Infection and and marasmus

R. G. Whitehead, Ph.D.,

the development in Africa1 2

M.A., F.I.Biol.

of kwashiorkor

ABSTRACT on the dren. development

Infection,

particularly

gastroenteritis

and

malaria,

can

have rural

a profound African chil-

effect

Am.

I. Clin.

of both growth faltering and Nutr. 30: 1281-1284, 1977.

hypoalbuminemia among

Elsewhere in this issue, Dr. Mata, a self-edema as well as to the processes of wasting (1). I made a point in an earlier discussion confessed frustrated microbiologist-bacteto Dr. Beisel and to Dr. Powanda, stressing riologist, takes us away from the laboratory, episodes of infection tended to follow out of the ward, into a Guatemalan village. how Now I, an equally frustrated biochemist, one another. Figure 1 illustrates this fact clearly. would like to do the same, but to take you very away from my laboratory in Cambridge into The importance of infection in the poor growth performance of Gambian children two African villages. already been studied extensively by For the past 5 years or so, my main scien- had and his colleagues (2), and betific interest has been to define why some McGregor it was our ultimate aim to introduce African children, subjected to what is now cause to improve the situation, it was called protein-energy malnutrition, develop schemes for us to try and quantitate to kwashiorkor, whereas others, perhaps the necessary extent the widespread marasmus majority, become victims of marasmus. I am what in these villages was due to sure readers are aware that the classic die- which is found as well as to a poor diet. tary explanation for the etiology of theseinfections Figure 2 shows the mean weight and two different types of malnutrition has been of the children relative to the Jelliffe in dispute. In an attempt to define moreheight (1966) standards (3). Weight faltering becompletely the wide range of environmental soon after 3 months of age, and the hazards which might be contributing to the gan was much greater during the 1st year development of these two forms of protein- effect energy malnutrition, we have carried out of life than in subsequent years. Estimates of incremental gains in weight two prospective 3-year longiludinal studies and length were also calculated from mearather like those of Dr. Mata and his colleagues in Guatemala. surements made routinely every month (4). interval between one anthropometnic One of our studies was in a village called The measurement and the next was then Namulonge, in Uganda, where kwashiorkor for bouts of illness. The duration is the predominant nutritional disease. Thesearched illness was then used to determine other study is at present being conducted inof each of lime the child was being Keneba, in The Gambia, West Africa,the proportion where marasmus is more frequently encoun- affected by that particular illness. The relationship between height and tered. weight gain and the duration of each of nine In both villages we have shown that the categories was then investigated by pattern of infection, as well as dietary inade- disease quacy, is clearly implicated. Figure 1 shows From the village called Namulonge, Uganda, and some of our very early results from Uganda; Keneba, in The Gambia, West Africa. it is obvious that episodes of frequent infec2Address reprint requests to: R. G. Whitehead, tion were responsible for the processes lead- Ph.D., M.R.C. Dunn Nutrition Unit, Milton Road, ing to hypoalbuminemia and hence to Cambridge, CB4 IXJ, England.

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The

American

Journal

of

Clinical

Nutrition 30:

AUGUST

1977,

pp.

1281-1284.

Printed

in

U.S.A.

1281

1282

WHITEHEAD

.4

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.

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-

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100

0/

OF

STANDARD HEIGHT 90 FOR AGE

80
WEIGHT FOR AGE

I AGE
(y..rs)

FIG.
in a rural

2.

