Konzo risk factors, determinants and etiopathogenesis: What is new? A systematic review.

Konzo is a toxico-nutritional upper motor neuron disease causing a spastic paraparesis in schoolchildren and childbearing women in some African countries. Almost a century since the first description of konzo, its underlying etiopathogenic mechanisms and causative agent remain unknown. This paper aims at refreshing the current knowledge of konzo determinants and pathogenesis in order to enlighten potential new research and management perspectives. Literature research was performed in PubMed and Web of Science databases according to the PRISMA methodology. Available data show that cassava-derived cyanide poisoning and protein malnutrition constitute two well-documented risk factors of konzo. However, observational studies have failed to demonstrate the causal relationship between konzo and cyanide poisoning. Thiocyanate, the current marker of choice of cyanide exposure, may underestimate the actual level of cyanide poisoning in konzo patients as a larger amount of cyanide is detoxified via other unusual pathways in the context of protein malnutrition characterizing these patients. Furthermore, the appearance of konzo may be the consequence of the interplay of several factors including cyanide metabolites, nutritional deficiencies, psycho-emotional and geo-environmental factors, resulting in pathophysiologic phenomena such as excitotoxicity or oxidative stress, responsible for neuronal damage that takes place at sparse cellular and/or subcellular levels.

Konzo outbreak in the Western Province of Zambia.

OBJECTIVE: To identify the etiology of an outbreak of spastic paraparesis among women and children in the Western Province of Zambia suspected to be konzo. METHODS: We conducted an outbreak investigation of individuals from Mongu District, Western Province, Zambia, who previously developed lower extremity weakness. Cases were classified with the World Health Organization definition of konzo. Active case finding was conducted through door-to-door evaluation in affected villages and sensitization at local health clinics. Demographic, medical, and dietary history was used to identify common exposures in all cases. Urine and blood specimens were taken to evaluate for konzo and alternative etiologies. RESULTS: We identified 32 cases of konzo exclusively affecting children 6 to 14 years of age and predominantly females >14 years of age. Fourteen of 15 (93%) cases ≥15 years of age were female, 11 (73%) of whom were breastfeeding at the time of symptom onset. Cassava was the most commonly consumed food (median [range] 14 [4-21] times per week), while protein-rich foods were consumed <1 time per week for all cases. Of the 30 patients providing urine specimens, median thiocyanate level was 281 (interquartile range 149-522) µmol/L, and 73% of urine samples had thiocyanate levels >136 µmol/L, the 95th percentile of the US population in 2013 to 2014. CONCLUSION: This investigation revealed the first documented cases of konzo in Zambia, occurring in poor communities with diets high in cassava and low in protein, consistent with previous descriptions from neighboring countries.

Protein deficiency after gastric bypass: The role of common limb length in revision surgery.

BACKGROUND: Bariatric surgery, especially the gastric bypass procedure, is an effective therapy for morbid obesity, but may reduce protein absorption and induce protein deficiency (PD). A recent study reported an issue about common limb length for PD. OBJECTIVE: This study aimed to examine the prevalence of PD after gastric bypass surgery and investigate the role of common limb length in PD-related revision surgery. SETTING: Hospital-based bariatric center. METHODS: From 2001 to 2016, 2397 patients with morbid obesity who underwent bariatric/metabolic surgery with 1-year follow-up were recruited. Serum albumin and total protein were measured before and 1 year after surgery. Medical records of patients who underwent revision surgery due to PD were reviewed. RESULTS: The overall prevalence of PD was .5% preoperatively. The prevalence of PD increased to 2.0% at 1 year after surgery. The incidence was highest in one-anastomosis gastric bypass (2.8%) followed by Roux-en-Y gastric bypass (1.8%). Until the end of follow-up, all 19 patients who underwent revision surgery for intractable PD had a relatively short common limb length of <400 cm. After elongation of the common limb length to >400 cm in revision surgery, PD improved in all patients. CONCLUSIONS: A subset of patients can develop PD after gastric bypass surgery when the common limb length is <400 cm. In patients with intractable PD after gastric bypass surgery, revision surgery for elongation of common limb length to >400 cm is mandatory to avoid PD-related complications.

Protein and micronutrient deficiencies in patients with radiation cystitis and outcome after hyperbaric oxygen therapy.

