The University of Alabama at Birmingham has a long heritage of involvement in nutrition going back more than 75 years. As is true for the history of any other endeavor spanning a long time, it is now possible to discern a number of periods, often overlapping, during which certain aspects of nutrition science were given preferential attention. This has occurred because of two main reasons: First, preferential attention was, and is, given to nutritional problems of national scope impacting, directly or indirectly, the health of many Americans. Second, it is always possible to identify the involvement of one or a few individuals of keen scientific foresight who linked the problems to nutrition and committed the institution to their solution.
The first such period took place from the 1920s to the late 1940s when two medical doctors, Dr. James S. McLester and Dr. Thomas D. Spies, labored with great zeal to put the recently discovered vitamins nicotinic acid, thiamin, ascorbic acid, and later folic acid to use in the treatment and prevention of the major deficiency diseases: pellagra, beriberi, scurvy, and the megaloblastic anemia of pregnancy. These age-old scourges of mankind were still very prevalent in this part of the country. Dr. McLester, the first professor of medicine of this university and later president of the American Medical Association, did research work on pellagra at the Birmingham’s Hillman Hospital during the 1920s. He subsequently authored a popular textbook, titled Nutrition and Diet in Health and Disease (first published in 1927), that went through a total of seven editions with Dr. William J. Darby, a noted professor of nutrition at Vanderbilt University, as co-author in later years.
During the mid 1930s until the early 1950s Dr. Spies became the standard bearer of clinical nutrition in Alabama. Described by those who knew him as a "human dynamo," a "super public relations man," and a "folk hero," Dr. Spies was, above all, a physician. "Doctor Tom," as his patients called him, became an untiring evangelist in the quest to overcome the resistance of major segments of the medical profession to the unrestrained use of vitamins. He spent most of his time at the old Hillman Hospital treating the still-numerous pellagra patients. He traveled frequently to Cuba and Puerto Rico, where legions of patients with tropical sprue, a devastating malabsorption syndrome, responded miraculously to folic acid. In his zeal to find new knowledge and get the best treatment for his patients, Spies was not to be deterred by what he perceived as legalistic minutia. This is best illustrated by an anecdote related by Dr. Thomas H. Jukes, professor of nutrition from the University of California at Berkeley, formerly from the American Cyanamid Company, where the synthesis of folic acid was accomplished in the mid 1940s. In Dr. Jukes's words, "I took a few grams [of folic acid] with me on a trip to California in August, 1945. While changing trains in Chicago, I went into a drug store and asked for a small box. I put the tube of folic acid powder in the box, addressed it to Tom Spies, and dropped it into a streetcorner mailbox. As a result, an article appeared in the Southern Medical Journal four months later, describing the remission of nutritional macrocytic anemia following the administration of folic acid. The statute of limitations prevents legal action from being taken against me [and Spies] for this violation of the Federal Food, Drug, and Cosmetic Act."
Dr. Spies, a gifted teacher, trained many young physicians who later had distinguished careers in medical research and education. One of these was Dr. Walter B. Frommeyer, Jr., who became chairman of the institution's Department of Medicine in the sixties following the retirement of the legendary clinician Dr. Tinsley Harrison. Undoubtedly influenced by his former mentor, Dr. Frommeyer created a division of nutrition in the Department of Medicine in 1964 and named Dr. Charles E. Butterworth, Jr., as its director.
The second period, the "folic acid" period, resulted from Dr. Butterworth's ("Ted" to his many friends) keen interest in this vitamin. He had completed in 1950 a fellowship in hematology, the medical specialty that more than any other was to feel the full impact of the momentous discoveries of folic acid and of its synthetic antagonists aminopterin and methotrexate. He participated in early studies on the treatment of acute leukemia with aminopterin, one of the first drugs in the history of medicine to bring about remissions of a malignant disease. He also witnessed the extraordinary benefits, described by Spies, that followed the administration of a few milligrams of folic acid to patients with anemia of pregnancy and tropical sprue. These dramatic experiences drew Dr. Butterworth to the study of folic acid, which remained the focus of his research for the rest of his life. While still in the military, he was assigned to the U.S. Army Tropical Research Medical Laboratory in San Juan, Puerto Rico, to study tropical sprue, a disease responsible for one-sixth of all casualties sustained by the Allied forces in India and Southeast Asia during World War II. There is no doubt that Dr. Butterworth's involvement in the research efforts to understand the pathogenesis of sprue had a crucial influence in his future commitment to nutrition. Sprue patients died from severe malnutrition resulting from a gamut of deficiencies and were saved by tiny amounts of the then poorly understood essential nutrient folic acid.
