THIAMINE STATUS in PROTEIN ENERGY MALNUTRITION Hamed A

SCI. MED. J. CAI. MED. SYNL). VOL. 8, NO. 1,Jan., 1996.

THIAMINE STATUS IN PROTEIN ENERGY MALNUTRITION Hamed A. Elkhayat*, Sa~zaaA.R. Mahrnoud*, Ahmed S. Hafez** and Osama Nour-Eldeen * (Department of Pecliatrics * and Community Medicine **, Faculty of Medicine, Ain Sharns University).

ABSTRACT Serwn thianzine was studied in 51 nzalnourished infants and children and in the sera of 17 apparently healthy infants and children sewing as a control group for apossible role of thiamine deficiency in nutritional edemagenesis. Patients were categoirzed according to Wellcome's classification into kwashiorkor, rnarasmus and marasmic kwashiorkor groups. Z'he mean serum thiamine levels of patient groups were significantly lower than that of the control group with lower values in kwash~orkorgropus than in the rnurastnic group. The nzean serum pyruvic acid levels, a substrate for thiunzinc. pyro~~l~osphutecoenzytne, were sigr~$cantly higher in the patient groups than in the control group. There was a sign(ficanr positive correaltion between serftin thianzine and albunzin levels arnong the nzalnourished gropus. We concluded that serunz tlzianzine dejiciency and consequently the accunzulation of pruvic acid besides hypoalbunzinenzia nzay play a role in the pathogenesis of edema in protein energy malnutrition.

Gdenia usually develops early in led to functio~ialthiamine deficiency (5), protein energy malnutrition. Some oxidative decarboxylation of of ketoacids researches suggested that and transketolation with accumulation of hypoalbuminemia is a major cause of the substrates of he reactions e.g. edema in kwashiorkor (I), while othcrs pyruvate and the kelocarboxylate believe that hypoalbuminhernia plays an insignificant role (2). Kidney malfunction dcrivatives of the branched ellain amino due to potassium deficiency (3) and acids (6). increased mineralocorticoids, renin and This work aims at studying the role antidiuretic hormone activities were also played by thiamine in Ihe pathogenesis of suggested factors responsible for ederna as a contributing factor lo other edemagenesis (4). etiological agents in cases of protein Malnutrition in rats fed differ en^ diets energy malnutrilion. containing variable amounts of proteins 52 -...-- ,,,,,, Hatn ed El Khayat, Sanaa Mahmo ud et al., ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;i

SUBJECTS & METHODS

The study was conducted on 68 Group IV : comprised 17 healthy subjects (36 males & 32 females) infants and children (11 males and 6 attending the nutrition out-patient clinic females) of a similar socioeconomic and the inpatient ward of the Children status of the patient groups serving a$ a Hospital of Ain Shams University. Their control group. age ranged from 3 to 42 months with a The following biochemical analyses median age of 13 months. Detailed were performed: history was k&en, thorough physical examination, and anthropometric 1- Serum albumin using drupt nleasurements were performed. technique (1974) (8). 2- Estimation of total serum proteins Patients were classified according to as determined by Peters, 1968 (9). Wellcome's classification of rotei in energy malnutrition into four groups: 3- Estimation of serum thiamine using thiochrome nlelhod (10). Group I : Comprised 17 kwashiorkor pateints (kwo); 12 males arid 5 females. 4- Estimation of serum pyruvic was performed bv Friedman & Haugan.- 1943 Group I1 : comprised 17 marasmus (1 1). patients; 7 males and 10 females. A11 clinical and laboratory data were Group 111 : Comprised 17 marasmic analyzed using t-test and correlation kwashiorkor patients (marasmic kwo): 6 coefficient (R) test (12). Signifkant level males and 1 1 females. was considered when P < 0.05.

