Infection and the development and marasmus in Africa1’ 2 R. G. Whitehead,
Ph.D.,
M.A.,
F.I.Biol.
ABSTRACT
Infection,
on the dren.
of both Clin. Nutr.
development
Am.
I.
particularly
American
Journal
of Clinical
Nutrition
30:
gastroenteritis
growth faltering 30: 1281-1284,
Elsewhere in this issue, Dr. Mata, a selfconfessed frustrated microbiologist-bacteriologist, takes us away from the laboratory, out of the ward, into a Guatemalan village. Now I, an equally frustrated biochemist, would like to do the same, but to take you away from my laboratory in Cambridge into two African villages. For the past 5 years or so, my main scientific interest has been to define why some African children, subjected to what is now called protein-energy malnutrition, develop kwashiorkor, whereas others, perhaps the majority, become victims of marasmus. I am sure readers are aware that the classic dietary explanation for the etiology of these two different types of malnutrition has been in dispute. In an attempt to define more completely the wide range of environmental hazards which might be contributing to the development of these two forms of proteinenergy malnutrition, we have carried out two prospective 3-year longiludinal studies rather like those of Dr. Mata and his colleagues in Guatemala. One of our studies was in a village called Namulonge, in Uganda, where kwashiorkor is the predominant nutritional disease. The other study is at present being conducted in Keneba, in The Gambia, West Africa, where marasmus is more frequently encountered. In both villages we have shown that the pattern of infection, as well as dietary inadequacy, is clearly implicated. Figure 1 shows some of our very early results from Uganda; it is obvious that episodes of frequent infection were responsible for the processes leading to hypoalbuminemia and hence to
The
of kwashiorkor
AUGUST
Downloaded from https://academic.oup.com/ajcn/article-abstract/30/8/1281/4650105 by guest on 14 February 2018
and
malaria,
and hypoalbuminemia 1977.
can
have
among
a profound rural
African
edema as well as to the processes (1). I made a point in an earlier to Dr. Beisel and to Dr. Powanda, how episodes of infection tended one another. Figure 1 illustrates very clearly.
The
importance
of infection
effect chil-
of wasting discussion stressing to follow this fact
in the poor
growth performance of Gambian children had already been studied extensively by McGregor and his colleagues (2), and because it was our ultimate aim to introduce schemes to improve the situation, it was necessary for us to try and quantitate to what extent the widespread marasmus which is found in these villages was due to infections as well as to a poor diet. Figure 2 shows the mean weight and height of the children relative to the Jelliffe (1966) standards (3). Weight faltering began soon after 3 months of age, and the effect was much greater during the 1st year of life than in subsequent years. Estimates of incremental gains in weight and length were also calculated from measurements made routinely every month (4). The interval between one anthropometnic measurement and the next was then searched for bouts of illness. The duration of each illness was then used to determine the proportion of lime the child was being affected by that particular illness. The relationship between height and weight gain and the duration of each of nine disease categories was then investigated by ‘From the village called Namulonge, Keneba, in The Gambia, West Africa. 2Address reprint requests to: R. Ph.D., M.R.C. Dunn Nutrition Unit, Cambridge, CB4 IXJ, England.
1977,
pp.
1281-1284.
Printed
Uganda, G.
in U.S.A.
and
Whitehead, Milton Road,
1281
1282
WHITEHEAD
“.4
multiple regression analysis; results are shown in Table 1. For height gain only diarrheal disease, gastroenteritis, had a significant negative correlation. For weight gain, gastroenteritis was still a predominant factor, but malaria also had a significant effect. The remaining disease groups were unimportant. The dramatic differences in growth at different times of the year in The Gambia has been comprehensively studied by McGregor et al. (5), and the relationship between the prevalence of gastroenteritis and the pattern of growth is illustrated in Figure 3. The point where each regression line cuts the growth axis represents the mean growth that would have occurred had there been no gastroenteritis. Mean growth rates of normal children calculated from the Jelliffe standards (3) vary from about 570 g/month at 6 months to 160 g/month at 3 years. Taking the age range 0.5 to 3.0 years as a whole, the average rate of growth is around 240 g/ month. At some times of the year, rates of growth of this magnitude would have been achieved, but the months of July and August, both in 1974 and 1975, are an obvious exception. This is the traditional hungry sea-
“U ‘I
‘(II.’.‘PG
it 2 AGE
(yr.)
FIG. 1. Relationship between pattern of infection, weight faltering, and episodes of hypoalbuminemia in a Ugandan child (1). U = upper respiratory tract infection; I = impetigo; B = bronchitis; P = pneumonia; M = malaria; D = diarrhea; Ms = measles; 0 = otitis media.
100
0/
b
OF
STANDARD HEIGHT
FOR AGE
90
80 WEIGHT
0
I
FIG. a rural
2. Percentage Gambian
weight
and
height
for
age,
judged
village.
Downloaded from https://academic.oup.com/ajcn/article-abstract/30/8/1281/4650105 by guest on 14 February 2018
AGE
2 AGE
in
FOR
3
(y..rs)
by the
Jelliffe
(3) standard
of children
ages 0.6 to 3 years
INFECTION, TABLE 1 Regression coefficients ±SE children ages 0.6 to 3 years
from from
KWASHIORKOR,
the regressions Keneba village,
AND
of height gain The Gambia
MARASMUS
and
weight
gain
Regressio Illness
1283
in nine
categories
n coefficientsb Wt gain
mm/month
respiratory respiratory
tract tract
-0.8 -3.1 -4.2 -1 .0 -7.0 0.3 -0.1 -0.9 -1.1
infections infections
Gastroenteritis
Infectious fevers Malaria Giardiasis Superficial infections Deep infections Nonspecific disorders 12
lence.
