From these investigations, during the years 1936-38 the Council published the fol- lowing conclusions in their final report:-
". . that the Australian people are on the whole well fed, but a certain
section (the exact size of which can not be stated from the nature of the enquiry) are not obtaining and may not be in a position to obtain enough food"; and
"(1) that there is much ignorance in the community as to the proper balance of food items.
"(2) that some people in both town and country are unable for various reasons to obtain the essential fresh foods."
Attributed to thesQ causes it is stated that "a considerable mass of minor departures from normal health, describable generally as malnutrition, exists among the young children in both town and country," and that "evidence points to faulty selection of diets as the main cause of malnutrition, a selection sometimes necessi- tated by poverty, but more often by igorance."
Thus it was determined that malnutrition does exist in Australia, and the manner in which it reveals itself was detected. Its extent could not be accurately estimated.
but it is to be hoped that it is less widespread than in Great Britain, where Sir Joint Orr reported that over 50 per cent. of the population is living on a diet which falls below the standards required for health. The causes of the condition in Australia were sought, and were deduced to be ignorance and poverty.
Thus the preliminary researches were made, enabling a constructive plan to be drawn up for combatting the problem. It was outside the powers of the Council to instigate the necessary remedial measures, but various recommendations were made.
Some of these are as follows:—
"(1) The provision of a daily supply of milk for school children, distributed where, on enquiry, it would probably do the most good.
"(2) The formation by the Commonwealth Department of Health of a division for the study of child growth, with special reference to child diet.
"(3) The extension under medical supervision and on a widespread geographic basis of the kindergarten, nursery school and similar movements.
"(4) The enlistment of the co-operation of State Health and Education Depart- ments in a scheme of general education in diet and food hygiene as an essential part of the standard curriculum for all school children.
"(5) The appointment in each State of a committee whose function should be to educate the public in respect to both proper dietetic and nutritional practice and to claims made, whether reliable or misleading, on behalf of proprietary or other articles or systems of diet, and to advise generally in relation to nutritional and dietetic matters."
Some of these recommendations have since been put into practice, and others have been carried out in part. The Lady Gowrie Child Centres have been estab- lished in each capital city for the welfare of children betwen the ages of two and six years, They are controlled by the Commonwealth Department of Health and the Australian Association for Pre-School Child Development, and are run on free kinder- garten or nursery school lines.
As a first move in public education in regard to diet the Commonwealth Depart- ment of Health has published a series of pamphlets for free distribution throughout Australia.
A Commonwealth Nutrition Committee was formed as a sub-committee of the Medical Research Council to consider nutrition matters, and local nutrition committees have been formed in certain States.
Outlined briefly, these are the steps which have been taken by the Common- wealth Government in tackling the problem of malnutrition in Australia.
It is now proposed to consider in more detail certain matters relating to the pre- vention of malnutrition.
It has been stated that ignorance is the primary cause, and that there is a wide- spread lack of knowledge of food requirements. More than may be realised the task of educating the public in regard to health matters falls to the medical man. It is true that such fundamentals as elementary dietetics and hygiene should be taught to every child in the schools, but it is to the physician that the public looks for guidance in all such matters. Frequently it is not until illness results or a child is born into the family that the layman seeks for help in the matter of diet. Then it becomes the loctor's responsibility to give the necessary instruction. This is comparatively simple if the patient has an ample income, but advice on the wisest use of food in cases where the income is very limited is much more difficult. It requires some knowledge of the composition of economical diets in which an adequate amount of each nutritive essential is provided for the least cost.
To provide this data an investigation was undertaken of adequate diets at low cost, and the salient points revealed are discussed below.
Adequate Nutritional Requirements for Minimum Cost.
Certain general characteristics, some good and others undesirable are found to apply to the diets of the lower income groups. One is that the lower the expenditure on food the greater the proportion of carbohydrate in the diet and the smaller the consumption of "protective foods," milk in particular.
It is inevitable that the proportioA of carbohydrate is high, since on the whole the cereals have a high "economic index," that is the number of calories provided per penny is relatively great. The extensive use of cereals is thus good economy, but an excessive expenditure on the more concentrated and refined carbohydrates such as sugars and sugar-and-flour concoctions in the form of biscuits, cakes and confectionery is a deplorable practice. It is to this disproportionately high intake of refined carbo- hydrate, associated with a low intake of vitamin B1 that certain of the minor depart- ures from health characteristic of malnutrition are considered to be due. Since of necessity cereals must play a major part in the low-cost diet, the importance of using whole-grain products becomes obvious. The unrefined forms of cereals, besides being relatively rich in minerals, are the most valuable source of vitamin Bl. Thus the disadvantage of the high consumption of cereals is counteracted by the use of whole- grain forms which have both a high economic index and a considerable "protective value."
