Diabetes is not caused by cassava toxicity. A study in a Tanzanian community.

OBJECTIVE: To test the hypothesis that consumption of cassava with liberation of cyanide causes diabetes in malnourished individuals. RESEARCH DESIGN AND METHODS: Glucose tolerance was assessed in two rural communities in Tanzania; in one (Nyambori), the main source of calories was cassava; and in the other (Uswaa), cassava was rarely eaten. Undernutrition was prevalent in both communities. The people of Nyambori were known to have high dietary cyanide exposure for many years from consumption of insufficiently processed cassava. Of the 1435 people in Nyambori greater than or equal to 15 yr old, 1067 (74%) were surveyed, and 1429 of 1472 (97%) eligible subjects in Uswaa were surveyed. All had 75-g oral glucose tolerance tests and measurement of BMI. Plasma and urine thiocyanate and blood cyanide also were measured in some subjects. RESULTS: Mean +/- SD plasma and urine thiocyanate levels in Nyambori were 296 +/- 190 and 497 +/- 457 microM (n = 204), respectively, compared with 30 +/- 37 and 9 +/- 13 microM, respectively, in Uswaa (n = 92) (P less than 0.001 for all differences). The mean blood cyanide level in Nyambori was elevated (1.4 [range 0.1-30.2] microM; n = 91). The prevalence of diabetes in the cassava village (Nyambori) was 0.5% compared with 0.9% in Uswaa (NS). The prevalence of IGT was similar in the two villages in the 15- to 34- and the 34- to 54-yr-old age-groups; but in those greater than or equal to 55 yr old, IGT was higher in Nyambori (17.4 vs 7.2%, P = 0.029). Mean fasting and 2-h blood glucose levels were slightly higher in Nyambori village after adjusting for age, sex, and BMI (4.5 vs. 4.2 and 5.0 vs. 4.4 mM, respectively). CONCLUSIONS: High dietary cyanide exposure was not found to have had a significant effect on the prevalence of diabetes in an undernourished population in Tanzania. Cassava consumption is thus highly unlikely to be a major etiological factor in so-called MRDM, at least in East Africa.

Human retroviruses HTLV-I, HIV-1, and HIV-2 and neurological diseases in some equatorial areas of Africa.

HTLV-I is associated with tropical spastic paraparesis (TSP) in the Caribbean area and with certain chronic myelopathies termed HAM (HTLV-I-associated myelopathy) in Japan. In order to investigate the situation in Africa, we tested for HTLV-I, but also for HIV-1 and HIV-2 antibodies, 94 patients with epidemic spastic paraparesis (ESP) from Zaire and Tanzania, 26 cases of sporadic spastic paraparesis (SSP) and 21 cases of tropical ataxic neuropathy (TAN), both from Ivory Coast, and 319 unselected neurological patients from Ivory Coast, Congo, and Tanzania. While none of the 94 ESP cases nor any of the 21 TAN patients exhibited antibodies to any retrovirus, 4 of the 26 sporadic spastic paraparesis patients had high HTLV-I antibodies in their sera and cerebrospinal fluid (CSF). Three of those were clinically and immunologically identical to TSP, as observed in persons from the Caribbean region, and the fourth case, a poorly explored chronic pyramidal syndrome, could also represent a TSP. Only one of these four cases originally had HIV-1 antibodies. Among the 319 unselected patients, only 5 (1.6%) had HTLV-I antibodies, but 32 (10%) had HIV-1 antibodies and 14 (4.4%) had HIV-2 antibodies, with a number of combined infections, indicating that retroviruses represent potentially important etiological agents for African neurological diseases.

Dietary determinants of a non-progressive spastic paraparesis (Konzo): a case-referent study in a high incidence area of Zaire.

BACKGROUND: Konzo is an upper motor neuron disease in Africa, characterized by an abrupt onset of a permanent but non-progressive spastic paraparesis. It is named after the local designation in the first report from Zaire. Konzo has been attributed to a metabolic insult from the combined effect of high cyanide and low sulphur intake from several weeks of exclusive consumption of insufficiently processed bitter cassava roots. METHODS: The association between insufficient soaking of cassava roots and konzo is assessed in a matched case-referent study with multivariate conditional logistic regression including 57 case-referent pairs from a rural high incidence community of Zaire. RESULTS: In the multivariate analysis short processing of cassava in the form of only 2 nights soaking yielded an odds ratio of 11.0 (95% confidence interval 1.7-73) when controlling for poverty-related factors and diet. We also show a dose-response relationship for insufficient cassava soaking, both unadjusted and adjusted for potential confounders. CONCLUSIONS: This study supports a causal relationship between insufficient processing of bitter cassava and konzo.

