Professional Documents
Culture Documents
Cutaneous Changes in
Nutritional Disease
Melinda Jen & Albert C. Yan
MICRONUTRIENTS
Fat-Soluble Vitamins
Historical Background
Bony deformities in children have been described
by artifacts dating back to the first and second
centuries c.e. The earliest classic descriptions of the
clinical symptoms of rickets appeared separately
in 1645 by Daniel Whistler and in 1650 by Francis Glisson. These two men described children in
southwest England, where rickets was endemic. At
the time they did not understand its etiology. As
early as 1824, cod liver oil was noted to help cure
rickets. In 1861, Trousseau of France hypothesized
that rickets was caused by inadequate diet and sun
exposure, but Theodor Palm was the first to study
and conclude that there was also a connection
between rickets and lack of sun exposure. During
the Industrial Revolution, a combination of poor
diet, smog and tall buildings obscuring the sun, as
well as inadequate time outdoors all contributed to
the persistence of rickets in the United States and
Europe. By 1918, John Howland, Edward Park, and
Paul Shipley had used rat models of rickets to identify
the anti-rachitic molecule in cod liver oil, vitamin D.53
In the past preterm infants were at risk for rickets
because of an inadequate supply of calcium and
phosphorus at the time of birth.
Following feeding with unsupplemented breast
milk, their phosphorus levels would fall over the
first 2 weeks of life with a subsequent increase
in alkaline phosphatase activity at 4-8 weeks,
indicating vitamin D defiency if dietary intake is
insufficient to meet daily requirements.
Since the introduction of breast milk fortifiers
and preterm formulas, the incidence of rickets of
prematurity has decreased dramatically. Rickets
also occurs with greater frequency during puberty,
when physical and behavioral changes modulate
vitamin D availability. The pubertal growth spurt
places greater demands for more calcium and phosphorus needed for bone growth, so increased levels
Water-Soluble Vitamins
Historical Background
In 1735, Gasper Casal noted poor peasants in
northern Spain were particularly affected by a
skin disorder referred to then as mal de la rose, so
named because of the reddish, glossy rash on the
dorsum of the hands and feet. He noted that these
peasants were all poor, ate mainly maize, and rarely
ate fresh meat. Francois Thierty published the first
description of pellagra in 1755, but it was Francesco
Frapoli who coined the name pellagra after the Italian words pelle, meaning skin, and agra, meaning
rough.
During the nineteenth century, the cause of many
diseases was attributed to infectious agents, and
pellagra had been thought to be related to some
infectious microorganism. While working as for
the United States Public Health Service, Joseph
Goldberger first suggested that pellagra might be
caused by an amino acid deficiency in 1922 and
that a dietary pellagra-preventative factor existed. Pellagra was endemic in the southern United
States in the early 1900s because of a ubiquitous
diet consisting principally of corn bread, molasses, and pork fat. Beginning in 1914, Goldberger
worked with two orphanages and one sanitarium
in the South. By increasing the amount of fresh
animal meat and vegetables available at the three
institutions, Goldberger was able to significantly
decrease the incidence of pellagra. He went on to
investigate pellagra among male prisoners. Using
12 prisoners from the Mississippi State Penitentiary and offering prisoners pardons as an incentive to participate, he successfully demonstrated
that pellagra could be induced by a monotonous
cereal-based, low calorie, and protein diet. In order
to disprove the allegation that pellagra was caused
by an infectious agent, he subjected 16 volunteers
to the blood, urine, feces, and epidermal scales of
pellagrous patients and showed that they were
not predisposed to develop pellagra.94 Goldberger
died before he identified the pellagra-preventative
factor, but in 1937, Conrad Elvanhjem identified
niacin as the antipellagra factor.95