Nutritional Problems of Developing Countries

Trends and Seasonality of Information Searches Carried Out through Google on Nutrition and Healthy Diet in Relation to Occupational Health: Infodemiological Study

This study aimed to analyze and relate the population interest through information search trends on Nutrition and Healthy Diet (HD) with the Occupational Health (OH). Ecological and correlational study of the Relative Search Volume (RSV) obtained from Google Trends query, segmented in two searched periods concerning antiquity; date of query: 20 April 2021. The RSV trends for the analyzed three Topics were: Nutrition (R² = 0.02), HD (R² = 0.07) and OH (R² = -0.72). There was a good positive correlation between Nutrition and OH (R = 0.56, p < 0.001) and a moderate one between HD and OH (R = 0.32, p < 0.001). According to seasons, differences were verified between RSV means in the Topics HD (p < 0.01) and OH (p < 0.001). Temporal dependence was demonstrated on Nutrition searches (Augmented Dickey-Fuller = -2.35, p > 0.05). There was only a significant relationship between the RSV Topic HD (p < 0.05) for the Developing and Least Developed countries. The data on the analyzed RSV demonstrated diminishing interest in the search information on HD and OH as well as a clearly positive trend change in recent years for Nutrition. A good positive correlation was observed between the RSV of nutrition and OH whereas the correlation between HD and OH was moderate. There were no milestones found that may report a punctual event leading to the improvement of information searches. Temporal dependence was corroborated in the RSV on Nutrition, but not in the other two Topics. Strangely, only an association was found on HD searches between the Developing and Least Developed Countries. The study of information search trends may provide useful information on the population's interest in the disease data, as well as would gradually allow the analysis of differences in popularity, or interest even between different countries. Thus, this information might be used as a guide for public health approaches regarding nutrition and a healthy diet at work.

Integrating a genome-wide association study with transcriptomic data to predict candidate genes and favourable haplotypes influencing Brassica napus seed phytate

Phytate is the storage form of phosphorus in angiosperm seeds and plays vitally important roles during seed development. However, in crop plants phytate decreases bioavailability of seed-sourced mineral elements for humans, livestock and poultry, and contributes to phosphate-related water pollution. However, there is little knowledge about this trait in oilseed rape (Brassica napus). Here, a panel of 505 diverse B. napus accessions was screened in a genome-wide association study (GWAS) using 3.28 × 10⁶ single-nucleotide polymorphisms (SNPs). This identified 119 SNPs significantly associated with phytate concentration (PA_Conc) and phytate content (PA_Cont) and six candidate genes were identified. Of these, BnaA9.MRP5 represented the candidate gene for the significant SNP chrA09_5198034 (27 kb) for both PA_Cont and PA_Conc. Transcription of BnaA9.MRP5 in a low-phytate variety (LPA20) was significantly elevated compared with a high-phytate variety (HPA972). Association and haplotype analysis indicated that inbred lines carrying specific SNP haplotypes within BnaA9.MRP5 were associated with high- and low-phytate phenotypes. No significant differences in seed germination and seed yield were detected between low and high phytate cultivars examined. Candidate genes, favourable haplotypes and the low phytate varieties identified in this study will be useful for low-phytate breeding of B. napus.

Network Inference of Transcriptional Regulation in Germinating Low Phytic Acid Soybean Seeds

The low phytic acid (lpa) trait in soybeans can be conferred by loss-of-function mutations in genes encoding myo-inositol phosphate synthase and two epistatically interacting genes encoding multidrug-resistance protein ATP-binding cassette (ABC) transporters. However, perturbations in phytic acid biosynthesis are associated with poor seed vigor. Since the benefits of the lpa trait, in terms of end-use quality and sustainability, far outweigh the negatives associated with poor seed performance, a fuller understanding of the molecular basis behind the negatives will assist crop breeders and engineers in producing variates with lpa and better germination rate. The gene regulatory network (GRN) for developing low and normal phytic acid soybean seeds was previously constructed, with genes modulating a variety of processes pertinent to phytic acid metabolism and seed viability being identified. In this study, a comparative time series analysis of low and normal phytic acid soybeans was carried out to investigate the transcriptional regulatory elements governing the transitional dynamics from dry seed to germinated seed. GRNs were reverse engineered from time series transcriptomic data of three distinct genotypic subsets composed of lpa soybean lines and their normal phytic acid sibling lines. Using a robust unsupervised network inference scheme, putative regulatory interactions were inferred for each subset of genotypes. These interactions were further validated by published regulatory interactions found in Arabidopsis thaliana and motif sequence analysis. Results indicate that lpa seeds have increased sensitivity to stress, which could be due to changes in phytic acid levels, disrupted inositol phosphate signaling, disrupted phosphate ion (Pi) homeostasis, and altered myo-inositol metabolism. Putative regulatory interactions were identified for the latter two processes. Changes in abscisic acid (ABA) signaling candidate transcription factors (TFs) putatively regulating genes in this process were identified as well. Analysis of the GRNs reveal altered regulation in processes that may be affecting the germination of lpa soybean seeds. Therefore, this work contributes to the ongoing effort to elucidate molecular mechanisms underlying altered seed viability, germination and field emergence of lpa crops, understanding of which is necessary in order to mitigate these problems.

