Pakistan Journal of Biological Sciences 8 (4): 589-595, 2005 ISSN 1028-8880 © 2005 Asian Network for Scientific

Information

Nutrition Rehabilitation of the HIV-Infected and Negative Undernourished Children Utilizing Spiruline
1,ZJacquesSimpore, 'Frederic Zongo, "Youssouf Ouattara, 'Fatoumata Kabore, lDeleli Dansou, 'Augustin Bere, 'Jean-Baptiste Nikiema and "Salvatore Musumeci lUnit of Formation of Research in Sciences of Life and Earth, University of Ouagadougou, Burkina Faso, 2Medical Center St Camille, Ouagadougou, Burkina Faso, 3Laboratoire de Physiologie Animale UFR-SVTlUniversite de Ouagadougou, Burkina Faso, "Department of Pharmacology, Gynecology and Obstetrics, Pediatrics, University ofSassari, Italy The objective of the study was to assess the impact of an alimentary integrator composed by Spiruline (Spirulina platensisi, produced at the Centre Medical St Camille (CMSC) of Ouagadougou, Burkina Faso, on the nutritional status of undernourished Hl v-infected and HIV negative children, We compared two groups of children: 84 children Hl'V-infected and 86 Hl'V-negative. The duration of this study was eight weeks, Anthropometries and haematological parameters allowed us to appreciate both the nutritional and biological effects of Spiruline supplement to traditional meals, The rehabilitation with Spiruline shows on average a weight gain of 15 and 25 g/day in HIV-infected and in HlV negative children, respectively, The level of anaemia decreased during the study in all the children, but the recuperation was less efficient among the HIV -infected children, in fact, 81,8% of HlV negative undernourished children recuperated against 63,6% of HlV-infected children [Z: 1,70 (95% CI: -0,366, -0,002, p=O,088)], Present results allow to confirm that Spiruline is a good food supplement for undernourished children In particular the rehabilitation by Spiruline seems to correct the anaemia and the weight loss also in HIV-infected, but more quickly in Hl V negative undernourished children,
Abstract: Key words: Malnutrition, Spiruline,

nrv, Burkina Faso
which occupIes an important place in this country, In fact, HIV prevalence of 40,5% was recognized in undernourished children-'' and compounds the prognosis of these children In Centre of Education and of the Nutritional Rehabilitation (CREN) of Ouagadougou, Burkina Faso, a supplement with Spiruline was used since January 2000 to improve the nutritional status of undernourished HIV-infected and HIV negative children, The choice of this alimentary integrators, a cyanobacterium which growth easily at the temperature of Burkina Faso, was guided by the biochemical composition in arninoacids, iron, carotenoids of the Spiruline powder, Spiruline has been recently introduced in the treatment of HIV infected undernourished children because of several advantages of Spiruline in the rehabilitation Hl V adult patients have been reported'Y'. Spiruline used in this study was also analysed for its glucid and lipid compositions since they are influenced by the environmental condition of growth,

INTRODUCTION Malnutrition constitutes a public health problem in all the world particularly in the developing countries!", In Africa, more than 30% of the infant mortality rate below five years of age results directly or indirectly from malnutrition'", Since 1999, Burkina Faso is confronted by protein-energetic malnutrition with 13% of infant population affected by emaciation, 29% by growth delay and 30% by insufficient weight!". The consequences of the protein-energetic malnutrition in Burkina Faso are several and manifest severe forms of marasma, kwashiorkor and kwashiorkor-marasma!", To day it is recognized that this form of malnutrition is coupled with deficiencies in vitamins and in minerals'S". It creates inexorably an uncorrectable spiral between malnutrition and infectious pathologies, which often is associated with chronic diarrhoeal". The more frequent infection found in severe undernourished children is the Hl V infection,
Corresponding Author:

Salvatore Musumeci, Professor,Departmentof Pharmacology,Gynecologyand Obstetrics, Pediatrics, Universityof Sassari,Viale San Pietro 12,07100, Sassari,Italy Tel: +39360285505 Fax: +390957179690 E-mail: smusumeci@tiscalinetit 589

