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Gizaw Z, Yalew AW, Bitew BD, Lee J, Bisesi M. Stunting among children aged 24-59 months and associations with sanitation, enteric infections, and environmental enteric dysfunction in rural northwest Ethiopia. Sci Rep 2022; 12:19293. [PMID: 36369357 PMCID: PMC9652362 DOI: 10.1038/s41598-022-23981-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022] Open
Abstract
Stunting is a public health issue of global concern. Despite, poor sanitation, diarrhea, parasitic infections, and environmental enteric dysfunction (EED) are associated with stunting, their link is poorly understood and has not been investigated in Ethiopia. This study was conducted to assess the associations of stunting with sanitation, enteric infections, and EED among children aged 24-59 months in rural northwest Ethiopia. A community-based cross-sectional study was conducted among 224 randomly selected children aged 24-59 months in rural areas of the east Dembiya district. We collected information on household food insecurity and dietary diversity using pre-tested questionnaires adopted from the food and nutrition technical assistance (FANTA) project. We used height-for-age-z score (HAZ) to define stunting. We also used the data collected to measure the environmental exposures of children to intestinal parasitic infections and fecal biomarkers of EED. A multivariable binary logistic regression model was used to assess the association of stunting with sanitation, enteric infections, and EED. Of the 224 children, 33% (95% CI 27, 39%) were stunted. Stunting in children was significantly associated with poor dietary intake (AOR 3.0, 95% CI 1.2, 7.3), open defecation practice (AOR 3.0, 95% CI 1.2, 7.9), presence of animal excreta in the living environment (AOR 3.4, 95% CI 1.2, 9.9), E. coli contamination of drinking water (AOR 4.2, 95% CI 1.1, 15.3), diarrheal disease incidence (AOR 3.4, 95% CI 1.5, 7.7), intestinal parasites in children (AOR 3.3, 95% CI 1.3, 8.8), and higher EED disease activity scores (AOR 2.9, 95% CI 1.2, 6.7). One-third of the children in the study area were stunted and this high prevalence of stunting was associated with poor dietary intake, poor hygiene and sanitation conditions, enteric infections, and EED. Thus, stunting can be prevented by improving sanitation and hygienic conditions to prevent repeated enteric infections in children and by promoting dietary diversity of children.
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Affiliation(s)
- Zemichael Gizaw
- grid.59547.3a0000 0000 8539 4635Department of Environmental and Occupational Health and Safety, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia ,grid.458355.a0000 0004 9341 7904Addis Continental Institute of Public Health, Addis Ababa, Ethiopia ,grid.261331.40000 0001 2285 7943Global One Health Initiative (GOHi), The Ohio State University, Columbus, OH USA
| | - Alemayehu Worku Yalew
- grid.7123.70000 0001 1250 5688School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Bikes Destaw Bitew
- grid.59547.3a0000 0000 8539 4635Department of Environmental and Occupational Health and Safety, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Jiyoung Lee
- grid.261331.40000 0001 2285 7943Division of Environmental Health Sciences, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, OH 43210 USA ,grid.261331.40000 0001 2285 7943Department of Food Science and Technology, The Ohio State University, Columbus, OH USA
| | - Michael Bisesi
- grid.261331.40000 0001 2285 7943Division of Environmental Health Sciences, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, OH 43210 USA
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Gizaw Z, Yalew AW, Bitew BD, Lee J, Bisesi M. Fecal biomarkers of environmental enteric dysfunction and associated factors among children aged 24-59 months in east Dembiya district, northwest Ethiopia. BMC Gastroenterol 2022; 22:172. [PMID: 35395735 PMCID: PMC8994394 DOI: 10.1186/s12876-022-02255-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 03/30/2022] [Indexed: 11/23/2022] Open
Abstract
Background Environmental enteric dysfunction is a subclinical intestinal disorder characterized by gut inflammation accompanied by morphological changes, such as blunted villi and crypt hyperplasia. This is a common illness in low and middle-income countries. However, environmental enteric dysfunction evidence is limited in Ethiopia. Accordingly, this study was conducted to measure fecal biomarkers of environmental enteric dysfunction and associated factors among children aged 24–59 months in rural northwest Ethiopia. Methods A community-based cross-sectional study was employed among 235 randomly selected children in a rural setting of the east Dembiya district. Stool samples were collected without fixative and analyzed for fecal biomarkers of environmental enteric dysfunction (Alpha-1-antitrypsin, neopterin, and myeloperoxidase) using commercial enzyme-linked immunosorbent assay kits and analyzed for intestinal parasites using wet mount and Kato-Katz techniques. Child behaviors related with exposure to enteropathogens, condition of the living environment and socio-demographic information were collected using interviewer-administered questionnaire and structure observation. We fitted multivariable linear regression model to assess the association between environmental factors and concentration of fecal biomarkers of environmental enteric dysfunction in the stool. Statistically significant associations were declared based on adjusted betas with the corresponding 95% confidence interval and p-value < 0.05. Results The median concentration of fecal markers of environmental enteric dysfunction was 350 μg/ml for Alpha-1-antitrypsin, 3320.2 ng/ml for myeloperoxidase, and 1562 nmol/l for neopterin. The median concentration of Alpha-1-antitrypsin among 161 (68.5%), myeloperoxidase among 168 (71.5%), and neopterin among 188 (80%) of the stool samples were above the normal values in non-tropical settings. Moreover, 100 (42.6%) of the children had high EED disease activity score (above the median score). The elevated concentrations of fecal biomarkers of gut inflammation and the high EED disease activity score were significantly associated with open defecation practice, mouthing of soil contaminated materials, Escherichia coli (E. coli) contamination of drinking water, E. coli contamination of foods, E. coli contamination of soil, and intestinal parasites. Conclusion Overall, Alpha-1-antitrypsin, myeloperoxidase, and neopterin levels among the children in the studied region were highly elevated in comparison to populations in high-income countries. Moreover, the EED disease activity score in significant proportion of children was high, suggesting widespread intestinal inflammation and increased intestinal permeability. Extensive E. coli contamination of the living environment (drinking water, ready-to-eat foods, and courtyard soil), hygiene and sanitation behaviors (such as open defecation and mouthing of soil contaminated materials), and a high burden of intestinal parasites were identified as factors associated with the elevated concentration of fecal biomarkers of environmental enteric dysfunction. Parental care to children to avoid mouthing of soil contaminated materials and other risky behaviors that increase exposure enteric infections, and protecting the living environment (water, food and soil) from fecal contamination are important.
