EVALUATION OF THE NUTRITIONAL STATUS OF PATIENTS AT A REHABILITATION CENTER Thosés far I‘M Degree of M. S. MICHIGAN STATE COLLEGE Mmy E. FumIvaII 193524 THESIS This is to certify that the thesis entitled EVALUATION OF THE NUTRITIONAL STATUS OF PATIENTS LT A REHABILITATION CENTER presented by Mary E. Furnivall has been accepted towards fulfillment of the requirements for L3. degree in Nutrition 0W iajor professor Date August 20, 195A 0-169 EVALUATION OF THE NUTRITIONAL STATUS OF PATIENTS AT A REHABILITATION CENTER By Mary E. Eyrnivall A THESIS Submitted to the School of Graduate Studies of Michigan State College of Agriculture and Applied Science in partial fulfillment of the requirements for the degree of Te MASTER OF SCIENCE Department of Foods and Nutrition School of Home Economics 1954 9 ACKNOWLEDGEMENTS The writer is most appreciative of the help and co- operation extended to her by Mrs. Beth Bates R.N., Mr. and Hrs. Butcher, Mr. Face, Dr. Fink, the staff of the Ingham County Rehabilitation Center and especially for the cheerful co-operation of the patients interviewed. The study undertaken was made possible by the kind permission of Dr. Frederick C. Swartz, M.D., President of the Ingham County Rehabilitation Center. It is with a sense of very real gratitude that acknow- ledgement is made of the patient guidance and assistance given by Dr. Margaret A. Ohlson throughout the year and of the help received from Dr. Wilma D. Brewer. The technical assistance of Beth Alsop, Lucile Decker and Dolores Kerélukihsgratefully acknowledged. The writer is indebted to Michigan State College for the provision of tuition and foreign partial maintainance scholar- ships and to the United States Department of State for funds, administered by the Institute of International Education, awarded under the Smith-Mundt and Fulbright Acts. The course of study undertaken would not have been possible without these means . EVALUATION OF THE NUTRITIONAL STATUS OF PATIENTS AT A REHABILITATION CENTER By Mary E. Furnivall AN ABSTRACT Submitted to the School of Graduate Studies of Michigan State College of Agriculture and Applied Science in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE Department of Foods and Nutrition School of Home Economics 195# Approved 0 W EVALUATION OF THE NUTRITIONAL STATUS OF PATIENTS AT A REHABILITATION CENTER A3 Abstract The study was undertaken as an attempt to evaluate the nutritional status of selected patients at the Ingham County Rehabilitation Center. Micro-chemical analyses for haemoglobin, serum protein and serum ascorbic acid were made on capillary blood samples. The findings were correlated with the dietary intake estimated from a 24 hour recall record. Dietary histories were used to investigate individual food patterns. The haemoglobin concentrations were estimated by an alkaline haematin method, using a Beckman spectrophotometer. The values found ranged from 11.12 to 16.39 gm./100 ml. blood. The mean value for the men was 14.44 gm./lOO ml. and for women 13.35 5m./100 ml. The serum protein concentrations were determined by the gradient tube method. The values found ranged from 5.9 to 8.5 gm./100 ml. The mean value for men was 7.07 gm./100 ml. and for women 7.13 gm./100 ml. The serum ascorbic acid concentration was estimated as total ascorbic acid with 2,4 dinitrophenylhydrazine. The values found ranged from 0.15 to 1.53 mg./100 ml. The overall mean values for men were 0.4 mg./100 ml. and for women 0.6 mg./100 ml. Newly admitted female patients showed concentrations averaging 0.80 mg./100 ml., while the longer term patients showed a range of from 0.39 to 0.42 mg./100 ml. These latter values were suggestive of a state of chronic Vitamin C deficiency, probably due to the fact that the patients had not all taken advantage of the Vitamin C supplies made available to them. The meals supplied in the Center were good and carefully planned. The calorie and protein intakes of the men were, in general, above the estimated requirements calculated from the National Research Council Recommended Allowances. The mean caloric intake of the women was within the limits of previously published studies, while their protein intake was relatively high. The overall Vitamin C intakes ranged from 8 to 208 mg./ day. Predicted calorie and protein requirements for 12 men for whom both height and weight data were available were contrasted with their estimated intakes. The value of serial weight records is indicated. Suggestions are made for improving the patient's understanding of his nutritional status through the use of simple educational materials. INDEX INTRODUCTION ......................................... REVIEW OF LITERATURE ................................. Methods of assessing nutritional status .......... . Food intake ................................... Bio-chemical investigation.. .................. . Haemoglobin concentration ...................... Serum protein concentration.. ................. . Serum ascorbic acid........ .................... EXPERIMENTAL PROCEDURE ......... . ................... .. Selection of patients.. ............... . ..... . ..... Estimations of blood sample concentrations........ Haemoglobin ................................... . Serum protein...... ........................... . Serum ascorbic acid. .......................... . Diet histories and 24 hour recall records ......... RESULTS......... ...... . ................. . .......... .. Estimation of blood sample concentrations ........ . Dietary intakes. ............... . .................. Case studies... ..................... .... ........ .. DISCUSSION. ..................... ..................... SUMMARY.... ......... ....... ............... ........... LITERATURE CITED..... ..... . .......................... . APPENDIX.... ............. ...... ..................... . List of Figures ....................... . .......... . *U rah: m mHmVu m u H E 19 19 19 20 21 22 22 24 24 28 36 38 45 47 53 54 INTRODUCTION The Ingham County Rehabilitation Center was established in February 1953. at the Ingham County Hospital. A programme was set up, guided by the Research Committee, to assist in the clarification of the many problems now unfolding with advances in rehabilitation and geriatric care. The present paper therefore forms part of a wider project. While articles by other authors (l9,22,51,64), have been published previously on the nutritional status of the geriatric patient, none have specifically stated whether such patients were at the same time undergoing any form of rehabilitation. The extent of the adjustment required of any person who has undergone either a natural or enforced slowing down of their previous mode of life has perhaps only now come nearer to full realisation. Reports on the initial condition of the aged living alone and those who have suffered a crippling disablement have consistently indicated the danger of a relapse into apathy (19,34,51,57,64). When this apathy is extended to the quantity and quality of food ingested and superimposed on the factors of poor dentition, pro-existent food patterns, physical degeneration and, for those living alone, often low economic status, a vicious circle has been set up (Vintner- Paulsen (64). The importance of adequate nutrition for all forms of activity has been amply demonstrated. In this paper the writer has attempted to evaluate the nutritional status of patients undergoing rehabilitation, in whom it is hoped that the vicious circle has been or is being broken. The majority of the patients interviewed should also be considered as geriatric cases. It is proposed that this evaluation be carried out for each patient by a correlation of a diet history, a 24»hour recall diet record and a nicrodhemical study of the concentrations of haemoglobin, serum protein and serum ascorbic acid of the blood. REVIEW OF LITERATURE Methods of Assessing Nutritional Status In considering the geriatric patient, ...'it is essential that there be individualization in analysis of the nutritional status and in any diet therapy. Generalisations are dangerousI (Steiglitz (60). Food Intake Methods of assessing food intake as a contributory factor to the nutritional status of an individual range from a dietary history, through estimates of food eaten over a 24 hour period and records kept of food intake over a week or more, to the detailed weighed intake used in laboratory controlled balance experiments. The dietary history'has been most generally used to describe food patterns (43). More detailed histories have been evaluated in terms of the presence of good sources of specific nutrients (8,22,57). The accuracy of the 24 hour recall diet is dependent on the informant's memory and knowledge of portion sizes. In studying the nutrition of aging women Ohlson et a1 (44), found "The apparent mean intake of all nutrients was greater when measured by the recall diets.II The contrast was made with 10 day periods when weighed intakes were recorded. It was considered that the increase was due in part to eating between meals during the recall periods, a practice temporarily relinquished when the food had to be weighed, and to the emotional tension induced by the attempt to keep accurate records. Weekly food diaries were kept by the participants in surveys done in London and Sheffield (51,19), on the diets of old age pensioners. In each case a dietitian of the Scientific Advisers Division of the Ministry of Food visited each subject 3 to n times a week to check the record and help weigh food portions. The use of this type of individual food intake record presupposes that the participants will be sighted, literate and at least sufficiently intelligent to be able to oo~operate under supervision. Nevertheless, careful records of this type provide information on the food intake and.habits of such a population group. Pyke (51), in London, and Yinther-Paulsen (64), in Copen- hagen, investigated the food intake of institutionalized geriatric patients by pre-weighing the portions offered and calculating the actual intakes from food tables. In Copenhagen the food was weighed without the patient's knowledge and any 'extras' brought in by friends were also recorded, (Table I). The low calcium and phosphorus intakes recorded from the 'Dc Gameles By' hospital were attributed to poor milk con- sumption. Elderly Danes apparently considered milk constipating. The intakes of the institutionalized patients in London, however, compared very favorably with those reported in the food mm ma m.a e.a comm ma ma.o m.aa nnam use: .usa \ mm o» om .owe an an :.a m.a ooan ma m.o m.aa amum .eoapspauuea uam tea uH.H ue.a uoomn nma ua.o um.oa nomom ownem Hausa ea .:03 pcoasnac Na .HHH .aa «a a m.o 5.0 mmoa .:.m o.o e.m: Anna use: .usa ‘mw on no .ome am m o.a H.H comm an a.o m.mm Rama .meaaooo use um um um.o na.o noowa sm u¢.o :a.~n named oweem meaoe .uouson leads an .moaos ma .HH .ao ma 0 «.0 m.o owed m.a o.o w.me mesa use: .msa am on on .om4 mm Ha m.a o.a comm ea c.” a.na mama .waaaooo 2:0 cw um am.o um.o noow um .e.o :w.ma name emcem waded .oeo: as £2.33 OH .H A8 .Aomv exam .4 .ma .wa .ma .wa .D.H .ma .aw .am 0 subway 4 undo ado» coda -umw> eaoeaz sondm eaaeanp uuwua eonH naeo scam uoaeo caspau upcoanem zmxoz 024 am: Hammndm 2H HMdBZH noon ho mm¢z .m ma 0H 0.H H.H 0000 0a 5.0 :.00 55nd eemz .ssa H5 owe omcaops 5H dd n.a H.H 00am «a 0.0 H.00 5H5H .emuaaeeoap and :0 o0.0 c5.0 -005” :0 :0.0 :5.mn :mmwa omeem sepdauea .noaos span and NH .> .ao 0: NH 0.H n.a 0000 n.0a H.H 0.m5 500m use: .0sa m0 0» Hm .om< .coapap 0: ma 5.H e.a 0000 ea a.a H.05 ~5~m unused sauna -50 .0a .:.H aa.a -0050 :0a -0.0 5.50 unoma omaem ea .eoa snag nan «d .5H .ao .wa .ws .wa .wa .