editor:
comments
Steven
H.
content
Dorfman,3
M.D.,
ABSTRACT and history of
Recent
diverticulosis, colonic
disease,
fiber
intake
in the
and in all
in
findings.
Since
the
that
diet
J. C/in.
Nuir.
intake
has
been
United
29: 87-89,
of
are
needed
patients
or
by their
The
American
low
diet
3.5
without in
in areas
fiber are
intake
1.6 to
is not
colon
related
to colon
British
and
in an area
in recall
disease.
question
are on
with
in subjects
loss
g. range
M.D.
diets based
histories
any colon
where
Floch,5
of fiber
for
2
history,
of high
data
uniform
carcinoma
was
agree
in
the
is of low
diet
incidence
no disease
and
we find
I I g. There The
cancer
African
a low no
with
United
with daily
statistical the
British
States
it is
incidence.
Am.
1976.
primary
care
had no gastrointestinal disease, six had carcinoma of the colon, and eight had cobonic diventicubosis. All subjects were residents of Fairfield County, Connecticut, which is a middle-class suburban area with a relatively high incidence of colon cancer, diverticulosis of the colon, and athenosclerosis. All subjects ate standard foods purchased in local supermarkets. The diet histories were obtained by a physicians.
or
diseases
Low dietary fiber content has been postubated to be linked with cancer ofthe colon and rectum ( I , 8), ischemic heart diseases (3, 5, 8, 10), diverticular disease ofthe colon (4, 8- 10), and disorders of serum lipids (7). Many of these reports.have based their theories on a comparison between English and African diets (4, 5, 1 1 13). The only recent data on intake of fiber we have been able to find on subjects living in the United States of America were obtained on vegetarians (14). We therefore instituted a simple dietary analysis based on retrospective 1-week diet histories obtained from Connecticut subjects eating a “normal” diet. Fourteen female and seven male subjects were interviewed. Their ages ranged from 29 to 77 years, with a mean of 57 years. All had complete gastrointestinal evaluations done as hospitalized
recall
mean
with the
that theories
to account
evaluated,
H.
assessment
Using
data
patients
incidence
surveys
postulated
no recent
diets1’
Martin
These
States.
our
21 subjects among
have
and
atherosclerosis.
correcting
difference
suggested
to
There
disease
colon
M.D.,
theories
and
information.
All,4
M.D.
in gastroenterology
of Connecticut Madad
H. Floch,
physician
using
diet
models
and
standard
Burke history forms (15), and consisted of mealtime and between meal intake for a 1-week period. Dietary constituents, calories, fiber, protein, carbohydrate, cholesterol, and fat for each meal were estimated and tabulated from standard reference tables (16). Values were totaled for the week, and then divided by seven to yield daily intake values. The daily ranges and mean for intake of calories, and all of the dietary constituents for all subjects and for each of the three constituent groups-normal controls, colon carcinoma, and cobonic diventiculosis-ane recorded in Table IA. The average daily intake obtained from the histories for all 21 subjects was 1,475 cal, 2.8 g of fiber (with a range of 1.3 to 8.8), 66 g ofprotein, 152 g of carbohydrate, 386 mg of cholesterol, and 63 g of fat. The only statistically significant difference
Seven
Journal
ofClinical
Nutrition
29: JANUARY
1
From
the
Gastrointestinal
Medicine, Norwalk of Medicine. 2Address reprint Chairman,
Department
Section,
Hospital requests of
and
Yale To:
Medicine,
Department University Dr.
M.
Norwalk
of School
H.
Floch,
Hospital,
Norwalk, Connecticut 06856. 3 Former Fellow in Gastroenterology, Yale Affiliated Gastroenterology Program. Former Resident House Officer, Norwalk Hospital. ‘ Chairman, Department of Medicine, Norwalk Hospital, Associate Clinical Professor, Yale University School of Medicine.
1976,
pp. 87-89.
Printed
in U.S.A.
