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Preventive Nutrition the British Cardiac Society on Prevention of Coronary Heart Disease, British Medical3journal, 1976, 1, 881

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Preventive Nutrition the British Cardiac Society on Prevention of Coronary Heart Disease, British Medical3journal, 1976, 1, 881 134 BRITISH MEDICAL JOURNAL 17 JULY 1976 triumphantly completed. At every session could be seen Mr The needs ofdistricts obviously vary, but, with their poten- J A (Gussie) Mehigan, making sure that everything ran tial in preventive as well as therapeutic medicine, we should smoothly-as chairman of the scientific committee, he and the surely encourage the establishment of dietitians and their use Br Med J: first published as 10.1136/bmj.2.6028.134-a on 17 July 1976. Downloaded from honorary secretary, Dr J P Alvey, earned warm praise for an in the Health Service. District dietitians should also have some imaginative and varied programme. Mrs Stanley McCollum clinical responsibilities and provide a service for the district and Mrs Edward Tempany were equally successful with the general hospital and teaching hospitals with specialist posts ladies' and children's programmes-while the profusion of in paediatric, renal, and metabolic units. A community dietetic flowers at every occasion, unwilting despite the unprecedented post could act as the link for the preventive work. heat wave, added a touch of elegance and femininity that was At present 150 dietitians qualify each year (after a four-year much appreciated. The varied social occasions gave the three training) and it will be difficult to increase this number until national contingents ample opportunity to mix (see p 160) hospitals have their full establishment of dietitians and so can while not weighing them down with ceremony. train students and give them the necessary practical ex- Departure from Ireland is always sad. On this occasion the perience. Meanwhile dietitians themselves could do two things. Emetald Isle was baked a delicate shade ofbrown, but as usual Firstly, they should ensure that they use their expert know- it had worked its magic on the visitors. Truly, a memorable ledge properly. Secondly, that they do not undertake tasks meeting. which are of little value (such as repeated advice to an obese patient) or which other staff could be doing. 1 DHSS, Prevention and Health: Everybody's Business. London, HMSO, 1976. 2 DHSS, Priorities for Health and Social Services in England. London, HMSO, 1976. 3 Joint Working Party of the Royal College of Physicians of London and Preventive nutrition the British Cardiac Society on Prevention of Coronary Heart Disease, British Medical3Journal, 1976, 1, 881. 4 DHSS, Health Services Development Baby Milks and Infant Feeding, HC(76)16. The recent consultative documentsl 2 have highlighted the Medical Research Council/Agricultural Research Council, Food and Nutrition Research. London, HMSO, 1974. importance of preventive measures for maintaining health. 6 Dietitians Board, Dietitians of the Future. London, Council for Professions Of these, one of the most important areas is nutrition. The Supplementary to Medicine, 1975. recommendations of the Royal College of Physicians on the prevention of coronary heart disease3 and those of the DHSS on infant feeding4 have further emphasised the importance of understanding of nutrition and its practical application. How many doctors have the knowledge, interest, or time to make recommendations based on current knowledge- Vinyl chloride: the defective5 as that may be? During training, medical students carcinogenic risk have very little of their time given to nutrition, and even less to ways of interpreting this knowledge and applying it to http://www.bmj.com/ the practical aspects of patients' diets. Yet, unless they under- Many an artisan has looked to his craft as a means to support stand nutrition, treatment may become meaningless and could life and raise a family but all he has got from it is some deadly even be dangerous. To some extent this gap has been recog- disease, with the result that he has departed this life cursing nised and dietitians have been employed to fill it-and it is the craft to which he has applied himself. worth recalling that the difference between a nutritionist RAMAZZINI and a dietitian is that the latter is the expert in the interpreta- tion and practical application of the scientific principles of In identifying occupational hazards the time relation between on 27 September 2021 by guest. Protected copyright. nutrition in health and disease. cause and effect leads to the greatest difficulties. In many A recent report, Dietitians of the Future,6 has recommended instances-for example, the association of 3-naphthylamine that dietitians should act much more in a consultative way. with bladder cancer or of asbestos with mesothelioma-the At present, while some dietitians do work in this way, usually cause may precede the effect by as long as 20 to 30 years. their expert knowledge is not being fully exploited. Until the More and more materials used in industry, at first thought to recent reorganisation of the NHS, dietitians worked mainly