Barbara
K. Zain,3
A.
H. Haquani,4
Naveed
of hair root protein malnutrition1’ 2
Qureshi,5
and
Iffat
el Nisa5
ABSTRACT acid ratio,
Hair root protein and DNA, serum nonessential amino acid/essential amino serum total protein, albumin, globulin and albumin/globulin ratio were estimated in children suffering from protein-calorie malnutrition (PCM) and the values compared to those obtained from healthy children. The data were presented in two ways: 1) classified as early malnutrition, marasmus, marasmic kwashiorkor, or kwashiorkor and the parameters compared; 2) all the malnourished children were divided into four groups on the basis of percentage of body weight for age and the parameters compared . There was a progressive decrease in the content of hair root DNA and protein with the severity of PCM with these values decreasing to less than half of the normal values. In all types of PCM the serum albumin decreased significantly and the globulin increased while the total protein was altered only in the more severe stages. Differences in the serum constituents between groups were more pronounced when classified clinically than when grouped as percentage of normal body weight. Since hair root changes are progressive and of greater magnitude than those in the serum, hair root DNA and protein might be useful chemical criteria in detecting various stages of PCM, and further to help understand the pathogenesis of the condition. Am. J. Clin. Nutr. 30: 1094-1097, 1977.
Although protein calorie malnutrition (PCM) has been studied extensively, the best criteria for its detection in early stages and further classification have not yet been established Since changes in physical characteristics of hair have always been one of the most prominent features of PCM and since the cells of the hair matrix have one of the highest turnover rates, .Bradfield (1-3) .
advocates
hair
malnutrition dren
tissue
for
Examining
.
suffering
the
assessment
hair
from
roots
marasmus
of
of chiland
kwa-
shiorkor he has observed a significant reduction in the mean hair root diameter as well as changes in the morphology. Chemical quantitation of these hair root changes might be of great value in detecting marginal
and
early
(4) determined roots
of
causes.
the DNA
normal
and
Crounse
and protein
protein
et
al.
of hair
malnourished
adults and observed significantly lower values in the latter. They found a significant correlation between hair root volume and soluble protein, and also between soluble protein and DNA content (5). Bradfield and Owens (6) also reported a significant correlation
between
DNA. In our study tent of the hair 1094
hair
root
diameter
the DNA and protein roots of PCM children
The American
Journal
ofClinical
and
conhave Nutrition
been determined along with the nonessential amino acid/essential amino acid ratio (NEAA/EAA), serum albumin, globulin, total protein, and albumin/globulin (A/G) ratio to see how biochemical changes in the hair root compare with other established criteria of PCM. Materials
and methods
Three hundred thirty five children from 4 months to 5 years, clinically diagnosed as suffering from PCM were studied from July 1974 to June 1976, in the Pediatric Ward of Jinnah Postgraduate Medical Center, Karachi . Hair and blood samples were taken before any treatment was given . Normal samples were collected from 48 children 2/2 to 5 years of age attending private nursery schools in Karachi . This represents a middle to upper socioeconomic group in Pakistan. Hair was plucked by a quick pull with Tygon-coated hemostat from the occipital area, and placed in 0.14 M saline and examined with a microscope . Hair roots (10 to 30) with intact bulbs were selected for analysis. The samples were extracted in 1 .5 ml of 1 N NHOH in a ground glass homogenizer and centrifuged (5). From the supernatant DNA was determined by the fluoro-
From
1
of Karachi
the
Department
graduate 2 Supported
project 3
rics.
of Biochemistry,
and Department Medical Center, by
the
University
of Pediatrics, Jinnah Karachi, Pakistan. Pakistan
Science
Post-
Foundation,
Su-CH-44.
Associate
Professor.
Research
30: JULY
1977,
Professor
of
Pediat-
Officer. pp.
1094-1097.
Printed
in U.S.A.
Downloaded from https://academic.oup.com/ajcn/article-abstract/30/7/1094/4650489 by East Carolina University user on 16 January 2019
Studies on the significance and DNA in protein-calorie
SIGNIFICANCE
OF
ROOT
HAIR
method of Hinegardner (7) and soluble protein by Lowry’s method (8). Serum total protein was estimated by the biuret method (9) and serum albumin with the Albustrate metric
reagent
the
determined overnight
fast
and have
were
malnutrition, kwashiorkor
taken after an by the paper
of Whitehead
been
and
were determined
ratios
and Dean (10). in two ways. First to clinical diagnosis:
tabulated
divided
early or
samples
the
method
The results cases
where
blood
chromatographic
(Morris Plains, N.J.). The were taken as the globulin the amino acid ratios were
according
marasmus, marasmic kwashiorkor, the biochemical data were deter-
mined for each category. The criteria used for clinical diagnosis were as follows: early malnutrition these children were usually in the first year of life with infection, failing to gain weight, and had been receiving insufficient calories and protein . Loss of subcutaneous fat
and
muscle
wasting
were
not
apparent
They could
.
