbsp. Place oil in saucepan. Add corn- 11/2 inches apart. Flatten cookies Cornstarch 2 tbsp. starch and salt and blend well. with fork. Bake in 300° F. oven Salt 1 tsp. Mix together Lofenalac and for 20-25 minutes. Lofenalac (dry) 1/2 c. water using rotary beater to Makes about 2 dozen small cookies. Warm water 2 c. blend well. Add to oil-corn- starch-salt mixture and cook Nutrients per cookie: until thickened. Pro. 0.3 gm., Fat 5.0 gm., CHO 7.0 gm., Phenylalanine 14.7 mg. (If oil is used, phenylalanine content is slightly decreased.) Makes about 2 cups white sauce. Two tbsp. chopped parsley may be CORNSTARCH COOKIES * added for variety. White sauce is useful in preparation of a variety of creamed vegetables, etc. Ingredients Amount Mixing Instructions Nutrients per serving (2 tbsp.): Cornstarch 1 c. unsifted Sift together cornstarch, salt, Pro. 0.7 gm., Fat 3.5 gm., CHO 3.6 gm., Phenylalanine 4 mg. Baking powder 1 tsp. and baking powder. Salt 1/4 tsp. Mix oil (or room temperature Oil or butter 1/3 c. butter), sugar, syrup, egg, and Sugar 1/2 c. vanilla in bowl. Beat with hand Corn syrup 2 tbsp. beater until thoroughly blended. CORN PONE Egg 1 unbeaten Add sifted dry ingredients and Ingredients Amount Mixing Instructions Vanilla 2 tsp. mix well. Cover baking sheet with brown paper. Do not Corn meal, yellow Sift cornmeal and salt together. enriched grease. Drop batter by tea- 1/4 c. Add boiling water to make a Salt spoonfuls 3 inches apart on 1/3 tsp. firm mixture. Shape into 5 thin paper. Bake in 350° F. oven 12 Boiling water 1/2 c. cakes, place in pan well greased with oil and bake in 400° F. minutes. oven 15-20 minutes. Cool slightly before removing from baking sheet. Makes 18 cookies. Makes 5 small cakes. NOTE: 1 tsp. cinnamon or nutmeg makes a pleasing variation. Nutrients per serving (per 1 small cake): Nutrients per cookie: Pro. 0.6 gm., Fat 0.1 gm., CHO 5.7 gm., Phenylalanine 29 mg. Pro. 0.3 gm., Fat 4.3 gm., CHO 13.4 gm., Phenylalanine 17.9 mg. (If butter is used, phenylalanine content is slightly increased.) * Recipes adapted from Allergy Recipes, American Dietetic Association, 1957. * Recipes adapted from Allergy Recipes, American Dietetic Association, 1957. 20 21 Source: https://www.industrydocuments.ucst.edu/docs/lycg0227 TNS 6-1 Published by the STATE OF CALIFORNIA DEPARTMENT OF PUBLIC HEALTH BUREAU OF HEALTH EDUCATION 2151 BERKELEY WAY BERKELEY 4, CALIFORNIA Source: industry is

Where was "Senior Olympics" held?

kzhd0227

kzhd0227_p5, kzhd0227_p6, kzhd0227_p7, kzhd0227_p8, kzhd0227_p9, kzhd0227_p10, kzhd0227_p11, kzhd0227_p12