Low phytic acid Crops: Observations Based On Four Decades of Research

The low phytic acid (lpa), or "low-phytate" seed trait can provide numerous potential benefits to the nutritional quality of foods and feeds and to the sustainability of agricultural production. Major benefits include enhanced phosphorus (P) management contributing to enhanced sustainability in non-ruminant (poultry, swine, and fish) production; reduced environmental impact due to reduced waste P in non-ruminant production; enhanced "global" bioavailability of minerals (iron, zinc, calcium, magnesium) for both humans and non-ruminant animals; enhancement of animal health, productivity and the quality of animal products; development of "low seed total P" crops which also can enhance management of P in agricultural production and contribute to its sustainability. Evaluations of this trait by industry and by advocates of biofortification via breeding for enhanced mineral density have been too short term and too narrowly focused. Arguments against breeding for the low-phytate trait overstate the negatives such as potentially reduced yields and field performance or possible reductions in phytic acid's health benefits. Progress in breeding or genetically-engineering high-yielding stress-tolerant low-phytate crops continues. Perhaps due to the potential benefits of the low-phytate trait, the challenge of developing high-yielding, stress-tolerant low-phytate crops has become something of a holy grail for crop genetic engineering. While there are widely available and efficacious alternative approaches to deal with the problems posed by seed-derived dietary phytic acid, such as use of the enzyme phytase as a feed additive, or biofortification breeding, if there were an interest in developing low-phytate crops with good field performance and good seed quality, it could be accomplished given adequate time and support. Even with a moderate reduction in yield, in light of the numerous benefits of low-phytate types as human foods or animal feeds, should one not grow a nutritionally-enhanced crop variant that perhaps has 5% to 10% less yield than a standard variant but one that is substantially more nutritious? Such crops would be a benefit to human nutrition especially in populations at risk for iron and zinc deficiency, and a benefit to the sustainability of agricultural production.

Vitamin A and Breast-Feeding: A Comparison of Data from Developed and Developing Countries

The vitamin A status of lactating women, its effect on the vitamin A content of human milk, and the adequacy of human milk as a source of vitamin A for the infant were assessed, comparing data from developing countries with those from developed countries. The vitamin A concentration in breast milk during the first two weeks of lactation is nearly double that at one month. It is even higher in preterm milk than in term milk during the first several months. Human milk alone provides sufficient vitamin A to prevent clinical deficiency throughout the first 12 months of life, even in presumably more poorly nourished populations in developing countries. However, it is not sufficient to allow liver storage after about six months of lactation.

Systematic Review of Tools and Methods to Measure Appetite in Undernourished Children in the Context of Low- and Middle-Income Countries

Child undernutrition has multifactorial causes, ranging from food insecurity to etiologies refractory to conventional nutritional approaches, such as infections, environmental enteric dysfunction, and other conditions that lead to systemic inflammation. Poor appetite may be an important symptom of these causes and may be a useful marker of an undernourished child's ability to recover. We conducted a systematic review to characterize the methods and tools to measure appetite among children <5 y old in low- and middle-income countries. A systematic search of 8 databases identified 23 eligible studies published since 1995. Thirteen described methods based on direct feeding observation or quantification of nutrient intake from caregiver report, 16 described tools that assessed caregiver perceptions of appetite, and 6 reported assessments in both categories. Four studies that gauged caregiver perceptions assessed multiple appetite domains, whereas 12 assessed 1 domain-often with a single question. Only 6 studies reported validation processes, the most common of which compared an observed test meal with daily energy intake. No studies reported the use of a method or tool that was validated in multiple cultural or linguistic contexts. Although dietary intake measures and observed feeding tests have shown validity in some contexts, they are resource intensive. Subjective caregiver questionnaires may offer a more efficient appetite evaluation method, but they have been evaluated less consistently. A rigorously developed and validated tool to rapidly assess child appetite is needed and could be best addressed by a questionnaire that leverages the multiple domains of appetite. The application of interventions that target causes of undernutrition that are not amenable to food-based interventions in clinical or research contexts could be facilitated by an efficient appetite screening tool to identify appetite-related causes of undernutrition and to monitor children's response to such interventions.