BACKGROUND & AIMS: Haemorrhagic radiation cystitis (HRC) is a late complication of pelvic radiotherapy. Severe cases are difficult to treat due to persistent or recurrent bleeding, despite urological and hyperbaric oxygen therapy (HBOT). However, wound healing requires a good nutritional status. In this respect, we aimed at analysing the nutritional status of patients with HRC prior to the onset of HBOT and at highlighting predictive nutritional factors of outcome. METHODS: Data were retrospectively collected from a cohort of 179 patients with HRC (between 2011 and 2015). Haematuria was graded according to the Subjective, Objective, Management, Analytic scale (SOMA): grade-4 (n = 46) was compared with grade-3 (n = 56), and with grades 1 and 2 (n = 77). S-albumin, prealbumin, vitamins C, D and B6, zinc, selenium, and essential fatty acids were evaluated before HBOT. HBOT response was measured at 3 months according to the haematuria SOMA grade. The Mann-Whitney test, Fisher's exact test and principal-component analysis were used to compare groups. RESULTS: Patients with higher haematuria grades (3 and 4) harboured significant deficiencies in S-albumin, prealbumin, vitamins C, D and B6, zinc, selenium and essential fatty acids. Moreover, grade-4 patients without improvement after 3 months of HBOT had significant lower initial levels of S-albumin, vitamin C, selenium and linoleic acid. Vitamin C levels <2.5 mg/L were strongly associated with HBOT non-response (OR 23.14, 95% CI 3.73-143.69, p = 0.002). CONCLUSIONS: Our analyses show serious nutritional deficiencies associated with higher grades of HRC and worse prognoses. Patients with haemorrhagic cystitis might benefit from an adequate dietary supplementation to support healing of their bladder mucosa.

The relevance of dietary protein after bariatric surgery: what do we know?

PURPOSE OF REVIEW: The growing obesity epidemic is associated with an increased demand for bariatric surgery with Roux-en-Y Gastric Bypass and Sleeve Gastrectomy as the most widely performed procedures. Despite beneficial consequences, nutritional complications may arise because of anatomical and physiological changes of the gastrointestinal tract. The purpose of this review is to provide an update of the recent additions to our understanding of the impact of bariatric surgery on the intake, digestion and absorption of dietary protein. RECENT FINDINGS: After bariatric surgery, protein intake is compromised because of reduced gastric capacity and aversion for certain foods. A minority of patients reaches the recommended protein intake of minimal 60 g per day, which results in the loss of fat-free mass rather than the desired loss of fat mass. Despite inadequate protein intake, protein digestion and absorption do not seem to be impaired suggesting that other mechanisms could counteract the reduced secretion of digestive enzymes and their delayed inlet. SUMMARY: After bariatric surgery, protein supplementation or diet enrichment could attribute to achieve the minimal recommended protein intake and benefit the amount and composition of postoperative weight loss.

Estimated Effects of Future Atmospheric CO2 Concentrations on Protein Intake and the Risk of Protein Deficiency by Country and Region.

BACKGROUND: Crops grown under elevated atmospheric CO2 concentrations (eCO2) contain less protein. Crops particularly affected include rice and wheat, which are primary sources of dietary protein for many countries. OBJECTIVES: We aimed to estimate global and country-specific risks of protein deficiency attributable to anthropogenic CO2 emissions by 2050. METHODS: To model per capita protein intake in countries around the world under eCO2, we first established the effect size of eCO2 on the protein concentration of edible portions of crops by performing a meta-analysis of published literature. We then estimated per-country protein intake under current and anticipated future eCO2 using global food balance sheets (FBS). We modeled protein intake distributions within countries using Gini coefficients, and we estimated those at risk of deficiency from estimated average protein requirements (EAR) weighted by population age structure. RESULTS: Under eCO2, rice, wheat, barley, and potato protein contents decreased by 7.6%, 7.8%, 14.1%, and 6.4%, respectively. Consequently, 18 countries may lose >5% of their dietary protein, including India (5.3%). By 2050, assuming today's diets and levels of income inequality, an additional 1.6% or 148.4 million of the world's population may be placed at risk of protein deficiency because of eCO2. In India, an additional 53 million people may become at risk. CONCLUSIONS: Anthropogenic CO2 emissions threaten the adequacy of protein intake worldwide. Elevated atmospheric CO2 may widen the disparity in protein intake within countries, with plant-based diets being the most vulnerable. https://doi.org/10.1289/EHP41.