=.H .wa .aw .sw o subway 4 Educ camp mean can caocaz tonamnaaasdna cda coma taco noam coaco omeucH unconnam tend» nepa> defindacoo H mqmdfl records of similar London patients living at home (51). It was considered that more food was eaten when it was presented ready prepared. Food rationing and shopping imposed very real difficulties on the aged at this period in England. Biochemical Investigation The investigation of the amounts of specific nutrients in body fluids has been gradually extended to the geriatric patient. With the introduction of micromethods of analysis (Bessey (4), it has become possible to make estimations of the blood concentration of many nutrients without subjecting the elderly patient to the trauma of venipuncture. As data are relative to geriatric cases collected, it becomes more im- perative that such data should be presented in absolute terms and include the range of distribution of blood values (43). Albanese (1), who investigated well-nourished older women on a self-selected diet, indicated the need to consider any findings in a geriatric case in terms of a "geriatric norm" and not in contrast to the "average" adult levels. Biochemical methods of investigating the nutritional status of the geriatric case have most usually been used to indicate either the existing quantity of a nutrient in the body fluids or the results of "saturation" tests, with concommitant data on excretion. Since the most frequently reported deficiencies in the elderly have been in intakes of protein, iron, calcium and phosphorus, attention has been directed towards investigating such cases together with those showing varying degrees of hypovitaminoses. In the present evaluation the concentrations of haemoglobin, serum protein and serum ascorbic acid were chosen for investigation. These factors have been considered to re- flect the dietary intakes of iron, protein and ascorbic acid, nutrients especially important in any rehabilitation scheme. Haemoglobin Concentrations The haemoglobin concentration in the blood of geriatric patients has been reported as carboxy-haemoglobin by a modifi- cation of the Haldane-Gowers method (18,33), as cyanmethaemo- globin (Collier (33), as oxyhaemoglobin (King (25), by an acid haematin method (Newman (41) and by an alkaline haematin method using either dilute sodium carbonate (Williamson (68), or dilute ammonia (Welsh (66). In all these methods 0.02 ml. blood is used. In the Sahli and Haldane-Gowers methods, the amount of haemoglobin is determined by matching a standard by dilution, using visual comparison. In the other methods the concentration is measured photoelectrically by light absorbtion following dilution and the result. calculated in gm. haemoglobin/100 ml. blood. The alkaline haematin method has been adapted to a micro- method using 10 cmm. blood laked in 2.5 ml. 0.2 percent ammonium hydroxide. The haemoglobin concentration is then calculaed from a density reading obtained with a Beckman spectrOphotometer set at 542 mp. (11). Published reports on haemoglobin values in the aged (Table II), indicate that the sex difference is maintained. Jefferson (21), Miller (37) and Olbrich (46), found decreases o.matm.m 5.HH .h :oalwm on o.mal5.m mm.~a .x Hmtmw om «anew Add” cmssoz ~.na .m +0muwm u segues m.na .x mmuae . .0.mez\eeeeaem A500 sedenao hoposoaon owes; n.5anma 0.:H .x eoaaom 00H emaaaem Anny sodas: n5.~a .a. on . 0.0H .x .eeme. 00 kammav mafia: A000 madam deacon maasmom m.ma .h natam mam noposoponm 0.3a .: 00:00 55H .0.mux .m oasuacm .H Amav comnom m.ma .m moa m.ea .: med unoceb w.ma .h mna 0.:a .x 0mm aseaaaaeo manom canoawoaosnamho AHNV comaohmoh m.ma .h 5N H.nH .: . n5 seeesemsaoeem o.mal5.m m.~a .h+.= omlmw ooa aesoosoz Away aoawoh omcdm ado: a con om p . .Ha 00H\.aw Rom owufi than convex .umm Aonusd sodasapcoocoo .nm .oz nm¢¢ may Mom mH=A<> ZHmoqéoxmdm 24H: ammmHamDm .HH mqm 00 In 0.5 00.00 50 m0 .0 .000005.00 .00000\.00 .00000\.00 .000 00000000m 0000 :0opo0m :0900& .02 0000 mandadoh 0000000 :0 00020: 00900004 32000 noamam om< 00:00pdm 202000 242020 2002 00040 00000000 20 02000 02000400200200 0004 00000000.20200 024 2000000 20000 .20000002042 mmezmo ZOHadaHAHmdmmm .zmzo3 .> mflmdy -28- and for women O.b mg./100 ml. The values obtained showed no consistent correlation with age. The correlations with intake of Vitamin C and length of residence will be discussed later. Haemolysis, an insufficient sample and a laboratory mishap prevented the serum ascorbic acid concentrations being ascertained in eleven of the original number of patients. Dietary Intakes Meals served to the patients were well planned and varied, but, as a result of individual idiosyncrasies in food habits, the patients did not invariably benefit fully from the food provided for them. Patients in the hospital received trays served in the diet kitchens from bulk containers. Second helpings were given only on request, if any food was left over. The men in the infirmary ate in a dining room and served themselves from a sidetable. Bread, milk and sugar were freely available on the tables. Some foods, noticeably meat and butter, were portioned out, but second helpings were available from any food left, once all had been served. All the patients' meals were served after the staff meal. Approximately one third of the 24 hour recall records obtained were taken on Monday. These therefore included two Sunday meals. While the food served was always appetising, the Sunday dinner seemed to be a "highlight“ in the week. It is therefore probable that, as has been frequently observed previously, the intakes recorded for these Sundays -29- were higher than they would have been for a weekday. The detailed dietary intakes of 20 men, aged from 33 to 87 years, and 15 women, aged from 47 to 93 years, are tabulated in Tables VI and VII. Height and weight data were available for 12 men only. Predicted values for weight and calorie and protein intake were calculated from the "desirable weights for height" listed in the National Research Council's Recommended Dietary Allowances pamphlet (40), (Table VIII). Starting from the specified percentage of the calorie allowance for the "standard man“ required to maintain the desired weight, adjustments were made, where applicable, for increasing ageand decreasing activity. Since only a few measurements for both height and weight were available, the valuesitahulated can only be regarded as examples. Unfortunately no comparable data was available for the women. The calorie intakes for all the men ranged from 1196 to 3577, with a mean of 2325. A comparison of mean calorie intake with the predicted requirement of the 12 men is made in Table VIII. If Case M16, ill,bedridden and a poor eater, is excluded, therecorded intakes exceed the predicted requirements by 245 and 275 calories for the hospital and infirmary patients respectively. It is unlikely that there is any significance in the difference in intakes between the two groups. The remainder of the recorded nutrient intakes were con- sidered in terms of the values predicted for the "standard" man and woman of 65 years in the National Research Council's -30- .Ammv