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Affiliation(s)
- Zemichael Gizaw
- Department of Environmental and Occupational Health and Safety, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia. .,Addis Continental Institute of Public Health, Addis Ababa, Ethiopia. .,Global One Health Initiative (GOHi), The Ohio State University, Columbus, OH, USA.
| | | | - Bikes Destaw Bitew
- Department of Environmental and Occupational Health and Safety, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Jiyoung Lee
- Division of Environmental Health Sciences, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, OH, 43210, USA.,Department of Food Science and Technology, The Ohio State University, Columbus, OH, USA
| | - Michael Bisesi
- Division of Environmental Health Sciences, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, OH, 43210, USA
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Mutasa K, Ntozini R, Mbuya MNN, Rukobo S, Govha M, Majo FD, Tavengwa N, Smith LE, Caulfield L, Swann JR, Stoltzfus RJ, Moulton LH, Humphrey JH, Gough EK, Prendergast AJ. Biomarkers of environmental enteric dysfunction are not consistently associated with linear growth velocity in rural Zimbabwean infants. Am J Clin Nutr 2021; 113:1185-1198. [PMID: 33740052 PMCID: PMC8106752 DOI: 10.1093/ajcn/nqaa416] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 12/10/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Child stunting remains a poorly understood, prevalent public health problem. Environmental enteric dysfunction (EED) is hypothesized to be an important underlying cause. OBJECTIVES Within a subgroup of 1169 children enrolled in the SHINE (Sanitation Hygiene Infant Nutrition Efficacy) trial in rural Zimbabwe, followed longitudinally from birth to 18 mo of age, we evaluated associations between the concentration of 11 EED biomarkers and linear growth velocity. METHODS At infant ages 1, 3, 6, 12, and 18 mo, nurses measured child length and collected stool and blood; the lactulose-mannitol urine test was also conducted at all visits except at 1 mo. Stool neopterin, α-1 antitrypsin, myeloperoxidase, and regenerating gene 1β protein; urinary lactulose and mannitol; and plasma kynurenine, tryptophan, C-reactive protein, insulin-like growth factor-1 (IGF-1), soluble CD14, intestinal fatty acid binding protein, and citrulline were measured. We analyzed the change in relative [∆ length-for-age z score (LAZ)/mo] and absolute (∆ length/mo) growth velocity during 4 age intervals (1-3 mo; 3-6 mo; 6-12 mo; and 12-18 mo) per SD increase in biomarker concentration at the start of each age interval. RESULTS In fully adjusted models, we observed only 3 small, statistically significant associations: kynurenine:tryptophan ratio at 12 mo was associated with decreased mean LAZ velocity during the 12-18 mo interval (-0.015 LAZ/mo; 95% CI: -0.029, -0.001 LAZ/mo); mannitol excretion at 6 mo was associated with increased LAZ velocity during the 6-12 mo interval (0.013 LAZ/mo; 95% CI: 0.001, 0.025 LAZ/mo), and plasma IGF-1 at 1 mo was associated with increased LAZ velocity during the 1-3 mo interval (0.118 LAZ/mo; 95% CI: 0.024, 0.211 LAZ/mo). Results for absolute growth velocity were similar, except IGF-1 was also associated with growth during the 12-18 mo interval. We found no other associations between any EED biomarker and linear growth velocity. CONCLUSIONS None of 11 biomarkers of EED were consistently associated with linear growth among Zimbabwean children.This trial was registered at clinicaltrials.gov as NCT01824940.
