Aetiological doctrines and prevalence of pellagra: 18th century to middle 20th century

Review Article Page 1 of 7 AUTHORS: Margaretha Viljoen1 Priyesh Bipath2 Johannes L. Roos1 AFFILIATIONS: Department of Psychiatry, University of Pretoria, Pretoria, South Africa 1 Department of Physiology, University of Pretoria, Pretoria, South Africa 2 Correspondence to: Margaretha Viljoen EMAIL: Aetiological doctrines and prevalence of pellagra: 18th century to middle 20th century Pellagra is characterised by dermatological, gastrointestinal and neuropsychiatric manifestations. Millions contracted the disease and hundreds of thousands died between the time it was first recorded until pellagra was finally recognised as a niacin-deficiency disease. Pellagra became epidemic when maize, with its limited bio-availability of nutrients such as niacin and tryptophan, became the staple food in the near-monophagic diets of the impoverished and institutionalised. By the mid-20th century, pellagra was all but eradicated in large parts. The decline in prevalence can largely be ascribed to a better understanding of the link between nutrition and disease, improvements in socio-economic conditions of workers and food enrichment. We briefly review aetiological doctrines on pellagra and the global spread of the disease from the early 18th century until the middle of the 20th century. In the final analysis, we examine the reasons for, and the legitimacy of, the persistent association between pellagra and the consumption of maize. Significance: • Almost two centuries have elapsed since the first description of pellagra and its general acceptance as a nutritional-deficiency disease. DATES: • The link between maize and pellagra is primarily a reflection of the nutritional inadequacies of a near monophagic diet over-dependent on a grain deficient in bioavailable niacin and tryptophan. • We refute the concept of nixtamalisation as the main reason for the apparent absence of pellagra in early pre-Columbian North American, Mesoamerican and South American cultures. Received: 23 Aug. 2017 Revised: 28 Feb. 2018 Accepted: 11 May 2018 Published: 11 Sep. 2018 KEYWORDS: Introduction HOW TO CITE: Pellagra is a nutrition-deficiency disease characterised by dermatological, gastrointestinal and neuropsychiatric manifestations. The symptoms are commonly referred to as the three D’s: dermatitis, diarrhoea and dementia, which may not necessarily present in that order. Although the symptoms of pellagra are defined as dermatitis, diarrhoea and dementia, a wide range of gastrointestinal and neuropsychiatric symptoms may present.1,2 The skin lesions appear primarily on those parts exposed to sunlight, such as the dorsum of the hands and feet, with the typical ‘Casal’s necklace’ of rough skin in exposed areas around the neck and upper chest.1 maize; niacin; tryptophan; nutritional-deficiency disease Viljoen M, Bipath P, Roos JL. Aetiological doctrines and prevalence of pellagra: 18th century to middle 20th century. S Afr J Sci. 2018;114(9/10), Art. #4597, 7 pages. https://doi. org/10.17159/sajs.2018/4597 ARTICLE INCLUDES: × Supplementary material × Data set FUNDING: None Pellagra is the classical syndrome of a severe deficiency of the water-soluble vitamin niacin.2 Niacin, also known as nicotinic acid or vitamin B3, and its amide derivative nicotinamide, are precursors of the co-enzyme nicotinamide adenine dinucleotide (NAD) which can be phosphorylated (NADP) and/or reduced (NADH and NADPH).3 As NAD and its derivatives are involved in a multitude of oxidation-reduction as well as non-redox reactions, severe niacin deficiency can lead to death with multi-organ involvement. Niacin is abundant in a number of different foods – dairy products, cereals, nuts, leafy vegetables, yeast, fish, and meat products.4 However, the form in which it occurs and its bio-availability differ. Some foods contain niacin in the free form that is highly bio-available. Cereal grains, as a source of niacin, vary depending on the type and the processes involved in food preparation. In addition to dietary intake, niacin can also be synthesised from the essential amino acid tryptophan via the kynurenine pathway.5 Such de novo synthesis of niacin decreases with a deficiency in iron, riboflavin (vitamin B2) or pyridoxine (vitamin B6).6 Several factors may have pellagragenic effects, either through their influence on the absorption of niacin and/or tryptophan, or through their effects on the conversion of tryptophan to niacin. These factors include excessive leucine intake7, chronic alcoholism1,2, antituberculosis drugs8, immunosuppressive drugs9, eating disorders and a variety of gastrointestinal disturbances2. Today, the name pellagra has become virtually synonymous with the term niacin deficiency. However, many aetiological theories were explored and almost two centuries elapsed between the first description of the condition and its general acceptance as a nutritional-deficiency disease. We briefly review the main proposed aetiological doctrines, the global spread of the disease from the early 18th century until the middle of the 20th century and the association between pellagra and maize. Aetiology of pellagra: From vampires to nutritional deficiency © 2018. The Author(s). Published under a Creative Commons Attribution Licence. South African Journal of Science http://www.sajs.co.za Up until its formal recognition as a dietary deficiency, pellagra has been blamed on various phenomena. It is even believed by some to be the origin of the vampire myth on which Bram Stoker’s blood-sucking Transylvanian vampire, Count Dracula, was based. This association was perhaps largely because of the sunlight sensitivity of pellagrins and the belief that vampires were said to avoid sunlight in order to maintain their strength, but also because of shared psychological traits such as insomnia, anxiety, aggression and depression. Similarities between the physical and psychological characteristics of pellagrins and that attributed by folklore to vampires are described in an intriguing overview by Hampl and Hampl10 based on early 1700s European literature and folklore. Theories on the aetiology of pellagra can broadly be divided into maize-based theories and those based on factors other than the consumption of maize. The latter includes theories that claimed pellagra was caused by a blood- 1 Volume 114 | Number 9/10 September/October 2018 Review Article Page 2 of 7 Aetiological doctrines and prevalence of pellagra sucking insect, the ingestion of semi-dried edible oils and the retention of mineral salts, or was an inherited disease, a race-dependent disorder, a type of scurvy, a disease related to leprosy and, perhaps the view with the most far reaching consequences, a communicable condition caused by infectious agents.11-14 A more comprehensive treatise on these early aetiological doctrines can be found in a 1912 document by Niles15. Probably most important among the theories that attributed pellagra to factors other th (...truncated)