Anthropometries parameters: The weight of the children was taken once a week since the day of their admission to the CREN with a 109 sensitivity balance. considering that it varies little for the children of less than four years. Dehydrated children in shock needing rapid transfer to hospital for intensive therapy. 8 (4): 589-595. those children over 2 years is measured in the upright position. The ages were confirmed by the birth notebooks. The height of children under 2 years is measured by resting the child on his back. recommended by the WHO and the Funds of the United Nations for l'Enfance (UNICEF) and their age was 14. fruit). This procedure was repeated separately for each group. Study patients: At the beginning of this study. No antiretroviral treatment was used in HIV -infected children because it was not available. All of our 590 .. Sci. At the end 170 children (84 HIV infected and 86 HIV negative chidren) were randomly enrolled in four rehabilitation protocols: B) 44 HIV infected children were given the supplement Spiruline together with the traditional meals (millet. The Ethical Committee of CMSC gave permission for the study. Each child was admitted to the protocol study given a progressive number and at the end each was selected with a casual number generator program. because our priority objective was to demonstrate the efficacy of this treatment in nutritional rehabilitation of HI V-infected and HIV negative children. vegetable. The nutritional status. death and the interruption of treatment at the Center during the study. The exclusion criteria were refusal to participate to the study. undernourished children were anhoressic and many of them had diarrhoea. while the discontinuation of participation criteria were abandonment. The nose-gastric rehydration was interrupted before inclusion in this study. vegetable. or slowdown of regular growth. D) 40 HIV infected children of the same age range were given only with traditional meals. The index height for age expressed in z-score (HAZ) or growth delay is an index that translated a chronic malnutrition provoked by an extended reduction of the food consumption and by repeated pathologic episodes. An anti HIV antibodies test was done with Biorad Genie II Rapid Test (USA) on children. fruit). HAZ (Height for age z-score). Biological analyses: The level of haemoglobin. The index weight for age expressed in z-score (W AZ) or weight insufficiency translates a global malnutrition affecting at once the linear growth and the weight increment. a greenhouse for the culture of the Spiruline and a Center for Education and for Nutritional Rehabilitation (CREN). The number of lymphocytes. The CREN follows in average 700 children for year. which was treated with nose-gastric rehydratation according the CMSC protocol!". The group C and D represent the control group for Spiruline supplement. number of leukocytes.Pak. a Center for Neonatal Pathology. The vitamin and mineral deficiencies were corrected only at the end of study. 2005 MATERIALS AND METHODS Study protocol: This research was conducted at the CMSC of Ouagadougou during 2002-2003. This Center was created in 1974 by the religious of St Camille order and comprises a maternity. an analysis laboratory for biological and biochemical examination. BioI. evaluated by brachial perimeters was compared to the classification of Jelliffel'". J. A) 46 HIV negative children were treated by the supplementation of Spiruline to traditional meals (millet. C) 40 HIV negative children were alimented only with traditional meals.37 (range 12-60 months). WHZ (Weight for height z-score) and WAZ (Weight for age z-score) parameters were calculated according to the references of the National Center for Health Statistics (NCHSr] Evaluation of results: The evaluation of nutritional status of the children has been made according to the nutritional indices. neutrophiles and leukocytes gives an idea of the severity of immune involvement. lymphocytes and neutrophiles were measured before and after eight weeks from the starting of the study only among HIV-infected and HIV negative children treated with Spiruline. The haemoglobin level and the hematocrite were measured in order to reveal an anaemia status. The emaciation or weight loss expressed by the index weight for height (WHZ) indicates a slighter status or weight deficit due to a decrease. were excluded from this study. Infants and children aged <5 years HIV-infected and HIV negative were enrolled using the CONSORT criteria!". All parents provided written consent for participation of their children in the study protocol. Participation criteria: All studied children were undernourished according to the z-score criteria. The blood numeration was made using a Coulter Counter T540. whose parents freely accepted our research protocol. These tests were performed to detect significant changes within the treatment groups in order to assess whether Spiruline is a useful supplement of feeding in rehabilitation. a health center.