not fit into any of the following categories. Marasrnusgrowth failure, obvious loss of subcutaneous fat and wasting of muscles in the first 3 years of life but usually in the first year; appetite not so poor. Kwashiorkorgrowth failure, edema, wasted muscles with some subcutaneous fat, apathy, and poor appetite; hair and skin
changes may or may not be present. years. Marasmic viz., a rnarasmic
child
intermediate
with
very
slight
edema
edema but marked hair and skin changes kwashiorkor. Alternately the cases were four groups on the basis for age using the tables
Harvard
significance
determined
by the
showing
a greater
of PCM
with
in kwashiorkor,
decline
the
with
the
the value
severity
of the disease The level in early malnutrition was not significantly different from the normal, but in all the other types of PCM it .
was significantly lower than the normal value (P < 0.0001) and also significantly lower than the value in early malnutrition. The value observed in kwashiorkor was significantly less than in marasmus (P < 0.001). The hair root protein was less than onehalf the normal value in all types of malnutrition (P < 0.0001). The level in kwashiorkor was less than ‘/3 the normal value and was significantly lower (P < 0.001) than that of early malnutrition, marasmus and marasmic
The cantly
kwashiorkor.
NEAA/EAA (P < 0.0001)
seen
malnutri-
The level in kwashiorkor was significantly higher (P < 0.001) than that in marasmus. Serum albumin decreased significantly from the normal in all cases (P < 0.001
groups
test.
the
next
was
signifiof PCM.
or no
of difference
ratio
ratio increased in all types
and
as seen in divided into
between
decrease
highest
weight on the
t
in all types
greatest
1095
tion
of percentage of body in Jelliffe (1 1) based
Student’s
decreased
IN PCM
The
standards.
Statistical was
DNA
form,
Age usually 1 to 4
kwashiorkor-an
tent
AND
in early
highest
in kwashiorkor.
to 0.0001), however the level was about the same in early malnutrition, marasmus, and marasmic kwashiorkor. The value in kwa-
Results
shiorkor
Table 1 shows the results of normal children and those with various forms of PCM. The mean DNA level of normal children was 2.01 pg/hair root and the mean protein level was 6.01 p,g/hair root. The DNA con-
mus or marasmic kwashiorkor (P < 0.001). The globulin was significantly (P < 0.001) elevated in all forms of PCM The A/G ratio decreased significantly (P < 0.001) in all types of PCM. The values in early malnutrition and kwashiokor were significantly less
TABLE 1 Mean biochemical
values
in clinical Early
type
1.76
pg/hair root Protein pg/hair root NEAA/EAAratio
mal
2.83
±
3.5
total
7.4
protein g/100 Serum albumin g/iOO ml
Globulin A/G a
ml
0.256b
±
g/iOO ml
4.71 0.55
ratio
Mean
±
SE
.
± 0.234
b
±
0295b
(30) ± 0.23’s (30) ±
±
0.98
0047b
0074b
(30) Significantly
different
than
in maras-
±
2.32
±
2.4
0131b
0.82
0062b
±
1.65
0138b
(99) 2.5 ±
0#{149}110b
(89) 7.32 ± 0.089 (130) 34 0.072’s (86) 4.2 ± 0.26” (86) 0.90 ± 0036b (86) from the normal
±
.
±
2.71
0#{149}087b
0.l2Sb
6.5
(97) 3.32
±
3.75
(36) ± 0.27 (36)
0.84 .
±
0#{149}134b b
2.62 453 0.65
0052b
(36) Total
± 0072b (74)
2.01
±
6.01
0099b
number
of
±
O.lS2
(55) ± O.l3O (67) ± 0.i26 (56) 0.2P (56) ± 0042b (56) subjects.
±
0.105
(48)
(74)
(76) 7.03
Normal
Kwaslnrokor
(99)
(132)
(30) 3.1
Marasmic . kwashiorkor
(132)
(30) (10)
Serum
1.16 2.35
0289b
less
.
Marumus
. .