87
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/1/87/4655723 by East Carolina University user on 14 January 2019
Low fiber
Martin
DORFMAN
88 TABLE
IA
Average
daily
diet
Subjects
intake
obtained
Calories
by recall Fiber
ET
AL.
histories (g)
Protein
(g)
Fat (g)
Carbhdrate
1594 (1133-2080)
2.7 (1.8-3.6)
68 (5278)
141 (88I97)
Coloncancer (n = 6) Diverticulosis
1557 (1220-2233) 1310
3.3 (1.4-8.8) 2.5
62 (33-92) 68
163 (l0l258) 154
(n
(1195-1434)
(1.3-3.5)
(55-106)
(79-275)
2.8
66
152
(1.3-8.8)
(55-106)
(79-275)
=
8)
Total (n
=
1475
21)
(1003-2234)
TABLE
lB
Average
daily
Subjects
Normal (n = 7)
Coloncancer (n=6) Diverticulosis (n = 8) Total (n = 21)
diet
intake
corrected
Calories 1993 (1416-2600)
1946 (1525-2791) 1638 (1494-1793) 1844 (1254-2793)
for age and normal Fiber
(g)
3.4 (2.3-4.5)
caloric Protein
(g)
85 (65-98)
4.1
78
(1.8-11.0) 3.1 (1.6-4.4) 3.5 (1.6-11.0)
(41-115) 85 (69-133) 83 (69-133)
between the values for any of the three constituent groups was the decreased total caloric and fat intake in patients with diverticubosis of the colon (P < 0.02). Tnowell (5) and Robertson ( I 1 ) have shown by diet surveys that the average Briton consumes 4 to 8 g of fiber daily. Hardinge et ab. (14), in a study of American vegetarians, found a dietary fiber intake of 8 to I 1 g/day. Rural African tribesmen, on the other hand, have been reported to consume from 15 to 20 g of fiber daily (12, 13). The average caloric diet intake for subjects with a mean age of 57 years is approximately 2,000 cab (17). The average daily caloric intake values obtained from this retrospective diet history study are less than the expected normal for this age group. Although Reshet and Epstein (18) state that retrospective histories are accurate methods, Young et al. (19) found that errors appear in recalled dietary intake as opposed to prospective diet logs. The values recorded in this study for intake of calories and cholesterol are approximately 75% of those suggested by standard texts (17), indicating an approximate 25% loss by recall history. The retrospective diet history probably does not get 100% recall
72 (4894)
373 (239495)
67 (49-104) 52
414 (214-825) 376
(42
(245-530)
71)
63
386
(4294)
(214-525)
intake Carbohydrate
(g)
Fat (g)
176 (110246) 204 (126-323) 193 (99-344) 190 (99-344)
90 (60
118)
84 (61-130) 65 (53-89) 79 (53-118)
Cholesterol
(mg)
466 (299-619) 518 (268-1031) 470 (306-663) 483 (168-656)
because of the subjects’ indiscriminate lack of recall. It is logical for one to assume that all factors are similar to the total caloric results and are recalled at approximately 75% of their total. Therefore, it would be more accurate if we connect our data by using a connection factor of I .25. This would then make the average daily intake: 1,993 cal, 3.5 g of fiber (with a range of I .6 to I I ), 83 g of protein, 79 g of fat, and 483 mg of cholesterol (see Table 1 B). These numbers do differ somewhat from those in the British series quoted above (5, 1 1), but are in a similar range, i.e., range for fiber intake in U.S.A. for this study I .6 to I I g/day, British 4 to 8 g/day. Burkitt has theorized that the foods we eat have changed considerably in the past 50 to 100 years, and that we do not know whether this changing dietary intake has really had an etiobogical effect on the present high mcidence of coronary artery disease, cancer of the colon, cobonic diverticubosis, and hyperlipoproteinemia (I 10). This retrospective senies and review ofthe recent literature further points out the need for prospective diet log surveys with disease correlation to help evabuate furTher the significance of diet factors in =
=
-
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/1/87/4655723 by East Carolina University user on 14 January 2019
Normal (n = 7)
ChIestrol
LOW
ies
are
CONTENT
OF
evaluations of disease. For incidence of colonic carcinoma in the United States. The high in Connecticut but much southern states. This diet study fiber content of the average diet but accurate diet intake stud-
needed
in many
areas,
such
as
among
bess colon cancer-prone groups, as exist in the Southern United States, in order to assess the etiological role of diet factors. Only when such information becomes available may the real significance of the present theories become evident. We would Drs. Arthur their
like to express D’Souza and
assistance
in collecting
our sincere Fereydoon some
of
appreciation Khoshnood the
data
to for in
this
paper.