In the interests of economy the restriction of "protective foods" is necessary to some degree, but it is poor economy to reduce them beyond a certain level (indicated in the tables which follow). The exclusion of milk or the scanty use of sweetened condensed milk, which is so common in the diets of the underprivileged, is both uneconomic and serious in its consequences, particularly in respect to the calcium intake of children and mothers. Milk, in actual fact, is one of the most economical foods available, since in addition to being a good source of animal protein, fat and carbohydrate, it is rich in calcium, phosporus and vitamins A, B1, and B2. Even more economical are skimmed milk, either fresh or dried, and cheese. These forms of milk compare favourably with the cheapest cuts of meat as a cheap source of protein, and are far richer in calcium. If skimmed milk is used in place of whole milk, extra fat will be required in the diet, and extra vitamin A. This supplement may he supplied as butter, which will fulfil both requirements or, more cheaply, as
dripping and certain green or yellow vegetables, rich in carotene. Half a pound of dried skim milk (making 4 pints) plus 4 lb. butter is equivalent to 4 pints of fresh whole milk, and costs less. The use of dried milk is of particular value in inland areas where fresh milk is sometimes unprocurable or very costly.
Whole-grain cereals and milk should form two of the basic foods of the low-cost diet. Another valuable staple article of diet is the potato. Its economic index is high compared with most other vegetables, and its particular merit, in addition to its mineral conteni, is that it retains its full vitamin C content on cooking. The quantity of potatoes which would normally be consumed would not supply the full requirement of vitamin C for health, but would probably be sufficient to prevent severe scurvy.
Three pounds of potatoes per week will provide about a fifth of the full vitamin C requirements for a man according to the Stiebeling's Standard. The most economical method of making up this quota is generally by means of citrus fruits; one orange of small to medium size provides more vitamin C than 11 lb. of apples or 1 lb. of pota- toes. A satisfactory substitute for oranges for use when they are not available is provided by tomatoes (either fresh or tinned) or paw paw. One orange weighing from 5-6 oz. is equivalent to 2 lb. ripe tomatoes or lb. ripe paw paw.
Fruits and vegetables are relied on mainly to supply minerals, vitamins and fibre in the diet. Apart from those already mentioned the further selection should be influenced mainly by the content of iron, vitamin A and the cheapness. Those higl.
in carotene (the precursor of vitamin A) are yellow or orange-coloured, such as carrots, pumpkins and turk's caps, and tomatoes, or green-coloured vegetables such as spinach or silver beet tops, and green cabbage. As a source of iron the leafy green vegetables and dried peas and legumes are foremost. The dried fruits are also rela- tively high in these constituents, and are particularly useful as a supplement or sub stitute for fresh cooking fruits when these are dear or unobtainable.
Butter, though an excellent form of fat and a good source of vitamin A, is, at its Australian price, a very costly ar'icle of diet. Though a certain amount is desirable, particularly from the aspect of palatability, it can in part be supplanted by cheaper fats, the cheapest of which is dripping.
The most expensive items in many household food budgets are meat and eggs. As a source of protein, eggs are very costly, but they are especially rich in iron, phos- phorus and vitamins A, B1, B2, and D. For this reason it is desirable to allow at least two per week per person. Meat is included in the diet chiefly as a source of protein and on account of its "satiety" value.
From the above discussion it can be seen that foods can be grouped according to their particular merits. In compiling a diet certain amounts of each group are selected to provide the total requirements of the individual. The groups are as follows:—
1. Bread, Flour and Other Cereals.
2. Milk and Equivalents.
3. Potatoes.
4. Dried Beans and Peas.
5. Citrus Fruits or Equivalents.
6. Leafy, Green and Yellow Vegetables.
7. Dried Fruits.
8. Other Fruits and Vegetables.
9. Fats (Butter, etc.).
10. Sugar and Equivalents.
11. Meat and Fish.
12. Eggs.
600 10 600 .,, 10.
600 10 600 ' 100 600 ' 100 600 95 600 100 600 :4100 600 95 580 90 540 85 450 80 450
Table 1 (see pp. 38-9) gives the quantities of these foods which constitute adequate diets for individuals of various ages and activities. The total amount of each group is shown in brackets, and beneath are listed the quantities of the various members of the group which have been selec' ed. The selection of these examples may be varied according to taste or season as long as the total amount of each group is reached.