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Affiliation(s)
| | | | - Mduduzi N N Mbuya
- Present address for MNNM: Global Alliance for Improved Nutrition, 1701 Rhode Island Ave NW, Washington, DC 20036, USA
| | - Sandra Rukobo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Margaret Govha
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Florence D Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Naume Tavengwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Laura E Smith
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe,Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA
| | - Laura Caulfield
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jonathan R Swann
- Division of Digestive Diseases, Department of Metabolism, Digestion, and Reproduction, Faculty of Medicine, Imperial College London, London, United Kingdom,School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Rebecca J Stoltzfus
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Lawrence H Moulton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Ethan K Gough
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe,Blizard Institute, Queen Mary University of London, London, United Kingdom
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Vaz Nery S, Bennett I, Clarke NE, Lin A, Rahman Z, Rahman M, Clements ACA. Characterisation of environmental enteropathy biomarkers and associated risk factors in children in the context of a WASH trial in Timor-Leste. Int J Hyg Environ Health 2018; 221:901-906. [PMID: 29891218 DOI: 10.1016/j.ijheh.2018.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/23/2018] [Accepted: 05/28/2018] [Indexed: 01/24/2023]
Abstract
Environmental enteropathy (EE) is characterised by subclinical inflammation and hyperpermeability of the small intestine, hypothesised to be caused by recurrent ingestion of faecal bacteria. It has been suggested that EE may be a contributor to malnutrition and growth delays seen in children living in unsanitary conditions. We measured putative faecal EE markers myeloperoxidase (MPO) (ng/mL) and alpha-1-antitrypsin (AAT) (mg/g) in stool samples collected from 133 children aged 1-5 years in 16 communities enrolled in the WASH for WORMS randomised controlled trial in Timor-Leste. Samples were collected two years after a community-wide water, sanitation and hygiene (WASH) intervention that was integrated with regular deworming. Mixed effects multivariable linear regression models were used to examine the impact of the study intervention and of various WASH and infection-related factors on EE biomarkers. Children who lived in communities that received both the WASH intervention and deworming had similar AAT values as those who lived in communities that received only deworming (regression coefficient -0.14, p = 0.583), but they had a trend towards lower MPO values (coeff -0.51, p = 0.055). Younger children showed significantly higher MPO levels (coeff: -0.29, p = 0.002). No WASH variables or parasitic infections were associated with AAT levels. Household water being stored in covered containers was associated with lower MPO levels (coeff -1.75, p = 0.046). We found little evidence that a community-based WASH intervention had an impact on EE over a two-year period.
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Affiliation(s)
- Susana Vaz Nery
- Research School of Population Health, Australian National University, Canberra, Australian Capital Territory, Australia.
| | - Isaac Bennett
- Research School of Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Naomi E Clarke
- Research School of Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Audrie Lin
- Division of Epidemiology, School of Public Health, University of California, Berkeley, California, USA
| | - Ziaur Rahman
- International Centre for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
| | - Mahbubur Rahman
- International Centre for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
| | - Archie C A Clements
- Research School of Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
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Cumming O, Cairncross S. Can water, sanitation and hygiene help eliminate stunting? Current evidence and policy implications. MATERNAL AND CHILD NUTRITION 2017; 12 Suppl 1:91-105. [PMID: 27187910 PMCID: PMC5084825 DOI: 10.1111/mcn.12258] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Stunting is a complex and enduring challenge with far‐reaching consequences for those affected and society as a whole. To accelerate progress in eliminating stunting, broader efforts are needed that reach beyond the nutrition sector to tackle the underlying determinants of undernutrition. There is growing interest in how water, sanitation and hygiene (WASH) interventions might support strategies to reduce stunting in high‐burden settings, such as South Asia and sub‐Saharan Africa. This review article considers two broad questions: (1) can WASH interventions make a significant contribution to reducing the global prevalence of childhood stunting, and (2) how can WASH interventions be delivered to optimize their effect on stunting and accelerate progress? The evidence reviewed suggests that poor WASH conditions have a significant detrimental effect on child growth and development resulting from sustained exposure to enteric pathogens but also due to wider social and economic mechanisms. Realizing the potential of WASH to reduce stunting requires a redoubling of efforts to achieve universal access to these services as envisaged under the Sustainable Development Goals. It may also require new or modified WASH strategies that go beyond the scope of traditional interventions to specifically address exposure pathways in the first 2 years of life when the process of stunting is concentrated.
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Affiliation(s)
- Oliver Cumming
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Sandy Cairncross
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Denno DM, Tarr PI, Nataro JP. Environmental Enteric Dysfunction: A Case Definition for Intervention Trials. Am J Trop Med Hyg 2017; 97:1643-1646. [PMID: 29016294 PMCID: PMC5805039 DOI: 10.4269/ajtmh.17-0183] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Donna M Denno
- Department of Pediatrics, University of Washington, Seattle, Washington.,Department of Global Health, University of Washington, Seattle, Washington
| | - Phillip I Tarr
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - James P Nataro
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
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Abstract
Environmental enteropathy is a chronic condition of the small intestine associated with increased intestinal permeability, mucosal inflammation, malabsorption, and systemic inflammation. It is commonly accompanied by enteric infections and is misleadingly considered a subclinical disease. Potential effects of enteric infections and enteropathy on vaccine responses, child growth, cognitive development, and even later life obesity, diabetes, and metabolic syndrome are increasingly being recognized. Herein, we review the evolving challenges to defining environmental enteropathy and enteric infections, current evidence for the magnitude and determinants of its burden, new assessment tools, and relevant interventions.