Associations between neighborhood food environments and deficient protein intake among elderly people in a metropolitan suburb: A case study in Kisarazu city, Japan.

OBJECTIVES: Living in a poor food environment and its association with an increased risk of inadequate nutrient intake are increasingly important issues in Japan due to an increase in the elderly population. METHODS: The present study examined the relationships between neighborhood food environment and the protein and fat intakes of elderly Japanese individuals (n = 181) living in the metropolitan Tokyo suburb of Kisarazu. RESULTS: A logistic regression analysis adjusted for sociodemographic and shopping behavior variables revealed associations between subjectively evaluated poor neighborhood food environment and deficient protein intake. However, there was no significant association between excessive fat intake and neighborhood food environments. CONCLUSION: The findings demonstrate that living in a poor neighborhood food environment, which is becoming increasingly prevalent in Japan and other developed countries, has the potential to result in malnutrition, or at least in a low-quality diet, in elderly populations.

Integrative Multivariate Logistic Regression Analysis of Risk Factors for Kashin-Beck disease.

To determine the current evidence on risk factors for Kashin-Beck disease (KBD) using an integrative meta-analysis. We searched five English and three Chinese databases from inception to September 2015, to identify case-control studies that examined risk factors for KBD using multivariate logistic analysis. DerSimonian and Laird effective models are applied in processing data using pooled odds ratios (ORs) and 95 % confidence intervals (CI). Seven studies were identified with 3087 cases and 6402 controls. The main risk factors found to be significantly associated with the onset of KBD were age (OR 1.19, 95 % CI 1.10-1.28), parents prevalence (OR 5.16, 2.51-7.80), family hygiene (OR 1.68, 1.42-1.93), food source (OR 3.29, 2.38-4.19), wheat (OR 1.12, 1.08-1.16), wheat germ necrosis rate (OR 6.03, 1.87-12.92), total volatile basic nitrogen (OR 6.85, 1.01-28.67), low selenium in hair (OR 2.29, 1.08-3.50) were found to be significant risks factors. The pooled ORs (95 % CI) of protein intake and rice were 0.79 (0.66-0.93) and 0.90 (0.86-0.95), respectively, indicating that the two factors may be protective for KBD. We found that the combination of low protein intake, polluted grain, and selenium deficiency may contribute to be onset of KBD together.

Zinc status and dietary intake of pregnant women, Alexandria, Egypt.

BACKGROUND AND OBJECTIVES: Deficiencies of protein, energy, and micronutrients are highly prevalent in developing countries and have major effects on pregnancy outcome. Low dietary intake is the most common reason for zinc deficiency. The present research is part of a larger double-blind randomized-controlled trial to evaluate the effect of zinc supplementation on the pregnancy outcome. The aim of the present study was to assess the zinc status and dietary intake of zinc and other macronutrients and micronutrients among pregnant women in Alexandria, Egypt. PARTICIPANTS AND METHODS: Participants were pregnant women attending two antenatal care centers that serve low-income and middle-income pregnant populations. A total of 1055 healthy pregnant women aged 20-45 years were assessed for eligibility. Of these, only 675 had serum zinc level below the median for the gestational age. They were assigned randomly to one of three parallel groups. Zinc supplements were provided from 16 weeks until delivery. A subsample of 100 women was assessed for their dietary intake. A questionnaire interview was used to collect basic socioeconomic and data on current pregnancy and labor. Dietary data were collected using the 24-h recall method and a food frequency questionnaire. The nutritive value of the daily diet was computed using the Egyptian food composition tables. The blood hemoglobin level, serum zinc level, and fasting blood sugar were determined. RESULTS: Zinc deficiency was detected among 53.5% of the sample. Dietary intake of zinc was low, representing 59.4, 59.4, and 62% of the recommended dietary allowance (RDA) for the zinc group, zinc plus multivitamins, and the placebo group, respectively. The iron intake was below 50% of the RDA. Protein intake was less than 70% of the RDA. The mean intakes of fat were 191.97, 211.8, and 196.3 g/day for the three groups. The mean energy intake represented 51.1, 53.5, and 49.8% of the RDA. CONCLUSION AND RECOMMENDATIONS: Except for carbohydrate intake, the dietary intake of all macronutrients and micronutrients was low. The lowest intake was of iron (below 50% of the RDA). Zinc and protein intake represented less than 70% of the RDA. The overall energy intake was around 50% of the RDA. Nutritional health education should be used as a preventive approach to allow the large sector of the low-income population to maximize the use of the limited resources in the best way. In women at high risk of zinc deficiency, zinc supplementation should be added to the routine supplements.