Irvine, California, IRVINE, CALIFORNIA

-5- - - The Experimental Effect of Diet on Co-existing Diseases DRUG-TREATED DISEASES RETURN TO NORMAL CLASSIFICATION AT START OF STUDY WITHOUT DRUGS No. of Subjects No. of Subjects % Angina 3 3 100 Hypertension 8 6 75 Diabetes: ADA Diet-controlled 10 9 90 Oral drugs 1 1 100 Insulin, 80 units 1 2 50 30 units ) 0 Gout 2 2 100 Arthritis 2 2 100 Congestive heart failure 3 2 66 Elevated blood lipids 2 2 100 TABLE 2 Comparison of Artery Stenosis before (1/20/75) and after Study (6/26/75) in L.S. ANGIOGRAPHICALLY AUTOPSY CONFIRMED LOCATION OF STENOSIS DETERMINED % STENOSIS % STENOSIS (1/20/75) (6/26/75) Right common iliac in proximal position 70% 40% Left common iliac at bifurcation 99% 40% Right common femoral at its origin 100% 50% TABLE 3 Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 () Figure 2. Initial baseline angiogram of L.S. This film demonstrates complete occlusion of the right common femoral artery at its origin (arrows). Figure 3. Macroscopic cross section of right common femoral artery stained for elastic tissue. Specimen was taken from a portion of artery which was shown angiographically (see Fig. 2) to be totally occluded. Note that the two branch arteries seen in the left lower quadrant of this cross-section correspond to branch arteries (at the occlusion site) in angio above. Source: ttps://www.industrydocuments.ucsf.edu/docs/kzhd0227 7 Figure 4a. Initial baseline angiogram (January '75) of K.B. Figure 4b. Final angiogram (June '75) of K.B. The numbers in the above line drawings correspond to numbers noted in the text. (1) The origin of the left external iliac indicates an 80% concentric stenosis in the January angiogram becoming a 50% concentric stenosis in the June angiogram; (2) The middle 1/3 of the external iliac is markedly irregular with an 80% concentric stenests in the January angiogram becoming a smooth eccentric 30% stenosis in the June angiogram: (3) The distal 1/3 of the external iliac shows moderately severe irregularities with is eccentric stenosis in the January angiogram becoming a smooth widely patent arterial segment in the June angiogram. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 8 Figure 5a. Dark field high power view of normal non-aggregating red blood cells 6 hours after a low fat meal. 3 Figure 5b. Example of red blood cell aggregation and rouleaux formation 6 hours after a high fat meal. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 () DISCUSSION The reasons for the dramatic results in reversing claudication and other atherosclerotic symptoms on a diet and exercise regimen are elucidated by tissue anoxia studies. Tissue anoxia is present III those consuming the conventional Western diet with its high 40% of total calories in fat Anoxia due to tliet in young undamaged arteries may not cause obvious symptomis, but when there IS some artery stenosis due to plaque formation (and this includes almost everyone over 25 years of age in this country) this results in increases in blood pressure and, in individuals with advanced atherosclerosis, angina and claudication. One of the first to study tissue anoxia produced by a high fat, meal was Swank11 who ted hamsters cream meals and then. through their transparent check pouches. observed the effects on the erythrocytes. As the chylomicrons started to pour in from the cream meal. the erythrocy les began adhering to each other. In 3 to 6 hours after the feeding. the aggregations. now in rouleaux and irregular formations, completely blocked many capillaries. Because of the aggregations. the full surface of the erythrocyte was not available for oxygen transfer and during this condition, the oxygen-carrying capacity of the erythrocyte was directly affected, decreasing the plasma OXY gen level to 68% of starting value. It took 72 hours before the oxygen level reached 95% of the original value. Kuo's study13 with angina patients showed that a cream meal could induce an angina attack by lowering the oxygen-carrying capacity of the blood. After an overnight fast, each subject drank heavy cream, then rested quietly while half-hour blood samples were drawn. In 5 hours. the chylomicron influx had peaked and caused the transparent fasting blood to become 600% more turbid on a plasma lactescence scale. Fourteen angina attacks occurred, simultaneously with ischemic ECGs and abnormal ballistocardiograms. The amazing similarity in the reaction of many individuals to fat was shown in almost identical lactescence curves for 13 of the 14 angina patients. These same patients on another morning drank a fat-free drink with identical calories and bulk. After 5 hours, no increased blood turbidity, no angina and no abnormal ECG tracings were noted. Platelet aggregation occurs under the same conditions that produce erythrocyte aggregation. A U.S. Department of Agriculture study, directed by Iacano13 placed normals on a 25% fat diet instead of their usual 40-45% fat intake. Not only did blood pressure and cholesterol levels drop. but there was a 50% drop in platelet aggregation. When the 40-45% fat diet was resumed. platelet aggregation returned to previous levels. As the aggregations broke up reducing the vessel blockage, the increased vessel area now availat le for blood flow permitted the same volume of blood to flow with lowered pressure. Thus. with reduced fat intake, Iacano achieved universal blood pressure drops even in normal subjects. This effect was confirmed in our study with hypertensives. Relief of coronary and calf angina both occur with increased blood flow and oxygen-carry ing capacity of the blood. In our study, these effects occurred within a few weeks after the diet-exercise regimen was begun and coincided with the rapid drop in blood lipids-an average cholesterol drop of 30% in a few weeks and one triglyceride drop from 360 mg.% to 85 mg.%. Thompson's¹ 6 report of 2 women in their 20's with elevated lipids demonstrates the relationship of blood lipid level to angina by utilizing a more drastic method than dietary reform for alleviating the symptoms. To lower the blood lipids-their cholesterol levels averaged 600 mg." they underwent plasma exchange with cholesterol-free plasma protein fraction. Approximately 50 gms. of cholesterol in the form of low density lipoproteins were removed during the 6 month treatment which involved about 8 exchanges of about 3000 ml. of blood. No other therapy changes were made. Blood lipid levels fell to half their previous value and both women lost their angina. While disappearance of angina can be rapidly achieved within weeks, as was demonstrated in our study, or months, as was accomplished in Thompson's, the ultimate cure depending upon artery plaque reversal, is another matter. In primate studies Armstrong¹ and Wissler¹ have reversed artery stenosis on a low-fat diet. Although our results need confirmation by others, we believe they are the first evidence demonstrating reversal of human atherosclerosis by diet. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 --10- AGE AS A LIMITING FACTOR IN REHABILITATION Our study has indicated the promising rehabilitative potential of a diet and activity regimen tor case of a woman, E.W. She began, almost (1 years ago at age 81. using the same regimen described claudication patients. That age need not be a limiting factor in rehabilitation is demonstrated by the in this paper for the experimental group. Her symptoms. like those of the study patients. included other atherosclerotic manifestations besides claudication. Only 5'3'` tall and weighing 100 lbs 101 the last 40 years, she had developed cardiovascular disease and was treated for angina at age (7 Al age 75 she was hospitalized with a severe heart attack. and at age 81 had claudication, congestive heart failure, hypertension, angina and arthritis. When she began the regimen at age 81. her claudication limited her walking to 100 feet and even then the calf pain was SO disabling she often had to be carried home; and the circulation to her hands was SO impaired she wore gloves in the summertime. Last year, at age 85. and after 4 years on the regimen. she was televised at the Senior Oly 111 Irvine, California, where she won 2 gold medals in the half-mile and mile running events. This youl at age 861/2, she repeated the runs and now has 4 gold medals. Each morning she runs a mile and rides her stationary bicycle 10-15 miles; twice weekly she works out in a gym: and she follows her diet assiduously. Her diastolic pressure is 70 mm. CONCLUSION: This combined low-fat diet and exercise approach has proven to be significantly (PK 0011 more effective in the treatment of severe peripheral atherosclerotic vascular disease than current therapies. It is hoped that the results reported by the use of this regimen will encourage other investigutoto to repeat our studies. Figure 6. Patient E.W. running the mile event at the Senior Olympics in Irvine, California. E.W. was 85 years old when this run was made. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 -- -11- REFERENCES 1. KANNEL, W.B., SKINNER, J.J., JR., SCHWARTZ, M.J., SHURTLEFF. D. Intermittent claudication inci- dence in the Framingham Study. Circulation 41:875, 1970. 2. DELIUS, W., ERIKSON, U. Correlation between angiographic and hemodynamic findings in occlusions of arteries of the extremities. Vascular Surg. 3:201, 1969. 3. SINGER, A., ROB, C. The fate of the claudicator, Brit. Med. J. 2:633, 1960. 4. LIVINGSTONE, P.D., JONES, C. Treatment of intermittent claudication with vitamin E. Lancet 11:602, 1958. 5. HOUSLEY, E., McFADYEN, I.J., Vitamin E. in intermittent claudication. Lancet 1:458, 1974. 6. HAEGER, K. Vitamin E in intermittent claudication. Lancet I:1352, 1974, and Vasa 2:280-287, 1973. 7. LARSEN, O.A., LASSEN, N.A. Effect of daily muscular exercise in patients with intermittent claudication. Scandinavian J. Clin. Lab. Invest. Suppl. 93:168, 1967 and Lancet II:1093, 1966. 8. JOHANSSON, B.W., SIEVERS, J. "Spontaneous course" of intermittent claudication. Scandinavian J. Clin. Lab. Invest. Suppl. 93:156, 1967. 9. ZETTERQUIST, S. The effect of active training on the nutritive blood flow in exercising ischemic legs. Scandinavian J. Clin. Lab. Invest. 25:101, 1970. 10. EBEL, A., KUO, J.C. Tolerance for treadmill walking as an index of intermittent claudication. Arch. Phys. Med. and Rehab. 611-614, Nov., 1967. 11. SWANK, R.A. A biochemical basis of multiple sclerosis. C.C. Thomas Publ., Springfield, III., 1961. 12. KUO, P.T. and JOYNER, C.R., JR. Angina pectoris induced by fat ingestion in patients with coronary heart disease. JAMA 158:1008-13, 1955. 13. IACANO, J.M. Lipid research lab. U.S. Department of Agriculture, Beltsville, Md., 20705. Private communication. 14. ARMSTRONG, M.L. and MEGAN, M.B., ET AL. Plasma and carcass cholesterol in rhesus monkeys after low and intermediate levels of dietary cholesterol Circulation Supp. II, 43: II-III, 1971. Also: ARMSTRONG, M.L. ET AL. Xanthomotosis in rhesus monkeys fed a hypercholesterolemic diet. Arch. of Path. 84:227-37, 1967. 15. WISSLER, R.W. Development of the atherosclerotic plaque. Hosp. practice 8:61-72, 1973. 16. THOMPSON, G.R., LOWENTHAL, R., MYANT, N.B. Plasma exchange in the management of homozygous familial hypercholesterolemia. Lancet I:1208, 1975. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 12 This study was financed in part by the Kirsten Foundation, Manhasset, N.Y., and the Longevity Research Institute, Santa Barbara, Ca. We would like to thank Wallace E. Carroll, M.D., William C. Gnekow, M.D., and Samuel H. Brooks, Ph.D., for their professional assistance in the pathological, radiological, and statistical evaluations made in this study. In addition we would like to give credit to Janie Sternal for her photographic assistance. Finally, we would like to acknowledge the support of the following corporations for their help in providing part of the foods used in the experimental diet: Archon Pure Products Corp.; Celestial Seasonings; Charles Soderstrom Enterprises; Chiquita Brands, Inc.; Erewhon, Inc.; Fisher Mills, Inc.: Hol-Grain Div. of Golden Grain; Hunt-Wesson Foods; and Pure Gold, Inc. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227

what is the disease mentioned in the first paragraph?

