Our Daily Bread

Our Daily Bread

~Content Source

In the northern Italian town of Ferrara hangs a little-known painting by Giuseppe Mentessi (1857-1931). Surrounded by a field of maize, a woman carries her exhausted child in her arms, her eyes downcast with suffering. Behind this painting lies a story of medicine, food, economics, and culture – the story of pellagra, perhaps one of the greatest tragedies of malnutrition known to the Western world.

Exhibited at the Venice Biennale in 1895, Mentessi’s image of a cornfield depicts what once was a common sight throughout the region. Maize or corn was first domesticated as a cereal crop in the Americas, making its way to Europe via traders in the sixteenth century. This new foodstuff proved to be a lifeline for Italian agricultural workers who labored under the pressures of wheat shortages and insecure employment. With its low cost and high yield, cornmeal or polenta was quickly established as the staple food of the poor. Landowners were eager to profit from maize production, and eventually forests, vineyards and pastures across the Veneto and Lombardy were replaced by fields of this single crop. It was fitting that Mentessi named his picture “Our Daily Bread” – for by the 1800s, northern Italian peasants were living on a diet made up almost exclusively of corn.

At the same time, increasing numbers of them were falling victims to a new disease. Characterised by a flaking rash on the sun-exposed skin of the arms and neck, they named it pellagra (from pelle agra, loosely translated as “rough skin”).  Symptoms included confusion, mania, lethargy, and eventual death. While the link between pellagra and maize dependence was quickly recognized by scientists at the time, the mechanism remained a mystery. Today, we know that pellagra is a disease of severe niacin (vitamin B3 or nicotinic acid) deficiency. Niacin is the precursor of two essential coenzymes of cellular activity – nicotinamide adenine dinucleotide (NAD) and NAD-phosphate (NADP) – both involved in DNA repair, cell signalling, and metabolism. Tissues with high energy requirements and high cell turnover are particularly vulnerable to their deficiency. Without sufficient dietary niacin – or tryptophan, the amino acid used in its biosynthesis – a systemic disease occurs affecting the skin, gastrointestinal tract, and nervous system. The resulting clinical features have been famously described as the 4 D’s: dermatitis, diarrhea, dementia, and death.

The unvarying cornmeal diet that poor Italians relied on in the lean winter months, without the addition of vegetables, dairy products, or meat, was severely deficient in both niacin and tryptophan.  An epidemic of pellagra resulted, with thousands of deaths attributed to the illness – particularly in women, who had increased nutritional needs because of pregnancy and breastfeeding, and whose inferior social position meant that they tended to have less food then the men in their family. So common did the neuropsychiatric effects of the illness become, that mental asylums such as Venice’s San Servolo and San Clemente were full of victims of what was then termed “pellagrous insanity.” For almost two centuries, pellagra was endemic in the agricultural lands of the Po valley across northern Italy.

It was this widespread suffering which Giuseppe Mentessi sought to depict in his painting. Born into poverty in Ferrara, Mentessi went on to have a successful career as an art teacher and professor at the Accademia di Brera in Milan. Nevertheless, his work maintained a deep affinity with his humble origins and he often used his art to highlight the social issues of the day. In “Our Daily Bread,” he shows the misery of the Italian rural poor, with the woman’s sickly countenance a mark of the effects of pellagra. What he depicted in paint, the writer Goethe described in words in his ‘Italian Journey:’ “Of the (Italian) inhabitants, I have little to say and that unfavourable … (the) sallow complexion of the women spoke of misery and their children looked just as pitiful …  I believe that their unhealthy condition is due to their constant diet of yellow polenta …”

It was not the diet of cornmeal alone which gave rise to pellagra in southern Europe, but also the method of preparation. While maize had been a staple food of central America for thousands of years, the indigenous peoples were accustomed to soaking the dried corn kernels in alkaline lye or quicklime before cooking. This process, known as “nixtamalization,” increased the bioavailability of bound niacin in the corn by converting it into the water-soluble free compound, allowing it to be absorbed by the gut. As a result of their traditional cultural methods of preparation, the native people of the Americas did not suffer from pellagra.