[The estimation of risk of deficit consumption of proteins, vitamins and substance mineral adult population of Samara].

Survey of the brainwork workers with low physical activity has revealed the risks of inadequate consumption of fiber, calcium, iron, vitamins B1, B2, C, A, due to mismanagement of their consumption.

[Nutrition and health status of pregnant women in 8 provinces in China].

OBJECTIVE: To investigate nutrition and health status of pregnant women in China. METHODS: 16 counties cities in 8 Provinces in China were selected to investigate nutrition and health information for pregnant women. RESULTS: The averaged age of pregnant women was 27.1 years old, and 6.3 percent of pregnant women are over 35 years old. The proportion rates of pregnant women who consumed supplements before or during pregnance accounted for 81.8% in city and 57.8% in rural (P < 0.01). Anaemia prevalence was 14% with significant difference between urban and rural, P < 0.01. The rate of sural spasm during pregnancy was 39.3%. Low daily intakes of protein, retinol equivalence, calcium, iron were the major nutritional problem. Calcium deficiency was the leading problem. Pregnant women got health improvement kowlege mainly from relatives, friends, hospitals or medical centers, books and televisions, furthermore, internet was a main media for city women. CONCLUSION: Low daily intakes of protein and micronutrients were major problems for pregnant women.

Consuming cassava as a staple food places children 2-5 years old at risk for inadequate protein intake, an observational study in Kenya and Nigeria.

BACKGROUND: Inadequate protein intake is known to be deleterious in animals. Using WHO consensus documents for human nutrient requirements, the protein:energy ratio (P:E) of an adequate diet is > 5%. Cassava has a very low protein content. This study tested the hypothesis that Nigerian and Kenyan children consuming cassava as their staple food are at greater risk for inadequate dietary protein intake than those children who consume less cassava. METHODS: A 24 hour dietary recall was used to determine the food and nutrient intake of 656 Nigerian and 449 Kenyan children aged 2-5 years residing in areas where cassava is a staple food. Anthropometric measurements were conducted. Diets were scored for diversity using a 12 point score. Pearson's Correlation Coefficients were calculated to relate the fraction of dietary energy obtained from cassava with protein intake, P:E, and dietary diversity. RESULTS: The fraction of dietary energy obtained from cassava was > 25% in 35% of Nigerian children and 89% of Kenyan children. The mean dietary diversity score was 4.0 in Nigerian children and 4.5 in Kenyan children, although the mean number of different foods consumed on the survey day in Nigeria was greater than Kenya, 7.0 compared to 4.6. 13% of Nigerian and 53% of Kenyan children surveyed had inadequate protein intake. The fraction of dietary energy derived from cassava was negatively correlated with protein intake, P:E, and dietary diversity. Height-for age z score was directly associated with protein intake and negatively associated with cassava consumption using regression modeling that controlled for energy and zinc intake. CONCLUSIONS: Inadequate protein intake was found in the diets of Nigerian and Kenyan children consuming cassava as a staple food. Inadequate dietary protein intake is associated with stunting in this population. Interventions to increase protein intake in this vulnerable population should be the focus of future work.

The nutritional status of patients admitted to Priest Hospital.

OBJECTIVES: To determine the prevalence of malnutrition in the Buddhist Priest Patients on admission to Priest Hospital. MATERIAL AND METHOD: During September 2007, 97 Buddhist Priest admitted to Priest Hospital were assessed for their nutritional status by using Subjective global assessment (SGA) and Body mass index (BMI). Serum albumin, hematocrit, and total lymphocyte count (TLC) were also evaluated. RESULT: The status of Protein-calorie malnutrition was found to be 41.3% due to subjective global assessment and 39.2% due to body mass index. Overweight patient found to be 16.5%. There were 16.5%, 83.5% and 20.6% of patients who had serum albumin, hematocrit, and total lymphocyte count below acceptable level. CONCLUSION: Malnutrition status in priests admitted to the Priest Hospital should be concerned and be properly managed for improved clinical outcome.