Percentage
Gambian

weight
village.

and

height

for

age,

judged

by

the

Jelliffe standard (3)

of children

ages 0.6 to 3 years

INFECTION, TABLE Regression children 1 coefficients ages 0.6 to SE 3 years from from

KWASHIORKOR,

AND

MARASMUS

1283

the regressions Keneba village,

of

height gain The Gambia

and

weight

gain

in

nine

categories

of

illness

in

Regressio Illness categoryR Ht gain mm/month

n coefficientsb Wt gain g/month

Upper Lower

respiratory respiratory

tract tract

infections infections

Gastroenteritis

Infectious fevers Malaria Giardiasis Superficial infections Deep infections Nonspecific disorders
12

-0.8 -3.1 -4.2 -1 .0 -7.0 0.3 -0.1 -0.9 -1.1 in P<0.05. growth rate

1 .8 2.6 1 5c 3.0 6.0 2.1 2.0 2.0 4.9 100%

-81 79 -53 117 -746 68 79 135 -1072 268 -131 93 25 88 27 91 440 219 prevalence and 10% preva-

For

definitions P<0.01.

see

(4).

Difference

between

lence.

dp<#{216}#{216}

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WEHT GAIN

n,nth

DIARRHOEA

PRE%tLENCE(%) by season in the September-October 1975; =7 May-June village of Keneba, The 1974; 4 = November1975; 8 SE July-August Gambia.

FIG. 3. Fitted relationship betw,een weight gain and diarrhea Periods of the year: I = May-June 1974; 2 = July-August 1974; 3 December 1974; 5 SE January-February 1975; 6 SE March-April 1975; 9 = September-October 1975.

son in The Gambia, when the previous be given years cereal crop has been used up and theease and new harvest is not yet ready. At this timethis is a there is little doubt that dietary improve- achieved, ment is necessary in the village, at least as sponsibility a short-term expedient. However, the role of quo, in diet in improving the nutritional status of child is this community at other times needs critical has been evaluation. There can be no doubt that in Children these villages a primary consideration must as those

to the reduction of diarrheal disto the eradication of malaria. But very tall order, and until it has been the nutritionist does have the reof trying to restore the status other words, making sure that the able to put back any weight which lost due to the diarrhea or malaria. who were as much underweight shown in Figure 2 should have been

1284

WHITEHEAD

growing very much faster than 240 g/month. normal rate. Certainly, when growth is freIn other words, they should have been quently being held back by periodic infecnutrient needs for catch-up must be showing quite dramatic catch-ups. Their di-tions, etary intake during most of the year, beallowed for if the child is not going to be tween the ages of 1 and 3 years of age, was permanently stunted. in the region of 400 kJ/kg/day. Although this would have allowed for a moderate degree of growth, approaching perhaps nor- References mal rates, it was insufficient to allow for any 1. FROOD, J. D. L., R. G.WHITEHEAD AND W. A. catch-up. COWARD. Relationship between pattern of infecThere have been various attempts in retion and development of hypoalbuminaemia and cent years to calculate how much energy and hypo--lipoproteinaemia in rural Ugandan children. Lancet 2: 1047, 1971. how much protein are required to support I. A., A. K. RAHMAN, A. M. THOMdifferent rates of catch-up growth, and these 2. MCGREGOR, SON, W. Z. BILLEWICZ AND B. THOMPSON. The will be discussed elsewhere. Because the health of young children in a West African (Gampercentage increase in protein requirement bian) village. Trans. Roy. Soc. Trop. Med. Hyg. is greater than the percentage increase in 64: 48, 1970. 3. JELLIFFE, D. B. The Assessment of the Nutritional energy, the protein:energy ratio of the diet Status of the Community. Monogr. Series No. 53, needs to be increased as well. Studies in our Geneva: World Health Organization, 1966. metabolic ward, both in Uganda and in The 4. ROWLAND, M. G. M., T. J. COLE AND R. G. Gambia, have indicated that rates of growth WHITEHEAD. A quantitative study into the role of infection in determining nutritional status in Gamin children from these villages can reach bian village children. Brit. J. Nutr. 37: 441, 1977. many times the overall mean normal rate 5. MCGREGOR, I. A., A. K. RAHMAN, B. THOMPwhen they are provided with sufficient food. SON, W. Z. BILLEWICZ AND A. M. THOMSON. The Even within the village itself,many children growth of young children in a Gambian village. exhibited growth rates up to 4 times the Trans. Roy. Soc. Trop. Med. Hyg. 62: 341, 1968.

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