Foodborne illness

Economic impact of society at large. These costs include loss

of income by the affected individual,

foodborne illness cost of health care, loss of productivity

due to absenteeism, costs of investiga-
tion of an outbreak, loss of income due
What is damaging and distressing at the to closure of businesses and loss of sales
level of the individual also has serious when consumers avoid particular prod-
implications on a far larger scale. In de- ucts. In 1989 it was estimated that the
veloped countries efforts to quantify the total cost of bacterial foodborne illness
economic impact of foodborne illness are to the United States economy was US$
comparatively recent, but it is clear from 6,777,000,000. In developing countries,
these that foodborne illness is a major where the problem of diarrhoeal disease
burden on the economy. Costs arise from is far greater, the effect on economic ac-
a number of different sources and are tivity and development can only be far
incurred both by the individual and by more severe.

KEY POINTS

l Food is essential for health and well-being.

l Food may also be a cause of illness.

l Foods may be intrinsically toxic or may be contaminated with toxic

chemicals or pathogenic organisms.

l Foodborne illness is extensively under-reported.

l Microorganisms (bacteria, viruses, moulds and parasites) are the

most important cause of foodborne illness.

l Bacteria are generally most important.

l Most foodborne illness is associated with gastrointestinal

symptoms of nausea, vomiting, stomach pains and diarrhoea.

l Foodborne illness is caused by two mechanisms: infection and

intoxication.

l The infectious dose varies between organisms and between individuals.

l Foodborne illness can have seriously damaging effects on

individuals, particularly young children, and on society as a whole.

16
 Basic Food Safety for Health Workers

t t
Food Contamination á Diarrhoea Death
t
Malnutrition
t

Figure 1.3 The malnutrition and diarrhoea cycle

15 BC - Bronchitis
BN - Bronchopneumonia
14 CEL - Cellulitis
CONJ - Conjuncivitis Normal growth curve
13 D - Diarrhoea
FUO - Fever of unknown origin
12 I - Impetigo
M - Measles
11 S - Stomatitis
Body weight in KG

URI - Upper respiratory illness

10
D
9 Child’s growth curve URI D
D URI
D S
8 D D URI BN D
D
URI BC D URI D
7 CEL D FUO BC URI URI
D D D D D D BC
URI M BC D
6 D URI
URI
5 I
D

4
3 CONJ
I
2

0 3 6 9 12 15 18 21 24 27 30 33 36
Age in months

Source : Mata, LJ Nutrition and infection. Protein Advisory Group bulletin (1971)

Figure 1.4 Growth pattern of a child with frequent episodes of diarrhoea and other
infections (The horizontal bars indicate the duration of the infectious disease)

15
 Foodborne illness

Table 1.7 Examples of secondary disease state resulting from foodborne

infections
Disease Associated complication
Brucellosis Aortitis, orchitis, meningitis, pericarditis, spondylitis
Campylobacteriosis Arthritis, carditis, cholecystitis, colitis, endocarditis, erythema
nodosum, Guillain-Barré syndrome, haemolytic-uraemic syndrome,
meningitis, pancreatitis,septicaemia
E.coli (EPEC & EHEC types) Erythema nodosum, haemolytic-uraemic syndrome,
infections seronegative arthropathy
Listeriosis Meningitis, endocarditis, osteomyelitis, abortion and stillbirth, death
Salmonellosis Aortitis, cholecystitis, colitis, endocarditis, orchitis, meningitis,
myocarditis, osteomyelitis, pancreatitis, Reiter’s syndrome, rheumatoid
syndromes, septicaemia, splenicabscess, thyroiditis
Shigellosis Erythema nodosum, haemolytic-uraemic syndrome, peripheral
neuropathy, pneumonia, Reiter’s syndrome, septicaemia, splenic
abscess, synovitis
Taeniasis Arthritis
Toxoplasmosis Foetus malformation, congenital blindness
Yersiniosis Arthritis, cholangitis, erythema nodosum, liver and splenic abcesses,
lymphadenitis, pneumonia, pyomositis, Reiter’s syndrome, septicaemia,
spondylitis, Still’s disease
Source: Mossel, 1988.

