Comparisons of body fat estimated from total body water and skinfold thicknesses of undernourished men.

In 49 chronically undernourished adult males, classified as having mild, intermediate, or severe nutritional compromise, comparisons were made of body fat calculated from total body water with values obtained from triceps and scapular skinfolds. These same comparisons were followed in 19 of the severely undernourished subjects during a 2 1/2-month period of dietary repletion. Results indicate that the correlations between fat estimates obtained from body water and skinfolds are good (r greater than 0.8) in mildly undernourished subjects, but that they are progressively reduced as the nutritional compromise becomes more severe until statistical significance disappears. Dietary repletion of 2 1/2-month duration did not restore a statistically significant relationship between fat and triceps and scapular skinfolds. These data imply that the triceps and scapular skinfolds do not adequately represent body fat in chronically undernourished adult males and that new empirical equations are required which take into account nutritional status and possible shifts in fat deposit sites in chronic undernutrition.

Body composition during nutritional repletion of severely undernourished men.

Body composition was studied in severely undernourished adult male inhabitants of a rural area of Colombia to evaluate the extent and the time course of the changes occurring upon nutritional repletion. During a 45-day basal period on a low (26g/day) protein diet containing adequate calories, body fat depots increased significantly (mean +/- SD = +3.02 +/- 2.9 kg), and there was a significant decrease in cell hydration from 81.8 to 76.4% (-5.4 +/- 9.1%). Upon protein repletion (100 g/day), cell hydration decreased significantly to 71.4%, while body cell mass increased markedly (9.0 +/- 1.1 kg). During protein repletion, muscle cell mass increased significantly (+5.5 +/- 0.6 kg) and rapidly, while the increase in nonmuscle cells (+3.5 +/- 3.8 kg) and specifically in red cell mass lagged behind. With repletion, the changes in the absolute values for plasma volume (+0.4 +/- 0.13 liters) were significant, but those in extracellular fluid volume (-0.7 +/- 1.9 liters) were not. Thus, the major compositional changes observed occurred in the body fat and the body cell mass components; these occurred independently of each other.

Aerobic work capacity in chronically undernourished adult males.

Maximal O2 consumption (VO2max) and maximal endurance time at 80% Vo2max (T80) were determined in 49 subjects with varying degrees of nutritional compromise. Vo2max was lover by 21% and 52% in subjects with moderate and severe undernutrition, respectively, when compared to men with mild nutritional compromise. Most (80%) of the change in Vo2max could be related to the estimated differences in muscle cell mass (MCM). A significant reduction (-18%) in the Vo2max per unit of MCM was found in the severely undernourished subjects, indicating basic physiological changes. Total body hemoglobin showed the highest correlation with Vo2max (r = 0.709) and at constant MCM (partial r = 0.796). A multiple regression equation was derived to estimate the Vo2max of populations on the basis of simple anthropometry and blood hemoglobin levels. T80 (93-103 min) and estimated maximum sustained 8-h percent effort (32%) in mild, intermediate, or severe undernutrition were not significantly different; by contrast, endurance at a given absolute work load was markedly lower in severe undernutrition (8 vs. 1.5 h) due presumably to the difference in Vo2max.

Body composition in chronic undernutrition.

Anthropometric (height, weight, and skinfolds), biochemical (serum proteins, albumin, and cholesterol), metabolic (nitrogen balance and creatinine excretion), hematological (plasma volume, hemoglobin, hematocrit, bone marrow hemosiderin, percent transferrin saturation, vitamin B12, and folic acid) variables and body water compartments (total and extracellular) have been measured in 49 adult male subjects who exhibited a wide range of nutritional states from normal to severely undernourished. Changes in body composition associated with moderate degrees of nutritional compromise were related principally to decreases in body cell mass (-15%). Body fat was normal. With severe nutritional involvement, both fat depots (-29%) and body cell mass (-29%) were significantly diminished. Muscle cell mass was more affected than other cells in the body (-41%). These data could indicate that in the group with moderate compromise, energy reserves (and hence energy balance) were maintained but dietary protein deficiencies were not compensated for. Both calorie and protein deficiencies were evident in the subjects with severe undernutrition. Multiple regression equations (r greater than 0.8) were developed that allow prediction of muscle cell mass, fat-free weight, and body cell mass from simple anthropometry and serum albumin levels. Decreases in serum albumin concentration were best related to deficits in muscle mass (r = 0.77).