Undernutrition, Vitamin A and Iron Deficiency Are Associated with Impaired Intestinal Mucosal Permeability in Young Bangladeshi Children Assessed by Lactulose/Mannitol Test

BACKGROUND

Lactulose/mannitol (L:M) test has been used as a non-invasive marker of intestinal mucosal -integrity and -permeability (enteropathy). We investigated the association of enteropathy with anthropometrics, micronutrient- status, and morbidity in children.

METHODS

The urine and blood samples were collected from 925 children aged 6-24 months residing in Mirpur slum of Dhaka, Bangladesh during November 2009 to April 2013. L:M test and micronutrient status were assessed in the laboratory of International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b) following standard procedure.

RESULTS

Mean±SD age of the children was 13.2±5.2 months and 47.8% were female. Urinary- lactulose recovery was 0.264±0.236, mannitol recovery was 3.423±3.952, and L:M was 0.109±0.158. An overall negative correlation (Spearman's-rho) of L:M was found with age (rs = -0.087; p = 0.004), weight-for-age (rs = -0.077; p = 0.010), weight-for-length (rs = -0.060; p = 0.034), mid-upper-arm-circumference (rs = -0.098; p = 0.001) and plasma-retinol (rs = -0.105; p = 0.002); and a positive correlation with plasma α-1-acid glycoprotein (rs = 0.066; p = 0.027). However, most of the correlations were not very strong. Approximately 44% of children had enteropathy as reflected by L:M of ≥0.09. Logistic regression analysis revealed that younger age (infancy) (adjusted odds ratio (AOR) = 1.35; p = 0.027), diarrhea (AOR = 4.00; p = 0.039) or fever (AOR = 2.18; p = 0.003) within previous three days of L:M test were the risk factors of enteropathy (L:M of ≥0.09).

CONCLUSIONS

Enteropathy (high L:M) is associated with younger age, undernutrition, low vitamin A and iron status, and infection particularly diarrhea and fever.

Low-phytic-acid Grains

As one approach to the improvement of the nutritional quality of crops for both foods and feeds, low-phytic-acid (lpa) mutants of maize and other cereals have been isolated. An important advantage of lpa mutants is that the bioavailability of a range of minerals may be improved, although phytic acid can also function as an antioxidant. Livestock producers are primarily concerned with excretion of feed phytic acid phosphorus by livestock and fish. This contributes to water pollution and is a major environmental issue in developed countries. In these mutants, phytic acid phosphorus is reduced by 55% to 66%, which is matched by an equal increase in inorganic phosphorus. Greater reductions in phytic acid, as high as 95% to 99%, may be desirable and are possible. The first two studies of an lpa maize in human nutrition found increased fractional absorption of iron and zinc in the lpa maize as compared with the control maize.

Yields of the best lpa lines, first developed in the mid-1990s, now range between 5% and 15% below those of the highest-yielding commercial varieties. Because of benefits for animal nutrition, lpa crops could become highly profitable for use as animal feeds. All lpa lines to date have been developed using classical genetic methods; these classically obtained mutants affect the expression of a given gene throughout the tissues and organs of a plant. BY using a biotechnology approach, it may be possible to achieve optimal levels of phytic acid reduction and target the desired effect to the seed, thereby reducing any undesirable agronomic effects of whole-plant mutants.