± 0.176a (30)”
significantly
of PCM
nutnt,on
DNA
was
±
0.19
(48) 1.68
±
0.051
(39) 7.5
±
0.140
(30) 4.16
±
0.07
(22) 3.1
±
0.150
(22) .20
±
(22)
0.074
Downloaded from https://academic.oup.com/ajcn/article-abstract/30/7/1094/4650489 by East Carolina University user on 16 January 2019
between all cases
levels. In
the
Lambert these
of Warner
differences
PROTEIN
ZAIN
1096
ET
than those in marasmus and marasmic kwashiorkor (P < 0.001). When the subjects were divided into grades on the basis of percentage of body weight for age (Table 2) as proposed by Bradfield and Jelliffe (1 2) there was a progressive decrease in hair root DNA and protein with the decline in body weight . All the values even those in grade I were significantly less (P 0.001) than normal, and the value of those in grade IV (weight less than 60%) was significantly lower (P < 0.001) than that of the others. The NEAA/EAA ratio was only elevated significantly (P < 0.0005) in grades II, III, and IV. The serum total protein did not show any decrease until malnutrition was very severe (grade IV) and this decrease was significant only at the 1 % level. The serum albumin significantly decreased from the normal in all grades but did not differ significantly from grade to grade The globulin similarly was elevated in all grades above the normal but did not differ between the grades except that the value in IV was significantly less than in III. The A/G ratio was from 0 .7 to 0 .78 in all cases which again was significantly less than the normal values.
normal adults which we observed in our laboratory, 1 1 .26 j.g/hair root is lower than that of 1 8 .04 tg/hair root as reported by Crounse et al. (5) However a later paper from the same laboratory (1 3) reported a mean of 14 .25 jig/hair root and stated that the lower limit of normal was 9 Our mean therefore is within this range Those authors (13) found no difference between whites and nonwhites, so our values falling within the same range can be taken as further evidence for lack of a racial difference in the hair root chemistry. Crounse et al. (5) reported a very low level of DNA (0 .85 pg/hair root) for normal adults while we observed 3 .65 j.g/hair root. In our normal subjects the mean hair root protein level was about 3 times greater than the mean DNA, both in children and .
adults,
about ratio
.
values
in grades
2.01
± ±
1.53
0.19
3.22
0.051
2.29
(39) Serum total protein g/100 ml Serum albumin gIlOOml Serum globulin g/100 ml
A/G
The
a
age
7.56
± 0.140 7.51 (30) 4.16 ± 0.07 3.38 (22) 3.1 ± 0.150 4.31 (22) 1.20 ± 0.074 0.78 (22) divided into grades I
ratio
.
subjects b
Mean
were ±
SE
.
Significantly
believe
II
I
(48) 1.68
in children
adults. the
Since values
are
the to be
.
90-81%
± 0.lO5’ (48)”
6.01
we
the
of PCM5
100%
DNA pg/hair root Protein pg/hair root NEAA/EAA ratio
is constant
values
of
.
Since there are no published data of protein and DNA levels of hair roots of normal children and few of adults, we established these values. The hair root protein level of 2 biochemical
the
those
correct. Of all the parameters investigated, the greatest change occurred in the hair root protein and DNA There was a dramatic fall in these values to 40 or 50% of the normal level in all types of malnutrition with the greatest fall in kwashiorkor. This confirms the observations of Bradfield (1-3) that in PCM there is a decrease in the number of actively growing hair roots There was also a highly significant difference between the mean values for the children with marasmus and those with kwashiorkor (Table 1). Fur-
Discussion
Mean
although
half
different
± 0.118c (13) ± 0.306c (13) ± 0.462 (6.0) ± 0.360 (13) ± 0.307’S (8.0) ± 0.315c (8.0) ± 0.10ic (8.0) to IV on from
III
71-80%
1.39
± 0.145c 1.36 (27) 2.64 ± 0.249c 2.32 (27) 2.44 ± 0.217c 2.82 (12) 7.30 ± 0.311 7.3 (27) 3.1 ± 0.231c 2.92 (19) 4.16 ± 0.286c 4.46 (19) 0.77 ± 0.094c 0.70 (19) the basis of percentage
the normal.
IV
61-70%
d
Total
± 0.08P (74) ± 0.118c (74) ± 0.159c (49) ± 0.104 (71) ± 0.115c (47) ± 0.150 (47) ± 0.041c (47) of normal
number
of subjects.
tha%
0.96 1.89 2.76 7.0 2.99 3.95 0.74 body
± 0.035t (196) ± 0.072c (196) ± 0.074c (169) ± 0.079c (192) ± 0.080c (118) ± 0.099t (118) ± 0.029c (118) weight for
Downloaded from https://academic.oup.com/ajcn/article-abstract/30/7/1094/4650489 by East Carolina University user on 16 January 2019
.
.
-
TABLE
AL.
SIGNIFICANCE ther
investigations
are
OF HAIR
required
to
ROOT
PROTEIN
AND
understand tion.
explain
this
difference. Whitehead the method
The and
the
1097
pathogenesis
of the
condiU
authors
blood
JPMC
IN PCM
wish
samples
to thank and
the
for the facilities
all those University
who
gave
hair
of Karachi
and
provided.