Intestinal function and morphology in strongyloidiasis.

Divergent available information on the capability of Strongyloides stercoralis to cause malabsorption prompted a long-term observation in which the nutritional state of the subjects was carefully defined. In spite of moderate to severe symptoms, well nourished patients, even with segmental jejunitis, did not show malabsorption. All patients presenting this parasitic infection with concomitant malnutrition showed absorptive defects. Abnormal absorption persisted in spite of parasitic cure when malnutrition was not immediately corrected, and disappeared with correction of the malnutrition even if parasitic infection was allowed to continue. The present experience indicates that the malabsorption syndrome seen in some cases of S. stercoralis infection is secondary to the concomitant malnutrition and not to the parasite per se.

Enterobacteriaceae in the jejunal microflora prevalence and relationship to biochemical and histological evaluations in healthy Colombian men.

When 23 healthy native Southwestern Colombian men were studied to determine the prevalence of Enterobacteriaceae in the jejunal microflora in a sample of thoroughly evaluated tropical inhabitants who were normal by physical examination, chest x-ray, and medical history, 14 of the 23 proved to be Enterobacteriaceae-positive, with counts of 10(3) to 10(9) per milliliter of jejunal aspirate. Thirteen had Escherichia coli, and the fourteenth had Klebsiella pneumoniae. Four had a second species of Enterobacteriaceae associated with E. coli: three were K. pneumoniae, and one was Proteus morganii. Laboratory studies routinely done on all subjects disclosed a total of 18 low biochemical values, 17 of which were associated with 12 of the 14 Enterobacteriaceae-positive subjects: six were low in serum cholesterol, four low in serum vitamin B12, four low in D-xylose excretion, and three low in creatinine coefficient; whereas, the Enterobacteriaceae-negative subjects had normal values for all biochemical tests except for serum vitamin B12 in one case. Nitrogen balance means were significantly different for the two groups: 3.39 g for the Enterobacteriaceae-positive subjects and 1.94 g for the Enterobacteriaceae-negative. No relationship was evident when the histology of the jejunal biopsies was compared with the microbiological or laboratory findings. When the 23 subjects were grouped into those (N = 19) with significant microbial recoveries of any type and those (N = 4) without, the data yielded no meaningful relationships.

Enteropathy in adult protein malnutrition: a review of the Cali experience.

Since 1964, 41 patients with strictly defined, severe primary (dietetic) protein malnutrition have been studied under metabolic ward conditions during prolonged periods, initially on a low (20 g) and later on a high (100 g) protein diet. Clinical, nutritional, hematological, intestinal absorptive and histological studies were performed in the malnourished state, during and after protein repletion. Classical signs and symptoms of malnutrition, lasting for at least 4 months, were present in most patients. Mild diarrhea was frequent. All were normoblastically anemic, hypoproteinemic, and hypocholesterolemic; serum folate values were normal or low but serum B12 values were normal or high. Liver biopsy showed fatty liver in the cases where it was performed. Mild malabsorption was detected in over one-half of the patients, with moderate intestinal radiological abnormalities. Malabsorption was independent of concomitant folate deficiency. All the clinical, absorptive and histological abnormalities reversed with treatment consisting only of a high protein diet. In addition to protein lack, another factor has to be invoked in the pathogenesis of the intestinal abnormalities present in severely malnourished adults from rural areas in the tropics.

Enteropathy in adult protein malnutrition: light microscopic findings.

Light microscopy evaluation of the intestinal abnormalities seen in 35 severely malnourished adults revealed changes which are common to other well-documented enteropathies. These included shortening, widening and fusion of the villi, lost convolution of the nuclear line, and diminished epithelial cell height. With Masson's trichrome stain, dense material was seen to have accumulated in a subepthelial location in villi (as described in other enteropathies), in crypts, and perivascularly around the capillaries of the lamina propria. Two findings however appear to characterize the severely malnourished state: a consistent, significant reduction of intestinal mucosal thickness, and in many cases atrophy of the crypts. Statistical analysis of the total mucosal thickness data does not justify five but rather three histological categories. With protein repletion as the sole therapeutic modality, 17 patients in which adequate biopsy samples were available at its completion showed significant amelioration of the aforementioned histological abnormalities, as well as normalization of their previous absorptive defects. The mild enteropathy of severe protein malnutrition must be considered in the differential diagnosis of malabsorption in a tropical setting.