foodborne microorganisms (Table 1.7). In for more than 15% of their young lives.
an outbreak of salmonellosis in Chicago The immediate cause of death from
in 1985, caused by contaminated pasteur- diarrhoeal disease is usually the dehydra-
ized milk, more than 2% of the 170,000- tion that results from the loss of fluid and
200,000 people infected suffered from electrolytes in diarrhoeal stools, but di-
reactive arthritis as a result of their in- arrhoea can also have other serious
fection (3). Guillain-Barré syndrome is a health consequences. It may lead to mal-
serious and potentially life-threatening nutrition since food intake is reduced ei-
neurological disease characterized by ther as a result of loss of appetite or the
acute weakness, autonomic dysfunction withholding of food, and those nutrients
and respiratory insufficiency. It is a that are ingested are poorly absorbed or
chronic sequela associated with acute simply lost by being swept out with the
gastrointestinal infection particularly by diarrhoeal stools. Malnutrition in its turn
Campylobacter jejuni. can predispose children to longer episodes
of diarrhoea as well as other infections,
In developing countries, diarrhoeal aggravating the problem still further. This
diseases, particularly infant diarrhoea, are can result in a downward spiral of increas-
a major public health problem. It has ingly poor health which, unless it is bro-
been estimated that annually some 1500 ken in some way, will lead ultimately to
million children under five years of age premature death (Figure 1.3). Even where
suffer from diarrhoea and over 3 million this does not proceed inexorably to a fa-
die as a result (4). Individual children ex- tal end, the physical and mental growth
perience on average 3.3 episodes of di- of the child is severely impaired. This is
arrhoea each year, though in some areas shown in Figure 1.4 which records the
the number of episodes may exceed 9 and effect of repeated bouts of diarrhoea and
children can be suffering from diarrhoea other illnesses on a child’s development.

14
 Basic Food Safety for Health Workers

differ appreciably. Shigella and limiting indispositions that are restricted

enterotoxigenic E. coli (ETEC) are oth- to gastroenteritis and are not usually life-
erwise very similar organisms but esti- threatening. Exceptions occur with par-
mates of their respective infective doses ticularly susceptible individuals such
are markedly different, reflecting differ- as the very old or very young, pregnant
ences in their virulence. women or those who are already very sick
or weak for some other reason. These
Susceptibility to infection can vary with
a range of factors such as age, general vulnerable groups constitute quite a large
proportion of the population and for
health, nutrition, immune status and
many of them diarrhoeal disease can be
whether a person is undergoing medical
treatment. Listeriosis can be mild or even fatal.
asymptomatic in some individuals but A number of foodborne pathogens such
can be severe and often life-threatening as Clostridium botulinum are also associated
in the unborn child. In people with low with acute extraintestinal (systemic)
gastric acidity, increased survival of disease. C. botulinum causes a severe
ingested pathogens can reduce the neuroparalytic syndrome which is often
required infective dose, thereby fatal. The mortality rate in outbreaks in
increasing the risk of infection. This is the United States between 1976 and 1984
often found in the elderly and may help was 7.5% but it can be substantially
explain their increased susceptibility to higher (3). Survival in cases of botulism
foodborne infections. The food that is the is critically dependent on early diagnosis
vehicle of infection may also help reduce and treatment.
the infectious dose by protecting the Sometimes extra-intestinal disease
pathogen from the lethal effect of the transmitted by food is particularly
stomach’s acidity. This has been noted associated with certain susceptible indi-
particularly with fatty foods such as sa- viduals. For example, infection by Liste-
lami, cheese, chocolate and ice cream ria monocytogenes can vary from a mild, flu-
where low numbers of salmonella have like illness to meningitis and
been implicated in foodborne disease meningoencephalitis. It is particularly
outbreaks (Table 1.6). serious in pregnant women; the mother
Where the infectious dose is high, the may experience relatively mild symptoms
food vehicle can play a very specific role but infection of the fetus can result in
in the illness. Depending on the food’s abortion, stillbirth or premature labour.
composition and conditions of storage, Listeriosis is also more than 300 times
a pathogen present at low and possibly more common in AIDS patients than in
harmless levels may grow to numbers the general population. Cancer patients
sufficient to produce illness. The speed and other immunocompromised
with which bacteria can grow is described individuals are subject to bacteraemia
in more detail in Chapter 2. caused by foodborne bacteria. Verotoxin-
producing E. coli generally results in a
bloody diarrhoea but can cause the
Health consequences haemolytic uraemic syndrome,
characterized by thrombocytopaenia,
of foodborne illness haemolytic anaemia and acute kidney
failure, particularly in children.
For most adults in the industrialized
world, incidents of foodborne illness are Some chronic diseases, particularly ar-
unpleasant but are generally mild and self- thritic conditions, can be triggered by