1 -2..84±5.038 p~O. but this difference was less significant in the control group (10 and 20 g/day. Statistic analysis: A power analysis was performed prior to the initiation of the study and the number of studied RESULTS Nntritional rehabilitation: Table 1 shows the anthropometries parameters of the children HIV infected and HIV negative atthe beginning of our study.7 -3.05 was considered significant. 8 (4): 589-595.5 IO.5 -294±-O.88±1 J -2.9 D 1496±5. The differences within groups were statistically significant considering the differences in the nutritional status changes across the groups.3 69. WHZ=Weigbt BP~Br achial P erim eter for height z-score.0 6. respectively). Fig.83±O . nutritional status normalized for the maj ority of children. of the children subjected to the otudy B 15.124 p~0882 p~O.2 -3. Bioi. in artificial ponds and dried at room temperature (Fig.9 -3.35 68.93.54±5. p<0. Fatty acids qnantification and identification: The Spiruline was ground and extracted three times with hexane. WAZ=Weigjl.88±O.37±1.65±1.Pak. This mixture was made at least two times a day. The HIV negative children who are nourished with Spiruline plus traditional meals had a more significant (p<0.91 ±1. they had to mix 10 g of Spimline with a graduated container to the traditional meal of their children composed of millet and flour. 1). VlTHZparameter decreasing from -2.D5±1.24±4. This mixture was given to children in a quantity covering their caloric requirements and outside the suckling moments in children whose mothers continued breast feeding. This improvement corresponds to an increment of weight which was on the average 15 g a day in HIV infected children and on average 25 g a day for mv negative children both treated with Spimlina plus traditional meals.9 Variance enalysis p~0789 p~O.9 69.14±O. 6 for the anthropometries data and SPSS-I0 for biological data.72±5. At the end ofthe eight weeks of the treatment. Model 5890. These changes among treatment groups are reported in Table 2. The components were identified by using standard fatty acid methyl esters and quantified by using methyl nonadecanoate (19:0) as an internal standard."ore.64±1.10±O.503 parameter. Sci. The nutritional changes pre/post improved in all children. The materi al was stored in the dark at 4°C to prevent photo degradation.0003) decrement of VlTHZ parameter than the HIV-infected children (p=0.t for age z-scor e.1 O±1. equipped with a Flame Ionization Detector (FID) and coupled to an electronic integrator.758 p~O. Each week they accompany children in the CREN for a control of weight and other anthropometric parameters. The data were treated with Excel (Office.1 6.0 -4. Epi-Info software V. Every day.59±1. Microsoft) software. 1: Particular ofbacins for the Spimline cultivation positive samples were tested with the technique of EIA (Enzyme Immuno Assay) using Abbott IMX System (USA) in order to confirm the samples HIV -infected. the average of nutritional status of the HIV -infected children was not so good as the average for Table I Anthropometric Groups -----------------------------------------------------------------A Age (m onths) H eight (em) 14.8 IOAO±1.t 591 .87±1.88±IO BP Weigbt(kgJ HAZ WHZ WAZ for age z.370 p~O. The compliance of mothers on how prepare mixes and feed them to their children was elevated and they continue to administrate the mixture also at home. Prep ar ati on and administration of the Spirnline: The mothers of the undernourished children which received Spiruline were given weekly rati ons of70 g of Spiruline in a sachet.2 -2. J.26 to -0.1 -2.8 C 15.1 1O. Plant material: Spimline was cultivated in Burkina Faso.9 5. The mixture of fatty acid methyl esters has been extracted with hexane and analyzed by Hewlett Packard gas-chromatograph.0 5 .0004).64±2.23±1.19±4. 2005 children was homogeneously distributed and reached the minimal number to discuss a statistical difference. according to the opportunities of calculations and of analysis.8 IO. The difference between mean values before and after eight weeks of treatment were calculated by Student t-test (for paired and unpaired data).02 -399±O .5 -2A2±I.37"<54 69. more significantly in the group who received Spimlina. ·HAZ~Heigjl.98±1 J -2.

