19 Junie 1965 S.A. TYDSKRIF VIR GENEESKUNDE 491 (Byvvegsel- Suid-Afrikul/Ilse Tydskrif vir VoedillK) V 33
TABLE IV. AVERAGE PERCENTAGE OF THE DAILY REQUIREMENTS OF NUTRIENTS SUPPLIED BY O:-lE SLICE OF BREAD (25 G)
Calories Protein Calcium Phosphorus Iroll Thiamill(' Ribofladll Nicotinic Acid One slice of ---- A1all Woman Man Woman Man Woman Man lVoman Mall Woman "'1an Jiloman Man Woman "-Ian ~Voma" White bread 2'2 3 '0 2 ·7 3 '3 \ ·2 1·2 4·2 4'2 4·0 2'7 3·3 5 ·0 ·82 \'1 \·1 1'6 Brown bread 2 .\ 2'9 2 '8 3 ·4 I '5 I '5 6'3 6 '3 6·0 4·0 4·2 6 ·2 \.\ 1'5 2 '5 3 '4 Who\ewheat bread .. 2-2 3·0 2 ·8 3 ·4 1'5 I '5 6 ·7 6·7 7 ·0 4·7 4·2 6 ·2 1·2 1·5 2 ·9 3 ·9 Spec. who\ewheat bread .. 2,' 2'9 2 ·7 3'3 1·8 1·8 6 '7 6 '7 6 '5 4 '3 4·2 6'2 \'1 I '5 2 '9 3 '9 is included in Table IV, and the value of the supply of those of bread produced in other urban areas of the phosphorus has been estimated on the basis suggested by Republic. Du Bruyn of NNRI (private communication), viz. that the SUMMARY desirable ratio of Ca to P is 0-84: 1. A study was undertaken to detcrmine and compare the The results show that the nutritive value of white nutrient contents of various types of bread produced in the urban area of Pretoria. Over a period of 3 - 4 months, 66 bread in respect of mineral content, thiamine and nico loaves of bread consisting of white, brown, wholewheat and tinic acid is lower than that of bread made from high special wholewheat bread were drawn from 6 bakeries which extraction flours. manufacture about 99% of the bread made in Pretoria. The moisture, protein, ash, fibre, fat, carbohydrate, calcium, Conclusions magnesium, iron, phosphorus, thiamine, riboflavin and nicotinic The conclusions drawn flOm the results of this study acid contents were determined. The calorific values of the are: samples were calculated from the data obtained. The results of this study indicate that there is no significant 1. The calcium contents of different samples of bread difference in the composition of the same type of bread tested varied considerably. produced by the 6 bakeries from which samples were drawn. 2. Each of 6 bakeries supplied the same kind of bread with no significant differences in nutrient value apart The authors wish to acknowledge the assistance of Dr. P. A. E. Kamerman of the NNRI with the practical work from calcium content. and with the preparation of the manuscript. Statistical advice 3. The thiamine and nicotinic acid contents of bread are was given by Mr. S. A. Fellingham of the NRIMS and the reduced by toasting. report was edited by Mr. V. A. Cachia of the NNRI. It is believed that the nutrient values obtained for bread REFERENCE manufactured in Pretoria would be representative of I. Engel. R_ w_ (1964): J. Amer. Diet. Assoc.. 44, 91.
