Dietary intake of sulfur amino acids and risk of kwashiorkor malnutrition in eastern Democratic Republic of the Congo.

BACKGROUND: Kwashiorkor is an often-fatal type of severe acute malnutrition affecting hundreds of thousands of children annually, but whose etiology is still unknown. Evidence suggests inadequate sulfur amino acid (SAA) status may explain many signs of the condition but studies evaluating dietary protein intake in relation to the genesis of kwashiorkor have been conflicting. We know of no studies of kwashiorkor that have measured dietary SAAs. OBJECTIVES: We aimed to determine whether children in a population previously determined to have high prevalence of kwashiorkor [high-prevalence population (HPP)] have lower dietary intakes of SAAs than children in a low-prevalence population (LPP). METHODS: A cross-sectional census survey design of 358 children compared 2 previously identified adjacent populations of children 36-59 mo old in North Kivu Province of the Democratic Republic of the Congo. Data collected included urinary thiocyanate (SCN), cyanogens in cassava-based food products, recent history of illness, and a 24-h quantitative diet recall for the child. RESULTS: The HPP and LPP had kwashiorkor prevalence of 4.5% and 1.7%, respectively. A total of 170 children from 141 households in the LPP and 169 children from 138 households in the HPP completed the study. A higher proportion of HPP children had measurable urinary SCN (44.8% compared with 29.4%, P < 0.01). LPP children were less likely to have been ill recently (26.8% compared with 13.6%, P < 0.01). Median [IQR] intake of SAAs was 32.4 [22.9-49.3] mg/kg for the LPP and 29.6 [18.1-44.3] mg/kg for the HPP (P < 0.05). Methionine was the first limiting amino acid in both populations, with the highest risk of inadequate intake found among HPP children (35.1% compared with 23.6%, P < 0.05). CONCLUSIONS: Children in a population with a higher prevalence of kwashiorkor have lower dietary intake of SAAs than children in a population with a lower prevalence. Trial interventions to reduce incidence of kwashiorkor should consider increasing SAA intake, paying particular attention to methionine.

The Rise and Fall of Protein Malnutrition in Global Health.

BACKGROUND: From the 1950s to the mid-1970s, United Nations (UN) agencies were focused on protein malnutrition as the major worldwide nutritional problem. The goal of this review is to examine this era of protein malnutrition, the reasons for its demise, and the aftermath. SUMMARY: The UN Protein Advisory Group was established in 1955. International conferences were largely concerned about protein malnutrition in children. By the early 1970s, UN agencies were ringing the alarm about a 'protein gap'. In The Lancet in 1974, Donald McLaren branded these efforts as 'The Great Protein Fiasco', declaring that the 'protein gap' was a fallacy. The following year, John Waterlow, the scientist who led most of the efforts on protein malnutrition, admitted that a 'protein gap' did not exist and that young children in developing countries only needed sufficient energy intake. The emphasis on protein malnutrition waned. It is recently apparent that quality protein and essential amino acids are missing in the diet and may have adverse consequences for child growth and the reduction of child stunting. Key Messages: It may be time to re-include protein and return protein malnutrition in the global health agenda using a balanced approach that includes all protective nutrients.

Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries.

BACKGROUND: Protein Energy Malnutrition is an important cause of child morbidity and mortality in middle- and low-income countries. It has been suggested that excessive free radical activity may be responsible for the clinical manifestation of kwashiorkor. Antioxidants may be able to curb excessive free radical activity and prevent the development of kwashiorkor in susceptible children. OBJECTIVES: To evaluate the benefits of supplementation of vitamin E, selenium, cysteine and riboflavin (alone or in combination) in preventing kwashiorkor. SEARCH STRATEGY: We conducted searches of CENTRAL 2009 (The Cochrane Library 2009 Issue 2), MEDLINE 1966 to 2009, EMBASE 1980 to 2009, CINAHL 1982 to 2009, LILACS 1982 to 2009, Meta register of Controlled trials, Open Sigle, African Index Medicus. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs evaluating vitamin E, selenium, cysteine and riboflavin alone or in combination in healthy pre-school children in middle- and low-income countries. DATA COLLECTION AND ANALYSIS: Two authors extracted and independently analysed data. MAIN RESULTS: One cluster-RCT including 2372 children met our inclusion criteria. Children were randomised, based on household, either to a supplement containing all four micronutrients or to placebo. No statistically significant difference in the incidence of kwashiorkor between the intervention and control groups could be demonstrated at 20 weeks (RR 1.70; 95% CI 0.98 to 2.42). Nor could any statistically significant difference in all-cause mortality be demonstrated (RR 0.75; 95% CI 0.17 to 3.36). AUTHORS' CONCLUSIONS: Based on the one available trial, we could draw no firm conclusion for the effectiveness of supplementary antioxidant micronutrients for the prevention of kwashiorkor in pre-school children.