Low prevalence of ataxic polyneuropathy in a community with high exposure to cyanide from cassava foods.

INTRODUCTION: Ataxic polyneuropathy, which occurs in endemic form in an area in southwest Nigeria, is attributed to exposure to cyanide from cassava foods. Exposure to cyanide from cassava is, however, not exclusive to this endemic area. In this study, the occurrence of ataxic polyneuropathy was compared in two communities in Nigeria, one located in the endemic area and the other located outside the endemic area. Both communities have been shown to have high exposure to cyanide from cassava foods. METHOD: The prevalence of ataxic polyneuropathy in Jobele, Nigeria, a community located outside the endemic area, was compared with the prevalence of ataxic polyneuropathy in Ososa, Nigeria, a reference community located in the endemic area. Subjects aged 10 years and above in both communities were screened for ataxic polyneuropathy. Ataxic polyneuropathy was diagnosed if sensory gait ataxia and sensory polyneuropathy were present. The intake of cassava foods, biomarkers of exposure to cyanide, and intake of protein and sulphur were measured. RESULTS: Prevalence of ataxic polyneuropathy were 490 per 10,000 in Ososa, and 17 per 10,000 in Jobele. The age-adjusted prevalence ratio is 4 (95% CI 0-9). The mean intake of all cassava foods in Jobele was 7 meals/person/week (95% CI 6-8), while the mean intake of all cassava foods in Ososa was 10 meals/person/week (95 % CI 9-11). The concentration of thiocyanate in the plasma was above the reference limit in 65% (95% CI 57-73) in Jobele, and 40 % (95% CI 27-52) in Ososa. The intake of protein was significantly lower in Ososa than in Jobele, but the concentrations of glutathione, cysteine and gamma-glutamylcysteine in the plasma were within the same range in Jobele and Ososa. CONCLUSION: This study shows that the occurrence of ataxic polyneuropathy is low in a community where exposure to cyanide is high. This suggests that exposure to cyanide is not a direct cause of ataxic polyneuropathy.

Glycaemic control of insulin-dependent diabetes mellitus in Sudan: influence of insulin shortage.

Insulin availability and routine diabetes care were cross-sectionally investigated in 122 (M/F; 59/63) insulin-dependent diabetic patients aged 6-60 years with > or = 1 year duration using a structured questionnaire interview followed by a free conversation. Haemoglobin A1c, blood glucose, and serum lipids were measured in the fasting state to assess the metabolic control. Only 12% of the patients had acceptable glycaemic control (HbA1c < 7.5%). Increased age, shorter diabetes duration, and higher body mass index were associated with better metabolic control. Omission or reduction of the insulin dose was experienced by 51% of the patients due to insulin shortage. The interview data consistently indicated that insulin non-availability had induced poor compliance to therapy regimens and lack of motivation for optimum glycaemic control. Due to limited resources, most of the patients received insufficient diabetes care and education, leading to lower rates of clinic attendance (55%), and dietary non-compliance (78.5%). Elevated haemoglobin A1c was associated with higher fasting blood glucose levels (P < 0.001), serum triglycerides (P < 0.05), and urinary glucose (P < 0.001). Measurable fasting C-peptide was observed in 52.5% of the patients and was related to the age at diagnosis, and body mass index (P < 0.001 for both). There is a considerable potential to improve diabetes care and education practice, and if accessibility to insulin is simultaneously facilitated, the glycaemic control in Sudanese diabetic patients will improve.

A simple method for determination of plasma thiocyanate.

We describe a method for the determination of thiocyanate in plasma from blood collected under field conditions in heparinised glass capillary tubes. After deproteinisation of plasma with perchloric acid, thiocyanate is directly determined colorimetrically by the König reaction with sodium hypochlorite as the chlorinating reagent and barbituric acid as the coupling agent. This simple method cannot be applied to urine as the latter contains interfering compounds.

Microdiffusion method with solid state detection of cyanogenic glycosides from cassava in human urine.

A method for quantitative determination of cyanogenic glycosides in human urine is described. It is based on enzymatic cleavage of the glycosides, microdiffusion of the hydrogen cyanide formed, solid state detection by colour formation on a picrate-impregnated sheet, and subsequent rating of the coloured spot by the absorption of transmitted light at 540 nm with a thin-layer (TLC) densitometer. The method has been tested using normal as well as pathological urines containing glucose, protein, leucocytes, blood and bacteria. The method allows quantification of urinary linamarin above 70 mumol/litre, in 40 microliters urine. In Mozambican subjects consuming insufficiently processed cassava the mean urinary linamarin levels were 211 mumol/litre, indicating for the first time that substantial amounts of the main cyanogenic glycoside in cassava may be absorbed from the human gut and excreted intact in the urine.