BODY COMPOSITION IN PROTEIN-CALORIE MALNUTRITION
J. D. L. HANSEN, G. L. BRINK MAN AND M. D. BoWIE, Departments of Chi-ld Health lInd Medicine, University of Cape Town
The term 'protein-calorie malnutrition' is one used to from the time of admission to hospital with kwashiorkor embrace the following syndromes under a single heading: l until complete recovery have been observed in 2 subjects (I) kwashiorkor; (2) incomplete mild kwashiorkor; (3) by doing serial determinations over a period of 2 - 5 nutritional marasmus, and (4) nutritional dwarfing (or months. underweight for age). In each of these the nutritional CASE MATERIAL background is one of protein deficiency, but with varying This consisted of 32 non-White male pre-school children. levels of intake of calories especially in the form of 17 of whom were admitted to hospital with kwashiorkor carbohydrate. The syndromes of protein-calorie malnu and 7 with nutritional marasmus. The 8 other children were trition are common in developing or under-developed com of low weight for age, i.e. below thc 3rd Boston percentilc in weight, but were otherwise asymptomatic and apparently munities where the death rate among children in the 1 - 4 healthy. The children with kwashiorkor all had oedema on year age group may be 20 - 50 times as high as in affluent admission. Their clinical details arc to be presented else societies.2,3 In the planning of more effective preventative where. 26 Two of these cases were kept in a convalescent and curative measures to meet this public health problem home for 2 and 5 months respectively where they reached 96% of their expected weight for age (the 50th percentile a better understanding is needed of the effect of protein line of growth charts of the Harvard School of Public Health, calorie malnutrition on body composition and function. Bostonl2 was used as expected weight). They were then With regard to body composition it is known that total assumed to be fully recovered and equivalent to 'normal body water (TBW) is increased in malnourished child control' subjects. The cases with marasmus were extremely wasted and underweight for age but had no clinical oedema. ren4·6, 26 and that the extracellular water (ECW) is also increased.7·11 In only one instance6 has the TBW and PROCEDURE AND METHODS ECW been measured simultaneously and this was done 80dy water determinations (TOW and ECW) were performed in 'kwashiorkor' children before and after loss of oedema. on the kwashiorkor cases within 6 days of admission and In the investigation to be reported here the TBW and again after loss of clinical oedema and not longer than 20 days after the first test. The average interval between tests ECW of cases of nutritional marasmus and nutritional was 10 days. The children with marasmus and the low-weight dwarfing (underweight) have been measured. This has children were tested once only. An ECW estimation was not been done to determine whether the subjects suffering performed on the low-weight children. from these variants of protein-calorie malnutrition differ Total body water was measured by determining the dilu tion in the serum of an intramuscular injection of tritiated in body water composition from cases of kwashiorkor. water allowing 5 hours for equilibration.13 Extracellular water In addition the changes that occur in body composition was measured with sodium thiosulphate.14 492 S.A. MEDICAL JOURNAL 19 June 1965 N 34 (SupplemellC - Sowll African Journal of Nwrition)
RESULTS lute weight instead of percent expected weight is used The results are summarized in Tables 1 - IV and Figs. on the X axis (Fig. 2). In Fig. 2 the values before and I- 5. after oedema are included showing that the oedematous (a) Weigh!. The children with marasmus were extremely underweight for age averaging only 47~~ (±4·9) of ex TABLE 1II. REDUCTION IN BODY SOLIDS pected weight. This is considerably less than the kwas % % hiorkor cases (70% ± 6-4) and the 'Iow-weight' children Ideal solids Ideal weighl (71·8% ±3·1). The recovered 'normal control' cases aver Recovered kwashiorkor 104 96 aged 96~6 expected weight (Table I). Low weighI 63 72 Marasmus 28 47 Kwashiorkor 55 70 TABLE I. BODY WATER COMPOSITION % TBW ECW cases appear to be little different from the non-oedematous Age ~Veighl Expected % % Solids mths. (kg.) weight Bod.