.
References
.
of the
less ratios
malnourished than 2 McLaren
children et al.
.
of less
dren.
than
However
in
1 . BRADFIELD, R. B., AND response to undernutrition.
had values of (14) also noted
2 in malnourished
chil-
both
(10,
these
reports
Biology
a classical
bio-
chemical finding in malnourished infants (1 5) has been verified in the present studies. The reduction was about the same in all forms of malnutrition except in kwashiorkor where it was the lowest This test therefore is not of much help in differentiating various categories of PCM. When grouped according to percentage of body weight for age , differences in the serum parameters between different grades of deficiency were not apparent. The hair root protein and DNA showed a steady decline with severity whether based on percentage
9
weight
for
age
or
PCM Therefore estimation tein and DNA can be very ing various stages of PCM .
clinical
types
RANDALL.
reagent.
WILLIN (SALLER) total serum proteins
Med.
11.
12.
13.
Technol.
Growth,
edited
root
in the
by W.
Mon-
,
21:
Protein
measurement
J. Biol. SISTER M . and albumin
Chem.
A
with
193:
265,
comparison values. Am.
of J.
1, 1955.
AND R. F. A. DEAN. Serum amino acids in kwashiorkor. II. An abbreviated method of estimation and its application. Am. J. Clin Nutr. 14: 320, 1964. JELLIFE, D . B . The assessment of the nutritional status of the community . WHO Monograph Series No. 53. World Health Organization, Geneva 1966. BRADFIELD, R. B., AND E. F. P. JELLIFFE. Early assessment of malnutrition. Nature 225: 283, 1970. BOLLET, A. J., AND S. OWENS. Evaluation of
WHITEHEAD,
nutritional
Am.
R. G.,
status
J. Clin. Nutr.
of selected
hospitalized
patients.
26: 931, 1973.
14.
MCLAREN, D. W., W. W. KAMEL AND N. M’youB. Plasma amino acids and the detection of protein-calorie malnutrition . Am . J . Clin . Nutr. 17: 152, 1965.
15.
WATERLOW,
of
of hair root prouseful in detectand further help
.
10.
.
of body
R. F.
folin phenol 1951.
AND
.
albumin,
Hair
and R. B. Dobson. New York: Pergamon 1969, vol. X p.109. 2. BRADFIELD, R. B. A rapid tissue technique for the field assessment of protein-calorie malnutrition. Am. J. Clin. Nutr. 25: 720, 1972. 3 . BRADFIELD, R. B . Hair tissue as a medium for the differential diagnosis of protein-calorie malnutrition, a comrnentary. Tropical Pediat. 84: 294, 1974. 4. CROUNSE, R. G., A. J. BOLLET AND S. OWENS. Quantitative tissue assay of human malnutrition using scalp hair roots. Nature 228: 465, 1970. 5. CROUN5E, R. G., A. J. BOLLET AND S. OWENS. Tissue assay of human protein malnutrition using scalp hair roots. Trans. Asso. Am. Phys. 83: 185, 1970. 6. BRADFIELD, R. B., AND S. 0. GRAY. Simplified procedure for field preparation of hair DNA specimens. Lancet 1: 406, 1975. 7. HINEGARDNER, R. T. An improved fluorometric assay for DNA. Anal. Biochem. 39: 197, 1971. 8. LOWRY, 0. H., N. J. ROSENBROUGH, A. L. FARR
.
in serum
Hair
BAILEY.
In: Advances
tagna Press,
14) there were much higher ratios in PCM than were found in our study. These high ratios were correlated with low total serum proteins (around 4 .5). In this study as well as in previous unpublished investigations in our laboratory, we have failed to find much change in serum total proteins in malnutrition although changes occur in its constituent fractions. The total serum protein levels are not greatly different from normal nor are they altered by treatment and improvement of the disease Hence there is no rationale for the common practice of including total serum protein analysis in the assessment of malnutrition or public health surveys. We observed a rise in the globulin fraction and a decrease in the A/G ratios in all forms of PCM Since most of these cases were complicated by infection this is probably attributable to increase in y globulins. Reduction
of Skin,
R. A.
J. C.,
AND
G. A. 0.
ALLEYNE.
tein malnutrition in children , advances edge in the last ten years. Adv. in Prot. 117, 1971.
Pro-
in knowlChem. 25:
Downloaded from https://academic.oup.com/ajcn/article-abstract/30/7/1094/4650489 by East Carolina University user on 16 January 2019
and Dean (10) in establishing for the determination of the NEAA/EAA ratios stated that healthy wellfed children have a ratio less than 2 However out of 39 healthy children in our study five had ratios of 2 or more Moreover some
DNA
K. Zain,3
A.
