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Symposium: Nutrition and Infection,Prologue and Progress Since
1968
Diarrhea and Malnutrition1
Kenneth H. Brown2
Program in International Nutrition and Department of Nutrition,
University of California, Davis, CA
ABSTRACT Publication of the WHO monograph, Interactions of
Nutrition and Infection, in 1968 by Scrimshaw,Taylor and Gordon
stimulated many scientists to pursue further research on these
issues. With regard to therelationships between diarrhea and
malnutrition, the research conducted since 1968 can be categorized
in one ofthree major areas: 1) the impact of diarrhea on
nutritional status, particularly in young children;2) nutritional
riskfactors for diarrhea; and 3) appropriate dietary therapy for
patients during and after enteric infections. The resultsof these
studies have prompted a number of changes in the clinical treatment
of patients with diarrhea and in publichealth policies regarding
its prevention. J. Nutr. 133: 328S332S, 2003.
KEY WORDS: diarrhea malnutrition infection dietary intake
breastfeeding
It is personally very gratifying to be able to contribute tothis
symposium, which revisits the 1968 treatise by Scrimshaw,Taylor and
Gordon entitled, Interactions of Nutrition andInfection (1),
because this publication had a major impact onmy own thinking and
career development. For individuals likeme who were U.S. university
students at the time, the year1968 was notable for the growing
distrust of the militaryindustrial complex, the widespread
resistance to the war inVietnam, and the reawakened social concern
for disenfran-chised peoples, both in the United States and
elsewhere. Atthe same time, Timothy Leary was counseling students
andother members of the love generation to turn on, tune in,
and
drop out (2); and the hippie movement was reaching its peak.As a
graduating senior confronting these competing claims onmy
attention, and as the recipient of a lottery number from theU.S.
Selective Service Board that all but ensured my inscrip-tion into
the U.S. Army immediately after graduation unlessother options were
pursued, I chose instead to enroll in med-ical school until I could
decide what I really wanted to do withmy life. Because I had
originally hoped to join the Peace Corpsafter finishing my
undergraduate studies, once in medicalschool I began to explore
opportunities for practicing medicineand/or conducting biomedical
research in the developingworld; and I soon discovered the series
of publications byScrimshaw, Gordon and colleagues on weanling
diarrhea (3)and the interactions between infection and nutrition
(4,5).
Thus began my personal and professional odyssey in quest
ofgreater knowledge on these topics.
The comprehensive monograph Interactions of Nutri-tion and
Infection stimulated many scientists to pursuefurther research on
these issues, and in this presentation Iwill highlight some of the
resulting studies on diarrhea andnutrition. In general, the
research conducted on this topicsince 1968 can be categorized in
one of three major areas:1) the impact of diarrhea on nutritional
status, particularlyin young children; 2) nutritional risk factors
for diarrhea;and 3) appropriate dietary therapy for patients during
andafter enteric infections. Notably, the results of these
studies
prompted a number of changes in the clinical managementof
patients with diarrhea and in public health policiesregarding its
prevention. For lack of time, and because ofmy own personal
interests and experience, my commentswill focus primarily on
epidemiological and clinical studiesthat were conducted in humans.
I will not attempt toprovide a comprehensive treatment of the
literature; rather,I will highlight those studies that I believe
have exerted thegreatest influence on current thinking.
Overview of diarrhea and nutrition
As articulated by Scrimshaw, Taylor and Gordon in their1968
review, the relationship between infection and malnu-trition is
bidirectional (Fig. 1). Infection adversely affectsnutritional
status through reductions in dietary intake andintestinal
absorption, increased catabolism and sequestrationof nutrients that
are required for tissue synthesis and growth.On the other hand,
malnutrition can predispose to infectionbecause of its negative
impact on the barrier protection af-forded by the skin and mucous
membranes and by inducingalterations in host immune function.
1 Presented as part of the symposium Nutrition and Infection,
Prologue andProgress Since 1968 given at the 2002 Experimental
Biology meeting on April 23,2002, New Orleans, LA. The symposium
was sponsored by The American Societyfor Nutritional Sciences. The
proceedings are published as a supplement toTheJournal of
Nutrition. Guest editors were Nevin S. Scrimshaw,
MassachusettsInstitute of Technology, Cambridge, MA, and Food and
Nutrition Programme,United Nations University, Tokyo, Japan, and
William R. Beisel, Department ofMicrobiology and Immunology, Johns
Hopkins School of Hygiene and PublicHealth, Baltimore, MD.