When corn was brought across the Atlantic to Europe, the tradition was lost. Furthermore, pellagra was then introduced to the Americas, where European colonizers grew and ate corn without realizing the benefit of nixtamalization or the importance of a varied diet. Particularly in the Southern states, in the economic downturn following the American Civil War, the daily fare for poor people consisted almost entirely of corn-based products such as cornbread and grits. Rural sharecroppers and populations lacking access to fresh produce – in prisons, coal-mining camps, and cotton-mill towns – were particularly vulnerable to niacin deficiency. The devastation occurred on a grand scale; across the United States from 1906 to 1940 approximately 3 million cases and 100,000 deaths were attributed to pellagra.

It was a US public health physician, Joseph Goldberger, who determined that pellagra was a nutritional deficiency and not (as was commonly supposed) an infectious epidemic. In 1915, he carried out a series of experiments in Mississippi prisoners which demonstrated that symptoms of pellagra appeared after six months of eating only corn-based foods; when fresh, varied produce was introduced, the illness resolved. He concluded that “no pellagra develops in those who consume a mixed, well-balanced diet,” yet struggled to convince the political establishment that poor social conditions might be responsible for the disease. It took several more decades of research – including the isolation of niacin itself from liver tissue by Conrad Elvehjem in 1937 – before federal recommendations to fortify flour supplies with vitamins led to the eradication of the condition in the United States by 1945.

In Italy, economic growth helped end the pellagra epidemic during the 1950s, but not before the illness had provoked widespread debate about the impact of social injustice and deprivation on human health, with commentators such as Flarer (1849) referring to pellagra as “malattia del padrone” – “illness due to the landlord.” Today, we understand more than ever the impact of socio-economic factors on our health, with recognition that the West’s adoption of a highly-processed, energy-dense diet has contributed to our modern epidemics of obesity and diabetes. Such “malnutrition in the midst of plenty” has echoes of Mentessi’s work. It is said that he had the idea for his painting when he was taking an afternoon walk through a field of corn and was struck by the contrast between the bountiful crop and the sickly peasant woman with her child: “misery, perhaps hunger, in the middle of that insolent and healthy wealth!” In both Europe and the United States, it is still the poorest sections of society who suffer the most from their dependence on an abundance of cheap calories. While it may have been largely forgotten, the story of pellagra ought to be a lasting lesson in how social structures, globalization, and economic change once conspired to cause thousands of deaths from an entirely preventable disease.


References

  1. Mariani-Costantini R, Mariani-Costantini A. An outline of the history of pellagra in Italy. J Anthropol Sci. 2007;85:163-171
  2. Ginnaio M. Pellagra in Late Nineteenth Century Italy: Effects of a Deficiency Disease. Popul (english Ed.) 2011.
  3. Gentilcore D. Peasants & Pellagra in 19th-century Italy. Hist Today. 2014
  4. Hegyi J, Schwartz RA, Hegyi V. Pellagra: Dermatitis, dementia, and diarrhea. International Journal of Dermatology. 2004.
  5. Gallery of Modern Art of Ferrara. http://artemoderna.comune.fe.it/index.php?id=1872. Accessed June 22, 2018.
  6. Goethe JW. Italian Journey [1786-1788].; 1970.
  7. Lanska D. Historical aspects of the major neurological vitamin deficiency disorders: the water-soluble B vitamins. Handb Clin Neurol. 2009.
  8. Bollet AJ. Politics and pellagra: The epidemic of pellagra in the U.S. in the early twentieth century. Yale J Biol Med. 1992.
  9. Elmore JG, Feinstein AR. Joseph Goldberger: An unsung hero of American clinical epidemiology. Ann Intern Med. 1994.
  10. Toffanello M. Giuseppe Mentessi. Opere nelle collezioni del Museo dell’Ottocento di Ferrara. 1999.

MEERA LADWA, MBBS, BSc qualified in medicine in 2008 and works as a clinical research fellow in London. Her interests include diabetes and metabolism, particularly the impact of the environment on human health and physiology. Currently, she is studying for a PhD in diabetes and nutritional sciences.

A Case of Pellagra Associated with Long Term Alcoholism

Content Source: The Journal of Psychiatry and Neurological Sciences

To the Editor,

Pellagra is a systemic, nutritional disease associated with deficiency of vitamin B3 (niacin) and/or tryptophan and often other B vitamins (1). Pellagra is mostly seen in chronic alcoholics as a result of nutritionally poor diet and malabsorption (2). We present a pellagra case with long history of alcohol use, admitted with psychiatric complaints to our clinic.

