am j clin nutr 1977 whitehead 1281 4

8/2/2019 Am J Clin Nutr 1977 Whitehead 1281 4

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The Am e ric an Jo urna l o f C lin ic a l N u trit ion 30 : A UG U ST 1977 , pp . 1 281 -1 284 . P rin te d in U .S .A . 1281

In fec tion and the deve lopm en t o f kw ash io rko rand m arasm us in A fr ica1 2R. G. Whitehead, Ph.D., M.A., F.I.Biol.

ABS TR AC T In fe c tion , p a r ticu la rly g as troe n te rit is a nd m a la r ia , ca n h ave a p ro fo und e ffe c to n the d eve lo pm en t o f bo th g row th fa lte rin g an d h yp oa lbum inem ia am ong ru ra l A fr ica n ch il-d r en . Am . I . C lin . N u tr . 30: 1281- 1284, 1977.

E lsewhe re in th is issue , D r. M a ta , a se lf-con fessed fru s tra ted m ic rob io log is t-bac te -rio log is t, ta kes us away from the labo ra to ry ,ou t o f the wa rd , in to a G ua tem a lan v illa ge .N ow I, an equa lly fru s tra ted b io chem is t,would like to do the same, but to take youaw ay from m y labo ra to ry in C am b ridge in totwo African villages.

For the past 5 yea rs o r so , m y m a in sc ien -tific i nt erest has been to define why someAfrican children, subjected to what is n owcalled protein-energy malnutritio n, developkwashiorkor, whereas others, perhaps themajority, become victi ms of marasmus. I amsu re reade rs a re aware that the classic die-ta ry exp lanation fo r the e tio logy of thesetwo dif ferent types of malnutrition has beenin d ispu te . In an a ttem p t to de fine m o recom p le te ly the w ide range o f env ironm en ta lhazards which mi ght be contributing to thedevelopment of these two forms of protein-energy malnutrition, we have carried outtwo prospe ctive 3-year longiludinal studiesra the r lik e those o f D r. M a ta and h is co l-le agues in G ua tem a la .

One of our studies was in a village calledN am u longe , in Uganda , w he re kw ash io rko ris the p redom inan t nu tr itio na l d is ease . Theother study i s a t present being conducted inKeneba, in The Gambia, West Africa,where marasmus is m ore frequently encoun-te red .In bo th v illa ges w e have show n tha t thepa tte rn o f in fe c tion , a s we ll as d ie ta ry inade -quacy , is c lea r ly im p lica ted . F igu re 1 show ssom e of ou r ve ry ea rly re su lts from U ganda ;it is obv ious tha t ep isodes o f frequen t in fe c-tio n w e re respons ib le fo r the p rocesses lead -ing to hypoalbuminemia and hence to

edem a as w e ll a s to the p rocesses o f w asting(1). I m ade a po in t in an ea rlie r d iscuss ionto D r. B e ise l and to D r. P ow anda , s tre ss inghow ep isodes o f in fe c tion tended to fo llowone ano the r. F igu re 1 illu s tra te s th is fa c tve ry c lea rly .

The im po rtance o f in fec t ion in th e poo rg row th pe rfo rm ance o f G am b ian ch ild renhad a lready been s tud ied ex tens ive ly byM cG rego r and h is co lleagues (2 ), and be -cause it w as ou r u ltim a te a im to in troduceschem es to im prove the s itua tion , it w asnecessa ry fo r u s to try and quan tita te tow ha t ex ten t the w idesp read m arasm uswhich is found in these v illa ges w as due toin fe c tions as w e ll a s to a poo r d ie t.

F igu re 2 show s the m ean we igh t andhe igh t o f the ch ild ren re la tiv e to the Je lliffe(1966 ) s tanda rds (3 ). W e igh t fa lte ring be -gan soon a fte r 3 m on ths o f age , and theeffect was m uch g rea te r du ring the 1s t yea rof life t han in subsequent years.

Estim a tes o f inc rem en ta l ga in s in we igh tand leng th w e re a lso ca lcu la ted from m ea -su rem en ts m ade routine ly eve ry m on th (4 ).The interval betwee n one anthropometnicm easu rem en t and the nex t w as thensea rched fo r bou ts o f illn ess . T he du ra tiono f each illn ess w as then used to de te rm inethe proportion of lime the child was be ingaffected by that particular illness.

The relat ionship between height andweight gain and the duration of each of nined isease categories was then inv estigated by

F rom th e v il lag e ca lle d N am u lon ge , U ga nd a , an dK eneb a , in T he G am b ia , W e st A fr ica .

2Ad dress rep rin t re qu es ts to : R . G . W h ite he ad ,Ph .D ., M .R .C . D unn N u tr itio n Un it, M ilton R oad ,Cam b rid ge , CB 4 IX J , E ng lan d .