For
definitions
see
‘P
Ph.D.,
M.A.,
F.I.Biol.
ABSTRACT
Infection,
on the dren.
of both Clin. Nutr.
development
Am.
I.
particularly
American
Journal
of Clinical
Nutrition
30:
gastroenteritis
growth faltering 30: 1281-1284,
Elsewhere in this issue, Dr. Mata, a selfconfessed frustrated microbiologist-bacteriologist, takes us away from the laboratory, out of the ward, into a Guatemalan village. Now I, an equally frustrated biochemist, would like to do the same, but to take you away from my laboratory in Cambridge into two African villages. For the past 5 years or so, my main scientific interest has been to define why some African children, subjected to what is now called protein-energy malnutrition, develop kwashiorkor, whereas others, perhaps the majority, become victims of marasmus. I am sure readers are aware that the classic dietary explanation for the etiology of these two different types of malnutrition has been in dispute. In an attempt to define more completely the wide range of environmental hazards which might be contributing to the development of these two forms of proteinenergy malnutrition, we have carried out two prospective 3-year longiludinal studies rather like those of Dr. Mata and his colleagues in Guatemala. One of our studies was in a village called Namulonge, in Uganda, where kwashiorkor is the predominant nutritional disease. The other study is at present being conducted in Keneba, in The Gambia, West Africa, where marasmus is more frequently encountered. In both villages we have shown that the pattern of infection, as well as dietary inadequacy, is clearly implicated. Figure 1 shows some of our very early results from Uganda; it is obvious that episodes of frequent infection were responsible for the processes leading to hypoalbuminemia and hence to
The
of kwashiorkor
AUGUST
Downloaded from https://academic.oup.com/ajcn/article-abstract/30/8/1281/4650105 by guest on 14 February 2018
and
malaria,
and hypoalbuminemia 1977.
can
have
among
a profound rural
African
edema as well as to the processes (1). I made a point in an earlier to Dr. Beisel and to Dr. Powanda, how episodes of infection tended one another. Figure 1 illustrates very clearly.
The
importance
of infection
effect chil-
of wasting discussion stressing to follow this fact
in the poor
growth performance of Gambian children had already been studied extensively by McGregor and his colleagues (2), and because it was our ultimate aim to introduce schemes to improve the situation, it was necessary for us to try and quantitate to what extent the widespread marasmus which is found in these villages was due to infections as well as to a poor diet. Figure 2 shows the mean weight and height of the children relative to the Jelliffe (1966) standards (3). Weight faltering began soon after 3 months of age, and the effect was much greater during the 1st year of life than in subsequent years. Estimates of incremental gains in weight and length were also calculated from measurements made routinely every month (4). The interval between one anthropometnic measurement and the next was then searched for bouts of illness. The duration of each illness was then used to determine the proportion of lime the child was being affected by that particular illness. The relationship between height and weight gain and the duration of each of nine disease categories was then investigated by ‘From the village called Namulonge, Keneba, in The Gambia, West Africa. 2Address reprint requests to: R. Ph.D., M.R.C. Dunn Nutrition Unit, Cambridge, CB4 IXJ, England.
1977,
pp.
1281-1284.
Printed
Uganda, G.
in U.S.A.
and
Whitehead, Milton Road,
1281
1282
WHITEHEAD
“.4
multiple regression analysis; results are shown in Table 1. For height gain only diarrheal disease, gastroenteritis, had a significant negative correlation. For weight gain, gastroenteritis was still a predominant factor, but malaria also had a significant effect. The remaining disease groups were unimportant. The dramatic differences in growth at different times of the year in The Gambia has been comprehensively studied by McGregor et al. (5), and the relationship between the prevalence of gastroenteritis and the pattern of growth is illustrated in Figure 3. The point where each regression line cuts the growth axis represents the mean growth that would have occurred had there been no gastroenteritis. Mean growth rates of normal children calculated from the Jelliffe standards (3) vary from about 570 g/month at 6 months to 160 g/month at 3 years. Taking the age range 0.5 to 3.0 years as a whole, the average rate of growth is around 240 g/ month. At some times of the year, rates of growth of this magnitude would have been achieved, but the months of July and August, both in 1974 and 1975, are an obvious exception. This is the traditional hungry sea-
“U ‘I
‘(II.’.‘PG
it 2 AGE
(yr.)
FIG. 1. Relationship between pattern of infection, weight faltering, and episodes of hypoalbuminemia in a Ugandan child (1). U = upper respiratory tract infection; I = impetigo; B = bronchitis; P = pneumonia; M = malaria; D = diarrhea; Ms = measles; 0 = otitis media.
100
0/
b
OF
STANDARD HEIGHT
FOR AGE
90
80 WEIGHT
0
I
FIG. a rural
2. Percentage Gambian
weight
and
height
for
age,
judged
village.
Downloaded from https://academic.oup.com/ajcn/article-abstract/30/8/1281/4650105 by guest on 14 February 2018
AGE
2 AGE
in
FOR
3
(y..rs)
by the
Jelliffe
(3) standard
of children
ages 0.6 to 3 years
INFECTION, TABLE 1 Regression coefficients ±SE children ages 0.6 to 3 years
from from
KWASHIORKOR,
the regressions Keneba village,
AND
of height gain The Gambia
MARASMUS
and
weight
gain
Regressio Illness
1283
in nine
categories
n coefficientsb Wt gain
mm/month
respiratory respiratory
tract tract
-0.8 -3.1 -4.2 -1 .0 -7.0 0.3 -0.1 -0.9 -1.1
infections infections
Gastroenteritis
Infectious fevers Malaria Giardiasis Superficial infections Deep infections Nonspecific disorders 12
lence.
For
definitions
see
‘P