Metabolic regulation of T lymphocytes

T cell activation leads to dramatic shifts in cell metabolism to protect against pathogens and to orchestrate the action of other immune cells. Quiescent T cells require predominantly ATP-generating processes, whereas proliferating effector T cells require high metabolic flux through growth-promoting pathways. Further, functionally distinct T cell subsets require distinct energetic and biosynthetic pathways to support their specific functional needs. Pathways that control immune cell function and metabolism are intimately linked, and changes in cell metabolism at both the cell and system levels have been shown to enhance or suppress specific T cell functions. As a result of these findings, cell metabolism is now appreciated as a key regulator of T cell function specification and fate. This review discusses the role of cellular metabolism in T cell development, activation, differentiation, and function to highlight the clinical relevance and opportunities for therapeutic interventions that may be used to disrupt immune pathogenesis.

Inositol hexaphosphate inhibits tumor growth, vascularity, and metabolism in TRAMP mice: a multiparametric magnetic resonance study

Herein, employing anatomical and dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI), we evaluated noninvasively, the in vivo, chemopreventive efficacy of inositol hexaphosphate (IP6), a major constituent of high-fiber diets, against prostate tumor growth and progression in transgenic adenocarcinoma of the mouse prostate (TRAMP) model. Male TRAMP mice, beginning at 4 weeks of age, were fed with 1%, 2%, or 4% (w/v) IP6 in drinking water or only drinking water till 28 weeks of age and monitored using MRI over the course of study. Longitudinal assessment of prostate volumes by conventional MRI and tumor vascularity by gadolinium-based DCE-MRI showed a profound reduction in tumor size, partly due to antiangiogenic effects by IP6 treatment. As potential mechanisms of IP6 efficacy, decrease in the expression of glucose transporter GLUT-4 protein together with an increase in levels of phospho-AMP-activated kinase (AMPK(Th172)) were observed in prostate tissues of mice from IP6 fed-groups, suggesting that IP6 is interfering with the metabolic events occurring in TRAMP prostate. Investigative metabolomics study using quantitative high-resolution (1)H-NMR on prostate tissue extracts showed that IP6 significantly decreased glucose metabolism and membrane phospholipid synthesis, in addition to causing an increase in myoinositol levels in the prostate. Together, these findings show that oral IP6 supplement blocks growth and angiogenesis of prostate cancer in the TRAMP model in conjunction with metabolic events involved in tumor sustenance. This results in energy deprivation within the tumor, suggesting a practical and translational potential of IP6 treatment in suppressing growth and progression of prostate cancer in humans.

Quantitative trait loci analysis of phytate and phosphate concentrations in seeds and leaves of Brassica rapa

Phytate, being the major storage form of phosphorus in plants, is considered to be an anti-nutritional substance for human, because of its ability to complex essential micronutrients. In the present study, we describe the genetic analysis of phytate and phosphate concentrations in Brassica rapa using five segregating populations, involving eight parental accessions representing different cultivar groups. A total of 25 quantitative trait loci (QTL) affecting phytate and phosphate concentrations in seeds and leaves were detected, most of them located in linkage groups R01, R03, R06 and R07. Two QTL affecting seed phytate (SPHY), two QTL affecting seed phosphate (SPHO), one QTL affecting leaf phosphate and one major QTL affecting leaf phytate (LPHY) were detected in at least two populations. Co-localization of QTL suggested single or linked loci to be involved in the accumulation of phytate or phosphate in seeds or leaves. Some co-localizing QTL for SPHY and SPHO had parental alleles with effects in the same direction suggesting that they control the total phosphorus concentration. For other QTL, the allelic effect was opposite for phosphate and phytate, suggesting that these QTL are specific for the phytate pathway.

Aging, Nutritional Status, and Infection in the Developing World

The fast rate of increase in the number of older people in less-developed countries threatens to further strain the limited health resources of these countries. However, very little is known about their health status and the risk factors that contribute to it. In this article, we review the burden of infectious diseases in elderly people in less-developed countries, discuss the contribution of nutrition and immune response to morbidity and mortality, identify gaps in current knowledge, and suggest strategies to address this fast-growing public health problem.

The family as a determinant of stunting in children living in conditions of extreme poverty: a case-control study

BACKGROUND

Malnutrition in children can be a consequence of unfavourable socioeconomic conditions. However, some families maintain adequate nutritional status in their children despite living in poverty. The aim of this study was to ascertain whether family-related factors are determinants of stunting in young Mexican children living in extreme poverty, and whether these factors differ between rural or urban contexts.