H. Haquani,4
Naveed
of hair root protein malnutrition1’ 2
Qureshi,5
and
Iffat
el Nisa5
ABSTRACT acid ratio,
Hair root protein and DNA, serum nonessential amino acid/essential amino serum total protein, albumin, globulin and albumin/globulin ratio were estimated in children suffering from protein-calorie malnutrition (PCM) and the values compared to those obtained from healthy children. The data were presented in two ways: 1) classified as early malnutrition, marasmus, marasmic kwashiorkor, or kwashiorkor and the parameters compared; 2) all the malnourished children were divided into four groups on the basis of percentage of body weight for age and the parameters compared . There was a progressive decrease in the content of hair root DNA and protein with the severity of PCM with these values decreasing to less than half of the normal values. In all types of PCM the serum albumin decreased significantly and the globulin increased while the total protein was altered only in the more severe stages. Differences in the serum constituents between groups were more pronounced when classified clinically than when grouped as percentage of normal body weight. Since hair root changes are progressive and of greater magnitude than those in the serum, hair root DNA and protein might be useful chemical criteria in detecting various stages of PCM, and further to help understand the pathogenesis of the condition. Am. J. Clin. Nutr. 30: 1094-1097, 1977.
Although protein calorie malnutrition (PCM) has been studied extensively, the best criteria for its detection in early stages and further classification have not yet been established Since changes in physical characteristics of hair have always been one of the most prominent features of PCM and since the cells of the hair matrix have one of the highest turnover rates, .Bradfield (1-3) .
advocates
hair
malnutrition dren
tissue
for
Examining
.
suffering
the
assessment
hair
from
roots
marasmus
of
of chiland
kwa-
shiorkor he has observed a significant reduction in the mean hair root diameter as well as changes in the morphology. Chemical quantitation of these hair root changes might be of great value in detecting marginal
and
early
(4) determined roots
of
causes.
the DNA
normal
and
Crounse
and protein
protein
et
al.
of hair
malnourished
adults and observed significantly lower values in the latter. They found a significant correlation between hair root volume and soluble protein, and also between soluble protein and DNA content (5). Bradfield and Owens (6) also reported a significant correlation
between
DNA. In our study tent of the hair 1094
hair
root
diameter
the DNA and protein roots of PCM children
The American
Journal
ofClinical
and
conhave Nutrition
been determined along with the nonessential amino acid/essential amino acid ratio (NEAA/EAA), serum albumin, globulin, total protein, and albumin/globulin (A/G) ratio to see how biochemical changes in the hair root compare with other established criteria of PCM. Materials
and methods
Three hundred thirty five children from 4 months to 5 years, clinically diagnosed as suffering from PCM were studied from July 1974 to June 1976, in the Pediatric Ward of Jinnah Postgraduate Medical Center, Karachi . Hair and blood samples were taken before any treatment was given . Normal samples were collected from 48 children 2/2 to 5 years of age attending private nursery schools in Karachi . This represents a middle to upper socioeconomic group in Pakistan. Hair was plucked by a quick pull with Tygon-coated hemostat from the occipital area, and placed in 0.14 M saline and examined with a microscope . Hair roots (10 to 30) with intact bulbs were selected for analysis. The samples were extracted in 1 .5 ml of 1 N NHOH in a ground glass homogenizer and centrifuged (5). From the supernatant DNA was determined by the fluoro-
From
1
of Karachi
the
Department
graduate 2 Supported
project 3
rics.
of Biochemistry,
and Department Medical Center, by
the
University
of Pediatrics, Jinnah Karachi, Pakistan. Pakistan
Science
Post-
Foundation,
Su-CH-44.
Associate
Professor.
Research
30: JULY
1977,
Professor
of
Pediat-
Officer. pp.
1094-1097.
Printed
in U.S.A.
Downloaded from https://academic.oup.com/ajcn/article-abstract/30/7/1094/4650489 by East Carolina University user on 16 January 2019
Studies on the significance and DNA in protein-calorie
SIGNIFICANCE
OF
ROOT
HAIR
method of Hinegardner (7) and soluble protein by Lowry’s method (8). Serum total protein was estimated by the biuret method (9) and serum albumin with the Albustrate metric
reagent
the
determined overnight
fast
and have
were
malnutrition, kwashiorkor
taken after an by the paper
of Whitehead
been
and
were determined
ratios
and Dean (10). in two ways. First to clinical diagnosis:
tabulated
divided
early or
samples
the
method
The results cases
where
blood
chromatographic
(Morris Plains, N.J.). The were taken as the globulin the amino acid ratios were
according
marasmus, marasmic kwashiorkor, the biochemical data were deter-
mined for each category. The criteria used for clinical diagnosis were as follows: early malnutrition these children were usually in the first year of life with infection, failing to gain weight, and had been receiving insufficient calories and protein . Loss of subcutaneous fat
and
muscle
wasting
were
not
apparent
They could
.