References I.
D. P. Epidemiology
BURKITT,
and
rectum.
2. TROWEL.L,
London:
Cancer H.
Arnold,
C.
ofcancer
ofthe
colon
28: 3, 1971. Noninfective
Disease
in
Africa.
1960.
T. L., G. D. CAMPBELL AND N. S. PAINTER. Coronary Thrombosis, and the Saccharine (2nd ed). Bristol: Wright, 1969. 4. PAINTER, N. S., AND D. P. Diverticulardisease of the colon: a deficiency disease of western civilization. Brit. Med. J. 2: 556, 1972. 5. TROWELL, H. C. lschemic heart disease and dietary fiber. Am. J. Clin. Nutr. 25: 926, 1972. 6. HARVEY, R. F., E. W. POMAPE AND K. W. HEATON. Effects of increased dietary fiber on intestinal transit. Lancet I: 1278, 1973. 3. CLEAVE, Diabetes, Disease
CONNECTICUT 7.
89
DIETS
M. Dietary fibre and serum lipids. 2: 1222, 1969. 8. REILLY, R. W., AND J. B. KIRSNER. Conference report: fiber deficiency and colonic disorders. Am. J. Digest. Diseases 20: 49, 1975. 9. BERMAN, P. M., ANt) J. B. KIRSNER. Diverticular disease of the colon-the possible role of “roughage” in both food and life. Am. J. Digest. Diseases 18: 506, 1973. 10. TROWELL, H. C., N. S. PAINTER AND D. P. BURKITT. EASTWOOD,
Lancet
Aspects of the epidemiology of diverticular disease and ischemic heart disease. Am. J. Digest. Diseases 19: 864, 1974. I I. ROBERTSON, J. Change in the fiber content of the British 12.
WALKER, composition
diet. A.
Nature R. and
P.
238: 290, 1972. Diet, bowel
colonic
cancer.
motility,
S. African
faeces Med. J.
45: 377, 1971. 13. LUBBE, A. M. A comparative study of rural and urban Venda males: dietary evaluation. S. African Med. J. 45: 1289, 1971. 14. MARDINGE, M. G., A. C. CHAMBERS, H. CRooKs AND F. 1. STARE. Nutritional studies of vegetarians. III. Dietary levels offiber. Am. J. Clin. Nutr. 6: 523, 1958. 15. BURKE, B. The dietary history as a tool in research. J. Am. Dietet. Assoc. 23: 1041, 1947. 16. CHURCH, C. F., AND H. N. CHURCH. Food Values of Portions Commonly Used (11th ed). Philadelphia: J. B. Lippincott, 1970. 17. ROBINSON, C. H. Normal and Therapeutic Nutrition (14th ed). New York: Macmillan, 1972. 18. RESHET, A., AND L. EPSTEIN. Reliability of a dietary questionnaire. Am. J. Clin. Nutr. 25: 91, 1972. 19. YOUNG, C. M., F. W. CHALMU5, H. N. CHURCH, M. M. CLAYTON, R. T. TUCKER, A. W. WERTS AND W. D. FOSTER. A comparison of dietary study methods. I. Dietary history vs. seven-day-records. J. Am. Dietet. Assoc. 28: 124, 1952. 20. BEST, W. R. On the logarithmic transformation of intestinal bacterial counts. Am. J. Clin. Nutr. 23: 1608, 1970.
