Nothing's simple about malnutrition: complexities raised by epidemic neuropathy in Cuba.
Nothing's simple about malnutrition: complexities raised by epidemic neuropathy in Cuba.
复制标题
营养不良并不简单：古巴的流行性神经病使情况变得更加复杂。
DOI：
10.1093/ajcn/64.3.383
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发表时间：
1996
期刊：
影响因子：
--
通讯作者：
R. Philen
中科院分区：
文献类型：
--
作者：
B. Bowman;C. Bern;R. Philen
在本期杂志中，Macias-Matos等人（1）提供了显著的数据，记录了1993年古巴人群中广泛的硫胺素缺乏，当时有50 000多名古巴人受到视神经和周围神经病变的影响。研究结果是惊人的：根据所使用的生化评估方法，650名受试者中有30-70%的人有异常的硫胺素状态。在一个研究地点，比那尔德尔里奥，生化硫胺素耗竭的流行率比哈瓦那高得多，与观察到的疾病发病率平行。然而，经过仔细研究，他们的结果说明了人类营养不良的复杂性。例如，在神经病受试者和未受影响的对照受试者中，生化硫胺素耗竭的严重程度相当。此外，在一些神经病患者中，即使经过3周的强化复合维生素和营养治疗，生化硫胺素状态也没有恢复正常（1）。这些发现迫使我们审视这一悲剧性流行病的历史观点、营养病理生理学和公共卫生意义，并考虑预防和控制的挑战。在过去，类似的流行病曾发生在H次世界大战和朝鲜战争期间的战俘中，以及战时粮食供应有限的平民中，例如，在美西战争期间的哈瓦那和1937-1939年西班牙内战期间的马德里（2-4）。在战俘营的饮食是基于大米和淀粉类蔬菜和稀疏的动物产品（2，5）。对各种治疗的临床反应的观察一致表明，使用任何单一维生素-mm的单独治疗都是无效的，而使用含有多种维生素和其他营养素的啤酒酵母（2）治疗后观察到明显的改善。1991-1993年在古巴发生的流行病符合这一特征模式：它发生在一个食物供应非常有限的环境中，饮食单一，以大米、豆类、木薯和糖为基础，只有少量的动物产品（6，7）。多种维生素治疗在大多数情况下是有效的，在全国范围内补充多种维生素后，疾病发生率大幅下降（7）。Macias-Matos等人（1）指出，“.潜在的营养缺乏是必要的，但不足以产生明显的临床体征和症状，在微量营养素缺乏症普遍存在的地方是常见的。这项研究中记录的惊人的生物化学硫胺素消耗与其他证据一致，即古巴人口的营养风险大幅增加，膳食中几种微量营养素和常量营养素摄入不足，体重持续下降（6，7）。这种营养风险的增加与古巴经济状况恶化造成的粮食和能源严重短缺暂时有关。由于营养素之间的功能和代谢相互作用，Macias-Matos等人记录的生物化学硫胺素耗竭状态可能反映了许多其他营养素的伴随耗竭。随后在比那尔德尔里奥进行的一项综合研究，包括人体测量、生物化学、临床和饮食评估，显示视神经病变的风险与吸烟（特别是抽雪茄）、几种营养素（蛋氨酸、维生素B-12、核黄素和烟酸）的饮食摄入量减少以及抗氧化剂类胡萝卜素的血清浓度降低有关（7）。较低的动物蛋白和复合维生素B的膳食摄入量是最重要的...
In this issue of the Journal, Macias-Matos et al (1) present remarkable data documenting widespread thiamine depletion in the Cuban population in 1993 during the epidemic of optic and peripheral neuropathy that affected more than 50 000 Cubans. The findings are striking: depending on the biochemical assessment method used, 30-70% of the 650 subjects examined had abnormal thiamine status. The prevalence of biochemical thiamine depletion was much higher at one study site, Pinar del Rio, than in Havana, paralleling observed disease incidence. However, on closer examination, their results illustrate the complexity of human malnutrition. For example, the severity of biochemical thiamine depletion was comparable in subjects with neuropathy and unaffected control subjects. Furthermore, in some individuals with neuropathy, biochemical thiamine status did not normalize even after 3 wk of intensive multivi-tamin and nutritional therapy (1). These findings compel us to examine the historical perspective, nutritional pathophysiol-ogy, and public health significance of this tragic epidemic and to consider the challenges for prevention and control. In the past, similar epidemics have occurred among prisoners of war during World War H and the Korean conflict, and in civilian populations during wartime when there was limited food availability, eg, in Havana during the Spanish-American War and in Madrid during the 1937-1939 Spanish civil war (2-4). In prisoner-of-war camps diets were based on rice and starchy vegetables and were sparse in animal products(2, 5). Observations of the clinical response to various treatments consistently showed that isolated therapy with any single vita-mm was ineffective, whereas marked improvement was seen after treatment with brewer’s yeast (2), which contains several vitamins and other nutrients. The 1991-1993 epidemic in Cuba fits this characteristic pattern: it occurred in a setting with very limited food availability and a monotonous diet based on rice, beans, cassava, and sugar, with very small amounts of animal products (6, 7). Multivitamin treatment was effective in most cases, and disease incidence decreased substantially after na-tionwide multivitamin supplementation was implemented(7). Macias-Matos et al (1) state that “... underlying nutritional depletion, which is necessary but not sufficient to produce overt clinical signs and symptoms, is common wherever mi-cronutrient deficiencies are widespread.” The striking bio-chemical thiamine depletion documented in this study is consistent with other evidence that the Cuban population was at substantially increased nutritional risk, with inadequate dietary intakes of several micronutrients and macronutrients, and con-tinuing weight loss (6, 7). This increased nutritional risk was temporally associated with acute food and energy shortages attributable to Cuba’s deteriorating economic situation. Because of the functional and metabolic interactions among nutrients, it is likely that the depleted biochemical thiamine status documented by Macias-Matos et al reflects concomitant depletion of many other nutrients.The epidemic was associated with multiple factors, both nutritional and toxic. A subsequent comprehensive study in Pinar del Rio, which included anthropometric, biochemical, clinical, and dietary assessment, showed that risk for optic neuropathy was associated with tobacco use (particularly cigar smoking), decreased dietary intakes of several nutrients(methionine, vitamin B-12, riboflavin, and niacin), and lower Serum concentrations of antioxidant carotenoids(7). Lower di-etary intakes of animal protein and B-complex vitamins were among the most significant …