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Affiliation(s)
- Elizabeth T Rogawski
- Department of Public Health Sciences, University of Virginia, PO Box 801379, Carter Harrison Research Building MR-6, 345 Crispell Drive, Room 2520, Charlottesville, VA 22908-1379, USA; Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, PO Box 801379, Carter Harrison Research Building MR-6, 345 Crispell Drive, Room 2520, Charlottesville, VA 22908-1379, USA.
| | - Richard L Guerrant
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, PO Box 801379, Carter Harrison Research Building MR-6, 345 Crispell Drive, Room 2520, Charlottesville, VA 22908-1379, USA
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Humphrey JH, Jones AD, Manges A, Mangwadu G, Maluccio JA, Mbuya MNN, Moulton LH, Ntozini R, Prendergast AJ, Stoltzfus RJ, Tielsch JM. The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial: Rationale, Design, and Methods. Clin Infect Dis 2016; 61 Suppl 7:S685-702. [PMID: 26602296 PMCID: PMC4657589 DOI: 10.1093/cid/civ844] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
UNLABELLED Child stunting and anemia are intractable public health problems in developing countries and have profound short- and long-term consequences. The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial is motivated by the premise that environmental enteric dysfunction (EED) is a major underlying cause of both stunting and anemia, that chronic inflammation is the central characteristic of EED mediating these adverse effects, and that EED is primarily caused by high fecal ingestion due to living in conditions of poor water, sanitation, and hygiene (WASH). SHINE is a proof-of-concept, 2 × 2 factorial, cluster-randomized, community-based trial in 2 rural districts of Zimbabwe that will test the independent and combined effects of protecting babies from fecal ingestion (factor 1, operationalized through a WASH intervention) and optimizing nutritional adequacy of infant diet (factor 2, operationalized through an infant and young child feeding [IYCF] intervention) on length and hemoglobin at 18 months of age. Within SHINE we will measure 2 causal pathways. The program impact pathway comprises the series of processes and behaviors linking implementation of the interventions with the 2 child health primary outcomes; it will be modeled using measures of fidelity of intervention delivery and household uptake of promoted behaviors and practices. We will also measure a range of household and individual characteristics, social interactions, and maternal capabilities for childcare, which we hypothesize will explain heterogeneity along these pathways. The biomedical pathway comprises the infant biologic responses to the WASH and IYCF interventions that ultimately result in attained stature and hemoglobin concentration at 18 months of age; it will be elucidated by measuring biomarkers of intestinal structure and function (inflammation, regeneration, absorption, and permeability); microbial translocation; systemic inflammation; and hormonal determinants of growth and anemia among a subgroup of infants enrolled in an EED substudy. This article describes the rationale, design, and methods underlying the SHINE trial. CLINICAL TRIALS REGISTRATION NCT01824940.
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Watanabe K, Petri WA. Environmental Enteropathy: Elusive but Significant Subclinical Abnormalities in Developing Countries. EBioMedicine 2016; 10:25-32. [PMID: 27495791 PMCID: PMC5006727 DOI: 10.1016/j.ebiom.2016.07.030] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 07/07/2016] [Accepted: 07/22/2016] [Indexed: 12/26/2022] Open
Abstract
Environmental enteropathy/Environmental enteric dysfunction (EE/EED) is a chronic disease of small intestine characterized by gut inflammation and barrier disruption, malabsorption and systemic inflammation in the absence of diarrhea. It is predominantly diseases of children in low income countries and is hypothesized to be caused by continuous exposure to fecally contaminated food, water and fomites. It had not been recognized as a priority health issue because it does not cause overt symptoms and was seen in apparently healthy individuals. However, there is a growing concern of EE/EED because of its impact on longitudinal public health issues, such as growth faltering, oral vaccine low efficacy and poor neurocognitive development. Recent works have provided important clues to unravel its complex pathogenesis, and suggest possible strategies for controlling EE/EED. However, effective diagnostic methods and interventions remain unsettled. Here, we review the existing literature, especially about its pathogenesis, and discuss a solution for children living in the developing world. EE/EED is acquired by the close contact with unsanitary condition, and abnormalities of EE/EED are reversible over time. EE/EED should be diagnosed as young as possible because poor growth is often evident within 1-2 years of life. EE/EED should be diagnosed by simple, noninvasive and low-cost methods, such as fecal biomarkers. It is hard to diagnose EE/EED and to predict consequences by a single marker/test due to the complexity in pathogenesis. Interventions for EE/EED other than sanitary reform are under investigation although no reports showed favorable outcomes currently.
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Affiliation(s)
- Koji Watanabe
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA; AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan.
| | - William A Petri
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA.