METHODS

A case-control study was conducted in one rural and one urban extreme poverty level areas in Mexico. Cases comprised stunted children aged between 6 and 23 months. Controls were well-nourished children. Independent variables were defined in five dimensions: family characteristics; family income; household allocation of resources and family organisation; social networks; and child health care. Information was collected from 108 cases and 139 controls in the rural area and from 198 cases and 211 controls in the urban area. Statistical analysis was carried out separately for each area; unconditional multiple logistic regression analyses were performed to obtain the best explanatory model for stunting.

RESULTS

In the rural area, a greater risk of stunting was associated with father's occupation as farmer and the presence of family networks for child care. The greatest protective effect was found in children cared for exclusively by their mothers. In the urban area, risk factors for stunting were father with unstable job, presence of small social networks, low rate of attendance to the Well Child Program activities, breast-feeding longer than six months, and two variables within the family characteristics dimension (longer duration of parents' union and migration from rural to urban area).

CONCLUSIONS

This study suggests the influence of the family on the nutritional status of children under two years of age living in extreme poverty areas. Factors associated with stunting were different in rural and urban communities.Therefore, developing and implementing health programs to tackle malnutrition should take into account such differences that are consequence of the social, economic, and cultural contexts in which the family lives.

Progress in breeding low phytate crops

Populations that depend on grains and legumes as staple foods consume diets rich in phytic acid (myo-inositol-1,2,3,4,5,6-hexkisphosphate), the storage form of phosphorus in seeds. This compound binds tightly to important mineral nutrients such as iron and zinc, forming salts that are largely excreted. This phenomenon can contribute to mineral depletion and deficiency. As one approach to solving this and environmental problems associated with seed-derived dietary phytic acid, the U. S. Department of Agriculture and others have isolated cereal and legume low-phytic acid mutations and have used these to breed first-generation low-phytate hybrids, cultivars and lines of maize (Zea mays), barley (Hordeum vulgare), rice (Oryza sativa) and soybean (Glycine max). Seed phytic acid is reduced in these crops by 50-95%. The progress in the genetics, breeding and nutritional evaluation of low-phytate crops are reviewed in this article.

Absorption of iron from unmodified maize and genetically altered, low-phytate maize fortified with ferrous sulfate or sodium iron EDTA

BACKGROUND

Reducing the phytate content in grains by genetic manipulation is a novel approach to increasing nonheme-iron absorption from mixed diets. Fractional iron absorption from a genetically modified strain of low-phytate maize (LPM) increased significantly, by 50%.

OBJECTIVE

We assessed iron absorption from porridges prepared from the same LPM (lpa-1-1 mutant) and unmodified wild-type maize (WTM), both of which were fortified with either ferrous sulfate or sodium iron EDTA.

DESIGN

Porridges providing 3.4 mg Fe were fortified with either ferrous sulfate or sodium iron EDTA to provide an additional 1 mg Fe/serving. In 14 nonanemic women, iron absorption was measured as the amount of radioiron incorporated into red blood cells (extrinsic tag method) 12 d after consumption of the study diets.

RESULTS

No significant effect of phytate content on iron absorption was found when porridge was fortified with either sodium iron EDTA or ferrous sulfate. Fractional absorption of iron from WTM porridge fortified with sodium iron EDTA (5.73%) was 3.39 times greater than that from the same porridge fortified with ferrous sulfate (1.69%). Fractional absorption of iron from the sodium iron EDTA-fortified LPM porridge (5.40%) was 2.82 times greater than that from LPM porridge fortified with ferrous sulfate (1.91%) (P<0.0001 for both comparisons, repeated-measures analysis of variance). Thus, the previously identified benefit of LPM was no longer detectable when maize porridge was fortified with additional iron.

CONCLUSION

Iron was absorbed more efficiently when the fortificant was sodium iron EDTA rather than ferrous sulfate, regardless of the type of maize.

Potential interventions for the prevention of childhood pneumonia in developing countries: improving nutrition

Acute respiratory infections are the leading cause of childhood death in developing countries. Current efforts at mortality control focus on case management and immunization, but other preventive strategies may have a broader and more sustainable effect. This review, commissioned by the World Health Organization, examines the relations between pneumonia and nutritional factors and estimates the potential effect of nutritional interventions. Low birth weight, malnutrition (as assessed through anthropometry), and lack of breast-feeding appear to be important risk factors for childhood pneumonia, and nutritional interventions may have a sizeable effect in reducing deaths from pneumonia. For all regions except Latin America, interventions to prevent malnutrition and low birth weight look more promising than does breast-feeding promotion. In Latin America, breast-feeding promotion would have an effect similar to that of improving birth weights, whereas interventions to prevent malnutrition are likely to have less of an effect. These findings emphasize the need for tailoring interventions to specific national and even local conditions.