tlnf0227

tlnf0227_p0, tlnf0227_p1, tlnf0227_p2, tlnf0227_p3, tlnf0227_p4, tlnf0227_p5, tlnf0227_p6

cardiovascular, cardiovascular disease, Cardiovascular Disease

American Heart Association Annual Report 1975 President's Message We know what the priorities and goals are: Research We still don't know the cause of coronary heart disease, even though heart attack During the past year, the Association death rates are declining; provided funds for the work of approximately We don't know the cause of 90 percent of 1,400 scientific investigators on all career all high blood pressure, though we have levels to assure that outstanding learned to control much of it; independent researchers may pursue We don't know the cause of primary myocardial disease; and original lines of thought to wherever they We still don't know why normal mothers may lead, that the established investigator have babies with congenital heart has the means to complete his project and disease. that younger scientists of promise have the Heart Association staff members and support they need to develop their skills. volunteers are rededicating themselves to unlocking more of these unknowns. We seek the support of all Americans so that the same sense of urgency that motivates us can have its expression in new and expanded programs. In the year covered by this report, the Our network of affiliates and chapters has American Heart Association allocated a steadily developed. Today it reaches into record amount of $18 million for heart thousands of communities involving citizen research, sending the total for such support volunteers, laymen, scientists, physicians, past the quarter billion dollar mark. During nurses and people from all walks of life in an the same period, there was confirmation that amalgam to cope with a complex of distinct the death rates from coronary disease had diseases generally referred to as turned downward. An analysis of these cardiovascular. closely watched statistics suggested that a Armies of distinguished scientists and combination of better prevention and more physicians, corps of non-medical personnel effective emergency treatment played an and more than two million volunteers form important role in this downtrend. the Heart Association. Much of the public There is reason to take satisfaction in funds donated to the Association support our contributions toward reaching these research scientists in their attempts to further milestones. But there is even more reason unlock the secrets of heart disease. Assisting to report that these achievements have in translating new medical knowledge from stimulated in us a new sense of urgency. We all sources into professional programs are have seen what dollars and dedication can about 10,000 scientists and physicians do. Yet, while heart and blood vessel forming 14 Scientific Councils, each diseases continue to impose an intolerable dedicated to a field of science or a medical health burden and economic cost on the specialty relating to heart disease. Through nation, we must do much more. their valuable guidance, the Association is in essence a micro-university, developing and conducting hundreds of postgraduate medical courses across the country throughout the year to refine the skills of physicians and nurses and thus ensure better patient care. The Scientific Councils also are active in the development of programs for the general public, assuring that those programs are based on scientific fact and designed to educate Americans in the prevention of heart attack and stroke. In the pages that follow you will find highlights of our programs in the year covered by this report. Elliot Rapaport, M.D. President 2 3 If we are to make further inroads on the Professional Education enormous toll of death and disability caused by cardiovascular diseases, we must continue to help develop new scientific knowledge. This is at the foundation of all programs, professional and public, conducted by the Association. What increases our sense of urgency in this matter is that progress against cardiovascular disease, while rapid and progressive, must rely on one piece of new knowledge being gathered here atop another piece gathered elsewhere. We are forging a mosaic of hope and help. The results of research projects supported by AHA continue to find clinical expression in improvements in the diagnosis and treatment of heart disease. Two of the more significant advances reported during the past year are: The first significant decrease in mortality from coronary artery disease; There are hundreds of other bits and pieces A doubling of the number of patients with reported each year that may prove to be hypertension who have been recognized, put on therapy and had part of a new weapon in the war on heart their blood pressure controlled. disease. Biomedical investigators are facing Examples of research supported by the AHA up to the challenges. What we need are more of the means. Each of these new which promise to provide additional advances in overcoming heart disease approaches must be tried, tested and include: duplicated in laboratories, on animals and Techniques for improved and earlier finally in humans-before they can be recognition of heart attacks and the accepted as conclusive and beneficial and Knowledge gained through research is only protection of injured heart muscle from added to the list of armaments. as good as its application. With the progressive damage; Providing the means requires a new acceleration in research in recent years has Recognition of the fundamental cellular defect in a form of hereditary commitment from the public to support our come a steady increase in new information hypercholesterolemia, associated with a responsibility to do all in our power to help about cardiovascular diseases and new high incidence of heart attacks among gather and disseminate new knowledge. ways of treating and preventing such affected people in their 20's and 30's; The faster scientists can nail down disorders. This new knowledge often Development of sophisticated X-ray preliminary findings, the faster they can be becomes available at a pace swifter than techniques which will graphically applied to reducing suffering and death. the busy cardiologist, coronary care nurse demonstrate the intricate workings of the heart in the intact human; Simply put, the urgency is dollars to save or other health care specialists can be Proof that a prolonged regimen of diet lives. expected to seek it out and assimilate it. and exercise improve circulatory As a result, a special sense of urgency derangements in the legs; stimulates us in development of our medical Application of new approaches to the education programs, to assure that they recognition and treatment of hypertension caused by decreased keep pace with advances in the field and blood flow to the kidneys; that they are geared to bringing new Improved diagnosis and therapy of research findings to the medical community thrombophlebitis in the legs, the source as quickly and as clearly as possible. of blood clots which cause 50,000 Keystones for dissemination of valuable deaths each year in the U.S. knowledge are the American Heart Association's 14 Scientific Councils, headed by many of the nation's foremost scientists and cardiovascular experts. Each of the Councils represents a special professional interest; together they reflect the broad scope of cardiovascular diseases and the concerns of the American Heart Association. They set the standards and conduct the professional activities of the Association. 4 5 The Councils conduct continuing education Public Education programs for their own members who total approximately 10,000. Reaching out to others A college professor in Baltimore, Maryland, in the medical community, the Councils are showed the AHA-produced film, 290 active in the development of a wide range ``Hypertension: The Challenge of Diagnosis,' of learning materials available to all to his biology class. One student was so 270 physicians and nurses. These include moved at learning hypertension or high pamphlets, newsletters, films, lecture series, blood pressure is a 'silent killer" that she 250 audio-visual aids and a group of scientific immediately urged her mother to undergo a journals which have a combined monthly long-delayed medical checkup. 230 circulation of more than 300,000. At the apex The examination revealed the woman of this activity is the annual Scientific indeed had high blood pressure, but thanks 210 Sessions, a meeting which attracts more than to a concerned daughter and a Heart 200 10,000 health professionals to exchange and Association message, her condition was assess the year's new findings. 190 brought to medical attention at an early 180 Affiliates and chapters of the Association time. 170 conduct hundreds of their own programs While that film was produced for 160 which bring together physicians and nurses professional education, it does show there on a community or state level, as contrasted are many ways of reaching the general 150 140 to Council-sponsored programs which are public with information vital to its welfare. conducted on a national basis. These 130 And the Association employs all means of programs are not necessarily of interest just 120 mass communication to alert Americans to / to the cardiologist, but are planned for the magnitude of the problem of heart 110 anyone concerned with better patient care 100 disease; to what is known about factors that for prevention of heart disease and increase an individual's risk; and what one 90 management of patients. 