In 1958, Dr. Butterworth committed himself to academic medicine, resigning from the Army. Once in charge of the newly formed Division of Nutrition, Dr. Butterworth, always focused on folic acid, proceeded to recruit two biochemists with expertise on the pathway of microbial biosynthesis of this vitamin. Charles M. Baugh, Ph.D., who in later years would become dean of the Medical School of the University of South Alabama at Mobile, joined him in 1966, and Carlos L. Krumdieck, M.D., Ph.D., in 1967. Dr. Butterworth was interested in the naturally occurring forms of folic acid, the so-called folyl-polyglutamates. Precious little was known about the biological role of these peculiar derivatives of the vitamin, but Dr. Butterworth, with remarkable scientific intuition, foresaw that in this obscure area of nutritional biochemistry lay important nuggets of knowledge. He encouraged Drs. Krumdieck and Baugh to pursue the chemical synthesis of these molecules, which, once achieved, allowed the Birmingham group to conduct pioneering studies on the digestion and absorption of dietary folates. It was also discovered that the anticancer folate antagonist methotrexate was itself converted to polyglutamyl derivatives, a finding that significantly helped in understanding the pharmacology of the antifolates. Basic studies on the biochemical role of the polyglutamyl derivatives of folic acid were greatly facilitated by the recruitment a few years later of an outstanding biochemist with expertise in pteridine biosynthesis, Isao Eto, Ph.D., a graduate of UAB's Department of Microbiology. With his participation, procedures for the analysis of reduced-one-carbon-substituted forms of the folate coenzymes with various polyglutamyl chain lengths were developed. Joseph E. Baggott, Ph.D., and Tsunenobu Tamura, M.D., continue to this day to do reseach on folic acid metabolism. The former, while still a doctoral student, provided strong support for the hypothesis that changes in the length of the polyglutamyl chain served to regulate the metabolism of one-carbon fragments in nature.
The emphasis on folic acid provided years later a fertile ground for projects by Sarah L. Morgan, M.D., M.S., R.D., who developed a new line of research concerning the control of toxicity of antifolates used for the treatment of non-malignant diseases, primarily rheumatoid arthritis. Her studies led to the worldwide use of supplemental folic acid during long-term low-dose treatment of autoimmune disorders with methotrexate. More recently, Charles W. Prince, Ph.D., who joined the department in 1987, and Carlos Krumdieck have initiated studies on the role of homocysteine, an amino acid that requires folic acid for its metabolism, on the pathogenesis of presbyopia and osteoporosis.
A third period, properly called the "hospital malnutrition" period, resulted from the involvement of Dr. Butterworth in the care of patients who often developed severe nutritional disorders while in the hospital. In 1974 a seminal paper by Dr. Butterworth, cunningly titled "The skeleton in the hospital closet," shook the medical establishment with dramatically documented observations of what became known as hospital malnutrition. This courageous disclosure led eventually to the improvement of the nutritional support of patients and to the elimination of long-established, ill-conceived hospital practices conducive to poor nutrition. The introduction of nutrition support teams, considered today to be indispensable for good patient care, can be traced to recommendations contained in this classic article. Dr. Butterworth received invaluable aid from a new recruit, Roland L. Weinsier, M.D., Dr.P.H., a young physician passionately devoted to clinical nutrition, who joined UAB in 1975. Shortly thereafter Dr. Weinsier distinguished himself by building a nutrition clinic and a nutrition support service while also developing an outstanding first-year School of Medicine nutrition course. At the time, Dr. Weinsier’s research was focused on the nutritional support of hospitalized patients in medical and surgical wards. His work attracted national attention after he reported two deaths from re-feeding syndrome after overzealous use of parenteral nutrition and a careful compilation of the complications associated with its use.