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/1/87/4655723 by East Carolina University user on 14 January 2019
epidemiobogical example, the is not uniform incidence is lower in some reveals a low in Connecticut,
FIBER
comments
Steven
H.
content
Dorfman,3
M.D.,
ABSTRACT and history of
Recent
diverticulosis, colonic
disease,
fiber
intake
in the
and in all
in
findings.
Since
the
that
diet
J. C/in.
Nuir.
intake
has
been
United
29: 87-89,
of
are
needed
patients
or
by their
The
American
low
diet
3.5
without in
in areas
fiber are
intake
1.6 to
is not
colon
related
to colon
British
and
in an area
in recall
disease.
question
are on
with
in subjects
loss
g. range
M.D.
diets based
histories
any colon
where
Floch,5
of fiber
for
2
history,
of high
data
uniform
carcinoma
was
agree
in
the
is of low
diet
incidence
no disease
and
we find
I I g. There The
cancer
African
a low no
with
United
with daily
statistical the
British
States
it is
incidence.
Am.
1976.
primary
care
had no gastrointestinal disease, six had carcinoma of the colon, and eight had cobonic diventicubosis. All subjects were residents of Fairfield County, Connecticut, which is a middle-class suburban area with a relatively high incidence of colon cancer, diverticulosis of the colon, and athenosclerosis. All subjects ate standard foods purchased in local supermarkets. The diet histories were obtained by a physicians.
or
diseases
Low dietary fiber content has been postubated to be linked with cancer ofthe colon and rectum ( I , 8), ischemic heart diseases (3, 5, 8, 10), diverticular disease ofthe colon (4, 8- 10), and disorders of serum lipids (7). Many of these reports.have based their theories on a comparison between English and African diets (4, 5, 1 1 13). The only recent data on intake of fiber we have been able to find on subjects living in the United States of America were obtained on vegetarians (14). We therefore instituted a simple dietary analysis based on retrospective 1-week diet histories obtained from Connecticut subjects eating a “normal” diet. Fourteen female and seven male subjects were interviewed. Their ages ranged from 29 to 77 years, with a mean of 57 years. All had complete gastrointestinal evaluations done as hospitalized
recall
mean
with the
that theories
to account
evaluated,
H.
assessment
Using
data
patients
incidence
surveys
postulated
no recent
diets1’
Martin
These
States.
our
21 subjects among
have
and
atherosclerosis.
correcting
difference
suggested
to
There
disease
colon
M.D.,
theories
and
information.
All,4
M.D.
in gastroenterology
of Connecticut Madad
H. Floch,
physician
using
diet
models
and
standard
Burke history forms (15), and consisted of mealtime and between meal intake for a 1-week period. Dietary constituents, calories, fiber, protein, carbohydrate, cholesterol, and fat for each meal were estimated and tabulated from standard reference tables (16). Values were totaled for the week, and then divided by seven to yield daily intake values. The daily ranges and mean for intake of calories, and all of the dietary constituents for all subjects and for each of the three constituent groups-normal controls, colon carcinoma, and cobonic diventiculosis-ane recorded in Table IA. The average daily intake obtained from the histories for all 21 subjects was 1,475 cal, 2.8 g of fiber (with a range of 1.3 to 8.8), 66 g ofprotein, 152 g of carbohydrate, 386 mg of cholesterol, and 63 g of fat. The only statistically significant difference
Seven
Journal
ofClinical
Nutrition
29: JANUARY
1
From
the
Gastrointestinal
Medicine, Norwalk of Medicine. 2Address reprint Chairman,
Department
Section,
Hospital requests of
and
Yale To:
Medicine,
Department University Dr.
M.
Norwalk
of School
H.
Floch,
Hospital,
Norwalk, Connecticut 06856. 3 Former Fellow in Gastroenterology, Yale Affiliated Gastroenterology Program. Former Resident House Officer, Norwalk Hospital. ‘ Chairman, Department of Medicine, Norwalk Hospital, Associate Clinical Professor, Yale University School of Medicine.
1976,
pp. 87-89.
Printed
in U.S.A.