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Mbuya MNN, Humphrey JH. Preventing environmental enteric dysfunction through improved water, sanitation and hygiene: an opportunity for stunting reduction in developing countries. MATERNAL AND CHILD NUTRITION 2015; 12 Suppl 1:106-20. [PMID: 26542185 PMCID: PMC5019251 DOI: 10.1111/mcn.12220] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 07/27/2015] [Accepted: 08/18/2015] [Indexed: 12/14/2022]
Abstract
In 2011, one in every four (26%) children under 5 years of age worldwide was stunted. The realization that most stunting cannot be explained by poor diet or by diarrhoea, nor completely reversed by optimized diet and reduced diarrhoea has led to the hypothesis that a primary underlying cause of stunting is subclinical gut disease. Essentially, ingested microbes set in motion two overlapping and interacting pathways that result in linear growth impairment. Firstly, partial villous atrophy results in a reduced absorptive surface area and loss of digestive enzymes. This in turn results in maldigestion and malabsorption of much needed nutrients. Secondly, microbes and their products make the gut leaky, allowing luminal contents to translocate into systemic circulation. This creates a condition of chronic immune activation, which (i) diverts nutrient resources towards the metabolically expensive business of infection fighting rather than growth; (ii) suppresses the growth hormone‐IGF axis and inhibits bone growth, leading to growth impairment; and (iii) causes further damage to the intestinal mucosa thereby exacerbating the problem. As such, the unhygienic environments in which infants and young children live and grow must contribute to, if not be the overriding cause of, this environmental enteric dysfunction. We suggest that a package of baby‐WASH interventions (sanitation and water improvement, handwashing with soap, ensuring a clean play and infant feeding environment and food hygiene) that interrupt specific pathways through which feco‐oral transmission occurs in the first two years of a child's life may be central to global stunting reduction efforts.
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Affiliation(s)
- Mduduzi N N Mbuya
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, 21205, USA
| | - Jean H Humphrey
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, 21205, USA
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11
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Abstract
BACKGROUND Environmental enteric dysfunction (EED) refers to an incompletely defined syndrome of inflammation, reduced absorptive capacity, and reduced barrier function in the small intestine. It is widespread among children and adults in low- and middle-income countries. Understanding of EED and its possible consequences for health is currently limited. OBJECTIVE A narrative review of the current understanding of EED: epidemiology, pathogenesis, therapies, and relevance to child health. METHODS Searches for key papers and ongoing trials were conducted using PUBMED 1966-June 2014; ClinicalTrials.gov; the WHO Clinical Trials Registry; the Cochrane Library; hand searches of the references of retrieved literature; discussions with experts; and personal experience from the field. RESULTS EED is established during infancy and is associated with poor sanitation, certain gut infections, and micronutrient deficiencies. Helicobacter pylori infection, small intestinal bacterial overgrowth (SIBO), abnormal gut microbiota, undernutrition, and toxins may all play a role. EED is usually asymptomatic, but it is important due to its association with stunting. Diagnosis is frequently by the dual sugar absorption test, although other biomarkers are emerging. EED may partly explain the reduced efficacy of oral vaccines in low- and middle-income countries and the increased risk of serious infection seen in children with undernutrition. CONCLUSIONS Despite its potentially significant impacts, it is currently unclear exactly what causes EED and how it can be treated or prevented. Ongoing trials involve nutritional supplements, water and sanitation interventions, and immunomodulators. Further research is needed to better understand this condition, which is of likely crucial importance for child health and development in low- and middle-income settings.
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12
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Korpe PS, Petri WA. Environmental enteropathy: critical implications of a poorly understood condition. Trends Mol Med 2012; 18:328-36. [PMID: 22633998 DOI: 10.1016/j.molmed.2012.04.007] [Citation(s) in RCA: 319] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 04/12/2012] [Accepted: 04/20/2012] [Indexed: 12/13/2022]
Abstract
Environmental enteropathy (also called tropical enteropathy) is a subclinical condition caused by constant fecal-oral contamination and resulting in blunting of intestinal villi and intestinal inflammation. Although these histological changes were discovered decades ago, the clinical impact of environmental enteropathy is just starting to be recognized. The failure of nutritional interventions and oral vaccines in the developing world may be attributed to environmental enteropathy, as the intestinal absorptive and immunologic functions are significantly deranged. Here we review the existing literature and examine potential mechanisms of pathogenesis for this poorly understood condition.
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Affiliation(s)
- Poonum S Korpe
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA 22908-1337, USA
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13
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Abstract
Intestinal biopsies constitute an ever-increasing portion of the pathologist's workload, accounting for nearly two-thirds of specimens accessioned yearly by the pathology department at The Children's Hospital of Philadelphia. The widespread use of endoscopy and gastrointestinal biopsies in current clinical practice presents the pathologist with a diversity of intestinal mucosal appearances corresponding to disease states of variable clinical severity, requiring close collaboration between clinician and pathologist for optimal interpretation. Many of the entities resulting in severe diarrhea of infancy have been recognized only in the last several decades, and although rare, the study of these disorders, especially when combined with the powerful methods of present-day genetics and molecular biology, has afforded important insights into enterocyte development and function, and intestinal immunity and tolerance. Other conditions once considered infrequent, such as celiac disease, have now been recognized to be much more common and can present with a wide range of pathologic features.
