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Background: Undernutrition contributes to 45% of all deaths in children <5 y of age worldwide, with a large proportion of those deaths caused by diarrhea. However, no validated tools exist for assessing undernutrition in children with diarrhea and possible dehydration., Objective: This study assessed the validity of different measures of undernutrition in children with diarrhea., Methods: A prospective cohort study was conducted at an urban hospital in Bangladesh. Children <60 mo of age presenting to the hospital rehydration unit with acute diarrhea were eligible for enrollment. Study staff randomly selected 1196 children for screening, of which 1025 were eligible, 850 were enrolled, and 721 had complete data for analysis. Anthropometric measurements, including weight-for-age z score (WAZ), weight-for-length z score (WLZ), midupper arm circumference (MUAC), and midupper arm circumference z score (MUACZ), were calculated pre- and posthydration in all patients. Measurements were evaluated for their ability to correctly identify undernutrition in children with varying degrees of dehydration., Results: Of the 721 patients with full data for analysis, the median percent dehydration was 4%. Of the 4 measures evaluated, MUAC and MUACZ demonstrated 92-94% agreement pre- and posthydration compared with 69-76% for WAZ and WLZ. Although each 1% change in hydration status was found to change weight-for-age by 0.0895 z scores and weight-for-length by 0.1304 z scores, MUAC and MUACZ were not significantly affected by dehydration status. Weight-based measures misclassified 12% of children with severe underweight and 14% with severe acute malnutrition (SAM) compared with only 1-2% for MUAC and MUACZ., Conclusions: MUAC and MUACZ were the most accurate predictors of undernutrition in children with diarrhea. WAZ and WLZ were significantly affected by dehydration status, leading to the misdiagnosis of many patients on arrival with severe underweight and SAM. This trial was registered at clinicaltrials.gov as NCT02007733., (© 2015 American Society for Nutrition.)

Malnourished piglets were studied to establish how a diet containing long-chain polyunsaturated fatty acids (LC-PUFA) of the (n-6) and (n-3) series, esterified in the form of phospholipids, affects intestinal recovery after severe malnutrition. Piglets (7-d-old) were randomly assigned to two groups. One group was fed a piglet milk formula and the other was malnourished by protein-energy restriction for 30 d. Healthy and malnourished piglets were then divided into two subgroups fed for 10 d either an adapted milk formula (C and M) or the same diet supplemented with LC-PUFA phospholipids (C-P and M-P). The M-P group had greater protein, DNA, cholesterol and phospholipid levels and a lower triglyceride level in the jejunal segment than did the M group. The fatty acid composition of the jejunal mucosa and microsomes of the M-P piglets did not differ from that of healthy piglets (C). However, in jejunal mucosa, microsomes and phospholipids from malnourished piglets that did not receive LC-PUFA (group M) had significantly lower percentages of (n-6) LC-PUFA than those in healthy piglets (C). The (n-3) LC-PUFA percentages of jejunal mucosa were also lower in the M group than in the C group. The small intestine of piglets fed the LC-PUFA-supplemented formula recovered more completely from histologic lesions and biochemical alterations caused by the malnutrition process than the small intestine of piglets fed the control formula without LC-PUFA.