Impact of protein deficiency on venous ulcer healing.

OBJECTIVE: The prevalence of protein deficiency and its impact on wound healing is not known for leg ulcers. The aim of this study was to determine the prevalence of protein deficiency in outpatients presenting with leg ulcers and the parameter's prognostic value for wound outcome. DESIGN OF STUDY: Prospective controlled observational study. SETTING: Ambulatory patients referred for chronic wounds to four university hospitals. METHODS: Consecutive out-patients with a leg ulcer present for at least 2 months, related to venous insufficiency, associated or not with moderate peripheral arterial disease (ankle-brachial pressure index > 0.7), were included in a prospective study. Wound evaluation (area and occurrence of complications) was performed at baseline and at 12 weeks of follow-up. Biologic nutrition assessment (serum albumin, transthyretin, c-reactive protein) was performed at baseline. The control group consisted of consecutive patients free of leg ulceration and attending the dermatology outpatient clinic for remissive skin cancer or miscellaneous skin disorders. RESULTS: Forty one patients and 43 controls were included. Serum albumin level was under 35 g/L (normal values: 36-44 g/L) in 27% of the patients and 2% of the controls (P < .001). At 12 weeks, 34% of the patients had an increase in wound area. Wound infections occurred in 12% (n = 5) of the patients. Protein deficiency was independently associated with an increase in wound area at 12 weeks (P = .034) and the presence of an inflammatory syndrome was associated with the occurrence of wound complications (wound infection or hospitalization) during follow-up (P < .001). CONCLUSION: The prevalence of protein deficiency in out-patients with leg ulcers is high and significantly associated with a poor healing prognosis.

Inadequate intakes of dietary zinc among pregnant women from subsistence households in Sidama, Southern Ethiopia.

OBJECTIVE: To assess the prevalence of zinc inadequacy based on dietary intakes and plasma zinc concentrations and, simultaneously, the prevalence of inadequate intakes of energy, protein, calcium and iron. DESIGN: A cross-sectional study of a convenience sample of subsistence farming households in Sidama, Southern Ethiopia. SUBJECTS: Dietary intakes were calculated from 1-day weighed food records and 40 repeats from 99 pregnant women in the third trimester using analysed values of major staple foods for zinc, iron, calcium and phytate. The distribution of observed intakes was adjusted for usual intakes and the prevalence of inadequacy estimated using the estimated average requirement (EAR) cutpoint method. Prevalence of inadequacy for zinc, protein and iron intakes were compared with those based on biochemical measures. RESULTS: Prevalence of zinc inadequacy was very high: 99% for US FNB EAR and 100% for IZiNCG EAR compared to 72% based on low plasma zinc concentrations. Corresponding prevalence estimates for iron were much lower: 4% for inadequate intakes based on US FNB EAR vs. 8.7% for iron deficiency anaemia (haemoglobin < 110 g l-1; ferritin < 12 microg l-1) and 32.3% for low storage iron. Prevalence of inadequacy for protein was 100% for adjusted intakes and 91% for serum albumin < 32 g l-1. For calcium, 74% were at risk for inadequate intakes. CONCLUSION: The high prevalence of inadequate intakes of zinc and protein was reasonably consistent with those based on biochemical measures. Such dietary deficits could be overcome by regular consumption of cellular animal protein. In contrast, both dietary and biochemical measures of iron inadequacy were low.

Coping strategies and nutritional health in rural Niger: recommendations for consumption of wild plant foods in the Sahel.

People who live in food and water deficit regions of Sahelien West Africa employ various coping strategies as they attempt to meet their food and water needs. In this paper we discuss various coping strategies employed by rural Nigeriens living in the Tanout and Mirriya administrative regions of central Niger. In rural Niger people often harvest or buy wild plant foods to eat. Laboratory studies of the nutritional content of these plants indicate that there are benefits to eating wild plant foods. In this study we summarize the results of field research conducted during the summer of 2002 on the use of wild plant foods in three regions of rural central Niger. Comparing local use of various wild plant foods with major nutrition-related health problems including protein deficiency, essential fatty acid deficiency, iron deficiency and iron deficiency anemia, calcium deficiency rickets, and zinc deficiency, suggests potential recommendations for consumption of these plants. However, further research on the bioavailability of these nutrients is needed to confirm the potential benefits of these plants.