44 g dL -I of haemoglobin) for all the children.04 FNS* 47. The only difference is situated at the level of the value of the glucides.56 4.47%. Children whowereHIV-infected were more anaemic (3.273.02 5. 46 Mean Red cen mm' (1) 1-72 Red cen mm' (2) Hb g dL-' (1) 1-72 Hb g dL-' (2) Leukocytes xl000 (1) 1-72 Leukocytes xl000 (2) Lymphocytes% (1) 1-72 Lymphocytes% N eutrophil% (1) 1-72 N eutr~hil% (2) * Student t-test (2) 3.53% oflbe D ·2.43 2.22 4.86 12. WHZZ~Weight height z-score at the end of the study.62 7.87 51.59 2.46 331.44 4.41% ·3.34 p=D.00 39. that in 1975 found a value ofl2.0 13.OOO* 3. 2005 Tabl e 2: Nutriti onal status at lbe beginning (1) and at lbe end of lbe study (2)' Groups A WHZl 1-72 WHZ2 WHZ21 (WHZ1+WHZZ) WAZI 1-72 WAZZ WAZZI Table 4: The Nutrition Composition for 100 g of cultivated Spiruline to lbe Medical Center St Camille in comparison Iiterature'!" B ·2.58±1.10 13.60 6.83 Student t test for paired data: p ~ 0.3% ·3.oOO* 42.16 1. respectively when Spiruline was added to traditional meals and 17.12) WI.48 1. 44 Mean 3.oOO* 10.14 7.19 6.82 0.03 4.0 T.01 22.92 106 mm "). 8 (4): 589-595.38 7.2 and 14.45±1. The compliance to treatment was excellent and any children drop out.42±1. the anaemia was slightly corrected for all HIV -infected and HIV negative children who remained nevertheless anaemic (3.63%.00 T. The composition of our Spiruline proves the good quality of the Spiruline of the CMSC (Table 4).53 FO.65 1.83 3.54 1. The median number of the red cells and the median concentration of haemoglobin. against 10.94±0.33 4.53 4. * 1-72 Student t test Table 3: Biological parameters of the children made at the beginning lbe end oflbe study wilb Spirnline (2) Chil dren HN negative treated with Spiruline No.00 38.02 FO. The index weight for age WAZ at the end of our study confirmed that the severe malnutrition was corrected by this protocol of treatment. J.87 15.72 8.75 FNS* 12. The percentage of WHZ and WAZ are reported in Table 2.64 49.52 7.0 T.44 18.85 SD 0.64 106 mm ").OOO* ·2.91 p=D.53 10.00±0. but only the first and the last visit (eight weeks) were considered in the final evaluation.19 18.08 HIV negative children.62 42.19%.81 16.01 10.2% ·4.17 6..0 beginning of study.90 FO.47 19.4% on the cultivated Spiruline in laboratory.20 7. They come to weekly appointments.64 4. 16:0 Palmitoleic acid.22 4.35 12.46 7.OOO* 9.19% composition oflbe Spirnline with the time 'r.69 4. 18:1 (9) Linoleic acid.42 13.004* ·2.OOO* ·2. In HIV negative children the gain was 42. respectively using alone traditional meals. The association of Spiruline plus traditional meals gave in HIV infected children gain of 22.91 14. respectively.1% ·3.88±0. % of total fatty acid 28.: p ~ 0.007* ·3.00 p=D.54 0.83 11.01 p=D.12 7.59106 mm ? of red cells and 592 8.09 p=D.73 p=D.00 6.9 FO. The quality of the Spiruline with the time-in the first three months of storage .76 338.: 54.96 8.07 1.00 4. WAZZ~Weight for age z-score at lbe end oflbe study.23+/·1.84 of the given values in the Green Flamant values 3·7 7·13 8·10 6·8 55·70 15·25 ·2.50 (1) and at Children HN·infected treated wilb Spirnline No.83 SD 0.12 363.625 Table 6: Fattv acid composition of Spirnlina strain from Burkina Faso Fatty acid Palmitic acid. T2 (1< monlb) (2""'monlb) 56. (3"monlb) 52. 18:0 Oleic acid.53% when they were alimented traditionally alone.47% Analysed sample for Protein (%) Fannie index (mLNaOH) Total sugars (%) Reductive sugars (%) Fat matter (%) Fatty acids (mgNaOH/g) pH Humidity (%) Ash (%) Phycocyanin (%) Water content (%) Ash(%) Vegetal fiber (%) Lipid(%) Protein (%) Glucide(%) Table 5: Physicochemical Our results 4.10 4.95 FO.oOO* 3. allowed to diagnose an anaemia (3.51 3.59 1.10+1·0. The lesser content in glucides of the analysed Spiruline in our culture conditions was near the one of Sautier and Trernolieres''". : p ~ 0.25 10.59±1.40 2. This response to the Spiruline supplement was more significant than the increment of weight and height showed by WHZ and WAZ parameters.82 p=D.88 21.Pak.98±1.013* ·3.99 17. WAZl~Weight for age z-score at the To (1< day) 57.76 9. BioI. Sci. 18:2 (9.OOO* 9. The analysis of this data shows that the best improvement was observed in the group of HIV -infected children (Table 3).16 22.OOO* ·1. 12) «Linolenic acid.29 5.763.1 and 22.9.70±1.92 6.41 FNS* 40. (10"'monlb) 49.63% C ·2.87 10.065* ·2.87 10.20 16.-7T.30 0.20 3.90 6.77 1.310.00 57.00 (WAZ1+WAZZ) 'WHZl~Weight for height z-score at beginning study.07 6.59+1·0.63 0.83 p=D. 16:1 (9) Steari c acid. To -7T.04 2.10 1. 18:3 (6.34106mm-J) than the childrenHIV negative (3.73 11.81 6.28 5.56 5. more significantly in the Spiruline group.64 FO.00 6.OOO* 41. To-7T.36 5. : p ~ 0.32 340.46 360.3 and 13.42 14.OOO* ·3.69 13.88±0.83±0.41 and 7. Tc-7T.87+/·1.00 p=D. Chemical analysis: The values of the composition of the Spiruline of the CMSC of Ouagadougou is in the interval of values of the international firm Green Flamant'!".99±0.78 4.69 7. At the end of the eight weeks.50 6.19 6.