It has become recognized that enhancing the antioxidant defense system during the early phase of rehabilitation is important to the survival of wasting protein-energy malnourished (PEM) patients. In this study, we compared the efficacy of dietary protein replenishment and supplementation with L-2-oxothiazolidine-4-carboxylate (OTC, 3.5 mg/d), a cysteine precursor, to protect against hyperoxia-induced lung damage in PEM rats. The PEM rats were produced by feeding weanling rats a protein-deficient diet (0.5% protein) for 14 d. PEM rats were then divided in three dietary treatment groups, 0.5% protein (-Pr), 0.5% protein plus the OTC supplement (+OTC), or 15% protein (+Pr) during 4 d of either hyperoxia (85% O2) or air exposure. Increased lung-to-body weight ratios, indicative of oxidative tissue damage, were observed following exposure to hyperoxia in -Pr and +Pr rats, but not in +OTC rats, even though the OTC supplement and the 15% protein diet contained a comparable amount of cysteine. Tissue reduced glutathione (GSH) status, GSH-dependent enzyme activity and antioxidant defense enzyme activities were monitored in the lung, liver and blood during 4 d of hyperoxia exposure. OTC supplementation enhanced GSH levels significantly in the lung of PEM rats, whereas protein repletion significantly elevated blood GSH concentrations. The protective effect of OTC was not a function of changes in activity of GSH-dependent enzymes or oxygen defense enzymes in the lung. These results indicate that a short-term strategy that selectively elevates GSH levels in the lung is more effective than protein repletion in protecting against hyperoxia-induced oxidative lung damage in PEM rats.

The goal of this study was to evaluate the influence of severe protein-energy malnutrition (PEM) on lipid composition and fatty acid profile in the small intestinal mucosa of lactating pigs. Malnutrition was achieved by 80% protein-energy restriction for 30 d (20% of the food intake in the control group) in 7-d-old newborn piglets. Malnourished piglets had significantly lower concentrations of cholesterol, phospholipid and triglycerides in the jejunum and ileum compared with freely fed controls. Fatty acid composition of the intestinal mucosa was severely affected by malnutrition. A sharp decline in the relative percentages of (n-3) and (n-6) long-chain polyunsaturated fatty acids (LC-PUFA) in malnourished piglets paralleled higher (n-9) fatty acid proportions in the total mucosa, microsomes and phospholipids of the jejunum. The structure of the small intestine was severely affected as assessed by light and electron microscopy, and alkaline phosphatase and disaccharidase activities in the intestinal mucosa were also significantly impaired. Plasma from malnourished piglets had significantly lower concentrations of (n-3) and (n-6) LC-PUFA than that of control piglets; however, the fatty acid composition of red blood cell membrane was unaffected. Our results suggest that early severe PEM dramatically modifies intestinal membrane lipid composition. Changes in the lipid composition of the small intestinal mucosa and in phospholipid distribution as well as in the fatty acid profile may alter membrane fluidity and organization. These alterations appear to affect the activity of membrane-bound hydrolytic enzymes.

The objective of this investigation was to determine whether an imbalance between naive- and memory-phenotype cells occurs within CD4+ and/or CD8+ splenic T cell subsets in models of protein-energy malnutrition (PEM) which produce wasting disease (loss of approximately 1.6% of body weight per day for 14 d) and profound depression in thymus-dependent immunity. Male and female weanling mice of disparate inbred strains, CBA/J and C57BL/6J, were allocated to the following groups: zero-time control (23 d old and 19 d old, respectively), ad libitum intake of a complete purified diet (19% crude protein, 17 kJ/g gross energy), restricted intake of the complete diet, and (C57BL/6J, only) ad libitum intake of an isocaloric low protein diet (0.6% crude protein). Surface expression of isoforms of CD45, a component of the T cell receptor complex, as well as of the accessory molecule, CD2, were assessed by flow cytometry of splenic mononuclear cell suspensions. Both major T cell subsets in the malnourished groups contained a significantly higher proportion of cells expressing the surface marker, CD45RA, than was found in the spleen cells of the control groups. CD45RA+ (naive-phenotype) T cells represent the extreme of quiescence and stringent activation requirements among thymic lymphocytes. The results provide the first clear evidence of a T cell subset imbalance in PEM which is consistent with depression in acquired immunity and which occurs, apart from antigenic challenge, in a site wherein immune responses take place. The T cell receptor complex may emerge as a focal point of the depressive influence of PEM on the competence of thymic lymphocytes.