not fit into any of the following categories. Marasrnusgrowth failure, obvious loss of subcutaneous fat and wasting of muscles in the first 3 years of life but usually in the first year; appetite not so poor. Kwashiorkorgrowth failure, edema, wasted muscles with some subcutaneous fat, apathy, and poor appetite; hair and skin
changes may or may not be present. years. Marasmic viz., a rnarasmic
child
intermediate
with
very
slight
edema
edema but marked hair and skin changes kwashiorkor. Alternately the cases were four groups on the basis for age using the tables
Harvard
significance
determined
by the
showing
a greater
of PCM
with
in kwashiorkor,
decline
the
with
the
the value
severity
of the disease The level in early malnutrition was not significantly different from the normal, but in all the other types of PCM it .
was significantly lower than the normal value (P < 0.0001) and also significantly lower than the value in early malnutrition. The value observed in kwashiorkor was significantly less than in marasmus (P < 0.001). The hair root protein was less than onehalf the normal value in all types of malnutrition (P < 0.0001). The level in kwashiorkor was less than ‘/3 the normal value and was significantly lower (P < 0.001) than that of early malnutrition, marasmus and marasmic
The cantly
kwashiorkor.
NEAA/EAA (P < 0.0001)
seen
malnutri-
The level in kwashiorkor was significantly higher (P < 0.001) than that in marasmus. Serum albumin decreased significantly from the normal in all cases (P < 0.001
groups
test.
the
next
was
signifiof PCM.
or no
of difference
ratio
ratio increased in all types
and
as seen in divided into
between
decrease
highest
weight on the
t
in all types
greatest
1095
tion
of percentage of body in Jelliffe (1 1) based
Student’s
decreased
IN PCM
The
standards.
Statistical was
DNA
form,
Age usually 1 to 4
kwashiorkor-an
tent
AND
in early
highest
in kwashiorkor.
to 0.0001), however the level was about the same in early malnutrition, marasmus, and marasmic kwashiorkor. The value in kwa-
Results
shiorkor
Table 1 shows the results of normal children and those with various forms of PCM. The mean DNA level of normal children was 2.01 pg/hair root and the mean protein level was 6.01 p,g/hair root. The DNA con-
mus or marasmic kwashiorkor (P < 0.001). The globulin was significantly (P < 0.001) elevated in all forms of PCM The A/G ratio decreased significantly (P < 0.001) in all types of PCM. The values in early malnutrition and kwashiokor were significantly less
TABLE 1 Mean biochemical
values
in clinical Early
type
1.76
pg/hair root Protein pg/hair root NEAA/EAAratio
mal
2.83
±
3.5
total
7.4
protein g/100 Serum albumin g/iOO ml
Globulin A/G a
ml
0.256b
±
g/iOO ml
4.71 0.55
ratio
Mean
±
SE
.
± 0.234
b
±
0295b
(30) ± 0.23’s (30) ±
±
0.98
0047b
0074b
(30) Significantly
different
than
in maras-
±
2.32
±
2.4
0131b
0.82
0062b
±
1.65
0138b
(99) 2.5 ±
0#{149}110b
(89) 7.32 ± 0.089 (130) 34 0.072’s (86) 4.2 ± 0.26” (86) 0.90 ± 0036b (86) from the normal
±
.
±
2.71
0#{149}087b
0.l2Sb
6.5
(97) 3.32
±
3.75
(36) ± 0.27 (36)
0.84 .
±
0#{149}134b b
2.62 453 0.65
0052b
(36) Total
± 0072b (74)
2.01
±
6.01
0099b
number
of
±
O.lS2
(55) ± O.l3O (67) ± 0.i26 (56) 0.2P (56) ± 0042b (56) subjects.
±
0.105
(48)
(74)
(76) 7.03
Normal
Kwaslnrokor
(99)
(132)
(30) 3.1
Marasmic . kwashiorkor
(132)
(30) (10)
Serum
1.16 2.35
0289b
less
.
Marumus
. .