The need to objectively evaluate the nutritional status of patients had been recognized years before and had already resulted in the creation of a laboratory committed to the Biochemical Assessment of Nutritional Status. For over thirty years this laboratory functioned under the direction of Dr. Phillip E. Cornwell, a Ph.D. microbiologist interested also in folic acid and pteridine chemistry recruited in 1971 by Dr. Baugh. The results provided by this laboratory helped to unequivocally demonstrate the existence of hospital malnutrition and to convince the medical establishment of the seriousness of the problem. Howarde E. Sauberlich, Ph.D., a very prominent nutrition scientist, author of a classic book on Laboratory Tests for the Assessment of Nutritional Status, contributed his vast knowledge to the operation of Dr. Cornwell’s laboratory after joining the group in 1982.
A fourth period during, the "nutrition education" period, the creation in 1977 by Dr. S. Richardson Hill, Jr., M.D., president of UAB, of a new university-wide department of nutrition sciences, greatly expanding the boundaries of the prior nutrition program of the Department of Medicine. The new undertaking was sponsored jointly by three schools: the School of Health Professions, the School of Medicine, and the School of Dentistry. From its inception, the Department of Nutrition Sciences was based on a philosophy of interdisciplinary collaboration involving many departments and several schools. With Dr. Butterworth as its founding chairman and Dr. Krumdieck as vice chairman and director of the Division of Nutritional Biochemistry, the department brought under one roof a diverse group of scientists trained in many disciplines with a unifying interest in nutrition. Among them was an outstanding nutrition educator: Ms. Carol B. Craig, R.D., a research dietitian who had already developed a successful dietetic internship program at UAB. She was at the time chairperson of the Department of Nutrition and Dietetics of the School of Health Professions, which became incorporated as the Division of Human Nutrition and Dietetics in the new department. Ms. Craig brought with her a number of M.S. dieticians who for years taught with exemplary dedication at the dietetic internship program and at a master's program developed later. Among them were Ms. Harriett Cloud, director of the Nutrition Division at the Center for Developmental and Learning Disorders; Ms. Rebecca L. Bradley; and Ms. Annie Adams Cornwell.
Among the founding members of the new department was Juan M. Navia, Ph.D., a senior scientist of the Dental Research Institute of the National Institutes of Health, which at the time had a branch at the UAB campus. Dr. Navia's pioneering studies on nutrition and oral health added an important dimension to the research efforts of the new department. Dr. Navia's outstanding career in nutrition and public and international health culminated years later with his tenure as dean of the UAB School of Public Health.
About a year prior to the founding of the department, a generous donation of one million dollars by Mr. Charles B. Webb, Jr., a Birmingham philanthropist, honoring the memory of his late wife, Susan Mott Webb, made possible the construction of the six-story building that the Department of Nutrition Sciences has occupied since 1983.
Although there were many contributors to the nutrition education period, there can be no doubt that the main driving force behind it was Dr. Weinsier. A physician par excellence committed to no other specialty than clinical nutrition, Dr. Weinsier became the model of a practicing doctor who used his knowledge of nutrition for the benefit of his patients. The medical students were inspired by his example, nutrition rapidly became the preferred course of the basic sciences curriculum, and Dr. Weinsier was repeatedly recognized as the best medical basic sciences professor at UAB.
With characteristic perseverance and tenacity, Dr. Weinsier pursued the development of methods to improve the nutrition education of physicians and medical students and successfully expanded his efforts to national and international dimensions. In the early 1980s he and Butterworth succeeded in recruiting another young physician-nutritionist, Douglas C. Heimburger, M.D., M.S., who also became very active in medical nutrition education, co-editing with Dr. Weinsier two of the three editions of their popular Handbook of Clinical Nutrition (1989 and 1997). Dr. Sarah L. Morgan, mentioned before for her contributions to the folic acid period, has also contributed very significantly to the nutrition education programs of the department. Trained both as a M.S. dietician and as a physician, she is currently director of the Division of Clinical Nutrition and Dietetics. Together with a group of very able dieticians—Ms. Beth Kitchin, Ms. Amanda Brown, and Ms. Suzanne Henson—Dr. Morgan continues the dietetic training programs initiated years before by Ms. Craig. Dr. Morgan has also co-edited with Dr. Weinsier two editions of their textbook Fundamentals of Clinical Nutrition. In addition she has established an active osteoporosis clinic aimed at treating and investigating this very prevalent disease with still poorly understood nutritional causative factors.
