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SA M E D IC AL JO U R N A LSupplement South African Journal of Nutrition

20 September 1975

ortisol and rowth Hormoneand Marasmus

KwashiorkorJ. M. VANDER WESTHUYSEN, J. J. JONES, C. H. VAN NIEKERK, P. C. BELONJE

SUMMARYCortisol and growth hormone concentrat ions in the plasmawere determined in 26 chi ldren with kwashiorkor 13 withmarasmus and 2 controls Cortisol levels were high inbabies with kwashiorkor and marasmus but higher in theformer in relation to a constant body mass. The concen-tration of plasma cortisol correlated positively with thebody mass deficit in kwashiorkor = 0 66 and in childrenwith low mass fo r age r = 0 75 . Growth hormone levelswere elevated in both kwashiorkor and marasmus. Theproposed role of these hormones in metabolic adaptat ion tomalnutrition is discussedS. Afr . med . J., 49, 1642 1975).

Adaptation to def icient nutrition depends primarily onthe endocrine cont rol o f t he metabolic processes involved.The two ult imate forms of protein energy malnutrition,namely kwashiorkor and marasmus, have been descr ibedas forms of failure of adaptation and successful adaptationto protein energy malnutrition, respectively.'

Failure of adaptation involves the inability of hormonesto maintain normal metabol ism because the malnutritionis too severe,' or the individual physiologically unableto adapt to the dietary deficiency. Hormonal changes, suchas increases in cor ti sol and growth hormone, have beenreported by many workers. Some workers ' ascribe theincrease in plasma cortisol to the general stress ofmalnutrition, whereas others attribute it to infection.The increase in growth hormone is a lso re la ted to changesin pl asma amino acid concentration: 'l1 particularly alanine and valine: Recently, Rao13 proposed that maladaptation to protein energy malnutrition (kwashiorkor)resul ts f rom an inabi li ty of the adrenal cortex to respondsufficiently to mobilise enough amino acids for use byan abnormally high secretion o f g rowth hormone. Thesuccessful adaptation in marasmus results from an adequately responsive adrenal and relat ively low growthhormone. This experiment was performed to test thishypothesis, by comparing these hormonal concentrationsin non-fatal and fatal kwashiorkor and marasmus, andto attempt to relate them to the severity of malnutrition.Department af Physiology, Godfrey Huggins School ofMedicine. University of Rhodesia, Salisbury, RhodesiaJ. M. VA J DER WESTH YSEN*, M s e PH.D.J. J. JONES, PH.D., M.B. B.S ., B se M.R.e.S .. Professor il lPreclinical StudiesC H. VAN NlEKERK*, B.\ .SC., ~ 1 . M E D . \ E T . D.\.SC., ProfessorP. C. BELONJE*, B.V.se. , M.MED.VET.Date received: 6 May 1975.Preseot address Department of Human and nimal PhYSiology Universityof Stel lenbosch. CP.

PATIENTS N METHODSThirty-nine patients between the ages of 12 and 48 monthswith protein energy malnutrition were studied. They wereadmitted to Harari Hospital, Salisbury, between December1972 and March 1973 and were all underweight for age(Boston 50th percentile).H Twenty-six patients with oedemaand less than 80% of the expected body mass for age,were classified as kwashiorkor , and 13 without oedemaand less than 60 of the expected body mass for age,marasmus.

is cus tomary to take a venous blood sample fromall children admitted to this hospital before treatmentis started. The blood is collected between 08hOO and 09hOOin plastic syringes conta in ing lithium sequest rene as ananticoagulant. Immediately after collection, blood samplesare placed in ice and spun down in a refrigerated centrifugewithin 2 hou rs o f collection. Plasma is stored at -20C,until i t is analysed. Another venous blood sample is takenfor analysis 1 week after the patient has been admittedto hospi tal and again during the patient's last week inhospital.In this study, at each blood sampling, the childexamined and the age, body mass and height wererecorded. Any signs of gastro-intestinal disturbance or

o f o ther infections were noted. Measurements were madeof sk info ld thickness over the triceps, using Harpendenskinfold calipers, and the mid-a rm circumference wasmeasured with a tape measure . From these measurementsthe mid-arm muscle circumference ' was determined, 'Oedema was measured as the pit ting depth, in mil limetres,obtained after pressure fo r 15 seconds on the dorsumof the foot and by scoring 0 - 9) for the total degree ofoedema in the limbs 0 - 3), face 0 - 3) and abdomen0 - 3). Further observations included skin, ha ir and liverchanges. Liver enlargement was measured in centimetres ,in the right midclavicular line by palpation, with the chi ldsupine. Skin lesions and s tomati tis were graded byinspection from 0 - 3.Routine treatment included feeding fortified milk(containing skimmed milk, oil, eggs, a multivitamin syrup,folic acid and potassium cWoride). Intravenous transfusionof plasma or half-strength Darrow s solution (containing2,5% glucose) were used only when there was ev idence oflow-output circulatory failure, and antibiotics were givenwhen indicated. Most deaths occurred during the first3 days in hospital and were usually assoc ia ted with anoverwhelming Gram-negative bacteraemia or with severegastro-enteritis. Patients who recovered remained inhospital fo r 2 - 5 weeks. A healthy contro l group consistedof 21 children, aged 12 - 24 months, of the same community.

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Plasma cort isol concentration was determined by competitive protein binding, and plasma growth hormonewas estimated by radio-immunoassay. The antibodies weresupplied by CEA-CIA Sorin. Total pia ma protein wasdetermined by the biuret method and albumin by cellulo t;acetate electrophoresis fol lowed by fiying- pot den itometry.

they differed ignificantly (P

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20 September 1975

DISCUSSION

TABLE I ll CORRELATION COEFFICIENTS OF PLASMACORTISOL AND T SEVERITY OF T CLINICALFEATURES IN PROTEIN ENERGY MALNUTRITION

of discharge than those of the controls.Growth hormone concentrations were significantlyelevated P