Hausdoo nopmomom Hmcoapmze mm ma m.H n.a coon c.aa com cqmm coma mmc.m.z a. oaa m.ma em.o mm.a caem a.ca coma m.ama mmma am um.a uma.H aam.c Icama Ia.m Immm nm.mc smmaa cause me ma.ca cm.a mc.a comm c.aa mmma c.mm mama H.cmcecz .oaacoa m m.a om.a am.c mmma a.m Ham a.m: mmaa mm ma .pccaznam cm m.oa cm.a mo.a mamm e.na mmma a.mm mmca cm ea enemas: can acanopsz. ma a.m om.a mm.c come a.m mama m.om mama mm ma .mapaacmacopoc a a.m mo.a ma.a mama a.ma mmm m.mm coma am m .cmsooac “Moccaansm mm m.m ce.a cm.c coon a.m mmma o.mm mama mm mm . p as: one anaconda“ .sopcoaseo me m.a mm.a mm.a aoma a.m mam m.mo mmma mm ea .conopdx :« ammo: m: a.m mm.m om.H mmmm m.m mmma m.mm mmwm mm mm .coscasoz .saanoaoos: mm m.m oc.m mm.a maom m.HH acme a.ma mmma om m .mpaaacoaacs assoc a: a.ma mm.a mm.a eaea m.ma cmma m.cca mmma mm ma .aceqxac: .saseoacoes ma a.m mm.a ma.a mmoa m.ca amm a.mm mmaa mm m .nopaoapmo ma o.oa m:.a mm.o :mma a.m mmm m.mm mmma mm Ha .ocacpso capo; an m.ma em.o mm.a ammo a.oa mmma m.mma mmmm cm ma .coeopaa ca sauce ma m.a am.H oH.H mmmm c.aa mam m.am mcoa mm ma .coscuaa :a canoe cad c.aa am.m ma.a mmmm m.oa mmma a.mm mmma mm m .oaaoneac aca m.m mm.m ma.a amao m.aa omna m.am mama mm aH .aoecaacs .aaencaocea ca m.ca om.a mm.H mmmm m.cH mafia c.am amma mm a .cosopca ca capo: a: m.m ma.m ma.H mmcm a.ma aooa m.aaa amma me ca .oaasnacccscmm co a.m mm.a mm.o cmcm a.m omma a.cm mmaa a ma .cceooaa ca capo: a: m.ma mm.a ma.a oamm m.ma coma m.ama mmmm m ma .pcmuaoom amazomm> Ioanoamo .pnmasnad a: a.m wN.H wH.H mmma a.m «mm a.m: mmam mm MN .2 .aa .aa .wa .aa .o.a .aa .aa .am ..sm 0 adhmau 4 Bade ~mama mean .02 megapsom anoaamm ads adouaz I adaddna ads aoAH I I I ow< uspa> cnam Inca» duo cum case coco mmmzmc zcaameHmHmmm m Nazacc ammcza m< 2a: cmacmmmm ca mo mauaa= mma m.oa mc.m mm.o amm.am a.ma mmm m.mm omaa mm ama .uoaoooeao .oaaoncaa mca m.m mm.a am.o cmmm m.aa mmaa o.am mmma mm ma .ooppaacs masoz mm m.m aa.a cm.o mmaa c.m mama a.mm mama am mm .coupaaco masoz ma .a.oa a:.a mm.o momm a.aa moma m.mm caaa am mm .omeooac ccoceasnsm mm m.m mm.a :a.a mmaa mam amm a.cm mama am am .maaaanoaaoa atone mm m.m ma.a ac.a aema m.m amma m.mm mmma mm a .oacaoaaam am m.m cm.o mm.o mama m.m omm c.cm mama mm ca .oooooac occccaassm ma c.m am.a mm.o mmma m.m amea m.mm omoa mm mm .uoeuco oaaoaepoa ..aoc acpaa. m: a.ma ma.m am.o ama.am m.ma amm a.mm mama ma oaa .aaaa cc oawaoaaa aa m.ma mm.a mm.o mama a.ca mom a.mm mmaa me ma .u .ma .wa .wa .wa .DMMI .wa .wa .aw .ahh o napdau 4 luau can» mean .02 «chanson pcoaamm mas manna: I aaadasa mas echH I I I omd Inca» onam Inca» aeo cam caec ococ amazmc zoamamaaamemmmramzocc z mamas -32- .ocoacnsa .apnaaoz I can coeopszg me am mmma omma ooa 2a + mma em mm :a.: .pcoacns< I .ccacsoo aaoa mm mm mama cmca oma ea + mca mm mm ma.a Incoaznaaa. I can» one aaoa moa mm mmma cmaa mca ma + mma am mm ma.a .ma» N puma ca aaoa .pz I .Ammaos obapod mma mm mmmn comm oma ma H oma mm om mN.z .occasnaa am am moca cmma oma ma a mma cm mm ma.a .aoascs osapoa mma mm mmmm cccm aaa ea + aoa mm mm ma.a nos humanaumH .m .ccccaaccm I .sccsc accm om mm mmaa cmaa am ea I mma m.mm ma ma.a .pccacnaa .apsaaca I can accuses: mm mm mama coma aaa ea + mma mm mm ma.a .aaosoaoons I .ooncoco aaoa mm mm mmma coca oma ea + aaa mm em m.m . HHQQOH¢0£3 .cna om cmca I on cacaas caccc mm mm mmaa cmaa mma ma + oma mm mm m.: .aadnoaoons . .oaacn macaaca am mm amma cmca mma ea * aaa mm mm a.m .pcoacnaa .cano I one aaoa mao> me am maaa omma mea ma + mma emIIImm ma.a mma dmaaadvammom .H .wca .mhh pmoa aaoa mampqa Iona: mm oxmpza IonaSUom adapod copooaxm .oz edoo 0 000 d 0 .Ho 0 d pcosaoo c on m Imwwow c c o m _Immwcw peaaom oma upcoapsm .am .caoposm ooapoaoc .pa .pnaaca mmezmo ZOH9 mdmda Allowances (40). Many of the individual intakes were high in relation to other published figures on older people, (Table I). The mean calorie intake for the women was 1578, with a range of 332 to 2297. If Case th, a bedridden woman of 93 who was a very poor eater, is excluded, the mean calorie intake for the remaining women becomes 1650, again a high value in contrast to the published figures, but approximating to the National Research Council “standard“ allowance. The mean protein intakes of 85 gm. for men and 70 gm. for women are above the recommended allowance of l gm./kg. desirable body weight. Only one woman and three men consumed substantially less protein than the allowance. Among the women, 50 percent of the calcium intakes were below the recommended 800 mg. Only three men consumed less than this amount. Individual variations in milk consumption accounted for these differences. Individual intakes of iron among the men ranged from 6.2 to 20.2 mg. The mean intake was 12.0 mg., equalling the recommended allowance, but 50 percent of the men had intakes below this figure. For women, the mean iron intake at 7.9 mg. was 4.1 mg. below the N.RJC. allowance. Only four women had intakes of more than 12 mg. iron daily. The Vitamin A intakes were expressed as pre-formed Vitamin A. The inclusion of liver in a mid-day meal eaten by five of the women interviewed raised their mean intakes to 11,143 I.U. The men also were served liver, but none were interviewed on thatéhy, so that their actual intake would have been higher than the mean recorded in Table VI, of 3800 I.U. These figures compare well with the N.R.C. Recommended Allowance of 3000 I.U. pro-formed Vitamin A per man per day. The mean thiamin intake for men was 1.43 mg. and for women 0.86 mg. Nine women and four men had intakes of thiamin providing less than 0.6 mg. per 1000 calories consumed. The riboflavin intakes varied widely in both sexes, but the means of 2.60 mg. for men and 2.34 mg. for women were well above the recommended allowances. The mean niacin intake for women was 11.3 mg. with a range of from 0.16 to 32.4 mg. Two-thirds of the women, however, showed intakes of less than 10.0 mg., the recommended allowance. The mean intake for men was 10.25 mg. niacin, with a range of from 2.3 to 23.5 mg. Only three men had intakes above the recommended allowance of 13.0 mg. The excellent protein in- takes would, however, ensure an adequate supply of tryptophane, which is considered to be a source of niacin. The wide range of intake reported was due to the inclusion of the "liver day" for the women