RESULTS

The age of the studied patient groups group (p < 0.001). The mean weight for ranged from 3 ro 42 months. The mean age values for marasmic and marasmic age of the four studied groups was 13.7 + kwo groups are significantly lower than 8.8, 9.8 + 6.3, 13.5 f 1 and 16.8 + 10.3 that of the kwo group (p < 0.001). months for groups I, 11, I11 & IV The mean length for age values of respectively. kwo, marasmic and marasmic kwo groups Their ~neariweights were 6.3 - 1.7, are significantly lower than that of the 4.2 + 1.1, 5.2 ? 1.5 and 10 + 2.4 kg control group (p < 0.001). Thc mcan respectively. Table (1) shows that the length for age values of the marasmic mean weight for age values of kwo, kw~group is significantly lower thrm that rnarasmus and marasmic kwo groups are of the kwo group (p < 0.001). Thc mean significantly lower than that of the kwo wcighr for length values of the kwo, -..------...... Thiamine Status in ... ;;;;;;; marasmic and marasmic kwo groups are group is significantly higher than that of significantly lower than that of the control the marasmic kwo group (p < 0.001). group (p < 0.001) while there is no The mean serum pyruvic levels of the statistically significant difference among 3 patients groups are significantly higher the kwo, marasmic and marasmic kwo than that of the control group. groups. the mean serum levels of the Table (2) shows the mean serum marasmic and the marasmic kwo gropus thiamine level (mgldl) and the mean are significantly lower than that of the serum pyruvic acid level (mgldl). kwo group (p < 0.05). There is a negative The mean serum thiamine levels of the correlation between the mean serum kwo, marasmus and marasmic kwo thiamine and pyruvic acid levels, groups (1.1 + 0.3,0.4 and 1.3 4 0.3 mgldl however statistically insignificant (p > respectively) are significantly lower than 0.05). There is a positvie correlation that of the control group (2 4 0.5 mgldl). between the mean serum thiamine and The mean serum thiamine level of the albumin levels which is statistically kwo group is significantly lower than that significant (p < 0.001) (Figures 1 & 2). of the marasmic group, and the mean There is no correlation between thiamine serum thiamine level of the marasmic and weight for age or weight for length.

DISCUSSION

The causal relationship between ede- thus hypoalbuminemia per se could not ma of malnutrition and hypoalbuminemia be the sole factor for the development of is proved in the present study as albumin edema in malnourished infants. This level was low in the sera of the malnu- finding is consistent with Landman and rourished groups. This notion is as well Jackson (1980) who found that kwo is not more emphasized by the finding that ser- always assocaited with protein deficient um albumin was significantly lower in diet (14). In addition Golden in 1982 kwo and marasmic kwo groups than in the stated that the rate of dedma resolution is marasmic group. This result agrees with strongly correlated with dietary energy that obtained in 1984 by Laditan (13) who intake rather than protein intake (15). found a significant negative correlation Thus other factors besides between edema and serum albumin. hypoalbuminemia have contributed to the Since serum albumin was low in both pathogenesis, sustenance and regresdsion edematous (kwo & marasmic kwo) and of nutritional edema (13). non edematous malnourished group The relationship between edema in (marasmic) and since serum albumin level wet beriberi and thiamine deficiency is a was normal in 3 patients of our studied fact stated by Vichai et d., in 1970 (16). kwo group despite the presence of edema, The important biochemical features of 54 ,,,,,,------Hamed EZKhaynt, Sanaa Mah~noudet al., ......

Table (1) :Mean and SD of Weight for age (%) and Weight for length in all groups.

Control Kwo Marasmus Marasmic Kwo (No = 17) (No = 17) (No = 17) (No = 17)

Mean weight for 90.9 + 8.1 63.6 + 5.8 51.1 If: 6.8 53.3 k 7.6 age %

Mean length for 95.9 rf: 5.4 89.7 +- 5.5 84.3 + 6.8 82.7 + 6.2 age %

Mean weigh 92.9 2 5.7 63.3 2 16.1 68 _+ 9.3 70.3 +- 10.8 for length 55 ...... Thiamine Status in ... ;<<<<,i

0 1 I I I I I 0 0.25 0.5 0.75 1 1.25 1.5 1.75 2 2.25 Thiamine (rng/d~)

Fig. (1) : Correlation between thiamine and serum albumin- 56 ...... ,,,,,,.---.-- Ha~ned ElKhayat, Sanaa Mahmoud et al., ......

00I 0 0.25 0.5 0.75 1 1.25 1.5 1.75 2 2.25 Thiamine (mgldl)

Fig. (2) : Correlation between thiamine and serum pyruvic acid. 57 _-_----_--.-._-_-.----.---.------*.----.-_-.------.--_-.-.-.- ...... Thiamine Status in ... ;<;;<<;

lliiamirie deficiency include increased dullness and apathy seen in some of the concentrations of pyruvic and lactic acid edematous malnourished subjects were in blood (17). This fact was evident in our aggravated by thiamine deficiency. study, however Suberlich in 1967 (18) The significant positive correlation found that fasting pyruvate level was between serum albumin and thiamine normal in Lhiamine deficiency and only could prove that deficiency of both rises following a glucose load. albumin and thiamine contribute to the Despite their biochemical thiamine develop~nentof edema in the studied deficiency, our studied subjects did not patients, however the exact relationship show classical features of beriberi. awaits further investigations. Although it is possiblc that the mental

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