Mr. A. was a 44 year old, married, primary school graduate male, who was running a coffeehouse. His socioeconomic status was low. His complaints were irritability, nausea, vomiting and loss of appetite. He had been drinking alcohol every day, for 33 years; its amount had increased to about 100cl for the last 15 years. The longest duration of remission was 3 months, when he was 13 years old. He was experiencing sweating, tremor of hands, insomnia, and irritability as withdrawal symptoms. In the last 2 years, periodically, he had problems in focusing and maintaining attention, delay in reaction time in answering any questions. He had depressive symptoms for 1 year and he had attempted suicide. In the last 2 months, he had diarrhea, vomiting, loss of appetite and erythema, followed by dark discoloration on the dorsal surfaces of his hands. On physical examination, hyper-keratotic plaques with well-defined borders on the dorsal surfaces of both hands, squamous lesions between fingers of both feet, loss of villi and hyperemia on the tongue was detected. He had tremor of both hands and wide-based gait. On psychiatric examination, he was confused, his time orientation was disturbed, self care was poor. Affect was restricted; associations and psychomotor activity were slow. The possibility of pellagra was considered as dermatitis, diarrhea and distortion of cognitive functions were observed. Electrocardiography (ECG), complete blood count, routine blood biochemical tests, routine urine tests, thyroid function tests, VDRL, microscopic stool examination, electroencephalography (EEG), vitamin B12 and folate measurements, cranial MRI, echocardiography, esophago-gastro-duodenoscopy were performed and no significant pathology was detected. As the patient’s symptoms did not respond to oral niacin treatment, niacin malabsorption was considered and a mixture of vitamin B1, B2, B6, B12, nicotinamide and dexpanthenol was given by intramuscular injection and a dramatical recovery was observed.

Pellagra is characterized by photosensitive symmetrical skin lesions, gastrointestinal disturbances, neurologic and psychiatric manifestations. The syndrome is known as “4 D’s”: dermatitis, diarrhea, dementia and death (1). Skin lesions seen in pellagra are photosensitive rash, primarily on the dorsal surfaces of the hands, arms, face and feet. In acute phase, skin lesions are erythema and bullae which resemble sunburn (wet pellagra), but after exposure to sun light, progress to chronic, symmetrical, scaled lesions occurs. Typically they are located on the neck (Casal necklace), hands and forearms (pellagra gauntlet) (3). Irritability, concentration problems, anxiety, fatigue, restlessness, apathy and depression are common psychiatric and neurological manifestations. Even uncommon, psychosis can be seen in pellagra, especially in pellagroid encephalopathy mostly encountered in chronic alcoholics. Confusion and eventually death occurs as the disease progresses (4). Gastrointestinal manifestations are fissures on the tongue and mouth, sourness, loss of appetite, dyspepsia and abdominal pain. Enteritis, which can be severe with nausea, vomitting and diarrhea can also be seen (5). Diagnosis is based on patient’s history and physical examination. There are no chemical tests to definitely diagnose pellagra (6).

In conclusion, low socioeconomic status, long duration of alcohol use, poor diet and characteristic findings should suggest pellagra, although it is a rare disease nowadays. It shouldn’t be considered as a disease that is seen only in undeveloped countries and considering pellagra in the differential diagnosis in chronic alcoholics with psychiatric, dermatologic and gastrointestinal symptoms has vital importance.

REFERENCES

1. World Health Organization. Pellagra and its prevention and control in major emergencies. Geneva, World Health Organization, 2000 (document WHO/NHD/00.10).

2. Stratigos JD, Katsambas A. Pellagra: a still existing disease. Br J Dermatol 1977; 96:99-106.

3. Pipili C, Cholongitas E, Ioannidou D. The diagnostic importance of photosensivity dermatoses in chronic alcoholism: Report of two cases. Dermatol Online J 2008; 14:15.

4. Cook CC, Hallwood PM, Thomson AD. B Vitamin deficiency and neuropsychiatric syndromes in alcohol misuse. Alcohol Alcohol 1998; 33:317-336.

5. Karthikeyan K, Thappa DM. Pellagra and skin. Int J Dermatol 2002; 41:476-481.

6. Hegyi J, Schwartz RA, Hegyi V. Pellagra: Dermatitis, dementia, and diarrhea. Int J Dermatol 2004; 43:1-5.