Nutritional Status: Health, Physiology and Clinics

The League of Nations’ Health Committee set up an Advisory Commission on Nutrition in 1932. It was committed to tackling the most important challenges involved in the scientific definition of malnutrition: promoting the standardisation of methods used in dietary studies and establishing optimum and minimum diet standards according to the physiological contribution of vitamins, minerals, fats, carbohydrates and protein requirements. Such big commitments were to be accompanied by other challenges such as: the discussion of guiding principles for a healthy human diet; the spread of clinical methods to determine the state of nutrition in school children; the establishment of patterns of nutritional requirements at all ages; the identification of specific diets for those sectors of the population on small incomes; and the implementation of surveys on the state of nutrition in every country, particularly in rural areas. This was an ambitious and long-term programme that required technical and methodological agreement among all the active countries in the League of Nations’ Health Committee.^[1] The international response promoted by the League of Nations required, as a first condition, the creation of a fully legitimated international group of experts. Then, a series of meetings, conferences, technical documents, scientific articles and regional surveys would produce an assessment of the situation as a point of departure for further strategies based on the coordination of national and international

action.^[2]

It was hoped that following the dissemination of new scientific knowledge about nutrition and its influence on social practices, substantial changes would take place in all the aspects involved. The Final Report of the Mixed Committee of the League of Nations on Relation of Nutrition to Health, Agriculture and Economic Policy (1937) marked the culmination of the nutritional programme against international under-consumption. Increasing the consumption of “protective” foods was a dual strategy intended to tackle malnutrition and agricultural depression. This reference report stressed the need for governments to take the lead in raising public awareness on nutrition, and established the centrality of consumption for global trade and agriculture improvement.^[3]

National and international organisations recognised the nutrition problem as affecting both industrial and agricultural countries even before the 1929 crash. During the early 1930s defective nutrition was not only limited to areas hit by the economic crisis, such as impoverished urban communities and depressed agricultural regions. The awareness of such a situation prompted regional surveys and made the new scientific concepts more trustworthy as key political tools to overcoming the crisis.

Scientific research led to the search for a formula regarding the optimum standard of human diet. Experimental physiologists identified a total of 12 inorganic mineral elements that play an important role in human nutrition. This meant that their absence definitely produced deficiency diseases. Then there were the vitamins, which were considered to exert a great deal of influence on health. At least the lack of any of nine of those inorganic elements was experimentally and clinically associated with definite deficiency diseases, defective nutrition or malnutrition. The primordial objective was not to prescribe a single type of diet for all the peoples of Europe, but to promote agricultural production to provide the most efficient food supply, taking into consideration the population’s traditional dietary habits. Children’s health was considered to be the kernel of the problem of nutrition and therefore education and instruction had to become the main instrument of intervention. Science and medicine asserted their authority, since “ignorance of the principles and main features of the modern science of nutrition is one of the commonest causes of deficiencies in nutrition”.^[4]

Social, sanitary and cultural implications became the focus of the work to be done regarding specific information to health professionals, doctors, hygienists, and public health nurses, as well as on the instruction of the general public in schools and associations through pamphlets, propaganda, films, posters, pictures and lectures. At the same time, economic and agricultural aspects of the problem revealed the need for a policy of nutrition and social welfare at a national level, within the framework of international coordination. Indeed, nutrition had become an essential part of public health work. Gradually, under the pressure of circumstances, governments were to adopt measures of protection and assistance with regard to the food supply, and legislation on food quality, consumption and food codes.^[5] These aspects firstly called for action on a national level, but also required international cooperation, something indispensable for the efforts made to improve workers’ nutrition to be in harmony with the needs of the world economy.

The diversity of surveys, reports and features aimed at assessing the nutritional state of the European population contributed a large amount of information for experts and authorities. Unfortunately, most of the work carried out in different countries and presented in international expert conferences and meetings was not suitable for comparison because of a lack of methodological agreement. Standards were to be defined in order to solve this particular problem.