Metabolic fates in humans of linamarin in cassava flour ingested as stiff porridge.

Insufficiently processed products from cassava roots may contain residual amounts of cyanogenic glucosides, mainly linamarin. The fate of orally ingested linamarin was studied following a meal of cassava porridge prepared from cassava flour from southern Tanzania with 82 mg cyanide equivalents (3035 micromol) of linamarin per kg dry weight. Following ingestion of amounts of porridge containing 243-571 micromol linamarin by 15 healthy adults a mean (range) of 21% (1-47%) of the linamarin ingested was excreted in the urine within 24 hours and a mean of 1% in the next 24 hours. Serum thiocyanate, the main cyanide metabolite, increased in all subjects from a mean (+/-SD) of 34+/-26 to 78+/-28 micromol/litre (P < 0.001). In a second group of seven subjects we found that the ingestion of porridge with a mean (range) of 431 micromol (203-669%) of linamarin resulted in a mean linamarin excretion of 127 micromol/litre and an excess thiocyanate excretion of 118 micromol/litre and that 216 micromol was unaccounted for. We conclude that less than one-half of orally ingested linamarin is converted to cyanide and hence thiocyanate, about one-quarter is excreted unchanged and another quarter is metabolized into an as yet unknown compound.

Analysis of the cyanogenic glycoside linamarin in urine by isotachophoresis.

A separation system based on isotachophoresis is described for the cyanogenic glycoside linamarin in aqueous solution and in human urine. Isotachophoresis is a migration of a substance in an electric field, which is applied to a system of electrolytes of specific design. Detection is carried out by monitoring conductivity changes. However, for linamarin in urine, a preseparation procedure was necessary because of the high amount of electrolytes. This was performed by affinity chromatography on a silica sorbent column, with cyclohexyl as the functional group by which linamarin was retained. After elution from the column by methanol, a separation and quantitation of linamarin was possible by means of isotachophoresis. The method allowed determinations of urinary linamarin exceeding 100 microM, with a coefficient of variation of 13% at 500 microM.

[Our new fragile world doesn't consist of developed and developing countries only]. / Vår sköra nya värld består inte bara av u- och i-länder.

PIP: Health conditions have improved worldwide; therefore, the division into developed and developing countries no longer holds true. International organizations tend to divide countries into three groups. An increasing number of people are born in middle income countries where health conditions continue to improve. However, in a number of the least developed countries, mortality is on the rise in a spiral of economic stagnation, environmental problems, social misery, and ethnic/civil conflicts. This requires the medical assistance of international agencies from abroad. Since the 1960s there has been a drastic decline of child mortality in developing countries, especially in Asia. 1 billion people live in countries with child mortality under 20/1000, almost 3 billion live in countries with child mortality ranging 20-100/1000, and over 1 billion live in the least developed countries with child mortality over 100/1000. Unicef divides countries into developed, developing, and least developed countries, while the World Bank groups them as high-, medium-, and low-income countries. Thailand's child mortality is the same as that of Russia, while Cuba has a lower rate than Washington, D.C. On the other hand, Singapore is a developed high-income country with one of the world's healthiest populations. Stagnation and conflicts in the former socialist countries mean that many Asian and Latin American countries have better health status than some parts of Europe. Despite Africa's high mortality, its population growth is the highest in the world: in 20 years its population has doubled. Economic stagnation and the debt burden in many of these countries has resulted in ethnic conflicts and the collapse of social institutions: Somalia, southern Sudan, Rwanda, Liberia, Angola, perhaps Zaire, and Mozambique. The organization Physicians Beyond Borders is an example of extending humanitarian help and combatting social collapse in the least developed countries.^ieng

Are donor allocations for humanitarian health assistance based on needs assessment data?

Donors have agreed to fund humanitarian assistance according to needs. We studied if project applications to a major donor, and the subsequent funding decisions for humanitarian health projects contained needs assessment data. In 2003, a total of 258 million SEK (37 million USD) was allocated by Swedish International Development Cooperation Agency (Sida) to 38 humanitarian health projects. Only 14 applications (37%) had data on the size of the target population while reference to any quantified health needs was found in less than 30% of the funding decisions. In contrast to stated policy, interviews with staff at Sida revealed that needs assessment data had a limited role in the funding decisions, whereas the implementing capacity of the applying agency was of great importance. Our findings suggest that needs assessment data has a very limited role in the decision to fund while other, not clearly defined factors are more important.