WHY BURKITT WAS CALLED AS FIBRE MAN?

My earlier knowledge about Burkitt was only about Burkitt lymphoma. I knew that he was also called ‘Fibre man’, because of his contributions in fibre hypothesis, only when I started reading about him in detail for my posts. I guess many of you also might not have known earlier.

I wrote so many posts about fibre hypothesis and the people who contributed and influenced this ‘Fibre man’. Let me sum up all the previous posts, so that it makes easy for everyone.

There was a single Eureka moment in the story of discovery of Burkitts lymphoma, which was isolating Epstein Barr virus from Burkitt lymphoma, proving it to be the etiology. But in fibre hypothesis, there was not single but many new significant findings, each contributed by different people, working at different places.

Pictures taken from  John H. Cummings and Amanda Engineer. Denis Burkitt and the origins of the dietary fibre hypothesis. Nutrition Research Reviews (2018), 31, 1–15

Dennis Burkitt. Picture taken from https://mccarrison.com/visionaries/burkitt/

Cleave and Campbell stressed on the role of refined carbohydrates, particularly sugar and starch as a cause for many diseases.

Painter was known for his work on diverticular diseases and its association with fibre.

Walker related fibre with atherosclerosis and coronary heart disease.

Trowell contribution was in treatment of Kwashiorkar, concept of non-infective diseases, dietary fibres and its association with diseases.

How Burkitt met all of them and how their contributions influenced Burkitt???

What was Burkitt contribution in fibre hypothesis which gave him the name as “Fibre man”?

Read further to know the answers for this questions.

Burkitt after returning to UK, continued his work on pathology of cancer based on geography, funded by the MRC. He had this idea that diet can have a role in cancer but he dint limit it only to fibre. He came into contact with Professor Richard Doll, known for his work on lung cancer and smoking, also asbestos and radiation. Doll had been made a Fellow of the Royal Society in 1966 and he was organising a meeting in Nairobi to gather data on cancer incidence in different populations. Burkitt  soon met Doll and Harold Himsworth, Secretary of the MRC, and proposed  for small cancer registries to be started and financed  in poor resource countries.

Burkitt believed that great ideas always came from small beginnings.

He used to meet Doll frequently to see the cancer registry but he also used to enquire about other diseases. He was ‘receiving information monthly from over 140 mainly rural hospitals in Africa and the Indian sub-continent’. Throughout 1966 and until 14 September 1967, Burkitt was focused on anything but diet. Fibre was not in his mind till then.

Burkitt meeting with Captain T.L. Cleave.

Something happened this day, which brought fibre in his life, mind, experiments and made him the “Fibre man”. He recalls that ‘I was sitting in my office… (when) the ’phone rang, and the brief conversation that followed was to be the beginning of a succession of events which were to reshape my research interests and entirely alter the direction of my endeavours.’

 He got the call from Richard Doll and said that someone was in his office and Burkitt might be interested to meet. That person was Captain T. L. Cleave.

He mentioned about this in his personal diary ‘Time and chance happen to all men.’ It was clearly a momentous meeting. There is no mention anywhere on what their discussion was. He took one fundamentally important message from Cleave, which was ‘when a group of diseases occur together geographically or in the same individual, no matter how disparate their nature,they most likely would have a common cause.’

Burkitt meeting with Neil Painter

Another significant meeting occurred a year after he met Cleave when Burkitt gave a lecture to the British Society of Gastroenterology Annual Meeting in London in November 1968.  He listened to another speaker, Neil Painter, who was well known for his work on diverticular disease. Burkitt wrote to Painter saying, ‘I was very interested in your comments suggesting a relationship between diet and diverticular  disease...particularly...the work on rats fed with low and high residue diets. They both met in 20 January 1969, and many times later and co-authored  seven papers  on the topic of diverticular disease.

Burkitt and Alec Walker   

Thus by early 1969 fibre was on Burkitt’s Agenda…

He planned to test Cleave hypothesis for which he wanted to measure the gut transit time. And it was Walkers’ work which influenced Burkitt on transit time. His frequent visits to Africa, meeting Alec Walker and other people like John Higginson and George Oettlé of the South African Institute of Medical research who also had worked on diet and its relation to cancer in African population.

Thus,in 1969, Burkitt focus was on the cause of large bowel cancer.He knew that there were major differences in large bowel cancer incidence between Africa and Western Countries but he needed to understand more about large bowel function in these populations. Burkitt was introduced to two important concepts for bowel cancer, one was diet relating to transit (contact time) and the other was gut flora.

In February 1969, he met Basil Morson, who was a leading pathologist of the gastrointestinal tract at that time. On 28 February he visited Dr George Misiewicz, a clinical gastroenterologist and a leading gut neurophysiologist, at the MRC Gastroenterology Unit in London where he had ‘discussions on bowel transit times’. Burkitt had a wide angle vision, he  also visited the Microbiology Unit at St Mary’s Hospital, London where he ‘discussed bowel bacterial counts with Prof Williams, Hill and Drasar’.

Burkitt was, however, already thinking beyond bowel cancer. Probably as a result of his discussions with Cleave and Walker he was now moving towards a more all-encompassing theory of diet and disease.

Burkitt and Trowell

He met his old colleague, Hugh Trowell, at the Centenary celebrations in Kampala. Burkitt gave a lecture on the epidemiology of diseases of the large bowel, which caught Trowell’s attention. Trowell went to see the wards where he had worked before and found cases of appendicitis, stroke, hypertension, CHD and diabetes, which was rare in his time and noted that many of the Africans were obese. Thus it was in 1970 that Trowell, stimulated by Burkitt,  shifted his interest towards the fibre story and the changing pattern of diseases he saw at his former hospital.

After returning to England, in April 1970, Burkitt met Godfrey Milton Thompson, Professor of Naval Medicine, who was working on the digestion of cellulose and told Burkitt that cellulose was extensively broken down in the human gut. Though it was already established, but it was first time that Burkitt became aware that fibre was in no way inert roughage but might interact with many aspects of gut function, especially the resident microflora.

ICONIC PAPER IN THE FIBRE STORY
Early in 1971, Burkitt gave an invited lecture about ‘bowel diseases and the role of fibre’  at the National Cancer Conference in San Diego, California. He wrote his  presentation as a paper for the journal Cancer. This is one of the iconic papers in the fibre story. It became a citation classic and is Burkitt’s most cited paper. The paper had its own importance though there was no statistics or P value. Burkitt mentions the epidemiology data, the ideas he developed from them , experimental data testing the ideas and also solution for its prevention.

In 1971, Burkitt wrote about varicose veins, diverticular disease and appendicitis and later haemorrhoids and hiatus hernia. Burkitt and Trowell together developed the hypothesis that relates not only to bowel diseases but also diabetes, obesity and CHD to the consumption of low-fibre diets.

In 1970, Burkitt suggested to write a book together which was eventually published in 1975, entitled Refined Carbohydrate Foods and Disease: Some Implications of Dietary Fibre.

Burkitt already well known for his work on lymphoma, set up his name in another cancer as well, in less than 5 years after his return from Uganda.

What a energy level and vision, this man had!!!

References:

1.     John H. Cummings and Amanda Engineer. Denis Burkitt and the origins of the dietary fibre hypothesis. Nutrition Research Reviews (2018), 31, 1–15

                                                                                  Written By Dr.Priyavadhana