Epidemiology of altered intestinal permeability to lactulose and mannitol in Guatemalan infants

BACKGROUND

Subclinical alterations of small intestinal function have been reported frequently in tropical countries. Studies of small intestinal permeability to lactulose and mannitol were therefore completed in Guatemalan infants from a low-income, periurban community to assess the prevalence of altered intestinal function and the factors associated with this condition.

METHODS

Two hundred studies were successfully completed in 158 infants who had been free of diarrhea for at least 1 week before the day of study. Urinary concentrations of lactulose and mannitol during the 5-hour period after ingestion of 400 mg/kg body weight of lactulose and 100 mg/kg body weight of mannitol were measured by gas-liquid chromatography and compared by age group, feeding practices, anthropometric indexes, and serum iron and zinc concentrations.

RESULTS

The overall prevalence of altered intestinal permeability (defined as a ratio of urinary recovery of lactulose to mannitol [L/M] > or =0.07) was 30%. The urinary L/M recovery ratio was positively associated with age; low weight for age; and, in infants less than 6 months of age, non-breast-feeding. Children with serum iron concentrations less than 7.16 microM/l (40 [microg/dl) had higher median L/M ratios (L/M = 0.068; 95% confidence interval [CI], 0.054, 0.085) than those with iron levels higher than this cutoff (L/M = 0.052; CI = 0.046, 0.058; p = 0.038). The median urinary L/M recovery ratio in 10 currently asymptomatic infants who had diarrhea during the week before testing (0.087; CI = 0.49, 0.154) was higher than that in children who had been free from diarrhea for at least 1 week (0.052; CI = 0.048, 0.056; p = 0.01).

CONCLUSION

Age, feeding practices, low weight-for-age, low serum iron concentration, and recent diarrhea were all associated with altered intestinal function in this group of Guatemalan infants.

The ten questions screen for childhood disabilities: its uses and limitations in Pakistan

OBJECTIVE

To assess the accuracy of the ten questions screen as a measure of childhood disability for epidemiologic studies in populations lacking resources for professional assessment of children's development and functioning.

DESIGN

Household survey and screening of children in phase one followed by clinical assessments in phase two.

SETTING

Karachi, Pakistan.

PARTICIPANTS

A cluster sample of 6365 children, aged 2 to 9 years, screened using the ten questions and a subsample referred for clinical assessments.

MAIN RESULTS

Although the sensitivity of the ten questions as a global screen for serious cognitive, motor, and seizure disabilities is high (84-100%), its sensitivity for identifying and distinguishing specific types of disability and for detecting vision, hearing, and mild disabilities, overall, is limited (generally < 80% and as low as 4% for mild vision disability). The predictive value of a positive screening result is also limited-using the ten questions in surveys without clinical confirmation results in overestimation of the prevalence of serious disability by more than 300%.

CONCLUSIONS

The ten questions screen is not an assessment tool. Its utility lies in its ability to screen or select a fraction of the population at high risk for serious disability. As a screening tool, it allows scarce diagnostic and other professional resources to be efficiently directed toward those at high risk.

Cellular and molecular effects of malnutrition and their relevance to periodontal diseases

In response to periodontal pathogens, the leukocytes (PMN) elaborate destructive oxidants, proteinases, and other factors. The balance between these factors, the antioxidants and endogenously synthesized antiproteinases determine the extent of periodontal damage. Malnutrition (PEM) is characterized by marked tissue depletion of the key antioxidant nutrients, including GSH (gamma-glutamyl-cysteinyl-glycine), and impaired acute-phase protein response (APR) to infections. The latter results in diminished production of the acute-phase proteins (APP). The APR plays a key role in promoting healing, and its deficit in PEM is due to impairment in the production and cellular action of the cytokines. Other features of malnutrition include inverted helper-suppressor T-cell ratio, histaminemia, hormonal imbalance with increased blood and saliva levels of free cortisol, and defective mucosal integrity. Malnutrition, particularly of the PEM type which usually involves concomitant deficiencies of several essential macro- and micronutrients, therefore has the potential to adversely influence the prognosis of periodontal infections.