87
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/1/87/4655723 by East Carolina University user on 14 January 2019
Low fiber
Martin
DORFMAN
88 TABLE
IA
Average
daily
diet
Subjects
intake
obtained
Calories
by recall Fiber
ET
AL.
histories (g)
Protein
(g)
Fat (g)
Carbhdrate
1594 (1133-2080)
2.7 (1.8-3.6)
68 (5278)
141 (88I97)
Coloncancer (n = 6) Diverticulosis
1557 (1220-2233) 1310
3.3 (1.4-8.8) 2.5
62 (33-92) 68
163 (l0l258) 154
(n
(1195-1434)
(1.3-3.5)
(55-106)
(79-275)
2.8
66
152
(1.3-8.8)
(55-106)
(79-275)
=
8)
Total (n
=
1475
21)
(1003-2234)
TABLE
lB
Average
daily
Subjects
Normal (n = 7)
Coloncancer (n=6) Diverticulosis (n = 8) Total (n = 21)
diet
intake
corrected
Calories 1993 (1416-2600)
1946 (1525-2791) 1638 (1494-1793) 1844 (1254-2793)
for age and normal Fiber
(g)
3.4 (2.3-4.5)
caloric Protein
(g)
85 (65-98)
4.1
78
(1.8-11.0) 3.1 (1.6-4.4) 3.5 (1.6-11.0)
(41-115) 85 (69-133) 83 (69-133)
between the values for any of the three constituent groups was the decreased total caloric and fat intake in patients with diverticubosis of the colon (P < 0.02). Tnowell (5) and Robertson ( I 1 ) have shown by diet surveys that the average Briton consumes 4 to 8 g of fiber daily. Hardinge et ab. (14), in a study of American vegetarians, found a dietary fiber intake of 8 to I 1 g/day. Rural African tribesmen, on the other hand, have been reported to consume from 15 to 20 g of fiber daily (12, 13). The average caloric diet intake for subjects with a mean age of 57 years is approximately 2,000 cab (17). The average daily caloric intake values obtained from this retrospective diet history study are less than the expected normal for this age group. Although Reshet and Epstein (18) state that retrospective histories are accurate methods, Young et al. (19) found that errors appear in recalled dietary intake as opposed to prospective diet logs. The values recorded in this study for intake of calories and cholesterol are approximately 75% of those suggested by standard texts (17), indicating an approximate 25% loss by recall history. The retrospective diet history probably does not get 100% recall
72 (4894)
373 (239495)
67 (49-104) 52
414 (214-825) 376
(42
(245-530)
71)
63
386
(4294)
(214-525)
intake Carbohydrate
(g)
Fat (g)
176 (110246) 204 (126-323) 193 (99-344) 190 (99-344)
90 (60
118)
84 (61-130) 65 (53-89) 79 (53-118)
Cholesterol
(mg)
466 (299-619) 518 (268-1031) 470 (306-663) 483 (168-656)
because of the subjects’ indiscriminate lack of recall. It is logical for one to assume that all factors are similar to the total caloric results and are recalled at approximately 75% of their total. Therefore, it would be more accurate if we connect our data by using a connection factor of I .25. This would then make the average daily intake: 1,993 cal, 3.5 g of fiber (with a range of I .6 to I I ), 83 g of protein, 79 g of fat, and 483 mg of cholesterol (see Table 1 B). These numbers do differ somewhat from those in the British series quoted above (5, 1 1), but are in a similar range, i.e., range for fiber intake in U.S.A. for this study I .6 to I I g/day, British 4 to 8 g/day. Burkitt has theorized that the foods we eat have changed considerably in the past 50 to 100 years, and that we do not know whether this changing dietary intake has really had an etiobogical effect on the present high mcidence of coronary artery disease, cancer of the colon, cobonic diverticubosis, and hyperlipoproteinemia (I 10). This retrospective senies and review ofthe recent literature further points out the need for prospective diet log surveys with disease correlation to help evabuate furTher the significance of diet factors in =
=
-
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/1/87/4655723 by East Carolina University user on 14 January 2019
Normal (n = 7)
ChIestrol
LOW
ies
are
CONTENT
OF
evaluations of disease. For incidence of colonic carcinoma in the United States. The high in Connecticut but much southern states. This diet study fiber content of the average diet but accurate diet intake stud-
needed
in many
areas,
such
as
among
bess colon cancer-prone groups, as exist in the Southern United States, in order to assess the etiological role of diet factors. Only when such information becomes available may the real significance of the present theories become evident. We would Drs. Arthur their
like to express D’Souza and
assistance
in collecting
our sincere Fereydoon some
of
appreciation Khoshnood the
data
to for in
this
paper.