At the head of each column the total calorie value per day of the diet is given, and at the bottom the total cost per week of the nutritive items and the accessories.
The factors considered in compiling the diets are the total caloric value, the pro- portion of calories from the various food constituents, and the content of calcium, phosphorus and iron and vitamins A, B1, B2 and C. The standard of caloric values taken is that used by Stiebeling, and is not very different from the values agreed upon by the League of Nations Health Organisation. The ratio between calories obtained from carbohydrate, protein and fat is within the range given by M. S. Rose, namely, 45 65%, 10-15%, and 20-40% respec'ively. Stiebeling's Standards for energy value, protein, minerals and vitamins are as follows:—
TABLE II.
STANDARDS OF MINIMUM DAILY QUANTITIES OF SPECIFIED NUTRIENTS FOR ADEQUATE DIETS. (STIEBELING'S STANDARD 193)
Individual. Calories.
Coefft. Protein. Calcium Phosph. Iron.
*gms. mgms. mg,11s. mgms.
$Vitamins A B1 1. Moderately active
man 3000 1.0 67 680 1320 15 4000 ' 600
2. Very active man .. 4500 1.5 67 680 1320 15 4000 600 3. Active man .. .. .. 4000 1.33 67 680 1320 15 4000 600 4. Man doing light
work 2700 0.9 67 680 1320 15 4000 600
5. Very active woman.. 3000 1.0 67 680-1000 1320 15 4000 600 6. Moderately active
woman .. .. .. 2500 0.83 67 680-1000 1320 15 4000 500 7. Active Boy over 15
years 3000-4000 1.33 75 880 1320 15 4000 600
8. Boy, 13-15 years .. 3000 1.0 75 880 1320 15 4000 600 9. Boy, 11-12 ; Girl over
2500 0.83 75 1000 1200 13-15 4000 500 10. Boy, 9-10 ; Girl, 11-
13 2400 0.8 75 1000 1200 12-15 3500 480
11. Boy, 7-8; Girl, 8-10 2100 0.7 65 1000 1000 11-15 3500 420 12. Boy, 4-6; Girl, 4-7 .. 1500 0.5 55 1000 1000 8-11 3000 300 13. Child under 4 years 1200 0.4 45 1000 1000 6-9 3000 240
Sherman Units.
B2 C
*At least 40% of the protein should be of high biological value.
T.The standards for vitamins B1 and B2 are not included in the reference from which the rest of the values have been quoted but have been taken from a later publication relating to "class A" diets. In the more recent recent literature a higher value is given for both vitamins A and C. Sherman units for these two vitamins have been reduced in value relative to the international unit, the equivalents now being given as—
Vitamin A. 1 Sherman unit— 0.5 I.U. instead of 1.4.
Vitamin C, 1 Sherman unit--10 I.U. instead of 15.
To reach the increased value for vitamin A an extra source of the vitamin such as cod liver oil would have to be added to the diets shown in table 1 for the two youngest age levels. Regarding the higher vitamin C levels, most British authorities consider them to be higher than necessary.
In the second column of this table (II.) are shown the "energy co-efficients" for the various individuals. This coefficient represents the multiple of 3000 Calories, which is equal to the individual's energy requirement. The standard of 3000 Calories, the requirement of a moderately active male, is taken as the unit and is described as a
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Using the figures given in table I., the minimum cost of providing an adequate diet for this family would be £1/19/6. The prices used, for this assessment were collected from various inexpensive shopping centres in Melbourne and Sydney during the years 1938 and '39. Since that period there has been an increase in the cost of living of approximately 5.6% (August, 1940), so that, if the cost of food has in- creased proportionately, the food budget for the family will now be £2/1/9.
The ques' ion which arises out of this discussion is whether or not the majority of families of five can afford a diet of this value. According to Rowntree, a British social economist, to obtain the "human needs of labour" a third of the income should be allotted to food,, a third to housing, and a third to clothing, and miscellaneous items.
This would mean that the family described above would require an income of approxi- mately £6 per week. Since the basic wage is only in the region of £4, it is obvious that there are many families with three children receiving less than this amount.
In a recent publication, the Commonwealth Statistician gave the figure of 36% as being the proportion of the income being spent on food in Australia at a time when the basic wage was about £4. This would enable £1/8/10 to be spent on food per week. According to the figures in Table I., the largest family for which this wou'd provide an adequate diet is one of man value 3.23. Such a family might be comprised of a moderately active man and woman and two children each of coefficient 0.7 e.g., a girl 8-10 years and a boy 7-8 years.