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2

HE IG HT FOR AG E

WE IGHT FO R A GE

A GE (y . . rs )I 2 3

128 2 W H ITEH EAD

F IG . 2 . Pe rc e n tag e w e igh t an d he igh t fo r a ge , ju dg ed b y th e Je llif fe3) stand ard of chi ldren ag es 0.6 to 3 yearsin a ru ra l G am b ian v illage .

.4 UI

(II..-PG

it

AG E (y r.)FIG . 1 . R e la tio nsh ip be tw ee n p a tte rn o f in fec t ion ,

w e ig h t fa lte ring , a nd ep is o de s o f hyp oa lbum inem ia in aUganda n ch ild (1 ) . U = u ppe r re sp ira to ry trac t in fec -t ion; I = impe t igo ; B = bronch i t i s ; P = pneumon ia ; M= mala r ia ; D = d ia r r hea ; M s = meas les ; 0 = ot it ismed ia .

10 0

0/ O FSTANDARD

90

80

0

m u ltip le reg ress ion ana ly s is ; re su lts a reshow n in T ab le 1 . F o r he igh t ga in on ly d ia r-rheal disease, gastroenteritis, had a signifi-can t nega tiv e co rre la tion . F o r w e igh t ga in ,gas troen te ritis w as s til l a p redom inan t fa c -to r, bu t m a la r ia a ls o had a s ign ifican t e ffe c t.T he rem a in ing d isease g roups w e re un im -portan t.

The d ram a tic d iffe rences in g row th a t d if-fe ren t tim es o f the yea r in The G am b ia hasb e e n com p rehens ive ly s tud ied by M cG regoret a l. (5 ), and the re la tionsh ip be tw een thep reva lence o f gas troen te r itis and the pa tte rnof growth is illustrated in Figure 3. Thepo in t w here each reg ress ion line cu ts theg row th ax is rep resen ts the m ean g row th tha twould have occurred had there been no gas-troen te ritis . M ean g row th ra te s o f no rm a lch ild ren ca lc u la ted from the Je lliffe s tan -da rds (3 ) va ry from abou t 570 g /m on th a t 6m on ths to 160 g /m on th a t 3 yea rs . T ak ingthe age range 0 .5 to 3 .0 yea rs as a who le ,the ave rage ra te o f g row th is a round 240 g /m on th . A t som e tim es o f the yea r, ra te s o fgrowth of this magnitude would have beenach ie ved , bu t the m on ths o f Ju ly and Au -gus t, bo th in 1974 and 1975 , a re an obv iousexcep tion . Th is is the trad itio na l hung ry sea -
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D IARRHO EA PR E% tLENCE (% )

INFEC T ION , KW ASH IO R KO R , AND MARASMUS 1 2 8 3TAB LE 1R eg res s io n c oe ffic ien ts S E from the reg res s io ns o f h e ig h t ga in a nd w e ig h t ga in in n ine c a te go rie s o f i llne s s inc h ild re n ag es 0 .6 to 3 ye a rs from Keneba v i llag e , T he G am b ia

Illne ss categoryRR egr ess o n coef fi ci entsb

H t gain W t gainm m /m onth g/m onth

U pper res p ira to ry tra c t in fe c tio nsL ow er resp ira to ry trac t in fec tio nsGastroen te r i t i s

-0.8 1 .8-3.1 2 . 6- 4 . 2 1 5c

-8 1 79- 5 3 11 7

-7 46 68 In fe c tio us fe ve rs -1 .0 3 .0 79 13 5M a la ria -7 .0 6 .0 -10 72 2 68 G ia r d ias is 0. 3 2 .1 -1 31 93S uper fic ia l in fe c t ion sD eep in fe c tio nsN on sp ec ific d is o rde rs

-0 .1 2 . 0-0 .9 2 .0-1.1 4. 9

2 5 8 82 7 91

44 0 219 12 Fo r de f in it ion s s ee (4 ). D iffe ren ce in g row th

len ce . P< 0 .01 . d p < { 2 1 6 } # {2 1 6 } P < 0 . 0 5 .ra te be tw ee n 1 00% p rev a le nc e a nd 10% p re va -

W EHTGAIN

n,nth

F IG . 3 . F itte d re la tio nsh ip b e tw ,e en we igh t ga in and d ia r rhe a by s ea so n in the v illag e o f K en eb a , Th e G am b ia .Pe rio ds o f th e yea r: I = M ay -Ju ne 1 97 4 ; 2 = J u ly -Au gu s t 197 4 ; 3 = S ep tem be r-O c tobe r 19 74 ; 4 = Nov embe r -D e cem ber 19 74 ; 5 SE Ja nua ry -Fe b ru a ry 19 75 ; 6 SE M arc h -A p r il 19 75 ; 7 M a y -J un e 19 75 ; 8 SE Ju ly -Augus t1 97 5 ; 9 = S ep tem be r-O c to be r 19 75 .