Probiotics and prebiotics for severe acute malnutrition (PRONUT study): a double-blind efficacy randomised controlled trial in Malawi.

BACKGROUND: Severe acute malnutrition affects 13 million children worldwide and causes 1-2 million deaths every year. Our aim was to assess the clinical and nutritional efficacy of a probiotic and prebiotic functional food for the treatment of severe acute malnutrition in a HIV-prevalent setting. METHODS: We recruited 795 Malawian children (age range 5 to 168 months [median 22, IQR 15 to 32]) from July 12, 2006, to March 7, 2007, into a double-blind, randomised, placebo-controlled efficacy trial. For generalisability, all admissions for severe acute malnutrition treatment were eligible for recruitment. After stabilisation with milk feeds, children were randomly assigned to ready-to-use therapeutic food either with (n=399) or without (n=396) Synbiotic2000 Forte. Average prescribed Synbiotic dose was 10(10) colony-forming units or more of lactic acid bacteria per day for the duration of treatment (median 33 days). Primary outcome was nutritional cure (weight-for-height >80% of National Center for Health Statistics median on two consecutive outpatient visits). Secondary outcomes included death, weight gain, time to cure, and prevalence of clinical symptoms (diarrhoea, fever, and respiratory problems). Analysis was on an intention-to-treat basis. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN19364765. FINDINGS: Nutritional cure was similar in both Synbiotic and control groups (53.9% [215 of 399] and 51.3% [203 of 396]; p=0.40). Secondary outcomes were also similar between groups. HIV seropositivity was associated with worse outcomes overall, but did not modify or confound the negative results. Subgroup analyses showed possible trends towards reduced outpatient mortality in the Synbiotic group (p=0.06). INTERPRETATION: In Malawi, Synbiotic2000 Forte did not improve severe acute malnutrition outcomes. The observation of reduced outpatient mortality might be caused by bias, confounding, or chance, but is biologically plausible, has potential for public health impact, and should be explored in future studies. FUNDING: Department for International Development (DfID).

Reduction in childhood malnutrition in Vietnam from 1990 to 2004.

Reduction in childhood malnutrition in Vietnam between 1990 and 2004 was assessed using data from 5 national surveys. The prevalence of malnutrition, including stunting, declined significantly for underweight from 45% in 1990 to 26.6% in 2004. While the average reduction was 1.3% per year in the period from 1990 to 2000, it was 1.8% per year in the period from 2000 to 2004. The prevalence of stunting declined from 56.5% in 1990 to 30.7% in 2004, with an average reduction of 2% per year in the period from 1990 to 2000 and 1.5% per year in the period from 2000 to 2004. There were clear differences in the decrease in malnutrition prevalence between urban, rural and mountainous areas, the reduction being highest in the urban regions and lowest in the mountainous areas. Regression analysis showed that the nutrition status of the child is positively related to better household living conditions and to the educational level of the father, but not the mother. Stunting is higher in children whose parents are farmers and higher in households with more children. Stunting prevalence is lower in households with safe water access and hygienic toilets. In future , the dramatic reduction is childhood malnutrition as seen in the period 1990 to 2004 might not continue. More comprehensive apptoaches will be needed to lower childhood malnutrition in Vietnam further.

Kwashiorkor--is it a dying disease?

