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Diarrhea and Malnutrition: Interactions, Mechanisms, and Interventions.
Edited by Lincoln C. Chen and Nevin S. Scrimshaw. Plenum Publishing Corporation, New York, in co-operation with the United Nations University, 1982.
Quantitatively, diarrhoeal disease predominates over all other non-dietary causes of malnutrition in low-income countries. It has been established that the nutritional status of a child is usually as much the product of infection as of diet (1); and studies in the Gambia have indicated that diarrhoeal illness contributes almost exclusively to the non-dietary element in failure to grow (2). Diarrhea and Malnutrition - the proceedings of a conference on the Interactions of Diarrhoea and Malnutrition held in Bellagio Italy, in May 1981 under the sponsorship of the Rockefeller and Ford Foundations, the United Nations University, end the International Centre for Diarrhoeal Disease Research, Bangladesh - provides information on the most recent advances in understanding and answering some of the long-standing problems on this subject.
Paradoxically, physicians for a long time have made the malnutrition produced by diarrhoeal disease worse: up to the mid-1970s doctors were being taught that the initial treatment for diarrhoea was to starve the patient, and there are those who are still following that practice. Thirty-two years ago Arthur Chung and his colleagues, working in the Children's Medical Service of Bellevue Hospital in New York and at the University Children's Clinic in Bratislava, Czechoslovakia, must have been extremely frustrated and depressed when virtually all physicians regarded their idea of giving food during diarrhoeal episodes as something of a medical heresy. Today, a generation later, it is recognized that Chung was correct: children fed throughout the acute phase of watery diarrhoea absorb substantial quantities of nutrients, demonstrate significantly better weight gain, and have diarrhoea for a shorter time than unfed matched controls. This rediscovered insight is vital in low - income countries of Asia, Africa, and Latin America, which have 94.4 per cent of all the diarrhoeal disease in the world occurring among children, as pointed out by Chen in table 1 of chapter 1 of Diarrhea and Malnutrition. Continuing breastfeeding and giving food and rehydration even in the presence of vomiting and diarrhoea involve changing traditional ideas, attitudes, and practices not only among lay people but among doctors themselves.
This book explains very clearly the mechanisms involved in producing malnutrition in diarrhoea, with ample proof from scientific and clinical studies. The mechanisms that precipitate malnutrition in diarrhoeal disease include loss of appetite, the witholding of food, and the inappropriate use of certain foods in treating the patient, the catabolic effect, direct loss of nutrients in the stool, and intestinal malabsorption. A wealth of new knowledge on malabsorption of carbohydrate, protein, and fat in relation to the causative organisms in diarrhoeal disease is presented. The fact that there is usually increased appetite and increased food intake during convalescence from diarrhoea to compensate for body weight loss and for catch-up growth in children is emphasized. The major fact has now come to light that the dietary protein allowance given by FAO/ WHO in 1973 did not consider the extra dietary protein required under conditions of repeated infections like diarrhoea in which protein is always lost through the gut, and sometimes also through catabolic processes, in lowincome countries. It is because of these considerations that scientists such as Roger Whitehead, supported by clinical and laboratory studies of other independent workers, recommend a 30 per cent increase in calories and a 100 per cent increase in protein (4 gm/kg/day) to optimize repletion in young children depleted by infection. This is why there is consensus that, in low-income countries of Asia, Latin America, and Africa, where repeated diarrhoeal episodes in childhood are the rule, the recommended dietary allowance for protein should be 25-30 per cent above the 1973 FAD/WHO recommendations to compensate for nutritional losses during frequent disease episodes in order to maintain normal growth and development.
On the question of definition of diarrhoea - which can raise controversies - the authors define diarrhoea as "increase in the frequency by two or more times of the usual daily number of stools that are, in addition, loose, extending over a period of 24 hours or more. The presence of nausea, vomiting, fever, abdominal cramps, dehydration or bloody mucoid stools is consistent with but not necessary for the diagnosis" (chap.16). The book strongly emphasizes that the correct therapeutic approach in the teatment of diarrhoea is to use electrolyte fluids and food without drugs. Much stress has been put on continuing breastfeeding during diarrhoea. The recommended therapeutic approach is summarized in chapter 17, where the authors say that "cereals, legumes, and other locally available staple foods may thus become, in proper quantities, the basis of a combined fluid, protein-energy oral therapy for diarrhoea, a single antidote for the FEM-PEM cycle." Absolute poverty in low-income countries is an important limiting factor in most programmes intended to reduce diarrhoea, as noted by Benjamm Tośn in chapter 15.
The book, compiled by highly competent scientists in the field of applied research in malnutrition and diarrhoea, delivers facts that are undisputable, as well as indicating areas that need further research. Medical and nutrition planners need to be made aware of the relevant facts so that rapid action will be taken at policy and operational levels to stop the abnormally high morbidity and mortality caused by interactions of diarrhoea and malnutrition. Asian, Latin American, and African countries should give high priority to the prevention and control of diarrhoea, using the relatively low-cost technologies suggested in the book (e.g., preparation and administration of oral rehydration fluid at home). These low-income countries can possibly seek goodwill and help from friendly developed and industrialized nations to give them materials, money, and manpower support to achieve the global aim "health for all by the year 2000." Lincoln Chen and Nevin Scrimshaw are to be congratulated for editing and producing this comprehensive, well-written, useful book aimed especially at stimulating and initiating programmes that will lead to a reduced incidence of malnutrition,
particularly in low-income countries. The book is highly recommended as essential reading for medical undergraduates and post-graduates, practicing physicians, and public health specialists.
References
1, Nevin S. Scrimshaw et al., in R.E. Olson, ea., Protein-Calorie Malnutrition {Academic Press, New York, 1975).
2. M.G.M. Rowland, T.J. Cole, and R.G. Whitehead, "A Quantitative Study into the Role of Infection in Determining Nutritional Status in Gambian Village Children," Brit. J. Nutr., 37: 441-450,
Vaierian P. Kimati
UNU-WHP Fellow and Visiting Scientist
MlT/Harvard International Food and
Nutrition Policy Program