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Affiliation(s)
- Pierre Russo
- Department of Pathology and Laboratory Medicine, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Veitch AM, Kelly P, Zulu IS, Segal I, Farthing MJ. Tropical enteropathy: a T-cell-mediated crypt hyperplastic enteropathy. Eur J Gastroenterol Hepatol 2001; 13:1175-81. [PMID: 11711773 DOI: 10.1097/00042737-200110000-00009] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Tropical enteropathy is widespread throughout the tropics, but its pathogenesis is unknown. T-cell activation has been demonstrated to result in enteropathy in vitro and in animal models, and occurs in untreated patients with coeliac disease. We have therefore examined the hypothesis that T-cell activation is important in the pathogenesis of tropical enteropathy. PATIENTS AND METHODS Healthy black Zambian subjects were compared with black and white South Africans. Quantitative microscopy was conducted on distal duodenal biopsies. Mucosal T-cell activation was quantitated by dual colour immunofluorescence staining for CD3 plus CD69 or HLA-DR. Crypt proliferation was measured by direct counting of Feulgen-stained mitotic figures, and systemic immune activation by assay of serum tumour necrosis factor alpha (TNF-alpha). RESULTS Villous height was reduced (P = 0.0004), crypt depth increased (P < 0.0001), and mitoses per crypt increased (P = 0.014) in black Zambians compared with black and white South Africans. Mucosal thickness was similar. Intraepithelial lymphocyte count was increased in the black groups compared with whites (P = 0.03). CD3+CD69+ (P = 0.0007) and CD3+HLA-DR+ (P < 0.0001) expression was increased in black Zambians compared with black and white South Africans. Serum TNF-alpha was similar in all groups. CONCLUSIONS Tropical enteropathy is associated with mucosal T-cell activation and crypt hyperplasia. Tropical enteropathy occurs in the absence of malnutrition, diarrhoea or systemic illness.
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Affiliation(s)
- A M Veitch
- Digestive Diseases Research Centre, St. Bartholomew's and the Royal London School of Medicine and Dentistry, London, UK.
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15
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Abstract
BACKGROUND Little is known about the small intestinal mucosal pattern of Myanmar children. METHODS Duodenal, jejunal and ileal mucosal specimens obtained from children within 6 h of death were examined under a dissecting microscope with the objective of determining villus pattern in relation to site within the small intestine and then correlated with age. RESULTS Abnormalities in the small intestinal mucosa were detected at a very young age. In children under 1 year of age, the changes are more marked proximally and become less marked distally, perhaps reflecting exposure to the causative agent(s) in early life. Presumably these agents are ingested orally and inactivated progressively. The pattern in older children reflects more severe changes in the ileum. CONCLUSIONS It is postulated that frequent intestinal infections or small bowel bacterial contamination could lead to damage of the intestinal mucosa.
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Affiliation(s)
- W M Aye
- Department of Child Health, Institute of Medicine (I), Yangon, Myanmar
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16
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Kendall CW, Rao AV, Janezic SA, Temkin RJ, Hollenberg MJ, Lea PJ. Tridimensional ultrastructure of perfusion fixed gastrointestinal epithelial cells by high resolution scanning electron microscopy. JOURNAL OF ELECTRON MICROSCOPY TECHNIQUE 1991; 18:223-30. [PMID: 1880595 DOI: 10.1002/jemt.1060180304] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Improvements in the design of modern scanning electron microscopes (SEM) and new methods of specimen preparation incorporating chemical removal of the cytosol and cytoskeleton, now make it possible to view cells and their organelles in three dimensions (3D) at high magnification. In this experiment, high resolution SEM (HRSEM) utilizing new methods of tissue preparation was used to study the intracellular structures of the mouse ileum. In addition, in vivo intestinal perfusion was used to further enhance cellular preservation. Using these modifications it was possible to visualize, in 3D, the fine structure of intestinal epithelial cells and intracellular organelles such as the nucleus, mitochondria, endoplasmic reticulum, and Golgi complex, as well as microvilli and cell membrane. Whole mitochondria appeared as irregularly shaped organelles which contained tubular cristae. Plate-like cristae were not observed. The brush border was found to be closely packed array of cylindrical projections. The extensive folding and structural intricacy of lateral cell membranes between absorptive cells could only be appreciated by viewing this tissue with 3D HRSEM. The use of HRSEM to study 3D ultrastructure of cells and their organelles will improve our understanding of the structure-function relationships in both the healthy and diseased gastrointestinal tract.
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Affiliation(s)
- C W Kendall
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Ontario, Canada
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17
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Kritchevsky D. Dietary fiber: a glance into the future. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1990; 270:1-5. [PMID: 1963999 DOI: 10.1007/978-1-4684-5784-1_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- D Kritchevsky
- Wistar Institute of Anatomy and Biology, Philadelphia, PA 19104
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18
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Ukabam SO, Homeida MM, Cooper BT. Small intestinal permeability in normal Sudanese subjects: evidence of tropical enteropathy. Trans R Soc Trop Med Hyg 1986; 80:204-7. [PMID: 3097886 DOI: 10.1016/0035-9203(86)90010-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Small intestinal permeability to mannitol and lactulose was studied in healthy English and apparently healthy Sudanese subjects to determine whether any differences were apparent. Permeability was assessed by measuring urinary recovery of the test substances after oral ingestion. The mean excretion of lactulose was significantly higher and the mean excretion of mannitol was significantly lower in the Sudanese than in the English subjects. Lactulose to mannitol excretion ratios were significantly higher in the Sudanese. These data demonstrate abnormal intestinal permeability in the Sudanese subjects and indicate the presence of an asymptomatic enteropathy.
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19
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Bennett MK, Sachdev GK, Jewell DP, Anand BS. Jejunal mucosal morphology in healthy north Indian subjects. J Clin Pathol 1985; 38:368-71. [PMID: 3988949 PMCID: PMC499159 DOI: 10.1136/jcp.38.4.368] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Morphometric measurements have been performed on small intestinal biopsy specimens obtained from 18 healthy adult Indian volunteers. The measurements were made using a computer aided measuring system, and results were similar to those previously reported for an adult Caucasian population.