OBJECTIVE: To review the occurrence of kwashiorkor before and after the establishment of the Diarrhoea Training Unit at a Nigerian tertiary hospital in 1992. DESIGN: A retrospective hospital-based analytical study was undertaken. Groups of subjects were compared using odds ratios (95% confidence intervals) and regression analysis. SETTING: The paediatric wards of the Wesley Guild Hospital, Ilesa, Nigeria. SUBJECTS: The number of children admitted with kwashiorkor, measles, gastroenteritis and marasmus between 1983 and 1991 (group I) was compared with similar data for the period 1993-2002 (group 2). RESULTS: There was a 30.4% reduction in the total admissions between these periods, while incidences of kwashiorkor, measles, gastroenteritis and marasmus fell by 70%, 55%, 57.4% and 55.8% respectively. Reduction in number of kwashiorkor cases between groups 1 and 2 was significantly related to the reduced incidence of measles (p = 0.000002) and gastroenteritis (p = 0.000003). The total number of admissions was correlated with the number of measles (r = 0.623 and 0.573 for group 1 and 2) and kwashiorkor cases (r = -0.412 and 0.233 for groups 1 and 2). CONCLUSION: The incidence of kwashiorkor has fallen in Ilesa, Nigeria. Given the relatively low HIV prevalence rate in the country during the study period, better management of diarrhoeal diseases, including measles, may have accounted for this drastic fall.

The quality of the diet in Malawian children with kwashiorkor and marasmus.

Nutritionists have suggested that kwashiorkor is related to low dietary protein and/or antioxidant intake. This study explored the hypothesis that among Malawian children with severe malnutrition, those with kwashiorkor consume a diet with less micronutrient- and antioxidant-rich foods, such as fish, eggs, tomatoes and orange fruits (mango, pumpkin and papaya), than those with marasmus. A case-control method with a food frequency questionnaire was used to assess the habitual diet. Children with severe childhood malnutrition presenting to the central hospital in Blantyre, Malawi during a 3-month period in 2001 were eligible to participate. The food frequency questionnaire collected data about foods consumed by siblings <60 months of age in the home. It was assumed that the habitual diet of all siblings 1-5 years old in the same home was similar. Dietary diversity was assessed using a validated method, with scores that ranged from 0 to 7. Regression modelling was used to control for demographic and disease covariates. A total of 145 children with kwashiorkor and 46 with marasmus were enrolled. Children with kwashiorkor consumed less egg and tomato than those with marasmus: 17 (15) vs. 24 (31) servings per month for egg, mean (SD), P < 0.01 and 27 (17) vs. 32 (19) servings per month for tomato, P < 0.05. Children with kwashiorkor had a similar dietary diversity score as those with marasmus, 5.06 (0.99) vs. 5.02 (1.10), mean (SD). Further research is needed to determine what role consumption of egg and tomato may play in the development of kwashiorkor.

Antioxidant supplementation for the prevention of kwashiorkor in Malawian children: randomised, double blind, placebo controlled trial.

OBJECTIVE: To evaluate the efficacy of antioxidant supplementation in preventing kwashiorkor in a population of Malawian children at high risk of developing kwashiorkor. DESIGN: Prospective, double blind, placebo controlled trial randomised by household. SETTING: 8 villages in rural southern Malawi. PARTICIPANTS: 2372 children in 2156 households aged 1-4 years were enrolled; 2332 completed the trial. INTERVENTION: Daily supplementation with an antioxidant powder containing riboflavin, vitamin E, selenium, and N-acetylcysteine in a dose that provided about three times the recommended dietary allowance of each nutrient or placebo for 20 weeks. MAIN OUTCOME MEASURES: The primary outcome was the incidence of oedema. Secondary outcomes were the rates of change for weight and length and the number of days of infectious symptoms. RESULTS: 62 children developed kwashiorkor (defined by the presence of oedema); 39/1184 (3.3%) were in the antioxidant group and 23/1188 (1.9%) were in the placebo group (relative risk 1.70, 95% confidence interval 0.98 to 2.42). The two groups did not differ in rates of weight or height gain. Children who received antioxidant supplementation did not experience less fever, cough, or diarrhoea. CONCLUSIONS: Antioxidant supplementation at the dose provided did not prevent the onset of kwashiorkor. This finding does not support the hypothesis that depletion of vitamin E, selenium, cysteine, or riboflavin has a role in the development of kwashiorkor.

A half-century perspective on world nutrition and the international nutrition agencies.

This paper reviews the birth and evolution of the international nutrition agenda. International nutrition issues of today are discussed, as are recommendations and projections for the future.

Indian nutritionists and international nutritional standards: concepts and controversies.