80 can do on his or her own and with a doctor's The Association constantly seeks to innovate help to change life styles moderately, 70 60 in its educational programs, as it has in control some easily identifiable health establishing research support programs conditions, and thus reduce that risk. 50 subsequently adopted elsewhere. Better The heart of this message includes these patient care is one of our goals and to get to major points: the crux of it, we conduct a unique Teaching If you have high blood pressure, follow Scholarship Program. This has a two-fold your doctor's orders and continue to take purpose: to raise standards of medication. undergraduate education for medical If you don't know whether you have high careers by creating a corps of unusually blood pressure, or suspect you might have it. visit your doctor. He can quickly, effective cardiology teachers, and thereby easily and painlessly find out. If usually on a day-to-day basis influence the has no set symptoms. So only a trained development of hundreds of students who person can tell. eventually will be in practice. This program If you smoke cigarettes, stop. has reached into medical schools across the If you eat foods rich in cholesterol and country and to date has supported 26 young saturated fats, cut down on them. If you don't know what they are, ask your Heart physicians, allowing them to devote virtually Association for booklets that tell you in all of their time to teaching and to plain, concise language. development of improved teaching If you don't exercise on a regular basis, methods. see that you do become more active. If you're existence, leading middle-aged more it would than be usual wise chair-borne to your and or have been a see doctor before engaging in unaccustomed activity. 7 Community Programs Having just learned it in school, cardiopulmonary resuscitation was fresh in the mind of 13-year-old Lyn Kraft of Ventnor, N.J., the October night her father suffered a massive heart attack and lost consciousness. Lyn was able to maintain his breathing and heart beat for 10 minutes until medical help arrived. Usually, a victim of cardiac arrest who is denied oxygen for more than four to six minutes suffers brain damage. But today, Mr. Kraft is recovering, thanks to Lyn's prompt action, the CPR training she received from her school nurse, Marie Paludi, and to the South Jersey Shore Heart Chapter which certified Ms. Paludi in CPR which quickly proved its worth in that community. CPR is just one facet of a growing concept of area-wide comprehensive emergency pressure screening and control. This latter cardiac care systems being promoted by one has received particular emphasis the Association. But CPR's life-saving because there may be as many as 12 million potential has spurred us into teaching it to "hidden" cases of high blood pressure in this cadres of health professionals who, returning country; and among those known to be to their home areas or institutions, can afflicted, only one out of eight is receiving quickly train others professionals and adequate medical care. public alike to provide basic emergency Other new efforts to improve and expand help wherever a life needs to be saved. community services include development of One example of this mushrooming effect: guidelines for medical management of last October, the Association conducted a teenagers with high levels of artery-clogging training course for 20 inspectors from the cholesterol in their blood; work on model Mining Enforcement and Safety programs applying principles of behavioral Minority Program Administration. Within two weeks, three of the science to risk reduction motivation; and a inspectors were conducting a course for 30 new film and stroke guide explaining the role Barrios, ghettos, isolated American Indian found heart disease, high blood pressure others- - six other inspectors and of community hospitals in the optimum reservations. depressed rural villages, inner- and their devastating aftermaths, heart representatives from 24 industries covering a treatment of stroke victims, and then in city slums and other "out-of-the- attack and stroke, more so than in urban, seven-state area. They, in turn, are now returning them to as useful a life as modern mainstream" places- - all are synonymous higher income societies. prepared to train other groups. science makes possible. with minority groups, poverty and apathy. In recent years as more became known Where these elements exist, there also are In the past year, the Association distributed about the present concepts of programming more than 1.2 million copies of a booklet on for the total community and about the new standards in CPR, developed in concert relatively more serious impact of with the National Research Council-National cardiovascular diseases on isolated and Academy of Sciences. These went to health lower income groups, the Association professionals across the country and around began reaching out to bring aid and the world. information to these groups and to encourage them to help design programs The same sense of urgency which underlies based on their urgent needs. our CPR activities, has prodded us into other community programming to motivate Starting in 1971, several national conferences Americans to reduce their risk of heart attack were sponsored by the Association to bring and stroke by making moderate changes in all interested organizations together. Today, life styles and controlling identifiable health Minority Involvement Working Group and a disorders. Poverty Planning and Development Fund These programs include smoking withdrawal Committee are working towards improving clinics, nutrition and diet instruction, the Association's program in the total community. rheumatic fever control, screening children for hidden heart disorders, stroke and heart Hand in hand with minority involvement in attack rehabilitation and high blood Association affairs has come a substantial 8 9 increase in programs of education and directors and in activities of state and local Major Awards Mrs. Alexander Ripley, Los Angeles. She prevention conducted jointly with those for Heart Associations. Thus, minority group Research Achievement Award, the "created an impressive record with the Heart whom the programs have been developed. leadership to further combat cardiovascular American Heart Association's highest award Cause in California and in the national The response has been impressive. Example: disease in these areas can be nurtured. for research accomplishment, to Arthur C. In South Dakota, at Standing Rock community," while encouraging other In 1975, AHA worked closely with the Guyton, M.D., in recognition of his brilliant, women's participation in that cause. Reservation alone, more than 5,000 Sioux Association of Black Cardiologists, the tireless research efforts spanning more than Moreover, she helped develop national are learning how to reduce their risk of heart National Medical Association composed of two decades, for his profound contributions attack and stroke. In Tulsa, Oklahoma, policies, and displayed organizational skills minority physicians, the National Congress of toward advancing knowledge of virtually in planning annual meetings for the Indians living in the urban area, are doing American Indians and the National every aspect of cardiovascular physiology, Association. likewise. Association of American Indian Physicians to and the influence his work had in stimulating Paul N. Yu, M.D., Professor of Medicine, Across the country, Heart Associations are encourage participation on regional, the efforts of other scientists. Dr. Guyton is University of Rochester (N.Y.) Medical Center. conducting high blood pressure screening affiliate and national boards and Professor and Chairman of the Department for blacks because this disease affects committees and on the Scientific Councils of Dr. Yu, a former AHA president, "performed of Physiology and Biophysics, University of brilliantly in the service of all elements of the blacks at double the rate of whites, and the Heart Association. Mississippi Medical Center. Association" for many years. Many of his usually with more devastating efforts have been directed toward consequences of heart attack and stroke. James B. Herrick Award, granted by the improving the quality of medical education When high blood pressure is detected, this Council on Clinical Cardiology to Lewis and the delivery of emergency cardiac program provides patients with follow-up Dexter, M.D., for outstanding achievement in care. resources for therapy and educational clinical cardiology. With almost 40 years programs. devoted to his field, he has 'excelled in Howard W. Blakeslee Awards for Though critically important, educating advancing scientific knowledge, improving distinguished media communication minorities at the local level is only a part of the practice of cardiology, and in regarding cardiovascular diseases: the program's mission. Equally as important developing legions of medical students and JoAnn Ellison Rodgers of the "Baltimore News in reaching its objectives is achieving a scores of research fellows who today are higher degree of minority member making significant contributions of their own American" for her four-part newspaper series involvement in committees, boards of to cardiology.' Dr. Dexter is Professor of that comprehensively reported the rising incidence of heart disease in women. Medicine at Harvard University and Director of the Cardiovascular Laboratory at Peter Good Times, a CBS-TV weekly series Bent Brigham Hospital, Boston, featuring the episode "The Check Up.' This Massachusetts. particular telecast, aired May 3, 1974, emphasized the importance of medical Gold Heart Awards honor those volunteers check ups for hypertension-prone black who have served with highest distinction in males. "Good Times" is produced by advancing the American Heart Association's Norman Lear and Tandem Productions. work. Recipients are: Andy Guthrie of WKYC-TV News, Cleveland, Julius H. Comroe, Jr., M.D., Herzstein Professor Ohio, for his five-part report, "The of Biology, University of California in San Ambulance Crisis: Who Will Come for You?" Francisco. As a scientist, he contributed It examined problems confronting importantly toward the enrichment of Cleveland's ambulance system, compared cardiovascular knowledge and improved it to those in other cities, and proposed clinical practice. Through his editorial solutions to these shortcomings. leadership, he brought "excellence" to AHA's scientific journal, "Circulation Research. Elwood Ennis, Vice President, Griffenhagen- Kroeger, a management consultant firm in San Francisco. His knowledge of management procedures proved invaluable in establishing performance standards for AHA Affiliates and in developing personnel and training policies during his 20 years as a volunteer leader of the Association. 10 11 Source: https://www.industrydocuments.ucsf.edu/docs/tInf0227