and individual high meat intakes among the men. No further deduction was made for cooking losses in cal- culating the Vitamin C intakes recorded. The mean intake for the men was 43 mg., with a range of from 8 to 114 mg. Seventeen of the men had intakes below thereoommended 75 mg. Among the women there was a range in intake of from 12 to 208 mg. Vitamin C, with a mean of 70 mg. equalling the recommended allowance. Only six of the women, however, had intakes above the allowance. The intake of 208 mg. was supplied by two daily doses of 100 mg. ascorbic acid in the form of tablets. The patients did not always take advantage of the dietary Vitamin 0 available to them. ggse Studies Dietary histories were taken as a means of evaluating individual food patterns. In several cases the information so obtained provided an explanation as to why the intake of a particular nutrient appeared low. Some examples are presented below to illustrate how such evidence may confirm the findings compiled from a 24 hour recall diet record. Case M27. Low Vitamin C intake. Found fruit Juice “too acid". Case Mll. Low Vitamin C and calcium intake. Poor teeth and possible duodenal ulcer. Found fruit Juice “too acidI and vegetables 'upsetting“. Professed to have liked milk previously, but did not drink it now. Case M7. Low Vitamin C intake. Found fruit Juice 'too acid“. Case M29. Low Vitamin C intake. Found orange Juice “too acid“. Case M24. Low protein and calcium intakes. Previously had high intake alcohol, desserts and concentrated carbohydrates. Now “watching his weight“. Had stopped eating cereals and potatoes and took little bread and milk. Case M9. Low calcium and Vitamin C intakes. Milk taken only as a scant serving on cereal or when flavoured with Case Case Case Case Case Case Case Case Case Case Case F18. F35 0 F20. F4. F33. F37. F6. F17. F41. F31. F42. -37.. chocolate. No fruit, fruit Juice or vegetable, except potato, taken. Low calcium and Vitamin C. Allergic to milk. Disliked all vegetables except potatoes. Took no fruit Juice or fruit except bananas and grapefruit. Forced as a child to take milk, fruit and vegetables, now determined not to. Low Vitamin C intake. Disliked fruit Juice. Low calcium and thiamin intakes. Had never drunk milk. Disliked breakfast cereals. Liked “plenty of sugar and candy”. Had not previously drunk milk but now took it 'for the vitamins“. Ate no potatoes and only half a slice of bread a day because she was ”afraid of getting diabetes“. Low Vitamin 0. Found fruit Juice “too acid". Low thiamin. Had always made own bread. Disliked l'shop bread“. Low calcium. Milk not liked, although she had had to drink it as a child. ‘Low calcium and Vitamin C. Disliked milk, cereals and most desserts. Took no fruit Juice except tomato. Found fruit Juice “too acid“. Low Vitamin 0. Found fruit Juice “too acid now”. Vegetables said to “give her diarrhoea”. Diptheria as a child left her'with a Iweak throat”. Had never been able to take any acid or rough fruit or vegetables. Ate very little. DISCUSSION In general, the findings reported in this study indicate that the patients investigated at the Ingham County Rehabili- tation Center have a reasonably good nutritional status. The haemoglobin concentrations found are well within the expected limits. 'The intake of dietary iron is relatively low. In this connection it should be remembered that there is no! evidence to indicate that, in the absence of blood loss, grown men and women past the menopause have a specific iron require- ment. Certainly the haemoglobin concentrations reported indicate that the dietary intakes of iron of these men and women are apparently sufficient for their needs. The serum protein concentrations reported are also good, . a finding to be expected in view of the excellence of the majority of the dietary protein intakes. The serum ascorbic acid concentrations reported vary considerably, as do the Vitamin C intakes in the dietaries. In view of the marked differences in the average ascorbic acid serum concentrations reported for each of the three categories of patients, (Table III), scatter diagrams were plotted showing serum ascorbic acid concentration against dietary intake of Vitamin‘C. Six of the nine patients admitted to the hospital between April 4 and June 9, 1954 were women whose serum ascorbic acid -39- concentrations ranged from 0.65 to 1.53 mg./100 m1. (Table V). The other three patients, all cases of Parkinsons disease, had serum ascorbic acid concentrations of 0.15, 0.15 and 0.22 mg./100 ml. respectively. It is considered that plasma or serum ascorbic acid concentrations reflect both the degree of tissue saturation and the recent dietary intake of Vitamin C (Stotg (60). It is therefore probable that the serum ascorbic acid concentrations of these six women reflected to some extent their Vitamin C intakes before admission. Excluding these cases, there was some trend towards a straight line relation- ship between the serum ascorbic acid concentration and the Vitamin C intake in the other women. The correlation coefficient was 0.714, a significant finding (probability less than 0.05). The cases of Parkinsons disease show low serum ascorbic acid concentrations associated with Vitamin C intakes of 25, 57 and 75 mg./day. The dietary histories suggested that Vitamin C intakes prior to admission had been reasonably satisfactory. Taylor (5), described Parkinsons syndrome as due to degenerative changes in the corpus striatum. He thought that the disease might also result from cerebral arteriosclerosis, encephalitis lethargioa, or from poisoning by carbon monoxide or manganese. Taylor reported that "the corpus striatum and other parts of the extraphyramidal system seem to be peculiarily susceptible to the action of certain toxic substances“. The_ three cases of Parkinsons syndrome reported on here had each contracted the disease some time previously, in one case, with. -40- a background of hereditary syphilis, over 18 years before. One case, F34, reported that she was in the habit of pulling out her own teeth when they became sufficiently loose. In view of Taylor's opinions and the known function of Vitamin C in aiding resistance to infection and maintaining intercellular substances, one might raise a question as to why