carry no health hazard, have recently come under suspicion within hospitals, where they concentrated particularly on as possible carcinogenic agents. therapeutic or modified diets, and only a handful were em- The latest chemical falling into the category of proved ployed as community dietitians working through medical carcinogens is vinyl chloride monomer (VCM), a gas at normal officers of health and based in health education departments. pressure and temperature. In its liquefied form under pressure Almost a year ago district dietitians were first appointed to it readily polymerises into polyvinyl chloride (PVC), a white integrate nutritional and dietetic policies for health districts solid, and in Britain some 2000 workers are concerned in its and to advise district management teams on nutrition. Many manufacture, 500 of whom are exposed to VCM vapour in health workers in contact with the public find that they have the early production stage in autoclaves. The chemical process to give nutritional advice, and until policies are agreed this was discovered in Germany in the mid 1930s and has been in advice will be inconsistent and confusing. For the general use for over 40 years in the United States and in Britain since practitioner-as well as for community medical staff, health the mid 1940s. At that time the fire and explosion risks of visitors, and health education officers-the mass of dietary VCM were known, and its narcotic effects led to experimental and nutritional advice issued and distributed from many trials ofVCM gas as an anaesthetic, but they were discontinued sources may be thoroughly misleading. Co-ordination ofsound because cardiac arrythmias occurred. policies and discussion with all concerned are of the utmost In 1966 occupational acro-osteolysis was first recognised importance. in VCM autoclave workers' in Belgium. The triad of BRITISH MEDICAL JOURNAL 17 JULY 1976 135 Raynaud's phenomenon, sclerodermatous skin changes, and Surveys now in progress will confirm whether the new osteolysis of the distal phalanges was confirmed in several limits for exposure to this chemical carcinogen have elim- investigations of autoclave workers in Canada and the USA, inated any further health risk. This example of a hitherto Br Med J: first published as 10.1136/bmj.2.6028.134-a on 17 July 1976. Downloaded from medical surveys showing an incidence of 3-5O and sug- unsuspected health hazard in a familiar material should act gesting that the disorder was largely confined to autoclave or as a warning to a!l chemists and toxicologists and adds weight reactor cleaners exposed to the VCM gas.2 3 to the wise advice of Ramazzini,9 who in 1700 pleaded with In 1974 an association was reported4 between exposure to his physician colleagues to inquire during the course of their VCM and a rare liver tumour-angiosarcoma-in men who medical examinations? "What trade do you follow ?" Already had worked as autoclave cleaners in the first stage of the our industries are trying much harder to achieve the new polymerisation process. Carcinogenic liver changes had been hygiene standards, to set up routine monitoring ofthe working reported5 in 1971 in rats exposed to a dosage of 30 000 ppm environment, and to provide medical supervision of the work vinyl chloride monomer, but that level of exposure was so high force. that its importance for man had been disregarded. Further Cordier, J M, et al, Cahiers de Medecine du Travail, 1966, 4, 3. testing, however, in 1973 by Maltoni6 in Italy confirmed that 2 Wilson, R H, et al,J'ournal of the American Medical Association, 1967, 201, liver cancer occurred in animals at exposures as low as 250 577. ppm. Since 1974 there have been 48 reported cases of angio- 3Dinman, B D, et al, Archives of Environmental Health, 1971, 22, 61. 4Creech, J L, and Johnson, M N, J7ournal of Occuipational Medicine, 1974, sarcoma associated directly with VCM, two ofthem in Britain. 16, 150. When the results of the early studies and the plant data Viola, P L, Bigotti, A, and Caputo, A, Cancer Research, 1971, 31, 516. 6 Maltoni, C, Crespi, M, and Burch, P J R, eds Excerpta Medica Inter- from the US were sent to HM Factory Inspectors and Em- national Congress Series no 275. Amsterdam, Excerpta Medica, 1973. ployment Medical Advisors monitoring of the six British Duck, B W, Proceedings of the Royal Society of Medicine, 1976, 69, 307. at 8 Barnes, A W, Proceedings of the Royal Society of Medicine, 1976, 69, 277. VCM plants began once. A time-weighted threshold limit 9 Ramazzini, B, De Morbis Artificium Diatriba. Modena, Capponi, 1700. value of 50 ppm in the working environment was imposed. The Health and Safety Executive issued a comprehensive code of practice in February 1975 as a result of the formation of a joint working. group of the Inspectorate, unions, and employers. In October 1975 a new hygiene standard was adopted: a ceiling level of 30 ppm; a time-weighted threshold Cancer of the oesophagus limit value for VCM of 10 ppm; and a policy that, wherever practicable, exposure of workers should be brought as near as About 2500 patients die each year in Britain from oesophageal possible to zero concentrations.
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