13
 Foodborne illness

Since the toxin is ingested with the food This is probably still true in many cases,
there is no direct person-to-person spread, but it has been shown more recently that
as can occur with some enteric infec- food may also be the vehicle of
tions, and the incubation period (the time contamination in up to 70% of cases.
between consumption of the food and To cause illness, a sufficient number of
the appearance of symptoms) tends to cells must be consumed. This is known
be shorter, generally of the order of one as the infectious dose. The infectious
or two hours or even less in some cases. dose varies from one organism to another
This is because the toxin begins to act as and from person to person. For
soon as it reaches the site of action, Campylobacter jejuni the infectious dose is
whereas with infections the microorgan- thought to be quite low, while relatively
isms need time to multiply in the body. high numbers of non-typhoid Salmonella
There are some similarities here with other are normally required to produce illness.
biotoxins such as mycotoxins and algal Experiments have been conducted where
toxins, though algae differ from toxigenic volunteers have consumed different lev-
bacteria and moulds in that they do not els of pathogens in order to determine
multiply in the food. Also, the health ef- the infectious dose. These results and data
fects of mycotoxins tend to be long-term from the investigation of actual
rather than acute (see Chapter 2). outbreaks give some indication of the
numbers of bacteria required to produce
illness, but they should be regarded only
Infectious dose as a rough guide (Table 1.6).
Successful infection is the result of the
Infective pathogens can be introduced interaction of two variable factors: the
into the body from a variety of sources. virulence of the pathogen (its ability to
In the past, it was thought that cause illness) and the susceptibility of the
contaminated water was the main source individual. The virulence of different
of the pathogens that cause diarrhoea. Salmonella serotypes, for example, can

Table 1.6 Estimated infectious doses

Escherichia coli
enteropathogenic 106–1010
enterotoxigenic 106–108
enteroinvasive 108
enterohaemorrhagic 101–103
Shigella 101–102
Salmonella Typhi <103
Other salmonellae 105-107
but:
Salmonella Newport 60 – 230 in hamburger
Salmonella Eastbourne 10 – 25 in chocolate
Salmonella Heidelberg 100 – 500 in cheese
Clostridium perfringens 106–108
Campylobacter 500
Vibrio cholerae 106
Vibrio parahaemolyticus 105–107

12
 Basic Food Safety for Health Workers

the normal functions of the gut are up- through the gut. It then multiplies, colo-
set in some way. nizing the surface. In some cases, such
as infection with enteropathogenic Es-
The gastrointestinal tract or gut is not an
cherichia coli, this produces changes in the
internal organ of the body but a tube run-
ning through it where foods are digested gut epithelium which reduce its absorp-
tive capacity or cause fluid secretion.
and absorbed, and unwanted waste prod-
Colonizing bacteria can also produce
ucts are expelled. In addition to absorp-
tion of nutrients from foods, absorption enterotoxins; toxins that alter the function
of the cells lining the gut and cause them
and secretion of water are important gut
to secrete water and electrolytes into the
functions. Water absorption normally
exceeds secretion. Each day, a typical intestine to produce a profuse watery
diarrhoea. A notable example of this is
adult will ingest about two litres of wa-
cholera, but a similar sequence of events
ter. To this must be added saliva and se-
cretions from the stomach, pancreas and occurs with enterotoxigenic E. coli
infections.
liver which altogether make a total of 8-
10 litres entering the small intestine daily. Invasive pathogens are not confined to
About 90% of this fluid is absorbed be- the intestinal lumen but can penetrate the
fore it enters the large intestine where 80- cells lining the gut. In some cases their
90% of the remainder is absorbed. penetration is limited to the immediate
Changes in the small intestine that either vicinity of the gut, as with the non-ty-
decrease absorption or increase secretion phoid salmonellas. Some pathogens in-
will reduce overall absorption and result vade the mucosa of the large intestine
in a larger fluid flow into the large intes- rather than the small intestine, producing
tine. If this exceeds the relatively limited inflammation, superficial abscesses and
absorptive capacity of the large intestine ulcers, and the passage of dysenteric
then diarrhoea occurs. stools containing blood, pus and large
amounts of mucus. In other cases,
Bacteria cause foodborne illness by two microbial invasion is not restricted to the
mechanisms: infection and intoxication. gut’s immediate locality and the organ-
The latter can also be caused by chemi- ism spreads further through the body,
cal contaminants and naturally occurring producing symptoms other than diarrhoea
toxins. at sites remote from the gut itself, as for
example in brucellosis, listeriosis, typhoid
Infection and paratyphoid fevers.
Infection occurs when living bacteria are Illnesses caused by foodborne viruses
ingested with food in numbers sufficient and parasites are also broadly similar in
for some to survive the acidity of the that viable organisms gain access to their
stomach, one of the body’s principal pro- site of action in the body via the
tective barriers. These survivors then pass gastrointestinal tract.
into the small intestine where they mul-
tiply and produce symptoms. Intoxication
Infections can be invasive or non-inva- With foodborne intoxications, the bac-
sive. In non-invasive infections, the or- teria grow in the food producing a toxin.
ganism attaches itself to the gut surface When the food is eaten, it is the toxin,
or epithelium to prevent itself from being rather than the microorganisms, that
washed out by the rapid flow of material causes symptoms.