How many gold medals did she won at age 85?

kzhd0227

kzhd0227_p5, kzhd0227_p6, kzhd0227_p7, kzhd0227_p8, kzhd0227_p9, kzhd0227_p10, kzhd0227_p11, kzhd0227_p12

2

-5- - - The Experimental Effect of Diet on Co-existing Diseases DRUG-TREATED DISEASES RETURN TO NORMAL CLASSIFICATION AT START OF STUDY WITHOUT DRUGS No. of Subjects No. of Subjects % Angina 3 3 100 Hypertension 8 6 75 Diabetes: ADA Diet-controlled 10 9 90 Oral drugs 1 1 100 Insulin, 80 units 1 2 50 30 units ) 0 Gout 2 2 100 Arthritis 2 2 100 Congestive heart failure 3 2 66 Elevated blood lipids 2 2 100 TABLE 2 Comparison of Artery Stenosis before (1/20/75) and after Study (6/26/75) in L.S. ANGIOGRAPHICALLY AUTOPSY CONFIRMED LOCATION OF STENOSIS DETERMINED % STENOSIS % STENOSIS (1/20/75) (6/26/75) Right common iliac in proximal position 70% 40% Left common iliac at bifurcation 99% 40% Right common femoral at its origin 100% 50% TABLE 3 Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 () Figure 2. Initial baseline angiogram of L.S. This film demonstrates complete occlusion of the right common femoral artery at its origin (arrows). Figure 3. Macroscopic cross section of right common femoral artery stained for elastic tissue. Specimen was taken from a portion of artery which was shown angiographically (see Fig. 2) to be totally occluded. Note that the two branch arteries seen in the left lower quadrant of this cross-section correspond to branch arteries (at the occlusion site) in angio above. Source: ttps://www.industrydocuments.ucsf.edu/docs/kzhd0227 7 Figure 4a. Initial baseline angiogram (January '75) of K.B. Figure 4b. Final angiogram (June '75) of K.B. The numbers in the above line drawings correspond to numbers noted in the text. (1) The origin of the left external iliac indicates an 80% concentric stenosis in the January angiogram becoming a 50% concentric stenosis in the June angiogram; (2) The middle 1/3 of the external iliac is markedly irregular with an 80% concentric stenests in the January angiogram becoming a smooth eccentric 30% stenosis in the June angiogram: (3) The distal 1/3 of the external iliac shows moderately severe irregularities with is eccentric stenosis in the January angiogram becoming a smooth widely patent arterial segment in the June angiogram. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 8 Figure 5a. Dark field high power view of normal non-aggregating red blood cells 6 hours after a low fat meal. 3 Figure 5b. Example of red blood cell aggregation and rouleaux formation 6 hours after a high fat meal. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 () DISCUSSION The reasons for the dramatic results in reversing claudication and other atherosclerotic symptoms on a diet and exercise regimen are elucidated by tissue anoxia studies. Tissue anoxia is present III those consuming the conventional Western diet with its high 40% of total calories in fat Anoxia due to tliet in young undamaged arteries may not cause obvious symptomis, but when there IS some artery stenosis due to plaque formation (and this includes almost everyone over 25 years of age in this country) this results in increases in blood pressure and, in individuals with advanced atherosclerosis, angina and claudication. One of the first to study tissue anoxia produced by a high fat, meal was Swank11 who ted hamsters cream meals and then. through their transparent check pouches. observed the effects on the erythrocytes. As the chylomicrons started to pour in from the cream meal. the erythrocy les began adhering to each other. In 3 to 6 hours after the feeding. the aggregations. now in rouleaux and irregular formations, completely blocked many capillaries. Because of the aggregations. the full surface of the erythrocyte was not available for oxygen transfer and during this condition, the oxygen-carrying capacity of the erythrocyte was directly affected, decreasing the plasma OXY gen level to 68% of starting value. It took 72 hours before the oxygen level reached 95% of the original value. Kuo's study13 with angina patients showed that a cream meal could induce an angina attack by lowering the oxygen-carrying capacity of the blood. After an overnight fast, each subject drank heavy cream, then rested quietly while half-hour blood samples were drawn. In 5 hours. the chylomicron influx had peaked and caused the transparent fasting blood to become 600% more turbid on a plasma lactescence scale. Fourteen angina attacks occurred, simultaneously with ischemic ECGs and abnormal ballistocardiograms. The amazing similarity in the reaction of many individuals to fat was shown in almost identical lactescence curves for 13 of the 14 angina patients. These same patients on another morning drank a fat-free drink with identical calories and bulk. After 5 hours, no increased blood turbidity, no angina and no abnormal ECG tracings were noted. Platelet aggregation occurs under the same conditions that produce erythrocyte aggregation. A U.S. Department of Agriculture study, directed by Iacano13 placed normals on a 25% fat diet instead of their usual 40-45% fat intake. Not only did blood pressure and cholesterol levels drop. but there was a 50% drop in platelet aggregation. When the 40-45% fat diet was resumed. platelet aggregation returned to previous levels. As the aggregations broke up reducing the vessel blockage, the increased vessel area now availat le for blood flow permitted the same volume of blood to flow with lowered pressure. Thus. with reduced fat intake, Iacano achieved universal blood pressure drops even in normal subjects. This effect was confirmed in our study with hypertensives. Relief of coronary and calf angina both occur with increased blood flow and oxygen-carry ing capacity of the blood. In our study, these effects occurred within a few weeks after the diet-exercise regimen was begun and coincided with the rapid drop in blood lipids-an average cholesterol drop of 30% in a few weeks and one triglyceride drop from 360 mg.% to 85 mg.%. Thompson's¹ 6 report of 2 women in their 20's with elevated lipids demonstrates the relationship of blood lipid level to angina by utilizing a more drastic method than dietary reform for alleviating the symptoms. To lower the blood lipids-their cholesterol levels averaged 600 mg." they underwent plasma exchange with cholesterol-free plasma protein fraction. Approximately 50 gms. of cholesterol in the form of low density lipoproteins were removed during the 6 month treatment which involved about 8 exchanges of about 3000 ml. of blood. No other therapy changes were made. Blood lipid levels fell to half their previous value and both women lost their angina. While disappearance of angina can be rapidly achieved within weeks, as was demonstrated in our study, or months, as was accomplished in Thompson's, the ultimate cure depending upon artery plaque reversal, is another matter. In primate studies Armstrong¹ and Wissler¹ have reversed artery stenosis on a low-fat diet. Although our results need confirmation by others, we believe they are the first evidence demonstrating reversal of human atherosclerosis by diet. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 --10- AGE AS A LIMITING FACTOR IN REHABILITATION Our study has indicated the promising rehabilitative potential of a diet and activity regimen tor case of a woman, E.W. She began, almost (1 years ago at age 81. using the same regimen described claudication patients. That age need not be a limiting factor in rehabilitation is demonstrated by the in this paper for the experimental group. Her symptoms. like those of the study patients. included other atherosclerotic manifestations besides claudication. Only 5'3'` tall and weighing 100 lbs 101 the last 40 years, she had developed cardiovascular disease and was treated for angina at age (7 Al age 75 she was hospitalized with a severe heart attack. and at age 81 had claudication, congestive heart failure, hypertension, angina and arthritis. When she began the regimen at age 81. her claudication limited her walking to 100 feet and even then the calf pain was SO disabling she often had to be carried home; and the circulation to her hands was SO impaired she wore gloves in the summertime. Last year, at age 85. and after 4 years on the regimen. she was televised at the Senior Oly 111 Irvine, California, where she won 2 gold medals in the half-mile and mile running events. This youl at age 861/2, she repeated the runs and now has 4 gold medals. Each morning she runs a mile and rides her stationary bicycle 10-15 miles; twice weekly she works out in a gym: and she follows her diet assiduously. Her diastolic pressure is 70 mm. CONCLUSION: This combined low-fat diet and exercise approach has proven to be significantly (PK 0011 more effective in the treatment of severe peripheral atherosclerotic vascular disease than current therapies. It is hoped that the results reported by the use of this regimen will encourage other investigutoto to repeat our studies. Figure 6. Patient E.W. running the mile event at the Senior Olympics in Irvine, California. E.W. was 85 years old when this run was made. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 -- -11- REFERENCES 1. KANNEL, W.B., SKINNER, J.J., JR., SCHWARTZ, M.J., SHURTLEFF. D. Intermittent claudication inci- dence in the Framingham Study. Circulation 41:875, 1970. 2. DELIUS, W., ERIKSON, U. Correlation between angiographic and hemodynamic findings in occlusions of arteries of the extremities. Vascular Surg. 3:201, 1969. 3. SINGER, A., ROB, C. The fate of the claudicator, Brit. Med. J. 2:633, 1960. 4. LIVINGSTONE, P.D., JONES, C. Treatment of intermittent claudication with vitamin E. Lancet 11:602, 1958. 5. HOUSLEY, E., McFADYEN, I.J., Vitamin E. in intermittent claudication. Lancet 1:458, 1974. 6. HAEGER, K. Vitamin E in intermittent claudication. Lancet I:1352, 1974, and Vasa 2:280-287, 1973. 7. LARSEN, O.A., LASSEN, N.A. Effect of daily muscular exercise in patients with intermittent claudication. Scandinavian J. Clin. Lab. Invest. Suppl. 93:168, 1967 and Lancet II:1093, 1966. 8. JOHANSSON, B.W., SIEVERS, J. "Spontaneous course" of intermittent claudication. Scandinavian J. Clin. Lab. Invest. Suppl. 93:156, 1967. 9. ZETTERQUIST, S. The effect of active training on the nutritive blood flow in exercising ischemic legs. Scandinavian J. Clin. Lab. Invest. 25:101, 1970. 10. EBEL, A., KUO, J.C. Tolerance for treadmill walking as an index of intermittent claudication. Arch. Phys. Med. and Rehab. 611-614, Nov., 1967. 11. SWANK, R.A. A biochemical basis of multiple sclerosis. C.C. Thomas Publ., Springfield, III., 1961. 12. KUO, P.T. and JOYNER, C.R., JR. Angina pectoris induced by fat ingestion in patients with coronary heart disease. JAMA 158:1008-13, 1955. 13. IACANO, J.M. Lipid research lab. U.S. Department of Agriculture, Beltsville, Md., 20705. Private communication. 14. ARMSTRONG, M.L. and MEGAN, M.B., ET AL. Plasma and carcass cholesterol in rhesus monkeys after low and intermediate levels of dietary cholesterol Circulation Supp. II, 43: II-III, 1971. Also: ARMSTRONG, M.L. ET AL. Xanthomotosis in rhesus monkeys fed a hypercholesterolemic diet. Arch. of Path. 84:227-37, 1967. 15. WISSLER, R.W. Development of the atherosclerotic plaque. Hosp. practice 8:61-72, 1973. 16. THOMPSON, G.R., LOWENTHAL, R., MYANT, N.B. Plasma exchange in the management of homozygous familial hypercholesterolemia. Lancet I:1208, 1975. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 12 This study was financed in part by the Kirsten Foundation, Manhasset, N.Y., and the Longevity Research Institute, Santa Barbara, Ca. We would like to thank Wallace E. Carroll, M.D., William C. Gnekow, M.D., and Samuel H. Brooks, Ph.D., for their professional assistance in the pathological, radiological, and statistical evaluations made in this study. In addition we would like to give credit to Janie Sternal for her photographic assistance. Finally, we would like to acknowledge the support of the following corporations for their help in providing part of the foods used in the experimental diet: Archon Pure Products Corp.; Celestial Seasonings; Charles Soderstrom Enterprises; Chiquita Brands, Inc.; Erewhon, Inc.; Fisher Mills, Inc.: Hol-Grain Div. of Golden Grain; Hunt-Wesson Foods; and Pure Gold, Inc. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227