Another key figure in the history of nutrition education at UAB was the late Dr. Sauberlich, mentioned before in reference to his contributions to the biochemical assessment of nutritional status of patients. Dr. Sauberlich, together with Dr. Prince, successfully collaborated to develop a Ph.D. program in nutrition that became effective in 1987. Dr. Heimburger has also contributed significantly to the success of the Ph.D. program by serving as director of the Cancer Prevention and Control Training Program, funded by the National Cancer Institute, which provides funding for Ph.D. students investigating the role of nutrition in cancer causation and prevention.
A fifth period, focused on nutrition and cancer risk, began in the 1970s as another spin-off of the folic acid period. Epidemiological evidence suggestive of an interaction between oral contraceptive agents, folic acid deficiency, and endometrial cancer, prompted pioneering studies by Dr. Butterworth and collaborators supporting this putative interaction. Shortly thereafter, the then novel concept of localized nutrient deficiencies was extended by Dr. Krumdieck, who proposed that tissues chronically exposed to agents such as tobacco smoke, known to accelerate the destruction of labile micronutrients, would be more likely to undergo neoplastic transformation. Work along these lines was initially pursued by Chandrika Piyathilake, Ph.D., and Dr. Heimburger, both now senior scientists at UAB's Comprehensive Cancer Center and still committed to investigating the role of nutritional factors in the prevention and pathogenesis of cancer. Gary Johaning, Ph.D., a molecular biologist with interest in nutrition and cancer, joined the department in 1993 and is currently evaluating associations among DNA methylation, biomarker expressions, and nutritional status in breast cancer tissues. Recently he has investigated the influence of folic acid on neoplastic progression as it relates to the development of resistance to chemotherapeutic agents.
Recognition of the growth and quality of the department led in 1979 to its being the first in the nation to be awarded a Clinical Nutrition Research Unit Grant supported by the National Cancer Institute. This unit, which functioned for 15 years, contributed greatly to further the development of the department, funding promising young investigators campus-wide and establishing research collaborations effective to this day. In 1985 Clinton Grubbs, Ph.D., an expert on animal models of cancer was recruited by Dr. Krumdieck to help study the role of dietary components and synthetic analogs thereof as potential cancer chemopreventive agents. He soon developed a very active program collaborating with many scientists from within UAB and from outside the university. His growing expertise in in vivo testing procedures to evaluate potential cancer preventive agents led him, in 1998, to establish a chemoprevention laboratory reporting directly to the dean of the School of Health Professions but maintaining close and productive relations with Nutrition Sciences.
Dr. Prince, already mentioned because of his involvement in folic acid-related research and in the development of the Ph.D. program, must be recognized here as the co-discoverer of osteopontin, a bone matrix protein whose gene is one of a few consistently expressed in association with the development of tumor metastasis. Work on this protein is actively pursued to this day by Dr. Prince and by Dr. Pi-Ling Chang, the first Ph.D. graduated from the Department of Nutrition Sciences at UAB, whom he mentored during her doctoral training.
The most recent period, focusing on obesity and type 2 diabetes, represents a major expansion of the research base of the department in response to the epidemic of obesity and type 2 diabetes affecting most of the western world. Dr. Weinsier was among the first to recognize the severity of the problem and to promote research on abnormalities of energy metabolism and body composition involved in the causation and development of obesity.
The enormously complex matters of the regulation of energy expenditure and the understanding of the multiple co-morbidities of obesity appealed to him as one of the major intellectual challenges confronting today's medicine. Dr. Weinsier, who succeeded Dr. Butterworth as chair of the department from 1988 until 1999, was able to remarkably expand his research during and after his chairmanship until his illness prematurely terminated his productive life in late 2002. From 1999 until mid 2003, when W. Timothy Garvey, M.D., assumed the chairmanship of the department, this position was held on an interim basis first by Dr. Prince and later by Michael C. Brooks, Ed.D., in his capacity as associate dean of the School of Health Professions.
Dr. Weinsier’s research on the role of inadequate physical activity in the pathogenesis of obesity led him to establish a very productive interaction with exercise physiologists working in the Department of Physical Education, in particular with Gary R. Hunter, Ph.D., a professor in the School of Education at UAB. The need to measure energy expenditure in humans, both during rest and during physical activity, led in mid-1991 to the construction with Dr. Krumdieck of a room calorimeter and to the recruitment in 1993 of Mr. Robert M. Petri, an engineer who refined the design of this instrument and is still responsible for its operation.