11
 Foodborne illness

figures are collected, but it is thought to n Changing lifestyles also means that
reflect an underlying increase in the food preparation may be in the hands
number of cases as well. of the relatively inexperienced as
more mothers go out to work and
A number of factors have contributed to
this trend. Their relative importance var- more people eat pre-prepared foods,
meals from catering establishments or
ies between countries and between patho-
food from street vendors.
gens but some of the most significant are
as follows: n An increasing proportion of the popu-
lation is more susceptible to
n Increasing industrialization and urban
living has meant that the food chain foodborne illness. This includes the
malnourished, the elderly, those who
has become longer and more complex,
have some underlying condition such
increasing opportunities for contami-
nation. It also means that more peo- as liver disease and those who are
immunocompromised as a result of
ple are likely to be affected by a sin-
infections such as HIV and immuno-
gle breakdown in food hygiene.
suppressive medical treatment.
n In poorer countries increased urbani-
zation and rapid population growth
have not been matched by develop-
ment of the health-related infrastruc-
Foodborne illness:
ture, including basic sanitation, and
this has led to increased risk of con-
its definition and
tamination of the food and water sup-
ply.
nature
n Increasing affluence in other areas has The term “food poisoning” has often been
led to greater consumption of foods used in some countries, but it is an ex-
of animal origin such as meat, milk, pression that can sometimes be restric-
poultry and eggs. These foods are rec- tive or misleading. Foodborne illness or
ognized as more common vehicles of foodborne disease are now the generally pre-
foodborne pathogens and this situa- ferred terms. Foodborne disease can be
tion can be exacerbated by the meth- defined as:
ods of intensive production required “any disease of an infectious or toxic
to supply a larger market. nature caused by or thought to be
n There is greater international move- caused by the consumption of food
ment of both foods and people. Ex- or water”.
otic Salmonella serotypes have been Though there are a number of important
introduced into Europe and the exceptions that will be described later,
United States as a result of the im- in most cases and in most people’s minds,
portation of animal feeds. A number the illnesses caused by foodborne micro-
of outbreaks of illness associated with organisms, principally bacteria, are asso-
imported foods have also been re- ciated with gastrointestinal symptoms of
corded. Tourism is one of the world’s nausea, vomiting, stomach pains and di-
major growth industries and every year arrhoea. Since diarrhoea is a common
more and more people travel abroad clinical symptom in foodborne diseases,
where they are exposed to increased many of these diseases are referred to as
risk of contracting foodborne illness. “diarrhoeal diseases”. These occur when

10
 Basic Food Safety for Health Workers

foodborne in origin or may not be re- cases being reported. Studies in some
ported to the relevant authority for re- countries point to an under-reporting
cording. Estimates vary but it is gener- factor of up to 350 in some cases.
ally believed that in developed countries
less than 10%, or even only 1%, of cases Statistics from both developed and de-
of foodborne illnesses ever reach official veloping countries show an increasing
statistics. In countries with fewer re- trend in foodborne illness over recent
sources, under-reporting must be even years (Figure 1.2). In part, this is prob-
greater, with probably less than 1% of ably due to improvements in the way the