± 0.176a (30)”
significantly
of PCM
nutnt,on
DNA
was
±
0.19
(48) 1.68
±
0.051
(39) 7.5
±
0.140
(30) 4.16
±
0.07
(22) 3.1
±
0.150
(22) .20
±
(22)
0.074
Downloaded from https://academic.oup.com/ajcn/article-abstract/30/7/1094/4650489 by East Carolina University user on 16 January 2019
between all cases
levels. In
the
Lambert these
of Warner
differences
PROTEIN
ZAIN
1096
ET
than those in marasmus and marasmic kwashiorkor (P < 0.001). When the subjects were divided into grades on the basis of percentage of body weight for age (Table 2) as proposed by Bradfield and Jelliffe (1 2) there was a progressive decrease in hair root DNA and protein with the decline in body weight . All the values even those in grade I were significantly less (P 0.001) than normal, and the value of those in grade IV (weight less than 60%) was significantly lower (P < 0.001) than that of the others. The NEAA/EAA ratio was only elevated significantly (P < 0.0005) in grades II, III, and IV. The serum total protein did not show any decrease until malnutrition was very severe (grade IV) and this decrease was significant only at the 1 % level. The serum albumin significantly decreased from the normal in all grades but did not differ significantly from grade to grade The globulin similarly was elevated in all grades above the normal but did not differ between the grades except that the value in IV was significantly less than in III. The A/G ratio was from 0 .7 to 0 .78 in all cases which again was significantly less than the normal values.
normal adults which we observed in our laboratory, 1 1 .26 j.g/hair root is lower than that of 1 8 .04 tg/hair root as reported by Crounse et al. (5) However a later paper from the same laboratory (1 3) reported a mean of 14 .25 jig/hair root and stated that the lower limit of normal was 9 Our mean therefore is within this range Those authors (13) found no difference between whites and nonwhites, so our values falling within the same range can be taken as further evidence for lack of a racial difference in the hair root chemistry. Crounse et al. (5) reported a very low level of DNA (0 .85 pg/hair root) for normal adults while we observed 3 .65 j.g/hair root. In our normal subjects the mean hair root protein level was about 3 times greater than the mean DNA, both in children and .
adults,
about ratio
.
values
in grades
2.01
± ±
1.53
0.19
3.22
0.051
2.29
(39) Serum total protein g/100 ml Serum albumin gIlOOml Serum globulin g/100 ml
A/G
The
a
age
7.56
± 0.140 7.51 (30) 4.16 ± 0.07 3.38 (22) 3.1 ± 0.150 4.31 (22) 1.20 ± 0.074 0.78 (22) divided into grades I
ratio
.
subjects b
Mean
were ±
SE
.
Significantly
believe
II
I
(48) 1.68
in children
adults. the
Since values
are
the to be
.
90-81%
± 0.lO5’ (48)”
6.01
we
the
of PCM5
100%
DNA pg/hair root Protein pg/hair root NEAA/EAA ratio
is constant
values
of
.
Since there are no published data of protein and DNA levels of hair roots of normal children and few of adults, we established these values. The hair root protein level of 2 biochemical
the
those
correct. Of all the parameters investigated, the greatest change occurred in the hair root protein and DNA There was a dramatic fall in these values to 40 or 50% of the normal level in all types of malnutrition with the greatest fall in kwashiorkor. This confirms the observations of Bradfield (1-3) that in PCM there is a decrease in the number of actively growing hair roots There was also a highly significant difference between the mean values for the children with marasmus and those with kwashiorkor (Table 1). Fur-
Discussion
Mean
although
half
different
± 0.118c (13) ± 0.306c (13) ± 0.462 (6.0) ± 0.360 (13) ± 0.307’S (8.0) ± 0.315c (8.0) ± 0.10ic (8.0) to IV on from
III
71-80%
1.39
± 0.145c 1.36 (27) 2.64 ± 0.249c 2.32 (27) 2.44 ± 0.217c 2.82 (12) 7.30 ± 0.311 7.3 (27) 3.1 ± 0.231c 2.92 (19) 4.16 ± 0.286c 4.46 (19) 0.77 ± 0.094c 0.70 (19) the basis of percentage
the normal.
IV
61-70%
d
Total
± 0.08P (74) ± 0.118c (74) ± 0.159c (49) ± 0.104 (71) ± 0.115c (47) ± 0.150 (47) ± 0.041c (47) of normal
number
of subjects.
tha%
0.96 1.89 2.76 7.0 2.99 3.95 0.74 body
± 0.035t (196) ± 0.072c (196) ± 0.074c (169) ± 0.079c (192) ± 0.080c (118) ± 0.099t (118) ± 0.029c (118) weight for
Downloaded from https://academic.oup.com/ajcn/article-abstract/30/7/1094/4650489 by East Carolina University user on 16 January 2019
.
.
-
TABLE
AL.
SIGNIFICANCE ther
investigations
are
OF HAIR
required
to
ROOT
PROTEIN
AND
understand tion.
explain
this
difference. Whitehead the method
The and
the
1097
pathogenesis
of the
condiU
authors
blood
JPMC
IN PCM
wish
samples
to thank and
the
for the facilities
all those University
who
gave
hair
of Karachi
and
provided.