Early work on methodologies for the determination of body composition was carried out by Dr. Mohammad A. Khaled, a Ph.D. biophysicist who joined the department in 1984. He developed non-invasive methods for body composition measurements based on nuclear magnetic resonance spectrometry and Fourrier-transform infrared spectrometry and invented a dual-frequency instrument to measure bioimpedance particularly useful to estimate hydration in children. He continues working along these lines and is very active in international nutrition programs in the Indian subcontinent.
In 1993, Dr. Roland brought to the department Michael Goran, Ph.D., whose expertise in childhood obesity and in doubly-labeled water for the free-living estimation of energy expenditure by isotope-ratio mass-spectrometry meant great improvements in the research capabilities of the department. Dr. Goran was appointed director of the Energy Metabolism Research Unit in 1994 and in this capacity recruited three new faculty. Dr. Tim R. Nagy, a Ph.D. physiological zoologist with interest in energy metabolism in animal models, mitochondrial energy economy, and the development of methods for the study of body composition; Dr. Barbara Gower, a Ph.D. endocrinologist with primary interest in the interaction of hormonal factors in the pathogenesis of obesity and type 2 diabetes; and Dr. Susan Sell, a Ph.D. geneticist with interest in the genetics of type 2 diabetes. Drs. Nagy, Gower, and Sell were responsible for establishing laboratory facilities in the areas of small animal phenotyping, hormone/substrate analysis, and genotyping, respectively. In 1996, the Energy Metabolism Research Unit was elevated to division status as the Division of Physiology and Metabolism, directed by Dr. Goran.
In 2000, Dr. Weinsier was awarded a Clinical Nutrition Research Unit grant funded by the National Institute of Diabetes and Digestive and Kidney Diseases for the purpose of establishing a Center for Clinical Nutrition Research (CNRC) focused on investigating the pathogenesis of obesity and means of preventing and treating it. With this in hand, Dr. Weinsier was able to attract to the department David B. Allison, Ph.D., a noted biostatistician with extensive research experience in obesity who in 2001 was recruited by the UAB School of Public Health. Dr. Allison accepted a secondary appointment in nutrition sciences and agreed to serve as associate director of the CNRC. This in effect re-established a solid link between the Department of Nutrition Sciences and the School of Public Health in keeping with the preventive medicine aspects of the department’s mission.
With Dr. Allison’s help, Dr. Weinsier recruited in 2001 Jose R. Fernandez, Ph.D., a young scientist whose research focuses on the identification of ancestry-informative genetic sequences in racially admixed individuals and their association with obesity, diabetes, and related co-morbidities. With his advanced statistical models, Dr. Fernandez is able to identify gene-gene interactions and the interaction of genes with the environment. This added an entirely new dimension to many of the nutritional studies of the department. Upon Dr. Weinsier’s departure, Dr. Allison assumed the directorship of the CNRC in November of 2002.
Probably the last faculty member recruited to the department with the participation and influence of Dr. Weinsier is Jamy D. Ard, M.D. He joined UAB in July 2003 highly recruited year by the departments of Nutrition Sciences and Medicine as a very promising young physician scientist. His principal research interests are in behavioral interventions for obesity and cardiovascular risk factor reduction, especially in minority populations. His presence in the department will significantly enhance UAB’s effort to reduce health disparities and decrease the risk for chronic diseases in minority populations.
Under Dr. Garvey, the new chairman of the department, increasing attention is being given to the problems of obesity and type 2 diabetes. Dr. Garvey, an endocrinologist by training, has achieved international recognition for his research in metabolic, molecular, and genetic aspects of the pathogenesis of insulin resistance, type 2 diabetes, and obesity. His studies have ranged from very basic cellular and molecular biology of cell and animal models to metabolic investigations of human subjects on metabolic wards and of free-living populations with unique genetic backgrounds. He has contributed substantially to the understanding of the glucose transport system and glucose transport proteins in human insulin resistance. His population studies have focused in particular on the Gullah-speaking African Americans of the South Carolina coast and on the Pima Indians of Arizona, two national cohorts characteristically affected by extremely high prevalence of obesity and diabetes.
The long-established tradition of the UAB nutrition community, which has historically committed itself to the solution of nutritional problems of national scope, will undoubtedly continue under Dr. Garvey’s leadership.