"Combined low-fat diet and exercise approach has proven to be significantly effective in the treatment of" which disease?

kzhd0227

kzhd0227_p5, kzhd0227_p6, kzhd0227_p7, kzhd0227_p8, kzhd0227_p9, kzhd0227_p10, kzhd0227_p11, kzhd0227_p12

Severe peripheral atherosclerotic vascular disease, SEVERE PERIPHERAL ATHEROSCLEROTIC VASCULAR DISEASE

-5- - - The Experimental Effect of Diet on Co-existing Diseases DRUG-TREATED DISEASES RETURN TO NORMAL CLASSIFICATION AT START OF STUDY WITHOUT DRUGS No. of Subjects No. of Subjects % Angina 3 3 100 Hypertension 8 6 75 Diabetes: ADA Diet-controlled 10 9 90 Oral drugs 1 1 100 Insulin, 80 units 1 2 50 30 units ) 0 Gout 2 2 100 Arthritis 2 2 100 Congestive heart failure 3 2 66 Elevated blood lipids 2 2 100 TABLE 2 Comparison of Artery Stenosis before (1/20/75) and after Study (6/26/75) in L.S. ANGIOGRAPHICALLY AUTOPSY CONFIRMED LOCATION OF STENOSIS DETERMINED % STENOSIS % STENOSIS (1/20/75) (6/26/75) Right common iliac in proximal position 70% 40% Left common iliac at bifurcation 99% 40% Right common femoral at its origin 100% 50% TABLE 3 Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 () Figure 2. Initial baseline angiogram of L.S. This film demonstrates complete occlusion of the right common femoral artery at its origin (arrows). Figure 3. Macroscopic cross section of right common femoral artery stained for elastic tissue. Specimen was taken from a portion of artery which was shown angiographically (see Fig. 2) to be totally occluded. Note that the two branch arteries seen in the left lower quadrant of this cross-section correspond to branch arteries (at the occlusion site) in angio above. Source: ttps://www.industrydocuments.ucsf.edu/docs/kzhd0227 7 Figure 4a. Initial baseline angiogram (January '75) of K.B. Figure 4b. Final angiogram (June '75) of K.B. The numbers in the above line drawings correspond to numbers noted in the text. (1) The origin of the left external iliac indicates an 80% concentric stenosis in the January angiogram becoming a 50% concentric stenosis in the June angiogram; (2) The middle 1/3 of the external iliac is markedly irregular with an 80% concentric stenests in the January angiogram becoming a smooth eccentric 30% stenosis in the June angiogram: (3) The distal 1/3 of the external iliac shows moderately severe irregularities with is eccentric stenosis in the January angiogram becoming a smooth widely patent arterial segment in the June angiogram. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 8 Figure 5a. Dark field high power view of normal non-aggregating red blood cells 6 hours after a low fat meal. 3 Figure 5b. Example of red blood cell aggregation and rouleaux formation 6 hours after a high fat meal. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 () DISCUSSION The reasons for the dramatic results in reversing claudication and other atherosclerotic symptoms on a diet and exercise regimen are elucidated by tissue anoxia studies. Tissue anoxia is present III those consuming the conventional Western diet with its high 40% of total calories in fat Anoxia due to tliet in young undamaged arteries may not cause obvious symptomis, but when there IS some artery stenosis due to plaque formation (and this includes almost everyone over 25 years of age in this country) this results in increases in blood pressure and, in individuals with advanced atherosclerosis, angina and claudication. One of the first to study tissue anoxia produced by a high fat, meal was Swank11 who ted hamsters cream meals and then. through their transparent check pouches. observed the effects on the erythrocytes. As the chylomicrons started to pour in from the cream meal. the erythrocy les began adhering to each other. In 3 to 6 hours after the feeding. the aggregations. now in rouleaux and irregular formations, completely blocked many capillaries. Because of the aggregations. the full surface of the erythrocyte was not available for oxygen transfer and during this condition, the oxygen-carrying capacity of the erythrocyte was directly affected, decreasing the plasma OXY gen level to 68% of starting value. It took 72 hours before the oxygen level reached 95% of the original value. Kuo's study13 with angina patients showed that a cream meal could induce an angina attack by lowering the oxygen-carrying capacity of the blood. After an overnight fast, each subject drank heavy cream, then rested quietly while half-hour blood samples were drawn. In 5 hours. the chylomicron influx had peaked and caused the transparent fasting blood to become 600% more turbid on a plasma lactescence scale. Fourteen angina attacks occurred, simultaneously with ischemic ECGs and abnormal ballistocardiograms. The amazing similarity in the reaction of many individuals to fat was shown in almost identical lactescence curves for 13 of the 14 angina patients. These same patients on another morning drank a fat-free drink with identical calories and bulk. After 5 hours, no increased blood turbidity, no angina and no abnormal ECG tracings were noted. Platelet aggregation occurs under the same conditions that produce erythrocyte aggregation. A U.S. Department of Agriculture study, directed by Iacano13 placed normals on a 25% fat diet instead of their usual 40-45% fat intake. Not only did blood pressure and cholesterol levels drop. but there was a 50% drop in platelet aggregation. When the 40-45% fat diet was resumed. platelet aggregation returned to previous levels. As the aggregations broke up reducing the vessel blockage, the increased vessel area now availat le for blood flow permitted the same volume of blood to flow with lowered pressure. Thus. with reduced fat intake, Iacano achieved universal blood pressure drops even in normal subjects. This effect was confirmed in our study with hypertensives. Relief of coronary and calf angina both occur with increased blood flow and oxygen-carry ing capacity of the blood. In our study, these effects occurred within a few weeks after the diet-exercise regimen was begun and coincided with the rapid drop in blood lipids-an average cholesterol drop of 30% in a few weeks and one triglyceride drop from 360 mg.% to 85 mg.