.
References
.
of the
less ratios
malnourished than 2 McLaren
children et al.
.
of less
dren.
than
However
in
1 . BRADFIELD, R. B., AND response to undernutrition.
had values of (14) also noted
2 in malnourished
chil-
both
(10,
these
reports
Biology
a classical
bio-
chemical finding in malnourished infants (1 5) has been verified in the present studies. The reduction was about the same in all forms of malnutrition except in kwashiorkor where it was the lowest This test therefore is not of much help in differentiating various categories of PCM. When grouped according to percentage of body weight for age , differences in the serum parameters between different grades of deficiency were not apparent. The hair root protein and DNA showed a steady decline with severity whether based on percentage
9
weight
for
age
or
PCM Therefore estimation tein and DNA can be very ing various stages of PCM .
clinical
types
RANDALL.
reagent.
WILLIN (SALLER) total serum proteins
Med.
11.
12.
13.
Technol.
Growth,
edited
root
in the
by W.
Mon-
,
21:
Protein
measurement
J. Biol. SISTER M . and albumin
Chem.
A
with
193:
265,
comparison values. Am.
of J.
1, 1955.
AND R. F. A. DEAN. Serum amino acids in kwashiorkor. II. An abbreviated method of estimation and its application. Am. J. Clin Nutr. 14: 320, 1964. JELLIFE, D . B . The assessment of the nutritional status of the community . WHO Monograph Series No. 53. World Health Organization, Geneva 1966. BRADFIELD, R. B., AND E. F. P. JELLIFFE. Early assessment of malnutrition. Nature 225: 283, 1970. BOLLET, A. J., AND S. OWENS. Evaluation of
WHITEHEAD,
nutritional
Am.
R. G.,
status
J. Clin. Nutr.
of selected
hospitalized
patients.
26: 931, 1973.
14.
MCLAREN, D. W., W. W. KAMEL AND N. M’youB. Plasma amino acids and the detection of protein-calorie malnutrition . Am . J . Clin . Nutr. 17: 152, 1965.
15.
WATERLOW,
of
of hair root prouseful in detectand further help
.
10.
.
of body
R. F.
folin phenol 1951.
AND
.
albumin,
Hair
and R. B. Dobson. New York: Pergamon 1969, vol. X p.109. 2. BRADFIELD, R. B. A rapid tissue technique for the field assessment of protein-calorie malnutrition. Am. J. Clin. Nutr. 25: 720, 1972. 3 . BRADFIELD, R. B . Hair tissue as a medium for the differential diagnosis of protein-calorie malnutrition, a comrnentary. Tropical Pediat. 84: 294, 1974. 4. CROUNSE, R. G., A. J. BOLLET AND S. OWENS. Quantitative tissue assay of human malnutrition using scalp hair roots. Nature 228: 465, 1970. 5. CROUN5E, R. G., A. J. BOLLET AND S. OWENS. Tissue assay of human protein malnutrition using scalp hair roots. Trans. Asso. Am. Phys. 83: 185, 1970. 6. BRADFIELD, R. B., AND S. 0. GRAY. Simplified procedure for field preparation of hair DNA specimens. Lancet 1: 406, 1975. 7. HINEGARDNER, R. T. An improved fluorometric assay for DNA. Anal. Biochem. 39: 197, 1971. 8. LOWRY, 0. H., N. J. ROSENBROUGH, A. L. FARR
.
in serum
Hair
BAILEY.
In: Advances
tagna Press,
14) there were much higher ratios in PCM than were found in our study. These high ratios were correlated with low total serum proteins (around 4 .5). In this study as well as in previous unpublished investigations in our laboratory, we have failed to find much change in serum total proteins in malnutrition although changes occur in its constituent fractions. The total serum protein levels are not greatly different from normal nor are they altered by treatment and improvement of the disease Hence there is no rationale for the common practice of including total serum protein analysis in the assessment of malnutrition or public health surveys. We observed a rise in the globulin fraction and a decrease in the A/G ratios in all forms of PCM Since most of these cases were complicated by infection this is probably attributable to increase in y globulins. Reduction
of Skin,
R. A.
J. C.,
AND
G. A. 0.
ALLEYNE.
tein malnutrition in children , advances edge in the last ten years. Adv. in Prot. 117, 1971.
Pro-
in knowlChem. 25:
Downloaded from https://academic.oup.com/ajcn/article-abstract/30/7/1094/4650489 by East Carolina University user on 16 January 2019
and Dean (10) in establishing for the determination of the NEAA/EAA ratios stated that healthy wellfed children have a ratio less than 2 However out of 39 healthy children in our study five had ratios of 2 or more Moreover some
DNA