Data colletced during the Commonwealth Nutrition Survey showed chat for the 1800 families taken as representing a cross sec+ion of the city population, the average man value per family was 3.52. The minimum cost of providing an adequate diet for a family of this size is estimated from Table I. to be £1/11/6, when the family includes only two children, of coefficients 1.0 and 0.7. If it is made up of three chil- dren the cost is £1/15/-, a considerably larger sum since the cost is not in direct proportion to the energy coefficient.
It is obvious that the average housewife has not the scientific knowledge nor the time to enable her to plan, each week, such an economical adequate dietary as that shown in Table I. So, unless she has access to a very cheap shopping centre, it is unlikely that she would obtain an adequate diet for her family without exceeding the costs given. Thus, in families of five or more, where less than £2 per week is being spent on food, it seems probable that the diet will be below standard.
A significant fact revealed by the Commonwealth Nutrition Survey was that the occurrence of malnutrition was, in the majority of cases, found to he in families con- taining more than three children.
From these considerations one is led to the conclusion that poverty or low income does not take second place as a cause of the malnutrition present in the community.
References,
Final Report of Commonwealth Advisory Council on Nutrition 19;38.
Fifth Report of Commonwealth Advisory Couneil On: NutAtD3n. _
"Food, 'Health and Income"—Sir John Ott.
"Guiding Principles for Studies on the Nutrition of Populations"—League of Nations Health Organisation, Technical Commission on Nutrition, 1939.
"Diets at Four Levels of Nutritive Content and Cost"—H. K. Stiebeling and M. M.
Ward, United States Department of Agriculture.
"The Human Needs of Labour"—Rowntree.
"Monthly Review of Business Statistics," June, 1940—Commonwealth Bureau of Census and Statistics.
"The Chemistry of Food and Nutrition"—H. C. Sherman.
"A Laboratory Handbook of Die etics"—M. S. Rose.
`Food Tables"—V. H. Mottram and Radloff.
"Table of Vitamin Content of Human and Animal Foods," Nutrition Abstracts and Reviews, 1937, VII, 823—Boas, Fixsen and Roscoe.
"Food and Health"—A. B. Callow.
The Avitaminoses"—Eddy and Daldorf.
LITERARY NOTE.
"For this Mr. Robt. Henryson he was questionles a learned and a witty man, and it is pity we have no more of his works being very old he dyed of a diarrhea or fluxe, of whom there goes this merry, though somewhat unsavoury tale, that all physitians having given hin. over and he lying drawing his last breath there came an old woman un'o him, who was held a witch, and asked him whether he would be cured, to a home he sayed very willingly, then quod she there is a whikey tree in the lower end of your orchard, and if you will goe and walke but thrice about it, and thrice repeate theis words whikey tree whikey tree take away this fluxe from me you shall be presently cured he told her how that beside he was extreme faint and weake it was extreme frost and snow and that it was impossible for him to go: She told him that unless he did so it was impossible he should recover.
Mr. Henryson then lifting upp himselfe, and pointing to an Oken table that was in the roome, asked her and seied gude dame I pray you telle me, if it would not do as well if I repeated thrice theis words oken burd oken burd garre* me shit a hard turde. the woman seeing herself derided and scorned ran out of the house in a great passion and Mr. Henryson within ha:fe a quarter of an houre peacefullie departed 'his life."
*garre = make.
—From the life of Robert Henryson, 15th century Scotch poet.
* * * *
MEDICO-LEGAL NOTE.
"It is ordained and enacted by authority of this present Parliament that the said Richard Rose ('he Bishop of Rochester's cook) be boiled to death without having any advantage of his clergy."—Act 22, Henry VIII, C.9.
The National Security Act has nothing on this.
OCCUPATION THERAPY.
"The convicts are distributed as much as possible in various classified gangs.
Upon their arrival they are closely searched, being prohibited from having money, tobacco or any document. The standing regulations of the settlement are then read and an earnest caution to act in conformity given. They are next, taken to the hos- pital, where each undergoes an individual examination by the medical officer.
Labour proportionate to their strength is then assigned, the physically incapacitated being employed in stone-breaking."---Port Arthur, the British Penal Settlement in Tas-
mania. Account of a. visit in 1842 by David Burn of Rotherwood, Ouse.