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20
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Hansen WE. [Effect of bulk materials on the upper intestinal tract]. KLINISCHE WOCHENSCHRIFT 1982; 60:1475-83. [PMID: 6300508 DOI: 10.1007/bf01716098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Dietary fibers comprise a very heterogenous group of indigestible plant compounds. Whereas they exert only little effects on the recovery of the digestible parts of a meal they can modify various digestive processes. Most important seems to be the ability to inhibit digestion and absorption of carbohydrates, which enables better treatment of diabetics. The observation that serum cholesterol can be decreased by certain dietary fibers finds special interest also because of the possible reduction of risk for developing atherosclerosis. The various effects depend upon the physicochemical properties of the different fibers: they comprise the ability to bind water and organic substances, viscosity and cationic-exchange.
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21
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Abstract
Non-specific ileojejunitis, characterised by mild to moderate structural changes in the intestinal mucosa and often associated with asymptomatic malabsorption, is known to occur in the tropics and in countries with hot climates. This acquired condition is probably related to environmental factors, and some consider it to be a subclinical form of tropical sprue. Changes in the intestinal mucosa typical of non-specific ileojejunitis were found in 10 indigenous Indians as well as 5 people of Latin stock living in the Southern Peruvian sierra, where tropical sprue has not as yet been demonstrated and which has a temperate climate.
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22
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Abstract
Tropical enteropathy, which may be related to tropical sprue, has been described in many developing countries including parts of Africa. The jejunal changes of enteropathy are seen in Rhodesians of all social and racial categories. Xylose excretion, however, is related to socioeconomic status, but not race. Upper socioeconomic Africans and Europeans excrete significantly more xylose than lower socioeconomic Africans. Vitamin B12 and fat absorption are normal, suggesting predominant involvement of the proximal small intestine. Tropical enteropathy in Rhodesia is similar to that seen in Nigeria but is associated with less malabsorption than is found in the Caribbean, the Indian subcontinent, and South East Asia. The possible aetiological factors are discussed. It is postulated that the lighter exposure of upper class Africans and Europeans to repeated gastrointestinal infections may accound for their superior xylose absorption compared with Africans of low socioeconomic circumstances. It is further suggested that the milder enteropathy seen in Africa may be explained by a lower prevalence of acute gastroenteritis than in experienced elsewhere in the tropics.
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23
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Cook GC. D-xylose absorption and jejunal morphology in African patients with pellagra (niacin tryptophan deficiency). Trans R Soc Trop Med Hyg 1976; 70:349-51. [PMID: 1006768 DOI: 10.1016/0035-9203(76)90098-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
D-xylose absorption tests and jejunal morphology have been shown to be unaltered in 12 African patients with pellagra when compared with normal values for Zambian Africa adults; that result is contrary to two previous investigations in India and Egypt respectively. A significant inverse association has been shown, however, between D-xylose absorption and serum immunoglobulin IgG and IgA concentrations; that is consistent with previous studies and probably reflects malabsorption of xylose in the presence of systemic infections. It is concluded that pellagra per se does not alter intestinal structure or monosaccharide absorption.
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25
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Cook GC. Jejunal absorption rates of glucose, glycine and glycylglycine in Zambian African adults with malnutrition. Br J Nutr 1974; 32:503-13. [PMID: 4139969 DOI: 10.1079/bjn19740104] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
1. Absorption rates of glucose (from a 200 mM solution), glycine (from a 100 mM solution), and glycylglycine (from a 50 mM solution) have been estimated in six Zambian African adults with clinical evidence of malnutrition. A double-lumen tube technique was used to determine absorption rates from a 300 mm section of jejunum in vivo.2. Two of the subjects had ileal tuberculosis and Kaposi's sarcoma respectively. A third probably had abdominal tuberculosis. Three of them had pellagra. Mean serum albumin concentration was 24 (14–43) g/l. Absorption rates have been compared with those in Zambian Africans (control subjects), previously studied, who had no clinical evidence of malnutrition, systemic infection or of gastrointestinal disease.3. Mean glucose, glycine and glycylglycine absorption rates in the malnourished subjects were not significantly different from those in the control subjects. Mean net water absorption rate from the glucose solution was similar in the malnourished subjects and controls; during the glycine and glycylglycine perfusions the mean net absorption rate was, however, significantly lower in the malnourished subjects (P < 0.01 and P < 0.05 respectively); mean net water transfer during the glycine perfusions was towards the jejunal lumen in the malnourished subjects. One subject with pellagra had an abnormal excretion of D-xylose after a 25 g oral load; all other tests were normal.4. It seems probable that malnutrition must be very severe, with jejunal mucosal abnormalities, before absorption rates of glucose, glycine and glycylglycine are significantly altered. The present study does not support the view that subclinical malnutrition is important in producing malabsorption of dietary components in Zambian African subjects. Systemic bacterial infections, and raised serum γ-globulin and immunoglobulin IgG concentrations have previously been associated with an impairment of glucose absorption rate in Zambian African subjects; those factors seem much more likely than subclinical malnutrition to be relevant, in the context of absorption, in the pathogenesis of overt malnutrition.
