Eating well on the Planet Earth

Diseases of Malnutrition

The word malnutrition actually means badly nourished. If you live in the United States or another affluent country, these diseases may be unfamiliar, but developing countries sadly still have many malnourished people, and these diseases and symptoms are all too common. About one in every three people in the world is suffering from malnutrition. Half of the child deaths in developing countries are a result of malnutrition. Besides the immediate suffering this causes, it also jeopardizes the economy and development of the country, continuing the cycle of poverty.


History and Causes of Beriberi

Beriberi is caused by a deficiency of thiamine, or vitamin B1. It was described in Chinese literature as early as 2600 B.C. The disease has always been prevalent in Asian countries, and doctors puzzled over it for years, thinking it was because of a substance in white rice.

Finally in 1934 they got down to the truth when the vitamin B1, thiamine, was identified. Beriberi was actually a result of something missing from rice which has been milled or polished. The thiamine is in the outer layer of the rice which was being polished away. To aggravative the condition, many of the foods eaten in this part of the world, such as raw fish and tea, contain anti-thiamine factor, which can deactivate thiamine so your body is not able to use it.

Symptoms of Beriberi

There are two types of beriberi: wet beriberi, which affects the cardiovascular system, and dry beriberi, which affects the nervous system. Wernicke-Korsakoff is a genetic disease most often seen in Europeans, where patients can not bind thiamine and absorb it properly. This disease affects the nervous system.

Symptom of Wet Beriberi

  • swelling of the lower legs
  • increased heart rate
  • congestive heart failure
  • enlarged heart
  • shortness of breath

Symptoms of Dry Beriberi

  • tingling in limbs
  • loss of feeling in hands and feet
  • vomiting
  • strange eye movements
  • confusion
  • coma and death

Symptoms of Wernicke-Korsakoff Disease

  • irritability
  • confabulation (making up stories to cover memory loss)
  • amnesia
  • confusion

Beriberi in the World Today

In the United States and Western countries, beriberi is most often seen in alcoholics, since they typically have very poor diets and alcohol makes it harder to absorb. Some types of gastrointestinal disease also make it hard to absorb thiamine. Some breastfed babies are deficient in thiamine if their mothers aren't getting enough in their diets. There have been a few cases of patients on total parenteral nutrition (tube feedings) where thiamine was omitted from the formula by mistake and they displayed symptoms of beriberi.

The area where this disease is prevalent is East Asia, where milled rice is a major part of the diet, and some of the other popular foods, like tea and raw fish, actually interfere with thiamine absorption. Parboiling rice, fortifying rice with B vitamins (as we do in the United States) or educating people about how to get enough thiamine can help this population. The most serious cases occur in Asian hospitals, prisons, labor camps, or on board ships, where there is not much variety in the diet.

Beriberi is seen in African countries, especially in urban populations that eat a lot of white rice, and in prisons or hospitals where rice is served as a main part of the diet. Refugee populations often have outbreaks of beriberi along with other nutritional deficiencies.

The good news is that symptoms of beriberi are easily reversed if you give a person thiamine in time. Thiamine is usually given to a patient orally or in an injection. Then you need to make sure that person will be getting the dietary thiamine that they need.

Good Sources of Thiamine

  • wheat germ
  • dry beans and peas
  • yeast
  • enriched breads and cereal products
  • whole eggs
  • nuts
  • most vegetables

Read more about thiamine.

Thiamine is measured in milligrams (mg). See your daily requirement for thiamine.

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Protein-Energy Malnutrition (Kwashiorkor and Marasmus)

History and Causes of PEM

Protein-energy malnutriton is also called protein-calorie malnutriton. It is a deficiency of carbohydrate (energy) and protein. Sadly this disease most often affects children, since they have much greater energy needs to support their growth.

Protein-energy malnutrition may be in the form of kwashiorkor, which is protein deficiency with calorie intake being OK, or marasmus, which is a calorie deficiency, or both at the same time.

Symptoms of Kwashiorkor

Kwashiorkor was first identified in 1935 in Ghana, West Africa. The name means "disease of the neglected child". Parent education is important for treating this disease as a child can be eating a normal amount of calories, but not getting enough protein. Also the enlarged liver and edema can actually make a child look like they are gaining weight, causing a parent to think they are getting enough, or too much, food.