·- Bod.,- (kg.) in total body water composition. Expressing water as weight weight Recovered {A.R. 20 11 ·51 98 59 24 4 ·74 ml. water/G of solids gives a similar picture (Fig. 3). kwashiorkor \V.C. 21 11 ·22 94 58 25 4 '76 'controls' (c) Extracellular water. As a percent of body weight Average =,=S.D. 20 '5 11 '36 96 58 '5 24'5 4·75 =0·21 =2'8 =0'7 :,:0'7 :,:0'05 the ECW was significantly less after loss of oedema in the kwashiorkor cases (33% and 27%, t=4'88, p ONOP.MAL. TABLE 11. INTRACELLULAR WATER o 6 0 XLOW WEIGHT. TBW ECW !CW !CW QKWASHIORKOP. I. I. I. % body. WITH OEDEMA. weight o o 6MAP.ASMUS. Reco\'ered {A.R. 6·77 2 ·81 3 '96 34 o 'controls' W.C. 6'47 2'78 3 '69 33 Mean 6'62 2 '79 3·83 34 Low weight Mean 6 '04:,:0 ·45 Marasmus Mean 4'09=0'74 1'81:,:0'2892'28=,=0'521 42 o o '" o 0 0 Kwashiorkor x lQ<> 0 Oedema 5·67-0'7482'73+0'5282·95+0'521 36 No oedema 5'29:;0'7562'05;>;0'3433·24;>;0'594 42 ox p x D of 69.9 0 6 and 68·1 "6 respectively before and after loss c of oedema, the low-weight children 66 0 6 and the 'controls' o 0 58 0 (Table I). This phenomenon is illustrated in Fig. I where it can be seen that there is a significant negative correlation between percent expected weight and percent SOL----~04r;-- (d) Intracellular waler. The derived figures (TBW (f) Changes during recovery. In Fig. 5 the changes from ECW) for the ICW compartment are summarized in Table admission with oedema to complete recovery are depicted n. In the kwashiorkor cases the ICW space increased for 2 children, AR. and W.e. Each child had 3 esti from 36% to 42~~ of body weight as oedema was lost. mations done, the first two being done before and after o NORMAL. 4S • o 1(.0$"10""0" bdo,( tou 01 ot:(l(Il'IQ X LOW WEIGHT. > :t o KWASHIORKOR WITH Cl .•••. "0 _•.••.• • l(.o~lor"or oltu lo'u 01 O(d(mo .. EDEMA . ~ 40 • KWASHiORKOR AFTE " > 0 LOSS OF EDEMA. o 0 /:). MARASMUS. o 3S L'1I1tro1ur( ..olur~ 0 CD ~ * .. . o ~ lor norlllol'§ *' LITERATURE VALUES G··•• ...... 0 FOR NORMALS. -"'·11 .. .. 30 ••.•. -...-_.0. •..•••-.-_ ••.•..' o ·0 · -.0 " "o 0 · 0 ~ o 2S o . w " o .. =-073 20 ,(0.001 · x · c 4 6 7 8 9 IQ 12 Kg BODY WEIGHT o Fig. 4. ECW of oedematous cases is in general higher [or their weight than the non-oedematous cases. 4 8 9 10 \I loss of oedema (Table IV). AR. was grossly underweight Kg Bcdy W\!iqht_ for his age of 15 months. With loss of oedema there Fig. 2. Significant negative correlation between actual was a shift of water from the extracellular to the intra weight and percent TBW. cellular compartment. At this time he had the weight (50th Boston percentile) and composition of a normal There was a significant increase of absolute value of ICW child of 3 months of age.!5 Five months of feeding in (p<0'05) which, when coupled with the loss of ECW a convalescent home restored his weight and composition volume, suggests that there was a shift of some ECW to that of a normal child of his own age (20 months). to the intracellular compartment. The ICW space is The changes, shown in Fig. 5 and Table IV, were par slightly higher in the oedema-free kwashiorkor cases and ticularly great in body solids. While the weight had children with marasmus than in the recovered 'control' nearly doubled, the body solids had increased by 4 times cases (42% cf. 34%). from the time of admission. (e) Body solids. Body solids = body weight-total body The second case, W.e., was less underweight for his water. Necessarily the body solids show a reciprocal age on admission. However, at 19 months he had the decrease with an increase of TBW. Using a total body weight and composition of a child of 8 months. Recovery water of 60~~ as an average normal figure for this age to normal weight and composition took only 2 months. group, the ideal body solids for a particular individual As with AR., the relative increase of solids was greater can be calculated.4 The reduction in body solids in the (1·7 times) than the increase of weight (1·35 times). groups under investigation is depicted in Table Ill. The degree of body solid deficit is much greater than the DISCUSSION weight deficit particularly for the marasmus group where From the data presented it appears that in the protein there is a 72% reduction in solids as opposed to a 53% calorie malnutrition syndromes of pre-school children, the reduction in weight. 