Physical standards was the technical name given to anthropometric, clinical and physiological methods used to assess the population’s nutritional condition. These methods were employed to identify people suffering from nutritional deficiencies or malnutrition and considered by the experts to be in need of dietary treatment. Experimental research on nutrition during the Inter-war period required the assistance of some systematic clinical screening in order to assess the effect of dietary regimes on the human condition. The problems of establishing satisfactory dietary and physical standards were intimately interconnected, since the ultimate proof of a satisfactory diet was its positive effect on the organism and the health status.^[6]

The complexity of factors intervening in human dietary systems and organic nutrition soon gave way to the methodological problem of establishing global standards for an adequate diet. General agreement had not been reached either on the boundaries of malnutrition nor on the methods to identify it in individuals under scrutiny. Physical standards were applied to determine children’s normal development, since school medical officers requested simple working methods that could be applied to large groups of children to enable them to spot those suffering from weakness, retarded development and malnutrition.^[7]

Nutrition is connected to the right functioning of every tissue, organ or system of the body and every aspect of human physiology had to be taken into account to determine the global state of nutrition of an individual. However, the expression nutritional status also included different and more restricted meanings, and at the time referred to the amount of flesh covering the skeleton. The equivalent of the German term Ernahrungszustand was the perspective adopted by some Anglo- American experts. Generally speaking, three different methods of assessing the state of nutrition were mentioned. One was the comparison of certain measures to a standard; another one was the assessment of the state of health and development based on clinical screening; and the last one was a more refined clinical test to detect physiological problems and early deficiency diseases.

Starting with a general check-up, somatometric screening aimed to classify the subject according to a type. Height and weight were recorded next to determine an index based on the height-weight-age ratio. Although it was recognised that the height of a child depended on heredity aspects, faulty feeding could influence it if prolonged. Since a child’s stature is so variable that single comparisons with standards made no sense, height gain rates and regularity provided useful information, even though growth was not a uniform evolving factor.^[8] The weight gain rate and the height-weight ratio were often used in assessing the nutritional status. The so-called indices of nutrition were formulated by establishing more complicated relationships between height, weight and other bodily measurements, although, concerning children, some experts preferred a simple comparison between the individual’s weight and the average height for an age. Four diagnostic elements were graded in clinical exploration: complexion, fat, water content in tissues and muscle condition. Other methods involved measurements of arm, chest and hip girths.

A great deal of work was devoted to finding out how clinical methods helped to detect children’s nutritional status. Obviously, the state of a schoolchild was directly related to his/her health condition; therefore, not only physical characteristics were to be studied but also the general functions of the body.^[9] To do so, a complete study would require laboratory techniques, not easily available and expensive to run on large groups. Some experts proposed clinical methods only, including careful examination of external features, a series of body measurements and the general examination of organs and systems.

Since malnutrition impaired many organic functions, the Conference of Experts in Nutrition convened in Berlin in 1932 proposed a number of tests on physical efficiency and fatigability. Some were especially devoted to the early detection of vitamin deficiency, although the clearest evidence of a defective diet, a poor nutritional state or malnutrition was deficiency disease.

In order to solve the crucial problem of establishing guidelines to make the diversity of surveys, reports and features aiming to assess the nutritional state of the European population comparable, the experts’ committee on nutrition of the League of Nations requested E.J. Bigwood, a professor at the University of Brussels, to propose some guiding principles and methods for research. In 1938 his proposal was presented to the commission of experts, who agreed on the final wording of Bigwood’s Guide, which was published shortly after and submitted to the Conference of Representatives of the National Nutrition Committees in October 1938 for its approval.^[10] In the meantime, the Secretariat collected data on the state of nutrition of populations living in rural regions of Europe to form preparatory documentation for the 1939 Rural Life Conference. Such data was considered to be of great value, particularly when dietary surveys and nutrition assessment were combined with information on the general conditions of public health.^[11]

• [1] Barona, 2010, pp. 28-32.
• [2] Introductory note on the work accomplished (History and method) by the League ofNations up to October 1935 (Nutrition), 12 p.
• [3] Final Report of the Mixed Committee of the League of Nations on Relation ofNutrition to Health, Agriculture and Economic Policy, League of Nations, Geneva,1937.
• [4] The Problem of Nutrition, 1936, pp. 20-21.
• [5] Ibidem, 1936, p. 66.
• [6] Burnet, Aykroyd, 1935, p. 336.
• [7] Barona, 2007a, pp. 93-96; Perdiguero, E. (ed.), Salvad al niho. La proteccion a lainfancia en los paises de la Europa mediterranea, Valencia, Seminari d’Estudissobre la Ciencia, Universitat de Valencia, 2005.
• [8] Burnet, Aykroyd, 1935, p. 360.
• [9] Nobecourt, P, Vitry, G.P., “Clinical methods for determining the state of nutrition inschool children”, League of Nations Quarterly Bulletin of the Health Organisation,Vol. 5, No. 3, 1936, pp. 544-548.
• [10] Bigwood, E.J., Guiding Principles for Studies On the Nutrition of Populations.Technical Commission on Nutrition, Health Organisation of the League of NationsGeneva, 1939 [C.H.1401; C.H./Com.Exp.Alim./50(2)].
• [11] Barona, 2010.