The adherence of fimbriated (Fim+) and nonfimbriated (Fim-) strains of Salmonella typhimurium to both isolated intestinal epithelial cells and intact intestinal mucosa of healthy and malnourished rats was investigated. Fim+ strains bound in significantly higher numbers than did Fim- strains to enterocytes isolated either from healthy or malnourished rats. Adherence to intact intestinal mucosa in situ was demonstrable with both Fim+ and Fim- bacteria, but Fim+ strains were preferred because they showed approximately twofold higher numbers of adhered bacteria compared to Fim- strains. Additionally, bacterial adherence to intact mucosa in situ was consistently higher in well-fed controls than in malnourished rats. Ultrastructural studies revealed marked cell destruction and lysis in malnourished rats, whereas no histological change was detected in the mucosa of control animals. These results suggest that malnutrition may lead to altered intestinal cell surfaces, thus increasing their susceptibility to infection through mechanisms that are different from adherence.

Experimental protein-calorie malnutrition was produced in rats by feeding them a low-protein diet for 6 weeks. Control animals were fed a high-protein diet. The deficient rats showed severe restriction of body weight gain, fatty liver and hypoproteinemia. In addition the present study demonstrated that the experimentally-induced protein-calorie malnutrition brings about striking pathological and electrocardiographic changes as well as increased cardiac catecholamine levels. Based on this demonstration and considering the synchronism of morphological, electrophysiological and biochemical data, we postulated that nutritional stress to the heart raises the myocardium norepinephrine concentration, and continued exposure to high levels of catecholamines may play a role in the development of cardiac changes in protein-energy malnutrition.

Development of gut IgA plasma cells was studied in early postnatal under- and overnutrition. Female mice were allowed to suckle in litters of 4, 9 or 20 pups to produce a state of obesity (litter of 4) or protein-energy malnutrition (litters of 20). Litters of nine were considered as control groups. Overfeeding during the suckling period did not change the development and the number of IgA plasma cells of the small intestine. By contrast, the weanling protein-energy malnourished mice had shorter intestines, reduced weight of gut mucosal, muscular and serosal layers and reduced length of villi. However, protein-energy malnutrition, when limited to the suckling period, had no marked effect on the development of IgA plasma cells. A diminished number of these cells was observed only when a more severe and prolonged state of malnutrition was induced.

Two experiments were conducted to study the effects of protein malnutrition on thyroid function. Resting oxygen consumption and serum concentrations of triiodothyronine (T3), thyroxine (T4) and thyroid stimulating hormone (TSH) were measured and correlated with thyroid histology, gain in weight, feed efficiency and carcass energy content in male rats fed isoenergetic diets ad libitum containing 22% (control) or 8% (protein malnourished, PM) casein for 28 or 32 days postweaning. A third group was pair-fed to the PM rats with the control diet. In experiment 2 additional groups were pair-fed to the PM rats with 8% casein diets in which the casein was substituted with different mixtures of carbohydrate and fat. Resting oxygen consumption/body weight (0.75) decreased as body weights increased in all groups, but was consistently greatest in PM rats. In PM rats, plasma T3 was 130% of controls after 11 days of the dietary regimen and averaged 215% of controls from days 18 through 32. In experiment 2 both T3 and T4 concentrations were approximately twice controls in all PM groups. TSH concentrations were within the normal range in all groups throughout. Feed efficiency averaged 36 to 40% of controls and mean weight gain was 30 g after 28 days in the PM groups, compared to 114 and 91 g, respectively, in the pair-fed control rats. Carcass energy content of PM rats after 28 days was significantly lower than in control or pair-fed control rats. Thyroid morphology was compatible with increased secretory activity in all the protein-malnourished groups, compared with normal activity in the control and pair-fed control groups. Thermogenesis, as measured by oxygen consumption, was markedly increased in the PM rats compared to controls. These observations are consistent with a diet-induced thermogenesis in the protein-malnourished rats. In contrast to simple under-nutrition where energy expenditure may be conserved by decreases in thyroid function and thermogenesis, increases in thyroid function and thermogenesis in protein malnutrition could provide an energy balancing mechanism whereby unneeded non-protein energy in the diet could be dissipated as heat, and survival enhanced.