these ascorbic acid serum concentrations have remained low in the face of apparently good Vitamin C intakes. Among the men, Cases M13, M26, M27 and M28 probably had higher dietary intakes of Vitamin C than those recorded. These four men either worked in the kitchen, with possible access to extra food, or drank relatively large quantities of milk, which could provide an extra source of Vitamin C. If these cases are excluded the remainder of the serum ascorbic acid concentrations are between 0.2 and 0.4 mg./1OO m1. These values tally closely with those reported by Horwitt (20), for over 1000 blood samples from patients of unspecified age at Elgin State Hospital. Horwitt found the plasma ascorbic acid concentration to fluctuate from 0.2 mg./100 ml. in April to June to 0.59 mg./100 ml. in October and November, with a mean of 0.4 mg./100 ml. The calculated average dietary intake of Vitamin C was 25 mg. daily. The relationship between the serum ascorbic acid concentration and the Vitamin C intake of the men reported from Ingham County Rehabilitation Center is expressed by a correlation coefficient of -0.1009. The lack of relationship indicated by this finding is most probably due to -41... the fact that some of the men served their own food in the dining room, so receiving less uniform portions. It is also likely that the men were less able to indicate quantitatively what the size of their portions had been than the women were. These circumstances would lessen the reliability of the data on the intake of Vitamin C. The maJority of the patients investigated, who were not newly admitted, had serum ascorbic acid concentrations ranging from 0.18 to 0.45 mg./100 ml. The picture presented would serve as an illustration of Kruse's concept of a state of chronic deficiency (27). The continued ingestion of an insufficient supply of a nutrient such as Vitamin C will result in the gradual depletion of the body stores. Eventually an equilibrium is reached, by which time the concentration of the vitamin in the body is below the accepted norm, but at which the body has not been depleted of Vitamin C. A continued low intake of the vitamin will maintain this concentration, provided no infection or other insult to the body intervenes. With the passage of time, and,possibly, with lack of activity, the tissue concentration of the nutrient may even rise slowly. Higher intakes of Vitamin C will improve the serum concentration, although published reports indicate that this takes longer in the elderly, who may require considerable persuasion to accept a sufficient intake of Vitamin C. Acidity is the most frequently used excuse for not eating citrus fruits. Achlorhydria is frequently found in the aged, often accompanied by poor dentition (Freeman (17). The post- prandial discomfort attributed by many of the Rehabilitation Center patients to the “acidity“ of fruit Juice may, in fact, have been due to fermentation resulting from lack of gastric acid. Acid fruit Juices may actually improve the gastric phase of digestion in these cases, if the patient can be persuaded to take them. Appreciation of the difficulties imposed by lack of teeth is evident in the carefully thought out menus used at the Center. The acceptance of fruit Juice as a source of Vitamin C also could be improved by patient education in the importance of its contribution to nutrition. Many people tolerate fruit Juice better if it is taken after, rather than before, a meal. Orange or lemon Juice may be incorporated in fruit cup, or in stewed fruit after it has been cooked. Citrus fruit Juice may be served as a sauce to accompany cake or cornstarch pudding. To avoid loss of Vitamin C in cooking, it is advisable to cook fine thickening agent of the sauce first, in as little as possible of the required amount of liquid. Citrus Juice sufficient to make up fine bulk of the liquid may then be beaten in when the sauce is cold. Human caloric requirements are known to be reduced by an increase in age or a decrease in activity (DuBois (13). Table VIII, explained in detail in an earlier section, was constructed, using such data as was available, to compare the predicted and actual intake calorie values. The value to a rehabilitation scheme of such a comparison of desirable and actual weights will be immediately apparent. Case M7, for example, is some 37 lbs. over his desirable weight. While it is reasonable to expect that at 68 years of age he would.have gained some weight, the extra 30 lbs. will militate severely against his chances of learning to walk again. Plans have already been made at the Center for recording regular monthly weights for as many patients as possible. If these could be kept serially, or in the form of a small graph for each patient, they would enable trends of weight gain or loss to be seen immediately. The appropriate action could then be instituted. The comparison of the desirable and actual protein intakes again indicates that, in general, a plentiful supply of protein is available. Ohlson (45), studying older women, found the predicted protein requirement for the maintenance of nitrogen equilibrium to remain between 65 and 70 gm./day for the age ranges studied here. The low protein intake of Case M24 may be attributed directly to his attempt to lose weight without supervision. Ohlson (44), reported that a reduction in bread, milk and potato intake, (see Case Studies, page 36), was a common finding in women desiring to lose weight. There was a concomittant reduction in nutrient intake. Reducing diets for the elderly require careful planning to ensure an adequate intake of essential nutrients. I The importance.of nutrition in a rehabilitation scheme has not yet perhaps been fully evaluated. While good and adequate foods may be available to the patient, it is still necessary to educate him to accept those essential for good nutrition. Overweight here, as in other branches of medicine, is an impediment to the patient. The provision of Ithings to do" can help lessen the importance of meals in a patient's day. Nutrition education can guide the patient in his eating. The education or regeneration of unusual or unused muscle groups will necessitate making available to the patient food containing the nutrients essential for muscle growth and