  • edema
  • swollen abdomen (enlarged liver)
  • diarrhea
  • peeling and white spots on the skin, also known as flaky paint dermatosis
  • reddish pigmentation of hair

Symptoms of Marasmus

  • failure to gain weight
  • stunted growth
  • thin limbs and baggy skin

Both of these diseases cause lethargy, apathy, and irritability and can eventually result in death.

Protein-energy Malnutrition in the World Today

Sometimes PEM can be a secondary condition of a disease such as AIDS or trauma that increases your energy needs, but mostly it is found in areas of the world where people do not have access to an adequate food supply. This can be due to famine, drought, political unrest or social issues. One in every four children in the world is afflicted with PEM. The majority of cases are found in Asian countries with Africa coming in second, and then Latin America and the Carribean.

Kwashiorkor often occurs in areas of the world where the staple foods, such as yams, cassava, plantains or sweet potatoes, are high in carbohydrates but low in protein.

Treating Protein-energy Malnutrition

This condition has to be treated carefully. You can't just start someone out on a high protein diet, or you can overtax their system when it is very weak. First the patient is re-hydrated to get the fluids and electrolytes back where they should be. Then you begin giving them carbohydrates slowly as their system can handle it, and then add protein to the diet.

The symptoms of PEM can be reversed if the patient is treated soon enough, but a child will probably never achieve their full potential height and weight after they have had this disease.

Read more about macronutrients.

Protein and carbohydrates are measured in grams. See your daily requirement for macronutrients.

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History and Causes of Pellagra

Pellagra is caused by a deficiency of niacin, or Vitamin B3.

Columbus discovered corn in the New World during the 15th and 16th centuries, and brought it back to Europe, where many people eventually adopted it as a staple food. Pellagra was first described by a physician for the Spanish court in 1735, when he noticed the disease in peasants who were eating a diet heavy on maize.

Why wasn't this a problem in the Americas where corn originated? The niacin in corn is in a bound up form that isn't bioavailable for humans. The Latin Americans soaked their corn tortillas in lime before they cooked them, and this released the niacin so that it could be absorbed.

In the early 20th century pellagra was epidemic in the southeastern US due to their high corn diet and poverty.

The cause of pellagra wasn't discovered until 1937 when niacin was isolated by a scientist at the University of Wisconsin. Pellagra results from a diet where niacin, or Vitamin B1, and the amino acid tryptophan, are deficient. Why tryptophan? It is a precursor of niacin, so your body can produce niacin if it gets enough tryptophan.

Niacin in widely used in the body since it is necessary to release energy from proteins, fats and carbohydrates. It is also used to synthesize nucleic acids such as DNA and RNA.

Symptoms of Pellagra

The name pellagra comes from the Italian words pelle and agra which means rough skin. The symptoms are often called the 3 D's.

  • diarrhea: irritation of the GI tract from the mouth to the colon
  • dermatitis: scaly, red lesions, which can be disfiguring
  • dementia: depression, delusions, insomnia, memory loss and stupor

If left untreated pellagra can lead to death after a period of years. However the symptoms can easily be reversed by administering niacin to the patient.

Pellagra in the World Today

In the United States and other Western countries pellagra is rarely seen except in alcoholics, people on extreme fad diets or people who can't absorb food properly for various reasons.

There is a population in India that eats sorghum as a staple food and has chronic cases of pellagra. This is actually due to another amino acid in the sorghum, leucine, which interferes with the niacin absorbtion.

Many countries now have mandatory fortification of their grain products with niacin, and so this disease is rarely seen. However there are outbreaks in areas of "food emergencies" such as natural disasters or civil wars. Some countries where these have occurred lately are Malawi, Mozambique, Nepal, Angola, and Zimbabwe. You can read more about these incidents and how we are trying to prevent pellagra in these populations in this World Health Organization document

Niacin is found in many plant and animal foods. In most plants it is bound in a form that is not bioavailable, but can be released if you soak it in an alkali (such as cornmeal in lime) or sometimes just with heat (such as roasting coffee beans). Most niacin in grains is lost during the milling, so is only available in whole grains or enriched flour.

Good Sources of Niacin:

  • yeast
  • meats
  • poultry
  • fish
  • whole grains
  • fortified flours
  • peanuts
  • lentils
  • milk (contains tryptophan)
  • leafy greens
  • coffee and tea

Read more about niacin.

Niacin is measured in milligrams (mg). See your daily requirement for niacin.