11 A. ~. w.e. c NORMAL WEIGHT 10 " LOW wEIGHT SOLIDS o kWASHIORKOR .tU, o OEDEMA ~E.CW. • I(WAS... IOIH(QR C11t~r ELLj I.C W 4 '"C LOSS 01 OEDEMA -' (. MARASMUS >- 6 0 :t '" o LITERATURE VALUES ~ ~ tor NORMAlS W ...... '< ~ :t E Ot 6 494 S.A. MEDICAL JOURNAL 19 June 1965 N 36 (Supplemenr - Soulh African Journal of NlIIrition) body water composition is related more to the degree tents in oedematous, non-oedematous and atrophic sub of underweight than any other factor. The correlation jects. The atrophic subjects were extremely underweight of TBW as a percent of body weight with the degree of for age (a mean of 39% expected weight) and on current deviation from the expected weight for age is very close. evidence this would account for the high water content This finding gives an explanation for the fact that in of the muscle biopsies. one reported series of oedematous kwashiorkor cases the It has been found also that in whole body analysis TBW (estimated by the same method) was considerably after death, the TBW was increased in a malnourished higher4 (84·5 o~) than in our own series (70°!'). In the infant of 3 months as compared to a newborn infant of former the children were more underweight for their age the same weight.22 than the group in Cape Town. With normal development and age the accumulation As far as ECW is concerned, the same relationship to of tissue solids (lean tissue, minerals and fat) causes a the degree of weight deficit is clearly demonstrable steady decrease of the percentage TBW.l5 It is therefore an observation already made by Kerpel-Fronius and understandable that with protein depletion and the sub Kovach.7 These malnourished children thus have the weight sequent wasting of muscle and other tissues the percent of and the body water composition of much younger infants, TBW increases. In the marasmic children where there is e.g. at a mean age of 18 months the group with marasmus also loss of fat, TBW is likely to be very high, as was weighed 539 kg. and had a TBW of 76·9% of body indeed found. The present study supports the conclusion weight and an ECW of 34%. These figures would apply that the degree of loss of tissue solids is usually greater to normal infants of 1 - 3 months of age.15 The hypo than the loss of weight would indicate.4 thesis16, 17 that undernutrition causes a reversal of body The cause of the excessive accumulation of ECW that composition to that of an earlier stage of development results in the appearance of clinical oedema is not as is thus supported by the present findings. These children yet satisfactorily explained. The phenomenon is undoub are not only underweight but have an abnormal or im tedly complicated by hormonal and electrolyte imbalance, mature body composition for their age. cellular function, salt intake, venous pressure, serum pro The changes that occur with recovery illustrate this tein concentration and numerous other factors which may point (Fig. 5). Both children on admission to hospital be acting singly or in combination in a particular indi had the weight and composition of much younger child vidual. ren. Proper feeding restored each to normal in a relatively The ambulant underweight group of children were very short time. close to the kwashiorkor cases in their TBW composition. Oedema per se does not seem to be related to TBW, This indicates a considerable reduction in body solids. a fact noted previously.4,26 However, it is closely related Stress of any kind, whether it be infection, diarrhoea to ECW volume and the present data support the sugges or psychological, might be expected to deplete the tissue tion of Kerpel-Fronius18 that there is an absolute increase reserves of these children further and precipitate them of ECW in oedema. With resolution of oedema the ECW into one of the clinical syndromes of malnutrition. is still relatively increased in accordance with the degree Clinical cases of kwashiorkor come from this popula of deviation from expected weight. Thus all children tion of underweight children.23 It is in this group also who are severely underweight for age can be expected that mortality and morbidity from gastroenteritis and to have a relatively increased ECW but only in those other childhood diseases is so high.24,25 There is thus an with oedema will there be an absolute increase. Because inescapable link between weight-for-age, body composi this increase is absolute the diuresis that occurs with tion and over-all child health. Deviation from expected resolution of the oedema results in a loss of weight. Some growth and weight gain is an indication of changing body times there is no diuresis or loss of weight as oedema composition and susceptibility to the effects of disease. resolves. In these instances it is possible that most of It is thus evident that every effort must be made to ensure, the