References I.
D. P. Epidemiology
BURKITT,
and
rectum.
2. TROWEL.L,
London:
Cancer H.
Arnold,
C.
ofcancer
ofthe
colon
28: 3, 1971. Noninfective
Disease
in
Africa.
1960.
T. L., G. D. CAMPBELL AND N. S. PAINTER. Coronary Thrombosis, and the Saccharine (2nd ed). Bristol: Wright, 1969. 4. PAINTER, N. S., AND D. P. Diverticulardisease of the colon: a deficiency disease of western civilization. Brit. Med. J. 2: 556, 1972. 5. TROWELL, H. C. lschemic heart disease and dietary fiber. Am. J. Clin. Nutr. 25: 926, 1972. 6. HARVEY, R. F., E. W. POMAPE AND K. W. HEATON. Effects of increased dietary fiber on intestinal transit. Lancet I: 1278, 1973. 3. CLEAVE, Diabetes, Disease
CONNECTICUT 7.
89
DIETS
M. Dietary fibre and serum lipids. 2: 1222, 1969. 8. REILLY, R. W., AND J. B. KIRSNER. Conference report: fiber deficiency and colonic disorders. Am. J. Digest. Diseases 20: 49, 1975. 9. BERMAN, P. M., ANt) J. B. KIRSNER. Diverticular disease of the colon-the possible role of “roughage” in both food and life. Am. J. Digest. Diseases 18: 506, 1973. 10. TROWELL, H. C., N. S. PAINTER AND D. P. BURKITT. EASTWOOD,
Lancet
Aspects of the epidemiology of diverticular disease and ischemic heart disease. Am. J. Digest. Diseases 19: 864, 1974. I I. ROBERTSON, J. Change in the fiber content of the British 12.
WALKER, composition
diet. A.
Nature R. and
P.
238: 290, 1972. Diet, bowel
colonic
cancer.
motility,
S. African
faeces Med. J.
45: 377, 1971. 13. LUBBE, A. M. A comparative study of rural and urban Venda males: dietary evaluation. S. African Med. J. 45: 1289, 1971. 14. MARDINGE, M. G., A. C. CHAMBERS, H. CRooKs AND F. 1. STARE. Nutritional studies of vegetarians. III. Dietary levels offiber. Am. J. Clin. Nutr. 6: 523, 1958. 15. BURKE, B. The dietary history as a tool in research. J. Am. Dietet. Assoc. 23: 1041, 1947. 16. CHURCH, C. F., AND H. N. CHURCH. Food Values of Portions Commonly Used (11th ed). Philadelphia: J. B. Lippincott, 1970. 17. ROBINSON, C. H. Normal and Therapeutic Nutrition (14th ed). New York: Macmillan, 1972. 18. RESHET, A., AND L. EPSTEIN. Reliability of a dietary questionnaire. Am. J. Clin. Nutr. 25: 91, 1972. 19. YOUNG, C. M., F. W. CHALMU5, H. N. CHURCH, M. M. CLAYTON, R. T. TUCKER, A. W. WERTS AND W. D. FOSTER. A comparison of dietary study methods. I. Dietary history vs. seven-day-records. J. Am. Dietet. Assoc. 28: 124, 1952. 20. BEST, W. R. On the logarithmic transformation of intestinal bacterial counts. Am. J. Clin. Nutr. 23: 1608, 1970.
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/1/87/4655723 by East Carolina University user on 14 January 2019
epidemiobogical example, the is not uniform incidence is lower in some reveals a low in Connecticut,
FIBER