repair. In this way the value of the already outstanding programme of physical re-education at Ingham County Rehabilitation Center could be enhanced. The co-operation of the patient is the essential factor in rehabilitation. Simple, colourful educational materials are available which could be used to improve the patient's understanding of the importance of nutrition to him. A check sheet listing good sources of the important nutrients could be used to bring home to the patient where he needs to improve his eating habits. Patients who are able might well keep such a sheet for themselves (42). SUMMARY A nutritional evaluation was carried out on patients at a rehabilitation centre in Ingham County, Michigan. Micro-chemical analyses for haemoglobin, serum protein and serum ascorbic acid were made on capillary blood samples. The findings were correlated with the dietary intake estimated from a 24 hour recall record. Dietary histories were used to investigate individual food patterns. The haemoglobin and serum protein concentrations were found to be within the limits expected. The serum ascorbic acid concentrations of the newly admitted patients were essentially normal, while those of the longer-term patients were suggestive of a state of chronic ascorbic acid deficiency due to the fact that they had not all taken advantage of the Vitamin C supplies made available to them. The meals supplied in the Center were good and care- fully planned. The calorie and protein intakes of the men were, in general, above the estimated requirements calculated from the National Research Council Recommended Allowances (40). The mean calorie intake of the women was within the limits of previously published studies, while the protein intake was relatively high. The Vitamin C intakes ranged from 8 to 208 mg./day; the significance of their correlation with the serum ascorbic acid concentrations are discussed. -45- The importance of good nutritional status to the patient in a rehabilitation proJect is discussed. Means of providing the patient with nutrition education are suggested. Nutrition is one of the keys to living. It is vitally important that it should never be neglected when considering those who are being taught to live again. (l) (2) (3) (4) (5) (6) '(7) (8) (9) (10) (11) (12) (13) LITERATURE CITED ALBANESE A.A., HIGGONS R.A., VESTAL B., STEPHANSON L. AND MALSCH M.: Protein requirements of old age. Geriatrics 7:109,l952. BARBOUR H.G. AND HAMILTON W.F.: The falling drop method for determining specific gravity. J. Biol. Chem. 69:625,1926. BERKENAU P.: Vitamin C in senile psychoses. J. Ment. Sci. 86:675,1940. BESSEY O.A.: Microchemical methods. 25 Vitamin Methods, Vol. I. (Gyorgy P.,ed.) New York: Academic Press Inc.,l950. BEST CRH. AND TAILOR N.B. The Physiological Basis of Medical Practice. 5th ed. Baltimore: The Williams and Wilkins Co.,1950. BONES A.deP. AND CHURCH C.F. Food values of portions commonly used. 7th ed. Philadelphia: College Offset Press,1951. BRCCK J. Serum protein fractionation in normal old individuals. J. Geront. 3:119,1948. BURKE B.S. AND STUART H.P. A method of diet analysis. J. Pediat. 12:493,1938. BUTLER A.M., AND CUSHMAN M. Distribution of ascorbic acid in the blood and its nutritional significance. COLLIER H.B. Standardisation of blood haemoglobin determinations. Canad. Med. Assoc. J. 50:550,l944. Cooperative nutritional status studies in the North East Region. Cornell Univ. Agri. Expt. Stn. Memoir No. 307, March 1942. CRANDON J.H., LUND 0.0. AND DILL D.B. Experimental human scurvy. New Eng. J. Med. 27:518,1942. DUBOIS E.F. Basal Metabolism in Health and Disease. 3rd. ed. Philadelphia: Lea and Febiger,1936. (14) (15) (16) (17) (l8) (19) (20) (21) (22) (23) (24) (25) ~48- DURAN-REINALS F. Age and infection — a review. J. Geront. l:358,l946. DISON M. The serum protein levels in unselected blood donors in the N.W. London Blood Supply Area. IQ Haemoglobin levels in Great Britain in 1943. Med. Res. Coun. Spec. Rep. Series No. 252, Chap. XI. London: Her MaJesty's Stationery Office, 1945. FOWLER W.M., STEPHENS R.M. AND STUMP R.B. in hematological values in elderly people. Clin. Path. ll:700,l94l. The changes Am. J. FREEMAN J.J. The basic factors of nutrition in old age. Geriatrics 2:4l,l947. HALDANE J.J. J. Physiol. 26:1901. In Haemoglobin levels in Great Britain in 1943. 'MEd. Res. Coun. Spec. Rep. Series No. 252, London: Her MaJesty's Stationery Office. HOBSON W. AND BLACKBURN E.K. Haemoglobin levels in a group of elderly persons living at home alone or with spouse. Brit. Med. J.i:6 7,1953. Ascorbic acid requirement of individuals Proc. Soc. Exp. Biol. HORWITT M.K. in a large institution. and Med. 49:248,l942. JEFFERSON D.M., HAWKINS W.W. AND BLANCHAER M.C. Haematological values in elderly people. Canad. Med. Assoc. J. 68:347,l953. JORDON M., KEPES M., HAYES R.B. AND HAMMOND W. Dietary habits of persons living alone. Geriatrics 9:230,l954. KAGAN B.M. Studies on the clinical significance of the serum proteins. 1. The protein content of normal venous and capillary serum and factors affecting its determination. J. Lab. Clin. Med. 27:1457,l942. KING,C.G., MUSULIN RnR. AND SWANSON W.F. Effect of Vitamin C intake upon the degree of tooth inJury produced by diptheria toxin. Am. J. Pub. Health 30:1068,l940. KING E.J., WOTTON I.D.P., DONALDSON R., SISSON R.B. AND MACFARLANE R.G. Comparison of haemoglobin methods. Lancet ii:97l,l948. (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) -49— KIRK J.E. AND CHIEFFI M. Vitamin studies in middle- aged and old individuals. XI. The concentration of total ascorbic acid in whole blood. J. Geront. 8:30l,l953. KRUSE H.D. A concept of the deficiency states. Milbank Mem. Fund quart. 20:245,1942. LAING M.K. Blood counts of elderly subJects. Med. J. Australia i:299,l953. LEVINE S.Z., GORDON H.H. AND MARPLES E. Defect in Metabolism of tyrosine and phenylalanine in premature infants; spontaneous occurrence and erradication by Vitamin C. J. Clin. Invest. 