90000

80000

70000
Notifications

60000

50000

40000

30000
1989 1990 1991 1992 1993 1994 1995 1996
Year

Figure 1.2a Foodborne illness : annual notifications, England and Wales

180

140
Cases per 100,000 population

120

100

80

60

40

20

0
1976 1978 1980 1982 1984 1986 1988 1990 1992 1994
Year

Figure 1.2b Incidence of foodborne disease in Venezuela

9
 Foodborne illness

DDT complex (DDT and its degradation

products) contaminates food mainly as a result
of its earlier use in agriculture and public health.
While DDT is now banned in most countries
for agricultural uses, the persistence and fat
solubility of DDT have resulted in widespread
contamination of the food chain. Levels of DDT
in breast milk reflect the exposure of the mother
to DDT and is a good indicator of the levels of
DDT in the food supply. Breast milk is also the
sole food for the first few months of life and
dietary intake of DDT complex by infants in
some countries approaches or exceeds the
WHO recommended provisional tolerable
intake of 20 µg DDT/kg body weight/day.
Source: GEMS/Food WHO document (WHO/FSF/FOS/97.9)

Figure 1.1 Dietary intake of DDT by infants from human milk

Data collected by the Food Contamina- A number of human viruses can be trans-
tion Monitoring and Assessment Pro- mitted by food and human diseases
gramme (GEMS/Food) indicate that in caused by protozoa, helminths and nema-
many countries the trend in chemical todes that are animal parasites are prob-
contaminant levels is generally down- lems of emerging importance in a
wards. This is most apparent in developed number of countries. These differ from
countries where exposure to these most bacterial foodborne illnesses in that
contaminants is often much lower than the causative organism does not multi-
in developing countries (Figure 1.1). ply in the food itself. A brief description
of the major foodborne pathogens and
Factors contributing to this disparity are
discussed in Chapter 2. The general over- some of their key features is presented
as Appendix 1. Most of the following is
all improvement is due to increased re-
concerned primarily with bacterial patho-
striction of the use of toxic chemicals
and pesticides that persist in the environ- gens, though specific aspects of other
pathogens are mentioned where appro-
ment, and improved control of environ-
priate.
mental pollution. Available data on
foodborne illness of biological origin pro-
vide a strong contrast to this reduction
in chemical contamination. Extent of foodborne
Several different types of organism can
cause foodborne illness. Bacteria, single- illness
celled organisms with typical dimensions
of around 1µm (10-6m), are the most im- Many developed countries have sophis-
portant and well studied foodborne ticated systems for collecting data on the
pathogens. A key factor is their ability to incidence and causes of foodborne illness.
multiply in food, thus increasing the haz- Yet it is known that these data represent
ard they pose. This is discussed in Chap- only a fraction of the number of cases
ter 2. Filamentous fungi (moulds) can also that occur. Infected individuals may not
grow in foods and some produce toxic seek medical advice, and if they do their
substances called mycotoxins. illness may not be recognized as

8
 Basic Food Safety for Health Workers

Table 1.4 Mean daily intakes (mg) of natural food toxicants

Class of compound (food source) Population
Total Vegetarian

Glucosinolates (brassicas) 50 110

Glycoalkaloids (potatoes) 13 70 - 90
Saponins (legumes) 15 100 (*220)
Isoflavones (soya) <1 105

* U.K. vegetarian population of East African origin

Source: Morgan, MRA. and Fenwick, GR National foodborne toxicants. Lancet, 15 December 1990, p. 1492/1495.

In most cases foods are not contaminated with pesticide residues, environmental
intentionally but rather from carelessness chemical contaminants and the use of food
or insufficient education or training in food additives cause most concern. Yet experi-
safety. In some cases, contamination may ence shows that most outbreaks of
be deliberate as, for example, in the mis- foodborne disease are associated with
use of food additives such as prohibited microbiological contamination.
colouring. In one serious case in Spain, con- This is reflected in the available statistics
taminated industrial rapeseed oil was sold on the etiology of foodborne illness.
for human consumption, killing more than (Table 1.5). One study estimated that
500 people and crippling more than 20,000 people are 100,000 times more likely to
(1). become ill as a result of microorganisms
How the relative importance of these haz- in food than as a result of pesticide
ards is perceived depends on who you ask. residues (2).
Surveys indicate that, as far as the general
public is concerned, hazards associated

Table 1.5 Etiology of foodborne disease outbreaks (with known etiology) in Latin
America and the Caribbean, 1995-1997
Etiological agent Percentage Percentage of cases involved
of outbreaks in outbreaks
Bacteria 46.3 83.03
Of which:
Bacillus cereus 1.3 1.2
Clostridium perfringens 4.2 4.1
Clostridium botulinum 0.4 0.1
Escherichia coli 11.4 7.8
Salmonella 37.0 43.1
Shigella spp. 3.1 21.9
Staphylocccus aureus 36.6 19.5
Vibrio cholerae 4.2 0.9
Vibrio parahemolyticus 0.2 0.4
Other 1.6 1.0
Total 100.0 100.0
Viruses 1.8 3.7
Parasites 1.8 2.9
Marine toxins 44.2 8.0
Plant toxins 0.4 0.1
Chemical substances 5.4 2.3
Total 100.0 100.0
Source: Adapted from data provided by the Pan American Institute for Food Protection and Zoonoses, INPPAZ, PAHO/
WHO 1998