excess ECW in the oedematous areas is redistributed with adequate nutrition, patterns of growth within normal to relatively less hydrated intra- and extracellular spaces.6 limits. With the use of acceptable growth charts this It has, for example, been observed that oedema of feet can be done with great ease at home, clinic and school. and at the same time dehydration of the upper trunk can occur together in cases of kwashiorkor.16 , l~ SUMMARY In the marasmus group the mean ECW was 34°~ of Body water composltlon in the various manifestations of the body weight. This high figure represented 1·81 litres protein-calorie malnutrition has been studied using tritiated water for measurement of total body water (TBW) and of fluid (Table 11). For a normal child of comparable sodium thiosulphate space as a measure of extracellular water age (18 months) the figures would be 25°!' and 2·97 1. (ECW). An increase of TBW as a percentage of body weight respectively.l4 The relative increase in marasmus is appar was found in kwashiorkor, marasmus and children who were ently due to the great loss of solids. A similar pheno underweight for age but asymptomatic. The increase of 20 TBW appears to correlate well with the degree of weight menon is discernible in wasted adults where the high deficit, being highest in the marasmus cases. The presence ECW volume is considered to be essentially relative rather of oedema appeared to bear no relation to the TBW. than absolute. EC\V was also increased in protein-calorie malnutrition and The body water compartment measurements in vivo bore a close relation to the weight deficit. However, in oede matous cases ECW was still further expanded. are in line with data obtained from direct tissue analysis. Children with protein-calorie malnutrition thus have an For example, in skin and muscle biopsies of malnourished abnormal or immature body composition for their age in children Frenk et al.2l reported equally high water con- addition to their growth failure. 19 Junie 1965 S.A. TYDSKRIF VIR GENEESKUNDE 495 (Byvoegsel - 5I1id-Afrikl/(l/Ise Tydskrif vir Vuedillg) V 37 This work was done in the CSIR Clinical 'utrition Research 9. Gollan, F. (194 ): J. Clin. Invest.. 27. 352. 10. Ram05-Galvan. R. and Cravioto. J. (195 ): Bol. med. Hasp. infant. Unit of the Depanment of Medicine, University of Cape (Mex.). 15. 763. Town, and the Red Cross War Memorial Children's Hospital. 11. Passaro. G. (1953): Boil. Soc. ital. BioI. sper.. 29. 245. Financial assistance was received from US Public Health 12. Nelson. W. E. (1959): Textbook of Pediarl'ics, 7lh ed.. p. 45. Phila- delphia: Saunders. Services Grant AM-03995 and the South African Atomic 13. Vaughan. B. E. and Boling. E. A. (1961): J. Lab. Clin. Med.. 57, 159. Energy Board. Thanks are due to Professors 1. F. Brock 14. Friis-Hansen, B. (1954): Acta paediat. (Uppsala), 43, 444. and F. J. Ford and Dr. J. F. W. Mostert for facilities 15. Idem (1961): Pediatrics. 28, 169. 16. Waterlow. J. c., Cravioto. J. and Stephen. J. M. l. (1960): Advanc. provided. Protein Chem.. 15. 13l. REFERE 'CES 17. Widdowson. E. M .. Dickerson. J. W. T. and McCance. R. A. (1960): 1. JeJliffe. D. B. (1959): J. Pediat., 54, 227. Brit. J. NUlr.. 14. 457. 2. Scrimshaw. '. S. ill Wolstenholme, G. E. W .. ed. (1964): In Diet alld 18. Kerpel-Fronius. E. (1960): J. Pediat.. 56. 826. Bodily Constitution. (Ciba Foundation Study Group no. 17.) London: 19. Behar. M .. Bressani. R. and Scrimshaw. N. S. (1959): W:d Rev. Nutr. Chutchill. Diet.. I, 77. 3. Hansen. J. D. L. (1962): Proc. 'utr. Soc. Sth Afr., 3, 126. 20. McConkey, B. (1959): Clin. Sci.. 18, 95. 4. Smith. R. (1960): Clin. Sci.. 19, 275. 21. Frenk. S.. Metcoff. J .. Gomez. F .. Ramos-Galvan. R .. Cravioto. J. 5. Schneiden. H., Hendrikse, R. G. and Haigh, C. P. (1958): Trans. Roy. and Antonowicz. I. (1957): Pediatrics. 20, 105. Soc. Trap. Med. Hyg.. 52, 169. 22. Klose. E. (1914): J. Kinderheilk.. 80, 154. 6. Brinkman, G. l. and Han,en, J. D. L. (1963): Proceedillgs of a 23. Moodie. A. (1961): J. Pediat.. 58, 392. National Conference on Nuclear Energy, p. 283. Pretoria: Atomic 24. RobertsoiL I., Hansen, J. D. l. and Moodie, A. (1960): S. Afr. Med. Energy Board. J .. 34, 338. 7. Kerpel-Fronius, E. and Kovach. S (1948): Pediatrics. 2, 21. 