Protein Z in patients with pregnancy complications.

OBJECTIVE: This study was undertaken to evaluate the association between protein Z concentration and pregnancy complications. STUDY DESIGN: A prospective case-control study was conducted over a 2-year period to evaluate the prevalence of protein Z deficiency in pregnancy complications. Protein Z levels were measured at the time of diagnosis of complications such as preeclampsia, intrauterine growth restriction, and intrauterine fetal demise. Protein Z deficiency was defined as a plasma level below 1.2 mg/L. In addition to patients presenting with pregnancy complications, healthy age-matched nonpregnant and pregnant women were invited to participate. RESULTS: A total of 145 women were included in the study: 50 nonpregnant women, 34 healthy pregnant women, 29 women with preeclampsia, 25 women presented with intrauterine growth restriction, and 7 women with intrauterine fetal demise. The median protein Z level was similar in healthy pregnant and nonpregnant women (1.63 [0.47-3.1] mg/L and 1.69 [0.7-3] mg/L, respectively). Three women with normal pregnancies had a low protein Z level (8.8%), compared with 8 patients presenting with intrauterine growth restriction (33.3%) and 8 patients with intrauterine fetal demise (50%). Compared with normal pregnancy, the frequency of decreased protein Z was significantly higher in cases of intrauterine growth restriction and in intrauterine fetal demise (relative risk [RR] 1.96, 95% CI 1.16-3.32; P = .041 and RR 3.36, 95% CI 1.65-6.8; P = .0031, respectively), but not in preeclampsia (RR 1.6, 95% CI 0.9-2.8; P = .23). Placenta histologic examination revealed vascular lesions in 50% of patients with protein Z deficiency and in 33% of patients with normal levels of protein Z (RR 0.84; 95% CI 0.6-1.2). CONCLUSION: Protein Z deficiency is associated with late fetal demise and intrauterine growth restriction. The pathophysiologic role of protein Z deficiency, either congenital or caused by the presence of specific antibodies remains unclear and should be further investigated.

The routine use of antibiotics to promote animal growth does little to benefit protein undernutrition in the developing world.

Some persons argue that the routine addition of antibiotics to animal feed will help alleviate protein undernutrition in developing countries by increasing meat production. In contrast, we estimate that, if all routine antibiotic use in animal feed were ceased, there would be negligible effects in these countries. Poultry and pork production are unlikely to decrease by more than 2%. Average daily protein supply would decrease by no more than 0.1 g per person (or 0.2% of total protein intake). Eliminating the routine use of in-feed antibiotics will improve human and animal health, by reducing the development and spread of antibiotic-resistant bacteria.

Food-consumption patterns in central West Africa, 1961 to 2000, and challenges to combating malnutrition.

We discuss food-consumption patterns in Central West Africa from 1961 to 2000 and some implications for combating malnutrition. The availability of food in the region improved in the 1960s, declined sharply in the 1970s and the early 1980s, and has shown a modest positive trend since the mid-1980s. Notwithstanding obvious progress over the past decades and in the region as a whole, food availability today remains below the required levels for large parts of the population and appears unstable over time, particularly in the Sahelian zone. On average, diets in this zone contain fewer than 2,200 kcal, compared with almost 2,500 kcal in the coastal zone. Conversely, protein deficiency is more common in the coastal zone, where a typical diet contains only 45 g of protein, compared with 60 g in the Sahelian zone. Furthermore, consumption is showing a dietary shift toward cereals, while yield growth lags far behind population growth. The associated import dependency and pressure on land seem to gain significance regardless of the region's agro-ecological capacity to increase and to substitute cereal imports for locally produced food. Moreover, food consumption appears responsive to income changes (calorie-income elasticity ranges from 0.25 to 0.62), while, in turn, it has a significant impact on nutritional outcomes (stunting-calorie elasticity of -1.42). We conclude that combating malnutrition requires first broad-spectrum income growth, and next specific policies that promote the yield and the contribution to diets of nutritious food produced within the region.