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The impoverished gut--a triple burden of diarrhoea, stunting and chronic disease - PubMed

Review

The impoverished gut--a triple burden of diarrhoea, stunting and chronic disease

Richard L Guerrant et al. Nat Rev Gastroenterol Hepatol. 2013 Apr.

Abstract

More than one-fifth of the world's population live in extreme poverty, where a lack of safe water and adequate sanitation enables high rates of enteric infections and diarrhoea to continue unabated. Although oral rehydration therapy has greatly reduced diarrhoea-associated mortality, enteric infections still persist, disrupting intestinal absorptive and barrier functions and resulting in up to 43% of stunted growth, affecting one-fifth of children worldwide and one-third of children in developing countries. Diarrhoea in children from impoverished areas during their first 2 years might cause, on average, an 8 cm growth shortfall and 10 IQ point decrement by the time they are 7-9 years old. A child's height at their second birthday is therefore the best predictor of cognitive development or 'human capital'. To this 'double burden' of diarrhoea and malnutrition, data now suggest that children with stunted growth and repeated gut infections are also at increased risk of developing obesity and its associated comorbidities, resulting in a 'triple burden' of the impoverished gut. Here, we Review the growing evidence for this triple burden and potential mechanisms and interventions that must be understood and applied to prevent the loss of human potential and unaffordable societal costs caused by these vicious cycles of poverty.

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Figures

Figure 1
Figure 1

The vicious cycles of diseases of poverty. Enteric infections, especially in the first 2–3 years of life, with or without overt diarrhoea, can predispose an individual to malnutrition and stunted growth through multiple mechanisms. Stunting by 2 years of age, in turn, is associated with impaired cognitive development that extends into later childhood and even adulthood and adult productivity. In addition, malnourished children experience both greater frequency and duration of diarrhoeal illnesses, and, documented in animal models, heavier infections. The latter is documented with Cryptosporidium and with enteroaggregative E. coli. Finally, enteric infections or stunting can predispose to obesity and its comorbidities of diabetes, hypertension, cardiovascular disease, metabolic syndrome and burgeoning health-care expenditures, contributing to individual and societal poverty in vicious cycles.

Figure 2
Figure 2

Catch-up growth in malnourished children and its eradication by recurring diarrhoea. Malnourished children (that is, with weight-for-age <3 z-scores, less than three standard deviations below normal weight for age) tend to catch up with a doubling of weight gains, if they do not experience heavy diarrhoeal burdens (that is, <15% of their days are spent with diarrhoea in this observation period in the first 2 years of life). However, heavy diarrhoeal burdens are associated with a progressive ablation of this crucial catch-up growth. Permission obtained from Elsevier © Schorling, J. B. & Guerrant, R. L. Lancet 335, 599–600 (1990).

Figure 3
Figure 3

Chronic consequences of early childhood enteric infections and stunting. The triple burden of enteric infections, impaired physical development (including low HAZ-2, or stunting and BMI-2) and cognitive development, and later life risk of obesity and its comorbidities are shown. Abbreviation: HAZ-2, height-for-age z-score at age 2 years.

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