son in T he G am b ia , w hen the p rev iousyea r s ce rea l c rop has been used up and thenew ha rves t is no t ye t ready . A t th is tim ethe re is little doub t tha t d ie ta ry im p rove -m en t is necessa ry in the v illa ge , a t leas t a s asho rt-te rm exped ien t. H ow eve r, the ro le o fd i et i n i mp r o v i ng t h e n u t r i t i on a l s t a t u s o fth is comm un ity a t o the r tim es needs cr itic a le va lua tion . T he re can be no doub t tha t inthese v illa ges a p rim a ry cons ide ra tion m ust

be g iven to the reduc tion o f d ia rrhea l d is -ease and to the e rad ic a tion o f m ala ria . B u tth is is a ve ry ta ll o rde r, and un til it h as beenach ie ved , the nu tritio n is t does have the re -spons ib ility o f try ing to re s to re the s ta tu squo , in o ther w o rds , m ak ing su re tha t thec h i l d i s a b l e t o p u t b a c k a n y we i g h t wh i chh a s b e e n l os t d u e t o t he d i a r r h e a o r ma l a r i a .

C h ild ren w ho w e re as m uch unde rw e igh ta s those show n in F igure 2 s h o u l d h a v e b e e n
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1 284 W H ITEHEADg row ing ve ry m uch fas te r than 240 g /m on th .I n o t h e r wo r d s , t h e y s h o u l d h a v e b e e nshow ing qu ite d ram a tic ca tch -ups . T he ir d i-e ta ry in ta ke du r ing m ost o f the yea r, be -tw een the ages o f 1 and 3 yea rs o f age, w asin the reg ion o f 400 kJ /kg /day . A lthoughth is w ou ld have a llow ed fo r a m ode ra te de -g ree o f g row th , app roach ing pe rhaps no r-m a l ra tes , it w as in su ffic ien t to a llow fo r anyc a t c h - u p.

The re have b e e n v a r i ou s a t t e mp t s i n r e -cen t yea rs to ca lcu la te how m uch ene rgy andh o w mu c h p r o t e i n a r e r e q u i r e d t o s u p p o r td iffe ren t ra te s o f ca tch -up g row th , and thesew ill b e d is cussed e lsew he re . B ecause thepe rcen tage in c rease in p ro te in requ irem en tis g rea te r than the pe rcen tage in c rease inene rgy , the p ro te in :ene rgy ratio o f t h e d i etn e e d s t o b e i nc r e a s e d a s we l l . St ud i e s i n o u rme t a b o l i c wa r d , b o t h i n Ug a n d a a n d i n Th eGamb i a , h a v e i n d i c a t ed t ha t r at es o f g r owt hin ch ild ren from these v illa ges can reachm any tim es the ove ra ll m ean no rm a l ra tewh e n t he y a r e p r ov i d e d wi t h s u f f i c i e n t f oo d .Ev e n wi t hi n t he v i l l ag e i t s e l f , ma n y c h i l d r ene x h i b i t e d g r o wt h r a t e s u p t o 4 t i me s t h e

no rm a l ra te . C e rta in ly , w hen g row th is fre -quen tly be ing he ld back by pe riod ic in fe c -tio ns , nu tr ien t needs fo r ca tch -up m ust bea llow ed fo r if th e ch ild is not go ing to bepe rm anen tly s tun ted . aReferences

1. FROOD , J. D . L., R . G .W H I T EH EAD A ND W . A .C OW A R D . Re la t ion sh ip b e tw e en p a tte rn o f in fec -tio n a nd d ev e lo pm en t o f hyp oa lbum ina em ia an dhy po - lip op ro te in aem ia in ru ra l U g an da n c h il-d ren . La nc e t 2 : 1 04 7 , 197 1 .

2 . M C G R E G O R , I. A ., A . K . R A H M A N , A . M . T H O M -S O N , W . Z. B ILLE W IC Z A N D B. TH O M P S O N . Thehea l t h of young children in a W est A frican (G am -b ia n ) v i llag e . T ra ns . R oy . S oc . T ro p . M ed . H yg .64 : 4 8 , 1 97 0 .

3 . J ELL I F FE , D . B . T he As se s sm en t o f th e N u tr itio na lS ta tu s o f the C om m un ity . M onog r. Se ries N o . 53 ,G ene va : W orld H ea lth O rg an iz a tio n , 19 66 .

4. R O W L A N D , M . G . M ., T. J. C O L E AN D R . G .WH I T E H EA D . A qu an t ita tiv e s tu dy in to the ro le o fin fec tio n in de te rm in ing nu trit ion a l s ta tus in G am -b ia n v illa ge c h ild re n . B rit. J . N u tr . 3 7 : 4 41 , 1 97 7 .

5. M C G R E G O R , I. A ., A . K . R A H M A N , B . T H OMP -SON , W . Z. B I L L EW I C Z AN D A . M . T H OMSO N . Theg row th o f y o ung c h ild re n in a G am b ian v il lag e .T ran s . R oy . S oc . T rop . M ed . H yg . 6 2 : 34 1 , 196 8 .
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am j clin nutr 1977 whitehead 1281 4

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