25. Wittmann, W. (964): M.D. thesis. University of Cape Town. 8. Cokington. L.. Hanna, F. M. and Jackson. R. L. (1963): Ann. '.Y. 26. Brinkman. G. L .. Bowie, M. D., Friis-Hansen. B. and Hansen. Acad. Sci., 110, 849. J. D. L. (1965): Pediatrics (in the press). AN ASSESSMENT OF THE NUTRITIVE VALUE OF 'MULTI-PURPOSE FOOD' (FORMULA C) IN THE TREATMENT OF CONVALESCENT KWASHIORKOR PATIENTS P. J. PRETORIUS, M.MED. (PAED.), M.D., NaIional Nutrition Research Instiulte, SOUIh African Council for Scientific and Industrial Research, Pretoria, and Department of PaediaIrics, UniversiIy of Pretoria On behalf of Meals for Millions, Inc., Los Angeles, USA, A second report will be published in due course which the efficacy of maize meal diets containing Multi-purpose describes the chemical analyses (including aflatoxin deter Food (Formula C) with and without added vitamin minations), the biological and bacteriological evaluations supplements was compared with that of dried skimmed and the organoleptic tests on Whites and non-Whites milk in the treatment of convalescent kwashiorkor carried out to complete the evaluation of this food. patients. MATERIALS AND METHODS The world-wide recognition of the prevalence of mal Thirty-six convalescent kwashiorkor patients, free from active nutrition among infants and young children in indigent tuberculosis or acute infection, were divided at random into population groups has led to an intensive investigation of 2 experimental groups and a control group. the possibilities of producing cheap protein foods and The investigations were commenced on all patients exactly 5 weeks after admission to hospital. At this stage all overt food mixtures for distribution or sale among the under signs of kwashiorkor with the exception of hair changes and privileged. The foods investigated have included slOmmed growth impairment had disappeared. milk powder, fish flour, various soya preparations, mix During the experimental period of 4 weeks the patients tures of pulses and cereals and various other food were weighed and examined every day. Blood was taken on the first day of the trial pt::riod and thereafter at weekly combinations too numerous to mention and reported on intervals for the estimation of various serum constituents. in an extensive volume of scientific literature. One of the ComposiIion of the Diets (Tables I and ll) better-known of these preparations, Incaparina, consists entirely of vegetable ingredients and has been used with TABLE 1. PERCENTAGE COMPOSITION OF THE DIETS (DRY INGREOIENTS) wide success in Guatemala. The development of this food Skimmed-milk mixture is reviewed in a recent publication by Neser and Ingredients MPF-diet diet Pretorius,l which also discusses numerous other foods and Sifted granulated maize meal 55·6 55·6 food mixtures, including some of those at present being MPF \3·9 manufactured in South Africa, and examines in detail the Dried skimmed milk 16-7 Maize starch \3·8 11·0 principles on which the formulation and evaluation of Cane sugar 16·7 16·7 food mixtures should be based. It is recommended by these authors that the evaluation 1. Multi-purpose food (MPF) diet. The basic ingredient was sifted, granulated maize meal (Table I). The maize meal of foods and food mixtures for the prevention of malnutri was supplemented, on a dry basis, with 13·9% MPF. 0 tion in young children should include chemical analyses, vitamin supplements were added. biological evaluation of the protein by means of animal 2. MulIi-purpose food and viIamin sllpplemenI (MPF + experiments, clinical investigation including balance VS). The diet was identical with that described above, except that all patients in this group received in addition a daily studies, and field trials to test the acceptability of the food. supplement of a multi-vitamin preparation. The present paper describes a typical clinical investiga 3. Skimmed milk (control) dieI. As in the case of the experimental diets, the control diet contained 55.6°:' maize tion of a food formulated for use in the prevention of meal. This was supplemented with 16.7°:' dried skimmed milk malnutrition. The experimental procedure described is (Table I). The patients in this group also received the multi similar to that previously employed by the ational vitamin supplement daily and since the diet was a very poor Nutrition Research Institute in the evaluation of fish source of iron, 0-4 G of ferrous sulphate per day was added. 2 The MPF contained 46% and the dried skimmed milk 34% flour and other foods regarded as potential weapons protein (Table IT). These ingredients were added in different against malnutrition in infants and young children. proportions and the protein content of the diets did not differ