7
 Foodborne illness

Table 1.2 Examples of vitamin and mineral deficiency syndromes

Micronutrient Deficiency syndrome
A Night blindness, xeropthalmia
Thiamine Beriberi, Wernicke’s encephalopathy; Korsakoff’s psychosis
Niacin Pellagra
Riboflavin Mucosal lesions
Pyridoxine Glossitis, neuropathy
Folate Megaloblastosis, villus atrophy
B12 Pernicious anaemia, megaloblastosis, neuropathy
C Scurvy
D Rickets, osteomalocia
K Hypoprothrombinaemia
Iodine Goitre, cretinism
Iron Anaemia

and established processing and handling Other foodborne hazards can be described
procedures are followed, the majority do as extrinsic, indicating that their presence
not cause serious problems. Natural food is a result of contamination of the food.
toxins are described in more detail in This includes contamination with indus-
Chapter 2 but a few examples are given trial chemicals or pesticide residues, right
in Table 1.3 and estimates for some mean through to the presence of pathogenic bac-
daily intakes in the United Kingdom are teria or parasites. The range of possibili-
presented in Table 1.4. ties is summarized in Table 1.3.
Table 1.3 Causes of foodborne illness
Examples
INTRINSIC HAZARDS
(Natural Toxins or Antinutritional Factors) oxalic acid (rhubarb, spinach)
alkaloids
solanine (potatoes)
dioscorine (yams)
cyanide (cassava, lima beans)
haemagglutinin (red kidney beans)
protease inhibitors (legumes)
phytic acid (bran)
amatoxin, psilocybin and others
(toxic mushroom)
EXTRINSIC HAZARDS
Chemical Contamination dioxins, PCBs
heavy metals
cadmium
mercury
lead
pesticide residues
Biological Contamination Bacteria
causing infection e.g. Salmonella
causing intoxication e.g. C. botulinum
Parasites
helminths e.g. roundworms
protozoa e.g. Giardia lamblia
Viruses e.g. Hepatitis A, Small Round-Structured
Viruses (SRSVs)
Fungi/mycotoxins e.g. aflatoxin
Algae (e.g.dinoflagellates leading to paralytic
shellfish poisoning)

6
 Basic Food Safety for Health Workers

Chapter 1
Foodborne
illness

Food in health and

disease
Food is essential both for growth and for Even when a diet provides enough pro-
the maintenance of life. It supplies the tein and energy, it may not supply suffi-
energy and materials required to build cient essential minerals or vitamins and
and replace tissues, to carry out work and may thus give rise to characteristic defi-
to maintain the body’s defences against ciency disorders (Table 1.2).
disease.
Illness can also result from what a food
Food can also be responsible for ill-health. contains rather than from what it lacks.
Failure to consume enough of the right kind Some hazards of this kind are described
of food will impede growth and impair as being intrinsic to the food in the sense
health. For example, protein-energy that they are normal and natural constitu-
malnutrition can lead to a range of clinical ents of the food. Many common food
manifestations. These vary from marasmus, plants, for instance, contain toxic com-
where consumption of protein, dietary pounds designed to deter predators or
energy and other nutrients are chronically invading microorganisms. Their intake is
reduced, to kwashiorkor (sometimes inevitably higher in those people with a
thought to be associated with an over- largely vegetarian diet.
reliance on low protein staples) which
results in a quantitative and qualitative However, in most cases where the food
deficiency of protein (Table 1.1). supply is generally varied and plentiful,

Table 1.1 Classification of severe protein-energy malnutrition in children

Weight for age* With oedema Without oedema
60 –80% Kwashiorkor Undernutrition
Less than 60% Marasmic kashiorkor Marasmus

* As % of standard (National Centre for Health Statistics) weight

Source: Tomkins, AM Nutrition in clinical medicine. In: Textbook of Medicine. RL Souhami and J Maxham (eds) 2nd edn.
Churchill Livingstone, Edinburgh, 1994: p.106.