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History and Causes of Rickets

Bony deformities similar to rickets were described by physicians as far back as Roman times. The first person to really give a good description of rickets was an English physician idd Daniel Whistler. There were many cases of rickets in the English countryside at that time. In fact it was known as the "English disease".

During the industrial revolution rickets became common in cities and was linked to poor diet, and lack of fresh air and sunshine, but no specific cause could be pinpointed. It wasn't until the early 20th century that vitamin D was discovered and linked to rickets.

Rickets are caused by a deficiency of vitamin D, calcium, or phosphorus. If you don't have enough calcium or phosphorus in your bloodstream your body will react by taking these minerals from the bone, making the bones weak. However if you don't get enough vitamin D, your body won't absorb calcium and phosphorus properly. You need all three of these nutrients in order to have healthy bones. This is why milk is fortified with vitamin D. It is high in calcium and phosphorus naturally, and the vitamin D helps you absorb these minerals.

Symptoms of Rickets

  • skeletal deformities such as bowed legs, curved spine and pelvic deformities
  • fragile bones
  • delayed growth
  • pain in bones
  • muscle weakness

The skeletal deformities usually show up in children who are still growing. Adults with a vitamin D deficiency will develop osteoporosis.

Rickets in the World Today

Cases of rickets are still being found in the United States today, in fact it seems to be making a comeback in many countries. This resurgence maybe due to children spending less time outdoors, or the recent advice to always use sunscreen. In October of 2008 the American Academy of Pediatrics doubled their recommended amount of Vitamin D for infants and children. Vitamin D is not available in a wide variety of foods, so you need to make sure you are getting enough of this nutrient.

Our bodies can synthesize vitamin D in the presence of sunlight, however you must have enough exposure to sun for this to happen. If you live in the northern hemisphere, or use sunscreen every day, you may not be getting enough vitamin D through sunlight. You can read more about how much sunlight you need to meet your vitamin D requirements at Eating Well on the Planet Earth.

Good Food Sources of Vitamin D

  • Fatty fish, such as salmon, sardines and mackerel
  • cows milk, soy milk or orange juice
  • fortified cereals
  • egg yolk

Read more about vitamin D.

Read about calcium and phosphorus.

Vitamin D is measured in milligrams (mg). See your daily requirement for vitamin D.

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History and Causes of Scurvy

Scurvy is caused by a deficiency of vitamin C. This disease has been recognized for centuries. It was written about by Crusaders in the 13th century, and occurred in the Middle Ages during the late winter months when fresh foods weren't available. Outbreaks of scurvy were documented during the Crimean War, the American Civil War and the Franco-Prussian War. Arctic explorers and gold prospectors in North America have come down with scurvy.

By the 18th century the British Navy had figured out that this condition could be avoided if they carried oranges, lemons or limes on board ship and rationed them out to the sailors. However no one knew exactly how scurvy was caused until vitamin C was discovered in the 1930's.

Vitamin C is required to make collagen, the connective tissue that holds our cells together. A deficiency can cause a break down of tendons, ligaments, bones and blood vessels.

Symptoms of Scurvy

  • bruising and bleeding easily
  • loss of hair and teeth
  • swelling and pain in joints

Read more about vitamin C.

Vitamin C is measured in milligrams. See your daily requirement for vitamin C.

Scurvy in the World Today

It only takes a very small amount of vitamin C to prevent scurvy, about 10 mg per day, so it is rare to find this disease today. Scurvy affects people on an extremely restricted diet. This could include fad dieters, homebound elderly people, soldiers, prisoners or alcoholics.

Outbreaks have been seen more frequently among populations that are having a food emergency, such as refugees. In the last 20 years there have been outbreaks in Sudan, Somalia, Ethiopia, Nepal and Kenya.

Read more about vitamin C and scurvy in this World Health Organization document.

Vitamin C is destroyed by heat, so is best found in foods eaten raw or lightly cooked.

Good Sources of Vitamin C

  • citrus fruits
  • guavas, rose hips and berries
  • peppers, including dried red peppers
  • tomatoes
  • leafy green vegetables eaten raw or lightly cooked
  • baobab fruit and locust bean pulp
  • amla fruit (India) and the Barbados cherry
  • potatoes and yams when they are a major part of the diet
  • camel milk
  • sprouted seeds and beans
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Read the World Health Organization pamphlet Turning the Tide of Malnutrition.