2 To whom correspondence should be addressed.E-mail:
[email protected].
0022-3166/03 $3.00 2003 American Society for Nutritional
Sciences.
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Nutritional impact of diarrhea
A time line showing each of the major lines of
researchconcerning the nutritional impact of diarrhea is provided
in
Figure 2. As indicated, a number offield studies conducted
during the 1970s and 1980s attempted to quantify the
nutri-tional impact of diarrhea on childrens growth. Leonardo
Mataand colleagues at the Institute of Nutrition of Central
Americaand Panama produced a series of graphic presentations
illus-trating the temporal relationships between individual
episodesof infection and periods of growth faltering (6), an
example ofwhich is presented inFigure 3. Subsequently, Martorell et
al.in Guatemala (7), Rowland et al. in West Africa (8) and Blacket
al. in Bangladesh (9) developed statistical models to esti-mate the
proportion of the total growth deficit that could beattributed to
diarrhea, and they concluded that an importantcomponent of the
observed growth failureperhaps as muchas one-fourth to one-thirdwas
attributable to enteric infec-tions.
The groups in Guatemala and Bangladesh proceeded toexplore the
mechanisms whereby diarrhea causes growth fail-ure, focusing on
dietary intake and intestinal malabsorption.Martorell et al. (10)
reported that fully weaned Guatemalanchildren reduced their energy
intake by 30% during acuteinfections, whereas Brown et al. (11)
found that Bangladeshichildren who were still breastfeeding reduced
their intakes byonly about 7%, suggesting that breastfeeding may
protectagainst diarrhea-induced reductions in intake. During a
sub-sequent study in Peru (12), intakes of breast milk energy
andnonbreast milk food sources were examined separately; andthis
analysis of disaggregated data confirmed the foregoinghypothesis.
Whereas intake of nonbreast milk energy declinedby about 30% during
illness, there were no changes in breast
milk consumption. Thus, the overall impact of illness onenergy
intake was partially mitigated by breastfeeding.
Beginning in the 1980s, researchers started to explore fac-tors
that might modify the nutritional impact of diarrhea.Rowland et al.
(13) discovered that the previously observeddiarrhea-induced growth
deficit was absent in fully breastfedinfants in an urban field site
in West Africa, and they con-cluded that exclusive breastfeeding
prevents the adverse nu-tritional consequences of diarrhea. Lutter
et al. (14) found thatthe usual diet also influenced the growth
response to diarrheain older children. Whereas the Colombian
children in thesestudies who lived in control villages displayed
the expectednegative relationship between diarrheal prevalence and
heightat 3 y of age, there was no effect of diarrhea on the height
of
those children who lived in villages where food supplementswere
being distributed.
The most recent phase of research on this theme has begunto
examine the effect of diarrhea on micronutrient balanceand
assessment of micronutrient status. For example, Castillo-Duran et
al. (15) assessed trace element balance during andafter acute
diarrhea, noting a negative balance of zinc duringthe early phase
of illness.
Nutritional risk factors for diarrhea
Nutritional risk factors for diarrhea can be grouped
asanthropometric risk factors, infant and child feeding
practicesand micronutrient status. Measures of resulting morbidity
fromdiarrhea include both incidence rates and the duration
andseverity of illness. Research on these issues is summarized
inthe time line presented in Figure 4.
Studies by James et al. in 1972 (16) and Sepulveda et al. in1988
(17) span the period when investigators confirmed arelationship
between preexisting anthropometric status anddiarrheal incidence.
Although most investigators accept theconclusion that malnutrition
increases the risk of diarrhea, itmust be recognized that the
design of these descriptive epide-miological studies does not
permit elimination of the possibil-
ity that confounding factors may explain as least some of
theobserved results. For example, researchers have noted
thepossibility that children with some underlying predispositionto
enteric infection, such as environmental exposures or
im-munodysfunction, may have become undernourished becauseof
earlier illnesses. Thus, baseline malnutrition, as defined
byanthropometric indicators, may have been a result of theseprior
illnesses rather than a cause of subsequent ones. Disen-tanglement
of the causal sequence of these events has re-mained
problematic.