20:209,194l. LOWRI O.H. AND HUNTER T.H. Determination of serum protein concentration with a gradient tube. J. Biol. Chem. l59:465,l945.' LOWRI O.H., LOPEZ J.A. AND BESSEY O.H. The determination of ascorbic acid in small amounts of blood serum. J. Biol. Chem. 160:609,l945. MADDEN S.C. AND WHIPPLE G.H. Plasma proteins: their source and utilisation. Physiol. Rev. 20:194,l940. MED. RES. COUN. SPEC. REP. SERIES NO. 252. Haemoglobin levels in Great Britain in 1943. London: Her Majesty's Stationery Office, 1945. MED. RES. COUN. SPEC. REP. SERIES NO. 280. Vitamin C requirements of human adults. Her MaJesty's Stationery Office, 1953. Geriatrics 2:149,1947. London: MEIER J. Diet for'the aged. MEIER K. acid and hyaluronidase. The biological significance of hyaluronic Physiol. Rev. 27:335,l947. MILLER I. aged. MINDLIN R.L. AND BUTLER A.M. The determination of ascorbic acid in plasma; a macromethod and micro- method. J. Biol. Chem. 122:673,l937-8. Normal hematological standards in the J. Lab. Clin. Med. 24:1172,l939. McCANCE R.A. AND WIDDOWSON E.M. The osmotic pressure of the serum proteins. Ig Studies of undernutrition, Wuppertal, 1946-9. Med. Res. Coun. Spec. Rep. Series, No. 275. London: Her MaJesty's Stationery Office, 1951. (40) (41) (42) (43) (44) (45) (46) (47) (48) (49) (50) (51) (52) (53) -50- National Research Council. Recommended Dietary Allowances. Publication No. 302, Nat. Acad. of Sciences, Washington D.C., 1953. NEWMAN B. AND GITLOW S. Blood studies in the aged. Am. J. Med. Sci. 205:677,1943. Nutrition Section, Michigan Department of Health. Check up on Your Meals, Lansing: Michigan Department of Health, 1951. Nutrition Surveys: Their Technique and Value. Bull. Nat. Res. Coun. No. 117, Washington, D.C.,l949. OHLSON M.A., JACKSON L., BOEK J., CEDERQUIST D.C. AND BREWER.W.D. Nutrition and dietary habits of aging women. AM. J. Pub. Health 40:1101,l950. OHLSON M.A., BREWER W.D., JACKSON L., SWANSON P.P., ROBERTS P.H., MANGEL M., LEVERTON R.Ms, CHALOUPKA M., GRAM M4R., REYNOLDS M.S. AND LUTZ R. Intakes and retentions of nitrogen, calcium and phosphorus by 136 women between 30 and 85 years of age. Fed. Proc. 11:775,l952. OLBRICH 0. Blood changes in the aged. Edin. Med. J. 54:306,1947. OLBRICH 0. Blood changes in the aged, III. Edin. Med. J. 55:100,l948. OSGOOD E.E. Normal hematological standards. Arch. Int. Med. 56:847,1935. PETERS J.P. AND EISENMANN A.J. The serum proteins in diseases not primarily affecting the cardiovascular system or kidneys. .Am. J. Med. Sci. 186:808,l933. The assessment of Biochem. J. 37:623,1943. PIKE M., HOLMES S., HARRISON R. AND CHAMBERLAIN K. Nutritional value of diets eaten by old people in London. Lancet ii:461,1947. RAFSKI H.A. AND NEWMAN B. Vitamin 0 studies in the aged. Am. J. Med. Sci. 201:749,l94l. RAFSKI H.A., BRILL A.A., STERN K.G. AND COREY H. ' Electrophoretic studies on the serum of “normal” aged individuals. Am. J. Med. Sci. 224:522,l952. PRUNTI F.T.G. AND VASS C.C.N. Vitamin C nutrition in man. (54) (55) (56) (57) (58) (59) (60) (61) (62) (63) (64) (65) (66) (67) ROE J.H. AND HALL J.M. The Vitamin C content of human urine and its determination through the 2,4 dinitrophenylhydrazine derivative of dehydroascorbic acid. J. Biol. Chem. 128:329,1939. ROE J.H. AND KUETHER C.A. A color reaction for dehydroascorbic acid useful in the determination of Vitamin C. Science 95:77,l942. ROE J.H. AND KUETHER C.A. The determination of ascorbic acid in whole blood and urine through the 2,4 dinitro- phenylhydrazine derivative of dehydroascorbic acid. J. Biol. Chem. 147:399,1943. SAINT E.G., ABRECHT H.F. AND TURNER C.N. Old age: a clinical, social and nutritional survey of 70 patients over 65 years of age seen in a hospital outpatient department in Melbourne. Med. J. Australia i:299,l953. SHAPLEIGH J.E., HAYES S. AND MOORE C.V. Hematologic values in the aged. J. Geront. 7:207,l952. STEPHENSON W., PENTON C. AND KORENCHEVSKY V. Some effects of Vitamins B and Cion senile patients. Brit. Med. J. ii:839,194l. STEIGLITZ E.J. Nutritional problems of geriatric medicine. J. Am. Med. Assoc. 142:1070,l950. STOTZ E., SKINNER R.M. AND CHITTICK R.A. The oral ascorbic acid tolerance test and its application to senile and schizophrenic patients. J. Lab. Clin. Med. 27:518,1942. TAYLOR C.M. Food values in shares and weights. New York: Macmillan,1942. U.S.D.A. Handbook No. 8. Misc. Pub. No. 572. Composition of foods. VINTHER-PAULSEN N. Investigation of the actual food intake of elderly chronically hospitalised patients. J. Geront. 4:33l,l949. VINTHER-PAULSEN N. Senile anorexia. Geriatrics 7:109,1952. WELCH G.K. AND WALTHER W.W. Rapid and simple method of estimating haemoglobin. Lancet i:548,l951. WEST E.S. AND TODD N.B. Textbook of Biochemistry. 2nd. ed. New York: Macmillan, 1952. (68) WILLIAMSON 0.3. Influence of age and sex on hemoglobin. Arch. Int. Med. 18:505,l916. w (69) WINTROBE M.M. Blood of normal men and women. Bull. Johns Hopk. Hosp. 53:118,l933. (70) WOLBACH S.B. The patholOgical changes resulting from vitamin deficiency. J.A.M.A. 108:7,1937. APPENDIX LIST OF FIGURES I Record sheet used to obtain 24 hour recall diet record. II Record sheet used in obtaining dietary histories. -55... FIGURE I RECORD OF MEALS FOR ONE DAY Name Code No. Date FOODS EATEN FOR BREAKFAST 1. 4. 7. 2. 5. 8. 3. 6. 9. ' What foods were on the table that you did not eat? What foods did you eat or drink between breakfast and noon? FOODS EATEN AT NOON l. 4. 7. 2. 5. 8. 3. ‘ 6. 9. What foods were on the table that you did not eat? What foods did you eat or drink between the noon and evening meal? FOODS EATEN AT EVENING MEAL l. 5. 9. 2. 6. 10. 3- 7. 5_ll. 4. 8. 12. What foods were on the table that you did not eat? What foods did you eat or drink before you went to bed? Medications -56- FIGURE II Code No. Name Hospital No.____ Date of interview Home town Sex Age Marital Status - S M W D Sep. Wt. 1b. Ht. in. St. Wt. lb. Teeth Diagnosis Prognosis Condition) Condition) On entry ) Now ) Rehabglitgtion Begun Progress Workshop Family Bacgground Father Mother Siblings Wife Children Previous occupation Meals at work Food Preferences and why: -57... Foods previously eaten ilk,ffresh Adult Times/week Child # canned Cheese Eggs Megt Bacon or ham Fish antLrgL cooged Vegetable, raw cooked A Potatoes —58- Adult Times/Week Child Rice,gpasta, corn Cereal, type Bread, type Crackers Cookies pesserts Preserves Sugar _Candy .Tga Coffee Qgher bevergge Alcohol Special Family dishes . nfl’iI .uUII' 1 USE ONLY a!” r - ‘v ‘(‘ .n !: )1 a L II; a ". vyflhf‘ -§‘}~ tax)", I: '-, A {TELL-4. A ”'TITINJH In?! Mil/317171 MINI/"I“ 9 56 7709