%. Thompson's¹ 6 report of 2 women in their 20's with elevated lipids demonstrates the relationship of blood lipid level to angina by utilizing a more drastic method than dietary reform for alleviating the symptoms. To lower the blood lipids-their cholesterol levels averaged 600 mg." they underwent plasma exchange with cholesterol-free plasma protein fraction. Approximately 50 gms. of cholesterol in the form of low density lipoproteins were removed during the 6 month treatment which involved about 8 exchanges of about 3000 ml. of blood. No other therapy changes were made. Blood lipid levels fell to half their previous value and both women lost their angina. While disappearance of angina can be rapidly achieved within weeks, as was demonstrated in our study, or months, as was accomplished in Thompson's, the ultimate cure depending upon artery plaque reversal, is another matter. In primate studies Armstrong¹ and Wissler¹ have reversed artery stenosis on a low-fat diet. Although our results need confirmation by others, we believe they are the first evidence demonstrating reversal of human atherosclerosis by diet. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 --10- AGE AS A LIMITING FACTOR IN REHABILITATION Our study has indicated the promising rehabilitative potential of a diet and activity regimen tor case of a woman, E.W. She began, almost (1 years ago at age 81. using the same regimen described claudication patients. That age need not be a limiting factor in rehabilitation is demonstrated by the in this paper for the experimental group. Her symptoms. like those of the study patients. included other atherosclerotic manifestations besides claudication. Only 5'3'` tall and weighing 100 lbs 101 the last 40 years, she had developed cardiovascular disease and was treated for angina at age (7 Al age 75 she was hospitalized with a severe heart attack. and at age 81 had claudication, congestive heart failure, hypertension, angina and arthritis. When she began the regimen at age 81. her claudication limited her walking to 100 feet and even then the calf pain was SO disabling she often had to be carried home; and the circulation to her hands was SO impaired she wore gloves in the summertime. Last year, at age 85. and after 4 years on the regimen. she was televised at the Senior Oly 111 Irvine, California, where she won 2 gold medals in the half-mile and mile running events. This youl at age 861/2, she repeated the runs and now has 4 gold medals. Each morning she runs a mile and rides her stationary bicycle 10-15 miles; twice weekly she works out in a gym: and she follows her diet assiduously. Her diastolic pressure is 70 mm. CONCLUSION: This combined low-fat diet and exercise approach has proven to be significantly (PK 0011 more effective in the treatment of severe peripheral atherosclerotic vascular disease than current therapies. It is hoped that the results reported by the use of this regimen will encourage other investigutoto to repeat our studies. Figure 6. Patient E.W. running the mile event at the Senior Olympics in Irvine, California. E.W. was 85 years old when this run was made. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 -- -11- REFERENCES 1. KANNEL, W.B., SKINNER, J.J., JR., SCHWARTZ, M.J., SHURTLEFF. D. Intermittent claudication inci- dence in the Framingham Study. Circulation 41:875, 1970. 2. DELIUS, W., ERIKSON, U. Correlation between angiographic and hemodynamic findings in occlusions of arteries of the extremities. Vascular Surg. 3:201, 1969. 3. SINGER, A., ROB, C. The fate of the claudicator, Brit. Med. J. 2:633, 1960. 4. LIVINGSTONE, P.D., JONES, C. Treatment of intermittent claudication with vitamin E. Lancet 11:602, 1958. 5. HOUSLEY, E., McFADYEN, I.J., Vitamin E. in intermittent claudication. Lancet 1:458, 1974. 6. HAEGER, K. Vitamin E in intermittent claudication. Lancet I:1352, 1974, and Vasa 2:280-287, 1973. 7. LARSEN, O.A., LASSEN, N.A. Effect of daily muscular exercise in patients with intermittent claudication. Scandinavian J. Clin. Lab. Invest. Suppl. 93:168, 1967 and Lancet II:1093, 1966. 8. JOHANSSON, B.W., SIEVERS, J. "Spontaneous course" of intermittent claudication. Scandinavian J. Clin. Lab. Invest. Suppl. 93:156, 1967. 9. ZETTERQUIST, S. The effect of active training on the nutritive blood flow in exercising ischemic legs. Scandinavian J. Clin. Lab. Invest. 25:101, 1970. 10. EBEL, A., KUO, J.C. Tolerance for treadmill walking as an index of intermittent claudication. Arch. Phys. Med. and Rehab. 611-614, Nov., 1967. 11. SWANK, R.A. A biochemical basis of multiple sclerosis. C.C. Thomas Publ., Springfield, III., 1961. 12. KUO, P.T. and JOYNER, C.R., JR. Angina pectoris induced by fat ingestion in patients with coronary heart disease. JAMA 158:1008-13, 1955. 13. IACANO, J.M. Lipid research lab. U.S. Department of Agriculture, Beltsville, Md., 20705. Private communication. 14. ARMSTRONG, M.L. and MEGAN, M.B., ET AL. Plasma and carcass cholesterol in rhesus monkeys after low and intermediate levels of dietary cholesterol Circulation Supp. II, 43: II-III, 1971. Also: ARMSTRONG, M.L. ET AL. Xanthomotosis in rhesus monkeys fed a hypercholesterolemic diet. Arch. of Path. 84:227-37, 1967. 15. WISSLER, R.W. Development of the atherosclerotic plaque. Hosp. practice 8:61-72, 1973. 16. THOMPSON, G.R., LOWENTHAL, R., MYANT, N.B. Plasma exchange in the management of homozygous familial hypercholesterolemia. Lancet I:1208, 1975. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227 12 This study was financed in part by the Kirsten Foundation, Manhasset, N.Y., and the Longevity Research Institute, Santa Barbara, Ca. We would like to thank Wallace E. Carroll, M.D., William C. Gnekow, M.D., and Samuel H. Brooks, Ph.D., for their professional assistance in the pathological, radiological, and statistical evaluations made in this study. In addition we would like to give credit to Janie Sternal for her photographic assistance. Finally, we would like to acknowledge the support of the following corporations for their help in providing part of the foods used in the experimental diet: Archon Pure Products Corp.; Celestial Seasonings; Charles Soderstrom Enterprises; Chiquita Brands, Inc.; Erewhon, Inc.; Fisher Mills, Inc.: Hol-Grain Div. of Golden Grain; Hunt-Wesson Foods; and Pure Gold, Inc. Source: https://www.industrydocuments.ucsf.edu/docs/kzhd0227

What is the Table number ?

yyhd0227

yyhd0227_p51, yyhd0227_p52, yyhd0227_p53, yyhd0227_p54, yyhd0227_p55, yyhd0227_p56, yyhd0227_p57