During this same period of time, investigators also
describedassociations between anthropometric indicators of
nutritionalstatus and the duration of illness (18), the severity of
fecalpurging (19) and, most important, the case-fatality rates
(20).
In each case, preexisting malnutrition was associated with
anincreased severity of diarrheal disease.
Infant feeding practices is another nutrition-related riskfactor
that received heightened attention during the periodafter 1968. Two
important studies published from Latin Amer-ica and Asia at the end
of the 1980s found that exclusivelybreastfed infants had
considerably reduced risks of diarrhea
FIGURE 2 Summary of research on the nutritional impact of
diar-rhea.
FIGURE 1 Relationship between nutrition and infection.
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complete, lactose-free formula, which provided 110 kcal/kgbody
weight d1; 2) the same formula diluted with water toprovide half
the amount of daily energy; 3) oral glucose-electrolyte solution
(GES); or 4) intravenous GES. The levelsof intake were
progressively advanced during ensuing 48-hperiods, so that all
children were receiving the complete dietby d 5 of hospitalization.
There were no differences in treat-ment failure rates or fecal
purging (except for the intravenous
group during thefirst 2 d), and the children gained weight
indirect relation to the amount of energy received. Even after 2wk
of therapy, children in the group that was fed continuouslywith the
full-strength formula weighed significantly morethan those who
initially received only GES. The advantage ofcontinuous feeding was
later confirmed during a multicenterstudy in Europe (36), and the
most recent version of thePediatric Nutrition Handbook concludes
that, It has nowbeen convincingly and repeatedly demonstrated that
childrenof all ages who return to normal feedings as soon as
appetiteallows after completion of rehydration (4 to 6 hours)
faremuch better in the duration and severity of illness (37).
A number of studies were carried out during the period from1968
to 1993 to determine whether substitution of lactose-
free, milk-based diets for ones that contained lactose
wouldmodify the outcome of treatment of acute diarrhea. The
resultsof these trials were inconsistent, although a meta-analysis
thatwas conducted to reexamine them indicated that the rates
oftreatment failure were nearly twofold greater (22 vs. 12%) inthe
groups that received lactose-containing milk feeding (36).However,
the excess rate of treatment failure was confined tothose studies
that enrolled children with initial severe dehy-dration. Among the
studies that enrolled children with mild orno dehydration, there
was no difference in the treatmentfailure rates. The authors
concluded that it is safe to managethe vast majority of children by
using lactose-containing milk,especially if they have no clinical
evidence of dehydration.
Nevertheless, dehydrated children may benefit from reduced
lactose intake and close supervision during the early phase
oftherapy.
As reviewed previously (41), a number of studies completedduring
the 1980s and 1990s examined the use of mixed dietsbased on staple
foods, and others assessed the effects of indi-vidual food
components, such as dietary fiber and micronutri-ents, on the
outcome of diarrhea. In general, children fared at
least as well with mixed diets as they did with more
highlyprocessed formulas, and dietaryfiber was found to reduce
theduration of the period of liquid stool excretion (42).
Withregard to micronutrients, studies were conducted to
determinethe impact of vitamin A and zinc. Little benefit of
vitamin Awas detected, except in nonbreastfed infants, in whom
vitaminA reduced slightly the number of bowel movements and
theduration of illness (43). By contrast with this limited impact
ofvitamin A, all of the published studies of zinc
supplementationduring both acute and persistent diarrhea found
significantreductions of about 20% in diarrheal duration (44).
Morestudies are currently under way to assess different
combina-tions and dosages of multiple micronutrients on outcomes
ofdiarrhea.
In summary, applied research published since 1968 hasconfirmed
the deleterious effect of diarrhea on childrens nu-tritional status
and has produced new evidence in support ofrevised approaches to
prevent and treat these illnesses (Fig. 6).In particular, promotion
of breastfeeding to prevent diarrheaand reduce its nutritional
complications, continued feedingduring illness and supplementation
with selected micronutri-ents, both to prevent enteric infections
and to reduce theirseverity, are all important nutritional aspects
in the control ofdiarrheal diseases and their associated
nutritional complica-tions.
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FIGURE 6 Overall summary of research on diarrhea and
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