Enteropathy in adult protein malnutrition: ultrastructural findings.

As part of a comprehensive study in adult patients with severe primary protein malnutrition, jejunal ultrastructural studies have been performed in nine adults in the malnourished state. Malnutrition was severe in all. D-Xylose malabsorption and abnormal fecal fat excretion were present in most. The main ultrastructural abnormalities encountered were: microvillar abnormalities such as shortening, diminished numbers, abnormal positioning, branching, and mesalike fusion of the microvilli; and abnormalities in the lamina propria characterized by deposits of osmiodense material and collagen fibers below the basement membrane of the epithelial cells and of the capillaries. None of the aforementioned findings were noted in our control cases. These ultrastructural alterations of severely malnourished adults are nonspecific, since they have already been described in other enteropathies frequently encountered in the tropics.

IgA heavy chain disease. A case detected in the western hemisphere.

IgA heavy chain disease (alpha chain disease) was detected in a 46 year old South American (Colombian) of mixed Spanish and Indian (Mestizo) descent. The clinical course was characterized by severe malabsorption, initially thought to be a variant of tropical sprue. Jejunal mucosal biopsy revealed marked villous atrophy with heavy infiltration of the lamina propria by a single monotonous cell type which, by light microscopy, had the appearance of either a large, abnormal plasma cell or a small histiocyte. Electron microscopy of the biopsy specimen demonstrated the presence of abnormal plasma cells, lymphatic distention and abnormalities of surface epithelial cells. At autopsy a 6 by 3 cm mass was found in the right para-aortic area along with many firm 2 cm mesenteric and para-aortic lymph nodes. Histologic examination revealed the presence of a monotonous cell type similar to that found in the jejunal mucosal biopsy specimen.

Malabsorption syndrome in ascariasis.

PIP: This group of researchers recently reported findings on the overall effect of Ascaris lumbricoides infection on human nutrition. On the basis of available data, it was suggested that intestinal malabsorption is a potential cause of nutritional impairment in children infected with Ascaris lumbricoides. The purpose of this discussion is to present additional data on the effect of Ascaris infection on small bowel function and structure in children. 5 children with heavy Ascaris infection without any evidence of clinical malnutrition were admitted to a metabolic unit. On admission, each child was placed on a constant diet consisting of 82-95 kcal and approximately 1 g protein/kg body weight/day. The amount of dietary fat varied from 55-60 g; the levels of vitamins and minerals in the diet were adjusted to meet the recommended dietary allowances. After an adjustment period of 4-6 days, fecal samples were collected during 2 periods of 4 days each for nitrogen and fat analysis. Peroral jejunal biopsies were obtained using an 8 mm Crosby-Kugler biopsy capsule. The samples were processed and stained according to standard techniques. The children then received deworming treatment consisting of 75 mg piperazine/kg body weight daily for 5 consecutive days. In 4 of 5 children there was reduced fecal nitrogen excretion; the mean reduction represented 6.5% of dietary nitrogen. Steatorrhea was present in 4 children; deworming resulted in a reduction of fecal fat from 9.9-2.3% of dietary fat. 3 children demonstrated an impairment in D-xylose excretion. It returned to normal following deworming in only 1 child. The jejunal morphology was found to be abnormal in all children. In each case a significant improvement was noted soon after deworming. The study results strongly suggest that there is a cause and effect relationship between Ascaris infection and intestinal lesions in children.^ieng

Effects of Ascaris infection on human nutrition.

PIP: The role of Ascaris lumbricoides infection in human nutrition was investigated in 12 children 5-10 years of age. Daily levels of dietary protein intake varied from 1-2.8 g/kg body weight but were kept constant for each child as was caloric intake. Nitrogen, fat balance, and d-xylose absorption determinations were done before and after deworming. A mean reduction in fecal nitrogen excretion of 230 mg/day was noted after worm removal. In 7 children harboring 48 or more parasites, the reduction in fecal nitrogen amounted to 7.2% of the dietary nitrogen. In 3 children receiving 1 g of protein/kg body weight, the improved nitrogen absorption after deworming led to an increased nitrogen retention. In 8 children the infection was associated with moderate steatorrhea (13.4% of dietary fat) and impairment of d-xylose absorption; the former was markedly reduced, and the latter was partially improved following treatment. It is concluded that Ascaris infection in children can lead to marked nutritional impairment when a high parasite load is associated with a low protein intake.^ieng