4-A, 4-a

TABLE 2-A MEANS AND STANDARD DEVIATIONS OF PSYCHOLOGICAL TEST SCORES BY SUPPLEMENTATION INGESTION CATEGORY, AND ANALYSES OF VARIANCE Nutritional Status Category: Test 0 1 2 S.D. Sig. X x X F (pooled) level Brazelton Neonatal Assessment BG1 38.83 36.00 39,05 .66 13.12 NS (42) (32) (83) Composite Infant Scale 6 Months Mental 74.17 76.45 77.81 2.54 13.44 1.100 (161) (223) (101) 6 Months Motor 70.11 70.96 72.72 1.06 14.14 NS (161) (223) (101) 15 Months Mental 61.77 66.30 72,31 16.40 14.14 /.005 (177) (255) (77) 15 Months Motor 73.62 77.35 82.60 7.36 17.61 /.005 (177) (255) (77) 24 Months Mental 59.44 65.39 67.85 17.46 13.76 /.005 (245) (220) (80) 24 Months Motor 67.33 74.61 79.07 13.56 20.28 /.005 (237) (218) (80) Source: https://www.industrydocuments.ucsf.edu/docs/yyhd0227 TABLE 2-B MEANS AND STANDARD DEVIATIONS OF PSYCHOLOGICAL TEST SCORES BY SUPPLEMENTATION INGESTION CATEGORY, AND ANALYSES OF VARIANCE Nutritional Status Category: Test 0 1 2 S.D. Sig. X X X F (pooled) level Preschool Battery 36 Months EFT Sum 9.43 10.03 9.70 1.91 . 3.44 NS (270) (232) (50) EFT Time 3.15 3.01 2.89 1.58 11,45 NS (270) (232) (50) EFT Adaptability .009 ,013 ,072 1.48 .240 NS (270) (232) (50) Digit Span 10,11 10,87 12.92 2.22 8.33 NS (224) (197) (44) Sentence Span 12.06 14.22 14.60 1.85 12.85 NS (228). (210) (48 ) RDL Sum 23.18 23.83 20.93 .38 20.52 NS (232) (220) (45) RDL Time 2.34 2.07 1.83 5.13 11.49 1.010 (232) (220) (45) Vocabulary Naming 6.44 7.44 8.06 5.07 4.31 1.010 (262) (227) (50) Vocabulary Recognition 19.40 20,62 20.70 2.83 5.67 /.050 (262) (227) (50) Source: https://www.industrydocuments.ucsf.edu/docs/yyhd0227 TABLE 2-B (CÓNT'D.) MEANS AND STANDARD DEVIATIONS OF PSYCHOLOGICAL TEST SCORES BY SUPPLEMENTATION INGESTION CATEGORY, AND ANALYSES OF VARIANCE Nutritional Status Category: Test 0 1 2 S.D. Sig. X X X F (pooled) level Verbal Inferences 1.25 1.52 2,08 3,28 1.22 7.050 (120) (106) (12) Draw-A-Line Slowly (cm/sec) 10.59 9.34 9.44 4.84 4.55 1.010 (250) (220) (50) Rompecabezas 5.98 5.86 6.46 .25 5.40 NS (203) (223) (50) Cognitive Composite - 5.28 48.97 54.20 2.75 . 280.39 NS (278) (237) (50) Source: https://www.industrydocuments.ucst.edu/docs/yyhd0227 TABLE 2-C MEANS AND STANDARD DEVIATIONS OF PSYCHOLOGICAL TEST SCORES BY SUPPLEMENTATION INGESTION CATEGORY, AND ANALYSES OF VARIANCE Nutritional Status Category: Test 0 1 2 S.D. Sig. X X X F (pooled) level 48 Months EFT Sum 4.63 4,83 5,55 1.74 2,60 NS (205) (236) (31) 2.90 2.69 2.85 1.54 1.24 NS EFT Time (205) (236) (31) EFT Adaptability .022 .054 .024 2,02 ,175 NS (205) (236) (31) Digit Span 21.05 21.43 19.24 .409 12.37 NS (200) (233) (29) Sentence Span 30,07 34,10 36.07 2,62 20,37 /.100 (204) (231) (28) RDL Sum 33,48 37.93 40.97 3.69 20.15 /.050 (209) (240) (31) RDL Time 1.69 1.55 1.58 2.66 .64 /.100 (209) (240) (31) Vocabulary Naming 11.70 13.89 14.10 11.18 5,19 . 1.005 (212) (238) (30) Vocabulary Recognition 25.59 27,30 26.63 5.83 5,35 /.005 (212) (238) (30) Source: https://www.industrydocuments.ucstf.edu/docs/yyhdo227 TABLE 2-C (CONT'D.) MEANS AND STANDARD DEVIATIONS OF PSYCHOLOGICAL TEST SCORES BY SUPPLEMENTATION INGESTION CATEGORY, AND ANALYSES OF VARIANCE Nutritional Status Category: Test 0 1 2 S.D. Sig. X X X F (pooled) level Verbal Inferences 2.76 3,05 3,00 1.50 1.54 NS (155) (191) (23) Draw-A-Line Slowly (cm/sec) 7.30 5.97 4.44 9.65 4.18 NS (203) (229) (31) Rompecabezas 9,01 9.06 8.00 .359 6.62 NS (184) (236) (31) Cognitive Composite -17,53 56.52 67.87 4.08 291.50 /.025 (215) (241) (31) Source: https://www.industrydocuments.ucst.edu/docs/yyhd0227 TABLE 3 THE ASSOCIATION OF PSYCHOLOGICAL TEST PERFORMANCE WITH SUPPLEMENT INGESTION m TV With total supplement With supplement ingesred : ingested to time of test- during preanancy (I), With total supplement ing (II), controlling for controlling for post-nata Test With supplement ingested ingested to time of supplement ingested supplement ingested during preanancy testing during preanancy (i) to time of tesring (II) Boys : Girls Boys Girls Boys Girls Boys Girls posite Infant Scale- inths Mental Scale 11 : * 13* : .04 .01 -.07 -.18** .13* .15* bosite Infant Scale - :onths Mental Scale .09 .24** 14* .12* .11 -.07 .01 .22* posite Infant Scale- .onths Mental Scale .20** .15* 19** 13* .11 .04 .12* .09 onths Cognitive Composite .09 .11 .04 .10 .00 .04 .12* .05 onths Verbal Inferences .36** .25** .20** .12* .04 -.03 .33** .23** "pprox. 250 for all tests except Verbal Inferences. "pprox 120 for Verbal Inferences. P . . 05 Z.01 Source: https://www.industrydocuments.ucsf.edu/docs/yyhd0227 TABLE 4-A RELATIVE RISK OF FALLING INTO EXTREME 20% ACCORDING TO SUPPLEMENTATION INGESTION AND SOCIOECONOMIC STATUS VARIABLE: Composite Infant Scale 15 Month Mental Score Sample Size (N's) Percentages Chi-Square Test Performance Group TOTAL SAMPLE Low 1 Med. 2 High 3 Tot. Low Med. High Tot. x2 d.f. P 52 101 24 177 29 57 14 100 27.1 4 2.01 0 54 255 17 62 21 100 1 44 157 2 5 46 26 77 6 60 34 100 T 101 304 104 509 20 60 20 LOW SES 0 23 50 6 79 29 63 8 100 18,4 4 L.01 61 22 100 1 22 79 29 130 17 2 2 28 13 43 5 65 30 100 T 47 157 48 252 19 62 19 HIGH SES 27 45 18 90 30 50 20 100 11.7 4 2.05 0 1 22 75 25 122 18 61 20 100 13 2 3 18 13 34 9 53 38 100 T 52 138 56 246 21 56 23 1 = Lowest pentile 2 = Middle 60% of scores 3 = Highest pentile Source: https:/lwww.industrydocuments.ucsf.edu/docslyyhdo227