This mechanism may be due to the high amount in the lipid fraction of w-6 derivative. in our study regarding a period of eight weeks. This exclusive presence of w-6 represents a metabolic gain. which was half that used in our study (5 vs. In fact.96% for the marasma and 3.370 mm ") with relative granulocytopenia was found elevated in the Hl V-infected children (49. the scarce results which they obtained could be due to the quantity of Spiruline. GO-linolenic. This frequency is less than the prevalence of 27% found at Bobo-Dioulasso (Burkina Faso) by Prazuck et aZ[24J and of 28. this result shows that the Spiruline is also effective for the haematopoiesis especially for the persons infected by HIV in accordance with the data of the international literature'Y'". [20J in Burkina Faso did not show a significant improvement adding Spiruline to traditional meal but. The lipid composition of the Spiruline growth in Burkina Faso is listed in Table 5. For longer period of storage some significant changes were detected.44% of HIV-infected children. however the unexpected increment in weight with the use of Spiruline confirms the opportunity for continuing the use of this supplement in undernourished children. 109 a day by inhabitant in Africa against 29 g in Latin America and 63 g in the industrialized countries.22% for the kwashiorkor plus marasma was found. which in turn causes inhibition of the proliferation and cytokine production of Thl cells. their weight grew and many of them appear less anaemic. the screening of these aforesaid children at the Medical Center confirmed a 24. Moreover. which was present at the beginning of treatment of these children'!". The strong prevalence the kwashiorkor and/or marasma is characteristic of sub-Saharan Africa. since desaturase enzyme could be deficient in the undernuorished children'"'. where maize and millet are the staple. such as a decrease of protein content and an increase of pH value. who received only traditional meals. The growth recovery is slower than the weight recovery and this could be determined by the diarrhoea. the variations of weight were more significant owing to the liquid content dehydratation associated with malnutrition.Pak. mediators of cellular imrnunity'i".. In the context of weak intake of proteins. BioI. who showed more severe alterations of WHZ and WAZ values. DISCUSSION After eight weeks of study. 8 (4): 589-595. Moreover. which may be considered as an alimentary integrator for undernourished children. in which the gain of weight was inferior. This improvement was less significant in the control group. but they were different according to the nutritional and serologic status. The anthropometries characteristics of studied children varied little according to the sex (Table 2). 2005 did not show significant changes. confirm the immune modulation of this cyanobacterium. The infection with Hl V among the undernourished children worsens the situation and highlights the problem J 593 .6% in Togo by Atakouma et aZ. which correspond to the effect of HIV infection on nutritional status of children in Burkina Faso'"! Moreover. Diet-associated inhibition of the Th1 subset is a major contributor to the high prevalence of these clinical pictures of malnutrition in sub-Saharan areas. WHZ was smaller in Hl V-infected children in comparison with HIV negative children (Table 1). linoleic. oleic. the present study is more conclusive than the one realized in Dakar by Alling et aZ. J.82% for the kwashiorkor. Previous study made by Branger et aI. [25J. Sci. HIV infected and HIV negative children treated with Spiruline plus traditional meals appear improved. An high intake of linoleic acid in a diet deficient in other polyunsaturated fatty acids and in riboflavin results in these countries in high tissue production of prostaglandin E2. to a reduced supplement in Spiruline. tearic s and palmitoleic acids. This choice could alter the analysis of results. The enrolment of this group could appear unethical among these severely malnourished children. [21J. 109). which correct the anemia due to deficient iron intake. as considered by the same authors. One could object that this study assigned the Spiruline treatment mainly to children with Hl V-infected and non infected. but it was organized choosing randomly a control group between children whose mothers did not accept the protocol study. In St Camille Medical Center a prevalence of 0. This observation is the same as the one of Kelly et aZ[22 in undernourished Hl V-infected children with persistent diarrhoea. The results of this study prompted us to continue the culture of Spirulina in the CMSC of Ouagadougou in order to utilize the biochemical composition and the beneficial action of this cyanobacterium. The fatty acid content is represented by palmitic. probably due also in this case.8%) (Table 3). the integration of traditional meal with Spiruline improve the nutritional and micronutrient requirement for undernourished children'!". This may be due to the iron content of Spiruline supplement'!". since they frequently show diarrhoea associated with Hl V infection. namely GO-linolenic acid'!". 95. Since at the beginning of this study the number of leucocytes: 12. so they were treated only with traditional meals. the increase of lymphocyte number in HIV -infected children who received eight weeks of Spiruline.

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