This paper explores how Indian nutritional scientists and policy planners have influenced the formulation and interpretation of standards of nutritional status. It draws on diverse published evidence by Indian scientists on three controversial issues: (1) the validity and applicability of international nutritional standards to India; (2) the so-called protein gap; and (3) the 'small but healthy' hypothesis. The paper concludes that Indian scientists have had considerable influence in international nutrition and food policy debates. Moreover, their positions seem to have been motivated more by nationalistic and scientific, rather than Indian ethnomedical cultural concerns. The paper provides one example of how Third World scientists and science have influenced a major area of scientific policy debate. The roles of cultural and political-economic factors in the construction of national and international nutritional standards are highlighted.

[Improved health in Zimbabwe's rural areas as a result of the rural development project]. / Bättre hälsa på Zimbabwes landsbygd genom byutvecklingsprojekt.

PIP: A rural development project carried out in Southern Zimbabwe for 5 years was aimed at improving nutrition, combatting diseases, educating villagers about proper hygiene, improving water quality, and assessing the development and nutritional status of children under 5. The community investigated consisted of 10,000 people or 1,439 families with an average of 7 persons per family. The main staple of their diet was maize, and malnutrition was prevalent. Water holes infested with bilharzia were the source of drinking water for both man and animal. The project succeeded in vaccinating 90% of preschool children against whooping cough, diphtheria, tetanus, polio, measles, and tuberculosis. A control district was chosen to compare the developmental data obtained by the Cole Slide Rule Calculator of 229 children under 5 with those of 242 children in the project. Malnutrition was studied in 200 children hospitalized in the children's ward of a district hospital, 1/3 of whom were less than 1 year old. Gastroenteritis, giardiasis and amebiasis were prevalent among them (37%), as were upper respiratory infections (27%), pneumonia (12%), and skin infections (7%). Nonspecific gastroenteritis was found in 86% of children under 2. Most over 2 were severely undernourished. A nutritional rehabilitation village called Hutano Village was established in 1982 to function as a nutritional center, staffed by a full-time health worker and an assistant. In the 1st 9 months of its existence, 114 children were taken in, and the mothers received instruction in vegetable gardening, raising chickens and rabbits, hygiene, and family planning. The average attendance runs to 25 children and 15 to 17 mothers. In spite of successful medical intervention in malnutrition cases, the relapse of children into an undernourished state remains a difficult issue, whose cause lies in inadequate water supply, poor soil, lack of resources, and low family socio-economic status.^ieng

The methyl folate trap. A physiological response in man to prevent methyl group deficiency in kwashiorkor (methionine deficiency) and an explanation for folic-acid induced exacerbation of subacute combined degeneration in pernicious anaemia.

It is suggested that in man the methyl folate trap is a normal physiological response to impending methyl group deficiency resulting from a very low supply of methionine. This decreases cellular S-adenosyl-methionine (SAM), which puts at risk important methylation reactions, including those required to maintain myelin. In order to protect these methylation reactions, the cell has evolved two mechanisms to maintain supplies of methionine and SAM as a first priority. (a) Decreased SAM causes the folate co-factors to be directed through the cycle involving 5-methyl-tetrahydrofolate (5-methyl-THF) and methionine synthetase and away from the cycles that produce purines and pyrimidines for DNA synthesis. This enhances the remethylation of homocysteine to methionine and SAM. In addition, by restricting DNA biosynthesis and with it cell, division, competition for methionine for protein synthesis is reduced. Thus, whatever methionine is available is conserved for the vital methylation reactions in the nerves, brain, and elsewhere. (b) 5-methyl-THF, the form in which almost all folate is transported in human plasma, must react with intracellular homocysteine before it can be retained by the cell as a polyglutamate. Since homocysteine is derived entirely from methionine, methionine deficiency will cause intracellular folate deficiency, and the rate of mitosis of rapidly dividing cells will be reduced. although these two processes have evolved as a response to methionine deficiency, they also occur in B12 deficiency, which the cell mistakenly interprets as lack of methionine. the resulting response is inappropriate and gives rise to a potentially lethal anaemia. In these circumstances the methylation reactions are also partly protected by the reduced rate of cell division. This explains why administration of folic acid, which induces cell division and use of methionine in protein synthesis, impairs methylation of myelin and precipitates or exacerbates subacute combined degeneration (SCD). During folate deficiency methionine biosynthesis is also diminished. As in methionine deficiency, the body responds to decreasing availability of SAM by diverting folate away from DNA biosynthesis towards the remethylation of homocysteine to methionine and SAM. The selective use pf available folate to conserve methionine, together with the ability of nerve tissue to concentrate folate form the plasma, explains the absence of SCD in folate deficiency.