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Cook GC. Inverse relation between serum IgG concentration and glucose and xylose absorption in Zambian African adults. BRITISH MEDICAL JOURNAL 1974; 4:200-1. [PMID: 4214345 PMCID: PMC1612372 DOI: 10.1136/bmj.4.5938.200] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In three separate investigations in Zambian African adults in Lusaka an inverse association has been shown between serum IgG concentration and either glucose absorption rate from the jejunum (from a 200-mM solution) or xylose absorption (from a 25-g oral load). In developing areas of the world, where serum IgG concentrations are often high, this finding may have widespread nutritional implications.
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Cook GC. Effect of systemic infections on glycylglycine absorption rate from the human jejunum in vivo. Br J Nutr 1974; 32:163-7. [PMID: 4846160 DOI: 10.1079/bjn19740066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Cook GC. Some factors influencing absorption rates of the digestion products of protein and carbohydrate from the proximal jejunum of man and their possible nutritional implications. Gut 1974; 15:239-45. [PMID: 4842999 PMCID: PMC1412888 DOI: 10.1136/gut.15.3.239] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Abstract
1. Rates of absorption of glycine and glycylglycine from a 300 mm jejunal segment were compared in vivo when those compounds were given alone or together to six Zambian African subjects who had no clinical evidence of malnutrition or of gastro-intestinal disease. Solutions containing (A) glycine (100 mmol/1), (B) glycine (100 mmol/l)+glycylglycine (50 mmol/l), and (C) glycylglycine (50 mmol/l) were infused into the upper jejunum by means of a double-lumen tube perfusion system.2. Rate of absorption of glycine was significantly higher from the glycylglycine solution (C) than from the glycine solution (A). Glycine absorption rate from solution B (glycine+glycylglycine) was very similar to the sum of absorption rates of glycine from solutions A and C in each subject. Luminal disappearance rate of glycylglycine from solutions C and B were very similar; however, the rate was significantly greater than the total glycine absorption rate from solution C and indicates back-diffusion of glycine into the lumen after glycylglycine hydrolysis.3. The results are interpreted as indicating that the transport mechanisms for glycine and glycylglycine in man are partly, and possibly wholly, separate.
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31
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Cook GC. Relation between glucose absorption rate and serum globulin concentration in man. Nature 1973; 241:284-5. [PMID: 4701889 DOI: 10.1038/241284a0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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32
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Abstract
Using a double-lumen tube perfusion system, solutions of glucose (1.0, 2.5, and 5.0 g 100ml(-1)) have been perfused into the upper jejunum of 22 Zambian African subjects in order to study their glucose absorption kinetics. None of them had clinical evidence of malnutrition or intestinal disease. In 10 there was no evidence of an infective disease (;normal' group); seven had tuberculosis; five had acute bacterial infections. The mean serum albumin concentration was significantly lower in those with infections; the mean total and gamma-globulin concentrations were significantly higher in the tuberculosis group. There was good reproducibility in triplicate assessments of glucose and water absorption rates in the individual subjects. Despite a wide scatter, the mean glucose kinetic curves were significantly flatter in those with infections than in the normal group (p<0.02). There was a significant association between glucose and water absorption rates in the individuals. D-xylose absorption was estimated in 11 subjects and there was a significant correlation between that and the glucose absorption rate. Jejunal morphology (n=9) and disaccharidase concentrations (n=6) were normal for African subjects and there were no significant associations between either of those and the absorption rates. Galactose absorption kinetics have been studied in an additional four relatively normal Zambian Africans. This study suggests that systemic bacterial infections can produce malabsorption. This may be relevant to the weight loss in patients with pulmonary tuberculosis and also to the aetiology of kwashiorkor.
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Abstract
1. In order to investigate a possible competition for intestinal transport between amino acids and monosaccharides in man, iso-osmotic solutions containing (A) 100 m-mole glycine 1.(-1), (B) 100 m-mole glycine and 200 m-mole monosaccharide (glucose or galactose) 1.(-1), and (C) 200 m-mole monosaccharide 1.(-1), were successively perfused into the upper jejunum of twelve African Zambian patients. None had clinical evidence of malnutrition or small-intestinal disease. By using a double-lumen tube and by reference to a non-absorbable marker (polyethylene glycol, 4000), the rates of absorption of these substances have been calculated for a 30 cm jejunal segment.2. The presence of glucose and galactose produced a significant impairment (up to 50%) in the rate of absorption of glycine. There was also a significant decrease in the uptake of both monosaccharides from the solutions in which glycine was also present.3. If this observation also applies to other amino acids it could have a practical value in population groups living on high carbohydrate diets with a marginal concentration of some essential amino acids. It could have special importance when the jejunal mucosa is damaged in severe malnutrition or gastrointestinal infection. This impairment of amino acid uptake may explain the very high incidence of genetically determined lactase-deficiency in Africa.
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Vogel A. Vergleichende Untersuchungen zur Morphologie der D�nndarmschleimhaut bei verschiedenen Formen des Malabsorptionssyndroms sowie bei anderen Erkrankungen im Kindesalter. Virchows Arch 1971. [DOI: 10.1007/bf00600673] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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